Tuberculosis Polymerase Chain Reaction Test Research Articles

A rare case of actinomycotic osteomyelitis of calcaneum: Presented with subtalar arthritis

We are reporting an unusual case of actinomycosis infection which presented with subtalar arthritis. Actinomycosis is a chronic granulomatous disease caused by Gram-positive anaerobic bacteria. Actinomycosis is very rare and of the cases reported Cervicofacial infection is the most frequent clinical presentation. Hematogenous osteomyelitis at distant sites can occur in the rare instance in immunocompromised or pediatric patients, only a few cases have been reported in healthy patients. Case Report: A 39years, female patient presented with pain, swelling around the right ankle for 4 years with healed sinuses over the lateral aspect. She was treated for the discharging sinuses of right ankle and foot 5 years back with antibiotics and surgery elsewhere. She had a history of taking treatment (ATT for 6months) for pulmonary TB, 10years back. X-rays and Magnetic resonance imaging showed a distorted subtalar joint with multifocal intraosseous lesions in the calcaneum. Curettage and subtalar arthrodesis with Cannulated cancellous screws was done and supported with short-term immobilization. The tissue culture, fungus culture, acid-fast bacillus (AFB) culture, AFB smear, and tuberculosis polymerase chain reaction test results of intraop samples were negative. A pathologic examination confirmed the presence of actinomycosis. The patient was treated with intravenous penicillin for 2 weeks followed by Oral Doxycycline for 6 weeks, given no evidence of active infection intraoperatively. After 1year follow-up, the patient had no signs of recurring infection or complications and she is ambulant pain-free.Conclusion: Actinomycosis of the foot, though rare, can mimic tuberculosis in areas with a high prevalence of tuberculosis. In patients with recurrent discharging sinuses, a high index of suspicion is warranted to early diagnose it.

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.

Erythropoietin-producing tubercle granuloma in a hemodialysis patient

BackgroundWe describe a case of a fever of unknown etiology that was caused by a caseating tubercle granuloma which produced erythropoietin. To our knowledge, this is the first report of an erythropoietin- producing granuloma.Case presentationA 48-year-old Japanese man with a 5-year history of maintenance hemodialysis for diabetic nephropathy presented with an intermittent fever over a few months. During febrile periods he developed erythema nodosum on his legs. Computed tomography showed axillary lymph node enlargement and this was further corroborated by a gallium scan that revealed high gallium uptake in these nodes. A Mantoux test was positive and an interferongamma release assay for tuberculosis diagnosis was also positive. Lymph node tuberculosis was suspected and the patient underwent lymphadenectomy. Histological analysis of the lymph nodes revealed a caseating granuloma that showed positive results on an acid-fast bacteria stain and a Mycobacterium tuberculosis polymerase chain reaction test. After lymphadenectomy, however, the patient’s hemoglobin levels rapidly decreased from 144 to 105 g/L, and this was further compounded by a decrease in serum erythropoietin from 223 mIU/mL to 10.7 mIU/mL by postoperative day 21. We suspected the tubercle to be a source of the erythropoietin and this was further confirmed by in situ hybridization.ConclusionsWe report for the first time ectopic erythropoietin production by a tuberculous lymph node. Our observations are substantiated by a postoperative decline in his erythropoietin level and a clinical requirement for erythropoietin treatment.

Arthrodesis in a neuropathic elbow after posttubercular spine syrinx

A 46-year-old man, who was left-hand dominant with knownparaplegia due to tuberculosis spondylitis, presented withcomplaints of progressively increasing weakness and instability ofthe left upper limb for the past 2 years. The patient had difficultyusing his left upper limb for activities of daily living such aseating, combing his hair, and maneuvering his wheelchair. Onexamination, the left elbow was swollen, but not warm, and wasnot tender. Range of motion was 25 to 100 , with palpable andaudible crepitation. There was grade 3 weakness of the inteross-eous muscles and digital flexors of the ipsilateral hand. A sensoryexamination revealed sensory loss in the ulnar nerve distribution.Examination showed the median, radial, and musculocutaneousnerves were normal.Radiographs of the left elbow showed severe destruction of thedistal humerus and proximal radioulnar joint with dislocation, andsevere erosion into the intercondylar area left both condyles in aninverted U-shape. The proximal radioulnar joint was dislocatedposterolaterally but no dissociation was noted in the proximalradioulnar bones. Diffuse soft-tissue swelling, especially in theposterior elbow and heterotopic ossification, was noted in theadjacent soft tissue (Figure 1).The patient gave a history of tuberculosis of the thoracic spineinvolving the second, third, and fourth thoracic vertebrae, whichwas treated with anterolateral decompression and antituberculardrugs 4 years previously. He remained paraplegic and wheelchair-bound, but bladder and bowel functions were spared. Previousmagnetic resonance imaging of his cervicothoracic spine revealeda cervicodorsal syrinx extending from C6 to T4, which wasdiagnosed 3 years previously (Figure 2). The patient had refusedany surgical intervention for syrinx at that time.Results of blood investigations of patient were within normallimits. Computed tomography (CT)-guided aspiration of fluidfrom the elbow joint was investigated for gram stain and acid-fastbacilli stain as well as culture and polymerase chain reaction testfor tuberculosis. All the results were negative. We discussed thetreatment options, both conservative and surgical, including thehigh risks of failure in the latter with patient. Our patient insistedon having a stable elbow.Through a posterior approach, we performed ulnar nervedecompression and anterior transposition with arthrodesis of theelbow joint. Intraoperatively, the ulnar nerve was markedly dis-placed to the radial side (Figure 3). The radial head was excised.The articular margins of the humerus and ulna were freshened,and a prebent 12-hole locking plate (AO, Synthes Inc, WestChester, PA) was applied with the elbow in a functional position at70 flexion. An anterior submuscular transposition of the ulnarnerve was performed. Results of gram stains, acid-fast bacillistain, and culture of removed tissue were negative.Postoperatively, the limb was supported in an above elbowsplint for 4 weeks. The patient was followed up at monthly

Clinical Evaluation of a 16S Ribosomal RNA Polymerase Chain Reaction Test for the Diagnosis of Lymph Node Tuberculosis

Reports on the sensitivity of polymerase chain reaction (PCR) for the diagnosis of lymph node tuberculosis (TB) show divergent results. We evaluated the accuracy of the Roche Amplicor Mycobacterium tuberculosis PCR test with lymph node aspirate and biopsy samples. The study was conducted at a public reference hospital in Lima, Peru. From the period of January 2003 to January 2004, we included patients who had lymphadenopathy and in whom the attending physician suspected TB. Aspirate and biopsy samples were submitted for culturing in Lowenstein-Jensen medium, for histopathologic testing, and for PCR. The sensitivity and specificity of PCR were calculated against a reference standard based on histopathologic findings and culture. Our study included 154 patients. Median age was 29 years (interquartile range, 21-40 years); 97 patients (62.9%) were men. Twenty-nine patients (18.8%) had acid fast bacilli-positive histopathologic findings, and 44 (28.6%) had a positive culture result. Using the combination of histopathologic findings and culture as reference standard, 55 patients (35.7%) had a diagnosis of tuberculous lymphadenitis. The sensitivity of the PCR test was 58.2%, and the specificity was 93.9%. For biopsy tissue only, the sensitivity of PCR was 52.7%, and the specificity was 97.0%. For aspirate samples only, the sensitivity of PCR was 47.3%, and the specificity was 96.0%. The Amplicor PCR test revealed low sensitivity and high specificity for the diagnosis of lymph node TB. The sensitivity was higher in cases in which the bacillary load was high--in acid fast bacilli-positive samples and among HIV-infected patients. Considering the results of microbiological and PCR tests together, there was still a patient group in whom no final diagnosis could be established.

COMPARISON OF VARIOUS MICROBIOLOGICAL TESTS INCLUDING POLYMERASE CHAIN REACTION FOR THE DIAGNOSIS OF OSTEOARTICULAR TUBERCULOSIS

Purpose: To evaluate the utility of the polymerase chain reaction(PCR) test for diagnosing osteoarticular tuberculosis (TB). Methods: Clinical samples (synovial tissue and synovial fluid) obtained from 23 cases of suspected osteoarticular tuberculosis were subjected to Ziehl Neelsen (ZN) smear examination, radiometric BACTEC culture and PCR test for tuberculosis by amplifying 65 kDa antigen coding region of Mycobacterium tuberculosis (M.tb) genome. Results: PCR test was found to be much more sensitive than the ZN smear examination and BACTEC culture(p < 0.05) in the diagnosis of osteoarticular TB. In synovial fluid samples, PCR was positive in 73.9%, ZN smear examination in 17.39% and BACTEC culture in 39.13% of cases.The positivities were relatively lower with synovial tissue samples, the corresponding figures being 60.8, 8.6 and 26.08% respectively. Moreover, on combining the results of synovial fluid and tissues, the corresponding figures further increased to 78.2, 21.7 and 43.3% respectively. Further, sensitivity and specificity for PCR employing BACTEC culture as the “gold standard” was 100% respectively. Using BACTEC culture, the earliest positivity was seen in three days using synovial tissue specimen and 13 days with synovial fluid, the average detection times being 23.2 days and 32.6days respectively. On the other hand, PCR test gave a positive result within 24 hours.Conclusions: PCR test was shown to be much more sensitive than ZN smear examination and BACTEC culture test for diagnosing osteoarticular tuberculosis.

The Clinical Utility of Polymerase Chain Reaction for the Diagnosis of Pleural Tuberculosis

There is no exact consensus about the usefulness of the Mycobacterium tuberculosis polymerase chain reaction (PCR) testing for the diagnosis of tuberculous pleural effusion because of the diverse PCR methods and the different diagnostic criteria that are described in other studies. We analyzed pleural effusion specimens obtained from 111 patients for whom the exclusion of the possibility of tuberculous pleural effusion was necessary. We performed M. tuberculosis PCR testing using the Cobas Amplicor MTB test (Roche Diagnostic Systems), which is fully automated and commercially available. Results of the M. tuberculosis PCR test of pleural effusion specimens were positive for 7 (17.1%) of the 41 patients with confirmed pleural tuberculosis and for 3 (18.8%) of the 16 patients with probable pleural tuberculosis. The overall sensitivity and specificity of M. tuberculosis PCR testing of pleural effusion were 17.5% and 98.1%, respectively. The sensitivity of M. tuberculosis PCR testing for each group of patients with tuberculous pleural effusion detected by smear-positive results, smear-negative and culture-positive results, and culture-negative and pleural biopsy-positive results, was 100.0%, 33.3%, and 3.7%, respectively. Of the 57 patients with pleural tuberculosis, only 3 (5.3%) had positive results of M. tuberculosis PCR testing along with negative results of smearing, negative results of pleural pathological analysis, and a low level of adenosine deaminase. For specimens such as pleural effusion, in which the bacillary load is very low, the clinical utility of PCR testing seems highly limited.

Rapid Diagnosis of Tuberculosis in Various Biopsy and Body Fluid Specimens by the AMPLICOR Mycobacterium tuberculosis Polymerase Chain Reaction Test

This study was undertaken to determine the usefulness of the AMPLICOR Mycobacterium tuberculosis (MTB) polymerase chain reaction (PCR) test (Roche Diagnostic Systems, Inc; Branchburg, NJ) in diagnosing TB in tissue and body fluid specimens other than respiratory secretions. Prospective analysis of clinical and laboratory data in patients with suspected TB at the four divisional hospitals of Catholic Medical Center, located in New York. A total of 1,090 tissue and body fluid specimens from 1,032 patients with suspected TB were subjected to acid-fast bacillus (AFB) smear, culture, and the AMPLICOR MTB PCR test. Of the 1,090 specimens, 32 grew M tuberculosis complex and 8 specimens grew isolates belonging to the Mycobacterium avium complex (MAC). The AMPLICOR MTB PCR test was positive for 24 of the 32 specimens that grew M tuberculosis. It was also positive for four additional specimens that were culture-negative for M tuberculosis or MAC. Two of these specimens were from patients with a previously recorded positive sputum culture for M tuberculosis. The AMPLICOR test was negative for all eight specimens that yielded MAC only. When AMPLICOR MTB PCR test results were compared with the confirmed clinical diagnosis of TB, the sensitivity, specificity, positive predictive value, and negative predictive value for the AMPLICOR MTB PCR test were 76.4%, 99.8%, 92.8%, and 99.2%, respectively. PCR results were available within 6.5 hours, compared with an average of 3 weeks for culture of M tuberculosis. These data establish the utility of the AMPLICOR MTB PCR test for the rapid detection of M tuberculosis in tissue and body fluid specimens other than respiratory secretions.