Diagnosis of tuberculous vertebral osteomyelitis (TVO) in a developed country and literature review

STUDY DESIGN: Review of medical and radiological records and literature to study the diagnosis of tuberculous vertebral osteomyelitis (TVO) and the differential diagnosis between TVO and pyogenic vertebral osteomyelitis (PVO). OBJECTIVE: To identify the correct criteria for the diagnosis. SETTING: National Spinal Injuries Centre, UK. METHODS: (1) Medical and radiological records of 10 patients diagnosed as vertebral osteomyelitis and treated elsewhere but later admitted to the NSIC were reviewed retrospectively. (2) Medical literature on vertebral osteomyelitis were reviewed. RESULTS: (1) Case review: Before the study, four of the 10 patients TVO had been diagnosed based on positive bacteriology. Of the other six, the diagnosis of PVO had been made in one based on positive blood culture of staphylococcus while in another without any positive result of bacteriology. The diagnosis had been uncertain in four because of negative results of both bacteriology and histology on both tuberculous and pyogenic infection. The author made the diagnosis of TVO in all 10 cases based on clinical manifestations and plain radiographs. Highly raised ESR with moderate rise of or normal WBC in eight cases supported TVO. Computer tomography and magnetic resonance imaging did not contribute to the differential diagnosis. Laminectomy in five patients led to some clinical improvement. The five patients without surgery deteriorated. Two of them died. (2) Literature review: A total of 188 articles were reviewed. The crucial role of plain radiographs in the diagnosis of TVO and the high incidence of false-negative of tuberculosis in both bacteriological and histological tests were neglected in most articles. Polymerase chain reaction (PCR) was more reliable in diagnosing tuberculosis. CONCLUSION: Clinical manifestations, discrepancy between ESR and WBC, plain radiographs and PCR are keys to a correct diagnosis of TVO.     

Migration Flow and Its Impact on Tuberculosis Notification in Portugal

Introduction

Tuberculosis notification in Portugal has decreased in the last few years. As a consequence of the economic crisis, emigration has increased and immigration has decreased. Immigrants are a risk group for tuberculosis. Most emigrants are 20–44 years old and belong to the age group most affected by tuberculosis.

Solitary pancreatic tuberculosis mimicking advanced pancreatic carcinoma

A 40-year-old woman was referred for pancreatic head carcinoma invading the portal vein. The dichotomy between the radiological findings and the general condition of the patient, as well as the laboratory results (no evidence of cholestasis), cast doubt on the diagnosis. There was no history of tuberculosis. The chest radiograph revealed no pathological findings. The anatomic relationships of the lesion entailed a high risk of vascular injury if tissue biopsy were to be done; therefore, diagnostic laparotomy was performed. Biopsy revealed granulomas with caseous necrosis, consistent with tuberculosis. After 6 months of antituberculosis treatment, the lesions had completely resolved. Tuberculosis should be considered in the differential diagnosis of pancreatic masses, particularly in regions where the disease is endemic. The condition usually resembles an advanced pancreatic tumor. Performing a biopsy of inoperable lesions and maintaining a reasonable skepticism in regard to the evaluation of operable lesions (attention to nonexclusive but helpful clues, such as young patient age, history of tuberculosis, absence of jaundice) will lead to the diagnosis in most patients. Diagnostic laparotomy may be required in a small subset of patients. The response to antituberculosis treatment is very favorable. The role of resection (e.g., pancreatoduodenectomy) is very limited. Received: December 1, 2000 / Accepted: January 25, 2001     

结核感染T细胞斑点试验在脊柱结核诊断中的应用

目的：探讨结核感染T细胞斑点试验在脊柱结核诊断中的临床应用价值。方法选取2012年4月～2013年1月本院骨科病区收治的疑似脊柱结核患者156例,分别采用结核感染T细胞斑点试验和结核菌素试验进行诊断,比较两者对脊柱结核诊断的临床意义（包括灵敏性、特异性、假阳性率和假阴性率指标的差别）。结果结核感染T细胞斑点试验的灵敏性和特异性明显高于结核菌素试验（P＜0．05）;同时,结核感染T细胞斑点试验的假阳性率和假阴性率明显低于结核菌素试验试验（P＜0．05）。结论结核感染T细胞斑点试验在诊断脊柱结核中具有良好的敏感性和特异性,具有重要临床应用价值。     

High resolution computed tomographic findings in pulmonary tuberculosis.

BACKGROUND: Although chest radiographs usually provide adequate information for the diagnosis of active pulmonary tuberculosis, minimal exudative tuberculosis can be overlooked on standard chest radiographs. The aim of the present study was to assess the findings of active pulmonary tuberculosis on high resolution computed tomographic (HRCT) scans, and to evaluate their possible use in determining disease activity. METHODS: Thirty two patients with newly diagnosed active pulmonary tuberculosis and 34 patients with inactive pulmonary tuberculosis were examined. The diagnosis of active pulmonary tuberculosis was based on positive acid fast bacilli in sputum and bronchial washing smears or cultures and/or changes on serial radiographs obtained during treatment. RESULTS: With HRCT scanning centrilobular lesions (n = 29), "tree-in-bud" appearance (n = 23), and macronodules 5-8 mm in diameter (n = 22) were most commonly seen in cases of active pulmonary tuberculosis. HRCT scans showed fibrotic lesions (n = 34), distortion of bronchovascular structures (n = 32), emphysema (n = 28), and bronchiectasis (n = 24) in patients with inactive tuberculosis. CONCLUSIONS: Centrilobular densities in and around the small airways and "tree-in-bud" appearances were the most characteristic CT features of disease activity. HRCT scanning clearly differentiated old fibrotic lesions from new active lesions and demonstrated early bronchogenic spread. These findings may be of value in decisions on treatment.     

Tests for latent tuberculosis in candidates for solid organ transplantation: A systematic review and meta‐analysis

Reactivation of latent tuberculosis following solid organ transplantation has serious consequences for the recipient. The most useful diagnostic test for latent TB is not clear. We conducted a systematic review and meta‐analysis to assess the relative test performance of interferon gamma release assays (IGRAs) and the tuberculin skin test (TST) in people undergoing solid organ transplantation. The clinical or radiological risk factors were used as the proxy reference standard. Test performance was expressed as an odd ratio (OR). We identified 24 studies (N = 7811), 12 studies compared IGRAs with TST directly, nine studies evaluated only TST and three studies only IGRAs. Direct comparison between tests and clinical risk factors indicated both tests were strongly associated with the presence of clinical risk factors for TB (TST: OR 3.17; 95%CI 1.55‐6.48, IGRA: OR 2.78; 95%CI 1.55‐5.01), and radiological evidence of past TB (TST: OR 3.26; 95%CI 1.85‐5.73, IGRA: OR 3.85; 95%CI 2.16‐6.86). Relative comparison indicated IGRAs positivity was more strongly associated with presence of radiological evidence of TB than TST (relative OR: 3.24; 95%CI 1.10‐9.56). While there is no strong evidence in supporting use of IGRAs over TST for diagnosing latent TB, IGRAs positivity is more associated with the presence of radiological evidence of previous TB.     

Update of SEPAR Guideline “Diagnosis and Treatment of Drug-Resistant Tuberculosis”

New evidence and knowledge about the clinical management of drug-resistant tuberculosis (TB) in the last 3 years, makes it necessary to update the recent guideline published by SEPAR in 2017, mainly in relation to new diagnostic methods, drug classification, and regimens of treatment recommended to treat patients with isoniazid-resistance TB, rifampicin resistance TB and multidrug-resistant TB. With respect to tuberculosis diagnosis, we recommend the use of rapid molecular assays that also help to detect mutations associated with resistance. In relation to the treatment of multidrug-resistant TB we prioritize effective all-oral shorter treatment regimens including bedaquiline, a fluoroquinolone (levofloxacin or moxifloxacin), bedaquiline and linezolid, instead of the previously recommended short-course treatment with aminoglycosides and other less effective and more toxic drugs. The design of these regimens (initial schedule and changes in the regimen if necessary) should be made in accordance with drug-resistant TB experts; the treatment should be the responsibility of personnel with experience in the treatment of TB and in TB units guaranteeing the follow-up of the treatment and the management of drugs adverse effects.     

Tuberculosis-HIV Co-Infection: Progress and Challenges After Two Decades of Global Antiretroviral Treatment Roll-Out

Despite wide antiretroviral scale-up during the past two decades resulting in declining new infections and mortality globally, HIV-associated tuberculosis remains as a major public health concern. Tuberculosis is the leading HIV-associated opportunistic infection and the main cause of death globally and, particularly, in resource-limited settings. Several challenges exist regarding diagnosis, global implementation of latent tuberculosis treatment, management of active tuberculosis, delivery of optimal patient-centered TB and HIV prevention and care in high burden countries. In this article we review the advances on pathogenesis, diagnosis, and treatment after nearly two decades of global roll-out of antiretroviral therapy and discuss the current challenges for the global control of tuberculosis-HIV co-infection.     

Diagnosis and treatment of latent tuberculosis infection in liver transplant recipients in an endemic area

BACKGROUND: Treatment of latent tuberculosis infection (LTBI) with isoniazid is recommended for transplant recipients with positive tuberculin skin test (TST). However, TST could be an imperfect identifier of LTBI in this population. In addition, the risk of isoniazid hepatotoxicity could be high in liver transplant recipients (LTR). A retrospective cohort study was performed to evaluate the diagnosis and treatment of LTBI in LTR. METHODS: Charts of all 547 patients who received primary liver transplantation at a University Hospital in Spain between 1988 and 1998 were reviewed. RESULTS: TST was performed in 373 patients (71%) before transplantation. The result was positive in 89 (24%). The median follow-up after transplantation was 49 months. None of the TST-positive patients developed tuberculosis (TB), but 5 out of 284 patients with negative TST (1.76%) had active TB (P=0.6). Twenty-three patients received isoniazid as treatment of LTBI according to the decision of the attending physician. None of these patients developed TB, but 4 of them (17%) presented isoniazid hepatotoxicity. Among patients who did not receive isoniazid, 2 out of 21 (9.52%) with radiologic previous TB developed active TB versus 0.44% (2/452) among the remaining patients (relative risk [RR], 27.8, 95% CI, 3.2-147). CONCLUSIONS: Treatment of LTBI with isoniazid can not be recommended to LTR on the basis of a positive TST because it is an imperfect identifier of patients at risk of TB. LTR with radiologic features of previous TB are at higher risk of posttransplant active TB. Isoniazid-related hepatotoxicity is more frequent among LTR than in the general population.     

Value of the tuberculin skin test in screening for tuberculosis in dialysis patients

BACKGROUND: Hemodialysis patients are at high risk for tuberculosis, and a tuberculin skin test (TST) is not usually helpful in detecting tuberculosis infection because of anergic reactions. Prophylactic therapy against tuberculosis in dialysis patients is important to enhance transplantation success. Herein we evaluated the value of TST in screening for tuberculosis and analyzed any compounding factors that might affect the results of the test in hemodialysis patients in an endemic area of Turkey. METHODS: A total of 187 (96 female, 91 male) patients were screened using a 2-step TST. Test results were compared with clinical, radiologic, and laboratory data. RESULTS: None of the patients had active tuberculosis during the study and 55% had been vaccinated against tuberculosis. After the first purified protein derivative (PPD) test, 55.1% of the patients showed a positive reaction, ultimately reaching a total of 68.4% following the second test. Cumulative positive TST results were significantly correlated with male gender (P=.001, r=.352), previous tuberculosis history (P=.013, r=.183) positively, whereas with the ferritin level (P=.001, r=-.233) negatively; but there were no significant relationships between TST results and other data. CONCLUSIONS: Impairment of delayed-type hypersensitivity reaction is frequent in dialysis patients, but we observed high rates of positivity with the two-step TST which could be attributed to tuberculosis being endemic in Turkey. Further comparative studies with more specific diagnostic methods will be helpful to evaluate the importance of TST positivity in identifying tuberculosis-infected HD patients.     

Performance of a whole blood interferon gamma assay for detecting latent infection with Mycobacterium tuberculosis in children

BACKGROUND: The diagnosis of latent Mycobacterium tuberculosis (MTB) infection with a tuberculin skin test (TST) in children is complicated by the potential influence of prior exposure to Bacille Calmette Geurin (BCG) vaccination or environmental mycobacteria. A whole blood assay has recently been developed to quantitatively measure interferon gamma (IFN-gamma) production by lymphocytes specific to the MTB antigens ESAT-6 and CFP-10, but its use and assessment in children has been limited. A study was undertaken to compare the performance of the whole blood IFN-gamma assay with the TST in diagnosing latent tuberculosis (TB) infection or TB disease in children in routine clinical practice. METHODS: One hundred and six children with a high risk of latent TB infection or TB disease were enrolled in the study. High risk was defined as contact with TB disease, clinical suspicion of TB disease, or recent arrival from an area of high TB prevalence. The whole blood IFN-gamma assay was undertaken in 101 children. RESULTS: Seventeen (17%) of the 101 assays yielded inconclusive results due to failure of positive or negative control assays. There was poor correlation between the whole blood IFN-gamma assay and the TST (kappa statistic 0.3) with 26 (70%) of the 37 children defined as latent TB infection by TST having a negative whole blood IFN-gamma assay. There were no instances of a positive whole blood IFN-gamma assay with a negative TST. Mitogen (positive) control IFN-gamma responses were significantly correlated with age (Spearman's coefficient = 0.53, p<0.001) and, in children with latent TB infection identified by TST, those with a positive IFN-gamma assay were older (median 12.9 v 6.92 years, respectively, p = 0.007). The whole blood IFN-gamma assay was positive in all nine children with TB disease. CONCLUSION: There was poor agreement between the whole blood IFN-gamma assay and TST for the diagnosis of latent TB. The whole blood IFN-gamma assay may have lower sensitivity than the TST in diagnosing TB infection in children. A significant proportion of whole blood IFN-gamma assays fail when used as a screening assay in routine practice.     

Diagnosis and Treatment of Skipped Multifocal Spinal Tuberculosis Lesions

Spinal tuberculosis, also known as Pott's disease or tuberculous spondylitis, is usually secondary to primary infection in the lungs or other systems, and in most instances, is thought to be transmitted via blood. Typical manifestations of infection include narrowing of the intervertebral disc by erosion and bone destruction of adjacent vertebrae. Atypical spinal tuberculosis is a specific type of spinal tuberculosis. It mainly consists of single vertebral lesions, single posterior structure lesions, multiple vertebral lesions, and intra-spinal lesions. Skipped multifocal spinal tuberculosis is one of these types and is characterized by two or more vertebral lesions without the involvement of the adjoining intervertebral discs, regardless of their location. To date, only a few cases have been reported. Upon clinical admission, it can be treated conservatively or surgically, depending on the patient's symptoms. In addition, gene or biological therapies are being investigated. However, because of the exceptional imaging findings and insidious symptoms, it is often misdiagnosed as a neoplastic lesion, osteoporotic fracture, or other infectious spondylitis, increasing the risk of neurological deficit and kyphotic deformity, and delaying the optimal treatment window. In this study, we review the diagnosis and treatment strategies for skipped multifocal spinal tuberculosis lesions and enumerate the common differential diagnoses, to provide reference and guidance for clinical treatment and diagnosis direction.     

Tuberculosis of the patella masquerading as prepatellar bursitis

Tuberculosis of bone is an uncommon entity in the Western world. We present a case of tuberculosis of the patella mimicking prepatellar bursitis in an otherwise fit and well woman of Bangladeshi origin. We believe tuberculosis of bone should form a differential diagnosis of the swollen knee in high risk patients.     

Tuberculosis of the thyroid. Diagnosis and treatment

Thyroid tuberculosis is rare. We present the case of a 25 year-old woman with tuberculosis of the thyroid. Although seldom observed, tuberculosis should be considered in the differential diagnosis of nodular lesions of the thyroid. Diagnosis is made by histological examination and demonstration of the tubercle bacilli from biopsy or aspiration specimen. The efficacy of fine-needle aspiration cytology in diagnosis of tuberculosis of the thyroid is proved. Administration of antituberculous drugs is considered as the treatment of choice. Abscess drainage is sufficient. In rare cases surgery is necessary. The prognosis is good.     

Postmenopausal Breast Tuberculosis – Report of 4 Cases

Background

Breast tuberculosis is an uncommon disease even in countries where the incidence of tuberculosis is high.

Case Report

This is a case series concerning 4 postmenopausal breast tuberculosis cases encountered in Moulay Youssef Hospital between January 2007 and December 2010. Breast tuberculosis represents 0.25% of all hospitalized tuberculosis patients in our department. The mean age of our patients was 62.5 ± 5.8 years. Clinical findings were heterogeneous; 1 case was multifocal tuberculosis, and another case was coexistent tuberculosis and malignancy of the breast. Mammography and ultrasonography findings were suspicious for malignancy in all 4 cases. Fine needle aspiration was negative in 3 cases. The diagnosis was made in all patients by histological examination of biopsy specimens, which revealed typical tuberculous lesions. Anti-tuberculosis therapy formed the mainstay of treatment.

Conclusion

The clinical and radiological features of mammary tuberculosis can be very confusing and easily mistaken for breast cancer. Symptoms suggestive of tuberculosis warrant a biopsy to exclude possible cancer.     

The value of tuberculin skin testing in haemodialysis patients.

BACKGROUND: Chronic haemodialysis patients are at increased risk for developing tuberculosis (TB). Appropriate screening methods to detect latent Mycobacterium tuberculosis infection are required. The aim of this prospective multi-centre study was to evaluate the tuberculin skin test (TST) as a screening method for detection of M.tuberculosis infection in haemodialysis patients. METHODS: A total of 224 patients in two haemodialysis centres were prospectively tested, using 2 units of tuberculin PPD RT23. Up to three booster injections were given with a 7 day interval to patients not responding to the previous test. The results were compared with clinical and radiological data. RESULTS: The cumulative prevalence of a positive TST was 14.7% for the first test, 27.8% for the second test and 32.6% for the fourth test. There was no influence of age, gender, haemodialysis centre, dialysis efficiency, nutritional state, levels of zinc, vitamin D therapy, primary renal disease, (previous or active) immunosuppressive therapy or response to hepatitis B vaccination. There was a significant, but weak, correlation between TST positivity and a history of positive TST or TB. Chest radiography and positive TST were not correlated, yet a positive chest X-ray increased the detection of patients with latent M.tuberculosis infection up to 47.8%. CONCLUSIONS: In haemodialysis patients, a positive response of >30% to repeated TST was obtained. Two consecutive TSTs were sufficient to recruit most of the booster reactions. Since only a weak correlation was found with anamnestic data, regular TST evaluation in combination with a chest X-ray, is a useful tool to detect infection with M.tuberculosis in haemodialysis patients.     

脊柱结核早期诊断的研究进展

探讨脊柱结核特点。脊柱结核如果能在早期发现,对于治疗和预后意义重大。目前脊柱结核的早期诊断已经成为研究热点,诊断方法种类繁多。最新提出免疫与结核诊断密切相关,将成为脊柱结核今后研究的焦点,也是未来检测的发展方向。另外,还需熟悉脊柱结核的鉴别诊断,以免误诊为其他脊柱疾病。     

踝关节镜下微创治疗踝关节结核的临床疗效

目的探讨踝关节镜技术微创治疗踝关节结核的临床疗效。方法从2009年4月至2010年4月,本组采用踝关节牵引状态下使用关节镜检查及手术28例,其中15例行关节镜下结核病灶清除术,13例因关节破坏较重而行关节融合术,术后继续联合、规范、适量和全程抗痨治疗并注意营养支持。结果术后患者恢复快,一般情况可,平均随访12个月以上,28例患者的术后踝关节未肿胀,血沉下降,无窦道形成,无结核复发。按Baird评分标准,优16例,良7例,可5例,优良率为82%。术前McGuire踝关节评分（58±6.1）分,术后（88.9±5.4）分,提高（30.9±1.7）分（t=18.5,P〈0.01）。结论踝关节镜可直接观察和处理踝关节内病变情况,明确诊断,处理病灶。选择镜下手术创伤小,术后康复快,疗效肯定。     

Diagnostic dilemma of tuberculosis in the foot and ankle

BACKGROUND: Isolated involvement of bone in tuberculous infection is uncommon, and the variable clinical and radiological features may mimic pyogenic osteomyelitis, bone tumor or other inflammatory and neoplastic processes of the synovium. We have reported our experiences with the diagnosis of tuberculosis infection in the ankle and foot with the hope of providing sufficient information about these cases to lead to early diagnosis. MATERIALS AND METHODS: We treated 15 patients with tuberculosis involving the foot and ankle between 1995 and 2005. They were followed for a minimum of 24 months, and the average duration of symptoms was 23 months. All patients underwent a physical examination, routine laboratory tests, plain radiographs, and a biopsy of the infection site. MRI studies were performed in 10 patients and a CT scan was done in one patient. RESULTS: The lesions were located in the forefoot (2), midfoot (3) and ankle (10). From the imaging studies, the presumptive preoperative diagnoses were tuberculous osteomyelitis (7), pyogenic osteomyelitis (4), pigmented villonodular synovitis (2), amyloidosis (1), and avascular necrosis of the talus (1). These diagnoses were verified by granulomatous inflammation with or without caseous necrosis on histology and tubercle bacilli were cultured in four cases. In three cases the diagnosis was made by polymerase chain reaction (PCR). CONCLUSION: When a patient presents with a localized, painful swelling and a persistent draining sinus of the foot and ankle, tuberculosis should be considered in the differential diagnosis. Additionally, we highly recommend taking a biopsy of the site of suspected infection because an early diagnosis is the key to successful treatment.     

Diagnosis of Non-nodal Paratracheobronchial Lesions by Linear Endobronchial Ultrasound

Linear endobronchial ultrasound (EBUS) allows samples of lesions close to the airways to be obtained, as it enables aspiration to be performed under visual control in real time, opening new possibilities for minimally invasive examination of the mediastinum. While there are many publications on its usefulness in the study of mediastinal or hilar lymphadenopathies, there are few that analyse the role of EBUS-guided transbronchial needle aspiration for the diagnosis of other lesions adjacent to the airways or digestive tract. We describe the characteristics and results obtained in a series of 26 cases of non-nodal lesions of different aetiologies studied by EBUS-guided transbronchial needle aspiration through the airways or oesophagus, demonstrating the usefulness and safety of this technique in the diagnosis of these types of lesions.