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   Table of Contents - Current issue
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April-June 2019
Volume 8 | Issue 2
Page Nos. 113-210

Online since Friday, June 14, 2019

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ORIGINAL ARTICLES  

Risk factors associated with unsuppressed viral load in HIV-1 infected patients at the first antiretroviral therapy in Morocco Highly accessed article p. 113
Titou Hicham, Elkassimi Ilyas, Hanafi Tarik, Baba Noureddine, Boudi Omar, Frikh Rachid, Hjira Naoufal, Boui Mohammed
DOI:10.4103/ijmy.ijmy_41_19  
Background: Nonsuppression of viral load (VL) in HIV-infected patients on antiretroviral therapy (ART) is associated with increased HIV transmission and poor survival. The objective of this work was to evaluate the factors associated with the unsuppressed VL (VL >400 copies/ml) in HIV-1-infected patients after 6 months of the first-line ART. Methods: This was a retrospective cohort study of 181 patients living with HIV-1 on ART in Dermatology and Venereology Department of Mohamed V Military Teaching Hospital of Rabat, during the period between January 1, 2007, and January 1, 2017. Associated factors were identified through a logistic regression model. Results: Of the 181 patients, 76% were men. At inclusion, the median age was 35 years. Five variables (male sex, initial fasting glucose >1.1 g/l, alcoholism, smoking, and initial VL >10,000 copies/ml) were significantly associated (P < 0.05) with unsuppressed VL. In multivariate analysis, smoking (relative risk [RR]: 4.27, 95% confidence interval [CI]: 1.67–10.89) and initial VL >10,000 (RR: 9.78, 95% CI: 2.40–39.73) were associated independently with unsuppressed VL. Conclusion: Approximately 83% of the patients in the cohort had been able to suppress VL after 6 months of the first-line ART. Smoking and high initial VL were independent risk factors of unsuppressed VL. This work highlights the importance of developing and evaluating targeted interventions for patients at risk of unsuppressed VL on ART.
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Determinants of pulmonary tuberculosis in public health facilities of Dire Dawa City, Eastern Ethiopia: Unmatched Case–control study p. 118
Jafer Kezali Hassen, Andamlak Gizaw, Shikur Mohamed
DOI:10.4103/ijmy.ijmy_50_19  
Background: The Federal Ministry of Health of Ethiopia Annual performance report in 2014–2015 showed that the highest prevalence of tuberculosis (TB) case in Ethiopia was reported from Dire Dawa city which was 400/100,000 population. The aim of this study was to identify the determinants of pulmonary TB (PTB) in public health facilities of Dire Dawa city, Eastern Ethiopia. Methods: A case–control study was conducted from October to December 2017 among 95 cases and 190 controls in Dire Dawa city. Dire Dawa is one of the two chartered cities in Ethiopia like the capital city Addis Ababa. Cases and controls were identified and selected randomly from the health facilities. Data were collected using a pretested and structured questionnaire by trained data collectors. We used logistic regression to model the associations of independent variables with PTB infection. Results: PTB was associated with patients' education (no formal education vs. formal education) (adjusted odds ratio [AQR] [95% confidence interval [CI]: 3.0, [1.3, 7.1]), human immunodeficiency virus (HIV) positive status (AOR [95% CI]: 3.1: [1.1,9.1]), previous contact history with TB patient (AOR [95% CI]: 9.9 [4.3,23.0]), body mass index (BMI) of ≤18 (AOR [95% CI]: 14.9 [6.4,35.1]), and cigarette smoking history (ever vs. never) (AOR [95% CI]: 6.7 [2.3,19.5]). Conclusion: This study showed that patients' educational status, HIV status, cigarette smoking, contact history with PTB patient, and BMI were independently associated with being infected with PTB. To reduce PTB transmission, peoples should be educated on TB prevention and consequences of risky behaviors.
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A rapid viability and drug-susceptibility assay utilizing mycobacteriophage as an indicator of drug susceptibilities of Anti-TB drugs against Mycobacterium smegmatis mc2 155 p. 124
Gillian Catherine Crowley, Jim O’Mahony, Aidan Coffey, Riona Sayers, Paul Cotter
DOI:10.4103/ijmy.ijmy_47_19  
Background: A rapid in-house TM4 mycobacteriophage-based assay, to identify multidrug resistance against various anti-tuberculosis drugs, using the fast-growing Mycobacterium smegmatis mc2 155 in a microtiter plate format was evaluated, based on phage viability assays. Methods: A variety of parameters were optimized before the study including the minimum incubation time for the drugs, phage and M. smegmatis mc2 155 to be in contact. An increase in phage numbers over 2 h was indicative that M. smegmatis mc2 155 is resistant to the drugs under investigation, however when phage numbers remained static, M. smegmatis mc2 155 found to be sensitive to the drug. Results: The study confirmed that the data are statistically significant and that M. smegmatis mc2 155 is, in fact, sensitive to isonazid, iifampicin, pyranzaimide, and ethambutol as phage numbers doubled over 2 h (P = 0.015, 0.018, 0.014, and 0.020). The study also confirmed that M. smegmatis mc2 155 is resistant to the drugs ampicillin, erythromycin, amoxicillin streptomycin as phage numbers remain static over the same 2 h period (P = 0.028, 0.052, 0.049, and 0.04). This drug-susceptibility profiling of eight different drugs against M. smegmatis mc2 155 was detected in as little as 1½ days with a cost of ~ one euro and fifteen cent to test four drugs. Conclusion: This test is rapid to perform and will have widespread applications in drug-susceptibility testing of other members of the mycobacterial genus. In addition, the platform could also be used as a tool for high-throughput screening of novel antimycobacterial drugs. The main assets of this assay include its relatively cheap cost, versatility, and quick turnaround time.
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Evaluation of GeneXpert Mycobacterium tuberculosis/Rifampin for the detection of Mycobacterium tuberculosis complex and rifampicin resistance in nonrespiratory clinical specimens p. 132
Maya Habous, Maimona Ahmed E. Elimam, Rajesh Kumar, Zulfa A L. Deesi
DOI:10.4103/ijmy.ijmy_83_19  
Background: The objective of this study is to assess the performance of Xpert Mycobacterium tuberculosis (MTB)/rifampin (RIF), an automated molecular test for MTB and resistance to RIF, against smear microscopy and culture method for the diagnosis of MTB infection. Methods: This is a retrospective analysis of 168 nonrespiratory patient specimens suspected of tuberculosis (TB) at TB Laboratory of Dubai Health Authority in the United Arab Emirates between September 2016 and November 2018. Each sample underwent smear microscopy, mycobacterial culture, and GeneXpert MTB/RIF test. Results: Of 168 nonrespiratory samples, 52 samples were positive by both culture and Xpert MTB/RIF, 9 samples were detected positive only by culture. Sensitivity, specificity, positive predictive value, and negative value of the Xpert MTB/RIF test were 82.69%, 100%, 100%, and 92.80%, respectively. No false positive was yielded by the Xpert MTB/RIF, and all 116 samples were true negative by Xpert MTB/RIF. The sensitivity of the Xpert MTB/RIF was 76.92% in lymph node tissue and aspirates, 66.67% in cerebrospinal fluid, 100% in gastric lavage and aspirate, 81.25% in other body fluids, 100% in pus, 85.71% in urine, and 66.67% in other tissue samples. Of 168 strains, five strains were rifampicin resistant by phenotypic and Xpert MTB/RIF and 163 were susceptible to rifampicin with culture and Xpert MTB/RIF. Conclusion: The performance of Xpert MTB/RIF assay was comparable to the gold standard culture method for identification of MTB in nonrespiratory clinical specimens. It does not replace the gold standard culture method, but it helps to achieve better sensitivity and obtain rapid results within 2 h.
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Prevalence and species diversity of nontuberculous mycobacteria in drinking water supply system of Bahía Blanca City, Argentina p. 138
Alejandra Soledad Oriani, María Jimena Marfil, Martín Jose Zumárraga, Mónica Diana Baldini
DOI:10.4103/ijmy.ijmy_39_19  
Background: There is evidence that tap water is the vehicle through which nontuberculous mycobacteria (NTM) infect or colonize the human body. The objective of this study was to determine the presence and diversity of NTM in the water distribution system of Bahía Blanca city, Argentina (sites S2/S3) and in the dike that supplies water to it (S1). Methods: Culture-dependent method, biochemical tests, and molecular method (16S rRNA sequencing gene) were combined to detect and identify NTM. Results: NTM were isolated in 51.6% (64/124) of all the samples analyzed. Mycobacterium gordonae was the most frequently isolated organism (15/64) in all samples analyzed, followed by Mycobacterium peregrinum and Mycobacterium frederiksbergense. Significant differences were found in the residual chlorine values between sampling S2 and S3. In both sites, maximum counts were recorded but they did not correlate with low chlorine values. A concentration higher than 500 colony-forming unit/L of NTM was never found, which can be attributed to the negative effect caused by decontamination methods being a point to consider for the recovery of NTM. In 46.9% (30/64) of samples, both methods coincided in the identification, and the obtained sequences presented ≥99% identity. Identification at the species level was achieved in 50% (32/64) of the isolates. Nearly 17.2% (11/64) of the isolates showed a similarity <99%. Conclusions: It should be taken into account that sequencing of the 16S rRNA gene and biochemical tests are useful for the identification of several species, but it is necessary to incorporate other genes (hsp 65 and rpo B) to obtain accurate identification.
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Evaluation of apoptotic protease-activating Factor-1 and cluster of Differentiation-4+ T-Cell counts in patients-infected with mycobacterium tuberculosis in Bauchi, Nigeria Highly accessed article p. 146
Muhammad Sagir Shehu, Juliana Unoifa OKpapi, Bolanle Olufunke Priscilla Musa, Idris Nasir Abdullahi, Abdurrahman Elfulaty Ahmad, Yahaya Usman
DOI:10.4103/ijmy.ijmy_66_19  
Background: This cross-sectional study evaluated Apoptotic Protease Activating Factor and cluster of differentiation-4+ (CD4+) T-cell counts in patients infected with Mycobacterium tuberculosis in Bauchi, Nigeria. Methods: This involved 180 blood samples from 90 tuberculosis (TB)-infected patients and 90 of their close contacts at home or attending Federal Medical Center Azare and Infectious Disease Hospital Bayara, Bauchi, Nigeria. The blood samples were analyzed for Apoptotic Protease Activating Factor (Apaf-1) expression using ELISA and CD4+ T cells using cyflow counter. Structured questionnaires were also used to collect the sociodemographic and clinical data of the study participants. Results: Eighty-six of the TB-infected patients had pulmonary TB (PTB), two had spine TB, and two had pleural TB. No statistically significant difference was recorded in CD4+ T-cell counts (P = 0.2935) between participants with PTB (mean ± standard deviation [SD]: 680.4 ± 235 cells/mm3) and those with extra-PTB (mean ± SD: 553.0 ± 130.5 cells/mm3). Similarly, there was no significant difference in Apaf-1 concentration (P = 0.1432) between participants with PTB (mean ± standard error of the mean [SEM]: 320.3 ± 35.4 pg/ml), and participants with extra-PTB (mean ± SEM: 143.7 ± 7.8 pg/ml). No significant difference was recorded in CD4+ T-cell counts (P = 0.4299) between the participants on treatment (mean ± SD: 758.6 ± 358.6 cells/mm3) and those who are treatment naïve (mean ± SD: 637.7 ± 208.4 cells/mm3). Similarly, there was no significant difference in Apaf-1 concentration (P = 0.6829) between the study participants on treatment (mean ± SEM: 336.3 ± 34.7 pg/ml) and those who are not on treatment (mean ± SEM: 381.2 ± 176.8 pg/ml). The CD4+ T-cells count was significantly higher in the controls (866.7 ± 288.4 cells/mm3) compared to the TB (675.0 ± 232.7 cells/mm3) patients (P < 0.0001). However, there was no significant difference in Apaf-1 expression between the control (312.4 ± 34.6 pg/ml) and the TB patients (329.1 ± 44.0 pg/ml) (P = 0.7658). Conclusion: Findings from this study showed a lower T-cell immune function during TB infection. However, Apaf-1 has no relevance on TB progression and control.
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Evaluation of thin-layered agar for Mycobacterium tuberculosis isolation and drug susceptibility testing p. 153
Divya Tharmalingam, Sridharan Sathyamoorthy Kopula, Kennedy Kumar Palraj
DOI:10.4103/ijmy.ijmy_45_19  
Background: Tuberculosis (TB) is India's major public health problem. According to the WHO, India harbors the largest number of cases, and TB control remains a challenge in diagnosis, drug resistance, and treatment. We undertook this study to compare the isolation rates of Mycobacterium tuberculosis (MTB) in agar, egg-based media, incidence of multidrug-resistant (MDR), and extended drug resistance (XDR) in MTB. This study aimed to compare and evaluate thin-layered agar (TLA) for the cultivation and drug susceptibility pattern of MTB with the conventional egg-based Lowenstein–Jensen's (LJ) medium and to differentiate atypical Mycobacterium by incorporating para-nitrobenzoic acid (PNB) in the TLA medium. This cross-sectional study was conducted in Sri Ramachandra Medical College and Research Institute, Porur, Chennai. Methods: A total of 68 smear-positive samples were inoculated into TLA (Middle Brook 7H 11) and LJ media with and without antibiotics (rifampicin, isoniazid, and ofloxacin) simultaneously after decontamination by the modified Petroff's method. TLA with PNB was also used to differentiate the growth of nontuberculous mycobacterium (NTM). Incubation was done at 37°C, and reading was taken every 3rd day for 6 weeks in case of TLA and for 8 weeks in case of LJ medium. Results: Out of the 68 samples, 64 (94.1%) grew in LJ, and the growth observed at the end of the 1st, 2nd, 3rd, 4th, 5th, and 6–10th weeks was 0, 12 (18.8%), 10 (15.6%), 14 (21.9%), 15 (23.4%), and 13 (20.3%), respectively. Similarly, in TLA, 65 (95.5%) samples were grown, among which 22 (33.8%) grew in the 1st week and the rest (43 [66.2%]) in the 2nd week. MDR and XDR were observed in 4 (5.8%) and 3 (4.4%) samples, respectively. Seven of them were NTM. Conclusions: TLA is a better medium, with time to positivity ranging from 1 to 2 weeks with drug susceptibility and the pattern is also comparable with LJ medium. Incorporation of PNB in TLA helps in differentiating NTM.
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Laboratory diagnosis of nontuberculous mycobacteria in a Belgium Hospital p. 157
Anandi Martin, Alexandre Colmant, Alexia Verroken, Hector Rodriguez-Villalobos
DOI:10.4103/ijmy.ijmy_40_19  
Background: Nontuberculous mycobacteria (NTM) have been identified in human pulmonary and extrapulmonary infections and are increasing globally, which makes it challenging to identify them. This article reports our experience with the laboratory identification of NTM in clinical practice among pulmonary and extrapulmonary samples received in our routine work. Methods: The study was conducted at the Université Catholique de Louvain at the Cliniques Universitaires Saint-Luc, Brussels, Belgium, from 2015 to 2018. A total of 386 clinical samples were collected from patients suspected of having pulmonary or extrapulmonary mycobacterial infections. Routine laboratory methods phenotypic and molecular tests were performed. Results: The majority of NTM species were isolated from pulmonary samples (68%). The most prevalent species identified were Mycobacterium chimaera_intracellulare group (32%), followed by Mycobacterium avium complex (21%), Mycobacterium abscessus complex (18%), Mycobacterium gordonae (9%), and Mycobacterium chelonae (4%). In extrapulmonary samples, M. avium and M. chimaera_intracellulare were the most frequently isolated. Conclusion: The species diversity of NTM found in our setting suggests the importance of the use of new modern methods for accurate identification of NTM at species level and in some case at subspecies level for the proper treatment and management of patients.
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HbA1c levels at presentation do not impact the clinical presentation or outcomes in abdominal tuberculosis p. 162
Jimil Shah, Harshal S Mandavdhare, Naresh Sachdeva, Kaushal K Prasad, Harjeet Singh, Usha Dutta, Vishal Sharma
DOI:10.4103/ijmy.ijmy_35_19  
Background: The relationship between diabetes mellitus and tuberculosis (TB) has received increasing attention, and diabetes may be associated with poor outcomes in pulmonary TB. Clinical relevance of HbA1c measurement in abdominal TB is unknown. Methods: We did a retrospective study of consecutive patients diagnosed with abdominal TB and treated with antitubercular therapy for 6 months. Patients were categorized as those with normal HbA1c (<5.7%) or those having elevated HbA1c (≥5.7%). The patients' baseline characteristics, their mode of presentation, type of abdominal TB, and their outcomes after treatment were retrieved and compared. Results: Of 84 patients included in the final analysis, the mean age was 35.52 years and 50% were male. While 19 patients had a confirmed diagnosis, 65 patients were diagnosed as probable abdominal TB. Of the 84 patients, 60 patients (71.43%) had a normal HbA1c and 24 patients (28.57%) had an elevated HbA1c. Those with elevated HbA1c were older in age (47.00 ± 13.98 vs. 30.93 ± 13.91; P < 0.001), and there were more males (75.0% vs. 40.0%; P = 0.004) as compared to the normal HbA1c group. However, other parameters such as their presenting features, pattern of abdominal TB, extra-abdominal involvement, outcomes after treatment, and need of intervention (surgery and dilatation) were comparable between both the groups. Conclusion: Presence of prediabetes or diabetes does not seem to impact the clinical presentation or outcomes in patients with abdominal TB.
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Detection of Anti-Phenolic Glycolipid-I antibody in sera from tuberculosis patients in Bandung, West Java, Indonesia p. 166
Hendra Gunawan, Nina Roslina, Jono Hadi Agusni, Iceu Dimas Kulsum, Kristina Makarti, Reti Hindritiani, Oki Suwarsa
DOI:10.4103/ijmy.ijmy_62_19  
Background: Mycobacterium tuberculosis (M. tuberculosis) and Mycobacterium leprae (M. leprae) are morphologically, immunologically, and pathologically similar. The incidence of simultaneous tuberculosis (TB) and leprosy is still controversial. The aim of this study was to detect anti-phenolic glycolipid-I (anti-PGL-I) antibody in sera from TB patients at Dr. Hasan Sadikin Hospital Bandung, West Java, Indonesia. The aim of this study is to detect anti-phenolic glycolipid-I (anti-PGL-I) antibody in sera from TB patients at Dr. Hasan Sadikin Hospital Bandung, West Java, Indonesia. Methods: We performed a cross-sectional descriptive study with consecutive sampling from 112 TB patients clinically diagnosed by internist from the Internal Medicine Department and confirmed through bacteriological, histological, and chest radiograph examinations. The specimens were taken from the blood serum of the patient. Furthermore, the anti-PGL-I immunoglobulin (Ig) M and IgG serum level were evaluated using the enzyme-linked immunosorbent assay. Results: The mean of anti-PGL-I IgM and IgG serum levels in TB patients of this study was 34.17 ± 21.94 pg/ml and 41.44 ± 18.93 pg/ml with the mean of optical density values was 0.18 ± 0.05 and 0.26 ± 0.07. The seropositivity of anti-PGL-I in TB patients was 27.68% for IgM and 41.96% for IgG. The seropositivity of anti-PGL-I IgM and IgG level based on clinical manifestation of TB in this study from the highest to the lowest were as follows: extrapulmonary TB patients (61.29% and 59.57%), pulmonary TB patients (29.03% and 36.17%), and pulmonary with extrapulmonary TB patients (9.68% and 4.26%), respectively. Conclusion: The seropositivity of anti-PGL-I antibody in sera from TB patients in Bandung, West Java, Indonesia was 27.68% for IgM and 41.96% for IgG. Furthermore, periodic observations are needed to determine the likelihood of clinical manifestation of leprosy in TB patients.
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Study of characteristics of mycobacteriophage – A novel tool to treat Mycobacterium spp. p. 170
Rajitha Satish, Anita Desouza
DOI:10.4103/ijmy.ijmy_42_19  
Background: Mycobacteriophages are viruses that infect Mycobacterium spp. Till date, 10427 mycobacteriophages have been isolated and 1670 mycobacteriophage genomes have been sequenced https://phagesdb.org/hosts/genera/1/ (cited on 30th December,2018). In the previous study, 10 different mycobacteriophages from 14 soil samples were isolated, by qualitative plaque formation method using Mycobacterium smegmatis as host. Among these, three phages were found to infect four different species of Mycobacterium, i.e., Mycobacterium fortuitum subsp. fortuitum MTCC993, Mycobacterium kansasii MTCC3058, Mycobacterium avium subsp. avium MTCC1723, and Mycobacterium tuberculosis MTCC300, besides the host M. smegmatis. The phage lysates were concentrated by polyethylene glycol (PEG) precipitation. One of the three phages showing host diversity was selected for further study. The various phage growth parameters such as incubation temperature, time of adsorption, host cell density and effect of cations were standardised. Methods: The studies were done by qualitative and quantitative plaque assay method. Results: The phage selected for further study showed an optimum adsorption time of 15 min. The optimum temperature for propagation was found to be 37°C. The phage was found to be stable at 42°C. In the presence of calcium, the phage showed a higher rate of infectivity. Conclusion: Understanding the biology of mycobacteriophages and their host diversity is the key to understanding mycobacterial systems. This could be the first step toward exploiting the potential of phages as therapeutic agents.
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The importance of multiple samples in mycobacterial recovery: A 10-year retrospective study p. 175
Angélica Ramos, Teresa Carvalho, João Tiago Guimarães
DOI:10.4103/ijmy.ijmy_68_19  
Background: Instead of the three samples previously recommended, the World Health Organization considered that two sputum samples are sufficient for the diagnosis of pulmonary tuberculosis. Our goal is to evaluate the value of multiple samples in the microscopic and cultural examination of Mycobacterium tuberculosis complex (MTBc) and nontuberculous mycobacteria (NTM). Methods: Through a 10-year retrospective study, including 38,887 sputum samples from 11,676 patients, the relative contribution of each sputum specimen for acid-fast bacilli detection and mycobacteria isolation was determined by calculating the yield of the first sample and the incremental yield of the second, third, and more than three samples. Results: With regard to patients with MTBc isolation, we found that 95.2% (435/457) of the cases could be detected in the first and second smear and 97.9% (659/673) in the first and second culture, with a very low increment of the third sample, corresponding to 3.1% (14/457) in smear and 1.3% (9/673) in culture. Among patients with an NTM strain, the percentage of cases detected in the first and second smear and culture was 69% (20/29) and 86.5% (316/365), respectively. In these patients, we found an increment yield of the third sample of 20.7% (6/29) for smear and 10.5% (38/365) for culture. The incremental yield of third and above-third sample for NTM detection was of 31% (9/29) in smear and 13.5% (49 of 365) in culture. Conclusions: We found an added value of multiple samples in NTM recovery. However, our findings suggest that only two samples are required for the diagnosis of pulmonary tuberculosis.
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Referral and treatment outcomes of tuberculosis patients who crossed the border from Japan to the philippines p. 180
Akihiro Ohkado, Aurora Querri, Tamae Shimamura, Masaki Ota, Anna Marie Celina Garfin
DOI:10.4103/ijmy.ijmy_49_19  
Background: The referral and treatment outcomes of tuberculosis (TB) patients referred from Japan to the Philippines have not yet been systematically reported. This study aimed to describe the cross-border referral process for TB patients referred from Japan to the Philippines. Methods: This is a retrospective descriptive review of the referral process between the two countries. The data on the pathways of Filipino patients with TB or latent TB infection initially treated in Japan from 2009 to mid-2018 were summarized. We calculated the proportion of the referred-and-accessed and that of the successfully treated in the health facilities in the Philippines. The Chi-square test or Fisher's exact test was applied to test significant differences between categorical data. Results: Among the 36 Filipino TB patients referred, 83.3% (30 patients) were successful in accessing any of the health facilities. Among these, 28 patients confirmed that they had started TB treatment in the Philippines. Age groups (P = 0.17), gender (P = 0.76), planned place of residence (P = 0.44), bacteriological results (P = 0.81), and TB patient types (P = 0.96) did not show any significant differences in the referred-and-access rate. The treatment success rate among the 23 TB patients (excluding five patients who were still receiving treatment as of writing) was 91.3%. However, only three out of five multidrug-resistant TB patients successfully started treatment. Conclusions: The current cross-border TB patient referral mechanism between Japan and the Philippines indicated successful results. However, it needs to be enhanced by strengthening the mechanism to track referral outcomes systemically.
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Recovery of Mycobacterium tuberculosis from positive mycobacterium growth indicator tubes stored at room temperature for up to 6 years in low-income and High-Tuberculosis-Burden Country p. 185
Joconiah Chirenda, Martha Chipinduro, Marianna de Kock, Claudia Spies, C Tanaka Sakubani, Robin Mark Warren, Samantha Lee Sampson, Elizabeth Maria Streicher
DOI:10.4103/ijmy.ijmy_46_19  
Background: Biobanking of Mycobacterium tuberculosis (Mtb) sputum samples for future research activities recommends the use of −70°C or −80°C freezers. Infrastructure for biobanking is not readily available in the majority of low-income countries. This study aimed to assess the recovery rate of Mtb isolates stored at room temperature for more than 6 years in Zimbabwe. Methods: Census samples of all confirmed rifampicin-resistant/multidrug-resistant tuberculosis isolates that were stored in mycobacterial growth indicator tubes (MGITs) at room temperature from 2011 to 2016 were identified and retrieved. The samples were subcultured on MGIT and 7H10 solid media for the extraction of genomic deoxyribonucleic acid using the phenol/chloroform method followed by precipitation with isopropanol. Results: A total of 248/400 (62%) isolates were successfully recovered. Recovery rates increased with declining time since the last culture, with 51% for samples stored for 6 years which increased to 77% for those stored for 1 year. The isolates that grew but were contaminated during the first subculture at the National Microbiology Reference Laboratory in Harare could not be recovered through decontamination because of limited resources. Decontamination was only possible during the second culture at the University of Stellenbosch. Conclusion: Storage of Mtb isolates at room temperature is a viable option in low-income countries where currently recommended biobanking procedures may not be available. This low-cost biobanking will facilitate research activities years later as new questions arise. Standard infection prevention and control when handling Mtb samples stored under room temperature for long periods is strongly recommended as these bacteria remain viable longer than previously reported.
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Immunological host responses as surveillance and prognostic markers in tubercular infections p. 190
Pranita Jwalant Waghmare, Trupti Lende, Kalyan Goswami, Anshu Gupta, Anupama Gupta, Nitin Gangane, Satish Kumar
DOI:10.4103/ijmy.ijmy_48_19  
Background: Tuberculosis (TB) control is challenging due to failure of drug compliance and resistance. Mycobacterial antigen-induced cytokine secretions are helpful in detecting Mycobacterium tuberculosis infection and to determine prediction for the fate of TB infection and its cure. Considering immunological response to be a crucial factor in pathogenesis and cure of TB, it can be explored to determine clinical prospects in different categorical tubercular infections. This study was designed to compare serum levels of inflammatory (tumor necrosis factor [TNF]-alpha and interferon [IFN]-gamma) and anti-inflammatory cytokines/chemokines (interleukin [IL]-10 and IL-8) among different TB groups (freshly diagnosed, relapse, cases on antitubercular treatment [ATT], and healthy controls). Methods: This cross-sectional study included total 100 subjects. The study subjects were further divided into four study groups with 25 cases in each of freshly diagnosed TB, TB relapse cases, cases on ATT, and 25 healthy controls. Levels of serum cytokines/chemokines (TNF-alpha, IFN-gamma, IL-10, and IL-8) were measured by flow cytometry. Results: Data analysis observed statistically significant differences in serum levels of TNF-alpha and IFN-gamma among the studied groups with significantly low levels in subjects on ATT and markedly high levels in TB relapse subjects. No statistically significant difference was observed in IL-10 and IL-8 levels. However, subjects with relapse revealed low IL-8 and high IL-10 levels. Conclusion: TNF-alpha and IFN-gamma have important roles in immune response and might be considered as indicators for response to ATT. However, high levels of IL-10 with low IL-8 appear to be associated with poor outcome and possibility of relapse.
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CASE REPORTS Top

Spermatic cord tuberculosis: The great masquerader p. 196
Sonam Sharma
DOI:10.4103/ijmy.ijmy_64_19  
Tuberculosis (TB) is a great mimicker of innumerable diseases and is often overlooked causing diagnostic dilemmas, especially when it occurs at extrapulmonary sites. Spermatic cord TB is a very rare form of genital TB with only a handful of cases documented in the world literature. Here, in this report, an unsuspected case of a spermatic cord TB in a 60-year-old male is described which not only disguised as a tumor but also led to an unneeded surgery as its treatment.
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The role of flexible bronchoscopy in lung tuberculosis mimicking mediastinal mass in an Infant: A rare case report p. 199
Rifan Fauzie, Heda Melinda Nataprawira
DOI:10.4103/ijmy.ijmy_63_19  
Tuberculosis (TB) is a systemic disease that can affect all parts in the body. The clinical manifestations sometimes mislead to other diagnoses. Mediastinal mass-like of TB in children is a rare manifestation. A 5-month-old boy presented to our hospital with respiratory distress, fever for 2 months, body weight loss, cough, and history of recurrent pneumonia. The lung sound decreased on the right hemithorax. Lung computed tomography revealed multiple irregular cysts with thick walls on the anterosuperior mediastinal area, consolidation on the right lobe, and suspected gangrenous lung disease. The right main bronchus stenosis with cheesy-like vegetation was found on flexible bronchoscopy procedure. Xpert/MTB RIF from bronchoalveolar lavage revealed Mycobacterium tuberculosis and sensitive to rifampicin. Anti-TB drugs were given for 12 months. He has clinical and radiological improvement. We must increase the awareness of TB disease in case of mediastinal mass-like appearance in the high-endemic area. The flexible bronchoscopy plays an important role in diagnostic purpose.
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Tuberculosis verrucosa cutis presenting with unilateral elephantiasis nostras verrucosa of the left lower limb: A rare entity p. 202
Preema Sinha, Durga Madhab Tripathy, Subramaniyan Radhakrishnan, Biju Verghese, BS Sunita
DOI:10.4103/ijmy.ijmy_38_19  
Elephantiasis nostras verrucosa is used to describe lymphedema of the lower limbs caused by a nonfilarial etiology. Infective etiologies include bacterial and fungal infections along with chronic venous stasis, postirradiation, congestive heart failure, obesity, and malignancies, all causes leading to lymphatic obstruction and edema. We herein describe a case of a 70-year-old male who presented with diffuse nonpitting edema of the entire left lower limb with cobblestoning of the surface with a positive Kaposi–Stemmer sign and presence of a verrucous plaque over the left ankle. Histopathology of the verrucous plaque revealed it to be tuberculosis verrucosa cutis (TVC). We report this rare presentation of TVC as a cause of unilateral lymphedema.
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A rare case of multiple lupus vulgaris in a multifocal tuberculosis pediatric patient p. 205
Hendra Gunawan, Gynaecia Lamsu, Pati Aji Achdiat, Oki Suwarsa, Reti Hindritiani
DOI:10.4103/ijmy.ijmy_33_19  
Multifocal tuberculosis (TB) is rare. The risk of occurrence of multifocal TB is increasing in immunocompromised patients. Cutaneous entanglement in multifocal TB occurs more infrequently, and its association with multifocal TB is scarcely reported. The aim of this case report was to show a rare case of lupus vulgaris accompanied by multifocal skeletal TB (vertebrae and knee joint) in a 15-year-old girl. There were kyphosis and deformities seen on physical examination. Dermatological status showed an erythematous plaque on the cheek and an erythematous nodule on the index finger of the left hand. The additional examinations such as bacteriological, histopathological, and polymerase chain reaction (PCR) examinations supported the diagnosis of cutaneous TB. Radiographic and PCR examinations confirmed the diagnosis of multiple skeletal TB. Mycobacterium tuberculosis was obtained from GeneXpert® examination of the skin lesion on the right cheek and synovial fluid of the knee. Therefore, multifocal TB could be confirmed in this patient. The uncommonness of the skin involvement in TB infection should warn the clinicians to commit every possible examination to detect the TB involvement in other organs, especially in immunocompromised children with suspected skin lesions.
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A dissimulate presentation of histoid Hansen's disease in the form of erythema nodosum leprosum p. 208
Vikas Pathania, Bhavni Oberoi, Sukriti Baveja, Divya Shelly, Ruby Venugopal, Prerna Shankar
DOI:10.4103/ijmy.ijmy_43_19  
Hansen's disease is a chronic infectious granulomatous disease with varied clinical presentation. Histoid Hansen's disease is an important emerging lepromatous subset of Hansen's disease known to mimic varied dermatoses. Occurrence of reactions, especially erythema nodosum leprosum (ENL), is rare in this form of leprosy. We report a case of Histoid Hansen's disease with initial presentation of ENL while undergoing management for infertility.
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