The transition to Xpert MTB/RIF ultra: diagnostic accuracy for pulmonary tuberculosis in Kampala, Uganda.

BACKGROUND: The World Health Organization (WHO) has endorsed the next-generation Xpert MTB/RIF Ultra (Ultra) cartridge, and Uganda is currently transitioning from the older generation Xpert MTB/RIF (Xpert) cartridge to Ultra as the initial diagnostic test for pulmonary tuberculosis (TB). We assessed the diagnostic accuracy of Ultra for pulmonary TB among adults in Kampala, Uganda. METHODS: We sampled adults referred for Xpert testing at two hospitals and a health center over a 12-month period. We enrolled adults with positive Xpert and a random 1:1 sample with negative Xpert results. Expectorated sputum was collected for Ultra, and for solid and liquid culture testing for Xpert-negative patients. We measured sensitivity and specificity of Ultra overall and by HIV status, prior history of TB, and hospitalization, in reference to Xpert and culture results. We also assessed how classification of results in the new "trace" category affects Ultra accuracy. RESULTS: Among 698 participants included, 211 (30%) were HIV-positive and 336 (48%) had TB. The sensitivity of Ultra was 90.5% (95% CI 86.8-93.4) and specificity was 98.1% (95% CI 96.1-99.2). There were no significant differences in sensitivity and specificity by HIV status, prior history of TB or hospitalization. Xpert and Ultra results were concordant in 670 (96%) participants, with Ultra having a small reduction in specificity (difference 1.9, 95% CI 0.2 to 3.6, p=0.01). When "trace" results were considered positive for all patients, sensitivity increased by 2.1% (95% CI 0.3 to 3.9, p=0.01) without a significant reduction in specificity (- 0.8, 95% CI - 0.3 to 2.0, p=0.08). CONCLUSIONS: After 1 year of implementation, Ultra had similar performance to Xpert. Considering "trace" results to be positive in all patients increased case detection without significant loss of specificity. Longitudinal studies are needed to compare the benefit of greater diagnoses to the cost of overtreatment.

Mediastinal mass mimicking a tumor in a patient with bladder cancer after Bacillus Calmette-Guerin treatment.

We describe the case of a 78-year-old male with bladder cancer who developed a mediastinal mass after intravesical immunotherapy with live Mycobacterium bovis BCG. The clinical diagnosis was mediastinal tumor suggestive for lymphoma. However, cultures of the biopsy specimens grew an acid-fast organism, which was identified as M. bovis BCG. To the best of our knowledge, this is the first reported case in which a post-instillation BCG infection induced a mediastinal mass that mimicked a tumor in a patient with bladder cancer.

Analysis of tuberculosis surveillance in Hungary in 2000.

SETTING: Hungary, Central Europe, with a population of 10.3 million living in 20 administrative districts (19 counties and the capital). OBJECTIVE: To summarize the results of the first year of the revised National Tuberculosis Surveillance System. DESIGN: Retrospective survey of the National Tuberculosis Surveillance Center (NTSC) database. METHODS: Analysis of data on all tuberculosis cases reported to the NTSC in 2000. Drug susceptibility results were evaluated in line with WHO and IUATLD definitions. RESULTS: During 2000, a total of 3598 patients with tuberculosis were reported. Only 40% of these were bacteriologically confirmed. Although susceptibility testing has been required for previously untreated culture-positive cases, only 801 (67.8% of the bacteriologically confirmed cases) were tested in 2000. Drug resistance was detected in 10.7% of previously untreated and in 23.5% of previously treated patients. Multidrug-resistant (MDR) cases were not common: only 1.5% of the isolates from previously untreated patients and 4.9% of those from previously treated patients were MDR. CONCLUSIONS: The results suggest that the NTSC should work towards increasing the numbers of cases that are bacteriologically confirmed. In addition, some form of surveillance system should be instituted to ensure that mandatory susceptibility testing is performed on all isolates from previously untreated tuberculosis patients.

Polymorphisms at position -308 in the promoter region of the TNF-alpha and in the first intron of the TNF-beta genes and spontaneous and lipopolysaccharide-induced TNF-alpha release in sarcoidosis.

TNF-alpha is a potent pro-inflammatory cytokine. Previous studies have proved that biallelic polymorphisms in the TNF-alpha (-308, TNFA) and TNF-beta genes (intron 1, TNFB) influence TNF-alpha production. In sarcoidosis, a chronic granulomatous disease, as a result of an unknown in vivo activation bronchoalveolar lavage (BAL) cells release high amounts of TNF-alpha, spontaneously and after in vitro stimulation. Thus, sarcoidosis could serve as a model to test the in vivo effect of TNF gene polymorphisms. We determined the TNFA and TNFB polymorphisms of 44 patients with sarcoidosis and found the following allele frequencies: 0.80, 0.20, 0.38 and 0.62 for TNFA1, TNFA2, TNFB1 and TNFB2, respectively. To examine the in vivo effect of the named polymorphisms on the TNF-alpha production, the spontaneous and LPS-induced TNF-alpha release of BAL cells and peripheral blood mononuclear cells were also determined in patients with sarcoidosis. Statistical analysis did not reveal any significant difference between sarcoidosis patients with different genotypes. The results show that TNFA and TNFB polymorphisms do not determine the level of TNF-alpha release of mononuclear cells activated during the course of sarcoid inflammation.

Different cytokine patterns correlate with the extension of disease in pulmonary tuberculosis.

The relative amounts of different pro- and anti-inflammatory cytokines released at the site of infection by bronchoalveolar lavage (BAL) cells may influence the presentation of tuberculosis. To investigate this hypothesis the in situ release by BAL cells of the following cytokines was measured and correlated with the chest X-ray findings of 43 patients with pulmonary tuberculosis: interleukin (IL)-8, macrophage inflammatory protein-1alpha (MIP-1alpha), IL-6, tumor necrosis factor-alpha (TNF-alpha), transforming growth factor-beta (TGF-beta), interferon-gamma (IFN-gamma), IL-2, IL-4 and IL-5. The release of IL-8 and IL-6 decreased with the progression of the disease, while the release of MIP-1alpha was increased in patients with advanced tuberculosis. The release of TNF-alpha and TGF-beta did not differ between patients with or without cavitary lesions. The Th1 (IFN-gamma and IL-2) and Th2 (IL-4 and IL-5) cytokine release exhibited a gradual increment with the advance of tuberculosis. Thus, our data provide evidence that a Th0 cytokine pattern is predominant at the site of pulmonary tuberculosis. In conclusion, immunoparalysis status could not be observed in our patients with severe tuberculosis.

[Pulmonary echinococcosis]. / Pulmonalis echinococcosis.

Two patients with pulmonal Echinococcosis are presented by the authors. Contact with cestoda carrier animals cannot be revealed. At the first patient, who was without any complaints, the two round shadows in her chest X-ray were detected accidentally by screening examination and before the operation only eosinophilia, many eosinophil granulocytes in the pleural effusion and the positive complement binding reaction were related to the Echinococcosis, which was proved by the histological examination of the intraoperative biopsy. The other patient had complaints during months. In this case the Echinococcus granulosus broke into the bronchus and emptied in the sputum. Postoperative histological diagnosis can be obtained by help of the excision from the intraluminal alteration which was visible during bronchoscopy. The authors summarize the etiology, the clinical signs, the diagnose and the therapy of Echinococcosis. They call attention to the incidence of this mainly tropical disease in Hungary and to the rare soliter pulmonal manifestation of the Echinococcosis.