Laparoscopic evaluation of female genital tuberculosis in infertility: An observational study

Background & objectives: Female genital tuberculosis (FGTB) is an important variety of extrapulmonary TB causing significant morbidity, especially infertility, in developing countries like India. The aim of this study was to evaluate the laparoscopic findings of the FGTB. Methods: This was a cross-sectional study on 374 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling/biopsy for acid-fast bacilli, microscopy, culture, PCR, GeneXpert (only last 167 cases) and histopathological evidence of epithelioid granuloma. Diagnostic laparoscopy was performed in all the cases to evaluate the findings of FGTB. Results: Mean age, parity, body mass index and duration of infertility were 27.5 yr, 0.29, 22.6 kg/m2 and 3.78 years, respectively. Primary infertility was found in 81 per cent and secondary infertility in 18.18 per cent of cases. Endometrial biopsy was positive for AFB microscopy in 4.8 per cent, culture in 6.4 per cent and epithelioid granuloma in 15.5 per cent. Positive peritoneal biopsy granuloma was seen in 5.88 per cent, PCR in 314 (83.95%) and GeneXpert in 31 (18.56%, out of last 167 cases) cases. Definite findings of FGTB were seen in 164 (43.86%) cases with beaded tubes (12.29%), tubercles (32.88%) and caseous nodules (14.96%). Probable findings of FGTB were seen in 210 (56.14%) cases with pelvic adhesions (23.52%), perihepatic adhesions (47.86%), shaggy areas (11.7%), pelvic adhesions (11.71%), encysted ascites (10.42%) and frozen pelvis in 3.7 per cent of cases. Interpretation & conclusions: The finding of this study suggests that laparoscopy is a useful modality to diagnose FGTB with a higher pickup rate of cases. Hence it should be included as a part of composite reference standard.

Diagnostic Yield of Xpert MTB/RIF in Bronchoalveolar Lavage in Children with Probable Pulmonary Tuberculosis

Objective: To evaluate utility of XpertMTB/RIF in bronchoalveolar lavage fluid in childrenwith probable pulmonary tuberculosis. Methods: Children with probable pulmonarytuberculosis with negative smear and Xpert on induced sputum/gastric aspirate weresubjected to bronchoalveolar lavage (BAL) for Xpert assay and mycobacterial liquid culture.Data of children <14 y undergoing bronchoscopy for suspected MDR-TB (n=12) were alsoanalyzed. The sensitivity of Xpert in BAL fluid for diagnosis of probable and confirmedpulmonary tuberculosis was calculated with clinico-radiological diagnosis and culture as goldstandards, respectively. Results: Of 41 enrolled children, 24 (58.5%) had Xpert positive inBAL fluid and 11 (26.8%) had culture confirmed tuberculosis (BAL fluid;10; sputum,1). Thesensitivity of Xpert in BAL fluid among probable and culture confirmed tuberculosis caseswas 58.5% (24/41) and 81.8% (9/11), respectively. Conclusion: Xpert in bronchoalveolarlavage fluid has good sensitivity in both probable and confirmed pulmonary tuberculosis inchildren

Comparison of interferon gamma release assay & tuberculin skin tests for diagnosis of latent tuberculosis in patients on maintenance haemodialysis.

Background & objectives: Tuberculosis (TB) is a common infection in patients on haemodialysis. There is a definite role of treatment of latent TB (LTB) in these patients. However, diagnosis of LTB in these patients by tuberculin skin test (TST) is unreliable. There is suggestion that interferon gamma release assay (IGRA) will be more reliable test for diagnosis of LTB in this setting. Thus, we evaluated value of IGRA and TST for the diagnosis of LTB in patients on dialysis in an Indian setting. Methods: Patients with end stage kidney disease on dialysis were included. Patients with active TB were excluded. Each patient was subjected to TST (induration of ≥10 mm was taken as positive) and QuantiFERON TB Gold In-Tube test (QFT-GIT) for diagnosis of LTB. Results: A total of 185 patients were included; 129 (69.7%) were males and mean age was 36.7 ± 12.3 yr. Past history of TB was present in 18 (9.7%) patients. One hundred and thirty four (72.4%) patients had scar of BCG vaccination. QFT-GIT test was positive in 66 (36%), TST in 32 (17%) and both in 13 (7%) patients. Of the 66 patients positive with QFT-GIT, only 13 (19.6%) were positive for TST. Of the 32 patients positive with TST, only 13 (40.6%) were positive with QFT-GIT; 100 (54%) patients were negative for both the tests. Overall, 85 (45.9%) patients were positive for either of the two tests. Poor agreement was shown between the two methods. On logistic regression analysis, odds of QFT-GIT to be positive in patients with BCG vaccination was 1.23 and with history of TB 0.99, both being insignificant. odds of tuberculin skin test to be positive in patients with BCG vaccination was 1.04 and with history of TB 0.99, both again being insignificant. Interpretation & conclusions: Our findings showed that more number of patients (36%) on haemodialysis were positive for QuantiFERON Gold In-Tube test as compared to TST (17%). There was poor agreement between the two tests. no significant effect of BCG vaccination and history of TB in past was observed on both tests.

mRNA and DNA PCR tests in cutaneous tuberculosis.

Background: The microbiologic diagnosis of cutaneous tuberculosis is difficult because most lesions harbor only a small number of mycobacteria that cannot usually be detected by staining for the organism or by culture. Nucleic acid amplification tests based on the polymerase chain reaction (PCR) are potentially useful in this situation. Aims: To evaluate the utility of mRNA PCR and DNA PCR in the diagnosis of cutaneous tuberculosis. Methods: Biopsies from 28 cases of cutaneous tuberculosis and 19 controls with other diseases were subjected to microbiologic tests including direct smears for mycobacteria, culture and both mRNA PCR and DNA PCR. The laboratory was blinded to the clinical diagnosis. Results: None of the patients or controls showed a positive reaction on mRNA PCR test. Seven of 28 cases and 5 out of 19 controls showed a positive result on DNA PCR test yielding a sensitivity of 25% and a specificity of 73.7%. Conclusion: The results of PCR tests in cutaneous tuberculosis should be interpreted in the light of clinical and histopathological findings.

Diagnostic potential of 16 kDa (HspX, α-crystalline) antigen for serodiagnosis of tuberculosis.

Background & objectives: Tuberculosis (TB) is a public health problem worldwide. Rapid and accurate diagnosis of tuberculosis is crucial to facilitate early treatment of infectious cases and to reduce its spread. The present study was aimed to evaluation of 16 kDa antigen as a serodiagnostic tool in pulmonary and extra-pulmonary tuberculosis patients in an effort to improve diagnostic algorithm for tuberculosis. Methods: In this study, 200 serum samples were collected from smear positive and culture confirmed pulmonary tuberculosis patients, 30 tubercular pleural effusions and 21 tubercular meningitis (TBM) patients. Serum samples from 36 healthy, age matched controls (hospital staff), along with 60 patients with non-tubercular respiratory diseases were also collected and evaluated. Humoral response (both IgG and IgA) was looked for 16 kDa antigen using indirect ELISA. Results: Sensitivity of detection in various categories of pulmonary TB patients ranged between 73.8 and 81.2 per cent. While in the extra-pulmonary TB samples the sensitivity was 42.8 per cent (TBM) and 63.3 per cent (tubercular pleural effusion). The test specificity in both the groups was high (94.7%). All of the non-disease controls were negative. Among non-tubercular disease controls, five patients gave a positive humoral response against 16 kDa. Interpretation & conclusions: Serodiagnostic tests for TB have always had drawbacks of suboptimal sensitivity and specificity. The antigen used in this study gave encouraging results in pulmonary TB only, while in extra-pulmonary TB (tubercular meningitis and tubercular pleural effusion), this has shown a limited role in terms of sensitivity. Further work is required to validate its role in serodiagnosis of TB especially extra-pulmonary TB.

Mycobacterial infections in human immuno-deficiency virus seropositive patients: role of non-tuberculous mycobacteria.

BACKGROUND: There is high prevalence of tuberculosis in patients with HIV infection; hence the role of non-tuberculous mycobacteria (NTM) in HIV patients has always been undermined. NTM may be responsible for clinical disease in a substantial number of immuno-compromised HIV sero-positive individuals even in a country endemic for Mycobacterium tuberculosis (M. tuberculosis). The study was designed to look for the contribution of NTM to morbidity in HIV seropositive patients. MATERIAL AND METHODS: In a prospective study of ninety-four HIV seropositive individuals presenting with pulmonary or extra-pulmonary symptoms suggestive of mycobacterial infection, appropriate samples were collected and processed. Detailed clinical history was utilized to differentiate colonization or contamination by NTM from true lung disease. RESULTS: Fourteen samples grew mycobacterial species, 8(57.2%) being NTM. The distribution of NTM was--3 M. avium complex, 2 M. fortuitum, 2 M. vaccae, 1 M. phlei. 6 isolates were M. tuberculosis. CONCLUSION: NTM may be responsible for a significant proportion of mycobacterial infections in HIV seropositive individuals. Despite the high endemicity of tuberculosis in developing countries like India, the presence of NTM should be ruled out; especially in immuno-compromised HIV seropositive individuals before instituting anti-tubercular therapy empirically. In addition, non-response of NTM to ATT may be wrongly attributed to multi-drug resistant tuberculosis.

PCR diagnosis of tuberculosis--experience in India.

Rapid and accurate diagnosis of tuberculosis is the cornerstone of global tuberculosis control programmes. With increasing incidence of tuberculosis epidemics, the low sensitivity and the length of time taken by traditional diagnostic modalities have hampered the efforts to interrupt disease transmission. Introduction of Polymerase Chain Reaction has enhanced the diagnostic predictability of the disease especially in the extrapulmonary, paucibacillary samples. High specificity and sensitivity have been reported in different samples. The technique is capable of picking as few as ten to fifty tubercle bacilli. When PCR technique is performed under quality controlled conditions, false negatives (due to underfined polymerase inhibitors) and false positives (due to cross contamination during sample collection or in the laboratory) can easily by avoided. Samples from sites with a possible latent infection focus or DNA from dead bacilli may give a positive reaction. The use of PCR with traditional diagnostic tools along with clinical presentation can prove helpful in patients presenting with a diagnostic dilemma.