A series of 18 cases of tuberculous encephalopathy (TBE) in children studied between June 1983 and October 1984 at Queen Elizabeth Hospital, Kota Kinabalu is presented. The data suggest that: the incidence is not as rare as previously thought; the occurrence of TBE is related to the absence of BCG vaccination; the presentation is often late; laboratory data, although helpful is not often confirmatory; early treatment is the key to better outcome; the clinical picture should outweigh laboratory diagnosis in the initial assessment and management.
The value of tuberculin skin testing in the diagnosis of active tuberculosis remains uncertain. Interpretation of tuberculin tests would be easier if the tuberculin test profiles in different communities were accurately known. We reviewed 468 Mantoux test reactions in patients coming to Hospital Universiti Sains Malaysia with suspected tuberculosis. Eighty six percent of patients with active tuberculosis had a positive Mantoux test. Forty two percent of the cases of positive Mantoux test did not have evidence of active tuberculosis. Most of these cases had evidence of past infection with tuberculosis. We conclude that Mantoux test is a sensitive but a non-specific test in the diagnosis of active tuberculosis.
Study site: outpatients, inpatients; Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
A female patient presenting with post-prandial epigastric pain and weight loss was diagnosed to have oesophageal tuberculosis by endoscopic biopsy. She responded well to standard anti-tuberculosis treatment.
This retrospective study documents a strong correlation between tuberculin reactivity and the subsequent development of active tuberculosis in student nurses. 12% of the 25 student nurses with tuberculin reactions above 20 mm developed tuberculosis over a period of 2 years, compared to only 0.3% of the 341 student nurses with reactions of 20 mm or less. The implications of these findings for preventive therapy are discussed.
Diagnosis of active mycobacterial disease in orangutans (Pongo pygmaeus) has been impeded by high levels of non-specific intradermal skin test reactivity to mycobacterial antigens. This may be due in part to cross reactivity between antigens, tuberculin concentrations used or other species-specific factors. Antigen 85 (Ag85) complex proteins are major secretory products of actively growing mycobacteria, and measurement of serum Ag85 could provide a method for determining active mycobacterial infections that was not dependent on host immunity. Serum Ag85 was measured by dot-immunobinding assay using monoclonal anti-Ag85, purified Ag85 standard and enhanced chemiluminescence technology in coded serum samples from 14 captive orangutans from a zoo in Colorado, 15 semi-captive orangutans in Malaysia, and 19 free-ranging wild orangutans in Malaysia. Orangutans from Colorado (USA) were culture negative for Mycobacterium tuberculosis and M. avium, although all had laboratory suspicion or evidence of mycobacterial infection; median serum Ag85 was 10 microU/ml (range, <0.25-630 microU/ml). Of the semi-captive orangutans, six were skin test reactive and two were culture positive for M. avium on necropsy. Median serum Ag85 for this group was 1,880 microU/ml (0.75-7,000 microU/ml), significantly higher than that of Colorado zoo or free-ranging Malaysian orangutans. Median serum Ag85 in the latter group was 125 microU/ml (range, 0.75-2,500 microU/ml). These data suggest that suggest that additional studies using more specific reagents and more samples from animals of known status are appropriate.
To determine the occupational risk of Mycobacterium tuberculosis infection among healthcare workers (HCWs) and to examine the utility of tuberculin skin testing in a developing country with a high prevalence of bacille Calmette-Guerin vaccination.
The diagnosis of patients with fever of unknown origin (FUO) is often problematic because the range of possible differential diagnoses is broad. We report on a case in which a patient presented with FUO and was subsequently found to have both a collagen vascular disease and an intercurrent infection. Treatment for the collagen vascular disease with corticosteroids exacerbated the intercurrent infection. The problems in the diagnosis and management of such cases are discussed.
This study was carried out to compare the performance of BACTEC MGIT 960 with the BACTEC 460 TB for growth and detection of Mycobacteria from human clinical specimens. The BACTEC MGIT 960 instrument is a fully automated system that utilizes MGIT tubes containing an oxygen sensor embedded in silicon at the bottom and filled with 7 mL of modified Middlebrook 7H9 broth. Identical samples were inoculated into the two automated systems and incubated for six weeks. Over a period of three months, 279 specimens were decontaminated and processed according to the standard CDC NALC/NaOH method, using the commercial MycoPrep kit. Forty-two specimens (15%) yielded Mycobacterium tuberculosis; 37 (88%) were detected by the fluorescent BACTEC MGIT 960 and 35 (83%) detected by the radiometric BACTEC 460 TB. Fifteen specimens (5%) yielded Mycobacterium Other Than Tuberculosis (MOTT); 10 (66%) were detected by BACTEC MGIT 960 and 11 (73%) detected by BACTEC 460 TB. The average time to detection and contamination rates and the average time to obtain results of antimicrobial susceptibility tests between the two systems were compared. The performance of the BACTEC MGIT 960 was comparable to the BACTEC 460 TB system which has been the "Gold Standard" for automated detection of TB. The former was more rapid, as sensitive and less labour intensive than the BACTEC 460. Our data demonstrates that the BACTEC MGIT 960 system is an accurate, automated and a non-radioactive alternative to the BACTEC 460 TB for the culture and susceptibility testing of M. tuberculosis.
Fasciolopsiasis is a disease caused by the largest intestinal fluke, Fasciolopsis buski. The disease is endemic in the Far East and Southeast Asia. Human acquires the infection after eating raw freshwater plants contaminated with the infective metacercariae. There has been no report of fasciolopsiasis either in man or in animal in Malaysia. We are reporting the first case of fasciolopsiasis in Malaysia in a 39-year-old female farmer, a native of Sabah (East Malaysia). This patient complained of cough and fever for a duration of two weeks, associated with loss of appetite and loss of weight. She had no history of traveling overseas. Physical examination showed pallor, multiple cervical and inguinal lymph nodes and hepatosplenomegaly. Laboratory investigations showed that she had iron deficiency anemia. There was leukocytosis and a raised ESR. Lymph node biopsy revealed a caseating granuloma. Stool examination was positive for the eggs of Fasciolopsis buski. The eggs measure 140 x 72.5 microm and are operculated. In this case, the patient did not present with symptoms suggestive of any intestinal parasitic infections. Detection of Fasciolopsis buski eggs in the stool was an incidental finding. She was diagnosed as a case of disseminated tuberculosis with fasciolopsiasis and was treated with antituberculosis drugs and praziquantel, respectively.
This retrospective study was conducted at the National Tuberculosis Center (NTBC) where 252 HIV-positive patients coexisting with tuberculosis (TB/HIV) were examined. We found that patients with pulmonary (PTB) and extrapulmonary tuberculosis (EPT) had similar mean age. A higher sex ratio between male to female (10.7:1) was observed in patients with PTB. The other characteristics of patients with pulmonary and extrapulmonary tuberculosis were not statistically different from each other. Cough (88%) and hemoptysis were the most common presenting symptoms, significantly related to patients with PTB. Lymphadenopathy (33.5%) was the most common sign in patients with EPT. The majority of patients with pulmonary and extrapulmonary tuberculosis had CD4 cell counts of less than 200 cells/mm3 (range 0-1,179 with a median of 57 cells/mm3). Lung (89%) and miliary (55.6%) forms were the most frequent disease locations in patients with PTB and EPT, respectively. A higher percentage of patients with PTB (42%) were treated successfully with short-course (6 months) therapy, whereas in patients with EPT (43%) needed a longer period (9 months) for successful treatment. Of the patients who defaulted treatment, a higher proportion (87%) had PTB. No MDR-TB or relapse cases were found in this study.
In the Malaysian setting of multi-ethnicity and high BCG coverage, interpretation of Tuberculin Skin Testing (TST) may be difficult. Between January 2001 and December 2003, a retrospective study on all adult patients with documented TST results treated for tuberculosis (TB) in chest clinics of two government hospitals was conducted to determine the reliability of TST and factors affecting its interpretation. One hundred and three patients [mean age (SD): 43 (17); male: 67%] were eligible for data collection: 72% and 57% of patients had positive TST results based on cut-off points of 10mm and 15mm respectively. The only significant univariate association with TST results was the severity of co-morbidity. A patient with co-morbidity score of 3 defined as those with any cancer, end-stage renal or liver disease, or HIV disease, was more likely to have a negative TST results [10mm cut-off point: Odd Ratio (95% CI) 6.6 (1.82 to 24.35), p = 0.003; 15mm cut-off point: 4.8 (1.21 to 18.95), p = 0.012]. A TST reading of 10mm had a higher sensitivity than 15mm as the cut-off point in diagnosing TB infection. Considering all possible confounding factors like ethnicity, prior BCG vaccination and TB burden in the population, severity of co-morbidity remains strongly predictive of a negative TST. Caution should be exercised in interpreting TST in these patients.
Study site: Chest clinic, Hospital Seremban, Hospital Kuala Pilah, Negeri Sembilan, Malaysia
Two tsunami survivors from Banda Acheh, Sumatra, presented with pyrexia of unknown origin and a nonresolving left-sided empyema, respectively. Both children had mixed infections of tuberculosis and melioidosis; Salmonella typhi was also present in the second patient. Mixed infections are common late sequela complications in post-tsunami victims.
The aim of the present study is rapid detection of tuberculosis from pleural effusion of suspected patients. Molecular technique Nested Polymerase Chain Reaction (PCR) was used for the purpose. A total of 67 pleural fluid collected at Hospital University Kebangsaan Malaysia during May 2005 to October 2006 were sent to Microbiology Laboratory enrolled in the study. Detection rate of Mycobacterium tuberculosis in pleural effusion was 0% by acid-fast bacilli (AFB) staining and 1.5% by culture on Lowenstein-Jensen medium. Mycobacterium tuberculosis was detected by PCR in 9% of the cases. PCR of pleural fluid had 19% sensitivity and 96% specificity, compared to AFB staining (0% sensitivity and 100% specificity) and culture (4% sensitivity and 100% specificity). PCR also has 67% Positive Predictive Value (PPV) and 72% Negative Predictive Value (NPV) in detecting Mycobacterium tuberculosis. Culture ofpleural fluid has 100% PPV and 71% NPV while AFB staining has 0% PPV and 31% NPV. This preliminary study showed that PCR is a rapid method for detection of Mycobacterium tuberculosis in pleural fluid but its sensitivity is not up the marked.
Gallbladder tuberculosis (GT) is an extremely rare condition. This is thought to be due to the protective property of bile against the infection. Clinical and radiological diagnosis of GT is difficult. We describe a case of GT who initially presented to us with jaundice, a right hypochondrial mass and computed tomographic findings suggestive of gallbladder empyema. Diagnosis was made from histopathological examination of the resected gallbladder which revealed epitheloid granulomas with caseating necrosis and presence of Langhan's giant cells. From a literature search and to the best of our knowledge, this is the first GT to be reported in South East Asia.
Immune restoration disease (IRD) associated with Mycobacterium tuberculosis parallels the reconstitution of a pathogen-specific Th1 response. However, it is not clear whether humoral responses to M. tuberculosis antigens also rise, or whether antibody levels predict IRD. Here, humoral immunity to M. tuberculosis antigens was investigated in four Asian cohorts.
BACKGROUND: Health care workers are exposed to patients with tuberculosis and are at risk of nosocomial infection. The aim of this study was to determine the prevalence and factors associated with latent tuberculosis infection among health care workers in Malaysia and also to evaluate the agreement between Quantiferon TB Gold in tube test with Tuberculin Skin Test.
METHODS: A cross sectional study was conducted at four randomly selected hospitals in the Klang Valley from December 2008 to May 2009. Self administered questionnaire was used to obtain information on health care workers and possible risk factors. The response rate for this study was 90.8% with 954 respondents completed the questionnaire and were tested with Quantiferon TB Gold in tube for latent tuberculosis infection. Agreement between Quantiferon TB Gold in tube and Tuberculin Skin Test was assessed among 95 health care workers who consented to undergo both tests.
RESULTS: The overall prevalence of latent tuberculosis infection among health care workers was 10.6% (CI: 8.6%; 12.6%). Factors significantly associated with latent tuberculosis infection were aged 35 years and older [9.49 (CI: 2.22; 40.50)], history of living in the same house with close family members or friends who had active tuberculosis [8.69 (CI: 3.00; 25.18)], worked as a nurse [4.65 (CI: 1.10; 19.65)] and being male [3.70 (CI: 1.36; 10.02)]. Agreement between Quantiferon TB Gold in tube test and tuberculin skin test at cut-off points of 10 mm and 15 mm was 50.5% and 82.1% respectively. However, Kappa-agreement was poor for both cut-off points.
CONCLUSION: The prevalence of latent tuberculosis infection in Malaysia was relatively low for an intermediate TB burden country. We could not comment on the occupational risk of latent tuberculosis infection among health care worker compared to the general population as there were no prevalence data available for latent tuberculosis infection in the general population. Kappa agreement between Quantiferon TB gold in-tube and tuberculin skin test was poor.
A real-time quantitative polymerase chain reaction (qPCR) was developed for detection and discrimination of Mycobacterium tuberculosis (H37Rv and H37Ra) and M. bovis bacillus Calmette-Guérin (BCG) of the Mycobacterium tuberculosis complex (MTBC) from mycobacterial other than tuberculosis (MOTT). It was based on the melting curve (Tm) analysis of the gyrB gene using SYBR(®) Green I detection dye and the LightCycler 1.5 system. The optimal conditions for the assay were 0.25 μmol/L of primers with 3.1 mmol/L of MgCl(2) and 45 cycles of amplification. For M. tuberculosis (H37Rv and H37Ra) and M. bovis BCG of the MTBC, we detected the crossing points (Cp) at cycles of 16.96 ± 0.07, 18.02 ± 0.14, and 18.62 ± 0.09, respectively, while the Tm values were 90.19 ± 0.06 °C, 90.27 ± 0.09 °C, and 89.81 ± 0.04 °C, respectively. The assay was sensitive and rapid with a detection limit of 10 pg of the DNA template within 35 min. In this study, the Tm analysis of the qPCR assay was applied for the detection and discrimination of MTBC from MOTT.