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Purpose: To describe a case of choroidal tubercle in a patient with Eales disease after 6 years, whose initial work-ups were negative for systemic diseases.Methods: A retrospective chart reviewResults: This case report describes a 39-year-old male with a 6-year history of Eales disease characterized by recurrent inflammations and vitreous hemorrhages in his both eyes. His systemic work-up at the initial presentation was normal which included a negative Mantoux test and a normal chest X-ray. On a follow-up visit after 6 years, fundus examination of the right eye revealed a choroidal tuberculoma and subsequent investigations revealed a positive Mantoux test, QuantiFERON TB Gold test and lymphadenopathy in high-resolution computerized tomography. The choroidal tuberculoma responded well to anti-tubercular treatment and oral steroid.Conclusions: Ocular tuberculosis can be associated with Eales disease and often manifest later in the course of the disease

Purpose: To describe a case of presumed tuberculous sclerokeratitis which presented with anterior uveitis and hypopyon Methods: A retrospective chart review Results: A 23-year-old female presented with nodular scleritis, peripheral corneal opacities, and severe anterior chamber reaction with hypopyon. Her Mantoux test and interferon gamma release assay were positive and high-resolution computerized tomography of chest revealed right hilar lymphadenopathy. Aqueous aspirate from anterior chamber paracentesis of her right eye was negative for Mycobacterium tuberculosis genome. She responded to antitubercular treatment and oral corticosteroid Conclusions: Tuberculous sclerokeratitis can rarely present with hypopyon and pose a challenge in diagnosis for the clinicians.

INTRODUCTION AND OBJECTIVES: Granulomatous mastitis is rare chronic inflammatory benign breast lesion, which clinically and radiologically resembles carcinoma breast thus creating a diagnostic dilemma. The term granulomatous mastitis includes two broad categories namely specific granulomatous mastitis for which aetiological factors can be defined such as infectious causes like Mycobacterium tuberculosis, blastomycosis, cryptococcosis, histoplasmosis, actinomycosis and filarial infection. Other factors include association with autoimmunue diseases such as Wegner’s granulomatosis and giant cell arteritis and there are other rare causes such as include duct ectasia, foreign body reaction and fat necrosis which also leads to granulomatous lesions of breast. Cytological features of granulomatous mastitis(GM) have not been widely discussed and described in literature, so through this study we have made an attempt to thoroughly discuss cytological spectrum of granulomatous mastitis. MATERIALS AND METHODS: A retrospective study was performed over a period of four years from 2016 to 2019. A total of 465 cases of breast lump reported to cytopathology section out of which 24 cases of GM diagnosed on FNAC were included in our study. Results of Erythrocyte sedimentation rate (ESR) and Mantoux test along with TB-PCR were recorded. FNAC slides were retrieved pertaining to study period. Granulomatous lesions of breast were further categorized broadly into IGM/ NGM, granulomatous mastitis without caseous necrosis and tubercular mastitis where diagnosis were made definite on basis of demonstration of AFB or positive TB-PCR . RESULTS: Patient age ranged from 23 years to 55 years with the mean age of 36.6 years with maximum of patients falling in second decade followed by third decade. Granulomatous lesions were broadly categorized into Idiopathic/ Non specific granulomatous mastitis(11 cases,45.8%), GM with caseous necrosis(8 cases, 33.3%) and tubercular mastitis(5 cases, 20.9%). Histopathology was available in 7 cases(29.2%). TB-PCR was sent in all cases of granulomatous mastitis diagnosed on cytology and was positive in 10 cases(41.7%). CONCLUSION: Idiopathic granulomatous mastitis and tubercular mastitis are rare inflammatory diseases of breast which mimic malignancy clinically and radiologically. FNAC plays important role in diagnosis of granulomatous diseases of breast and also their differentiation from malignant tumors. Tubercular mastitis needs to be differentiated from IGM since treatment options are different in both the cases. Cytopathology plays an important role in differentiationg both the diseases supplemented by radiological and microbiological investigations. The present study thus highlights the importance of FNAC as an infalliable tool in diagnosis of granulomatous mastitis and its differentiation from neoplastic lesions of breast thus avoiding time consuming histopathological work up of cases.

AIM: To determine the spectrum of uveitis, causes of visual loss in systemic tuberculosis (TB), role of investigations and outcome after anti-TB therapy (ATT). METHODS: A retrospective study was conducted on 250 patients with systemic TB at a referral center in Chennai, South India from April 2016 to May 2019. Systemic workup comprised of Mantoux, chest X-ray, polymerase chain reaction (PCR) and QuantiFERON (QFT) TB Gold. Aqueous humor analysis by nested PCR or real time PCR (RT-PCR) and ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography were performed. RESULTS: Multifocal choroiditis and vasculitis were the most common manifestations (39% and 24% respectively) together accounting for 61% of cases and they had a higher risk of recurrence (3%). Pulmonary tuberculosis (PTB) was more frequently associated with uveitis (18%). Among those with extra-pulmonary tuberculosis (EPTB), uveitis occured in miliary TB (2%), bone (1%) and abdominal TB (1%). Complications such as cystoid macular edema, choroidal neovascular membranes and macular scarring caused visual loss. Aqueous humor analysis detected mycobacterium TB antigen. Collectively, systemic investigations such as chest X-ray, Mantoux test and those performed on blood samples such as PCR and QFT were positive in 39% of patients. In inconclusive patients, nested PCR and/or RT-PCR were done on aqueous humor samples and were diagnostic in 96%. A combination of tests was diagnostic in 92%. ATT in isolation in 71% and combined with corticosteroids in 29% was used for treatment of which signs of resolution and improvement in vision started as early as 6wk in those who were started immediately on corticosteroids and ATT and longer than 3mo in those on ATT alone. Prompt treatment with ATT and corticosteroids improved vision in 23% of our patients within 2mo. Vitritis with choroiditis causes cystoid macular oedema and requires longer duration of ATT. Vision improved in 69%. Complete resolution occurred in 75% and worsening in 12%. CONCLUSION: A combination of investigations guided by clinical suspicion helps in precise diagnosis. In diagnostic dilemmas analysis of ocular samples is reliable and confirmatory. Screening all patients and a multidisciplinary approach in TB (active, healed or during treatment) is recommended.

Background HIV-associated tuberculosis (TB) is a major cause of death among pregnant women in South Africa. Isoniazid prevention therapy (IPT) strategy was implemented in South Africa concurrently with life-long antiretroviral therapy (ART) to reduce the TB-associated morbidity and mortality in individuals living with HIV. This study assessed the extent of the implementation of IPT and the performance of the Mantoux test by geographic settings of health facilities and residences of pregnant women living with HIV in the Eastern Cape, South Africa. Methods We conducted a data analysis of 1709 pregnant women enrolled in the new electronic database of the prevention of mother-to-child transmission programme of the East London Prospective Cohort Study. Relevant data on place of residence and antenatal care, performance of the Mantoux test and subsequent initiation of IPT were obtained. Descriptive and inferential statistics were employed to analyse the geographical variations and accessibility to Mantoux test and IPT. Results The analysis shows that Mantoux test was performed on 803 pregnant women (47%) with significant geographical variation. After controlling for relevant covariates, pregnant women who resided in rural areas (AOR:0.63; CI: 0.47–0.84) compared to those who resided in urban areas were significantly less likely to receive Mantoux test. The rate of uptake of IPT was 79% with significant geographic variations. In the unadjusted model, rural place of residence (UOR:0.68; CI: 0.49–0.96) was independently associated with lower likelihood of uptake of INH prophylaxis; however, the effect was not significant after controlling for important covariates. Conclusions The high uptake rate of isoniazid prevention therapy in pregnant women living with HIV at the study sites is commendable; however, concerted efforts are needed to address the inequality gaps in the roll-out of IPT. Poor performance of Mantoux test is a serious concern and requires the attention of TB programme managers and other relevant authorities.

Introduction: The Collaborative TB Strategy recommends latent TB (LTBI) screening in New Entrants who have entered the UK in the previous 5 years, are aged 16–35 and from countries with a TB incidence of ≥150 cases/100,000 population.1 This screening programme was started in Bolton in 2017 and in discussion with Local Commissioning Group all screening activity was carried out via secondary care. Aims and Objectives: We aimed to look at the effectiveness of our new entrant TB screening program. Methods: We collected data from consecutive new entrants referred for TB screening between April 2018 and December 2018. The data included the source of referral (asylum centres and primary care registration [Flag 4]), country of origin, and diagnosis of LTBI by interferon gamma release assay (IGRA) results. Patients from the asylum team are pre-screened using Mantoux test and are only referred if positive (>5mm). Results: 279 new entrants were referred to our service. 118 were from Africa, many of whom were referred by the asylum centre, 88 (74%) of those referred attended the TB clinic, and 34 (38%) were diagnosed with LTBI. 161 patients referred were from Asia (mostly GP registration data), 98 (60%) of those attended clinic and only 16 (16%) were diagnosed with LTBI. Conclusions: The majority of new entrants invited to our clinic attended (66%). A significant number (26%) of these patients are diagnosed with LTBI. The incidence of LBTI is greater in the patients referred by asylum team, noting that they were pre-screened with the Mantoux test. We aim to continue to monitor our new entrant screening service and clinic outcomes, and to compare with services in neighbouring regions. Reference: 1. Collaborative TB Strategy for England 2015–2020: PHE2015, January

Background Childhood TB constitutes 10–20% of the total TB cases in high burden countries. The most common clinical features in pulmonary TB in children are non-productive cough, low fever and weight loss. Radiological features in pediatric pulmonary TB may also remain non-specific, most typical being hilar or paratracheal lymphadenopathy. So the diagnosis remains difficult. Microbiological confirmation remains challenging due to suboptimal pulmonary specimens in such cases. This study was aimed to analyze the clinico-microbiological profile of gastric aspirate in pediatric pulmonary TB. Methods Clinically suspected pediatric pulmonary TB cases ≤12 years of age were recruited over a period of 1 year. Gastric aspirates were processed for microbiological diagnosis. As per Revised National Tuberculosis Control Program definitions, the cases were clinically diagnosed (clinical history and Mantoux test and/or contact history and/or radiological evidence) or microbiologically confirmed [≥1 of smear/culture/Cartridge Based Nucleic Acid Amplification Test (CBNAAT)] to be pediatric pulmonary TB. Results Mean age of children in the study was 5.8 years. Of 27 cases, Mantoux test was reactive in 13 (48%), 13(48%) had a history of contact with an infectious case and BCG scar was present in 22 (81.5%) cases. Fever was the predominant symptom followed by loss of appetite, weight loss and cough. Only one case did not have suggestive chest radiography while 18 (66.7%) showed consolidation. Microbiological diagnosis could be established in 20 (74%) cases, 8 (29.6%) being smear positive, 12 (44.4%) culture positive and 17 (63%) positive by CBNAAT. Conclusions Pediatric pulmonary TB remains difficult to diagnose due to the non-specific presentation, suboptimal samples and paucibacillary nature of the disease. Though microbiological confirmation by conventional tests remains low, using CBNAAT marginally increases the positivity. An integrated approach based on history, Mantoux test, radiology and microbiology increase chances of reaching an early diagnosis. Further research is needed for newer techniques to detect and manage paucibacillary disease in children at the earliest.

Background The tuberculin skin test (TST) is a screening tool for detection of occult or remote tuberculosis infection. Although skin tightness is a classic manifestation in systemic sclerosis (SSc), there are no reports vis-a-vis any limitation of the TST in SSc patients nor a definition on the cut-off for a positive TSTtest size for a diagnosis of tuberculosis. Objectives Our aims were to determine (a) the indurated reaction size of the TST; (b) the cut-off size for the indurated TST; and, (c) the sensitivity and specificity of the test for the diagnosis of tuberculosis in SSc patients. Methods A cross-sectional study was conducted among Thai adult SSc patients, followed up at the Scleroderma Clinic, Khon Kaen University, Thailand between November 1, 2016 and November 30, 2017. The TST was performed using 0.1 ml purified protein derivatives (PPD) injected intradermally (Figure 1), and interpreted 72 hours after testing. Results A total of 168 SSc patients were enrolled (female to male ratio = 1.8:1). The median age and duration of disease was 57.2 and 6.4 years, respectively. The majority (71.8%) was the diffuse cutaneous SSc subset. Seventeen cases (10.1%) were defined as tuberculosis infection. All of the patients had a history of BCG vaccination at birth. An indurated skin reaction size TST of 20 U/L had a high specificity for tuberculosis (99.3%: 95%CI 96.4-100) (Kappa 0.86; p=0.03). The modified Rodnan skin score (mRSS) had a significant negative correlation with the indurated skin reaction size (Rho -0.23; p=0.003). While other clinical parameters—such as BMI, SSc subset, serum albumin level, steroid or immunosuppressant use—were not correlated with the TST result (p=0.06, 0.14, 0.09, 0.23 and 0.89, respectively). Conclusion Indurated skin ≥ 20 mm indicated a high specificity for tuberculosis infection in SSc patients with history of BCG vaccination. The high mRSS resulted in a smaller skin reaction size when using the TST. The TST is thus less useful as a diagnostic tool for tuberculosis among SSc patients, especially among those with severe skin tightness. References [1] Foocharoen C, Nanagara R, Foocharoen T, Mootsikapun P, Suwannaroj S, Mahakkanukrauh A. Clinical features of tuberculous septic arthritis in Khon Kaen, Thailand: a 10-year retrospective study. Southeast Asian J Trop Med Public Health. 2010 Nov;41(6):1438–46. [2] Rose DN, Schechter CB, Adler JJ. Interpretation of the tuberculin skin test. J Gen Intern Med. 1995 Nov;10(11):635–42. [3] Jamil B, Qamruddin S, Sarwari A, et al. An assessment of Mantoux test in the diagnosis of tuberculosis in a BCG-vaccinated, tuberculosis endemic area. Journal of Infectious Disease Parkistan. 2008;17(1):18–22. [4] Liam C, Lim K, Wong C. Changes in serum proteins, erythrocyte sedimentation rate and Mantoux tuberculin skin test reactivity in active tuberculosis. JUMMEC. 1998;3(1):47–53. [5] Wang L, Turner MO, Elwood RK, Schulzer M, FitzGerald JM. A meta-analysis of the effect of Bacille Calmette Guerin vaccination on tuberculin skin test measurements. Thorax. 2002 Sep;57(9):804–9. [6] Araujo Z, de Waard JH, de Larrea CF, Borges R, Convit J. The effect of Bacille Calmette-Guerin vaccine on tuberculin reactivity in indigenous children from communities with high prevalence of tuberculosis. Vaccine. 2008 Oct 16;26(44):5575–81. [7] Farhat M, Greenaway C, Pai M, Menzies D. False-positive tuberculin skin tests: what is the absolute effect of BCG and non-tuberculous mycobacteria? Int J Tuberc Lung Dis. 2006 Nov;10(11):1192–204. [8] Abdel-Samea S, Ismail Y, Fayed S, Mohammad A. Comparative study between using QuantiFERON and tuberculin skin test in diagnosis of Mycobacterium tuberculosis infection. EJCT. 2013;62:137–43. Acknowledgement The Scleroderma Research Group and the Faculty of Medicine, Khon Kaen University (Grant Number GR60101) Disclosure of Interests None declared

Background Underlying causes of inflammation cannot be established sometimes, despite meticulous medical history and physical examination, laboratory tests including cultures, immunologic and serologic tests and widely used radiologic procedures such as plain x-rays, echocardiography, ultrasonography and computed tomography. Rheumatologists quite oftenly face with these patients which is termed as inflammation of unknown origin (UIO). Differential diagnosis of UIO is diverse and investigation of such cases are challenging and time consuming. Objectives: to assess diagnostic utility of PET CT in the diagnosis of patients with UIO Methods Study comprised 68 (36 male, mean age 58.7±14.8, range 19-87 years) adult IUO subjects without a previous diagnosis of an inflammatory or malignant disease. Patients were screened with PET CT after 8 hours fasting, if a specific diagnosis could not be established with comprehensive evaluation including; meticulous history and physical examination, pertinent microbiologic cultures, brucella agglutination, Mantoux test, serum protein electrophoresis, echocardiography, plain x-rays, computed tomography of thorax and abdomen/pelvis. Results Final diagnosis were established in follow up were inflammatory diseases in 37 (54.4%), malignant disorders in 16 (23.5%) and infections in 5 (7.4%), whereas a final diagnosis cannot be made in 10 (14.7%). PET CT aided diagnosis in 40 (58.8%) patients but was ineffective in 28 (41.2%). All three PET CT positive subjects with a final diagnosis of infection had tuberculosis (tb). On of two PET negative subjects had EBV and one other also had tb. PET CT was positive in 24 of 37 (64.9%) subjects with a final diagnosis of inflammatory rheumatic disease. Final inflammatory diseases were large vessel vasculitis 15, polymyalgia rheumatica 5, seronegative arthritis 4, and other rare miscellaneous diseases, such as small vessel vasculitis, inflammatory myositis, polychondritis, sarcoidosis and IgG4 related disease. PET was positive in 11 of 15 (73.3%) large vessel vasculitis patients and 2 of 5 (40%) PMR patients. Because of small number of miscellaneous rheumatic diseases, diagnostic value of PET cannot be evaluated in these. Conclusion Investigation of underlying etiology of UIO is time and effort consuming. PET CT may help to identify final diagnosis more quickly by directing an obscure inflammatory site. PET CT may also have advantages like reducing number of unnecessary biopsies, diagnostic time, anxiety, work loss, morbidity and mortality References [1] Kan Y, Wang W, Liu J, Yang J, Wang Z. Contribution of 18F-FDG PET/CT in a case-mix of fever of unknown origin and inflammation of unknown origin: a meta-analysis. Acta Radiologica. 2018:0284185118799512. Disclosure of Interests None declared

Takayasu arteritis (TA) is a granulomatous vasculitis of large vessels with unknown aetiopathogenesis. An association between TA and tuberculosis (TB) has been suggested by several authors. The objective of this study was to perform a systematic review of the literature on the association of Mycobacterium tuberculosis (MT) infection in patients with TA. The research was conducted using the PUBMED/Medline and LILACS databases including studies published until June 2019 and using the descriptors "takayasu arteritis", "tuberculosis", "mycobacterium tuberculosis", "purified protein derivate" (PPD), "mantoux test", "quantiferon tb gold", and "interferon gamma release assay" (IGRA). A total of 113 publications were found, but only 38 publications were included after the pre-established criteria were applied. The results were divided into (1) active TB in adolescents with TA: 13 cases; (2) active TB in adults with TA: 116 cases, with a prevalence ranging from 6.3 to 20%, including a South Korean study of 267 cases of TA that found a prevalence of active TB of 17.7%; (3) latent TB in TA patients: the most widely used method was PPD, and only one study compared PPD with IGRA; the prevalence ranged from 20 to 82%; (4) findings that indicate TB in arterial biopsy or autopsies: 5 studies, with different results ranging from an absence of MT DNA in the aortic tissue to 70% positivity; and (5) immunological studies that evaluated the presence of antimycobacterial antibodies and heat shock proteins in TA patients. Although most of the studies show a high prevalence of TB, it is not possible to establish a causal relationship. We suggest that greater care be taken with latent TB screening in patients who are TA candidates for immunosuppressive therapy.

BackgroundTrue burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care.MethodsThis was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or "Working") TB diagnosis and modelled associations with TB tests amongst guideline-eligible children.Results23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5("Working TB" diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09-1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05-4.75), 2.98(CI 2.69-3.31) and 2.98(CI 2.60-3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08-1.42) and 1.15(CI 1.04-1.28) respectively]. "Working TB" diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed.ConclusionsMore than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines.

A 67-year-old man with an 8-year history of seropositive rheumatoid arthritis (RA) on conventional synthetic disease-modifying antirheumatic drug (csDMARD) and history of hypertension and bilateral total knee replacement done 2 years ago presented with active arthritis. He was advised to switch to a biological DMARD etanercept (tumour necrosis factor inhibitor (TNFi)). For this reason, screening tests for latent tuberculosis, hepatitis B and hepatitis C were performed. His chest X-ray showed a fibrotic lesion in the left upper zone and his Mantoux test was positive. He was commenced on etanercept biosimilar along with rifampicin and isoniazid for latent tuberculosis infection. Two days after the commencement of this treatment, the patient developed a loss of appetite and somnolence. His condition progressively deteriorated culminating …

To determine the utility of CSF Xpert MTB/RIF (GeneXpert) in diagnosis of tubercular meningitis in children in the age group of 2 mo to 12 y.This hospital based prospective observational study was conducted at Department of Pediatrics, Karnataka Institute of Medical Sciences (KIMS), Hubli from December 2015 through November 2016. All children with clinically suspected tuberculous meningitis (TBM) were included in the study. These children underwent a detailed history taking, clinical examination, blood investigations, lumbar puncture and CT brain. Cerebrospinal fluid (CSF) samples were sent for CSF GeneXpert examination. Statistical analysis was done using IBM SPSS Statistics Version 20.A total of 28 children were enrolled in the study. Six (21.4%), 4 (14.3%) and 18 (64.3%) cases were definite, probable and possible TBM cases respectively. Most common age group affected was5 y (83.33%) with median age 2.5 y (IQR 4.875). Male:female ratio was 1.5:1. CSF GeneXpert was tested positive in 6 cases (21.4%). The sensitivity of the test against the clinical scoring (/=10) was 46.15% (95% CI, 19.22-74.87) and specificity was 100% (95% CI, 78.20-100). There was a significant association between CSF GeneXpert and Mantoux test (P = 0.002), CSF cell type50% lymphocytes (P = 0.005) and CSF protein100 mg/dl (P = 0.025) along with CT hydrocephalus (P = 0.021), granuloma (P = 0.009) and basal exudates (P = 0.025). None of the cases were tested smear positive for acid-fast bacilli (AFB).CSF GeneXpert is superior to smear for AFB in TBM.

Background: Mantoux test is the most widely used screening test that aid diagnosis of latent tuberculosis infection (LTBI) especially in resource poor countries. This study aimed to determine the seven year trend of Mantoux test result at the University of Port Harcourt Teaching Hospital, Rivers State Nigeria. Methods: A secondary data analysis was carried out on abstracted data from 2011 to 2017 in the Mantoux result register. Descriptive statistics was computed for all categorical variables. Chi-square of trend was used to assess significant differences in positivity. P-value less than 0.05 was considered significant. Results: Using a cut-off point of ≥10 mm diameter, a total of 5863 clients were screened for TB. Chi square for trends showed statistical significant decreasing proportion of significant Mantoux reaction status among clients over the study period. Conclusion: The study showed a high prevalence of negative Mantoux reaction compared to positive reaction. Trend analysis showed a notable downward plunge of significant Mantoux positivity. The trend was towards continuous reduction in Mantoux test result positivity suggesting a tailing of LTBI in this region.

Urinary tract tuberculosis (TB) is a rare extrapulmonary manifestation of TB in children. The disease is potentially underdiagnosed because it clinically resembles other urinary tract infections. A 13-year-old adolescent girl presented with pain, difficulty in micturition, and gross hematuria for almost two years before admission, and she had left flank pain since one year ago and significant loss of body weight during the illness. The close TB contact was her grandmother who was on TB treatment. Acid-fast bacilli yielded positive result, Mantoux test was positive (17 mm), urine GeneXpert MTB/Rif was positive; tuberculoma was identified on kidney histopathology, and a diuretic renogram revealed an uncorrected glomerular filtration rate (GFR) of the right and left kidney to be 32.5 mL/min/1.73 m2and 5 mL/min/1.73 m2, respectively. During the treatment, oral anti-TB drug-induced hepatotoxicity (ADIH) occurred to the patient. This problem was solved with management according to the British Thoracic Society (BTS) guidelines. Screening TB in children is very important for a better outcome. If children complain of some complicated urinary tract infection, TB should be suspected. Optimaly treating children with urinary tract TB exagerrated with ADIH and CKD is very challenging.

Introduction: Aim of the study is to evaluate the prevalence of HBV, HIV, HCV, tuberculosis and syphilis infection among immigrants assigned to the immigrant centre of the province of Modena. Methods: At the time of arrival all immigrant were tested for: HBsAg, HBsAb, HBcAb, Ag p24/HIVAb, HCVAb, RPR, TPPA, Mantoux test (>10 mm diameter of induration was considered to be positive), Chest X-rays. In case of positive samples, second level tests were performed (HbeAg, HBeAb, HDVAb, and baseline management and treatment of the infection detected). Results: A total of 304 immigrant people were enrolled in the study. HBsAg positivity was 12.2%, HCVAb 3.3%, HIVAb 1.6%, TPPA + RPR positivity in the 0.7%; 10.2% had a positive Mantoux test; 5.6% had Chest X-rays positive for signs of infection and 6 patients had an active tuberculosis. 83.8% HBsAg were HBeAb positive/HBeAg negative. HDVAb resulted positive in 1 patient (2.7%). Previous HBV infection was detected in 28.6% of cases, isolated HBcAb in 2.3%; 5.6% of patients resulted to be positive to HbsAb alone (probable vaccinated). Conclusion: Our study confirms the high prevalence of HBsAg positivity and latent tuberculosis among immigrants, underlying the importance of screening for infections in this special population. Keywords: Immigrant population, Sexually transmitted infections, Tuberculosis, Screening

Annually about two million deaths occur globally due to tuberculosis (TB). Bangladesh ranks the sixth position among 22 highest burden TB countries in the world and also one of the 27 high multidrug resistant tuberculosis (MDR-TB) burden countries where about 70,000 people die every year due to TB. Among six key components of Stop TB Strategy (STS) Plan, the first one includes increase case notification of all forms of TB and improve diagnosis of new smear negative, extrapulmonary cases and TB in children by 2016. As TB can affect any organ in human body, the TB cases are managed by any discipline in medical community. Unfortunately diagnostic accuracy is not satisfactory and is not only due to uniform unavailability of the latest diagnostic facilities but also due to inadequate knowledge of the professionals about currently available modern laboratory techniques to diagnose TB. Light-emitting diode (LED) microscopy with fluorescence (auramine-rhodamine staining) should be preferred than conventional microscopy with Zeihl-neelsen (acid fast) staining to identify TB bacilli. Mantoux test (MT) indicates only infection by TB bacilli, does not necessarily the active disease. It may be positive in latent TB and in BCG (Bacillus Calmette-Guerin) vaccinated cases. Antibodies from Lymphocyte Secretion or Antibodies in Lymphocyte Supernatant (ALS) assay can detect active TB cases within three days of sample collection. The test is very useful to diagnose TB in children where sputum collection is difficult. Interferon gamma release assay (IGRA) tests are not advocated in low and middle-income countries, typically those with a high TB and/or HIV burden. Anti TB IgG/IgM/IgA tests should be avoided because these are being misinterpreted by someone as active TB cases. Adenosine Deaminase Assay (ADA) is a reliable test to diagnose tuberculous pleural effusion together with other evidences. ADA in pleural fluid 100 IU/L is highly specific for TB origin. Gene Xpert MTB/RIF, an Xpert test for mycobacterium tuberculosis (MTB) and Rifampicin (RIF) resistance, is used for rapid identification for TB bacilli, specially when MDR-TB is suspected, in human immunodeficiency virus ( HIV) infected cases and highly suspected sputum negative cases ( as a follow on test ) where microscopy frequently failed due to low bacterial load. The test exhibits high sensitivity and specificity for detecting pulmonary TB.Faridpur Med. Coll. J. Jul 2015;10(2): 71-75

Goal of the study: to define efficiency ofthe screening with the tuberculous recombinant allergen (TRA) in children and adolescents with the purpose of tuberculosis detection and defining the groups of the advanced risk of developing tuberculosis. Materials and methods. Efficiency ofscreening fortuberculosis was compared upon the results ofskin tests withTRA in 72,601 children and Mantoux test with 2 TU PPD-L in 99,448 children in the age from 1 to 14 years old. Results. The frequency of tuberculosis detection in the mass screening with TRA among children made 0.4 per 1000 of those examined, among adolescents it made 0.7 per 1000 of those examined which was significantly and confidently higher compared to the screening with Mantoux test. The use of TRA test allowed reducing more than 5 times the number of candidates for preventive chemotherapy under direct observation ofthe drug intake.

Co-infection of tuberculosis and HIV-infection continues to be the current crucial issue not only due to the persistent growth of HIV-infection but also due difficulties in diagnostics of tuberculosis. Often X-ray changes in the lungs are atypical, clinical signs are manifested only in case of the severe and disseminated disease. At present the IGRA-tests are widely used worldwide while in Russia TRA tests are used. The trial provided the data on the use and comparative efficiency of the above immunological tests against Mantoux test with 2 TU when examining 239 persons from 2014 to 2015. The comparativeness of diagnostic sensitivity of all immunological tests had been proved. The specificity of IGRA-tests and TRA tests is twice higher compared to Mantoux test with 2 TU. Also it was proved that when diagnosing tuberculosis in HIV patients the skin tests (Mantoux test with 2 TU and TRA test) had low diagnostic informativeness compared to IGRA tests, among which ELISPOT was the most sensitive.

Objectives The aim of this study was to determine the incidence of active tuberculosis (TB) among household contacts of TB-index cases diagnosed during a 7-year period in a public Primary Care Center located in a high-incidence area. Design and Sample A retrospective cohort study was performed. Data collection was based on the capture-recapture method; the two main sources crossed information from TB-index and contact cases from the El Fondo Primary Care Center (Santa Coloma de Gramenet, Spain) and their reports to the National Epidemiologic Surveillance Service. Measures Variables were divided into demographic and health data (result of the Mantoux test, chest X-ray, presence of risk factors, and indication for chemoprophylaxis). Results Community nurses identified 103 household contacts that underwent the conventional contact study. Overall, 60.19% were male; the mean age was 29.08 years. Only one case of secondary active TB was found, representing an incidence of 0.56% per TB-index case and year. Conclusion The incidence of new secondary TB among household contacts with TB-index cases was of a case. Nevertheless, a long-term follow-up of these householders beyond the conventional contacts study should be considered in areas with higher incidences of TB or among specific high-risk populations.

BACKGROUND To report a rare presentation of culture-positive Mycobacterium chelonae corneal ulcer and its management. FINDINGS We report a rare case of a patient with a history of chronic pain and blurriness of vision. Examination revealed a chronic nonhealing paracentral corneal ulcer inferiorly at the 5-7 o'clock meridian with anterior chamber reaction unresponsive to routine antibiotic and antifungal medications with Mantoux test positivity in a middle-aged nondiabetic patient with no prior history of trauma, ocular surgery, and contact lens usage. Ziehl-Neelsen staining of the nonhealing ulcer revealed acid-fast bacilli typical of M. chelonae, with subsequent culture positivity in Lowenstein-Jensen medium. Subsequent treatment with topical fortified amikacin and tobramycin resulted in rapid healing of the corneal ulcer. CONCLUSION M. chelonae presenting as a chronic nonhealing corneal ulcer spontaneously occurring in a healthy adult with no predisposing factor draws attention towards the need to have a good index of suspicion by performing a Ziehl-Neelsen stain and culture, and subsequent successful management with topical fortified amikacin and tobramycin.

Purpose: To report tuberculosis (TB) T-spot diagnosis and management of two cases of presumptive tubercular retinal vasculitis in Singapore.Method: Retrospective case reports.Results: Two patients were diagnosed with presumptive TB retinal vasculitis using clinical features, TB T-spot test and ancillary investigations. They were successfully treated with a combination therapy of oral steroids, anti-tuberculosis medications and pan retinal photocoagulation (PRP). Follow-up demonstrated resolution of symptoms and signs with no complications arising from anti-tuberculosis medications.Conclusions: TB retinal vasculitis presents diagnostic and therapeutic challenges. Ocular TB diagnosis is often presumptive, as confirmatory evidence of organisms from the eye has low yield. The results of culture and Mantoux test require a long waiting period. TB T-spot provides rapid results with high sensitivity and specificity, thus holding promise as a diagnostic tool. Management of TB retinal vasculitis is multi-modal and multi-disciplinary requiring oral steroids and pan-retinal photocoagulation by the ophthalmologists and anti-tuberculosis medications by the Physicians.

Background: Warts are known to clear spontaneously with the development of cell-mediated immunity (CMI) to the virus. Purified protein derivative (PPD) of tuberculin bacilli has been used as a non-specific stimulant of CMI to achieve this outcome. Aim: To study the effect of PPD in the treatment of warts. Methods: Patients with difficult-to-treat warts were selected for immunotherapy. Each patient received 2.5 TU of PPD intralesionally in a few warts. A total of four sessions were given at 2 weekly intervals and patients were followed up for 6 months after the last dose. Results: Sixty-one patients were recruited of which 55 completed 6 months follow up and were available for analysis. Of these, 25 had verruca vulgaris, 18 had verruca plana and 12 had plantar warts. Forty two (76%) patients showed complete clearance after four sessions while the remaining 13 (24%) patients were non-responders. One patient developed a recurrence after total clearance during the follow-up period. Adverse effects were erythema, edema and pain at the site of injections. Limitations: As this was an uncontrolled trial, there is no comparison with a non-intervention group. Also, a Mantoux test was not done due to practical difficulties. Conclusion: Immunotherapy with PPD is helpful in the treatment of cutaneous warts.

The main epidemiological indicators of tuberculosis were studied in children and adolescents in Russia over the past two decades, the work done in groups at risk for the disease was characterized, and its efficiency was analyzed. The results of introducing a procedure to detect tuberculosis in children were summarized using innovative technologies both in the antituberculosis service and during screening of the pediatric population older than 8 years of age. The author defined new problems in phthisiopediatrics with the advent of multidrug resistance of Mycobacterium tuberculosis, HIV infection in patients with tuberculosis and with the necessity of revising the approaches to preventing it in the risk groups and to treating children with this disease. She showed the importance of the tuberculosis problem and the need for continuing researches of these issues.

Mycobacterium tuberculosis is very rarely found in erythema induratum of Bazin; recently, we found an unusual case with positive acid‐fast bacilli and polymerase chain reaction for detecting M. tuberculosis in both skin lesions of the extremities and the site of Mantoux test.

We present a case of pleural tuberculosis (TB) in a patient on infliximab for ankylosing spondylitis. A 36-year-old male presented to our hospital with low back ache of inflammatory type along with multiple symmetric inflammatory type of joint pain. Further clinical examination, laboratory and radiological investigations were suggestive of ankylosing spondylitis. He was initially treated with nonsteroidal anti-inflammatory drugs but citing poor response it was decided to initiate biologic therapy using infliximab (antitumor necrosis factor-alpha). Mantoux test and chest radiograph were done before the therapy to rule out TB. Following three doses of infliximab, patient came with complaints of fever and cough for 1 week. On investigation, it was found to be a case of pulmonary TB. This shows the importance of close monitoring of patient for TB among patients on infliximab even though the screening test has come out to be negative.

Background:Extrapulmonary forms of tuberculous septic arthritis account only for 1% of tuberculous infections. Although TB infection is rare in western countries, arthropathy is still a common problem in developing countries.Objectives:Describe clinical features of tuberculous septic arthritis seen by the rheumatologist.Methods:Retrospective descriptive study, lead in the rheumatology department of Farhat Hached Hospital, including medical files between 1999 and 2020. Data of patients diagnosed with tuberculous arthropathy were analysed.Results:Twelve patients were diagnosed with tuberculous septic arthritis. Six men and women were enrolled with a sex ratio of 1. The mean age of diagnosis was 47.5±16.16 years. Mean delay of diagnosis was 12.83±15.12 months. A triggering factor like a trauma was described in 8.3% and comorbidities were associated in 16.7% of the cases, mainly diabetes and chronic renal dysfonction. Type of pain was inflammatory in 91.7% of the time. The disease presented as a monoarthritis in 91.7% and an oligoarthritis in 8.3% of the cases. Chronic forms were observed in 91.7% and acute forms in 8.3% of the cases. Transmission was hematological in 60%, directly inoculated in 20% and secondarily disseminated from another site in 20% of the cases. Arthritis affected the knees in 50%, followed by the hips in 33.3% and then the ankles and wrist in 8.3% of the cases each. Fever was noted in 41.7% and general condition was altered in 50% of the patients. Chest radiographs showed the presence of infiltrates or micronodules in 33.3% of the patients. Bone erosions were detected in 66.7% of plain radiographs, while narrowing of the joint was seen in 83.3% and and juxta articular osteoporosis in 50% of the cases. MRI showed the presence of abces in 33% of the cases. The Mantoux test was positive in 2 cases, of which, one didn’t receive the recommended neonatal vaccine. Culture was positive in the synovial fluid in 25%, in sputum in 16.7%, and in urine in 8.3% of the cases. Synovial biopsy was performed for all patients. It showed a non specific synovial inflammation in 50%, granulomatous inflammation in 33.3% and caseous necrosis in 16.7% of the cases. Common quadri therapy was prescribed for all patients with a mean treatment duration of 11.41±1.37 months. Surgery was performed in only two cases with an uncontrolled infection under antibiotics. Disseminated tuberculosis accured in 33.3%, recurrence of the infection in the same site in 16.7% and extension to another articular localisation in 25% of the cases. One patient had a tuberculous meningoencephalitis leading to his death.Conclusion:Tuberculous septic arthritis is difficult to diagnose and should be recalled especially in endemic countries when dealing with chronic monoarthritis. Synovial biopsy is needed most of the time to confirm the diagnosis. Treatment is long and the disease may be complicated with fatal disseminated forms.References:[1]Foocharoen C, Nanagara R, Foocharoen T, Mootsikapun P, Suwannaroj S, Mahakkanukrauh A. Clinical features of tuberculous septic arthritis in Khon Kaen, Thailand: a 10-year retrospective study. Southeast Asian J Trop Med Public Health. nov 2010;41(6):1438-46.Disclosure of Interests:None declared

Tuberculosis is typically a pulmonary chronic infectious disease with a high prevalence in developing countries which carries a substantial rate of mortality. Extrapulmonary disease may occur, mainly second to the endogenous spread of the pathogen from the primary site. Oral or mandibular involvement represents a minority among the reported cases. A 12-year-old female patient with a diffuse left-sided facial swelling and dull pain that gradually developed over 8 months, presented to us with misdiagnosis and poor management. Examination was found to have a firm swelling involving the buccal region, and left posterior mandible with intact overlying skin and mucosa, and palpable cervical lymphadenopathy. Imaging showed a heterogeneous osteolytic lesion of left ramus extending to the surrounding soft tissue. The diagnosis with oro-facial tuberculosis was established by histopathological study and confirmed by the Mantoux test and polymerase chain reaction. Although it occurs rarely, oro-facial tuberculosis has detrimental local and systemic effects, and devoid of characteristic clinical and radiographic features, poses a diagnostic challenge.

Tuberculosis (TB) is still one of the most life-threatening infectious diseases, resulting in high mortality in adults and is commonly found in developing countries. Lung is primarily affected while extrapulmonary TB is rarely encountered. Oral lesions, although rare, can be seen in both primary and secondary stages of TB. Primary oral TB may present a diagnostic challenge as its clinical features can be nonspecific that mimics other diseases and is usually misdiagnosed. Thus, it is very important to be aware and be highly suspicious of oral TB especially in endemic area. We share 4 such cases of primary oral TB with uncommon presentations (two on the gingiva, one on the palate and one on the tongue) The diagnosis was made by histopathological examination, polymerase chain reaction analysis and Mantoux test. They were successfully treated with antituberculous treatment. In secondary TB, the oral manifestations may be accompanied by lesions in the lungs, lymph nodes or in any other part of the body and can be detected by a systemic examination.

Background & Objective: Screening for latent TB infection is recommended prior to the initiation of the newer and more effective treatment modalities of spondyloathritis such as biologic agents and tofacitinib. The prevalence of latent TB infection in the adult population of Bangladesh is not yet known. The figure is 40% in the general population in India that is demographically similar to the Bangladeshi population. The objective of this study was to assess the frequency of latent TB infection in patients with spondyloarhtritis visiting a tertiary hospital. Materials & Methods: This study was conducted in the Department of Rheumatology of Enam Medical College & Hospital, Savar, Dhaka, Bangladesh from October 2018 to December 2019. Each of the 75 participants underwent Mantoux test as a screening procedure for the detection of latent TB infection. Results: Mantoux test was positive (≥10 mm) in 10.3% of the participants. A reading between 5 and 9 mm was found in 33.7% of the participants and the rest of the participants (56%) had induration diameters

Background and Aims: Most of the available treatment therapeutic modalities for warts are aimed at destruction of virus. However, despite adequate treatment, the virus may persist in the surrounding tissues leading to recurrence. Owing to side effects such as pain, scarring, and risk of secondary infection, these modalities may not be suitable for multiple lesions, extensive involvement and for the treatment of warts in the paediatric age group. The aim of the study was to evaluate the efficacy and safety of intra lesional BCG vaccine in the management of patients with multiple extensive non-genital common warts. Methods: Thirty patients with multiple, extensive non-genital cutaneous common warts, with age ranging from 6 to 60 years who were not on any treatment for warts and did not have any active infections (including HIV) or past history of tuberculosis attending the department of dermatology of our hospital in a 2-year period were included. Mantoux test was performed in all patients and positive responders were taken up for study. BCG vaccine was administered into the largest wart intradermally and the injection was repeated every 3 weeks for a maximum of five injections or till the complete clearance of warts, whichever was earlier . The efficacy was assessed every 3 weeks and a final assessment was done at the end of the 12th week. Patients were followed up for another 6 months. Observations: Majority of patients were in the age group of 5-14 years. Males (63.3%) were afflicted more than females. Most patients (63.3%) exhibited partial response at the site of injected wart at the end of one month and 70% patients showed complete clearance at the end of 3 months and 36.6% responded with 3 injections and 26.6% patients required 4 for response followed 23.3% requiring 5 injections. Conclusion: Intralesional immunotherapy using by BCG vaccine appears to be is a promising treatment modality for the treatment of warts, particularly the multiple and recalcitrant ones. The advantages include the resolution of both the injected and distant warts with negligible recurrence and with minimal side effects.

Wegener's Granulomatosis (WG) is an immunologically mediated rare multisystem disease characterized by necrotizing granulomatous inflammation affecting the upper and lower respiratory tracts, disseminated vasculitis and glomerulonephritis. WG oral lesions are reported to occur in 6%–13% of patients; they were an initial presenting feature in only 2% of cases. A case of strawberry gingivitis as the first sign of WG presented with erythematous and painful localized gingival enlargement affecting the maxillary anterior region of jaw in a 17-year-old boy is reported here. Correlation of histopathology with routine hematoxylin and eosin and special stains such as Grocott-Gomori's methenamine-silver nitrate and periodic acid–Schiff, peripheral blood smear, chest radiographs, Mantoux test and clinical presentation were established in diagnosing this rare entity. By the above-mentioned procedures, we arrived at the diagnosis of WG. The aim of reporting this case was to emphasize that, the dental surgeon often being the first person to examine the oral cavity, should be familiar with the typical appearance of gingiva as “strawberry gingivitis,” its clinical course, diagnostic parameters and adequate management of WG.

Sacral tuberculosis (TB) is extremely rare and its unusual entity might delay the diagnosis and treatment of this treatable disease. A 38-year-old lady presented with a 1 year history of lower back pain with radiculopathy more to right lower limb. The patient was initially treated as Prolapsed Intervertebral Disc (PID), but showed no improvement despite regular physiotherapy and medication. Subsequently, the pain was confined to the right gluteal area and became more severe. Quality of life was impaired in which patient started using walking aids and stopped working. There was a weight loss of 20kg. No other symptom of TB infection or history of contact with TB patient. Bowel and urinary functions were normal. Examination showed localized tenderness at the right gluteal area. Neurological assessment of both lower limbs were MRC grade 5. Blood investigations were normal including the ESR level (17mm/hour). Mantoux test was positive with 18mm induration. MRI revealed a large rim enhancing paravertebral collection at pre-sacral space which extended into bilateral piriformis and gluteal muscles. The patient underwent CT-guided drainage of both gluteals and specimens taken to confirm the diagnosis of TB. Patient showed significant improvement clinically within 1 week after the drainage procedure and initiation of antituberculous chemotherapy. The initial presentation of this patient mimics PID due to irritation of sciatic nerve at piriformis level. However a change in the presentation and failure of conservative treatment should raise a high index of suspicion and necessitates further investigation to establish correct diagnosis hence proper treatment can be initiated.

Background Acute multifocal retinitis is a rare condition that has been considered to be often idiopathic. The purpose of this study was to analyze clinical features and causes of acute multifocal retinitis. Results This study is a retrospective review of the charts of 35 patients with acute multifocal retinitis. Patients with three or more retinal lesions in at least one eye, with at least one lesion of less than 500 μm in size were included. All patients had complete ophthalmological examination, fundus photography, and fluorescein angiography. Twelve patients (34.3%) had optical coherence tomography. An extensive work-up was performed including a detailed comprehensive medical history, examination by an internist and an infectious disease specialist, a chest X-ray, Mantoux test, and laboratory tests for syphilis, human immunodeficiency virus, Bartonella, and Rickettsia. Of the 35 patients, 25 (71.4%) had bilateral involvement and 10 (28.6%) had unilateral involvement (total number of eyes: 60). Mean best-corrected visual acuity (BCVA) was 20/25 (range, 20/1000–20/20). Retinal lesions ranged from 3 to more than 20 in number in at least 1 eye, and from 150 to 1500 μm in size. Associated findings included mild anterior chamber inflammation in 5 eyes (8.3%), mild vitritis in 46 eyes (76.7%), optic disc swelling in 9 eyes (15%), macular star in 4 eyes (6.7%), exudative retinal detachment in 6 eyes (10%), and branch retinal artery occlusion in 6 eyes (10%). Acute multifocal retinitis was found to be caused by Rickettsia conorii infection in 20 patients (57.1%), Rickettsia typhi infection in 4 patients (11.4%), cat-scratch disease in 8 patients (22.9%), and syphilis in 1 patient (2.9%). It was idiopathic in two patients (5.7%). Retinal lesions resolved without scarring in 3 to 12 weeks in all but three eyes (5%), in which residual retinal pigment epithelial changes were noted. Conclusion Rickettsial disease was the most common cause of acute multifocal retinitis. Other identified causes included cat-scratch disease and syphilis, and a very small subset of patients was diagnosed with idiopathic multifocal retinitis.

Background: Moscow (city of 12 million of population) has one of the lowest TB notification rate in the country for children aged 0-14 - 5.5 per 100K or 93 cases in 2016. Before 2012 in whole Russia, procedure of TB detection among children included mass screening by Mantoux test (MT) and clinical and X-ray assessment for MT positive cases. During last 5 years, for MT positive cases as for as children from TB contact, and social and medical risk groups, Moscow TB control service provides a immunological recombinant TB allergen skin test (RTAT) with subsequent clinical and X-ray assessment, which covered a significantly smaller number of children. Aims: Evaluate results of modern TB detection tools among children in Moscow. Methods: Data of screening of Moscow children (0-14) population by RTAT Diaskintest® (Global investments in tuberculosis. Research and development, WHO, 2017, P.30) were analyzed. Results: Mantoux test covered 76.3% of children (1 282 235), 74% from which had positive results. RTAT was used in 131 000 children, with MT positive and/or belonged to TB risk groups. RTAT was positive in 3304 (2.5%) children. TB detection rate was 5.0% among them (91 children 0-14) in comparison with 0.13% for Mantoux test. 2 new TB cases among children were detected with negative reactions of RTAT. Sensitivity of RTAT was 98.4% (95% CI: 94.2-99.8). Additionally 102 children were detected by RTAT with post TB changes, which can indicate undetected TB cases among family and close contacts of the child. Conclusions: The introduction of a new diagnostic algorithm allowed to significantly reduce the number of children subjected to TB screening, while maintaining the accuracy of detection of the disease.

Purpose: To describe the clinico-radiological features and long-term outcomes in patients with tubercular dacryoadenitis (TbD)Methods: Retrospective, observational study of TbD patients who...

Background. A group of Russian scientists has developed Diaskintest, which comprises Mycobacterium tuberculosis-specific recombinant proteins CFP10-ESAT6, for skin testing (0.2 µg/0.1 ml).Study purpose: to evaluate the comparative sensitivity of TST with 2 TU PPD-L and a skin test with tuberculous recombinant allergen (Diaskintest) containing the ESAT6-CFP10 protein in children and adolescents with newly diagnosed respiratory tuberculosis during mass screening in the primary medical service in Moscow, 2013–2016.Materials and methods. The trial was a comprehensive retrospective group study of children and adolescents diagnosed in Moscow with respiratory tuberculosis in 2013–2016, aged 0 to 17 years inclusive. From 441 patients selected for analysis 408 patients had both tests (TST with 2 TU PPD-L and Diaskintest) performed, in 193 patients both tests were given simultaneously, of them 162 patients were BCG-vaccinated.Results. Comparative results of both tests in 408 patients with tuberculosis: at cut-off 5 mm, both tests has similar sensitivity: Diaskintest 98.3 % (95 % CI 97.0–99.6 %), TST 98.0 % (95 % CI 96.7–99.4 %), at cut-off 10 mm, the sensitivity decreases for both tests: Diaskintest 90.0 % (95 % CI 87.0–93.0 %), TST 88.7 % (95 % CI 85.6–91.9 %), but at cut-off 15 mm, the decrease in sensitivity is statistically significant: for Diaskintest 61.5 % (95 % CI 56.7–66.3 %), and for TST 46.3 % (95 % CI 41.4–51.3 %), p The results of simultaneous setting of tests on different hands in 193 people (including 162 BCG-vaccinated), do not differ from the results for 408 people.The correlation between the results of Diaskintest and TST was significant in all groups.Conclusion. In children and adolescents with respiratory tuberculosis, Diaskintest of 0.2 µg/ml and the Mantoux test with 2 TU PPD-L have high sensitivity (98%) at a cut-off of 5 mm; however, at cut-off 15 mm sensitivity is significantly reduced, and the decrease is more pronounced in the Mantoux test. The advantage of Diaskintest is that, unlike the Mantoux test, it has high specificity under the conditions of mass BCG vaccination. The test is cost-effective, simple to carry out, and can be used in mass screening.

Background Studies have shown a correlation between Tuberculosis (TB) and Takayasu arteritis (TA). Some even postulate that infection with TB is required for the initiation of aortoarteritis. Hence, this project was undertaken to find an association of TB and TA by studying the prevalence of Latent Tuberculosis Infection (LTBI) in Indian TA patients. Objectives To study the prevalence of LTBI in Indian TA patients and see whether LTBI is more in these patients as compared to the historical cohort (40% in Indian population). Methods This was a cross sectional observational study. All consecutive patients with TA (satisfying the ACR 1990 criteria) were included prospectively from a period of May 2016 to December 2017. Their clinical, laboratory and radiological data were collected after obtaining informed consent. Patients were divided into groups based on the angiographic classification. LTBI was assessed by the Mantoux test and Quantiferon TB Gold test. Mantoux test (MT) was done with 5TU and results were read after 48–72 hours. An induration more than 10 mm was considered positive. Quantiferon TB Gold assay (QTB) was done by ELISA technique and (patient minus control) value >0.35 IU/ml was considered positive. A positive result of MT and /or QTB was considered positive for LTBI. Chest X-ray was included to access evidence of past or active TB lesions. Active infection was defined as clinical and microbiological and /or radiological evidence of TB. The study was approved by the Ethics committee of Medanta hospital. Results Out of 66 consecutive TA patients, 46 patients had tests available for LTBI and these were included in the analysis. The mean age of the cohort was 34.9 years with a median disease duration of 24 months. Males consisted of 11 patients whereas females formed the majority i.e. 35 patients (M: F= 1: 3.1). Angiographic Type V (54.3%) was the commonest in the cohort followed by Type IIB (17.3%), Type IV, I, IIA and III (15.2%, 8.6%, 2.1% and 2.1% respectively). LTBI positivity was present in 32.6% of the cohort; with 5 patients (10.8%) having both tests positive. 6 patients were MT positive without being QTB positive and 4 patients were only QTB positive. Eight patients had history of Tuberculosis out of which 1 was diagnosed with TB and TA simultaneously. Four patients were diagnosed as TA during the course of Anti tubercular treatment (ATT) between 4 to 6 months, whereas the rest were diagnosed after ATT completion. The mean duration of Anti tubercular treatment was 8 months. Koch’s contact was seen in 7 patients. Conclusions The prevalence of LTBI in Indian Takayasu patients was 32.6%, which was not higher than the population prevalence (40% in the historical cohort). However, a larger cohort and further association studies are needed for the relationship between TA and Tuberculosis. Disclosure of Interest None declared

Background Latent TB infection (LTBI), defined as ‘a state of persistent immune response to Mycobacterium tuberculosis without clinically-manifested disease’, inflicts a third of the world’s population and nearly 10% of LTBI positive persons develop TB within 2–5 years. The tuberculin skin test (TST) and, more recently, interferon gamma release assays (IGRAs) are most commonly used for detection of LTBI. However, in a high TB burden setting such as India, both the assays have been found to grossly underestimate the true prevalence of LTBI, since almost equal number of new TB cases emerged from the test-positive and test-negative groups during the follow-up1. Objectives This study was aimed at exploring whether an in vitro CD3 +T cell response to PPD can complement the in vivo TST response for the determination of true prevalence of LTBI in healthy Indians. Methods In this ongoing study, 80 apparently healthy workers (age 19–61 years) at SGPGIMS have been recruited. Their demographic data, including BCG vaccination status and duration of contact with TB patients, was recorded. TST was performed with 5 TU of PPD. Blood T cell (CD3+) responses to PHA (a mitogen, used as positive control) and PPD were determined by flow cytometry in terms of expression of the proliferation-induced nuclear protein Ki67. Results 48% of the study subjects showed positivity for TST (skin induration ≥10 mm) and the size of reaction could be correlated with age. There was no association between BCG vaccination status and TST positivity. 72% of the TST positive and 62% of TST negative persons showed positivity for CD3 +T cell response to PPD. Positivity for either assay was found to be 82%. Conclusions By combining TST with CD3 +T cell responses, the positivity for PPD was enhanced from 48% (TST alone) to 82%. Therefore, both the assays could be considered as complementary. It remains to be seen whether these assays, either singly or jointly, show a correlation with the emergence of TB in our study population during the follow-up. Reference [1] Sharma SK, Vashishtha R, Chauhan LS, Sreenivas V, Seth D. Comparison of TST and IGRA in Diagnosis of Latent Tuberculosis Infection in a High TB-Burden Setting. PLoS ONE2017;12(1):e0169539. Disclosure of Interest None declared

Aim Tuberculosis (TB) is one of the major adverse events of concern associated with the use of biologics for managing autoimmune inflammatory rheumatic diseases (AIRDs). The study presents the data on incidence of TB in relation to biologic used, screening test and TB prophylaxis in a real-world setting. Methods The cross-sectional, observational, retrospective study was conducted across 12 centres in Karnataka, India. The study included patients receiving biologics therapy for AIRDs, established based on the respective diagnostic criteria. The development of TB after receiving biologic therapy and other clinical variables and the predictability of the test performed for latent TB were evaluated. Results One hundred and ninety-five AIRDs patients with an average age of 41 years were initiated on biologic therapy. Twenty-one patients were latent TB positive and were given antitubercular prophylaxis, prior to biologics treatment. During follow-up, seven patients belonging to the negative test group (n = 174) developed TB. The negative predictive values noted for Mantoux test (n = 120) and quantiFERON TB gold test (n = 178) were 96.52% and 96.25%, respectively. Patients on anti-tumor necrosis factor were more likely to develop TB. Presence of comorbidities and steroid use increased the likelihood of developing TB by 1.5 and 4.6 times, respectively. Conclusion Close monitoring of patients receiving biologics is essential for early identification of adverse events, especially in test negative patients. Prophylaxis can effectively reduce the risk of developing TB in patients positive for screening.

Tuberculosis (TB) remains a significant source of morbidity and mortality among children in endemic settings. Demografic and clinical profiles of children with TB in Yogyakarta have not been well documented. A total of 80 children with TB were diagnosed with TB during the study period. There were 41 (51.2%) females and 39 (48.8%) males. The case findings of child TB cases has been increasing from 20 cases in 2014, 28 cases in 2015, and 32 cases in 2016. The majority of the children (89.3%) aged less than 5 years. The most common symptoms were cough 50 (62.5%), followed by weight loss 45 (56.3%), and fever 28 (35%). Contact with a TB case was identified in 46 (57.5%) children. Mantoux test was done in 76 (95%) children with positive result documented in 61(76.3%) children. Chest X-ray was done in 54 (67.5%) children, of which 52 (65%) chest X- rays showed suggestive of TB. Confirmed diagnosis (bacteriology) was only documented in one child (1.25%).