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Patient Age
INF- on blood Culture
1st evaluation
2nd evaluation
Days for positivization
Identification
DA 1y 2m POS 13 days M. tuberculosis
EOA 4y 3m INDPOS
7 days later 13 days M. tuberculosis
GG 16y NEGPOS
14 days later 14 days M. tuberculosis
VD 1y 11m POS 11 days M. tuberculosis
MENINGITISMENINGITIS
Patient Age
INF- Culture
on Bloodon Pleural
fluidDays for
positivizationIdentification
CG 11y 5m POS POS 15 days M. tuberculosis
PM 14y 2m IND Not Done 12 days M. tuberculosis
GSA 16y 7m IND POS 15 days M. tuberculosis
VRN 7y 5m POS POS 11 days M. tuberculosis
PLEURAL TBPLEURAL TB
Patient Age
INF- Culture
on Bloodon
Peritoneal fluid
Days for positivization
Identification
VG 12y 1m NEG POS 14 days M. tuberculosis
PERITONEAL TBPERITONEAL TB
ResultsResults
Computed Tomography images showed hydrocephalus and basilar meningitis Computed Tomography images showed hydrocephalus and basilar meningitis but without any evidence of tuberculomabut without any evidence of tuberculoma
Four children received the finaly diagnosis of tuberculous meningitisFour children received the finaly diagnosis of tuberculous meningitis
TST was not reactive (negative) in all childrenTST was not reactive (negative) in all children
QFT-G was positive during the first evaluation for two children under 2 years of QFT-G was positive during the first evaluation for two children under 2 years of age age
All children had foreign origin (three from Est Europe and one from Africa)All children had foreign origin (three from Est Europe and one from Africa)
Computed Tomography images showed a large ammount of effusion in Computed Tomography images showed a large ammount of effusion in pleural cavity but without any parenchymal involvement or typical pleural cavity but without any parenchymal involvement or typical granulomasgranulomas
Four children received the finaly diagnosis of pleural tuberculosis and one child Four children received the finaly diagnosis of pleural tuberculosis and one child had a peritoneal TB localizationhad a peritoneal TB localization
Three children received TST (two were TST positive and one TST negative)Three children received TST (two were TST positive and one TST negative)
QFT-G was always positive when performed on pleural or peritoneal fluid QFT-G was always positive when performed on pleural or peritoneal fluid
Two children were italian and three had foreign origin (with history of TB Two children were italian and three had foreign origin (with history of TB immunization)immunization)
ConclusionsConclusions
AcknowledgementsAcknowledgements
Silvia Gobbi and Eugenia Galeno laboratory technicians – Microbiology Unit – Laboratory DepartmentStefania Colafati MD - Radiology Department - for supporting in CT images and interpretation
Tuberculosis is a systemic infection caused by Tuberculosis is a systemic infection caused by Mycobacterium tuberculosisMycobacterium tuberculosis. It is transmitted by . It is transmitted by
coughed aerosol and usually presents with respiratory symptoms; however, it can produce disease in coughed aerosol and usually presents with respiratory symptoms; however, it can produce disease in
any organ system by haematogenous spread, specially in newborn, children and teen agers. The mean any organ system by haematogenous spread, specially in newborn, children and teen agers. The mean
annual number of cases referred to extra-pulmonary TB cases are approximately unchanged during the annual number of cases referred to extra-pulmonary TB cases are approximately unchanged during the
last five years (about 25-30% of all TB cases) in Europe . Extra-pulmonary TB is often diagnosed on the last five years (about 25-30% of all TB cases) in Europe . Extra-pulmonary TB is often diagnosed on the
basis of clinical experience which may lead to diagnostic errors. A correct diagnosis depends on the basis of clinical experience which may lead to diagnostic errors. A correct diagnosis depends on the
possibility of obtaining appropriate specimens for cultures and often requiring invasive procedures possibility of obtaining appropriate specimens for cultures and often requiring invasive procedures
and more sophisticated laboratory techniques. and more sophisticated laboratory techniques.
In conclusion, evaluation of an increase in the IFN-In conclusion, evaluation of an increase in the IFN- level in the pleural fluid is a good and useful level in the pleural fluid is a good and useful
diagnostic marker of pleural tuberculosis and, in our experience, QFT-G has revealed as a powerful tool diagnostic marker of pleural tuberculosis and, in our experience, QFT-G has revealed as a powerful tool
in a rapid diagnosis approach in case of suspected extra-pulmonary TB in childrenin a rapid diagnosis approach in case of suspected extra-pulmonary TB in children
Extrapulmonary manifestation of tuberculosis disease is a rare event. In the last three years, at “Bambino Gesù” Children Hospital, Reference Centre for Diagnosis and Healthcare of Mycobacteria Infection in Children, we evaluated the QuantiFERON TB Gold to assess the assay performance in extra-pulmonary TB diagnosis.
Four cases referred to TB meningitis, one occurred in a child over 5 years and three in children under 5 years, were investigated with QFT-G in whole blood. During the first evaluation, two cases out of 4 had already QFT-G positive, one generated an Indeterminate result and one a Negative result. These two patients received a second QFT-G test a few days later and both resulted QFT-G Positive
Four cases of pleural TB without any pulmonary lesion were collected in this study. Three cases out of four were strongly positive for INF- measured directly on pleural effusion, in one patient an enough amount of pleural effusion for QFT-G was not collected.
One case with peritoneal fluid, as only evidence of a peritoneal TB manifestation, was investigated both in blood and in the pleural fluid. QFT-G performed in peripheral blood was negative while QFT-G was strongly positive when tested directly on pleural effusion.
All of these cases were confirmed as extra-pulmonary TB by culture isolation of Mycobacterium tuberculosis.
In conclusion, in our experience QFT-G has revealed as a powerful tool in a rapid diagnosis of extra-pulmonary TB in children.
The clinical presentation of TB in The clinical presentation of TB in
children is extremely variable. It children is extremely variable. It
depends by different factors as: the depends by different factors as: the
age, the immunocapability of the host age, the immunocapability of the host
response and also the TB spread. In response and also the TB spread. In
particular Tuberculous meningitis has particular Tuberculous meningitis has
high rate of morbidity and mortality. high rate of morbidity and mortality.
Demonstration of tubercle bacilli in Demonstration of tubercle bacilli in
cerebrospinal fluid, the only reliable cerebrospinal fluid, the only reliable
method of diagnosis, is time consumingmethod of diagnosis, is time consuming
Background and Rationale of the StudyBackground and Rationale of the Study
Population and MethodsPopulation and Methods
Surveillance of tuberculosis in EuropeSurveillance of tuberculosis in EuropeSurveillance of tuberculosis in EuropeSurveillance of tuberculosis in Europe
The aims of our study have been:The aims of our study have been:
at “Bambino Gesù” Children Hospital at “Bambino Gesù” Children Hospital
(Rome, Italy) presenting with: (Rome, Italy) presenting with: Signs or symtoms of meningitis Signs or symtoms of meningitis
compatible wich a TB suspectedcompatible wich a TB suspected Pleural effusion Pleural effusion
oror Peritoneal effusionPeritoneal effusion
In wich any other etiology were foundIn wich any other etiology were found
From 2004 to 2007 we From 2004 to 2007 we
investigated children admittedinvestigated children admitted
BAMBINO GESU’ BAMBINO GESU’ Children HospitalChildren Hospital
HealthCare and HealthCare and
Research InstituteResearch Institute
Rome - ITALY Rome - ITALY
and has a low yield.and has a low yield. Pleural or peritoneal tuberculosis presenting with effusions are not Pleural or peritoneal tuberculosis presenting with effusions are not
always easy to diagnose because conventional tests for extra-pulmonary TB have always easy to diagnose because conventional tests for extra-pulmonary TB have
several limitations. Also Nucleid Acid Amplification commercial kits have low and several limitations. Also Nucleid Acid Amplification commercial kits have low and
varying sensitivities, and therefore should not be used for excluding a diagnosis of varying sensitivities, and therefore should not be used for excluding a diagnosis of
tuberculous pleuritis. Moreover, Cutaneous sensitivity to Purified Protein antigen tuberculous pleuritis. Moreover, Cutaneous sensitivity to Purified Protein antigen
Derivative is not satisfied. In recent years, numerous authors studied possible Derivative is not satisfied. In recent years, numerous authors studied possible
biochemical markers such as interferon gamma (IFN- biochemical markers such as interferon gamma (IFN- ), to improve diagnostic ), to improve diagnostic
efficiency.efficiency.
to apply the new QuantiFeron TB Gold (QFT-G – to apply the new QuantiFeron TB Gold (QFT-G – Cellestis Limited, Carnegie, Victoria, Cellestis Limited, Carnegie, Victoria,
AustraliaAustralia) both in blood and in pleural or peritoneal effusion to asses the performance ) both in blood and in pleural or peritoneal effusion to asses the performance
of QFT-G in samples specimens different from blood as marker of TB;of QFT-G in samples specimens different from blood as marker of TB; to test if the new QuantiFeron TB Gold (QFT-G) is able to work in suspected TB to test if the new QuantiFeron TB Gold (QFT-G) is able to work in suspected TB
meningitis as rapid tool for TB diagnosis.meningitis as rapid tool for TB diagnosis.
to apply the new QuantiFeron TB Gold (QFT-G – to apply the new QuantiFeron TB Gold (QFT-G – Cellestis Limited, Carnegie, Victoria, Cellestis Limited, Carnegie, Victoria,
AustraliaAustralia) both in blood and in pleural or peritoneal effusion to asses the performance ) both in blood and in pleural or peritoneal effusion to asses the performance
of QFT-G in samples specimens different from blood as marker of TB;of QFT-G in samples specimens different from blood as marker of TB; to test if the new QuantiFeron TB Gold (QFT-G) is able to work in suspected TB to test if the new QuantiFeron TB Gold (QFT-G) is able to work in suspected TB
meningitis as rapid tool for TB diagnosis.meningitis as rapid tool for TB diagnosis.
AFBAFB fluorescence fluorescence StainStain
Solid and liquid media Solid and liquid media culturescultures
Nucleid Acid Nucleid Acid AmplificationAmplification (Cobas Amplicore (Cobas Amplicore®®- Roche) - Roche) direct on samples direct on samples
QuantiFeronTB-Gold
OUR PATIENTSOUR PATIENTS
Liquid and Liquid and In TubeIn Tube version version
Step 1 samples collectionStep 1 samples collection
Step 2 ELISA assayStep 2 ELISA assay
Step 3 Interpretation of INF-Step 3 Interpretation of INF-γγ amount amount
The QFT-G was performed The QFT-G was performed on blood as manufacture on blood as manufacture instructions and on body instructions and on body fluids both whole and fluids both whole and after fluid concentration. after fluid concentration.
All specimen fluids (cerebrospinal, pleural and peritoneal) were collected and All specimen fluids (cerebrospinal, pleural and peritoneal) were collected and processed by using our Mycobacterial TB laboratory protocolprocessed by using our Mycobacterial TB laboratory protocol
INF-INF- ELISA assay ELISA assay
DiscussionDiscussion
Our study was carried out prospectively in a clinical routinely situation during the last three years. Our study was carried out prospectively in a clinical routinely situation during the last three years.
We assessed whether the new Interferon-We assessed whether the new Interferon-γγ release assay QuantiFERON-Gold could be used in practice in release assay QuantiFERON-Gold could be used in practice in
special setting (as pediatric population) and in extra-pulmonary localization as meningitis, pleural and special setting (as pediatric population) and in extra-pulmonary localization as meningitis, pleural and
peritoneal tuberculosis. peritoneal tuberculosis.
Potential limitations of our study Potential limitations of our study
should be: should be:
the low number of cases may affect the low number of cases may affect
precisionprecision
we did not evaluate children HIV we did not evaluate children HIV
affectedaffected
Our results reveal that:Our results reveal that:
in pleural and peritoneal effusion, INF-in pleural and peritoneal effusion, INF-
levels are significantly higher than in whole levels are significantly higher than in whole
blood in tuberculous disease;blood in tuberculous disease;
in case of suspected TB meningitis in in case of suspected TB meningitis in
children under 2 ys the QFT-G assay gives a children under 2 ys the QFT-G assay gives a
positive results positive results
AbstractAbstract
Poster Board NUMBER H28Poster Board NUMBER H28
