The Diagnostic Value of Endobronchial Ultrasound-Guided Fine Needle Aspiration (EBUS-FNA) in Diagnosing FDG-PET-Avid Lymph Nodes in Extrapulmonary Malignancies.

Background and objective The accurate diagnosis of extrapulmonary malignancies with mediastinal lymphadenopathy is crucial for effective patient management. Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) has emerged as a valuable tool in assessing fluorodeoxyglucose (FDG)-positron emission tomography (PET)-avid lymph nodes (LNs). In this study, we aimed to evaluate the diagnostic value of EBUS-FNA in patients with mediastinal lymphadenopathy in extrapulmonary malignancies and compare its efficacy with PET-CT.  Methodology This retrospective, cross-sectional study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, from February 2018 to February 2023. It included patients with extrapulmonary malignancies with mediastinal lymphadenopathy displaying abnormal PET-CT uptake, with LN diameters ≥5 mm, excluding lung cancer cases. Data on demographics, malignancy type, LN involvement, PET-CT findings, and EBUS-FNA histopathology were collected. EBUS-FNA procedures involved a 22-gauge needle, and samples were analyzed cytologically and histologically. SPSS Statistics version 20 (IBM Corp., Armonk, NY) was used to perform the statistical analysis. Results The study analyzed a total of 216 patients. Males comprised 56.3% of the cohort, and females 43.7%. The most common malignancy was lymphoma (33.0%), followed by breast cancer (12.6%). EBUS-FNA exhibited a sensitivity of 90.9% compared to PET-CT's sensitivity of 72.7%. Lymph node morphology on EBUS showed low echogenicity and irregular borders in malignant cases. Subcarinal and right hilar were the most frequently sampled lymph nodes. The study found significant differences in lymph node characteristics between non-malignant and malignant groups, with EBUS-FNA effectively identifying malignancies.  Conclusions EBUS-FNA demonstrates high sensitivity and diagnostic utility in identifying malignant lymph nodes in patients with extrapulmonary malignancies. Its effectiveness in detecting true positive cases highlights its importance as a complementary diagnostic tool to PET-CT in oncological diagnostics.

Rectovaginal fistula due to undiagnosed rectal tuberculosis in a nulliparous young woman: A case report.

INTRODUCTION: Rectovaginal fistulas (RVFs) can arise from various etiologies, the most common cause especially in developing countries is obstetric injury. Uncommonly, rectal tuberculosis can present as RVF, posing a diagnostic and treatment challenge especially in a patient without established risk factors. The first case of rectal tuberculosis was reported by Davis et al., in 1957, and a 2022 systematic review identified only 28 cases reported since then. PRESENTATION OF CASE: we report the case of a 25-year-old college woman who presented with a 3-month history of lower abdominal pain and fecal passage per vagina. She had undergone a failed RVF repair attempt at another hospital. Examination revealed a single rectovaginal fistula with surrounding granulation tissue, despite the absence of prior TB history. Investigations revealed chronic granulomatous inflammation and acid-fast bacilli on biopsy, confirming rectal tuberculosis as the cause of RVF. She received a 6-month course of anti-tuberculous medication after which she underwent a successful surgical repair of the RVF via a transverse transvaginal approach. DISCUSSION: Rectal tuberculosis is a rare condition, typically occurring in the third and fourth decades of life. The ileocecal junction is the most common site for gastrointestinal TB Risk factors include impaired immunity. It is usually secondary to pulmonary TB, Diagnosis can be challenging due to the varied symptoms, which can overlap with other conditions like rectal cancer. Treatment involves a 6-month course of antituberculosis medication, and surgery may be needed for complications like rectovaginal fistula. CONCLUSION: this case highlights the atypical presentation of tuberculosis and emphasizes the importance of considering tuberculosis as a cause of RVF especially in young patients without apparent risk factors living in TB-endemic areas. It also highlights the challenges in differentiating TB-induced RVF from other causes of RVF.

The outcomes of total knee arthroplasty following the incidental finding of tuberculosis and its treatment: A prospective study.

INTRODUCTION: Extrapulmonary tuberculosis (EPTB) accounts for 16 % of tuberculosis cases globally, with knee joint tuberculosis more prevalent in underdeveloped nations. Total knee arthroplasty (TKA) is commonly used to treat tubercular arthritis of knee, however, there is a marked paucity of research on the outcomes after an incidental diagnosis. The aim of the study is to investigate the outcomes of total knee arthroplasty after an incidental diagnosis of tuberculosis and its management. METHODS: A prospective-observational study was conducted in NCR-Delhi from May 2019 to June 2023, wherein 533 patients had synovial tissue abnormalities and 11 patients reported with positive histopathological examination (HPE) for knee tuberculosis. All the patients whose informed consent was obtained were put on a twelve-month standard treatment (2HRZE or S/10HR) according to World Health Organization (WHO) guidelines for extrapulmonary TB after TKA and were monitored for the outcome of treatment, any postoperative complication, or implant failure. RESULT: The mean age of the patients was 63 ± 13 years and 72.7 % of patients were female. The mean hemoglobin, Body Mass Index (BMI), and Erythrocyte Sedimentation Rate (ESR) values were 10.29 ± 1.36 mg/dl, 29.78 ± 6.1 kg/m2, and 37.37 mm/h respectively and the median of the C-reactive protein (CRP) value was 11 mg/dl at the time of operative procedure. All patients presented with knee-joint pain and swelling and were operated for knee-joint replacement surgery. After one year of standard treatment (2HRZE or S/10HR), no relapses, pain, or progressive radiolucency around the component, or postoperative neurologic or vascular complications were observed. The median range of motion (ROM) was improved from 10 - to 100 to 0-115, the average knee score improved from 44.9 ± 8.9 to 84.9 ± 7.73 points and the average function score improved from 28.82 ± 15.56 to 94.0 ± 7.68 points which were statistically significant at 95 % CI (p < 0.0001). CONCLUSION: We concluded from this study that any abnormalities in ESR, CRP level prior to, and bone tissue or synovial tissue during operative procedure should be considered for articular tuberculosis and managed according to guidelines. This will make replacement procedures more sustainable and effective by lowering the risk of post-operative infection or implant-related complications and improving patients' quality of life.

Bilateral tuberculous dactylitis of both hand and feet in a female toddler: a case report on a rare presentation of skeletal tuberculosis in children.

BACKGROUND: Even though tuberculosis is a common disease among children in developing countries, tuberculous dactylitis is an uncommon form of Skeletal tuberculosis specially with involvement of both the hands and feet. CASE PRESENTATION: A one-and-a-half-year-old previously healthy female Ethiopian toddler presented to our pediatric outpatient clinic with a history of two-month duration of painful multiple swellings over both her hands and feet. The swelling involved the proximal phalanx of the left index finger, dorsum of the right hand, and dorsum of both feet over the first metatarsal bone. Physical examination, radiologic findings, and histopathology suggested tuberculous dactylitis. The patient was treated with anti-tuberculosis drugs for one year and she showed clinical and radiologic improvement and recovery. CONCLUSION: Tubercular dactylitis should be considered in the differential diagnosis of children from endemic areas presenting with bone and joint pain or swelling. Our experience of a twelve-month course of antitubercular treatment, which is in line with WHO recommendations, for skeletal tuberculosis, showed excellent outcomes.

Clinical insights into tuberculosis otitis media: diagnosis, treatment, and management outcomes.

OBJECTIVES: The diagnosis of tuberculosis otitis media (TBOM) remains a great challenge. This study aims to suggest potential diagnostic clues and proper management of TBOM. METHODS: The study is a retrospective review of TBOM cases that were treated at our department, between January 2015 and June 2023. Summarizing their clinical characteristics, diagnosis, and treatment. Additionally, a literature review is conducted. RESULTS: Eight cases of TBOM, 6 female and 2 male patients, median age was 32 years old, were included in the study. TBOM mainly presents with symptoms of otorrhea, hearing loss, and occasional early-onset facial palsy. One case had a positive Purified Protein Derivative (PPD) before the operation. Middle ear tissue was pathologically biopsied in 7 cases, with 3 cases testing positive for Acid Fast Bacillus and 6 cases testing positive for Mycobacterium tuberculosis PCR. Middle ear surgery and Anti-tubercular treatment (ATT) were completed in all cases. The median follow-up was 11 months. No cases of TB relapse were observed. CONCLUSIONS: Proper suspicion and confirmation of TBOM is the primary clinical orientation. Middle ear surgery combination with ATT results in satisfactory outcomes. Hearing reconstruction should be performed after ATT is completed.

The Performance of GeneXpert in the Diagnosis of Lymph Node Tuberculosis: A Prospective Study Comparing GeneXpert and Culture Findings.

Background and objective Lymph node tuberculosis (LNTB) is a common manifestation of extrapulmonary tuberculosis (EPTB). GeneXpert is a rapid diagnostic molecular test that simultaneously detects tuberculosis and rifampicin (RIF) resistance. In this study, we aimed to assess the epidemiology of LNTB and diagnostic performance parameters of the GeneXpert in routine ENT practice. Methods We conducted a cross-sectional prospective study from January to July 2019, in the Department of Otorhinolaryngology and Head Neck Surgery at the Hassan II University Hospital Center of Fez, Morocco. The samples were collected using lymph node biopsy and subjected to GeneXpert assay, culture, and histopathology. Diagnostic performance parameters of the GeneXpert were calculated and compared with culture. Results All patients with cervical adenopathy were included. Lymph node biopsies were performed for all patients. The performance of the GeneXpert was assessed according to culture findings. Among the 75 cases, the mean age was 21.6 ± 12.7 years with a female predominance (60%). GeneXpert was positive in 66.7% of specimens. The sensitivity and specificity of the GeneXpert assay were 78.6% and 40.4% respectively. GeneXpert accuracy was 54.6%. The positive predictive value (PPV) and negative predictive value (NPV) were found to be 44% (95% CI: 30.2-57.8) and 76% (95% CI: 59.3-92.7) respectively. Mycobacterium bovis was isolated in all samples, with no case of resistance to RIF found. Conclusions The performance of GeneXpert was found to be superior in terms of establishing the diagnosis of LNTB. It offers speedy and prompt results and clinicians should adopt it in routine clinical practice.

An Unusual Case Report of Male Genital Tuberculosis.

The burden of extrapulmonary tuberculosis (EPTB) is significant, constituting up to 20% of all TB cases in HIV-negative patients and 50% of new cases in HIV-positive individuals. However, diagnosing EPTB remains challenging due to its pauci-bacillary nature and the necessity for invasive sampling methods in many forms of the disease. Urogenital tuberculosis represents approximately 4% of the annual cases of extra-pulmonary tuberculosis in India, with isolated testicular tuberculosis being a particularly rare manifestation. In this report, we present three cases of testicular tuberculosis, diagnosed through tissue biopsy and Acid Fast Bacilli (AFB) smears.

Impact of fine needle aspiration cytology strategy implemented at the microscopy center level for diagnosis of tuberculous lymphadenitis.

INTRODUCTION: In India, EPTB accounts for about 50% of TB cases especially in people living with HIV/AIDS. Microbiological confirmation is present in only about 15% of EPTB cases. Tuberculous Lymphadenitis is the most common form of EPTB in India, accounting for around 35% of EPTB cases. Fine needle aspiration cytology has been found to be highly sensitive and specific in the diagnosis of tuberculous lymphadenitis with 83-94% accuracy. The procedure of AFB detection is exactly the same for the FNAC obtained smears as for the presently examined sputum smears at the DMCs. The aim of the present study was to determine the feasibility and effectiveness of FNAC strategy implemented at DMC level for detection of tuberculous lymphadenitis cases. METHODS: The present study was a randomized cluster trial with one control and one intervention arm. At the intervention units (DMCs) all suspected tuberculous lymphadenitis cases was subjected to FNAC of the suspected superficial lymph nodes by the trained Medical Officers. The control group was free from any such intervention. Effectiveness and feasibility of FNAC strategy in the intervention group was determined by relevant indicators. RESULTS: At the seven intervention DMCs, FNAC was performed on a total number of 1298 suspected cases of Tuberculous Lymphadenitis. Among them 294 cases were selected in the intervention arm and 196 cases in the control arm. Intervals between advice of FNAC and performance of FNAC as well as start of therapy was significantly low in the intervention arm. Complication was insignificant. The concordance between FNAC reports generated at the DMCs and that at Medical College estimated by agreement measurement kappa (0.970) suggested a high level of agreement. CONCLUSION: Implementation of FNAC strategy at the DMC level for detection of tuberculous lymphadenitis cases was found to be feasible as well as effective.

Clinical Outcomes of Transcatheter Aortic Valve Replacement (TAVR) vs Surgical Aortic Valve Replacement (SAVR) in Patients With Sarcoidosis.

Introduction Data regarding clinical outcomes after transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) in patients with sarcoidosis is lacking. This study aims to clarify the clinical outcomes of TAVR vs SAVR in patients with sarcoidosis. Methods Data was collected from the National Inpatient Sample database from 2016-2019 using validated ICD-10-CM codes for sarcoidosis, TAVR, and SAVR. Patients were divided into two cohorts: those who underwent TAVR and those who underwent SAVR. Statistical analysis was performed using Pearson's chi-squared test to determine clinical outcomes of TAVR vs SAVR in patients with sarcoidosis. Results The prevalence of sarcoidosis was 0.23% among total study patients (n=142,420,378). After exclusions, the prevalence of TAVR was 650 (49%) and SAVR was 675 (51%) in patients with sarcoidosis. Patients who underwent TAVR were on average older (74 vs 65 years old, p=0.001), and more likely to be female (57 vs 40%, p<0.001) compared to patients who underwent SAVR. The TAVR cohort had higher rates of congestive heart failure (CHF) (77.7 vs 42.2%, p=0.001), chronic kidney disease (CKD) (42.3 vs 24.4% p=0.001), anemia (5.4 vs 2.2%, p=0.004), percutaneous coronary intervention (PCI) (1.5 vs 0%, p=0.004), and hypothyroidism (31.5 vs 16.3%, p=0.001) compared to the SAVR cohort. Inpatient mortality post-procedure was higher in the SAVR cohort compared to the TAVR cohort (15 vs 0, p=0.001). Regarding post-procedure complications, respiratory complications were more common in the SAVR cohort (4.4 vs 0%, p=0.001), while TAVR was associated with a higher incidence of permanent pacemaker (PPM) insertion (2.15 vs 0.8%, p=0.001). There was no statistical difference in the development of acute kidney injury (AKI) (0.8 vs 1.5%, p=0.33), AKI requiring hemodialysis (0 vs. 0.7%, p=0.08), or stroke (0.8 vs 0.7, p=1) post-procedure between the two cohorts. Conclusion This study found that in the sarcoidosis population, TAVR was associated with reduced mortality, shorter hospital length of stay, and lower hospitalization costs in comparison to SAVR.