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Non-Respiratory Tuberculosis
Published in Peter D O Davies, Stephen B Gordon, Geraint Davies, Clinical Tuberculosis, 2014
Uveitis and choroiditis are associated with underlying TB disease. Where there is overt clinical disease elsewhere, such as on chest x-ray or in lymph nodes, the diagnosis is easily made. More often there is no overt TB disease, but the diagnosis needs to be considered in high-prevalence countries and in high-prevalence groups in developed countries, when other causes of ocular inflammation (e.g. HLA-B27, rheumatological or sarcoid associated forms) have been excluded. The diagnosis is rarely confirmed by histology or bacteriology, or even PCR, from ocular tissue. The new Interferon Gamma Release Assay (IGRA) tests seem to be more accurate than the tuberculin skin test in diagnosing underlying TB infection but cannot confirm disease [204,205] because no single test is diagnostic [206]. Ultimately, a trial of full TB treatment may be required [207], although not all respond and some may need additional local or systemic anti-inflammatory treatment [208]. When giving a six-month course of TB treatment, because of concerns regarding the use of ethambutol in patients with reduced visual acuity, there is a case for using moxifloxacin instead of ethambutol for the initial two months. Moxifloxacin had been shown to have better early bactericidal activity [209], and sterilising activity [210], than ethambutol in pulmonary disease. The avoidance of ethambutol in the regimen by using 2RHZMoxi/4RH means that any reduction in visual acuity during treatment is clearly due to the underlying ocular inflammation and not due to drug toxicity, allowing additional anti-inflammatory treatment to be given if needed [208].
Respiratory Disease
Published in John S. Axford, Chris A. O'Callaghan, Medicine for Finals and Beyond, 2023
Ian Pavord, Nayia Petousi, Nick Talbot
Definitive diagnosis requires direct visualization and/or culture of M. tuberculosis. In suspected cases, the priority should be obtaining a specimen for microbiological analysis. Bloods: These are often normal, but baseline tests are required prior to treatment.Sputum microscopy and culture: This is the first-line investigation in patients with a productive cough. Send at least two samples. If negative, consider bronchoscopy with lavage, pleural aspiration or lymph node biopsy.Chest X-ray: Classically there is upper-zone cavitating opacity with lymphadenopathy. There may be a pleural effusion. Miliary deposits are usually visible on X-ray but easily missed.CT scan: A scan is not required if the chest X-ray is classic, but it may be helpful to guide bronchoalveolar lavage. Cavitating consolidation and ‘tree-in-bud’ nodularity is typical of active disease.Microbiology: Ziehl–Neelsen staining is used to visualize mycobacteria. Conventional culture and drug susceptibility testing can take 4–6 weeks or longer as M. tuberculosis is slow-growing. PCR may be used for more rapid diagnosis and can identify genetic mutations predictive of resistance to rifampicin. Whole genome sequencing can provide rapid diagnosis and predict susceptibility across a wider range of drugs, but its use is not yet widespread.HIV testing: This should be offered to all patients with TB.Mantoux test (tuberculin skin test): This is not recommended in the investigation of active disease. It is usually strongly positive in that setting, but a positive test can reflect latent TB or BCG vaccination. False negatives can occur in miliary TB or HIV.Interferon-gamma release assay (IGRA): A highly sensitive assay of the cellular response to TB, IGRA is useful in identifying latent TB but unable to distinguish between latent and active disease, so it is not recommended for investigation of the latter.Histopathology: Caseating granulomas are typical but not diagnostic. All specimens should also be sent for microbiological analysis (without fixative).
The Application of T.SPOT-TB Assay for Early Diagnosis of Active Tuberculosis in Chronic Kidney Disease Patients Receiving Immunosuppressive Treatment
Published in Journal of Investigative Surgery, 2020
Haitao Wang, Songlan Wang, Lengnan Xu, Yonghui Mao
TB screening in CKD patients could provide early diagnosis of asymptomatic or minimally symptomatic active TB and may detect latent TB infection (LTBI), enabling the initiation of preventive therapy for patients at high risk of developing active disease. The traditional tuberculin skin test is inexpensive and supported by robust evidence, but it carries a higher rate of false-negative results in the kidney disease population than in the general population [4]. Recently, an interferon-gamma release assay, T-SPOT.TB, was developed. The assay measures an antigen-specific immune response to Mycobacterium tuberculosis infection and shows promises in TB diagnosis in many populations. The T-SPOT.TB assay utilizes two specific antigens encoded by the regions in the M. tuberculosis genome to stimulate T cells. The interferon-gamma released by these T cells is detected in the peripheral blood via enzyme-linked immunoassays. A positive T-SPOT.TB result indicates activation of M. tuberculosis-specific T cells, suggesting infection with the pathogen [5]. Although use of the assay has been reported in many countries [6,7], there are limited data on its use in clinical settings in China.
Vitamin D Levels in Active TB, Latent TB, Non-TB Pneumonia and Healthy Children: A Prospective Observational Study
Published in Fetal and Pediatric Pathology, 2018
Danilo Buonsenso, Michela Sali, Davide Pata, Enrico Masiello, Gilda Salerno, Manuela Ceccarelli, Giovanni Delogu, Piero Valentini
Nevertheless, the high TST conversion rate may reflect a “booster phenomenon” observed after repeated TST, rather than acquisition of LTBI, even though this would not explain why a statistically significant higher conversion rate was found only in one group. Unfortunately, while interferon gamma release assay (IGRA) was performed at baseline in both groups, it was not performed at the end of follow up. This would have been an important data since a booster phenomenon with IGRAs has not yet been described. In any case, these findings deserve a strong consideration if we consider that the macrophage is the first cell of the immune response that encounters the tubercle bacilli in the alveoli. A strengthened macrophage response, obtained by basal higher vitamin D levels, could allow the definitive elimination of tubercle bacilli before the development of the first stages of TB infection. This hypothesis would sustain Ganmaa’s findings [44]. Recently Cegielsky et al. [45] hypothesized that a constantly sufficient level of vitamin D, acting as an enforcement of the initial response to Mtb, could avoid the occurrence of multidrug resistant (MDR)-Mtb.
A case of otitis media with ANCA-associated vasculitis accompanied with pituitary mass successfully treated by corticosteroids
Published in Modern Rheumatology Case Reports, 2018
Hidenori Takahashi, Hiroto Tsuboi, Naoto Umeda, Hirofumi Toko, Fumika Honda, Ayako Ohyama, Saori Abe, Masahiro Yokosawa, Hiromitsu Asashima, Shinya Hagiwara, Yuya Kondo, Isao Matsumoto, Yuki Hirose, Akira Hara, Takayuki Sumida
On admission to our hospital, she presented with saddle nose deformity (Figure 1(A,B)) and left facial nerve palsy (House-Brackmann Classification of Facial Function; Grade II. mild dysfunction [10]). The ear and nose investigation by the otolaryngologist revealed bilateral middle ear effusion and bilateral severe conductive-sensorineural hearing loss with positive air-bone gaps on pure tone audiometry (Figure 1(C)). Bilateral tympanic tube insertions were ineffective. Laboratory data showed increased white blood cell count (WBC) (12,500/μL) and C-reactive protein (CRP) (0.26 mg/dL; normal range was <0.2), with normal liver, kidney, and urinary panels. The MPO-ANCA titer was slightly increased at 4.3 U/mL (normal range was <3.5) while other autoantibodies such as PR3-ANCA, anti-nuclear antibody (ANA), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (CCP) antibody were all negative. Serum IgG and IgG4 were within the normal range (975 mg/dL and 48 mg/dL, respectively). Tuberculosis-specific interferon gamma release assay was negative. (1-3)-β-D-glucan, serum antigens of Aspergillus, Candida, and Cryptococcus neoformans, and cytomegalovirus antigenemia were all negative. Thus, we thought that IgG4-related disease, mycotic and tuberculosis otitis media, and cytomegalovirus infection were excluded in this patient.