Acid-fast Bacilli Staining Research Articles

Clinical and Molecular Findings in Mendelian Susceptibility to Mycobacterial Diseases: Experience From India.

Mendelian Susceptibility to Mycobacterial diseases (MSMD) are a group of innate immune defects with more than 17 genes and 32 clinical phenotypes identified. Defects in the IFN-γ mediated immunity lead to an increased susceptibility to intracellular pathogens like mycobacteria including attenuated Mycobacterium bovis-Bacillus Calmette-Guérin (BCG) vaccine strains and non-tuberculous environmental mycobacteria (NTM), Salmonella, fungi, parasites like Leishmania and some viruses, in otherwise healthy individuals. Mutations in the IL12RB1 gene are the commonest genetic defects identified. This retrospective study reports the clinical, immunological, and molecular characteristics of a cohort of 55 MSMD patients from 10 centers across India. Mycobacterial infection was confirmed by GeneXpert, Histopathology, and acid fast bacilli staining. Immunological workup included lymphocyte subset analysis, Nitro blue tetrazolium (NBT) test, immunoglobulin levels, and flow-cytometric evaluation of the IFN-γ mediated immunity. Genetic analysis was done by next generation sequencing (NGS). Disseminated BCG-osis was the commonest presenting manifestation (82%) with a median age of presentation of 6 months due to the practice of BCG vaccination at birth. This was followed by infection with Salmonella and non-typhi Salmonella (13%), Cytomegalovirus (CMV) (11%), Candida (7%), NTM (4%), and Histoplasma (2%). Thirty-six percent of patients in cohort were infected by more than one organism. This study is the largest cohort of MSMD patients reported from India to the best of our knowledge and we highlight the importance of work up for IL-12/IL-23/ISG15/IFN-γ circuit in all patients with BCG-osis and suspected MSMD irrespective of age.

Association of Cartridge Based Nucleic Acid Amplification Test (CBNAAT) Grading on the Basis of Cycle Threshold Value with Conventional Microbiological Diagnosis in Pediatric Tuberculosis

Background: Microbiological confirmation of tuberculosis disease in children remains difficult due to paucibacillary disease and inability to obtain optimal samples. Recently introduced Cartridge based nucleic acid amplification test (CBNAAT) has improved microbiological diagnosis in pediatric tuberculosis.
 Objectives: We aimed to study association of CBNAAT grading based on cycle threshold value with conventional microbiological diagnosis.
 Methodology: This prospective study was conducted over a period from November 2016 to October 2017 in the Departments of Microbiology and Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi. CBNAAT positive pediatric TB cases ≤12 years were recruited and subjected to Ziehl-Neelsen staining for acid fast bacilli (AFB) & culture on Lowenstein Jensen medium. CBNAAT positivity was graded based on cycle threshold value: very low, low, medium and high.
 Results: Smear and culture positivity was highest (100%) among specimens with high positive CBNAAT result based on CT value. Time to culture positivity was inversely related to CBNAAT grading (p=0.000).
 Conclusion: CBNAAT grading has significant positive association with smear and culture positivity.
 Bangladesh Journal of Infectious Diseases 2020;7(2):72-77

Role of routine nephrectomy for non-functioning kidneys due to genitourinary tuberculosis: Data from an Indian subcontinent

Objective: To evaluate the role of routine nephrectomy for tuberculous non-functioning kidney (TNFK) after receiving anti-tubercular therapy (ATT) by demonstrating whether live tubercle bacilli persist in nephrectomy specimens after treatment or not. Materials and methods: Patients with TNFK who underwent nephrectomy after completion of at least 6 months of ATT were included in this prospective cohort study. We sent tissue/pus from a nephrectomy specimen for acid-fast bacilli (AFB) staining, polymerase chain reaction (PCR) and culture to look for live bacilli. Bacilli were considered alive only if AFB culture was positive. Results: Twenty-four patients underwent nephrectomy for TNFK between April 2015 and October 2017 (18 laparoscopic and 6 open nephrectomy). Laparoscopic nephrectomy was associated with lower blood loss (225 ml versus 408 ml, p = 0.0003) and shorter hospital stay (3 versus 3.8 days, p = 0.06) compared with open nephrectomy; however, mean operative time and overall complications were similar. Eight specimens were AFB smear and/or tuberculosis PCR positive, out of which three showed viable bacilli upon culture. Drug sensitivity testing showed multi-drug resistant strain in all three patients who were treated with second-line ATT. Conclusion: It is preferable to do routine nephrectomy for TNFKs as they are more likely to harbour live bacilli and lead to disease recurrence. Viability testing for AFB must be performed on all operated specimens to identify drug resistant bacilli so that patients may be treated with second-line therapy if required. Level of evidence: 4.

Development and evaluation of a multiplex loop-mediated isothermal amplification (LAMP) assay for differentiation of Mycobacterium tuberculosis and non-tuberculosis mycobacterium in clinical samples.

IntroductionThe rapid and accurate diagnosis of tuberculosis (TB) is important to reduce morbidity and mortality rates and risk of transmission. Therefore, molecular detection methods such as a real-time PCR–based assay for Mycobacterium tuberculosis (MTB) have been commonly used for diagnosis of TB. Loop-mediated isothermal amplification (LAMP) assay was believed to be a simple, quick, and cost-effective isothermal nucleic acid amplification diagnostic test for infectious diseases. In this study, we designed an in-house multiplex LAMP assay for the differential detection of MTB and non-tuberculosis mycobacterium (NTM), and evaluated the assay using clinical samples.Material and methodsFor the multiplex LAMP assay, two sets of specific primers were designed: the first one was specific for IS6110 genes of MTB, and the second one was universal for rpoB genes of mycobacterium species including NTM. MTB was confirmed with a positive reaction with both primer sets, and NTM was identified with a positive reaction by only the second primer set without a MTB-specific reaction. Total 333 clinical samples were analyzed to evaluate the multiplex LAMP assay. Clinical samples were composed of 195 positive samples (72 MTB and 123NTM) and 138 negative samples. All samples were confirmed positivity or negativity by real-time PCR for MTB and NTM. Analytical sensitivity and specificity were evaluated for the multiplex LAMP assay in comparison with acid fast bacilli staining and the culture method.ResultsOf 123 NTM samples, 121 were identified as NTM and 72/72 MTB were identified as MTB by the multiplex LAMP assay. False negative reactions were seen only in two NTM positive samples with co-infection of Candida spp. All 138 negative samples were identified as negative for MTB and NTM. Analytical sensitivity of the multiplex LAMP assay was 100% (72/72) for MTB, and 98.4% (121/123) for NTM. And the specificity of assay was 100% (138/138) for all.ConclusionsOur newly designed multiplex LAMP assay for MTB and NTM showed relatively good sensitivity in comparison with previously published data to detect isolated MTB. This multiplex LAMP assay is expected to become a useful tool for detecting and differentiating MTB from NTM rapidly at an acceptable sensitivity.

Study on role of cytology in diagnosis of head and neck lesions in a tertiary care hospital

Background: Head and neck lesions are commonly encountered in patients across all age groups. This region encompasses a multitude of congenital, inflammatory or neoplastic lesions. FNAC is a clinically appropriate procedure associated with minimal trauma and complications for patients for analysis of head and neck swellings because of factors such as easy approachability of the target site, increased compliance and helping to avoid surgery in non-neoplastic lesions, inflammatory conditions and also some tumors. Objective: This study is undertaken to assess the accuracy of cytopathological diagnosis of head and neck lesions by FNAC and to correlate and analyze FNAC of head and neck lesions with that of histopathological study. Material and Methods: The present study was Laboratory based Cross sectional descriptive type of observational study. A total of 100 cases undergoing FNAC among the head and neck lesion were enrolled for present study. FNAC was done using 10 cc disposable syringe and 22/23 gauge needle taking all aseptic precautions. Both aspiration and non-aspiration techniques were used wherever required. Smears were stained with PAP, Haematoxylin-Eosin stain and Leishman stain. Zeihl-Neelsen staining for acid fast bacilli was done in suspected tubercular lesions. Results: Out of 100 patients lymph node lesions (46%) was the predominant site of FNAC. Out of 46 lesions of Lymph node; tubercular lymphadenitis was the most common pathological findings. Among 28 thyroid lesion Colloid goitre (45.5%) was the predominant finding. Out of 18 salivary gland lesions the most common lesion was pleomorphic adenoma. Out of 14 soft tissue and miscellaneous lesions benign lesions were commonest finding. Conclusion: FNAC is a simple, rapid and cheap diagnostic tool that can be done as an outpatient procedure with overall accuracy rate of more than 90 % which differentiates non-neoplastic lesions from neoplastic lesions thus avoiding unnecessary surgeries.

An Insight on Cytomorphological Patterns of Tuberculous Lymphadenopathy in Paediatric Age Group

Introduction: The incidence of Tuberculosis (TB) in a developing country like India is very high. Lymphadenopathy is the commonest extrapulmonary manifestation of the disease. In rural and remote areas of India where adequate infrastructure is not available, many cases remain undiagnosed for a long time. Fine Needle Aspiration Cytology (FNAC) may be used as an important diagnostic tool in these cases. Aim: To provide an insight in the cytomorphological patterns of tuberculous lymphadenopathy complemented with Acid Fast Bacilli (AFB) staining in patients of paediatric age group. Materials and Methods: It was an observational study involving 175 patients of 0-18 years of age, presenting with peripheral lymphadenopathy in the Out Patient Department/In Patient Department (OPD/IPD) of different departments of Silchar Medical College and Hospital, Silchar, Assam. The duration of the study was one and half years from June 2013 to December 2015. FNAC was done from the enlarged lymph nodes and smears were stained with Giemsa, Papanicolaou, and Ziehl- Neelsen (ZN) staining. Cytomorphological analysis was made for the cases diagnosed with tuberculous lymphadenopathy. Simple statistical analysis was done using Microsoft (MS) EXCEL 2013. Results: Out of 175 cases, 58 (33.14%) cases were diagnosed with tuberculous lymphadenopathy. Cervical lymph nodes were most commonly involved (42 cases, 72%), followed by axillary lymph nodes, and then generalised lymphadenopathy followed by inguinal lymph node involvement. Cytomorphological analysis showed 33 (56.89%) cases of epithelioid granulomas with caseous necrosis; 14 (24.14%) cases of epithelioid granulomas without caseous necrosis and 11 (18.97%) cases of caseous necrosis without epithelioid granulomas. Overall AFB positivity was 34.48%. Necrosis was found to be associated with highest AFB positivity (81.82%). Conclusion: The incidence of tuberculous lymphadenopathy in the current study was significantly high. In a resource poor setting, FNAC is useful in diagnosing tuberculous lymphadenopathy where cytomorphology can be complemented with AFB staining to improve diagnostic accuracy.

Comparison of Gabbet's staining, Ziehl–Neelsen staining with fluorescent microscopy for diagnosis of pulmonary tuberculosis: A cross-sectional study

Background: Sputum staining for acid-fast bacilli and microscopic examination methods are more sensitive and specific, less time consuming, low cost than other methods for the diagnosis of pulmonary tuberculosis (TB). Methods: In this cross-sectional study conducted over 1-year (n = 109), the sensitivity, specificity and cost-effectiveness of Gabbet's staining, Ziehl–Neelsen (Z-N) staining for the diagnosis of pulmonary TB were studied considering with fluorescence staining method as the gold standard. Results: Majority of the patients belonged to the age group between 21 and 40 years (45.5%). With fluorescence staining, it was found that 25 of the 44 positive smears were of good quality, 12 were of average quality and 7 had poor quality. With Z-N staining, 9/29 of the positive smears were of good quality, 10 were of average quality and poor quality each. With Gabbet's staining, 12 of the 33 positive smears were of good quality, 14 were of average quality and 7 were of poor quality. The sensitivity of the Gabbet's staining (75%) was found to be greater than the Z-N staining (65.9%) considering fluorescence staining as the gold standard. Conclusions: Gabbet's staining can be used as an effective alternative to Z-N staining in low resource settings.

Diagnostic Challenges and Clinical Profile of Spine Tuberculosis – An Experience from Medium Sized Health Care Center, South India

Introduction: Skeletal tuberculosis accounts for 10-35% of Extra-Pulmonary Tuberculosis (EPTB) and 3% of all cases of tuberculosis. Spine is involved in about 50% cases of skeletal tuberculosis. The diagnosis of Spine TB in the developing world until recently has been carried out by clinical presentation and neuro imaging modalities like X-ray/CT/MRI. Until the molecular era, the diagnostic tests at laboratories had mostly remained less contributory with low reliability and accuracy. The objective of the study was to review the spinal cases of TB and present an overview of the different methods of microbiological diagnosis in patients with Spine TB at our center. Methodology: Retrospective study (April 2016 – April 2019) of all consecutive patients suspected with pyogenic or Spine TB was undertaken with relevant clinical details. With the radiological screen the probable TB patients were sampled (tissue, pus, abscess fluids and exudates) and were processed for ZN stain, Culture (conventional), Xpert RIF/MTB assay (at reference lab) and Histopathology. Anti-Tubercular Therapy (ATT) was administered to all definitive cases with or without surgery. Results: A total of 26 patients of Definite TB were identified out of 42 suspected. The mean age was47 years (14-78 range). Fever (n=17) and pain (n=18) were most common symptoms reported by over 80% of the patients. The twenty-six patients characteristically had positive radiological changes in MRI. Lumbar (n=6) and thoracic (n=6) vertebrae were equally involved and over 50% (n=14) had two or more vertebral involvement. All 26 spine samples were negative for Acid Fast Bacilli (AFB) by ZN staining. Individually, the positive detection rate by Xpert MTB/RIF was 88% (n=23), by HPE was 65% (n=17) and by culture was 42% (n= 11) respectively. Xpert MTB/RIF was 82.3% sensitive and 64% specific when compared with Histopathological Evidence (HPE) alone and the sensitivity and specificity rose up 81% on comparing with cross HPE and or culture. Conclusion: Improved case detection of Spine TB was noted by using Xpert MTB/RIF assay at our center. We recommend Xpert MTB/RIF molecular test as the first-line investigation at laboratories for all the suspected cases of Spine TB and for confirmation when the clinical and MRI findings are inconclusive or unavailable. Staining and culture have proved less contributory. Age-old Histopathological evidence may no longer be viewed as a reference standard and needs more evaluation. Small and medium sized hospitals may gradually scale-down the Spine TB processing by AFB stain, and consider establishing on-site molecular infrastructure.

Morphological patterns of FNAC of lymph nodes

Introduction: Fine needle aspiration cytology is fast becoming preoperative method of choice for diagnosis and management of various lumps and lesions since few decades. It helps clinician to decide mode of treatment in most cases in both non-neoplastic and neoplastic disorders. The aim of our study was to assess utility of FNAC in the diagnosis and management of lymph node disorders and distribution of these lesions according to different lymph node groups and age and sex distribution of these lesions. Materials and Methods: The present study was done during the period between December 2015 and May 2017 in the department of pathology (central clinical laboratory), Koppal Institute of medical sciences, Koppal. 10ml syringe and 23/24 gauge needles were used for the procedure. Material obtained was expressed on slide and smears were made by standard smearing technique. Both wet and air dried smears were made. Wet smears were stained with Haematoxylin and Eosin stain and dry smears with Lieshman stain and Giemsa stain. Ziehl-Neelson staining for acid fast bacilli was done wherever required. Results: We assessed 204 cases of lymphadenopathy cases. We got satisfactory aspirate in most (97.1%) cases. Cervical group of lymph nodes were most commonly (82%) involved. Granulomatous lesions were most common in young adults and reactive nonspecific lesions were most common in paediatric group. Metastatic carcinomas were most common type after 50yrs age group. Conclusion: Fine needle aspiration is simple, rapid and cost effective method to know the cause of lymphadenopathy. It significantly reduced unnecessary surgical biopsy for diagnosis of lymphadenopathies in our case. Keywords: FNAC, Lymph node, Morphology, Lymphadenopathy.

Microbiological profile and antibiotic sensitivity pattern in sputum cultures-A retrospective study

Introduction: Respiratory tract infections (RTI) are one of the most common cause of infections and are responsible for loss of working hours in affected individuals. Many newer antibiotics have been introduced to treat these infections whose sensitivity pattern is still not clearly understood due to paucity of published data in this regard.Several studies have been published in different parts of the world but still there are limited data from Indian subcontinent. The present retrospective study was carried out in microbiology department of our diagnostic centre with the aim of analyzing the various causative bacteria of CAP and to study their antibiotic sensitivity pattern. Materials and Methods: The present retrospective study of sputum cultures was carried out between July to September 2017 in the microbiology department of our diagnostic centre. A total of 100 sputum samples collected from patients of all ages and both sexes were included in the study. Sputum samples were collected in wide mouth, sterile containers by standard protocols. Gram’s staining and Zheil Neelsen staining for acid fast bacilli was done after inoculating the specimen on Blood and MacConkey Agar plates. Results: There were 68 males and 32 females with a male to female ratio of 2.1:1. Maximum 23% patients were in 61-70 years age group followed by 15% each in 41-50 and 51-60 years age group. 3% patients were above 80 years of age. Normal bacterial flora was grown in 71% cases. Growth of pathogenic bacteria was observed in 29% cases. Klebsiella pneumoniae was the most commonly isolated micro-organism accounting for 13% cases. Staphylococcus aureus was isolated in 6% cases followed by Pseudomonas aeruginosa in 3% and 2% each of Enterococcus, E.coli and Candida species. Conclusion: The role of sputum culture has for long been debatable and is limited by the fact that it is difficult to obtain a deep cough specimen in paediatric and geriatric patients .However, epidemiological value of sputum

Tuberculosis-Infected Giant Bulla Treated by Percutaneous Drainage Followed by Obliteration of the Pulmonary Cavity Using Talc

Tuberculosis (TB)-infected giant bullae are rare. A 55-year-old man was referred when an infected bulla did not respond to empirical treatment. Computed tomography showed a giant bulla in the right upper lobe with an air-fluid level and surrounding infiltrate. Sputum culture, acid-fast bacilli (AFB) stain, and polymerase chain reaction (PCR) for TB were negative. Percutaneous drainage of the bullous fluid was performed. AFB stain and PCR were positive in the drained fluid. The patient was given anti-TB drugs and later underwent obliteration of the pulmonary cavity using talc. To summarize, we report a patient with a TB-infected giant bulla that was treated successfully with anti-TB drugs and obliteration of the pulmonary cavity using talc.

The association between osteopontin and tuberculosis: A systematic review and meta-analysis.

We examined the data reported in the studies for comparison of osteopontin (OPN) levels in tuberculosis and healthy participants, and to discuss whether OPN could be extended to disease diagnosis, severity assessment and therapeutic effect monitering. A systematic literature search was conducted in PubMed, EMBASE, Scopus, the Cochrane Library, Web of Science, the China National Knowledge Infrastructure (CNKI) and WanFang databases. The pooled risk estimates were shown in standardized mean difference (SMD) with 95% confidence interval (CI) for OPN levels. The random effect model was used according to the test of heterogeneity among studies. Subgroup analyses and meta-regression models were performed to identify the possible sources of heterogeneity. 17 retrospective studies with 933 tuberculosis participants and 786 healthy controls were finally included in this article. In the primary meta-analysis, higher serum/plasma OPN levels were found in tuberculosis patients (SMD = 2.58, 95%CI = 2.09~3.08, P<0.001). Besides, pooled results from positive acid-fast bacilli (AFB) staining and imaging-severe tuberculosis group demonstrated higher OPN concentrations (SMD = 0.90, 95%CI = 0.58~1.21, P<0.001; SMD = 1.11, 95%CI = 0.90~1.33, P<0.001; respectively), and OPN levels decreased after two months of standard anti-tuberculosis therapy (SMD = 2.10, 95%CI = 1.36~2.85, P<0.001). Elevated serum/plasma OPN levels may be associated with an increased risk of tuberculosis, while further well-designed studies are needed. Moreover, OPN could be considered as a potential biomarker for tuberculosis surveillance and severity assessment.

Whipple\u2019s disease scleral nodules: a novel presentation in 2 consecutive patients

BackgroundWhipple’s disease (WD) is a rare, chronic, infection caused by gram-positive filamentous aerobic actinobacterium Tropheryma whipplei occurs classically in the gastrointestinal tract and shows histopathologically foamy macrophages with typical numerous PAS-positive, non-acid fast particles. Ocular WD in the form of uveitis may occur in the absence of systemic disease but has not been reported to present with scleral manifestation. We describe for the first time to the best of our knowledge 2 cases of scleral nodules with typical histopathological morphology of WD and without systemic involvement.Case presentationThe first was a 53-year old diabetic male farmer who presented with 2 nontender right eye scleral nodules for 3 months, had a negative systemic workup, and surgical excision showed Periodic acid Schiff (PAS)-positive eosinophilic structures inside macrophages. Grocott’s methenamine silver (GMS) stain and acid-fast bacilli (AFB) stain of the tissue itself were negative. The second case was a 60-year old male who presented with an asymptomatic superior scleral nodule for 4 months, which showed similar appearance and negative GMS and AFB stains.ConclusionWD should be included in the differential diagnosis of scleral nodules even in the absence of systemic symptoms. Surgical excision without systemic treatment resulted in successful outcome without recurrence.

A Prospective Study for comparison of diagnostic utility of Gene XPERT MTB/RIF Assay, adenosine deaminase and cytology in Tuberculous Pleural Effusion

Introduction: Tubercular pleural effusion is the second most common extrapulmonary form of tuberculosis in India. It poses several health challenges in a developing country like India which has limited resources, for developing appropriate methods to diagnose. Aim: The objective of the study was to determine the role of cartridge-based nucleic acid amplification test (CBNAAT) in the diagnosis of tubercular pleural effusion (TPE) and compare it with the diagnostic utility of Adenosine Deaminase (ADA) and lymphocyte counts in pleural fluid. Methods: Total 100 patients were selected from July 2019 to December 2019. Pleural fluid was collected in sterile container. Gene/xpert, Adenosine deaminase, total leukocytes count and lymphocytes percentage were evaluated. Results: It was found that high leukocytes count and lymphocyte predominance was present in >80% of the patient. Mean ADA was 68.7 U/L 13.2 (SD). CBNAAT was positive in 30 patients. Acid fast bacilli stain was negative in the entire patient. Conclusion: The usefulness of Xpert MTB/RIF to diagnose pleural TB is limited by its poor sensitivity. A high ADA40 U/L in combination with Light’s criteria to define exudates, with lymphocyte predominance is sufficient evidence to diagnose tuberculous pleural effusion and initiate anti-tubercular therapy, thereby deferring the need to perform an invasive pleural biopsy. Keywords: Tuberculosis, Xpert MTB/RIF, Adenosine deaminase, Lymphocytes, Pleural fluid.

Bone marrow involvement: Atypical presentation of early-onset childhood sarcoidosis.

Childhood sarcoidosis is a chronic multisystemic, non-caseating granulomatous disease of unknown etiology. Early-onset disease classically presents with a triad of skin rash, uveitis, and arthritis, but bone marrow involvement is rare. We report a 9-1/2-year old Indian female child who presented with bleeding manifestation, skin rash, uveitis, and arthritis. Bone marrow biopsy showed multiple non-necrotizing granulomas comprising epithelioid cells, mature lymphocytes, and multinucleated giant cells with few eosinophils in the background, with negative staining for acid-fast bacilli or fungi. She was treated successfully with oral prednisolone. This is the first report of an early-onset childhood sarcoidosis with bone marrow involvement from India.

Tuberculosis Coexistence in Pediatric Hodgkin's Lymphoma: A Tropical Country Experience.

Introduction Hodgkin’s lymphoma (HL), being one of the common cancers among children, may occasionally masquerade as an infectious illness. Similarly, an underlying infection like tuberculosis (TB) may be missed in cases of HL because of similarity in clinical and radiological features. Here, we present our data of association of HL with histopathologically proven TB lymph node, their clinical presentation, treatment details, and outcome. Materials and Methods A retrospective review of all the cases of HL diagnosed between January 2007 and December 2016 was done. The cases which had an association of TB, based on the histopathology, were reviewed separately. Results A total of 262 children with HL were treated at our institute from January 2007 to December 2016. Of these cases, 42 children had received empirical antitubercular therapy (ATT) (due to suspicion of TB) before presenting to us, and only five cases had histopathologically proven TB lymph node. Ziehl–Neelsen (ZN) stain for acid-fast bacilli (AFB) was positive in the biopsy specimen of all the five cases, proving TB lymph node coexistence with HL. They were treated with six-drug ATT as per the Revised National Tuberculosis Control Program (RNTCP) guidelines along with chemotherapy with adriamycin, bleomycin, vinblastine, and dacarbazine regimen. All the five patients are healthy and disease free until their last follow-up. Conclusion A high-end suspicion for concomitant TB and HL is needed, especially in our country where TB is still rampant. Biopsy with immunohistochemistry and demonstration of AFB can enable a definite diagnosis of both the entities.

IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME: THE RISK OF ADALIMUMAB CESSATION IN TB TREATMENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pharmacologic inhibition of tumor necrosis factor-alpha (TNF-a) is a mainstay in the treatment of autoimmune disease. Guidelines recommend starting TNF-a antagonists after a negative screening test result for tuberculosis (TB) infection is confirmed, due to the increased risk of reactivation TB in an immunosuppressed host. We present the case of a patient on adalimumab who developed extrapulmonary TB and immune reconstitution inflammatory syndrome (IRIS) after starting TB treatment. CASE PRESENTATION: A 67-year-old woman with a history of psoriasis, on adalimumab therapy for one year, presented to our hospital with chills, fevers, and a non-productive cough for one month. She denied hemoptysis and night sweats but acknowledged a 30-pound weight loss over the prior two months. On presentation, she was afebrile, normotensive, saturating 95% on room air. Chest X-ray was notable for bilateral miliary nodules and CT scan showed extensive miliary lesions in her lungs and spleen. She was admitted to the medicine service and put on airborne isolation. Interferon-gamma release assay (IGRA) and testing for HIV were negative. Induced sputum was collected, acid-fast bacilli (AFBs) were noted on smear microscopy, and PCR-based assay confirmed presence of Mycobacterium tuberculosis (MTb). Mycobacterial blood cultures were sent. Anti-TB therapy was started, and she was discharged to home isolation. One month later, she re-presented with dyspnea on exertion. Repeat CT scan showed a large left pleural effusion and a small pericardial effusion. AFB stain and culture of pleural fluid was negative. Repeat sputum AFB stain and culture was also negative, and MTb was not detected by PCR. Prior blood cultures resulted as positive for MTb. She was discharged home after clinical improvement with resolution of her dyspnea. DISCUSSION: TB is one of the top 10 causes of death worldwide. 20% of patients with active TB can have false negative IGRAs, especially if immunosuppressed. IRIS, most often seen in HIV+ patients, can develop with TB treatment initiation. Paradoxical worsening of clinical status occurs as the depressed immune system begins to recover. Patients on TNF-a antagonists are also at risk for IRIS, more commonly in lung and extrapulmonary TB. Thus, the combination of TNF-a antagonist discontinuation and TB treatment placed our patient at heightened risk for IRIS. CONCLUSIONS: This case demonstrates TB dissemination in an immunocompromised patient on a TNF-a antagonist who developed IRIS with adalimumab cessation and TB treatment initiation. Among commonly used biologic agents, adalimumab has been associated with a greater risk for both TB infection and IRIS development after starting TB treatment. Clinicians should be aware of this risk and monitor patients accordingly once treatment is initiated. Reference #1: World Health Organization. Global tuberculosis report 2019. Geneva, Switzerland: World Health Organization; 2019. Reference #2: Dobler, C. C. (2016). Biologic agents and tuberculosis. Microbiology Spectrum, Dec; 4(6). Reference #3: Cheng, V. C. et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur. J. Clin. Microbiol. Infect. Dis. 21, 803–809 (2002). DISCLOSURES: No relevant relationships by Mark Adelman, source=Web Response No relevant relationships by Vickie Kassapidis, source=Web Response

Fine-needle aspiration cytology of Bacille Calmette-Guerin adenitis: A perplexing distinct clinical entity.

Bacille Calmette-Guerin (BCG) adenitis is a common complication of post-BCG vaccination. Awareness of this lesser known entity in fine-needle aspiration (FNA) is important to prevent misdiagnosis. This study described the clinical presentation, cytomorphological features and disease pattern in patients with BCG adenitis. We analyzed a series of 15 patients with BCG adenitis seen from July 2017 to July 2019. The detailed clinical and cytomorphology of these cases were studied. Age of presentation ranged from 3 to 12 months. Male to female ratio was 2.75:1. A total of four children were diagnosed with primary immunodeficiency. Three children had acyanotic heart disease. Most of the children had left axillary lymph node enlargement. Cytomorphology showed the presence of polymorphs (66.7%), histiocytic aggregates (80%) and reactive lymphoid population (60%). Epithelioid granulomas (26.7%) and giant cells (6.7%) were present. The necrotic background was present in all but one case. Ziehl-Neelsen stain for acid-fast bacilli was positive in all but two cases. A high index of clinical suspicion for BCG lymphadenitis should be kept in mind for patients who are recently vaccinated. FNA cytology, combined with clinical correlation, is useful for diagnosis and management.

Clinical Performance of Mycobacterial Immunohistochemistry in Anatomic Pathology Specimens.

Diagnosis of mycobacterial infections poses significant challenges in anatomic pathology. We recently described the use of antimycobacteria immunohistochemistry (IHC) as a sensitive, efficient diagnostic tool and now report the clinical performance of this assay among general, noninfectious disease pathology-trained anatomic pathologists. Over a 2-year period, all cases were retrospectively identified in which mycobacterial IHC was performed during routine diagnostic workup. From October 2017 to September 2019, mycobacterial IHC was evaluated for 267 cases, resulting in 58 (22%) positive stains. Compared with culture and molecular results, the sensitivity and specificity of IHC were 52% and 80%, respectively. IHC performed significantly better than acid-fast bacilli (AFB) staining (Ziehl-Neelsen) (P < .0001; sensitivity 21%, specificity 92%) but similarly to modified AFB staining (mAFB; Fite-Faraco) (P = .9; sensitivity 61%, specificity 84%). In cases with discordant IHC and mAFB staining, there were no differences in rates of culture or polymerase chain reaction-confirmed positivity. Mycobacterial IHC was well adopted with superior clinical performance to AFB and comparable performance to mAFB. These results support the use of IHC as an adjunctive tool in the diagnosis of mycobacterial infections and suggests its potential role as a rapid screening test for molecular testing.

Pott’s disease with extensive bilateral psoas abscesses in a Nigerian woman: an unusual case

Bilateral psoas abscesses are uncommon in Pott's disease. We describe a 28-year-old Nigerian woman with a 2-year history of constitutional symptoms and a 1-year history of bilateral paravertebral masses. She had received anti-tuberculosis (TB) treatment in an interrupted manner. A computed tomography (CT) scan revealed T10-T12 spondylitis, wedge collapse and extensive bilateral psoas abscesses. Histology of the abscess wall was definitively diagnosed as soft tissue TB, and special staining for acid-fast bacilli was positive. She was successfully treated with anti-TB therapy and ultrasound-guided surgical drainage of 6 L of abscess fluid. Complicated cases of Pott's disease may require multi-disciplinary interventions for optimal outcome.