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Avaliamos o rendimento diagnóstico da fibrobroncoscopia óptica no diagnóstico de tuberculose pulmonar com baciloscopia negativa em pacientes atendidos em um hospital de referência em Lima, Peru. Dos 611 pacientes submetidos ao procedimento, 140 (23%) foram diagnosticados com tuberculose com base nas amostras de LBA. Ser mais jovem e do sexo masculino foi associado a culturas positivas. Além disso, 287 pacientes realizaram baciloscopia de escarro após a broncoscopia, e os resultados aumentaram o rendimento diagnóstico em 22% em relação às amostras de LBA. Concluímos que amostras de LBA e de escarro pós-broncoscopia tiveram um bom rendimento diagnóstico nos pacientes com suspeita de tuberculose pulmonar com baciloscopia negativa. We evaluated the diagnostic yield of fiberoptic bronchoscopy for the diagnosis of smear-negative pulmonary tuberculosis in patients treated at a referral hospital in Lima, Peru. Of the 611 patients who underwent the procedure, 140 (23%) were diagnosed with tuberculosis based on the analysis of BAL samples. Being young and being male were significantly associated with positive cultures. In addition, 287 patients underwent post-bronchoscopic sputum smear testing for AFB, the results of which increased the diagnostic yield by 22% over that obtained through the analysis of BAL samples alone. We conclude that the analysis of BAL samples and post-bronchoscopic sputum samples provides a high diagnostic yield in smear-negative patients suspected of having pulmonary tuberculosis.

ObjectivesTo compare the performance of liquid culture on simple Middlebrook 7H9 to the one of manual mycobacterial growth indicator tube (MGIT) and solid culture on Ogawa for the diagnosis of smear-negative tuberculosis (SN-TB) in a high-burden, resource-constrained setting. MethodsSputum samples from patients with clinical suspicion of SN-PTB admitted to two-third-level hospitals in Lima between September 2005 and May 2008 were cultured in parallel on simple Middlebrook 7H9, manual MGIT and Ogawa. A case of SN-TB was defined as one with a positive culture in any medium. ResultsAmong samples from 542 patients, 151 (28%) cases of SN-TB were identified. The sensitivity of Middlebrook 7H9 (0.76, 95% CI 0.69-0.83) was not substantially different from that of MGIT (0.85, 95% CI 0.79-0.91). Ogawa had the lowest sensitivity (0.63, 95% CI 0.55-0.71). The median turnaround time was similar for both liquid media (18days), and it was shorter than that of Ogawa (30days). ConclusionsCulture on simple Middlebrook 7H9 performs almost as well as MGIT, at a probably more affordable cost. Further studies on the cost-effectiveness of this overlooked technique should be performed. ObjectifsComparer les performances de la culture liquide sur milieu simple Middlebrook 7H9 a celles sur MGIT manuel et sur milieu solide Ogawa pour le diagnostic de la tuberculose pulmonaire a frottis negatif (TBP-FN) dans une region a prevalence elevee et a ressources limitees. MethodesDes echantillons de crachats de patients avec une suspicion clinique de TBP-FN, admis dans deux hopitaux tertiaires a Lima entre septembre 2005 et mai 2008, ont ete cultives en parallele sur milieu simple Middlebrook 7H9, MGIT manuel et Ogawa. La TBP-FN a ete defini comme un cas avec au moins une culture positive sur n'importe quel milieu. ResultatsParmi les echantillons de 542 patients, 151 (28%) cas de TBP-FN ont ete identifies. La sensibilite du Middlebrook 7H9 (0,76; IC 95%: 0,69 a 0,83) n'etait pas significativement differente de celle du MGIT (0,85; IC 95%: 0,79 a 0,91). Ogawa avait la sensibilite la plus faible (0,63; IC 95%: 0,55 a 0,71). Le delai median etait similaire pour les deux milieux liquides (18 jours) et etait plus court que pour Ogawa (30 jours). ConclusionsLa culture sur milieu simple Middlebrook 7H9 est presque qu'aussi performante que sur MGIT a un cout probablement plus abordable. Des etudes supplementaires sur le rapport cout-efficacite de cette technique neglige devraient etre effectuees. ObjetivosComparar el desempeno del cultivo en medio liquido Middlebrook 7H9 con el sistema manual MGIT y el cultivo solido en Ogawa, para el diagnostico de tuberculosis con baciloscopia negativa (TB-BN) en un lugar con una carga alta de enfermedad y pocos recursos. MetodosLas muestras de esputo de los pacientes con sospecha clinica de TB-BN admitidos en dos hospitales de tercer nivel en Lima, entre Septiembre 2005 y Mayo 2008, se cultivaron en paralelo en medio liquido de Middlebrook 7H9, en MGIT y en Ogawa. Un caso de TB-BN se definio como positivo para cultivo en cualquier medio. ResultadosEntre las muestras de 542 pacientes, se identificaron 151 (28%) casos de TB-BN. La sensibilidad del 7H9 (0.76, IC 95% 0.69-0.83) no era sustancialmente diferente de la del MGIT (0.85, IC95% 0.79-0.91). El Ogawa tenia la menor sensibilidad (0.63, IC 95% 0.55-0.71). El tiempo medio de respuesta era similar para los dos medios liquidos (18 dias) y era mas corto que el del Ogawa (30 dias). ConclusionesEl cultivo en medio liquido Middlebrook 7H9 tiene un desempeno casi tan bueno como el de MGIT, con un coste probablemente mas asumible. Se deberian realizar mas estudio sobre la costo-efectividad de esta tecnica olvidada.

Objectives Diagnosis of smear-negative pulmonary tuberculosis (SNPT) remains a challenge, particularly in resource-constrained settings. We evaluated a diagnostic algorithm that combines affordable laboratory tools and a clinical prediction rule (CPR). Methods We derived, based on published evidence, a diagnostic algorithm for SNPT. Sputum concentration constitutes its first step. In suspects with negative results, SNPT probability is classified with a CPR as low (excluded), high (confirmed) or intermediate. For intermediate patients, sputum Middlebrook 7H9 liquid culture is performed, and they are assessed after 2 weeks. If clinically deteriorated, with still negative liquid culture, bronchoscopy is offered. Otherwise, results of Middlebrook 7H9 culture are awaited. We prospectively evaluated this algorithm against a reference standard of solid and liquid cultures in two reference hospitals in Lima, Peru. Results 670 SNPT suspects were included from September 2005 to March 2008. The prevalence of SNPT was 27% according to the reference standard. The algorithm's overall accuracy was 0.94 (95% CI 0.91–0.95), its sensitivity was 0.88 (95% CI 0.82–0.92) and its specificity, 0.96 (95% CI 0.94–0.98). Sputum concentration, the CPR, Middlebrook 7H9 sputum culture and bronchoscopic samples defined a diagnosis of SNPT according to the algorithm in 57 (37%), 25 (16%), 63 (41%) and 8(5%) of patients, respectively. 65% of patients were diagnosed within 3 weeks. Conclusions The algorithm was accurate for SNPT diagnosis. Sputum concentration, CPR and selective Middlebrook 7H9 culture are essential components. Objectifs Le diagnostic de la tuberculose pulmonaire a frottis negatif (TPFN) reste un defi, en particulier dans les pays a ressources limitees. Nous avons evalue un algorithme de diagnostic qui combine des outils de laboratoire abordables et une regle de prediction clinique (RPC). Methodes Nous avons etabli, sur base des donnees publiees, un algorithme de diagnostic pour la TPFN. La concentration des expectorations constitue sa premiere etape. Chez les suspects avec des resultats negatifs, la probabilite de TPFN est classee avec une RPC comme: faible (exclue), elevee (confirmee) ou intermediaire. Pour les patients intermediaires, la culture des crachats dans du milieu liquide Middlebrook 7H9 a ete effectuee et evaluee au bout de deux semaines. Dans le cas d'une deterioration clinique avec une culture liquide toujours negative, la bronchoscopie est offerte. Dans le cas contraire, les resultats de culture dans le Middlebrook 7H9 sont attendus. Nous avons evalue prospectivement cet algorithme par rapport a une norme de reference basee sur la culture en milieux solides et liquides dans deux hopitaux de reference a Lima, au Perou. Resultats 670 suspects de TPFN ont ete inclus de septembre 2005 a mars 2008. La prevalence de la TPFN etait de 27% selon la norme de reference. La precision globale de l'algorithme etait de 0.94 (IC 95%: 0.91–0.95), sa sensibilite etait de 0.88 (IC 95%: 0.82–0.92) et sa specificite de 0.96 (IC 95%: 0.94–0.98). La concentration des expectorations, la RPC, la culture des expectorations dans le Middlebrook 7H9 et des echantillons bronchoscopiques ont defini un diagnostic de la TPFN selon l'algorithme chez 57 (37%), 25 (16%), 63 (41%) et 8 (5%) patients respectivement. 65% des patients ont ete diagnostiques endeans 3 semaines. Conclusions L'algorithme etait precis pour le diagnostic de la TPFN. La concentration des expectorations, la RPC et la culture selective dans le Middlebrook 7H9 sont des elements essentiels. Objetivos El diagnostico de la tuberculosis pulmonar con baciloscopia negativa (TPBN) continua siendo un gran reto, particularmente en lugares con pocos recursos. Hemos evaluado un algoritmo de diagnostico que combina herramientas de laboratorio asequibles y una regla de prediccion clinica (RPC). Metodos Basandonos en evidencia publicada, derivamos un algoritmo diagnostico para TPBN. El primer paso es concentrar el esputo. En pacientes con resultados negativos pero con sospecha de TB la probabilidad de TPBN se clasifica con una RPC como baja (excluida), alta (confirmada) o intermedia. Para pacientes con una clasificacion intermedia, se realiza un cultivo de esputo en medio liquido Middlebrook 7H9 y se evaluan dos semanas mas tarde. Si estan clinicamente deteriorados, con un cultivo liquido aun negativo, se realiza una broncoscopia. Evaluamos de forma prospectiva este algoritmo frente a un estandar de referencia de cultivos solido y liquido en dos hospitales de referencia en Lima, Peru. Resultados Se incluyeron 670 pacientes con sospecha de TPBN entre Septiembre 2005 y Marzo 2008. La prevalencia de TPBN era un 27% segun el estandar de referencia. La precision del algorithmo era de 0.94 (IC 95% 0.91–0.95), la sensitibilidad era de 0.88 (IC 95% 0.82–0.92) y la especificidad de 0.96 (IC 95% 0.94–0.98). La concentracion de esputo, el RPC, el cultivo de esputo Middlebrook 7H9 y las muestras de la broncoscopia definieron un diagnostico de TPBN segun el algoritmo en 57 (37%), 25 (16%), 63 (41%) y 8(5%) de los pacientes respectivamente. Un 65% de los pacientes fueron diagnosticados en un plazo de tres semanas. Conclusiones El algoritmo era preciso para el diagnostico de TPBN. La concentracion de esputo, la RPC y el cultivo en Middlebrook 7H9 eran componentes esenciales.

Summary Objectives To assess the diagnostic validity of laboratory cerebrospinal fluid (CSF) parameters for discriminating between tuberculous meningitis (TBM) and other causes of meningeal syndrome in high tuberculosis incidence settings. Methods From November 2009 to November 2011, we included patients with a clinical suspicion of meningitis attending two hospitals in Lima, Peru. Using a composite reference standard, we classified them as definite TBM, probable TBM, and non-TBM cases. We assessed the validity of four CSF parameters, in isolation and in different combinations, for diagnosing TBM: adenosine deaminase activity (ADA), protein level, glucose level, and lymphocytic pleocytosis. Results One hundred and fifty-seven patients were included; 59 had a final diagnosis of TBM (18 confirmed and 41 probable). ADA was the best performing parameter. It attained a specificity of 95%, a positive likelihood ratio of 10.7, and an area under the receiver operating characteristics curve of 82.1%, but had a low sensitivity (55%). None of the combinations of CSF parameters achieved a fair performance for ‘ruling out' TBM. Conclusions Finding CSF ADA greater than 6 U/l in patients with a meningeal syndrome strongly supports a diagnosis of TBM and permits the commencement of anti-tuberculous treatment.