Epidemiology of multidrug-resistant, extensively drug resistant, and totally drug resistant tuberculosis in Middle East countries

The 2015 represent the deadline for the global tuberculosis [TB] targets set through the Mil-lennium Development Goals [MDG]

From 2016 and onward, new goals were set to end the global TB epidemic via implementing new campaign entitled [the End TB Strategy]

The major hurdle to end TB epidemic in several parts of the world is the emergence and spread of drug resistant Mycobacterium tuberculosis [MTB] strains. The better understanding of the actual global burden of drug resistant tuberculosis would feed into better implementing the End TB Strategy. In this article we summarize the current knowledge on the patterns of drug resistance tuberculosis cases in the Middle East countries. These countries are served by the Eastern Mediterranean Regional Office [EMRO], one out of six regional offices of World Health Organization. Middle East countries are characterized by geographic vicinity and population's interaction. However, they are dissimilar in several aspects such as economy and health infrastructures. Regarding economy, countries in this region are ranging from wealthy to very poor. Prevalence of tuberculosis and patterns drug resistance tuberculosis cases are also following variable trends within countries of this region. In almost all Middle East countries, there is under-reporting of drug-resistance tuberculosis cases

There are shortages in the infrastructures and facilities for detecting the pattern of drug-resistance tuberculosis. For instance, sixout of 14 countries have neither in-country capacity nor a linkage with a partner laboratory for second-line drug susceptibility testing and only 4 countries have registered site performing Xpert MTB/RIF

[Prevalence of non-tuberculosis mycobacteria in patients referring to Mycobacteriology Research Center of Iran]

Considering the increasing significance of diseases due to NTM all over the world, we investigated the burden of such diseases in our region. The aim of this study was to assess NTM prevalence from different clinical samples during a period of 8 years in Massih Daneshvari Hospital, in Iran. This descriptive study was performed on 8322 samples obtained from pulmonary TB patients in Mycobacteriology Research Center from 2004 -2012. Using Tb1 and Tb2 primers, a 190 bp fragment of IS6110 gene was amplified in order to identify Mycobacterium species. Specimens with negative IS6110 PCR results were analyzed with PCR-RFLP using hsp65 gene, for NTM investigation. Out of 8322 samples, we identified 124 [1.5%] strains of NTM. The mean age of the patients was 57 +/- 18/9 years [age range: 7 - 88 years]. 55/6% of the patients were male. The most common species detected in our study were Mycobacterium simiae [44.3%], Mycobacterium chelonae [16.9%] and Mycobacterium kansasii [12.9%]. We found a high prevalence rate of Mycobacterium simiae among our patients. Treatment protocols for NTM are different from the protocols for Mycobacterium tuberculosis complex, so early diagnosis of these species will be of great importance

Drug resistance pattern and outcome of treatment in recurrent episodes of tuberculosis

Patterns of drug resistance in recurrent cases of tuberculosis may be different than in those without a history of treatment. In this retrospective study, the drug resistance pattern and outcome of treatment with DOTS category I [CAT I] regimen was compared in 63 recurrent cases and 872 new cases of pulmonary tuberculosis from April 2003 to January 2008 at the National Research Institute of Tuberculosis and Lung Disease in Tehran, Islamic Republic of Iran. Resistance to isoniazid and ethambutol was significantly more common in recurrent cases, but there were no differences in rates of resistance to rifampin, pyrazinamide, streptomycin or the rate of multi-drug resistant strains. Resistance to streptomycin was the most common. No significant differences in treatment outcome and deaths were found between the 2 groups. Due to the low frequency of multi-drug resistance in the recurrent cases, a CAT I regimen may be suitable for empirical therapy before drug sensitivity results become available

[Investigation of the relationship between polymorphism of IFN-gammaR1 [-611],IFN-gamma[2109] and IL-12B[-1188] genes and pulmonary TB]

A large number of factors are involved in the development of TB, but the most important one belongs to the host genetic factors. One of the genetic factors is cytokine gene polymorphisms. The results of recent studies indicate that IL-12 and IFN-gamma play a central role in regulating the type and level of immune response in mycobacterial infections. Mutations in these genes may be associated with susceptibility to pulmonary TB. The aim of this study was to investigate the frequencies of IFN- gamma [2109], IFN-gamma R1 [-611] and IL-12B [-1188] genes polymorphisms and their relationships with susceptibility to pulmonary TB in Iranian population. This was a case-control study. Thirty TB patients with positive smears hospitalized in TB departments of Masih Daneshvari Hospital and 30 healthy controls with no history of TB were selected for this study. Genotypes of IFN- gamma [2109], IFN-gamma R1 [-611] and IL-12B [-1188] genes were determined by using PCR-RFLP method. The PCR-products were analyzed by use of restriction enzymes. The data were analyzed by means of SPSS and Hardy - Weinberg equilibrium. Considering IFN-gamma R1 [-611] and IL-12B [-1188] genes there was a significant difference between the control and study groups [P < 0.05], but in regard to IFN- gamma [2109], this difference was not detected between the two groups. Mutation in the regions of -611 of IFN-gamma R1 and -1188 of IL-12B genes may increase the host susceptibility to mycobacterium tuberculosis and genotyping of these regions can be used for screening of the high risk individuals

[Comparison of the genetic convergence degree of mycobacterium tuberculosis [TB] strains isolated from patients infected with TB by MIRU-VNTR technique]

In recent decades, epidemiology has significantly been considered in hygienic studies and disease control, and has made a way into all the programs and hygiene policies. By examining the convergence of harmful lineage genetic patterns, the common infectious resources among the patients can be inferred. The purpose of this study was to compare the Mycobacterium Tuberculosis genetic patterns convergence isolated from patients infected with Mycobacterium Tuberculosis by MIRU-VNTR technique. After isolation the samples from Lowenstein Jensen culture environment and taking segregate tests and drug susceptibility, the DNA was extracted using CTAB/Nacl technique. The genetic patterns of lineages were calculated according to 12 loci format with MIRU-VNTR technique. Demographic and molecular information of patients was used for epidemiological purposes. After performing drug sensitivity test, 65/140 [64/4%] samples fall into MDR, 29 [20/7%] samples in non MDR category, and the rest of them were among drug. sensitive lineages. Lineage genetic pattern analysis indicated that 49 [35%] of samples related to Delhi/CAS, 28 [20%] to Uganda I, 16 [11/4%] to New I, 1 [0.7%] to EAI, 3[2/1%] to Haarlem, and 5[3/5%] to H37RV families. The genetic pattern convergence comparison exhibited that the most common and variant genetic patterns was seen in Tehran province which were mostly connected to south [from the South of Tehran to Azadi Square] and to the border cities neighboring Afghanistan, Iraq, Turkmenistan and cities with extreme percentage of immigration, all of which signified shared polluted resources among patients

[Identifying Mycobacterium tuberculosis resistance to rifampin by multiplex specific PCR method]

Mycobacterium tuberculosis is still considered the most common cause of death cases related to pathogenic infectious factors in the world. Rifampin is among the most important first-line drugs to treat tuberculosis. The most common mutations in resistance to Rifampin occur due to the displacements in Codons 531, 526, and 516 in rpoB gene. This study was carried out with the aim of introducing the method [Multiplex Allele Specific] PCR in order to identify tuberculosis patients resistant to rifampin through detecting mutations in the rpoB gene. In this study, three cases of mutation were evaluated in three Codons of rpoB gene in 90 samples of the positive cases of culture from pulmonary TB patients who had referred to Research Center of Mycobacteriology located in Masih-Daneshvari Hospital of Tehran from 1385 to 1387 after the drug sensitivity test. To examine three codons 531, 526 and 516, MAS PCR method was used. The results of the culture showed that 33.3% of the samples were sensitive and 66.6% were resistant to drugs of which 44.4% were resistant to Rifampin. By using MAS PCR method, 32.2% of these cases of resistance were identified. Among these cases, 43.4% had mutation in codon rpoB 531, 34.5% in rpoB 526 codon and 31% in rpoB 516 codon. Based on the results of this study, MAS PCR method used in this research is an accurate and appropriate method to rapidly diagnose resistance to Rifampin in the clinical samples of Mycobacterium tuberculosis

Comparison of the genetic convergence degree of Mycobacterium tuberculosis [TB] strains isolated from patients infected with TB by MIRU-VNTR technique

In recent decades, epidemiology has significantly been considered in hygienic studies and disease control, and has made a way into all the programs and hygiene policies. By examining the convergence of harmful lineage genetic patterns, the common infectious resources among the patients can be inferred. The purpose of this study was to compare the Mycobacterium tuberculosis genetic patterns convergence isolated from patients infected with Mycobacterium Tuberculosis by MIRU-VNTR technique. After isolation the samples from Lowenstein Jensen culture environment and taking segregate tests and drug susceptibility, the DNA was extracted using CTAB/NaCl technique. The genetic patterns of lineages were calculated according to 12 loci format with MIRU-VNTR technique. Demographic and molecular information of patients was used for epidemiological purposes. After performing drug sensitivity test, 65/140 [64/4%] samples fall into MDR, 29 [20/7%] samples in non MDR category, and the rest of them were among drug - sensitive lineages. Lineage genetic pattern analysis indicated that 49 [35%] of samples related to Delhi/CAS, 28 [20%] to Uganda I, 16 [11/4%] to New I, 1 [0.7%] to EAI, 3[2/1%] to Haarlem, and 5[3/5%] to H37RV families. The genetic pattern convergence comparison exhibited that the most common and variant genetic patterns was seen in Tehran province which were mostly connected to south [from the South of Tehran to Azadi Square] and to the border cities neighboring Afghanistan, Iraq, Turkmenistan and cities with extreme percentage of immigration, all of which signified shared polluted resources among patients

[Relationship between TNF-alpha gene polymorphisms and susceptibility to pulmonary tuberculosis]

Tuberculosis [TB] caused by Mycobacterium tuberculosis, is an infectious disease in human which kills nearly three millions of people annually. Approximately, one - third of the world populations are infected with this bacteria and 5 - 10% of them develop the active form of the disease. Individuals are different in susceptibility to TB infection. These differences might be due to the host characteristics especially genetic factors. TNF- alpha as a pro-inflammatory cytokine, plays a key role in host defense against tuberculosis. Presence of mutation in this gene can influence the effectiveness, performance and capability of immune responses against TB infection. The Aim of this study was to investigate the frequency of TNF- alpha gene polymorphisms and its relation with susceptibility to the pulmonary TB. Sixty healthy controls and 60 TB patients were enrolled. Genotype of TNF[-238], TNF -244, TNF[-308], TNF[-857] and TNF[-863] were determined using PCR-RFLP method. The results were analyzed by Fisher Exact and kappa[2] tests using SPSS v.14 and evaluated with Hardy-Weinberg equilibrium. The results of this study showed a significant difference in TNF-308 and TNF [-857] regions between the control and study groups [P < 0.05]. Presence of mutation in TNF[-308] and TNF [-857] regions may increase the host susceptibility to mycobacterium tuberculosis and genotyping of these regions can be used for screening of the high risk individuals

[ rapid identification of atypical mycobacterium in pulmonary tuberculosis [PTB] patients: evaluation of QUB3232 locus using the VNTR method]

Identification of atypical mycobacterium [Non tuberculosis Mycobacterium; NTM] is important because of the worldwide propagation of these organisms. Recently, molecular studies have identified the specific loci for mycobacterium species by DNA - finger printing methods, but these methods are time-consuming and expensive. In this study, in addition to hsp65 PCR-RFLP method, QUB3232 locus was evaluated for differentiation of atypical mycobacterium from mycobacterium tuberculosis complex. This study was performed on 371 pulmonary and non pulmonary specimens separated from patients with the symptoms of pulmonary tuberculosis [PTB]. After the isolation and culturing of mycobacterium strains using the Lowenstein Jensen media, biochemical tests including production of Niacin, Catalase activity, Nitrate reduction, pigment production and growth rate were performed. Drug susceptibility testing was performed by proportional method. DNA extraction was performed by phenol-chloroform method. hsp65 gene was amplified by PCR. Subsequently the amplicons were digested with three restriction enzymes namely AvaII, HphI and HpaII and electrophoresed on 3% agarose gel. QUB3232 locus was also evaluated for differentiation of atypical mycobacterium and mycobacterium tuberculosis complex. Out of 371 isolates, 32 [8.6%] were multi-drug resistant TB [MDR-TB], 184 [49.5%] were susceptible and 155 [42.5%] were non MDR [combined resistance] that 15% of MDR cases and 25% of non MDR cases were non tuberculosis mycobacterium. Out of 31 slow growing isolates, 58% were M. simiae and 19% were M. kansasii. The sensitivity of QUB3232 locus for differentiation of the atypical mycobacterium from mycobacterium tuberculosis complex was 80%. From the total of 43 NTM samples, 12 [27.9%] were rapid growing and 72% were slow growing. QUB3232 locus has the high discriminative power for differentiation of atypical mycobacterium from the mycobacterium tuberculosis complex, therefore, it can be used as a substitute for PCR-RFLP method

[Mycobacterium tuberculosis complex strains identification with spoligotyping method in patients attending to Masih Daneshvari Hospital]

Spoligotyping is a method based on 36bp Direct Repeat [DR] chromosomal loci polymorphism which is connected to one or two 35-41 bp spacer sequences. There are 94 different intra DR spacer sequences which are identified so far and only 43 of them are used as usual. Mycobacterium tuberculosis complex strains can be identified based on lacking or having these sequences. Spoligotyping test was carried out on 238 TB smear positive patients. Primary separation of mycobacterium strains was done through Petrof 4% method and Lowenstein Jensen [LJ] media. Biochemical tests such as Niacin test/Catalase activity/Nitrate reduction were done in order to identify the strains. Drug sensitivity to INH [0.2Mg/ml]/ RIF [40Mg/ml]/ STM [10Mg/ml] and ETBl [2Mg/ml] identified by proportional method and according to that, the strains were divided into three groups: sensitive, multi drug resistance [MDR] and non MDR. Then DNA was extracted by CTAB method from the positive colonies. Sequences were amplified by PCR and after denaturizing, hybridization with Streptavidine peroxidase enzyme was performed by Line reverse blot method. Radiography was done after adding the Luminoscense and membrane onto the X-ray films. Serotypes were divided into 9 groups [Beijing/ CAS1/ Haarlem / U/ T2/ T1/ EAI3/ EAI2 and CAS2]. Most of the strains were from Haarlem [27%] and CAS1 [25%] groups. Two strains were also identified in this method that belonged to Mycobacterium bovis. Spoligotyping method is an easy, rapid and sensitive test in order to identify Mycobacterium tuberculosis complex strains

Microsatellite instability in young women with endometrioid type endometrial cancer

This study was designed to determine the frequency of Microsatellite Instability [MSI] in young Iranian patients with endometrial carcinoma and to evaluate its association with histopathologic and clinical features of disease. Microsatellite status was analyzed in 23 patients with endometrioid type endometrial cancer who were less than 55 years. Clinicopathologic characteristics such as age, International Federation of Gynecology and Obstetric [FIGO] grading and staging of tumor, family history of Hereditary Non-polyposis Colorectal Cancer [HNPCC], oral conception [OC] consumption, number of pregnancies, fertility, menstrual cycles and underlying disease were considered. Chi-square and Fisher exact tests were used to find the significant relationships. MSI analysis showed 8 patients [34.8%] were MSS [Microsatellite Stable], 15 patients [62.5%] were MSI positive. Among cases with MSI phenotype, 4 cases [17.45] had low instability [MSI-L] and 11 cases [47.8%] had high instability [MSI-H]. Three cases with MSI-H had family history of HNPCC related cancers. Five cases [21.7%] had infertility in which 4 of them [80%] had MSI phenotype. There was no statistically significant relationship between MSI phenotype and tumor grade and stage. Few studies reported high frequency of MSI among young patients. Some studies mentioned similar results in endometrioid type of tumor. This study showed even higher frequency [65%] when MSI analyzed in young endometrioid type endometrial patients. Most cases with infertility had MSI-H phenotype. It may suggest that beside women with family history of HNPCC, EC screening using MSI would be beneficial in infertile women too

Clinical and laboratory profile of patients with tuberculosis/HIV coinfection at a national referral centre: a case series

This case series describes the clinical and laboratory profile of 15 patients with tuberculosis [TB] HIV coinfection admitted to a referral centre in the Islamic Republic of Iran. Most of the patients [13] were male; the mean age was 36.9 years. Intravenous drug use was the route of transmission for all males and heterosexual intercourse for the 2 females; 12 patients had a history of imprisonment. All patients had pulmonary TB; 13 were smear-positive and all except 1 had atypical radiological presentation. Drug-induced hepatitis occurred in 3 patients and 12 had hepatitis C coinfection. Five patients died. The mean CD4 count was 229.2 [SD 199.5] cells/mm[3] and 78.6% had CD4 count < 350. TB may be an AIDS-defining illness in this country

Tuberculosis of the breast: report of 4 clinical cases and literature review

Nearly 18% of tuberculosis [TB] cases have only extrapulmonary manifestations. Breast tuberculosis is a rare type of extrapulmonary TB. This paper reports 4 cases of breast TB confirmed either pathologically or mycobacteriologically or both. These reports showed that TB should always be considered first in the differential diagnosis of granulomatous mastitis in TB-endemic areas. Therapy included at least 6 months of anti-TB medication and surgery when indicated

Impact of anti-tuberculosis therapy on plasma zinc status in childhood tuberculosis

This study compared plasma zinc levels in 15 children with active pulmonary tuberculosis, 15 malnourished children and 15 healthy children. Mean plasma zinc concentrations in children with tuberculosis [71.7 microg/dL] were not significantly different than the other 2 groups [72.5 and 76.9 microg/dL]. The zinc status of the children with tuberculosis was evaluated after 2 months and 4 months of DOTS therapy. The serum zinc level during anti-tuberculosis therapy decreased after 1 month and then recovered to the initial level after 4 months of treatment

Primary and acquired drug resistance in childhood tuberculosis

This study determined the resistance pattern of Mycobacterium tuberculosis to 4 first-line anti-tuberculosis drugs in children with pulmonary tuberculosis at the Iranian National Research Institute of Tuberculosis and Lung Diseases from 1999 to 2004. There were 350 children with positive cultures over the study period: 7 [2%] were resistant to at least one of the 4 anti-tuberculosis drugs. Primary resistance was detected in 4 cases and secondary resistance in 3 cases. Most cases [6] were among Afghan refugees. Resistance to rifampicin both in primary and secondary resistances was high, showing that children in the Islamic Republic of Iran face the threat of drug-resistant tuberculosis transmission

[A survey of detecting Chlamydia pneumoniae DNA with the aid of PCR in human coronary arteries and ascending aorta at postmortem and in alive patients]

Atherosclerosis is an important agent of mortality and morbidily among humans. Knowledge of the causative and precipitating factors of atherosclerosis is therefore highly important. Among the factors, infections have been cited among which Chlamydia pneumoniae. Accordingly we performed a systemic dissection of the 3 coronary arteries and ascending aorta in 49 postmortem subjects who underwent operation and 5 atherosclerotic plaques in alive subjects and studied the relationship in individual persons between the presence of Chlamydia pneumoniae DNA and the number of major risk factors. Other major risk factors comprising age, sex, blood pressure, diabetes mellitus, smoking, hypercholestrolemia and history of deaths due to heart ailment in families were also studied. From each vessels, two sections were obtained, one determining pathological grading of atherosclerosis [study classification], and other determining the prevalence of Chlamydia pneumonia DNA by polymerase chain Reaction [PCR] method. PCR was performed in Pasteur Institute. C.Pneumoniae was detected by PCR in 14 [25.9%] out of 54 subjects. 19 segments of vessels were positive for C. Pneumoniae out of which 16 segments [84.2%] had atherosclerosis and an equal or more than 3 in pathologic gradings. In the C. Pneumoniae positive patients, in comparison of the two groups comprising of patients with one or more risk factors, no statistically significant difference was seen [P>0.05]. This study opens up the path for management strategies in eradicating C. Pneumoniae, and decreasing morbidity, mortality secondary to atherosclerosis

Reasons for delay in the management of patients with pulmonary tuberculosis

The study assessed reasons for delay between patient's first symptoms of tuberculosis and initiation of therapy. Fifty newly diagnosed cases of pulmonary tuberculosis admitted to the NRITLD in Teheran were studied. Mean patient delay before consulting a physician was 12.5 +/- 10 days, significantly higher among men than women. Mean delay until the physicians' diagnosis was 93 +/- 80 days, significantly higher for women than for men. Almost no treatment delay was observed [mean 4 +/- 4 days after diagnosis had been confirmed]. The major delay was the time taken by physicians to diagnose tuberculosis in symptomatic patients. An active and effective national tuberculosis programme is needed in the Islamic Republic of Iran, with integration of the programme in medical school curricula and in continuing professional training

Study of bacterial agents of intestine in infants under one year of age suffering gastroenteritis observed among the Iraqi refugees residing at Iran's western camps

One hundred and thirty specimens of faeces of infants under one year old suffering from gastroenteritis and residing at the Camp of Iraqi Kurdish refugees [Paveh and Sar Pol Zahab cities] were collected and evaluated from the point of some bacterial agents. At the same time, some important clinical findings and environmental conditions were also collected for the study. The results showed that gastroenteritis mostly had a rapid incidence accompanied by fever, pain, straining, tenesmus and mucus-containing faeces. From a total number of 130 specimens collected, 10% Proteus, 18%Pseudomonas, 10%Aeromonas, 1%Serratia, 1% enteropathogenic E. coli, 4% Klebsiella, 2% Shigella, and 3% Yersinia were isolated. Antibiotic sensitivity test indicated a severe resistance of opportunistic pathogens against two antibiotics, i.e., chloramphenicol and co-trimoxazole which were mostly isolated in Sar-PolZahab Camp. We can link this to prophylaxis with these two antibiotics the result of which is the augmentation of normal flora and its change to pathogens. The studies have shown that there is a significant relation between the camp's living conditions, nutrition, public health and isolated microbes

Childhood respiratory tuberculosis in Iran

To estimate the bacterio-epidemiological situation of childhood respiratory tuberculosis in Iran, 2185 symptomatic patients of 0-14 years old were studied. Among 110 bacteriologically confirmed cases, 60% were less than five years old and the number of females was slightly more than males. In 21% of patients, the Mantoux test was negative. None of the miliary cases had a history of BCG vaccination. In 54.6% of patients less than two years old, one of the family members was suffering from infectious tuberculosis. Clinical findings were fever, cough, weight loss and respiratory distress respectively. Radiological findings were mostly pneumonia or bronchopneumonia-like infiltrations and in 44% of cases were found in the right lung. Mycobacterium tuberculosis strains in 11.7% of patients were resistant to isoniazid or streptomycin