Biobank for multidrug-resistant tuberculosis research: importance of sequential samples.

Since 2013, Masan National Tuberculosis Hospital has collected standardized specimens from its tuberculosis patients, which include a large number of multidrug-resistant strains. The repository collects matched participants and their bacilli samples, compiling sequential samples from the beginning of treatment. The repository aims to provide resources for in-depth international research.

Challenges in urogenital tuberculosis.

PURPOSE: For better understanding of urogenital tuberculosis (UGTB), its clinical spectrum and characteristic features need to be evaluated. MATERIALS AND METHODS: One hundred and forty-two cases of UGTB patients were analyzed retrospectively. We considered age, gender, symptoms, and diagnostic procedures. RESULTS: The total of 142 patients were divided into group A (consisted of 93 patients with only urinary TB), group B (consisted of 13 male patients with generalized UGTB, including urinary TB and male genital TB (MGTB). Group C consisted of 36 patients with MGTB. Sixty patients in groups A and B 56.6% had kidney TB third-to-fourth stages, which are incurable for anti-TB therapy and require surgery. The urinary tract was involved in 48 patients (45.3%): 25 (23.6%) had ureteral TB and 23 (21.7%) had also bladder TB. The most common symptom for kidney TB was flank pain (69.8%) followed by dysuria (47.2%). Perineal pain and dysuria were most common symptoms for prostate TB and were found in 87.5% (14 patients) and 56.3% (9 patients), respectively. Of total, in only 58 UGTB patients (40.8%), the culture for Mycobacterium tuberculosis (Mtb) was positive. CONCLUSION: Of 142 patients with UGTB, 106 (74.7%) had kidney TB and 13 (9.2%) of them had kidney TB in combination with MGTB. Only MGTB (prostate, scrotal, or generalized) was diagnosed in 49 (34.5%) patients. The most common symptoms were flank pain and dysuria. Identification of Mtb in UGTB is difficult. Therefore, the most advanced microbiological technology should be used to establish the correct diagnosis.

Is sterile pyuria another minor diagnostic criterion in urinary tuberculosis?

INTRODUCTION: Composite reference standard (CRS) is used for diagnosis of urinary tract tuberculosis (UTB). We examined if addition of a new 'component test' as minor criterion in the form of SP could improve the yield. METHODS: We identified patients admitted with a diagnosis of UTB from January 2009 to February 2016 from our patient database. We performed the validation of addition of a new 'component' "sterile pyuria" to the existing basic CRS. RESULTS: SP was seen in 50 patients (65.7%). Forty (52.6%) of these patients had one major criterion positive and 10 (13.1%) were diagnosed based on minor criteria. If SP was added as a minor criterion, an additional 8 (9.2%) patients would have been diagnosed based on minor criteria alone without the need for a histopathology. CONCLUSIONS: SP could improve the diagnostic yield of existing CRS by 8% with a 70% decrease in reliance on histopathology for diagnosis.

Atypical testicular pain.

Testicular tuberculosis (TB) is rare, and, because of this, the lack of pathognomonic clinical features and its tendency to mimic other commoner conditions, the diagnosis is frequently delayed or may be missed. In this case, the initial clinical presentation was typical for bacterial epididymo-orchitis in a 38-year-old man. When the patient failed to improve with standard treatment including broadening of antibiotics, the diagnosis was re-considered because some unusual signs suggested testicular malignancy or lymphoma. Further, history-taking and subsequent cross-sectional imaging with CT/MRI identified co-existent pulmonary nodularity, thoracic and abdominal lymphadenopathy and bony changes that, together, raised the suspicion of TB. Mycobacterium tuberculosis was confirmed on DNA-based testing of the hydrocele fluid, although standard acid-fast bacilli culture was negative. This case prompted a review of the literature to explore the optimal steps in the investigation and diagnosis of this rare disease.

The incidence of subclinical forms of urogenital tuberculosis in patients with pulmonary tuberculosis.

The aim of our study was to determine whether patients with pulmonary tuberculosis may have subclinical forms of urogenital tuberculosis. Between 2011 and 2012, a prospective study was conducted. Basic demographic parameters were recorded and the following investigations were performed: direct bacilloscopy of sputum, evaluation of affected lung fields and presence of cavities on chest X-ray, Mantoux tuberculin skin test II, and interferon gamma release assay. Culture and molecular methods for Mycobacterium tuberculosis in urine were performed. In cases with a positive urine test, an ultrasound examination, computed tomography scan of the abdomen, and endoscopy of the urinary tract were performed. A total of 102 patients (75 men and 27 women) were included in the study, with a median age of 46.8 years. Subclinical forms of urogenital TB were detected in 7 patients; 5 by molecular methods, 1 by urine culture, and 1 with both methods The presence of subclinical forms of genitourinary TB was found in 4 patients without and 3 patients with findings on imaging methods corresponding to TB. A significant number of patients with pulmonary tuberculosis may simultaneously have subclinical forms of urogenital TB.

High incidence of fluoroquinolone resistance and effect of efflux pump inhibitors on moxifloxacin resistance among Mycobacterium tuberculosis isolates causing urinary tract infection in Taiwan.

This study explored the prevalence of urinary tract tuberculosis (UTB) and whether efflux pump activation accounts for resistance to moxifloxacin in Taiwan. Of 3034 patients with culture-confirmed TB from 2005-2012, 47 patients (1.5%) with UTB were included in this study. Minimum inhibitory concentrations (MICs) of moxifloxacin were determined in the presence and absence of efflux pump inhibitors (EPIs), including verapamil, reserpine and carbonyl cyanide 3-chlorophenylhydrazone (CCCP). EPI responders were defined as isolates with at least a four-fold reduction in MICs in the presence of EPIs. Among the 47 isolates, 24 (51.1%) were resistant to ofloxacin and 22 (46.8%) were resistant to moxifloxacin by the agar proportion method. Among the 22 moxifloxacin-resistant isolates, 19 (86.4%) had low-level resistance (MIC = 1.0-2.0 mg/L). Patients with prior exposure to fluoroquinolones were more likely than non-exposed patients to have moxifloxacin-resistant isolates [14/22 (63.6%) vs. 8/25 (32.0%); P = 0.030]. All 3 isolates with high-level moxifloxacin resistance (MIC ≥ 4.0 mg/L) had mutations in the gyrA or gyrB genes; however, among the 19 isolates with low-level resistance, only 1 (5.3%) had a mutation in the gyrA gene. Among the 19 isolates with low-level moxifloxacin resistance, 16 isolates (84.2%) were EPIs responders, but none of the high-level resistant isolates were EPIs responders. Approximately one-half (46.8%) of the isolates from patients with UTB were resistant to moxifloxacin, and activation of efflux pumps accounted for most low-level moxifloxacin-resistant isolates.

[Characterization of microbial flora in patients suspected of having urogenital tuberculosis].

INTRODUCTION: In the structure of tuberculosis morbidity, urogenital tuberculosis (UGT) ranks second or third only to pulmonary tuberculosis. Every fourth patient has the stage of cavern formation at first presentation. Seventy five percent of nephrotuberculosis cases co-occur with nonspecific pyelonephritis, which excludes "sterile pyuria". We aimed to determine the microbial spectrum of urine and gonadal appendages in patients with suspected UGT and to investigate the susceptibility of the isolated microorganisms to the main antibacterial drugs. MATERIAL AND METHODS: The study investigated the spectrum of pathogenic microflora isolated from patients admitted to the urogenital clinic of the TB Research Institute from January 1, 2012 to September 30, 2016 to rule out UGT. Microorganism species were identified by time-of-flight mass spectrometry using the microbiological analyzer Phoenix 100 (Becton Dickinson, USA). Antibiotic resistance was determined using the Phoenix 100 microbiological analyzer (Becton Dickinson, USA). RESULTS: A total of 3004 bacteriological tests for nonspecific microflora were performed during the analyzed period. In the structure of pathogens, E. coli comprised about half of the cases thus confirming its role as the leading uropathogen. Only piperacillin/tazobactam and nitrofurantoin provided relatively plausible antimicrobial resistance rates, for other antibacterial drugs the rates of susceptible strains progressively decreased and by 2016 dropped to 40% and lower. CONCLUSION: Our findings cannot be extrapolated to the entire population since patients presenting for differential diagnosis receive multiple courses of treatment with various antibacterial drugs, which led to the selection of resistant strains. The findings emphasize the need for a strict selection of antibiotics for urogenital infection empirical therapy. In the absence of response, the patient should be immediately examined for tuberculosis using molecular and genetic diagnostic techniques.

Diagnosis and treatment of paediatric tuberculosis: An insight review.

Tuberculosis (TB) is a major public health problem, invading all age groups world-wide. It is an opportunistic infection affecting the individuals alone or with co-infections. Childhood TB is a neglected aspect and a significant health problem in epidemic areas. It constitutes more than 20% of TB incidence. Pediatric TB exists in the shadow of adult TB. The clinicians concentrate on pulmonary manifestation of TB, whereas it is a major problem in both pulmonary and extra-pulmonary infections. The rate of infection with this disease is mostly associated with poverty, social disruption and human immunodeficiency virus (HIV) infection. The diagnosis of extra-pulmonary TB (EPTB) is more difficult than pulmonary TB (PTB). Delayed diagnosis and executive treatment contribute to increase in the mortality rate in endemic areas. This article provides the evidence-based simple and safe screening method, indicating rapid, highly sensitive and specific diagnostic tests for pulmonary and EPTB in children. The most important aspect of treatment is the correct course of anti-tubercular drugs. This review serves the purpose of quick reference for microbiologists, epidemiologists, academicians, students and researchers. It provides guidance regarding early diagnosis and treatment accuracy of pediatric TB.

[REASONS OF DELAYED DIAGNOSIS OF BLADDER TUBERCULOSIS].

UNLABELLED: The fourth, terminal, stage of bladder tuberculosis (BT) manifests itself in irreversible changes and requires surgical treatment. OBJECTIVE: To identify the reasons for delayed diagnosis of this urogenital tuberculosis complication. Medical history of 26 urogenital tuberculosis patients with a complicated form of stage 4 BT, referred to the Novosibirsk TB Research Institute for reconstructive surgery were analysed. In 22 patients, bladder volume ranged from 55 to 100 ml, 4 patients previously underwent cystostomy due to extremely small bladder volume. Average duration of BT hidden in the guise of "urogenital infection" was 6.2 years. Patients were treated with norfloxacin (a total of 104 courses), ciprofloxacin (86 courses), amikacin (43 courses), nitroxoline (27 courses), third generation cephalosporins (32 courses), lomefloxacin (17 courses), levofloxacin (11 courses), Amoxicillin clavulanate (4 courses), ampicillin (2 courses). It was demonstrated that all cases of BT stage 4 were iatrogenic. Irreversible debilitating complications occurred due to suboptimal therapy, primarily due to administration of amikacin and fluoroquinolones for urogenital infections, which was tuberculosis in disguise. Absence of M. tuberculosis growth does not exclude tuberculosis; pathological specimens must be further examined at least by PCR. Interventional material must be mandatory examined histologically and stained by Ziehl-Neelsen method to identify M. tuberculosis. Effective and not masking tuberculosis, optimal therapy for urogenital infections includes fosfomycin, furazidin (nitrofurantoin), gentamicin, III generation cephalosporins (in outpatient settings dispersible form of efixime should be preferable).

Challenges and perspectives in the diagnosis of extrapulmonary tuberculosis.

Extrapulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis cases worldwide. Nevertheless, the diagnosis is often delayed or even missed due to insidious clinical presentation and poor performance of diagnostic tests. Culture, the classical gold standard for tuberculosis, suffers from increased technical and logistical constraints in EPTB cases. In this review the authors outline current diagnostic options for the main forms of EPTB. The authors also discuss the opportunities and challenges linked in particular to microbiological diagnostics and to the attempts to find a new gold standard test for EPTB. Finally, new biomarkers and tests currently under evaluation are hopefully on the way to introduce significant improvements in EPTB diagnosis, for which clinical suspicion will nevertheless be essential.

High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting.

BACKGROUND: This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence. METHODS: A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of M. tuberculosis, (2) positive M. tuberculosis PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment ('early', started during initial admission; 'late', subsequent periods), reasons for delay, and short- and long-term survival were analyzed. RESULTS: Altogether 349 patients were studied [median(IQR) age 62(48-77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received 'early' and 'late' treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3-9) vs. 43(25-61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3-85.2) delayed diagnosis of tuberculosis. Failure to receive 'early' treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1-3.0). CONCLUSIONS: Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.

[Revisiting the causes of low detection of M. tuberculosis in urine].

The evaluation of potential anti-TB activity and bactericidal activity against opportunistic enterobacteria in urine of healthy people using the automated BACTEC MGIT 960 system for cultivation and determination of drug resistance of mycobacteria and culture on solid media was performed. It has been established that the urine of healthy people do not have bactericidal activity against M. tuberculosis and E. coli in vitro. The one of the possible reasons for the low detection of the pathogen in urogenital tuberculosis--asymptomatic bacteriuria--was identified.

Growth of mycobacteria in urine determined by isothermal microcalorimetry: implications for urogenital tuberculosis and other mycobacterial infections.

OBJECTIVE: To overcome the limitations of current urine-based diagnostic assays of urogenital tuberculosis, we used isothermal microcalorimetry to detect the metabolic activity of Mycobacterium tuberculosis and other commonly neglected pathogenic mycobacteria in urine and accurately determine their growth parameters. METHODS: A microcalorimeter equipped with 48 channels was used. Detection was accomplished, and growth was monitored for 4 different Mycobacterium species in sterilized and modified urine at 37 °C by measuring metabolic heat flow (µW = µJ/s) as a function of time. These strains were M. smegmatis, M. phlei, M. kansasii, and M. tuberculosis. The data were integrated to perform curve fitting and extract the growth parameter from the raw data. RESULTS: In sterilized urine, M. smegmatis showed the fastest growth rate (0.089 ± 0.017 [h(-1)]), followed by M. phlei (0.072 ± 0.016 [h(-1)]) and M. kansasii (0.007 ± 0.001 [h(-1)]). No growth of M. tuberculosis was detected in sterilized urine. However, in serum-supplemented urine, growth of M. tuberculosis was observed within 3 weeks at a growth rate of 0.008 ± 0.001 [h(-1)]. Biofilm formation was enhanced in the serum supplemented urine. CONCLUSION: Isothermal microcalorimetry allows rapid and accurate detection of mycobacterial growth in urine. Given the absence of data on the mycobacterial growth in urine, isothermal microcalorimetry could be used to unravel key aspects of Mycobacterium physiology in the urinary tract and potentially contribute to improvement in the diagnosis and treatment of urogenital tuberculosis.

Clinical and microbiological characteristics of urine culture-confirmed genitourinary tuberculosis at medical centers in Taiwan from 1995 to 2007.

All patients with urine culture-confirmed genitourinary tuberculosis (GUTB) diagnosed between 1995 and 2007 at two medical centers in northern Taiwan were included in this retrospective study. Genotypes of 48 preserved Mycobacterium tuberculosis (MTB) isolates from these patients were determined by spoligotyping and double repetitive element PCR (DRE-PCR) analysis. Among the 64 patients, 38 (59.4%) were male with a mean ±SD age of 60.3 ± 16.1 years old. The overall mortality rate was 26.2%. Poor prognostic factors included age over 65 years (HR = 4.03; 95%; CI: 1.27-12.76), cardiovascular disease (HR = 5.96; 95% CI: 1.98-17.92), receiving steroids (HR = 10.16; 95% CI: 2.27-45.47), not being treated (HR 4.81; 95% CI 1.12-20.67). Spoligotyping and DRE-PCR of the 48 MTB isolates revealed that 20 (41.7%) belonged to the Beijing family and 40 (83.3%) had a clustering pattern. Identification of a Beijing family isolate was not correlated with drug resistance or mortality. Clustering strains were likely to be resistant to isoniazid (OR = 4.71; 95% CI: 1.10 to 23.53). In this study of patients with urine culture-confirmed GUTB, age and coexisting diseases were independently associated with an unfavorable outcome. The Beijing family was the dominant genotype of GUTB isolates, but did not correlate with drug resistance or outcome.

Urinary polymerase chain reaction for diagnosis of urogenital tuberculosis.

INTRODUCTION: The aim of this study was to evaluate diagnostic value of urinary polymerase chain reaction (PCR) in urogenital tuberculosis (UTB). MATERIALS AND METHODS: In 33 patients with confirmed diagnosis of UTB by urine culture and/or acid-fast staining, clinical symptoms and laboratory and radiological findings were evaluated. For each patient, 3 consecutive urine samples were examined by PCR for Mycobacterium tuberculosis and the results were compared with the standard microbiological methods and radiological findings. RESULTS: The mean interval between the appearance of the symptoms and the diagnosis was 12.3 +/- 12.2 months. Symptoms were irritative bladder symptoms such as dysuria and diurnal or nocturnal frequency (51.5%), flank pain (27.3%), microscopic hematuria (18.2%), gross hematuria (9.1%), and suprapubic pain (9.1%). The laboratory findings included hematuria (27.3%), pyuria (12.1%), and hematuria with pyuria (48.5%). Diagnosis of UTB was made in 19 patients by positive urine culture for MT in 19 patients (57.6%), positive acid-fast staining in 6 (18.2%), and both in 8 (24.2%). Intravenous urography showed abnormal findings in 16 patients (61.5%), including pyelocaliceal dilatation (26.9%), ureteral stricture and hydroureter (23.1%), multiple small caliceal deformities (15.4%), severe parenchymal destruction (11.5%), autonephrectomy (11.5%), and calcification (7.7%). Urinary PCR was positive in 16 patients (48.5%) and in 10 (62.5%) with abnormal findings on intravenous urography. CONCLUSION: A high index of suspicion is necessary for diagnosis of UTB even in patients with nonspecific manifestations. Urinary PCR is recommended for instant diagnosis and screening before further examinations, but it cannot be the sole diagnostic modality for diagnosis of UTB.

Tubercular sinus of labia majora: rare case report.

Tuberculosis of the female external genitalia is unusual and primary infection is rare. We report a 50-year-old female patient admitted to Department to Surgery with swelling over left inguinal area with discharging sinus from labia majora to left inguinal crease which was found to be tubercular sinus on histopathology.