Tuberculosis Endemic Regions Research Articles

Multi-spectral Pattern of Clinical Presentation and the Resultant Outcome in Central Nervous System Tuberculosis: A Single Center Study on the Ubiquitous Pathogen.

Central nervous system (CNS) tuberculosis (TB) is a great medical masquerader having a multi-spectral pattern of clinical presentation, thereby complicating early diagnosis and appropriate management. This review article describes clinical presentation of CNS TB in a group of 47 patients, who were managed in the Nobel Medical College and Teaching Hospital in Biratnagar, Nepal during the last 2years. We evaluated demographic profile, mode of management, and clinical outcome in these patients. The findings were that intracranial TB was present in 27 (57.5%) patients and the spinal involvement was in 20 (42.5%) patients. The most frequent presentation of the former was TB meningitis with hydrocephalus (55.5%) and that of the latter was Pott's spine with abscess in 50% of cases. TB meningitis with hydrocephalus was the commonest cause of mortality (83.3%) among the patients. CNS TB should be considered in the differential diagnosis in patients presenting with equivocal neurological signs and symptoms, especially in TB endemic regions. It seems prudent to commence early antitubercular therapy for safeguarding such patients from poor neurological outcome as well as mortality it harbingers.

BCG revaccination boosts adaptive polyfunctional Th1/Th17 and innate effectors in IGRA+ and IGRA- Indian adults.

BACKGROUNDBacille Calmette-Guérin (BCG) vaccine is protective against Tuberculosis (TB) in children, but its efficacy wanes with age. Consequently, determining if BCG revaccination augments anti-TB immunity in young adults in TB endemic regions is vital.METHODSTwo hundred healthy adults, BCG vaccinated at birth, were tested for their IFN-γ release assay (IGRA) status. Of these, 28 IGRA+ and 30 IGRA- were BCG revaccinated, and 24 IGRA+ and 23 IGRA- subjects served as unvaccinated controls. T and innate cell responses to mycobacterial antigens were analyzed by 14-color flow cytometry over 34 weeks.RESULTSIFN-γ and/or IL-2 Ag85A- and BCG-specific CD4+ and CD8+ T cell responses were boosted by revacciantion at 4 and 34 weeks, respectively, and were > 2-fold higher in IGRA+ compared with IGRA- vaccinees. Polyfunctional Ag85A, BCG, and mycobacterium tuberculosis (Mtb) latency Ag-specific (LTAg-specific) CD4+ T cells expressing up to 8 cytokines were also significantly enhanced in both IGRA+ and IGRA- vaccinees relative to unvaccinated controls, most markedly in IGRA+ vaccinees. A focused analysis of Th17 responses revealed expansion of Ag85A-, BCG-, and LTAg-specific total IL-17A+,IL-17F+,IL-22+, and IL-10+ CD4+ T cell effectors in both IGRA+ and IGRA- subjects. Also, innate IFN-γ+ NK/γδ/NKT cell responses were higher in both IGRA+ and IGRA- vaccinees compared with controls. This is the first evidence to our knowledge that BCG revaccination significantly boosts antimycobacterial Th1/Th17 responses in IGRA+ and IGRA- subjects.CONCLUSIONThese data show that BCG revaccination is immunogenic in IGRA- and IGRA+ subjects, implying that Mtb preinfection in IGRA+ subjects does not impact immunogenicity. This has implications for public health and vaccine development strategies.FUNDINGThis work was funded principally by DBT-NIH (BT/MB/Indo-US/HIPC/2013).

Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature.

Few data are published on perianal tuberculosis. This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

LEAVE NO LOBE UNSCOPED: A CASE OF MYCOBACTERIUM TB OF THE RIGHT MIDDLE LOBE

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Tuberculosis (TB) is one of the top ten leading causes of death worldwide, now surpassing HIV/AIDS as the leading cause of death from infectious disease (1). Earlier detection significantly reduces mortality from tuberculosis, and the World Health Organization estimates that earlier diagnosis has averted 54 million deaths since the year 2000 (1). Assumptions that TB only presents in certain patterns often delays diagnosis to the detriment of the patient and those close to them (2). We describe an atypical presentation of TB presenting in the right middle lobe. CASE PRESENTATION: A 75 year-old Ecuadorian woman with a history of hypertension, diabetes, and emphysema presented to the hospital with hemoptysis and fevers. CT of the chest with contrast demonstrated a right middle lobe cavitary lesion, which was read as necrotizing pneumonia. Broad-spectrum antibiotics were initiated to treat pneumonia. However, due to the presentation, cavitary nature of the lesion, and the patient coming from a TB endemic region, a bronchoscopy was pursued. Acid-fast bacillus stains performed on the bronchoalveolar lavage were positive for mycobacterium tuberculosis, confirming the diagnosis of active pulmonary tuberculosis. RIPE treatment was initiated. The patient soon afterward developed massive hemoptysis requiring intubation and upgraded to the medical intensive care unit. IR-guided embolization of the right bronchial artery middle lobe segment resolved the bleed. She extubated shortly afterward and eventually discharged home on RIPE treatment. DISCUSSION: TB has recently surpassed HIV/AIDS as the leading cause of death from infectious disease (1). A major reason for this alarming statistic is that TB can manifest in so many different fashions, leading to delays in diagnosis (2). An increasing number of atypical manifestations of TB are being described in the literature, challenging traditional concepts of its presentation (2, 3). Classically, tuberculosis affects the upper lobes in immunocompetent hosts, which is believed to be due to the increased oxygen tension and decreased lymphatic drainage facilitating replication of the organism (3, 4). In immunocompromised hosts, it has been found to commonly affect the lower lobes, particularly the superior segments (5, 6). However in this patient, TB presented in the middle lobe, which has rarely been described (4). We present a case of TB affecting the middle lobe in the hopes of contributing to literature challenging traditional concepts about this lethal and evasive disease. CONCLUSIONS: TB typically presents in the upper lobes. Atypical presentations in other areas of the lung may lead to delayed or incorrect diagnosis. Patient factors such as medical conditions, demographics, and overall clinical picture should be considered in patients with cavitary lung disease. Presented is an atypical case of TB of the right middle lobe. Reference #1: World Health Organization. Global Tuberculosis Report 2018. Geneva, WHO, 2018. Reference #2: Restrepo et al. “Imaging manifestations of thoracic tuberculosis.” Radiologic Clinics of North America 2016; 54(3):453-473. Reference #3: Mathur M et al. “Radiological manifestations of pulmonary tuberculosis – a comparative study between immunocompromised and immunocompetent patients.” Journal of Clinical and Diagnostic Research 2017; 11(9):TC06-TC09. DISCLOSURES: No relevant relationships by Dawn Maldonado, source=Web Response Stock holder relationship with Eli Lilly Please note: $5001 - $20000 Added 03/26/2019 by Terence McGarry, source=Admin input, value=Dividends Stock holder relationship with Merek Please note: $5001 - $20000 Added 03/26/2019 by Terence McGarry, source=Admin input, value=Dividends No relevant relationships by Michael Megally, source=Web Response

Whole genomic sequencing as a tool for diagnosis of drug and multidrug-resistance tuberculosis in an endemic region in Mexico

BackgroundWhole genome sequencing (WGS) has been proposed as a tool for diagnosing drug resistance in tuberculosis. However, reports of its effectiveness in endemic countries with important numbers of drug resistance are scarce. The goal of this study was to evaluate the effectiveness of this procedure in isolates from a tuberculosis endemic region in Mexico.MethodsWGS analysis was performed in 81 tuberculosis positive clinical isolates with a known phenotypic profile of resistance against first-line drugs (isoniazid, rifampin, ethambutol, pyrazinamide and streptomycin). Mutations related to drug resistance were identified for each isolate; drug resistant genotypes were predicted and compared with the phenotypic profile. Genotypes and transmission clusters based on genetic distances were also characterized.FindingsPrediction by WGS analysis of resistance against isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin showed sensitivity values of 84%, 96%, 71%, 75% and 29%, while specificity values were 100%, 94%, 90%, 90% and 98%, respectively. Prediction of multidrug resistance showed a sensitivity of 89% and specificity of 97%. Moreover, WGS analysis revealed polymorphisms related to second-line drug resistance, enabling classification of eight and two clinical isolates as pre- and extreme drug-resistant cases, respectively. Lastly, four lineages were identified in the population (L1, L2, L3 and L4). The most frequent of these was L4, which included 90% (77) of the isolates. Six transmission clusters were identified; the most frequent was TC6, which included 13 isolates with a L4.1.1 and a predominantly multidrug-resistant condition.ConclusionsThe results illustrate the utility of WGS for establishing the potential for prediction of resistance against first and second line drugs in isolates of tuberculosis from the region. They also demonstrate the feasibility of this procedure for use as a tool to support the epidemiological surveillance of drug- and multidrug-resistant tuberculosis.

The risk of refeeding syndrome among severely malnourished tuberculosis patients in Chhattisgarh, India

BackgroundA secondary care hospital in rural India serving a highly tuberculosis (TB) and malnutrition endemic region. ObjectiveIn this study conducted on patients with chronic protein energy malnutrition (PEM) and TB, we sought to compare nurse-estimated vs. smartphone photograph analytic methods for assessing caloric intake and determine the incidence of refeeding hypophosphatemia (RH) and refeeding syndrome (RFS) in patients with TB. MethodsInpatients were prospectively enrolled. Baseline demographic, comorbidity and preadmission caloric data were collected. Nurse estimated caloric intake was compared with digital “before and after” meal images. Serum phosphorus was measured on days 1, 3 and 7 post admission. Patients with RH underwent further evaluation for RFS-associated findings. Results27 patients were enrolled. 85% were at risk of RFS by National Institute for Health and Care Excellence (NICE) criteria. Significant discrepancy (>700 calories) was noted between nurse-estimated caloric intake compared to digital images. RH was found in 37% (10/27). None developed clinical RFS. ConclusionsOur study suggests more standardized methods of caloric intake are needed in resource-limited settings with high co-prevalence of PEM and TB. We noted that despite RH being common in inpatients with PEM+TB given high caloric diets, RFS was not detected.

Primary encapsulating peritoneal sclerosis in a tuberculosis-endemic region.

Primary encapsulating peritoneal sclerosis is an enigmatic entity that may be erroneously diagnosed as abdominal tuberculosis in tuberculosis-endemic regions. In patients with a history of recurrent intestinal obstruction, a high index of suspicion along with characteristic images of computed tomography scan can help in diagnosis. Unless there is strong supportive evidence preoperatively, empirical antituberculosis treatment should be avoided.

Risk of tuberculosis in patients with immune-mediated diseases on biological therapies: a population-based study in a tuberculosis endemic region.

Real-world epidemiological data on the risk of tuberculosis (TB) in patients with immune-mediated diseases treated with biologics are scarce in TB endemic areas. We investigated the incidence of TB in a population-based setting and stratified the risk of TB among different biological therapies. We collected medical data from a territory-wide computerized database in Hong Kong. We reported the incidence of TB in patients treated with various classes of biologics, and calculated standardized incidence ratio by comparing with the general population. Subgroup analyses were performed based on disease subtypes and biological drugs. Among 2485 subjects with immune-mediated diseases (82.5% rheumatology diseases; 10.6% IBD; 6.9% dermatology diseases), 54 subjects developed active TB during 6921 person-years of follow-up. The mean age (±s.d.) was 43 (14) years, and the median follow-up duration was 24.9 months (interquartile range 4.9-45.0). The overall standardized incidence ratio of TB was 10.91 (95% CI 8.00-13.82), and patients treated with infliximab had a nearly 26 times increased risk of TB compared with the general population (standardized incidence ratio 25.95; 95% CI 17.23-34.67). The risk of TB with TNF inhibitor was higher than with a non-TNF biologic (hazard ratio 4.34; 95% CI 1.31-14.39), while the risk of infliximab was higher than etanercept and adalimumab (hazard ratio: 4.10 and 2.08, respectively). The risk of TB is much higher in patients with immune-mediated diseases on biological therapy compared with the general population, and infliximab is associated with the highest risk of TB among the biologics analysed.

Noncaseating suppurative granulomatous lymphadenitis in adult onset Still\u2019s disease \u2013 a diagnostic dilemma in a tuberculosis-endemic region: a case report

BackgroundLymphadenopathy is not an uncommon presentation of adult onset Still’s disease: it is present in up to two thirds of patients with adult onset Still’s disease. The characteristic appearance of lymphadenopathy is described as intense, paracortical immunoblastic hyperplasia. Changes in light microscopy may resemble lymphoma, but immunohistochemistry reveals a benign polyclonal B cell hyperplasia.Case presentationWe describe a 67-year-old Sri Lankan woman who manifested relapsing prolonged fever, raised inflammatory markers, arthralgia, myalgia, transient skin rash, and cervical lymphadenopathy histologically characterized by noncaseating granulomatous adenitis with central suppuration. Due to the fact of high prevalence of tuberculosis in the region, an extensive diagnostic evaluation was done to exclude the possibility of extrapulmonary tuberculosis; unsuccessful therapeutic trials of complete antituberculosis regime reliably excluded the possibility of tuberculosis and strengthened the diagnostic validity. Disease flares were characterized by systemic inflammatory response syndrome with immediate clinical and laboratory response to corticosteroids. After systematic diagnostic workup which ruled out possible malignant, rheumatic, or autoimmune diseases and infections previously described as causes of granulomatous adenitis, our patient was diagnosed as having adult onset Still’s disease based on Yamaguchi criteria. She required a trial of indomethacin followed by methylprednisolone pulse therapy and long-term maintenance steroid therapy without steroid-sparing immunosuppressive agents or biological disease-modifying antirheumatic drugs. She achieved full disease remission in 3 months. Reevaluation after 6 months and 1 year did not reveal residual disease activity.ConclusionsTo the best of our knowledge this is the first report of suppurative noncaseating granulomatous lymphadenitis attributed to adult onset Still’s disease among Asian or South Asian ethnicities and it is also rarely reported among Europeans and North Americans. It is an extremely challenging situation to diagnose Still’s disease with granulomatous lymphadenitis where tuberculosis is highly prevalent. This case highlights the importance of consideration of adult onset Still’s disease as a potential diagnosis in a compatible clinical context in the presence of noncaseating granulomatous adenitis and indicates that one should not be misled into a diagnosis of tuberculosis by the fact of the high prevalence of tuberculosis, however, the exclusion of other diagnoses is a prerequisite.

The challenge in diagnosing Crohn’s disease in TB endemic region – A case report with review of literature

The challenge in diagnosing the regional ileitis existed since 1932 when Crohn, Ginzberg and Oppenheimer first reported their case1. Many Indian researchers accepted that during last decade there was considerable increase in the incidence of Crohn’s disease (CD) in India which poses great challenge in diagnosing it, due to high prevalence of tuberculosis2. In this perspective we report a case which made a stimulus to review the literature. The purpose of this manuscript is 1. To document the occurrence of an additional case of CD in India, 2. To report that CD can rarely present as post operative enterocutaneous fistula, 3. To discuss the criteria in diagnosing the CD in Tuberculosis (TB) endemic area.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.688-690

Primary immunodeficiency diseases in a tuberculosis endemic region: challenges and opportunities.

While individual primary immunodeficiency diseases (PIDs) are rare, collectively they represent a significant burden of disease. Recent estimates show that about one million people in Africa suffer from a PID. However, data from African PID registries reflect only a small percentage of the estimated prevalence. This disparity is partly due to the lack of PID awareness and the masking of PIDs by the endemic pathogens. Over three million tuberculosis (TB) cases were reported in Africa in 2016, with many of these from southern Africa. Despite concerted efforts to address this high burden of disease, the underlying genetic correlates of susceptibility to TB remain poorly understood. High penetrance mutations in immune system genes can cause PIDs that selectively predispose individuals to TB and other mycobacterial diseases. Additionally, the identification of individuals at a heightened risk of developing TB or of presenting with severe or disseminated TB due to their genetic ancestry is crucial to promote a positive treatment outcome. The screening for and identification of PID mutations in TB-endemic regions by next-generation sequencing (NGS) represents a promising approach to improve the understanding of what constitutes an effective immune response to TB, as well as the range of associated PIDs and phenotypes.

A novel stacked generalization of models for improved TB detection in chest radiographs.

Chest x-ray (CXR) analysis is a common part of the protocol for confirming active pulmonary Tuberculosis (TB). However, many TB endemic regions are severely resource constrained in radiological services impairing timely detection and treatment. Computer-aided diagnosis (CADx) tools can supplement decision-making while simultaneously addressing the gap in expert radiological interpretation during mobile field screening. These tools use hand-engineered and/or convolutional neural networks (CNN) computed image features. CNN, a class of deep learning (DL) models, has gained research prominence in visual recognition. It has been shown that Ensemble learning has an inherent advantage of constructing non-linear decision making functions and improve visual recognition. We create a stacking of classifiers with hand-engineered and CNN features toward improving TB detection in CXRs. The results obtained are highly promising and superior to the state-of-the-art.

Risk factors for diagnostic delay in Crohn's disease and their impact on long-term complications: how do they differ in a tuberculosis endemic region?

The diagnosis of Crohn's disease (CD) can be delayed in clinical practice. In tuberculosis endemic areas, empirical anti-tubercular therapy further delays treatment. To assess risk factors for diagnostic delay and its impact on the long-term complications of Crohn's disease in India where tuberculosis is endemic. Data from a large prospectively established inflammatory bowel disease registry were analysed retrospectively. The time from onset of symptoms to diagnosis (diagnostic delay) was calculated and categorised into two groups based on median diagnostic delay. The risk factors for delay including anti-tubercular therapy were analysed. Logistic regression analysis was done to assess impact of diagnostic delay on development of stenotic and fistular complications including need for surgery. Seven hundred and twenty Crohn's disease patients (60.3% male, median: 28years) were included. Main outcome measures were stenosis, fistula and need for surgery. Subjects with diagnostic delay >18months (median) developed significantly higher stenotic complications and surgery (OR 4.12; 95% CI: 2.74-6.33, P<0.001 and OR 2.41, 95% CI: 1.68-3.42, P<0.001), respectively, compared to those ≤18months. There was no difference in the development of fistulous complications. 193/720 (27%) received anti-tubercular therapy which significantly contributed to diagnostic delay (OR: 2.47; 95% CI: 1.76-3.47, P<0.001) with 47% showing initial clinical response (Crohn's disease activity index- CDAI decrease >100). Moreover, the incidence of stenotic complications was significantly higher in patients who had received prior anti-tubercular therapy (55/193 (28.49%) vs 78/527 (14.8%), P<0.001, OR: 2.60, 95% CI: 1.64-4.12). Diagnostic delay in Crohn's disease is associated with significantly higher stenotic complications and need for surgery. Empirical anti-tubercular therapy is the single largest contributor to diagnostic delay in tuberculosis endemic areas. Despite initial clinical response to anti-tubercular therapy, long-term stenotic complications are higher.

Necrotizing Neck Mass in a Young Female

In the USA, it is more common in immune suppressed conditions such as HIV or if there is a significant history of travel to tuberculosis-endemic regions. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Mycobacterial cervical lymphadenitis, also known as scrofula refers to lymphadenitis of the cervical lymph nodes associated with tuberculosis as well as atypical mycobacteria. We report a case of a 20-year-old HIV negative, immunocompetent female, who was previously treated for latent tuberculosis, now presented with tuberculous lymphadenitis without pulmonary symptoms.

Antineutrophil cytoplasmic antibody-positive scleritis: Clinical profile of patients from a tuberculosis-endemic region.

Purpose:To report the clinical profile of a series of antineutrophil cytoplasmic antibody (ANCA)-associated scleritis in Indian population.Methods:We conducted a retrospective review of medical records of 33 eyes of 26 consecutive patients with scleritis, who tested positive for either antibody to proteinase 3 [anti-PR3/cytoplasmic antineutrophil cytoplasmic antibody (cANCA)] or myeloperoxidase [anti-MPO/perinuclear anti-neutrophil cytoplasmic antibody (pANCA)] between 2006 and 2015.Results:The mean age at presentation was 54.1 (11.1) years and 61.5% of the patients were female. Underlying systemic disorder was found in 46.2% of patients and includes granulomatosis with polyangitis (30.8%) and tuberculosis (15.4%). Necrotizing scleritis (48.5%) was the most common scleritis observed, followed by diffuse anterior scleritis (42.4%). Positive cANCA was found in 65.4% of patients and 34.6% was found positive for pANCA. Four of the six patients with positive Mantoux test were started on anti-tuberculosis treatment (ATT) by pulmonologist. Cyclophosphamide was the most common immunosuppressive and 11.5% of the patients required combination of two immunosuppressives. Seventeen eyes developed cataract and four eyes required patch graft. Female gender was more frequently associated with pANCA-associated scleritis than cANCA (P = 0.037). Incidence of necrotizing scleritis was higher in patients with positive cANCA, but this difference was not statistically significant (P = 0.806). cANCA-positive patients had statistically significant higher association with systemic rheumatic diseases (P = 0.021).Conclusion:Necrotizing scleritis is the most common subtype of scleritis in ANCA-positive individuals and even in the absence of systemic involvement. All patients with ANCA positivity should be thoroughly screened to rule out any evidence of tuberculosis, especially in tuberculosis-endemic region before planning aggressive immunomodulatory therapy.

Diagnostic Delay and Associated Clinical Features of Tuberculosis among Adult Patients with Acute Myeloid Leukemia in Doha, Qatar

Background: Tuberculosis is currently the world’s leading cause of death arising from a single infectious condition. While T cell mediated immunity is recognized to have a major contribution to tuberculosis activation, the present investigation confirmed that TB was more prevalent among patients with acute myeloid rather than lymphoid leukemia and such association was frequently overlooked. The primary objective of this study is to estimate the diagnostic delay of tuberculosis among patients with acute myeloid leukemia (AML) and compare it to the general population in Qatar. Secondary objective is to study the clinical and epidemiologic characteristics of tuberculosis in patients with AML. Methods: This is a retrospective study of tuberculosis cases diagnosed in subjects with AML during the period from January 2008 till December 2016. Results: Among 215 subjects with AML identified during the study period, 12 (5.58%) received the diagnosis of tuberculosis. The estimated incidence of tuberculosis among AML cases was 7.14 cases per 1000 per year. The mean delay in diagnosis of tuberculosis was 64.2 days (95% CI: 26.8 - 101.5) and the median was 45 days (interquartile range; Q1 - Q3, 29.5 - 97.5). Prolonged fever was the most common presentation (100% of cases). Parenchymal lung involvement was the most common radiologic abnormality (83.3% of cases). Three patients (25%) died and 8 patients completed 9 to 12 months of anti-tuberculous treatment with clinical and radiological remission. Conclusion: Infections caused by Mycobacterium tuberculosis are not uncommon in patients with AML especially in patients from tuberculosis endemic regions. It constitutes a diagnostic challenge so high index of suspicion is of paramount importance.

Dilemma of diagnosing thoracic sarcoidosis in tuberculosis-endemic regions: An imaging-based approach. Part 2.

The second part of the review discusses the role of different existing imaging modalities in the evaluation of thoracic sarcoidosis, including chest radiograph, computed tomography, magnetic resonance imaging, endobronchial ultrasound, and positron emission tomography. While summarizing the advantages and pitfalls of each imaging modality, the authors propose imaging recommendations and an algorithm to be followed in the evaluation of clinically suspected case of sarcoidosis in tuberculosis-endemic regions.

Disseminated TB Presenting as Knee Arthritis

SESSION TITLE: Fungal Infections 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Disseminated tuberculosis (TB) can lead to significant morbidity and mortality. The presentation is variable and dependent on the organs affected. Monoarticular arthritis of knee is uncommon especially in an immunocompetent host and in developed settings. High index of clinical suspicion is required as the condition may imitate other forms of inflammatory arthritis and may have an indolent course. Diagnosis can be challenging and delayed given the focal subacute presentation. We present a case of disseminated TB presenting as knee arthritis. CASE PRESENTATION: A 42-year-old-male presented with 18 month history of worsening left knee pain. It has progressed with inability to bear weight for 3 weeks. He had weight loss but no cardio-respiratory symptoms. A recent travel to South East Asia was noted. Clinical examination revealed a small left knee effusion and reduced range of motion. Rest of the examination was unremarkable. Knee XR showed sclerotic changes. Knee MRI showed non-haemorrhagic synovitis causing significant cartilage disruption and bony erosion. The inflammatory markers were raised. Knee aspiration showed acid fast bacilli and raised white cells. The patient proceeded an arthroscopic washout with good surgical outcome. Further imaging reveals mild bilateral pleural effusion. He developed gross haematuria and imaging identified a right ureteric lesion. Urine microbiology and pleural fluid microbiology was positive for Mycobacterium Tuberculosis. The diagnosis of disseminated TB was made and the patient was started on anti-tuberculosis agents. At follow up the patient was able to complete weight bear and had responded well to treatment. DISCUSSION: This case represents a rare extra-pulmonary presentation of an uncommon disease process in an immunocompetent host. Osteoarticular TB is typically result of direct haematogenous spread from primary focus. The presentation is indolent with subacute pain, joint swelling and stiffness with significant overlap with more common monoarthritidis such as crystal or bacterial monoarthritis. A significant delay is noted between symptoms and treatment with time range upto 104 weeks which can contribute to significant morbidity and mortality especially if it is initial presentation of disseminated TB. The diagnosis is difficult. Biochemistry of synovial fluid is not helpful and synovial fluid AFB is positive only in 20% cases. Culture can be positive in 80% cases and biopsy synovium may show granuloma. Adenosine deaminase (ADA) should be sent as may help early diagnosis. CONCLUSIONS: Knee arthritis secondary to TB is rare and insidious. Delayed TB diagnosis can be avoided by high clinical suspicion in cases where patients have constitutional symptoms, focal joint inflammatory pathology and a travel history in TB endemic regions. Synovial aspiration, Ziehl-Neelsen staining, culture and adenosine deaminase test are recommended if TB is a differential. Reference #1: Acta Reumatol Port.2016;41:256-159 DISCLOSURE: The following authors have nothing to disclose: Sumit Mehra, Aaron Gaekwad No Product/Research Disclosure Information

Dilemma of diagnosing thoracic sarcoidosis in tuberculosis endemic regions: An imaging-based approach. Part 1.

Sarcoidosis is a multi-systemic disorder of unknown etiology, although commonly believed to be immune-mediated. Histologically, it is characterized by noncaseating granuloma which contrasts against the caseating granuloma seen in tuberculosis (TB), an infectious disease that closely mimics sarcoidosis, both clinically as well as radiologically. In TB-endemic regions, the overlapping clinico-radiological manifestations create significant diagnostic dilemma, especially since the management options are markedly different in the two entities. Part 1 of this review aims to summarize the clinical, laboratory, and imaging features of sarcoidosis, encompassing both typical and atypical manifestations, in an attempt to distinguish between the two disease entities.

The efficacy of latent tuberculosis treatment for immunocompetent uveitis patients with a positive T-SPOT.TB test: 6-year experience in a tuberculosis endemic region.

To assess the efficacy of latent tuberculosis (TB) treatment for immunocompetent uveitis patients with a positive T-SPOT.TB test. This is a consecutive case series of all T-SPOT.TB positive latent TB patients with presumed tuberculous uveitis managed with anti-tuberculous therapy (ATT) from 1 January 2000 to 31 December 2015. Patients with active TB or other known causes of uveitis, immunocompromised states and those followed up <12months were excluded. Descriptive statistics and hypothesis testing were performed, with a significance level of p<0.05 taken. Among the 75 T-SPOT.TB tests performed for uveitis, 14 cases were enrolled. Mycobacterium tuberculosis was isolated in none of the sputum and intraocular samples. Most cases had posterior uveitis (10/14 cases, 71.4%) and/or intermediate uveitis (9/14 cases, 64.3%). Vasculitis was predominantly occlusive. The mean presenting best-corrected visual acuity (BCVA) was 0.18, improving to 0.44 at 6months (p=0.03) and 0.40 at 12months. (p=0.03). At 1year, remission of uveitis was achieved in 92.9%, in which none of them recurred at the last follow-up. High-dose systemic steroid was required in 50% of patients. Only 1 patient was steroid dependent at 18months. The BCVA improvement in patients treated with or without steroid was comparable. In a TB-endemic region with wide Bacille Calmette-Guerin vaccination coverage, ATT for immunocompetent uveitis patients with latent TB identified from T-SPOT.TB test can improve vision, induce long-term steroid-free remission, and prevent recurrence and systemic reactivation of TB in those who require steroid.