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Objective: To determine the types, clinical spectrum and outcome of Extra-Pulmonary Tuberculosis (EPTB) in children admitted at a tertiary care hospital. Study Design: Cross Sectional study. Setting: The Children's Hospital and The Institute of Child Health, Lahore. Period: May to December 2019. Material & Methods: A total of 63 patients diagnosed with EPTB aged 1 month to 16 years were included. All patients with lung involvement were excluded from the study. Anti-tuberculous therapy (ATT) was started in all patients and outcome was monitored during the hospital stay. Results: In a total of 63 patients, mean age was 9.03+3.1 years. There were 35 (55.5%) male and 28 (44.4%) female. The mean duration of symptoms at the time of presentation was 5.93+2.4 months. The common sites of EPTB were meninges noted in 17(26.9%), pleural in 13 (20.6%), abdominal in 12 (19.04%), lymph nodes in 11 (17.4%), disseminated in 6 (9.52%) and bone and joints in 4 (6.34%) patients. The most common systemic complaints were fever in 58 (92.06%), weight loss in 48 (76.1%) and anorexia in 45 (71.4%). After treatment, fifty-four patients improved and discharged while 9 (14.2%) patients died. Conclusion: The commonest sites of EPTB were meninges, pleural, abdomen and lymph nodes. Fever, weight loss and anorexia were the most frequent systemic complaints. Most of the patients recovered while the most common cause of mortality was tuberculous meningitis.

Mycobacterium tuberculosis as the bacteria that causes TB disease where the healing process takes a long time, using boredom and drug blockages in TB sufferers. This is one reason germs become resistant to several types of anti-tuberculosis drugs known as TB Multi Drug Resistance (MDR TB). The molecular rapid test (TCM) method using GenExper can quickly determine ATD resistance. This study aims to see the results of TCM examination using GenExper in patients with pulmonary tuberculosis and extra pulmonary tuberculosis at dr. Pirngadi Medan. This study used a cross-sectional method by taking laboratory data from the GenExper examination contained in the medical records of patients diagnosed with tuberculosis at Pirngadi Hospital, Medan. Samples obtained from patients using GenExper from January to December 2018 obtained 354 patients with 68.1% more TB incidence in male patients (241/354) than women by 31.9% (113/354). The patients most affected by TB were elderly people aged 56-65 years with a proportion of 23.7%. The largest population affected by TB is self-employed 30.5% and the highest level of education diagnosed is high school graduates 60.5%. Most patients suffered from pulmonary TB at 86.4%.

Diagnosing EPTB is difficult as various clinical presentations are seen with paucibacillary nature of the disease. Maurya AK et al. (J Postgrad Med 58(3):185–189) AFB smear hasn’t been much effective in diagnosing of EPTB. Tuberculosis of head and neck diagnosis can be missed due to large number of smear negative cases, leading false negative cases increase. CBNAAT is cartridge-based nucleic acid amplification test which detects the presence of TB bacilli this study we have examined the effectiveness of CBNAAT for diagnosing EPTB with cervical lymphadenitis and compared with Sputum AFB Microscopy smear. Aims and objective 1.To study the role of cartridge-based nucleic acid amplification test (CBNAAT) in early diagnosis of extra pulmonary tuberculosis. 2 Comparative analysis of CBNAAT with AFB smears in EPTB. Type of Study Descriptive retrospective observational study was done at the department of ENT and Head & surgery, A.B.V. Govt medical college, Vidisha, M.P, India. Result Out of 184 patients 43 samples were AFB smear positive and 141 were negative. In CBNAAT 88 out of 184 and 96 were found to be negative.32 patients were negative on Sputum microscopy AFB analysis but found to be positive on CBNAAT. Sensitivity of CBNAAT was 86% AFB 64%, Specificity of CBNAAT, AFB is 91% and 89% respectively. Our study finds that CBNAAT is much more effective in diagnosis of EPTB with cervical lymphadenitis when compared to AFB smear microscopy alone.

Mycobacterium tuberculosis (MTB), a bacterium which causes the tuberculosis disease, is one of the most trounce disease in the country. It mainly affects the lungs and other parts of the body. Currently smear-positive cases are further confirmed through chest radiography for PTB. These cases are further subjected for short course chemotherapy (SCC), followed by first line primary drugs, a scheme undertaken by National Tuberculosis Programme to overcome PTB infection. However, the identification of infection through smear-negative results are challenging as the cases may become positive over the time and progresses to cause the Extra Pulmonary Tuberculosis (EPTB). Such infections are asymptomatic and referred to as latent infection, where, MTBremains stable for many years at a specific site and later activates. Worldwide about 10-25% of latent infections progress to an active disease and if undiagnosed, the mortality rate may reach up to 50%. Twenty five percent of EPTB infection differs from organ to organ of the body. However, in such cases, diagnosis may be elusive and is usually delayed. The proper identification of infection that strongly focuses on the infection of either i.e., TB or EPTB is the need of the hour. The diagnosis of EPTB will be elusive, necessitating a high index of suspicion over TB or EPTB. However, smear-negative cases may be positive for EPTB infection, where the suspects are to be further subjected for molecular methods of EPTB detection and confirmation.

BACKGROUND AND OBJECTIVES: The burden of tuberculosis (TB) in India is the highest accounting for 26% of the global incidence. A total of 1.4 million people died from TB in 2019 (including 208 000 people with HIV). India accounts for a fourth of the global burden of TB and 29% of global mortality. Therefore, we carried out this study to compare demographic, lifestyle and clinical characteristic between pulmonary TB (PTB) and extrapulmonary TB (EPTB). MATERIALS AND METHODOLOGY:Aretrospective analysis was carried of 348 patients diagnosed in DOTS centre, Pravara Rural Hospital, Loni. Characteristics of demographic and clinical characteristics were obtained from medical case records. RESULTS:Among the 348 cases, 71.3% were PTB and 28.7% were EPTB including, pleural (36%), meningeal (27%) and lymphatic (20%) cases. The male to female ratio in PTB and EPTB are 1.99 and 1.22 respectively. EPTB was more common at younger age (

Early diagnosis of tuberculosis continues to be a challenge for clinicians. The World Health Organization (WHO) guidelines recommend the application of GeneXpert MTB/RIF in extra-pulmonary tuberculosis (EPTB) diagnosis. This study aimed to test and compare the accuracy of the GeneXpert MTB/RIF assay to diagnose pulmonary tuberculosis (PTB) and EPTB, compared to bacterial culture and to composite reference standard (CRS). The GeneXpert assay diagnosed tuberculosis (TB) in 19.5 % of patients. With reference to bacterial culture, the sensitivity of this assay for detection of the pulmonary and extra-pulmonary specimens was perfect. For pulmonary specimens, on using CRS; the detected sensitivity and specificity of the GeneXpert assay were 78.3 % and 99.1 %, respectively. However, for extra-pulmonary specimens, the sensitivity and specificity of the GeneXpert assay were 37.1 % and 99 %, respectively. In the current study, the GeneXpert assay showed almost perfect agreement with the bacterial culture for TB diagnosis. The diagnostic accuracy of the GeneXpert assay was high in ruling in, but not in ruling out of EPTB.

Despite the efforts made to fight the tuberculosis, Mycobacterium tuberculosis still remains a public health problem, particularly for low-income countries. According to the World Health Organization data, our country, Mali has detected only half of the 10,385 cases of tuberculosis expected for 2014 for a population of 17,309,000 inhabitants. The objective of this present work was to describe the different clinical aspects and the epidemiology of tuberculosis at Hospital Somin&eacute Dolo in Mopti. We performed a retro-prospective and descriptive of tuberculosis cases diagnosed in our department of medicine between May 2016 and August 2018. A total of 96 tuberculosis cases were recorded, i.e. 4.6% and 1.0% for hospitalizations and consultations patterns, respectively. The median of age was 41 with extremes from 5 to 80 years. The age group [31 - 40 years] was the most affected with 20.8%. Men and women were affected in identical proportions, i.e. 50%. Pulmonary locations were the most frequent with 55.2%. Pleural tuberculosis was far the most frequent of the extra-pulmonary forms with 24.0% followed by the peritoneal and bone localization with 6.3% each. The majority of patients were followed on an outpatient basis, i.e. 90.6%. The disease lethality was 7.3%. Our data show that the cases of extra-pulmonary tuberculosis are in an increasing proportion and their diagnosis confirmation remains difficult in our context.

Introduction Pulmonary tuberculosis (PTB) is one of the rare pulmonary infections causing hyponatremia (serum sodium ˂135 mmol/L) and severe hyponatremia (serum sodium ˂125 mmol/L). Although the major cause of hyponatremia in TB patients is syndrome of inappropriate antidiuretic hormone (SIADH) secretion, cerebral salt wasting syndrome (CSWS) can occur and requires evidence of inappropriate urinary salt losses and reduced arterial blood volume. Adrenal insufficiency (AI) is rare in TB with scanty literature describing it. The two reported cases highlight three possible causes of severe symptomatic hyponatremia in TB pleural effusion and disseminated TB, their treatment modalities, and the need to increase the index of suspicion to diagnose TB hyponatremia in children. Case Report Case 1: a 10-year-old girl with TB pleural effusion who developed recurrent hyponatremia in the first few weeks of anti-TB treatment which was responsive to sodium correction. Case 2: an 8-year-old girl presenting to our facility with presumptive TB. She deteriorated over several months and progressed to disseminated TB with AI. Discussion Early diagnosis and prompt and correct treatment of TB hyponatremia cannot be overemphasized, as AI, SIADH secretion, and CSWS, each require different therapeutic regimens, most especially AI on its own poses a huge clinical challenge. Conclusion A high index of suspicion, with intensified case finding at all levels of care, is necessary to identify and manage children with TB hyponatremia because early diagnosis and prompt treatment is lifesaving.

Tuberculosis (TB) has reemerged as one of the main cause of death in human beings in recent years. TB is caused by a group of species called Mycobacterium tuberculosis complex, and it causes three million deaths each year around the world. In 2010, the global estimated incidence of TB was about 8.0 million. The number of deaths from TB among HIV-negative patients was 1.0 million while the number of deaths among the HIV-positive TB was about 0.40 million. The higher incident and elevation of MDR cases demand efforts to shift focus to various control strategies against TB. According to WHO, in 2014 magnitude of TB was recorded as 126 positive cases per 0.1 million population in the world. Pakistan ranks fourth in high TB burden countries where each year approximately 297,000 TB cases are reported. Tuberculosis can be comprehensively grouped into two main types; pulmonary and extra pulmonary tuberculosis. Pulmonary tuberculosis affects the lungs and is most common type of TB. In 15 to 20 % cases of the active TB, the infection spreads from lungs to different parts of the body. This condition is called extra-pulmonary tuberculosis. Different treatment regimens are available for tuberculosis.

Background: It is important to determine the type of tuberculosis and its related factors in order for effectively treating a disease and reducing its side effects in the society. Objective: This study aimed to determine vitamin D level in patients with pulmonary and extra-pulmonary tuberculosis in Karaj, Iran in 2017-2018. Materials and Methods: In this observational study, 102 patients suffering from pulmonary and extra-pulmonary tuberculosis disease were availably selected in Karaj, Iran in 2017-2018. They were examined and, then, their vitamin D level were assessed and compared according to the type of tuberculosis. Results: The study results showed that vitamin D level was normal in 39.2% of the case study population, but it was abnormal in 60.8% of it (18.6% deficiency and 42.2% insufficiency). Vitamin D deficiency was 15.8% in pulmonary tuberculosis patients and it was 22.2% in extra-pulmonary tuberculosis ones, showing no significant difference (P>0.05) statistically. Conclusion: According to the obtained results, hypovitaminosis-D was detected in more than half of the patients with pulmonary and extra pulmonary tuberculosis, which was not associated with the type of tuberculosis. Seemingly, the patients needed the same amount of – or even more – food, medical supplements, sports, and sunlight compared to healthy people.

Introduction: Tuberculosis is a common condition in underdeveloped countries, with approximately 100,000 cases in Nepal today. Tuberculosis is the 6th leading cause of death in Nepal. This study aims to find out the Extra Pulmonary Tuberculosis in the specimen received in the pathology lab. Method: This is a retrospective descriptive study of the histopathology database of Extra Pulmonary Tuberculosis at the pathology lab of Patan Hospital, Nepal from 2012 to 2019. Data were analyzed for prevalence, cite, and pathology details. Ethical approval was obtained from the Institutional review committee of Patan Hospital. Result: There were 300(1%) Extra Pulmonary Tuberculosis out of 29629 specimens. The majority 170(57%) were from the lymph nodes, 36(12%) skin, followed by intestine and urogenital each 28 and 26(9%). Male to female ratio was 2:3 (n=116, 39% vs n=184, 61%). The most common age group was 20-39 years comprising 194(64%). Granuloma was present in 288(96%), and 21(7%) tested positive for Acid Fast Bacilli. Conclusion: Among the Extra Pulmonary Tuberculosis, more than half of them had tubercular lymphadenitis with granuloma present in the majority.

Introduction: Tuberculosis (TB) is still a leading cause of death in many parts of the world. Adept techniques of rapid detection, isolation, identification and susceptibility testing of Mycobacterium tuberculosis (M.tb) are essential for management. Our aim was to compare the sensitivity and rapidity of smear microscopy, concentration method, rapid slide culture, Lowenstein - Jensen (LJ) culture and MGIT semiautomated culture methods in detection of Mycobacterium tuberculosis among smear negative pulmonary TB and extra pulmonary TB cases and to detect the drug resistance pattern to first line drugs among M.tb isolates. Materials and Methods: A prospective study was conducted for one year between January 2016 to January 2017 in the Department of Microbiology at a tertiary care hospital. Sputum smear negative pulmonary and extra pulmonary specimens were subjected to direct microscopy by Zeihl-Neelsen and fluorescent staining. Culture was done by Rapid slide culture, Lowenstein-Jensen media (LJ media) and BACTEC MGIT system. Positive isolates were confirmed by appropriate biochemical reactions and rapid immunochromatographic test. Drug susceptibility testing was done for first line drugs. Results: The sensitivity of direct microscopy was 3% and after concentration it was 4%. Overall culture positivity was 12%. Detection rate by LJ method, rapid slide culture method and MGIT methods was 6%, 4% and 12% respectively. The mean detection time was 22.5 days by MGIT and 31.5 days by conventional LJ method. Conclusion: This study highlights the importance of culturing suspected smear negative pulmonary and extra pulmonary Tuberculosis cases prior to empirical therapy. Newer automated culture methods aid in earlier detection of cases. Keywords: Extrapulmonary tuberculosis, MGIT, Mycobacterium tuberculosis, Smear negative tuberculosis.

Background Currently there is no guideline based on preoperative clinical parameters for assessing the prognosis of the adjunctive surgery for drug-resistant tuberculosis. Methods We retrospectively analyzed 138 patients who had undergone surgical resection as a treatment for drug- resistant tuberculosis after 24 months. Four clinical parameters on lesion type, treatment history, body physiological status, and surgery approach were evaluated. Categorical preoperative clinical parameters were analyzed by ordinal logistic regression model when considering postoperative complications as outcomes ordered in terms of severity. Statistically significant parameters were then combined in a single classification system for predicting the outcomes of the adjunctive surgery. Findings Diffused, progressive bilateral lesions, or active/progressive extra pulmonary tuberculosis (L3), and history of less than 2 months treatment before surgery (T3) were the strongest predicative parameters for postoperative complications and for surgery failure. Classification systems based on the four parameters were found to have a statistically significant effect on postoperative complications and postoperative efficacy. 24- month follow up indicated a high cure rate (above 95.5%) among patients without T3, L3, or severe physiological complications (B3). Interpretation A classification system based on objective clinical parameters showed predicative value for the prognosis of the adjunctive surgery and could guide management of drug-resistant Tuberculosis.

Suprasellar tuberculomas are uncommon causes of intracranial tumours worldwide, even in areas endemic for tuberculosis. Often, they present with combinations of pituitary hormone involvement, which can lead to various complications due to hypopituitarism. We present a rare case of suprasellar tuberculoma leading to diabetes inspidus.

Because of the current limits of immunological tests in the diagnosis of tuberculosis there is a need to identify new and rapid tests that can be carried out on a large scale in endemic countries and useful in the identification of infected subjects, but also able to discriminate those with latent infection from subjects with active. We have taken into consideration and analysed the LIODetect®TB-ST Tuberculosis Rapid Test, a membrane test for the qualitative detection of specific IgG, IgA, and IgM antibodies against Mycobacterium tuberculosis, performed on serum, plasma, or whole blood.85 samples positive to QuantiFERON TB-GOLD PLUS test were processed using this test and the results obtained were concordant with clinical diagnosis.To our knowledge, the LIODetect®TB-ST Tuberculosis Rapid Test is the only test; that identifies active tuberculosis disease with high sensitivity and specificity and its use might be of help in the diagnosis of tuberculosis, especially in endemic countries.

Introduction: Extra-pulmonary tuberculosis is a major public health issue with a significant cause of morbidity and mortality in developing countries. Diagnosis is difficult due to various clinical presentations and pauci-bacillary nature. The less number of tubercular bacteria at extra-pulmonary sites may cause diagnostic difficulty demanding for rapid, sensitive and specific test. Material and Methods:It was a 1 year retrospective study in tertiary care hospital. Different extra-pulmonary samples received by laboratory were included in the study. Microscopy by ZN stain, culture on Lowenstein-Jensen media and RT-PCR on ABI 7300 was performed after decontamination of the samples using 4% NaOH and 2.9% sodium citrate. Results:Total 300 extra-pulmonary samples were tested. 122 samples were positive by either method. Sensitivity of PCR was 59%. ZN microscopy and culture method showed 46% and 48% sensitivity respectively. Tubercular bacilli were isolated were mainly body fluids, pus and endometrial biopsy. The most common age group affected was 20-29 years. Conclusion:PCR is still a good diagnostic tool for extra-pulmonary tuberculosis even if CBNAAT is available. Even more comparative studies should be done between different molecular methods, so that in future the best option for diagnosis of extra-pulmonary tuberculosis without much more false negative results will be available. Keywords: Extra pulmonary, Tuberculosis, PCR

Disseminated Tuberculosis is a potentially lethal disease if not diagnosed and treated early. Therefore a high index of clinical suspicion for early diagnosis and timely institution of anti-tuberculosis treatment is important. We report a case of an elderly female who presented with complaints of weight loss, generalised fatigue, altered sensorium and moderate hypercalcemia. Investigations excluded multiple myeloma and hyperparathyroidism. A PET scan to rule out occult malignancy showed suspicious uptake in juxtaphrenic nodes and terminal ileum. Biopsy of lymph nodes showed granulomatous inflammation with detection of Mycobacterium tuberculosis by GeneXpert. Culture of the tissue yielded Mycobacterium tuberculosis. The patient showed good clinical response to anti-tuberculosis treatment.

Background Anterior cervical tuberculous abscess is a rare presentation of extrapulmonary tuberculosis even in endemic countries. Case presentation We report a case of a 14-year-old girl with a 5 day history of an anterior mass. The diagnosis of an infected fourth branchial cleft cyst was first evoked. Fine-needle aspiration cytology was suggestive of tuberculosis. Polymerase chain reaction analysis was the key to the diagnosis of a tuberculous abscess. Conclusions In endemic countries, abscesses occurring in uncommon sites should be dealt with a high degree of suspicion for tuberculosis. Early diagnosis is essential to initiate specific and effective treatment. Pre-operative diagnosis avoids invasive surgery and related complications.

Tuberculosis is a global problem and incidence of extra pulmonary tuberculosis is increasing day by day. Diagnosis of extra pulmonary tuberculosis is a little bit difficult than pulmonary tuberculosis.Aim and Objective: The aim of this study is to correlate between isolates of mycobacterium in GeneXpert and ZiehlNeelsen (ZN) staining. It also detects the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of GeneXpert assay and ZN staining.This prospective study was carried out in the Department of Microbiology, RIMS, Ranchi, Jharkhand. Seventy two samples from suspected patients of Extra pulmonary tuberculosis were taken. These samples were processed for test in GeneXpert assay, ZN staining and MGIT culture. Mycobacterium tuberculosis complex isolated from culture was taken as gold standard and compared with result of GeneXpert and ZN staining. Result: Out of 72 samples, detection rate of GeneXpert, MGIT and ZN staining were 27.77%, 26.38% and 18%. The sensitivity, specificity, PPV and NPV of ZN staining and GeneXpert were 63.15%, 98.11%, 92.3%, 88.13% and 94.73%, 96.22%, 90%, 98% respectively. GeneXpert is a rapid and easy method for extra pulmonary tuberculosis diagnosis. It not only detect the bacilli but also diagnose rifampicin drug resistance. This method prompts in diagnosis and treatment.

Background: Few studies have explored the relative burden and trends in pulmonary (PTB) vs. extra-pulmonary (EPTB) tuberculosis in the United States using a nationally representative sample. Methods: This study examined trends in hospitalization rates, length-of-stay (LOS), in-hospital mortality and inflation-adjusted charges, for PTB vs. EPTB using the Nationwide/National Inpatient Sample (NIS) from 1998 to 2014. Descriptive and multivariable analyses (linear, negative binomial and logistic) were utilized adjusting for demographics, co-morbidity and hospital characteristics. Results: During the study period there were a survey-adjusted, estimated 258,631 PTB (75.5%), 76,476 EPTB (22.3%) and 7552 concurrent PTB and EPTB (2.2%) discharges. Whites accounted for 27.6% of PTB, 21.9% of EPTB and 17.6% of concurrent discharges; and self-pay or no insurance accounted for 22.2%, 18.4%, and 25.9%, respectively. EPTB was more common among blacks (22.5%), and combined TB more common among Hispanics (24.8%). Mean LOS was 11.4 days, 13.2 days, and 19.5 days; with mean nominal charges of $48,031, $62,255, and $89,364 for PTB, EPTB and combined TB respectively. Inpatient mortality for all three groups was approximately 5.7%. Miliary TB and TB of meninges and central nervous system were positively associated with mortality (odds ratios of 2.44 and 2.11, respectively), as was alcohol abuse (OR 1.21). Trend analyses showed decreased hospitalizations for all TB types, no change in LOS trends, decreased mortality for PTB and ETB and increased charges for PTB and ETB from 1998 to 2014. Increased utilization, higher charges and higher risk of mortality (to some extent) among the EPTB cases warrant improved methods for screening, diagnosis and treatment. Conclusion: Though rates of TB hospitalization are declining, EPTB is becoming relatively more common and is more costly compared to pulmonary TB. Screening methods that focus on identification of ETB contrary to current practice guidelines are needed to aid ETB case finding. Keywords: Tuberculosis, Epidemiology, Health care utilization, Alcohol, Health care disparities

Objectives: Extra Pulmonary Tuberculosis (EPTB) presents with atypical symptoms and heterogeneous clinical features. Management of EPTB including diagnosis, localization, extension and monitoring treatment response of active disease is quite challenging. Moreover, localization of active disease, differentiation between active and latent disease by conventional methods is troublesome. So this study was done to evaluate the metabolic activity of active disease by 18F Flurodeoxyglucose (FDG) PET-CT in diagnosed cases of EPTB patients. Patients and methods: A total of 17 patients with EPTB were included in this study. FDG PET-CT scan was performed to evaluate the metabolic activity of tubercular lesions before anti-TB treatment. Clinical features, biochemical changes including ESR, WBC count, CRP, MT test and maximum standardized uptake value (SUVmax) of most intense FDG avid lesions and sizes were recorded in 18F FDG PET-CT scan. Results: All 17 patients (09 female, 08 male) had lymph node involvement, two had bone TB and two had abdominal TB. Active TB lesions showed increased FDG uptake in extra-pulmonary tubercular lesions in 16 patients. The mean SUVmax value of the involved lymph nodes were 9.4 ± 6.0 and the mean size (maximum diameter) 19.8 ± 10.4 mm (mean ± SD). One histologically proven EPTB patient had non avid lesions in FDG PET-CT scan. Conclusion: 18F FDG PET-CT scan plays an important role in the localization, extension and differentiation between active and latent TB. In this study, the metabolic activity and size of the involved tubercular lymph nodes were increased in active lesions. Increased FDG uptake in active tubercular lesions may help in treatment monitoring of EPTB. Non avid lesions in EPTB patients revealed suggested latent TB which can change further management plan. Although PET-CT is an expensive technology, application of this sophisticated imaging technique in atypical or doubtful cases of EPTB might modify the treatment plan significantly after proper evaluation of the disease status. , 18F FDG PET-CT scan will be helpful to evaluate the disease status and modification of treatment regime in non-responders cost-effectively. A nationwide large-scale study would be the better way for clinical validation. Bangladesh J. Nuclear Med. 22(1): 9-14, Jan 2019

Introduction: Extrapulmonary Tuberculosis (EPTB) has been increasingly diagnosed and reported compared to Pulmonary TB (PTB) in Bhutan in the recent years. In this comparative study, our study describes the epidemiology, diagnostic modalities used, inconsistency in case-classification and treatment outcomes of PTB and EPTB cases diagnosed from 2015-2017. Methods: A retrospective descriptive study was conducted by retrieving patient records maintained at the 11 TB Reporting Centres. Using two stage cluster sampling technique, nine primary sampling units (9-PSUs) were generated for the years 2015, 2016 and 2017 respectively. Based on the highest caseloads among 32 TB Reporting Centres, nine primary clusters were selected first and final sample of 350 for each year were drawn using systematic random sampling technique from the PSUs. Results: We recruited a total of 1048 cases (PTB=555, EPTB=493) in the final descriptive analysis. The median age of the subjects was 27 years (range 1-87) with slight female predominance (53%). Students were the highest (23.85%) followed by farmers (17.94%). The proportion of PTB was (52.95%), EPTB of (47.08%) and clinically diagnosed EPTB accounted for (92%), which is extremely high. Twelve miliary/disseminated TB cases (1.15%) were miss-classified as EPTB and (56%) EPTB cases were not classified based on the body sites involved. The overall treatment success rate (TSR) of PTB and EPTB was (93.26%). Conclusion: We recommend an expert team to revisit National TB treatment guidelines on diagnosis of EPTB and ensure EPTB site/s are properly identified and documented. Sensitize clinicians and other units (ENT, Surgery, Orthopedics, MCH, General OPD etc.) on the referral of EPTB cases to Medical Specialist/Chest Physician for consultation.

Background Diagnosis of extra pulmonary tuberculosis (EPTB) is challenging due to its atypical clinical presentation and frequently results in a delay or deprivation of treatment. Apart from rapid case detection, early determination of MDR status is imperative in such situations. The commercially available Geno Type MTBDRplus assay version 2.0 (Hain Lifescience, Nehren, Germany) detects both the presence of Mycobacterium tuberculosis (MTB) complex as well as the presence of INH and Rifampcin resistance. We aim to evaluate the role of this test in diagnosis and detection of resistance by comparing its performance against gold standard i.e. culture and against the composite reference standards (CRS) in the diagnosis of EPTB. Material and methods The data of 130 EPTB samples processed form January 2014 till May 2017 at Poona Hospital and Research centre were selected for the study. All the samples were processed for Ziehl–Neelsen stain, Geno Type MTBDRplus assay (LPA) and liquid automated culture (BacT/Alert) simultaneously. Geno Type MTBDRplus assay (LPA) was performed directly on the samples. The 24 samples giving positive results on LPA and grown M. tuberculosis on culture were subjected to anti mycobacterial susceptibility testing for 1st line anti-tubercular drugs by BACTEC MGIT 320 system. Results Out of 130 samples, 7 samples grew atypical mycobacterium and all the 7 samples turned negative on Line Probe Assay. Direct LPA on processed samples yielded 48/130 (36.9%) positivity. Geno Type MTBDRplus assay was positive for M. tuberculosis in (72.09%) 31/43 culture positive cases and (21%) 17/80 of culture negative cases. Geno Type MTBDRplus assay sensitivity and specificity results were assessed in comparison to CRS made up of culture results and clinical, radiological and histological findings. The overall sensitivity of Geno Type MTBDRplus assay was 45.19% (47/104) and specificity was 94.73 (18/19). Out of 24 samples which were compared for results between LPA and culture, Geno Type MTBDRplus assay accurately identified 3 of 3 of Rifampcin resistant strains and 20 of 21 Rifampcin sensitive strains. Geno Type MTBDRplus assay identified 4 of 4 INH resistant strains and 19 of 20 INH sensitive strains and MDR was obtained for 3 of 3 strains. Conclusions Geno Type MTBDRplus assay can give early diagnosis and sensitivity for both INH and Rifampcin in extra pulmonary samples. More number of studies is further required to establish Geno Type MTBDRplus assay as an important tool for obtaining diagnosis and resistance to first line drugs in extra pulmonary samples.

Diagnosis of Tuberculosis (TB) is a challenging problem with the currently available conventional methods such as microscopy for Acid Fast Bacilli (AFB) and culture techniques.The diagnosis of Extra pulmonary tuberculosis (EPTB) is still more challenging due to the low yield of bacilli in the clinical specimens. Recently, a chip based Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) was introduced in India. This study was conducted for finding out the sensitivity and specificity of TrueNAT RT-PCR for the diagnosis of Pulmonary and EPTB at a Tertiary Care Hospital in Southern India. A total of 145 samples including both Pulmonary (80) and EPTB (65) were examined by Smear microscopy, culture on Lowenstein Jensen (LJ) medium and TruNat RT PCR. All the positive samples were confirmed by conventional PCR technique as well. Out of 80 Pulmonary samples such as sputum, bronchial wash and tracheal aspirate 41(51.25%) samples were positive in RT-PCR, 22 (27.5%) were positive in microscopy and 29 (36.25%) was positive for culture on LJ medium. Among the 65 EPTB samples such as pus, pleural fluid, Cerebro spinal fluid (CSF), ascitic fluid, Tissue, Peritoneal fluid, Pericardial fluid, Urine, synovial fluid, Fine needle aspiration cytology (FNAC) 38 (58.46%) were positive in RT-PCR, 08 (12.30%) were positive in microscopy and 31(47.69%) were positive for culture on Lowenstein Jensen (LJ) medium. The sensitivity and specificity of TrueNat RT-PCR for the diagnosis of Pulmonary tuberculosis (PTB) is 93.1% and 72.5 % and for EPTB is 96.77 %and 76.4 %, respectively. The newer diagnostic tool has a Turn Around Time (TAT) of less than 2 hours, can detect rifampicin resistance, longer shelf life, cost effective and can work from 2°C to 40°C. It is portable and comes with an inbuilt rechargeable battery which makes it a compatible equipment for any health care setup and out reach programs to detect and treat patients even in remote villages.

There were reports of the occurrence of TB during therapy for leukemia with possible complications. In patients with acute leukemia, therapy might be delayed or complicated by the presence of tuberculosis. We present a patient who was diagnosed with acute leukemia and concomitant tuberculosis. The patient’s therapy of leukemia had to be delayed and he had relapse of leukemia but was subsequently treated successfully for both diseases despite a prolonged culture positivity for tuberculosis. He required a prolonged course of therapy and additional secondary anti-tuberculosis therapy. The possibility of tuberculosis should be considered in the differential diagnosis of patients with pneumonia, persistent fever, and those with focal signs or symptoms suggestive of tuberculosis. Despite having a sensitive organism, the infection was difficult to treat, even with the addition of two second-line drugs. The standard anti-tuberculosis therapy is usually adequate, but response may be slow, and inadequate even if the organism is sensitive requiring the addition of second-line agents.

Introduction: Extra-pulmonary Tuberculosis (EPT) amounts to about forty percent (40%) of the total epidemiology of Tuberculosis (TB). Detailed data of various systems and organ involvement of EPT is the objective of this article. Materials and Methods: Data of the EPT were collected from Indian Journal of Tuberculosis (IJT) since 2010-2016 for a period of 7 years. Details of age, side of lesion, affected sex and immune status were recorded in an excel sheet. The data were analyzed using Microsoft Excel 2007, SPSS version 23 software. Results: Total cases reported were 428, between 3-84 years. Females (220) were affected more than the males (186); genders of 22 cases were not specified. Genitourinary system was predominantly affected by EPT (213cases). Patients aged between 21- 40 were affected in highest percentage (69.39%) versus genitourinary system with a significant p-value of 0.000. Females were affected by EPT more than males with predominant involvement of the left side with a significant p-value of 0.000. Conclusion: This study provides significant information about the EPT with respect to the number of cases reported in a specified period and their age, gender, most common side of the disease. This study also highlights the predominant system involved by EPT and also the affected rare organs like tongue, clavicle, conjunctiva and breast. Keywords: Extra-pulmonary tuberculosis, Systems involved, Rare organs.

Background: Ulcers and surgical wounds not healing well and expectedly are common problems among patients in countries like us. Ulcers may develop spontaneously or following a penetrating injury. wounds not healing well are common among poor, lower middle class and middle class people. Postsurgical non-healing wound or chronic discharging sinuses at the scar site are also common in that class of people. Suspecting malignancy or tuberculosis in these types of wounds we have sent wedge or excision biopsy for these ulcers in about 500 cases and found tuberculosis in 65 cases. In rest of the cases histopathology reports found as non- specific ulcers, Malignant melanoma, squamous or basal cell carcinoma, Verruca vulgaris. Objectives: To find out the relationship of tuberculosis with chronic or nonhealing ulcers. Methods: This is a prospective observational study conducted for patients coming to our chambers, OPD of a district general hospital and Shaheed Suhrawardy Medical College Hospital, Dhaka from July 2012 to June 2018. Results: Mean age of the study subjects were 28±2. Among the study subjects nonspecific ulcer or sinus tracts were found in 418 (83.6%), tuberculosis in 65 (13%), Malignant melanoma 7 (1.4%), Verruca vulgaris 5(1%), squamous cell carcinoma 3(0.6), basal cell carcinoma 2 (0.4%). Biopsy done only for very suspicious ulcers or wounds. Conclusion: With this very small sample size it is difficult to conclude regarding incidence of cutaneous involvement of extra pulmonary tuberculosis , but every clinician should think of it in case of suspicious non healing wounds, ulcers and prolonged discharge from a surgical incision site. J Shaheed Suhrawardy Med Coll, December 2018, Vol.10(2); 86-90

Background Confirmatory diagnosis of extra-pulmonary tuberculosis remains a true challenge owing to difficulty in procuring appropriate specimen, inefficient laboratory methods and paucibacillary nature of infection. These obstructions become all the very difficult in pediatric EPTB cases, due to non-specific clinical signs and symptoms, low sensitivity of smear microscopy and culture, lack of awareness among clinicians, etc. Aim of the study The present study aimed to evaluate the diagnostic accuracy of rapid and cost-effective loop-mediated isothermal amplification (LAMP) assay for EPTB diagnosis in children. Methods A total of 154 cases were analyzed by EPTB-site smear microscopy, culture, PCRs for IS6110, MPB64 & Pab genes, nested PCR and LAMP assay. Single-gene PCRs were performed by custom-synthesized primers. Nested PCR was performed using the 3B BIOTUB Kit and the LAMP assay was done using the Nu-LAMP TB kit. Results We observed that the molecular tests displayed 4-fold higher positivity rate (minimum 46%) in comparison to the microbiological tests (maximum 11.03%). In contrast to the composite reference standard, LAMP assay was found to be 79.6% sensitive and 78% specific for EPTB diagnosis in childhood cases. Conclusions Our results indicate that LAMP assay is a promising technique for efficient diagnosis of EPTB in children belonging to resource-limited regions.

The aim of study is to evaluate early diagnosis of tuberculosis with simple and easy technique and to study in occurrence at various extra pulmonary sites. In our country, tuberculosis is the most common and serious infectious cause of death. Tuberculosis can affect any organ system in our body, and while pulmonary tuberculosis is the most frequent, extrapulmonary tuberculosis is still a serious disease. Fine Needle Aspiration Cytology is very useful in diagnosis of extra pulmonary tuberculosis. This is a 12 yr study of 17,640 cytological smears received in cytology laboratory of a tertiary care centre between Jan 2000 to March 2012 out of 17,640 smears 1038(5.88%) turned out as tubercular lesions. Our study reveal tuberculosis is more common in females 721 cases(69.46%) than in males 317(30.53%) with male is to female ratio 1:2.27 . lymph node was the most common site in both sexes i.e. 975 cases(93.93%) out of 1038. We also found that tuberculosis is most common in age group 14-45 yrs. Fine Needle Aspiration Cytology is a significant diagnostic technique that is gaining popularity because to its simple method, quick results, and low risk of consequences.

Background: Drug resistant M.tuberculosis is one of the serious public health trouble that intimidating progress made in tuberculosis cases and control in several countries. Early detection of drug-resistant tuberculosis is crucial for patient management and infection control. Methods: Hospital based cross-sectional study design was conducted from October 2020 to February 2021. Detection of Mycobacterium tuberculosis and resistance to Rifampicin pattern was determined by using GeneXpert MTB/RIF assay. Data were entered and analyzed by SPSS version 23.0. Bivariate and multivariate analyses were used to examine the relationship between dependent and independent variables. Less than 0.05 P-value was used to show significance.Results: A total of 301 presumptive tuberculosis patients were included in the study; of these, 46 (15.3%) of them were identified as having Mycobacterium tuberculosis, 2/46 (4.35%) were resistant to Rifampicin and 4/46 (14.8%) patients were TB/HIV co-infected. From the total of M. tuberculosis detected 40 (16.7%) were identified in pulmonary and 6 (9.8%) were in extra-pulmonary presumptive patients. Rifampicin-resistant M. tuberculosis was detected in 2 patients who had a history of taking Anti-tuberculosis drugs. Conclusion: Previous history of tuberculosis treatment and having close contact history with tuberculosis patients were found as important associated factors that enhance the prevalence of tuberculosis among presumptive tuberculosis patients. This indicates the mandate to make better and oversee the treatment protocol to control the burden of drug resistant M.tuberculosis.

(1) Background: Tuberculosis (TB) in humans is a serious chronic epidemic disease caused by Mycobacterium tuberculosis (M. tb). The diagnosis of TB, especially extra-pulmonary TB (EPTB), is difficult. Isolation of M. tb from culture has a low sensitivity in patients with TB and an even lower sensitivity in cases of EPTB. Although Xpert MTB/RIF assays and serological tests are more sensitive than the above tests, they still lack sensitivity for EPTB diagnosis. (2) Methods: To improve the accuracy of TB diagnosis, a Rv0222-Rv2657c-Rv1509 fusion protein based iELISA was constructed, the diagnosis of TB, pulmonary TB (PTB) and EPTB was then evaluated. Sera of 40 TB patients including 14 with PTB, 14 with EPTB and 12 with no information about the form of TB, and five pneumonia patients were investigated. (3) Results: The sensitivity of the ELISA in TB, PTB and EPTB patients was 80% (95% CI: 64.4, 90.9%), 85.7% (95% CI: 57.2, 98.2%) and 92.8% (95% CI: 66.1, 99.8%), respectively, with a specificity of 70% (95% CI: 53.5, 83.4%). Both the sensitivity and specificity with this fusion protein were higher than for CFP10/ESAT6 (used as reference antigen) fusion protein (71.4%, 95% CI: 41.9, 91.6%, and 67.5%, 95% CI: 50.9, 81.4%), respectively, in cases of EPTB. All pneumonia patients’ sera tested negative in both ELISAs. (4) Conclusion: use of these new fusion proteins as antigens in serological assays has the potential to improve the diagnosis of all forms of TB in humans, especially EPTB.

Abdominal tuberculosis is one of the common extra pulmonary tuberculosis with diverse clinical manifestations. It has high disease burden in endemic countries like India leading to significant morbidity and mortality when left untreated. It is of vital importance to treat to prevent significant disease related mortality. We report 4 patients of abdominal tuberculosis who presented with atypical presentations. The aim of our case series is to know the uncommon presentations of a common disease.

Background Seasonality in tuberculosis (TB) has been found in different parts of the world, showing a peak in spring/summer and a trough in autumn/winter. The evidence is less clear which factors drive seasonality. It was our aim to identify and evaluate seasonality in the notifications of TB in Germany, additionally investigating the possible variance of seasonality by disease site, sex and age group. Methods We conducted an integer-valued time series analysis using national surveillance data. We analysed the reported monthly numbers of started treatments between 2004 and 2014 for all notified TB cases and stratified by disease site, sex and age group. Results We detected seasonality in the extra-pulmonary TB cases (N = 11,219), with peaks in late spring/summer and troughs in fall/winter. For all TB notifications together (N = 51,090) and for pulmonary TB only (N = 39,714) we did not find a distinct seasonality. Additional stratified analyses did not reveal any clear differences between age groups, the sexes, or between active and passive case finding. Conclusion We found seasonality in extra-pulmonary TB only, indicating that seasonality of disease onset might be specific to the disease site. This could point towards differences in disease progression between the different clinical disease manifestations. Sex appears not to be an important driver of seasonality, whereas the role of age remains unclear as this could not be sufficiently investigated.

Background:Extra-pulmonary tuberculosis can affect the lymph nodes, pleura, bones, joints, genitourinary tract, nervous system (meningitis, tuberculoma), abdominal tuberculosis (intestines, mesentery, solid organs), skin. Materials and Methods: It is a record based, observational prospective study which assesses the presentation and evaluation of the socio-economic distribution of extrapulmonary tuberculosis and management of it in a tertiary care hospital. Result: In present study, out of 50 cases 52% patients were from low socio-economic class, 44% patients were from middle socioeconomic class and 4% were from high socio-economic class. Conclusion:The frequency of extrapulmonary TB in this study was highest in low socio-economic class followed by middle and high socio-economic class.

BackgroundTuberculosis (TB) is a cause of high morbidity and mortality across the world but more so in developing countries. A large proportion of patients with tuberculosis present with extra-pulmonary disease which is often misdiagnosed or under-diagnosed. In Southwest Nigeria, there are reports on tuberculosis but only a few focused on extra-pulmonary tuberculosis (EPTB). This study was aimed to determine the burden of EPTB and its associated factors in a tertiary health care centre in Nigeria.MethodsThis was a cross-sectional retrospective study involving all the TB cases seen from 1st January 2015 and 31st December 2019. Relevant information was retrieved from the clinical records of the patients with the use of a well-structured proforma. Data obtained was analysed using the Statistical Package for Social Sciences (SPSS) version 23.0.Results Five hundred and nine subjects were involved with a mean age of 39.8±16.99 years. Three hundred and sixteen (62.1%) were males, 69 (13.6%) participants were HIV positive. Eighty-three (16.3%) had EPTB, of these 32 (38.6%) had spinal tuberculosis while 23 (27.7%) had pleural tuberculosis. Age, new cases of TB, and smear-negative TB were found to be significantly associated with the development of EPTB.ConclusionExtra-pulmonary tuberculosis is a common form of tuberculosis in our community, and the commonest presentation is spinal and pleural tuberculosis. There is a need for an improvement in diagnostic capacity for EPTB especially among the middle-aged and those presenting with TB for the first time. This will aid in the prompt detection and management of patients with EPTB.

The Coronavirus disease 2019 (COVID-19) pandemic continues to cause significant global morbidity and mortality, leading to the need to study the course of the disease in different clinical circumstances and patient populations. While co-infection between COVID-19 and many pathogens has been reported, there has been limited published research regarding co-infection with Mycobacterium tuberculosis. We describe a case of co-infection involving COVID-19 and extra-pulmonary tuberculosis in a patient with cirrhosis, and review the current literature regarding COVID-19 and tuberculosis co-infection. In spite of several co-morbidities that have been shown to portend a poor prognosis in patients with COVID-19 infection, our patient fully recovered.

Introduction/Objectives Public Health England 2019 report showed that extra-pulmonary tuberculosis represents over half (59.3%) of all diagnosed cases of TB in the UK. Foreign-born population had almost twice as many cases of extra-pulmonary disease (48.5%) compared with those born in the UK (27.8%). Aiming to improve early diagnosis in east London’s large migrant population, we compare baseline demographics and clinical features between UK-born and foreign-born EPTB cases. Methods We conducted a retrospective analysis of all TB cases at a large institution in East London between 2016 and 2019. Cases of EPTB were identified and comparison made between UK-born and foreign-born populations. Statistical analyses were performed using R version 4.0.2. Results 1263 patients were identified from the London TB registry as having been treated for TB between 2016 and 2019. In total we identified 850 patients (67.3%) with extra-pulmonary TB involvement. 78.2% (665/850) had extra-pulmonary disease only while 21.8% (185/850) had both pulmonary TB and extra-pulmonary disease. 69% of people (702/1018) with TB born outside the UK had extra-pulmonary involvement. UK born TB cases also recorded a significant proportion of extra-pulmonary disease at 60.9% (143/235). Foreign-born EPTB cases were significantly older than UK-born with a mean age of 41.8 and 33.2 respectively (p Central nervous system (CNS) TB was more common in UK-born populations at 15.4% compared to 8.7% in foreign-born (p=0.02). Pleural TB was also more common in UK-born at 20.3% compared to 14.7% in foreign-born (p=0.100). Foreign-born populations recorded a higher extra-thoracic lymph nodes involvement at 34% compared to UK-born at 27.3% (p=0.120). Conclusion Our data reports way more EPTB cases among the UK-born and foreign-born populations in East London (60.9% and 69% respectively) than the national average. In both population groups, EPTB predominantly affected people of South Asian ethnicity. Foreign-born EPTB cases tend to be older and have been resident in the UK for longer.

The optimal duration of treatment in different forms of extrapulmonary tuberculosis (EPTB) is not clearly defined. This study aimed to identify predictors of slow clinical response and extended anti-TB treatment in EPTB patients. Socio-demographic, clinical, and microbiological characteristics of EPTB patients registered for anti-TB treatment at a tertiary care hospital, were analysed for identification of predictors of extended treatment. A total of 251 patients (137 lymphadenitis, and 114 pleuritis) were included in the analysis. Treatment was extended to more than 6 months in 58/251 (23%) patients. In the multivariate regression analysis, culture-positive EPTB (p = 0.007) [OR (95% CI) = 3.81 (1.43, 10.11)], history of diabetes (p = 0.014) [OR (95% CI) = 25.18 (1.94, 325.83)], smokeless tobacco use (p = 0.002) [OR (95% CI) = 17.69 (2.80, 111.72)], and slow regression of local signs and symptoms after 2 months of treatment (p < 0.001) [OR (95% CI) = 17.09 [(5.79, 50.39)] were seen to be significantly associated with treatment extension. Identification of predictors of extended treatment can help clinical decisions regarding optimal duration of treatment. Further studies are needed to identify subgroups of EPTB patients who can benefit from a shorter or longer treatment regimen.

We report a case of primary adrenal insufficiency (PAI) due to adrenal tuberculosis with no findings of active tuberculosis in the lung of a 51-year-old female patient. The patient was admitted with a 10-year history of skin hyperpigmentation and was diagnosed with PAI. The primary cause was adrenal tuberculosis. An adrenocorticotropic hormone stimulation test, T-Spot test and adrenal computed tomography scan were used to confirm the diagnosis. The patient’s status improved, and the hyperpigmentation subsided after 15 months of treatment with anti-tuberculosis drugs and cortisol replacement therapy.

Introduction: Sputum negative pulmonary Tuberculosis (TB) is a major public health problem. So, the emergence of new techniques for a more precise and rapid microbiological identification of Mycobacterium tuberculosis in clinical samples is of great importance to improve the management of TB. Aim: To determine and compare the sensitivity and turnaround time for Mycobacterium tuberculosis detection by the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system, Lowenstein Jensen (LJ) medium and Ziehl-Neelsen (ZN) staining. Materials and Methods: An Institution based, observational, cross-sectional study was conducted at Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India, from July 2013-March 2016. Sputum, pericardial fluid, pleural fluid, peritoneal fluid, pus and endometrial tissue samples were collected from 80 patients of suspected TB cases. All were Acid-Fast stained by ZN staining method and cultured on solid culture LJ medium and on liquid medium (MGIT). Data was analysed using Statistical Package for the Social Sciences (SPSS) software, Version 20.0 (SPSS Inc, Chicago, IL, USA). Fisher’s-Exact test was used to show association of categorical variables. Non-parametric Mann-Whitney U test was used to show median difference of non-normally distributed continuous variables of two groups. Results: Out of the 80 samples, 41 cases were positive by either of the all methods. The positive specimen for ZN staining, LJ media and MGIT were 21, 29 and 41 cases respectively. The mean Time To Detection (TTD) was shorter for MGIT system than LJ media. Both LJ medium and MGIT 960 detected all cases of sputum smear positive cases and in addition significantly higher number than ZN stain in sputum smear negative cases. MGIT 960 detected significantly higher number of cases of sputum negative cases than LJ Media. The mean TTD was also significantly shorter in case of smear positive cases than the smear negative cases by both the solid and liquid culture mediums. Conclusion: The use of liquid media (MGIT) is more accurate and rapid method for the diagnosis of TB. The combination of more than one method is also highly recommended for rapid detection and early treatment of TB.

Extra-pulmonary tuberculosis (EPTB), caused by Mycobacterium tuberculosis, is the leading cause of communicable disease-related deaths in people with human immunodeficiency virus (HIV) worldwide and in South Africa. Mycobacterium tuberculosis disseminates haematogenously from an active primary lung focus and may affect extra-pulmonary sites in up to 15% of patients. Extra-pulmonary TB may present with a normal chest radiograph, which often causes a significant diagnostic dilemma. This review describes the main sites of involvement in EPTB, which is illustrated by local imaging examples.