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Diagnosis of Tuberculosis
Diagnosis of Tuberculosis
Dr.T.V.Rao MD
Dr.T.V.Rao MD
A Global Emergency
The Tuberculosis in the beginning of the 21st Century declared as Global Emergency
(WHO)
Dr.T.V.Rao MD
Dr.T.V.Rao MD
Dr.T.V.Rao MD
Tuberculosis kills young adults. Premature death of the infected a prominent future. Today many are co infected with HIV. The open cases of Tuberculosis infects a few around his/her environment. A social burden to the family, society and Nations.
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Lack of health infrastructure. Control is plagued with lack of Accurate, Robust, and Rapid Diagnostic methods, Technologies.
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DIAGNOSTIC METHODS
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Diagnosis.
Tuberculosis is a diversified disease. Any organs can be involved. Any age group, gender no bar for Tuberculosis. Involvement of Lungs contribute to majority of tuberculosis. And involvement of Lungs is designated as Pulmonary tuberculosis.
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Majority of Adults suffer with pulmonary tuberculosis. Microbiological examination of Sputum continues to be a Gold standard in proving the Diagnosis. Sputum examination in Children is not sensitive in Diagnosis. Radiological examination of Lungs, most commonly prescribed investigation.
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Sputum Specimens*
*Train the staff to obtain the appropriate specimen A few minutes of education to patients on importance of ideal sample make a great difference and improves the Diagnosis.
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SALIVA
Appears clear, watery, and frothy. Contains many squamous epithelial cells Absence of
Polymorphoneutrophils.
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Why Microscopy
Only we need Microscope, and few stains. Most rapid, economical, Can detect bacterial load. A Diagnostic, and Prognostic tool. A little of sputum 0.2 l is adequate. A prompt diagnosis after searching as few as 100 fields.
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Repeated sample examinations. load on technical staff. Training and dedication of Microscopist. The load of bacilli must be more than 10,000 / 1 ml of sputum. Low in sensitivity < 50 % Repeated requests for samples High drop out by patients, for repeated samples. Not dependable in pediatric age group.
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Sputum Microscopy can be improved with Sputum liquefaction, concentration and gravity sedimentation. Popular solvents Sodium hypochlorite. Sodium hydroxide. Ammonium Sulphate N-acetyl-L-cysteine sodium hydroxide.
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Major studies showed processing of sputum with chemicals and centrifugation improved sensitivity up to 18 %. Incremental yield ( positive with bleach minus positives with Ziehl Neelsen stain) up to 9 %. Treating specimens with Sodium hypochlorite is Mycobactericidal and also kills HIV and improves the safety and acceptability by technical staff.
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There is a growing need for screening for AFB by Florescent Microscopy. Several studies prove, Florescent Microscopy in Diagnosis of Tuberculosis is a priority, Developing world should opt and initiate florescent microscopy.
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Useful when few bacilli are present. Increases the sensitivity in HIV patients with tuberculosis. Reduces the time needed for testing. About 15 times as many fields of view can be scanned by fluorescent microscopy than by Ziehl Neelsenmethod in the same period. Increases the sensitivity by 10 % Better conclusions with one or two specimens, unlike Ziehl Neelsens method needing 3 or > 3 specimens.
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Culturing Mycobacterium
Culturing for isolation of Mycobacterium spp continues to be a Gold standard, particularly in Developing countries. Need only 10 100 bacilli / 1 ml of sputum.
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Surveillance, Drug sensitivity testing patterns. Identify treatment failures. Useful in Patients presenting with respiratory symptoms, X- rays suggestive, but smear negative. Can prove culture positive. Cultures remain suggestive and helpful in early treatment periods, failed drug regimes.
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Methods of Culturing.
Culturing on Lowenstein Jensons culture medium remain the affordable ,economical method in developing world.
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Limitation in Culturing
Mycobacterium spp are slow growing. Need 6 8 weeks for growing. Specimens can be contaminated while growing, needs repeated specimens, in turn patients loose confidence in Laboratories.
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Pitfalls in Culturing
Specificity is lost due to contamination. Can yield false positive results in 1 4 % of the cases. Cultures may be negative in spite of x rays are suggestive of tuberculosis.
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PCR ( Polymerase chain reaction ) used by several investigators. However most cases can be diagnosed with simple methods if effectively used. The definite role of PCR continues to be controversial Above all not cost effective to Developing countries.
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amplification
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Microscopic observation drug susceptibility assay. ( MODS ) A new method gained importance in several reviews. Use a tissue culture plate based assay with use of Middle Brook 7HG. Needs a inverted light microscope. Even the drug resistance can be tested with Rifampicin, and Isoniazid. Safe to work with cultures.
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Test to be interpreted in relation to clinical evaluation. Even the induration of 5 mm to be considered positive when tested on HIV patients. Lacks specificity.
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Serology in Tuberculosis.
Several serological methods were evaluated. But never gained the acceptance of the majority of the clinicians. Serological tests are low sensitivity. Many physicians depend on serology in extra pulmonary tuberculosis.
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HIV/AIDS
Tuberculosis
Consider the HIV status Identify the severity of Tuberculosis. Early use of chest radiography. Maximal number of sputum smear examinations. Sputum concentration methods to be encouraged even by smaller laboratories. Explore the use of Florescent Microscopy. All smear negative specimens should be cultured.
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A real challenge to Clinicians and Laboratories. Optimal specimen collection a priority, Molecular Methods are growing need. Clinicians start drug regimes on empirical basis. Several serological tests for antibody determinations are evaluated.
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Atypical Mycobacterium
Needs the help of reference laboratories. Needs different drug regimes, unlike typical Mycobacterium isolates. Now a gowning concern in the era of AIDS.
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Future perceptions
It is highly essential to explore and discover rapid, simple, and accurate tuberculosis diagnostic tools. A massive investment, greater scientific interest, political commitment a top priority, Man power development, Human resource utilization a greater concern. Microscopy and Florescent Microscopy utilization should be immediate concern, and strengthening of treatment initiation protocols. Effective methods in diagnosing smear negative patients a growing priority.
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GeneXpert MTB/RIF
The Xpert MTB/RIF is a cartridge-based, automated diagnostic test that can identify Mycobacterium tuberculosis (MTB) and resistance to rifampicin (RIF). It was co-developed by Cepheid, Inc. and Foundation for Innovative New Diagnostics, with additional financial support from the US National Institutes of Health (NIH) and technical support from the University of Medicine and Dentistry of New Jersey
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The Xpert MTB/RIF detects DNA sequences specific for Mycobacterium tuberculosis and rifampicin resistance by polymerase chain reaction It is based on the Cepheid GeneXpert system, a platform for rapid and simple-to-use nucleic acid amplification tests (NAAT).
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The Xpert MTB/RIF purifies, concentrates, amplifies (by real-time PCR) and identifies targeted nucleic acid sequences in the Mycobacterium tuberculosis genome, and provides results from unprocessed sputum samples in 90 minutes, with minimal biohazard and very little technical training required to operate
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