Role of chest radiography in the diagnosis of pulmonary tuberculosis during nCovid19 pandemic.

Pulmonary tuberculosis and nCovid 19 share many common risk factors. nCovid19 may increase the risk to develop pulmonary tuberculosis. Pulmonary tuberculosis may precede, co-exist or follow nCovid19. Careful evaluation of chest radiography is useful to differentiate tuberculosis from nCovid19 bronchopneumonia. Symptoms of tuberculosis may be mistaken for long covid. A normal chest x ray in the absence of sputum production may help to rule out tuberculosis in such cases. All patients with nCovid19 bronchopneumonia should undergo a careful chest x ray evaluation for any lesions suggestive of tuberculosis. All patients with chest radiological abnormality should undergo sputum examination to rule tuberculosis as atypical radiological manifestations may be more common in patients with nCovid19. Symptoms, signs, clinical features and chest radiographic features of Pulmonary tuberculosis and nCovid19 bronchopneumonia may overlap in some cases. Correlation of chest radiographic findings with epidemiologic history, clinical presentation, and RT-PCR test results or in later stages antibody titres will help in confirming or excluding the diagnosis in suspected cases of nCovid19. In pulmonary tuberculosis definitive diagnosis should be established by bacteriological confirmation. Molecular diagnostic tools should be used to confirm or exclude tuberculosis in suspect cases as the results are rapid, accurate and reliable.

Predictors of unfavorable responses to therapy in rifampicin-sensitive pulmonary tuberculosis using an integrated approach of radiological presentation and sputum mycobacterial burden.

INTRODUCTION: Despite the exalted status of sputum mycobacterial load for gauging pulmonary tuberculosis treatment and progress, Chest X-rays supplement valuable information for taking instantaneous therapeutic decisions, especially during the COVID-19 pandemic. Even though literature on individual parameters is overwhelming, few studies have explored the interaction between radiographic parameters denoting severity with mycobacterial burden signifying infectivity. By using a sophisticated approach of integrating Chest X-ray parameters with sputum mycobacterial characteristics, evaluated at all the three crucial time points of TB treatment namely pre-treatment, end of intensive phase and completion of treatment, utilizing the interactive Cox Proportional Hazards model, we aimed to precisely deduce predictors of unfavorable response to TB treatment. MATERIALS AND METHOD: We extracted de-identified data from well characterized clinical trial cohorts that recruited rifampicin-sensitive Pulmonary TB patients without any comorbidities, taking their first spell of anti-tuberculosis therapy under supervision and meticulous follow up for 24 months post treatment completion, to accurately predict TB outcomes. Radiographic data independently obtained, interpreted by two experienced pulmonologists was collated with demographic details and, sputum smear and culture grades of participants by an independent statistician and analyzed using the Cox Proportional Hazards model, to not only adjust for confounding factors including treatment effect, but also explore the interaction between radiological and bacteriological parameters for better therapeutic application. RESULTS: Of 667 TB patients with data available, cavitation, extent of involvement, lower zone involvement, smear and culture grade at baseline were significant parameters predisposing to an unfavorable TB treatment outcome in the univariate analysis. Reduction in radiological lesions in Chest X-ray by at least 50% at 2 months and 75% at the end of treatment helped in averting unfavorable responses. Smear and Culture conversion at the end of 2 months was highly significant as a predictor (p<0.001). In the multivariate analysis, the adjusted hazards ratios (HR) for an unfavorable response to TB therapy for extent of involvement, baseline cavitation and persistence (post treatment) were 1.21 (95% CI: 1.01-1.44), 1.73 (95% CI: 1.05-2.84) and 2.68 (95% CI: 1.4-5.12) respectively. A 3+ smear had an HR of 1.94 (95% CI: 0.81-4.64). Further probing into the interaction, among patients with 3+ and 2+ smears, HRs for cavitation were 3.26 (95% CI: 1.33-8.00) and 1.92 (95% CI: 0.80-4.60) while for >2 zones, were 3.05 (95% CI: 1.12-8.23) and 1.92 (95% CI: 0.72-5.08) respectively. Patients without cavitation, zonal involvement <2, and a smear grade less than 2+ had a better prognosis and constituted minimal disease. CONCLUSION: Baseline Cavitation, Opacities occupying >2 zones and 3+ smear grade individually and independently forecasted a poorer TB outcome. The interaction model revealed that Zonal involvement confined to 2 zones, without a cavity and smear grade up to 2+, constituting "minimal disease", had a better prognosis. Radiological clearance >50% along with smear conversion at the end of intensive phase of treatment, observed to be a reasonable alternative to culture conversion in predicting a successful outcome. These parameters may potentially take up key positions as stratification factors for future trials contemplating on shorter TB regimens.

What did we learn from South Africa's first-ever tuberculosis prevalence survey?

The World Health Organization (WHO) has urged countries to conduct tuberculosis (TB) prevalence surveys to better understand the burden of TB and to enable the WHO to conduct global estimates. Until the report from the first-ever prevalence survey in South Africa (SA), the country had to rely on WHO estimates. The recently published report on the SA TB prevalence survey provides important estimates of the burden of TB disease as well as information on health-seeking behaviour. This review notes the key findings of the 2018 prevalence survey. The high prevalence of TB in SA continues to be a major cause for concern, and calls for a significantly improved response to reach the End TB targets set by the WHO.

PSSPNN: PatchShuffle Stochastic Pooling Neural Network for an Explainable Diagnosis of COVID-19 with Multiple-Way Data Augmentation.

AIM: COVID-19 has caused large death tolls all over the world. Accurate diagnosis is of significant importance for early treatment. METHODS: In this study, we proposed a novel PSSPNN model for classification between COVID-19, secondary pulmonary tuberculosis, community-captured pneumonia, and healthy subjects. PSSPNN entails five improvements: we first proposed the n-conv stochastic pooling module. Second, a novel stochastic pooling neural network was proposed. Third, PatchShuffle was introduced as a regularization term. Fourth, an improved multiple-way data augmentation was used. Fifth, Grad-CAM was utilized to interpret our AI model. RESULTS: The 10 runs with random seed on the test set showed our algorithm achieved a microaveraged F1 score of 95.79%. Moreover, our method is better than nine state-of-the-art approaches. CONCLUSION: This proposed PSSPNN will help assist radiologists to make diagnosis more quickly and accurately on COVID-19 cases.

Unusual association of COVID-19, pulmonary tuberculosis and human immunodeficiency virus, having progressed favorably under treatment with chloroquine and rifampin.

Infection with the new coronavirus has been declared an international health emergency. Its curative treatment is unknown and is the subject of several clinical trials. In addition, the concomitant association of COVID-19 with tuberculosis and the human immunodeficiency virus, hitherto never described, is potentially fatal. We report the illustrative case of a 32-year-old patient who presented this trifecta of infections and who did well under treatment with chloroquine and anti-mycobacterial drugs. This patient arrived at the ER with respiratory discomfort that had been evolving over a month with symptoms of flu and deterioration of her general condition. A chest CT scan revealed an aspect of lung miliary tuberculosis with isolation of Koch's bacilli in the sputum. A polymerization chain reaction (PCR) was positive for COVID-19 on a nasopharyngeal swab. HIV serology was positive. The course was marked by a spectacular clinical improvement and two negative COVID-19 PCR controls at the end of treatment (at days 9 and 10). Anti-tubercular drugs (especially, rifampin) are powerful enzyme inducers that can reduce the effectiveness of chloroquine in our patient. This therapeutic success may be linked to the effect of anti-tubercular drugs against SARS ncov-2, especially rifampin, inhibiting the formation of messenger RNAs of SARS ncov-2 or to the synergistic effect of chloroquine and rifampin. Researchers should explore the effect of these drugs on SARS ncov-2.