An immunocompromised woman in her twenties with abdominal pain and vaginal discharge. / Immunsupprimert kvinne i 20-årene med magesmerter og utflod.

BACKGROUND: Women of reproductive age who present with abdominal pain and purulent vaginal discharge are commonly seen in primary health care and gynaecological outpatient clinics. Their symptoms are often caused by sexually transmitted infections and efficiently treated with empiric antibiotics. However, in some cases diagnostics are more challenging. CASE PRESENTATION: We present the case history of a woman in her twenties with multiple sclerosis under rituximab treatment. She presented with a wide range of symptoms over twelve months, including upper and lower respiratory tract infections, urinary bladder urgency, chronic abdominal pain, diarrhoea, bloody stools, weight loss and fatigue. She underwent urological and gastroenterological examinations which yielded normal findings. After the onset of genital discomfort and copious amounts of vaginal discharge, gynaecological examination and routine microbiological testing of discharge were negative. Finally, she presented with septicaemia and progressive abdominal pain. Laparoscopy was performed due to absence of recovery after initial transvaginal ultrasound-guided aspiration of ovarian cysts. The microbe Ureaplasma urealyticum was detected in ovarian pus. Treatment with doxycycline resulted in full recovery. INTERPRETATION: It is important to consider opportunistic microbes in immunocompromised patients, as they might pose a major diagnostic challenge and require the involvement of several specialties.

Diagnosis of extrapulmonary tuberculosis using the MPT64 antigen detection test in a high-income low tuberculosis prevalence setting.

BACKGROUND: Extrapulmonary tuberculosis (EPTB) poses diagnostic challenges due to the paucibacillary nature of the disease. The immunochemistry-based MPT64 antigen detection test (MPT64 test) has shown promising results for diagnosing EPTB in previous studies performed in low-resource settings, with higher sensitivity than microscopy and culture. The aim of this study was to investigate the performance of the MPT64 test in a routine clinical setting in a high-income low TB prevalence country. METHODS: Extrapulmonary samples sent for TB diagnostics to microbiology and pathology laboratories at three regional tertiary care hospitals in Norway in a one-year period were included and subjected to the MPT64 test in parallel to the routine TB diagnostic tests. RESULTS: Samples from 288 patients were included and categorised as confirmed TB cases (n = 26), clinically diagnosed TB cases (n = 5), non-TB cases (n = 243) and uncategorised (n = 14), using a composite reference standard (CRS). In formalin-fixed biopsies, the sensitivity (95% CI) of the MPT64 test, microscopy, PCR-based tests pooled, and culture was 37% (16-62), 20% (4-48), 37% (16-62) and 50% (23-77), respectively, against the CRS. The MPT64 test showed a good positive predictive value (88%) and an excellent specificity (99, 95% CI 92-100) in formalin-fixed biopsies. In fine-needle aspirates, pus and fluid samples, the test performance was lower. CONCLUSIONS: The MPT64 test was implementable in pathology laboratories as part of routine diagnostics, and although the sensitivity of the MPT64 test was not better than culture in this setting, the test supplements other rapid diagnostic methods, including microscopy and PCR-based tests, and can contribute to strengthen the diagnosis of EPTB in formalin-fixed biopsies in the absence of culture confirmation.