Tuberculosis Polymerase Chain Reaction Research Articles

Role of Laparoscopy in the Diagnosis of Genital TB in Infertile Females in the Era of Molecular Tests

To assess diagnostic value of polymerase chain reaction (PCR) in endometrial aspirates (EAs) in comparison with conventional tests for diagnosis of female genital tuberculosis (TB) and to find agreement between EA PCR done for endometrial TB and laparoscopic findings of pelvic TB in women with unexplained infertility. Prospective observational cohort study. Tertiary care hospital. A total of 732 infertile females screened and 385 enrolled to undergo procedure to obtain EAs. EAs were tested by conventional tests (histopathology, acid-fast bacilli, Lowenstein-Jensen staining, liquid culture) and PCR for Mycobacterium tuberculosis. Patients with positive conventional tests were started on antitubercular treatment (ATT). Patients with negative conventional tests underwent laparohysteroscopy irrespective of PCR results to assess changes of tubercular infection in the pelvis. Peritoneal washings were also sent for liquid culture and PCR for TB, and suspicious lesions were biopsied at laparohysteroscopy. Findings at laparoscopy upgraded the diagnosis in these women. EAPCR results were analyzed to find agreement with the findings at laparoscopy. Conventional tests were positive in 8 of 385 (2%) patients. PCR was positive in 58.1% (n = 224) of endometrial samples, with sensitivity of 62.5% (95% confidence interval [CI], 24.49-91.48), specificity of 41.91% (95% CI, 36.88-47.07), positive predictive value of 2.23% (95% CI, 1.31-3.78), negative predictive value of 98.14% (95% CI, 95.53-99.24), and a diagnostic accuracy of 42.34% (95% CI, 37.35-47.45) with conventional tests. A total of 265 patients underwent laparoscopy, of whom 165 were PCR positive and 100 were PCR negative. Laparoscopic findings suggestive of TB were found in 39.3% of patients who were PCR positive and 9% of patients who were PCR negative. Kappa agreement was 0.25, suggesting fair agreement between PCR and laparoscopy. PCR as a stand-alone diagnostic test for endometrial TB is not justified to confirm diagnosis and initiate ATT. The addition of laparohysteroscopy improves diagnostic yield for genital TB. Referring patients with a suspicion of female genital TB to tertiary care for 1-time laparoscopy is better than initiating ATT solely on the basis of PCR results.

Infective Spondylodiscitis: A Comparative Analysis of Magnetic Resonance Imaging Findings with Etiology

Introduction: Spondylodiscitis in the Indian population is mostly tubercular and pyogenic. Gadolinium-enhanced magnetic resonance imaging (MRI) is currently most suited for radiological evaluation of the spine in patients with suspected vertebral osteomyelitis. Histology is highly sensitive in detecting the presence or absence of spondylodiscitis but fails in addressing the causative organism. The identification of organism is mainly through microbiological methods such as culture and tuberculosis (TB) polymerase chain reaction. The use of both pathologic examination and culture of the specimen along with imaging findings is paramount in establishing the diagnosis. Methodology: We performed prospective analysis of MR images obtained from patients with suspected spondylodiscitis who have undergone spinal biopsy for confirmation of diagnosis. T2- and T1-weighted images with and without contrast enhancement were subjected to assessment in coronal, axial, and sagittal planes. The sample obtained from biopsy was sent for microbiological and pathological analyses. Based on the final results, MRI findings and histopathological findings were correlated. Results: Out of 45 studied cases, 35 were confirmed to be infective spondylodiscitis, 5 were degenerative disc disease, 1 lymphoma, and 4 metastatic disease of the spine. Out of 35 confirmed cases, 17 (48.6%) were caused by TB and 18 (51.4%) by pyogenic organisms. The sensitivity and specificity of MRI for correctly diagnosing tuberculous spondylodiscitis were 70.6% and 77.8%, respectively, whereas the sensitivity and specificity of MRI for correctly diagnosing pyogenic spondylodiscitis were 44.4% and 85.2%, respectively. The statistically significant features specific for tuberculous spondylodiscitis for MRI were thin and smooth abscess wall, involvement of >2 vertebral bodies (52.9% in tuberculous vs. 44.4% in pyogenic), skip lesions (23.5% in tuberculous vs. 0% in pyogenic), and cold abscess (17.6% in tuberculous vs. 0% in pyogenic). Conclusion: It has been found that MRI is highly sensitive in detecting infective spondylodiscitis and has been widely accepted as the imaging modality of choice for the same. Although many imaging features have been identified to differentiate pyogenic and tuberculous etiologies, due to overlapping of these features, the sensitivity of MRI to conclusively diagnose the etiology needs further studies.

A Study on Diagnostic Evaluation of Two Different Rapid DNA Polymerase Chain Reaction Techniques Namely Gene Xpert Mycobacterium Tuberculosis/Rifampin (MTB/RIF) and Mycoreal Polymerase Chain Reaction in the Diagnosis of Endometrial Tuberculosis Considering Culture as Gold Standard.

Context:The study involves the evaluation of two polymerase chain reaction (PCR) techniques one of which has been endorsed by the WHO for their diagnostic capabilities.Aims:The aim of this study is to evaluate the diagnostic accuracy of GeneXpert mycobacterium tuberculosis/Rifampin (MTB/RIF) and mycoreal PCR techniques in the diagnosis of endometrial tuberculosis (TB) considering culture as the gold standard.Settings and Design:A retrospective study conducted at Gunasheela surgical and maternity hospital. Patients who attended the outpatient department between January 2013 and August 2016, satisfying the eligibility criteria, were included in the study.Methodology:Women included in the study underwent endometrial pipelle sampling premenstrually after ruling out pregnancy in that cycle. Endometrial samples were tested for TB by Mycoreal PCR, Gene Xpert and BACTEC culture.Statistical Analysis Used:Statistical analysis was done using the R software version 3.6.1. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of test were calculated.Results:A total of 3229 samples were analyzed, of which 1754 were evaluated by Mycoreal TB PCR and 1475 were evaluated by Gene Xpert MTB/RIF assay. The sensitivity of mycoreal TB PCR technique was 34.78%, specificity was 99.08%, PPV was 33.33%, NPV was 99.13%, and accuracy was 98.23%. The sensitivity of GeneXpert MTB/RIF technique was 6.90%, specificity was 99.79%, PPV was 40.00%, NPV was 98.16%, and accuracy was 97.97%.Conclusions:MYCOREAL seemed to be more sensitive than Gene Xpert (MTB/RIF) considering culture as the gold standard in the diagnosis of endometrial TB.

A case of autoimmune hepatitis with tuberculosis caused by prednisolone from undeterminable enzyme-linked immunospot assay

An 88-year-old woman was referred to our hospital for autoimmune hepatitis in 2016. She was treated with prednisolone. In 2018, she was rehospitalized owing to hepatitis relapse. Steroid pulse therapy was performed. She exhibited good recovery of hepatitis, but was transferred to a convalescent ward in a general hospital because of decreased activity of daily life. After a month later, she had high fever and cough. She was diagnosed as having tuberculosis because of positive Mycobacterium tuberculosis polymerase chain reaction. At our first medical examination in 2016, we performed enzyme-linked immunospot and the result was undeterminable. There is an increase in the opportunities to use immunosuppressant and biologic agents for elderly patients. Our case report should contribute to future medical care for elderly patients who are at risk of latent tuberculosis infection.

Cystic Neutrophilic Granulomatous Mastitis: A Clinicopathological Study With 16s rRNA Sequencing for the Detection of Corynebacteria in Formalin-Fixed Paraffin-Embedded Tissue.

Cystic neutrophilic granulomatous mastitis (CNGM) is a histologically characterized variant of granulomatous lobular mastitis that is associated with lipophilic Corynebacterium species. It remains a largely underrecognized entity in India. Our aim was to study CNGM in the Asian Indian population and explore if 16s rRNA sequencing could be used on formalin-fixed paraffin-embedded (FFPE) tissue to identify the causative organism. We studied 24 cases with histological features of CNGM with hematoxylin and eosin, Gram, Ziehl-Neelsen, and Periodic acid-Schiff stains. Tuberculosis-polymerase chain reaction and 16s rRNA gene sequencing on DNA extracted from FFPE was attempted (N = 23). Gram-positive bacilli were seen in 20/24 cases. Routine culture with prolonged incubation yielded Corynebacterium species in 8 cases; 7 of these cases were evaluated by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for species identification. C matruchotti was identified in one case by BD Phoenix. MALDI-TOF MS identified the remaining 7 cases as C kroppenstedtii (N = 4) and C tuberculostearicum (N = 2), with no identification in one. Corynebacteria were identified by 16s rRNA sequencing on DNA extracted from FFPE in 12/23 cases using a primer targeting the V5-V6 region that was found to be more conserved in Corynebacterium species. All cases were negative for the diagnosis of tuberculosis. CNGM can be identified by routine stains. Culture using routine media with prolonged incubation is often adequate to isolate the organism. 16s rRNA sequencing on DNA extracted from FFPE tissue can help make an etiological diagnosis in some cases where only paraffin blocks are available.

Crohn’s Disease With Progressive Renal Impairment

Question: The patient was diagnosed with Crohn’s disease of the colon at the age of 39 years and had a chronic active disease course with rapid response to infliximab. Biopsies from the colon showed extensive inflammation with granulomas. The patient had secondary loss of response to infliximab due to formation of antidrug antibodies (ADA). She did not tolerate azathioprine or 6-mercaptopurine owing to pancreatitis and had severe hair loss when treated with methotrexate. Owing to previous good response to anti-TNF treatment, the patient was given adalimumab and subsequently certolizumab pegol, both with good initial responses, but unfortunately with subsequent loss of response caused by ADA formation. The patient also had significant extraintestinal manifestations (iridocyclitis, sacroiliitis, and peripheral arthropathies) that tended to respond to biologics. At the age of 45, the patient was switched to golimumab with good symptomatic control of the disease and extraintestinal manifestations, but fluctuating C-reactive protein levels between 0.5 and 2.5 mg/dL. At the age of 48, her estimated glomerular filtration rate decreased to <60 mL/min with more rapid decreases in periods with elevated inflammatory markers (Figure A). Urinalysis revealed proteinuria and no occult blood. Urinary excretion of protein was between 0.2 and 0.6 g/d. An initial ultrasound examination of the kidneys and urinary tracts was normal and a Tc-99-MAG3 renography showed bilateral decreased kidney function. A kidney biopsy was performed (Figure B). What is the diagnosis and treatment? Look on page 59 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. The kidney biopsy showed normal glomeruli and well-preserved tubuli without atrophy. However, granulomatous inflammation was found in the interstitial tissue. No crystal casts, amyloid deposits, or vasculitis were found. The diagnosis is granulomatous interstitial nephritis. The patient was in her childhood treated for suspected tuberculosis, but polymerase chain reaction for tuberculosis was negative, as was immunohistochemistry for Epstein–Barr virus and cytomegalovirus. There was no sign of fungal infection. Other etiologies associated with granulomatous disease, especially sarcoidosis, were also ruled out. Granulomatous interstitial nephritis is generally a rare condition and is typically secondary to exposure to drugs including antibiotics and nonsteroidal anti-inflammatory drugs.1Shah S. Carter-Monroe N. Atta M.G. Granulomatous interstitial nephritis.Clin Kidney J. 2015; 8: 516-523Crossref PubMed Scopus (51) Google Scholar The patient had been sporadically exposed to ciprofloxacin. Both adalimumab and infliximab (but not golimumab or certolizumab) have been associated with autoimmune nephritis, but not specifically to granulomatous interstitial nephritis.2Piga M. Chessa E. Ibba V. et al.Biologics-induced autoimmune renal disorders in chronic inflammatory rheumatic diseases: systematic literature review and analysis of a monocentric cohort.Autoimmun Rev. 2014; 13: 873-879Crossref PubMed Scopus (61) Google Scholar In fact, anti-tumor necrosis factor agents have been used to alleviate granulomatous interstitial nephritis in patients with Crohn’s disease.3Timmermans S.A. Christiaans M.H. Abdul-Hamid M.A. et al.Granulomatous interstitial nephritis and Crohn's disease.Clin Kidney J. 2016; 9: 556-559Crossref PubMed Scopus (9) Google Scholar First-line treatment is glucocorticoids, and the patient was kept on golimumab and had 50 mg prednisolone. The treatment was ceased after 4 weeks owing to intolerance to side effects, and lack of improvements on estimated glomerular filtration rate levels. Ileocolonoscopy and gastroscopy were without signs of active inflammation. Renal function plateaued at around 37 mL/min for some months, but a subsequent decrease to <30 mL/min required reevaluation of the condition. Owing to the patient’s tendency to form granulomas, we considered the granulomatous interstitial nephritis to be an extraintestinal manifestation-like condition to Crohn’s disease. Alternatively, the granulomatous inflammation could be a direct drug reaction to golimumab exposure. Despite the lack of activity in the intestine, a switch of treatment was considered in the face of decreasing kidney function and ongoing systemic inflammation. Because a systemic effect of the new drug was considered important and the inflammation was not driven by intestinal activity, ustekinumab was preferred over vedolizumab. The change from golimumab to ustekinumab resulted in remarkably better control of systemic inflammation with continued undetectable C-reactive protein for the first time in the disease course and was accompanied by an almost complete regain of renal function within 8 months (Figure C). Interestingly, a correlation was found between C-reactive protein levels and the speed of renal function loss (ie, the derived function of estimated glomerular filtration rate; R2 = 0.42; P < .02), suggesting that the granulomatous inflammation in the kidneys were the main driver of the systemic inflammatory response during the observed period.

Diagnosing Kikuchi's disease on fine needle aspiration biopsy

To investigate the diagnostic utility of fine needle aspiration (FNA) smear, cell block (CB), flow cytometry (FC) and tuberculosis polymerase chain reaction (Tb-PCR) analysis for Kikuchi's disease (KD). A total of 173 FNA biopsy samples were collected using a Youyi aspirator. KD was diagnosed by FNA smear, with or without, CB, FC and Tb-PCR. Out of 173 patients, 131 (75.7%) were female and 126 (72.8%) aged 21-40years. Of these, 171 patients (98.8%) presented with painful enlarged cervical lymph nodes. All cytological samples identified intracellular apoptotic debris embedded in the cytoplasm of crescentic and phagocytic macrophages. In 24 cell-blocks (CBs), clusters of CD123 positive plasmacytoid monocytes were observed in KD. FC and CBs showed non-specific lymphoid hyperplasia in nine cases with suspicious lymphoma. Tb-PCR was negative in five cases with suspicion of tuberculosis. In summary, FNA biopsy is a fast, reliable, and relatively inexpensive diagnosis tool for KD. CB preparation is an important adjunct method for the diagnosis of KD.

Tuberculous spondylitis after percutaneous vertebroplasty: A case series of 9 cases

BackgroundPercutaneous vertebroplasty has become the treatment of choice for compression fractures. Although the incidence is low, infection after vertebroplasty is a serious complication. The pathogens most often responsible for infection are bacteria. Meanwhile, mycobacterium tuberculosis-induced infection is extremely rare. In this study, we reported our treatment experience with 9 cases of tuberculous spondylitis after vertebroplasty. MethodsBetween January 2001 and December 2015, 5749 patients underwent vertebroplasty or kyphoplasty in our department. Nine cases developed tuberculous spondylitis after vertebroplasty (0.16%). Data on clinical history, laboratory examinations, image, treatment and outcomes were examined. ResultsOne male and 8 female patients with a mean age of 75.1 years developed tuberculous spondylitis after vertebroplasty. 5 patients had a history of pulmonary tuberculosis (TB). Revision surgeries were performed from 5 days to 1124 days after vertebroplasty. Seven patients underwent anterior debridement and fusion with or without posterior instrumentation, and 2 cases received posterior decompression and instrumentation only. After operation, the diagnosis of tuberculous spondylitis was confirmed by TB polymerase chain reaction (TB-PCR) or mycobacteria culture. Mean follow-up period after revision surgery was 36.8 months. At the end of follow-up, 1 patient with paraplegia had passed away, 2 needed a wheel chair, 4 required a walker and 2 were able to walk unassisted. ConclusionsVertebroplasty is a minimally invasive procedure but still retains some possibility of complications, including TB infection. Patients with a history of pulmonary TB or any elevation of infection parameters should be reviewed carefully to avoid infective complications.

Diagnosis of mediastinal tuberculous lymphadenitis using endobronchial ultrasound-guided transbronchial needle aspiration with rinse fluid polymerase chain reaction

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been gradually introduced in the diagnosis of mediastinal tuberculous (TB) lymphadenitis. The purposes of this study were to evaluate the utility of polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) using EBUS-TBNA rinse fluid and to explore the factors that influence the accuracy of EBUS-TBNA. A retrospective study with prospective data collection was carried out with patients with unselected mediastinal lymphadenopathy who underwent EBUS-TBNA and a TB-PCR study from April 2010 to July 2017. Patients without TB were excluded. The diagnostic accuracy rate for each diagnostic modality (pathology, smear, culture, and TB-PCR) was calculated respectively. The characteristics of the lymph node (LN) and the pathologic findings were analyzed as possible impact factors. 240 consecutive patients who received EBUS-TBNA were enrolled, and in the end, 21 patients with a diagnosis of TB lymphadenitis were included. When combined with histologic results and traditional microbiologic studies, the diagnostic accuracy of EBUS-TBNA was 57.1%. If TB-PCR was also utilized, the diagnostic accuracy would significantly increase to 71.4% (p<0.001). Univariate and multivariate regression analysis revealed that pathology showing necrosis had a higher positive microbiologic result when using EBUS-TBNA rinse fluid. EBUS-TBNA is a valuable tool for diagnosis of mediastinal TB lymphadenitis. Using TB-PCR assay and targeting LNs with a necrotic component would improve the diagnostic performance of EBUS-TBNA.

Critical role of molecular test in early diagnosis of gastric tuberculosis: a rare case report and review of literature

BackgroudEarly diagnosis of gastric tuberculosis is often challenging because the disease is very rare and its clinical manifestation is nonspecific and misleading. To raise the awareness and emphasize early diagnosis of gastric tuberculosis, we present a case of gastric tuberculosis secondary to pleural and pulmonary tuberculosis.Case presentationA 26-year-old woman complained gastric pain for 1 month but showed no other symptoms, who had no previous exposure to tuberculosis.Gastric stromal tumor was originally suspected. However, the pathology of her gastroscopic biopsy of the gastric lesion showed granulomatous lesions and caseating necrosis. Gene sequencing of the biopsy specimen identified deoxyribonucleic acid fragment of Mycobacterium tuberculosis. Chest computed tomography scan revealed nodular shadows in the lesser curvature soft tissue of the stomach, patchy densities and calcified nodular shadows in the upper right lung, bilateral pleural thickening, and calcified pleural nodules. Thus, the diagnosis was gastric tuberculosis secondary to pulmonary and pleural tuberculosis. The patient was hospitalized and treated with the antituberculosis therapy for 1 week. After discharged from the hospital, the patient continued routine antituberculosis therapy for 18 months and was follow-up was normal.Literature search found 22 cases of gastric tuberculosis reported from 2000 to 2016. Review of the 22 cases suggested that polymerase chain reaction has been increasingly used in the recent years in addition to the conventional histopathological and bacteriological approaches.ConclusionClinical presentation of gastric tuberculosis is not specific.When granuloma or caseation is detected on biopsy in patients who are suspected of having gastric malignancy or acid peptic diseases, polymerase chain reaction for Mycobacterium tuberculosis could be used as an available and sensitive diagnostic test in addition to pathology, acid-fast bacilli smear staining and culture.

Multifocal Tuberculosis with Prolonged Paradoxical Reaction

This is a case report describing successful treatment of a challenging case of an 18-year old previously healthy high school male student with multifocal tuberculosis involving the spleen and mediastinal and abdominal lymph nodes confirmed by histopathology of splenectomy tissue. The patient initially responded well to antituberculosis therapy with complete resolution of fever and improvement in his general health and weight. However, two months after initiation of anti-tuberculosis therapy, the patient developed paradoxical reaction manifest as recurrence of fever that persisted for five months and was associated with enlargement of lymph nodes. The fever failed to abate with continuation of the same antituberculosis therapy. Despite reassurance that the fever was due to a prolonged paradoxical reaction, a decision was made by the family to seek advice in another hospital where lymphoma was excluded again by histopathological examination of an excisional lymph node biopsy that revealed caseating granulomatous lymphadenitis and negative tuberculosis stain, culture, and polymerase chain reaction. The patient was continued on anti-tuberculosis therapy and treated with corticosteroids that resulted in complete resolution of fever and subsequent full recovery from his tuberculosis.

Actinomycotic osteomyelitis of a long bone in an immunocompetent adult: a case report and literature review

BackgroundActinomycosis is a rare, chronic granulomatous disease caused by Gram-positive anaerobic bacteria that colonize the oral cavity. Cervicofacial actinomycosis is the most frequent clinical presentation of actinomycosis, but hematogenous osteomyelitis at distant sites can occur in rare instance in immunocompromised or pediatric patients, only a few cases have been reported in healthy patients. Here we described a new case of distal femur osteomyelitis caused by Actinomyces in an adult patient who was immunocompetent and had no predisposing factors.Case presentationA woman aged 52 years with no history of trauma presented with severe pain, swelling, and increased local heat in the proximal area of the right knee 3 weeks after she first noticed discomfort. Magnetic resonance imaging showed persistent osteomyelitis of the distal metaphysis and diaphysis of the femur with a multifocal intraosseous abscess pocket. An incision and drainage of the abscess were conducted. The tissue culture, fungus culture, acid fast bacillus (AFB) culture, AFB smear, and tuberculosis polymerase chain reaction test results were negative. A pathologic examination confirmed the presence of actinomycosis. The patient was successfully treated with intravenous penicillin G for 8 weeks followed by oral amoxicillin-clavulanate for 6 weeks with repeated surgical debridement and drainage. After a 5-year follow up, the patient had no signs of recurring infection or complications and she had full range of movement in the affected knee.ConclusionsAlthough rare, actinomycotic osteomyelitis can occur in healthy people. Furthermore, actinomycotic osteomyelitis is easily misdiagnosed as tuberculosis in areas with a high prevalence of tuberculosis. To detect and identify the bacteria accurately, pathologic examination should be performed as well as culture tests, because the probability for culture confirmation of actinomycosis is quite low. The initial treatment is vital to a successful outcome without ostectomy or amputation.

Clinical usefulness of routine AFB culture and MTB PCR of EBUS-TBNA needle rinse fluid.

We evaluated the usefulness of acid-fast bacilli (AFB) culture and Mycobacterium tuberculosis (MTB) polymerase chain reaction (PCR) of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) needle rinse fluid for diagnosing tuberculous lymphadenitis. EBUS-TBNA needle rinse fluid was routinely used for AFB culture and MTB PCR. The patients were categorized according to the pre-procedural diagnosis (Group A, suspected/histology-confirmed lung cancer; Group B, extrapulmonary malignancy; and Group C, other benign diseases). Of the 4672 subjects, 104 (2.2%) were diagnosed with tuberculous lymphadenitis; 1.0%, 4.6% and 12.7% of Group A, B and C, respectively. Tuberculous lymphadenitis was diagnosed in 0.2%, 1.0% and 4.5% Group A, B and C patients, respectively, by histopathology. On addition of AFB culture to histopathology, tuberculous lymphadenitis was diagnosed in 1.0%, 4.4% and 10.3% of Group A, B and C patients, respectively (P < 0.001, P = 0.001 and P = 0.005, respectively). On addition of MTB PCR to histopathology, tuberculous lymphadenitis was diagnosed in 0.4%, 1.9% and 8.8%, respectively (Group C; P = 0.029). Routine AFB culture of needle rinse fluid was useful to increase the diagnostic yield of tuberculous lymphadenitis for all subjects who underwent EBUS-TBNA regardless of pre-procedural diagnosis in an intermediate tuberculosis (TB)-burden country. However, MTB PCR was only useful in subjects with pre-procedural diagnosis of benign pulmonary diseases.

Analysis, comparison, and significance of nested polymerase chain reaction with conventional methods for the diagnosis of pulmonary and extrapulmonary tuberculosis among the rural population of North India

Introduction: Tuberculosis (TB) is one of the most common infectious diseases among the Indian population, especially in rural scenario. It affects young people in majority. Living at slum areas and poverty are predisposing etiological factors. The diagnosis of TB is based on microbiology, cytology, and histopathology. Materials and Methods: The present study was carried out in the Department of Microbiology in collaboration with the Department of Pathology, UPUMS, Saifai, Etawah, UP, India, from January 2015 to June 2016. Samples were collected from suspected tubercular patients. A total of 101 samples were collected including tissue, ascitic fluid, pleural fluid, cerebral fluids, bronchoalveolar lavage, tracheal aspirates, urine, sputum, and pus from clinically suspected cases. Ziehl–Neelsen (ZN) staining, fluorescent staining with auramine phenol, culture on Lowenstein–Jensen (LJ) media, mycobacterial growth indicator tube (MGIT), and Middlebrook media were done. Subsequently, biochemical tests such as niacin detection, catalase test, and nitrate reduction test were done for identification of mycobacteria. Nested polymerase chain reaction (PCR) was performed for the detection of Mycobacteria in clinical samples. Results: Of the 101 suspected tubercular patients, males were more, and the maximum age group involved was 21–40 years. ZN staining was found positive in 16 cases which included ten extrapulmonary and six pulmonary, whereas auramine phenol was found positive in 22 cases which included 14 extrapulmonary and 8 pulmonary. Of 101 patients, 35 (34.6%) were found to be LJ culture positive, whereas 49 (48.5%) were found positive with MGIT culture. PCR for TB was found maximum, which was 76 (75.2%). Conclusion: TB is common among the young group with more predilection among males. Smear- and culture-negative specimens could not rule out TB. Nested PCR proved to be highly sensitive in detecting Mycobacterium tuberculosis DNA. Hence, when TB is suspected, a combination of conventional test and newer rapid techniques such as PCR is always required for the early diagnosis and treatment of TB.

Guidelines versus ground lines: Tuberculosis of the central nervous system.

This questionnaire-based national survey is aimed at understanding the patterns of practice of various aspects of central nervous system (CNS) tuberculosis (TB) among neurologists. Neurology department of a tertiary medical college. A questionnaire was sent through email to all practicing neurologists in India. The responses were analyzed. Inferential statistics. In all, 144 responses were received (out of the 853 questionnaires sent). The major discrepancies were in the primary antitubercular drug regimen (HRZE + HR), duration for tubercular meningitis (TBM) [12 months] and tuberculoma (12-18 months) to develop, follow-up (varied), linezolid use (varied), proportion of drug-resistant cases (<25%), and not taking histological aids (91%). The cerebrospinal fluid (CSF) TB polymerase chain reaction (PCR) utility (75%), not using CSF adenosine deaminase [ADA] (58%), the strategy to stop antitubercular drugs, and the use of steroids (77%) were according to guidelines. The present survey, for the first time, provides ground-level evidence of various aspects of CNS TB as practiced by neurologists in India. The major diversity was observed in therapeutics such as the choice of antitubercular drugs, its duration, linezolid use beyond the recommended duration, and knowledge of drug resistance. The monitoring aspects of CNS TB also showed variations. The investigational aspects of CNS TB such as using TB PCR, not using CSF ADA, and regular neuroimaging revealed a good clinical practice. Other CSF parameters require uniformity. This survey thus helps to identify areas of future work in CNS TB in India.

Retraction Statement

It has been brought to our attention that the paper entitled “Diagnostic efficacy of adenosine deaminase levels in cerebrospinal fluid in patients of tubercular meningitis: A comparison with polymerase chain reaction for Mycobacterium tuberculosis” [Ann of Neurosciences 2010; 17(3): 126–130] written by Chacko F, Modi M, Lal V, Prabhakar S, Rana SV, Arora SK, submitted by the second author has been found to be simultaneously published in another journal with many of the authors being common. (Please also see our ­Expression of Concern published in 2015). The editors have informed the ­Institute of this duplication. Now, the corresponding author has communicated to us and retracted the above-mentioned paper. We apologize to those scientists and committees who might have been influenced by the content and conclusions of the this paper published in Annals of Neurosciences. The Editors

BIOPSY-PROVEN CENTRAL NERVOUS SYSTEM AND PULMONARY SARCOIDOSIS: FIRST REPORTED CASE IN HONG KONG

SESSION TITLE: Pulmonary SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Lung is the commonest organ to be involved by sarcoidosis. Nervous system is involved in around 5% of cases only. [1] Due to rarity, neurosarcoidosis has never been reported in Hong Kong Chinese patients. CASE PRESENTATION: A 34-year-old Chinese clerk lady presented with headache and personality changes. CT brain showed hydrocephalus and MRI showed ill-defined T2 hyper-intense lesion without enhancement at superior-dorsal aspect of pons. (Fig.1) Endoscopic third ventriculostomy with brain biopsy found granulomatous inflammation with negative mycobacterial tuberculosis polymerase chain reaction (MTB-PCR). CT thorax showed numerous tiny pulmonary nodules with extensive mediastinal lymphadenopathy. (Figs 2,3)She was managed as miliary tuberculosis (TB) with central nervous system (CNS) involvement. Cognitive symptoms persisted despite 8 months of TB treatment and interstitial involvement worsened on CT thorax. Further investigations with transbronchial biopsy and endobronchial ultrasound guided needle aspiration of station 7 lymph node confirmed granulomatous inflammation with negative MTB-PCR. After multi-disciplinary team discussion, diagnosis was revised to be sarcoidosis. TB medications were stopped and she was started on oral prednisolone. The cognitive problem improved and repeat CT 3 months after steroid treatment showed reduced extent of bilateral lung nodules and lymphadenopathy. DISCUSSION: Sarcoidosis was thought to be rare among Asians. The incidence rate ranged from 0.027 (Taiwan) to 2 (Japan) per 100000. Reports in Chinese patients were scarce. The epidemiology in Hong Kong is unknown but there were a number of case reports over last 30 years showing it is not that rare.Diagnosis remained by exclusion from compatible clinical and radiological picture with histology of noncaseating granuloma. [2] This highlighted the diagnostic challenge: TB notification rate was 58.27 per 100000 in Hong Kong; that is 50-2000 times more common than sarcoidosis. Two diseases can overlap, making it more complicated. [3] Many cases therefore received TB treatment during pursuit of diagnosis. Symptoms and signs are non-specific. Usually patients need to have symptoms for more than 3 months, and require three or more encounters with health care providers before arriving diagnosis.Nervous system sarcoidosis is even rarer but it can be first symptoms before systemic disease. Imaging findings are also non-specific. It is difficult to obtain biopsy and some can only be found in autopsy. It is one of the most fearful complications of sarcoidosis as it can carry mortality up to 18%. More aggressive immunomodulating treatment are needed. CONCLUSIONS: Sarcoidosis is still rare but is likely under-recognized. Diagnosis can be challenging in particular to exclude TB. We presented the first biopsy-proven case of central nervous system sarcoidosis in Hong Kong Chinese patient with successful treatment. Reference #1: 1. Dominique V, Antje P, Hilario N, et al. Sarcoidosis. Lancet 2014; 383: 1155–67 Reference #2: 2. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med 1999; 160: 736–55. Reference #3: 3. Wong CF et al. A case of concomitant tuberculosis and sarcoidosis with mycobacterial DNA present in the sarcoid lesion. Chest 1998; 114:2; 626-9 DISCLOSURES: No relevant relationships by Yu Hong Chan, source=Web Response no disclosure on file for Yiu Cheong Yeung

Peritoneal epithelioid angiosarcoma

Introduction:Peritoneal angiosarcoma is an extremely rare sarcoma (0.01287% incidence per 100,000) with an aggressive course and a poor prognosis. In this case, the manifestation of peritoneal angiosarcoma was ascites, which caused difficulty in early diagnosis and the diagnosis of peritoneal angiosarcoma, was made only after the surgery.Patient concerns:A 61-year-old man working in Mainland China presented with a 1-month history of abdominal distension. A contrast-enhanced abdominal computed tomography (CT) scan revealed peritoneal carcinomatosis with massive ascites. However, his tuberculosis (TB) polymerase chain reaction was negative. The ascites cell block and cytology also revealed negative for malignant cells. The patient underwent intra-abdominal tumor excision. After the operation, the patient's blood pressure (BP) dropped. Due to the state of shock, he was transferred to an intensive care unit (ICU).Diagnoses:According to the pathology report, the neoplastic cells were positive for cytokeratin, cluster of differentiation 31 (CD31), cluster of differentiation 34 (CD34), and negative for cytokeratin 7 (CK7), cytokeratin 7 (CK20). Therefore, the diagnosis of epithelioid angiosarcoma was made.Interventions:The patient took 400 mg of Pazopanib once a day.Outcomes:Even though vasopresser was used, the patient's BP was still low. Finally, he expired.Lessons:Initialy, the patient presented with abdominal distension and large amount of ascites in the beginning. TB peritonitis was highly suspected after the abdominal CT scan. Therefore, surgical procedures would be essential in the identification of proper diagnosis. In the future, the diagnosis of peritoneal epithelioid angiosarcoma should also be taken into consideration for patients with abnormal ascites besides the common diagnoses of TB, liver cirrhosis, and infection.

Effect of Adjunctive Pars Plana Vitrectomy on Focal Posterior Segment Inflammation: A Case-Control Study in Tuberculosis-Associated Uveitis

Pars plana vitrectomy (PPV) is commonly performed for managing complications of uveitis but the anti-inflammatory potential of PPV has not been extensively investigated beyond aqueous/vitreous inflammation. We studied the effect of PPV on resolution of focal posterior segment lesions in tuberculosis-associated uveitis (TBU). Case control study. Patients with bilateral TBU and active retinal/choroidal lesions in both eyes, and who received PPV in one eye were included. Fellow eyes of same patients, matched for patient characteristics and systemic therapy, were designated as controls. Study eyes received 3-port 23-guage PPV, involving removal of nearly the entire vitreous. Part of vitreous sample was used for quantitative polymerase chain reaction (qPCR) for Mycobacterium tuberculosis. Post-operatively, anti-TB and/or systemic corticosteroid therapy was initiated depending on level of clinical suspicion of tubercular etiology, degree of intraocular inflammation and qPCR results. Focal lesions were documented in preoperative and postoperative fundus diagrams. Clinical photographs were taken whenever adequate media clarity was present. Primary outcome measures were rate of clinical resolution of focal posterior segment lesions and improvement in best-corrected visual acuity (BCVA), at 1 month post-surgery. Thirty-six patients with bilateral posterior segment lesions consistent with TBU were included. Possible and probable TBU (depending on radiographic evidence of TB) were diagnosed in 28 (77.7%) and 4 (11.1%) patients respectively, whereas remaining 4 patients were diagnosed only on basis of qPCR results. Focal posterior segment lesions included retinal vasculitis (n = 27), multifocal-serpigenoid choroiditis (n = 5), multifocal choroiditis (n = 3) and focal choroiditis (n = 1). At one month postvitrectomy, 28 eyes (73.7%) showed complete resolution of focal posterior segment lesions compared to 7 non-vitrectomised eyes (19.4%), while improvement in BCVA was significantly more in study eyes (0.38 logarithm of the minimum angle of resolution [logMAR], P=0.04), compared to controls (0.12 logMAR, P = 0.17). Time to resolution following vitrectomy was unaffected by duration of disease, pre-operative systemic steroids or grade of vitritis. At 3 months, complete resolution was noted in 29 of 30 study eyes (96.7%) and 25 of 30 control eyes (83.3%). PPV facilitates faster resolution of focal posterior segment inflammation and BCVA improvement in TBU.

Endometrial tuberculosis among patients undergoing endometrial biopsy at Tikur Anbesa specialized hospital, Addis Ababa, Ethiopia

BackgroundFemale genital tuberculosis (FGTB) is known to cause severe tubal disease leading to infertility and its incidence closely parallels with the overall prevalence of tuberculosis (TB) in a community. Its magnitude is underreported because diagnosis is difficult and requires invasive techniques. In this study we determined the prevalence of endometrial tuberculosis and characterized isolates among women who underwent endometrial biopsy for evaluation of various conditions at a Tikur Anbessa Specialized Hospital (TAHS), Addis Ababa, Ethiopia.MethodsA cross sectional study was conducted on 152 consecutive gynecologic patients who underwent endometrial biopsy for different gynecologic diseases. Endometrial tissue taken for routine histopathology examination was shared after informed consent was obtained from the patient and subjected to polymerase chain reaction (PCR) and culture for Mycobacterium tuberculosis (Mtb).ResultsThe prevalence of endometrial TB in this study by IS1081PCR was 4.6% (7/152) while culture proven endometrial TB was 2.6% (4/152). However, histological examination identified only 2/152 (1.3%) endometrial tuberculosis. While all culture proven TB samples were also PCR positive for Mtb, only one histologic proven endometrial TB was culture and PCR positive. All of the four isolates by culture were M. tuberculosis.ConclusionThis study has shown that the magnitude of endometrial TB is fairly high in gynecologic patients visiting outpatient departments for various complaints and PCR detects more cases than culture or Histopathology.