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BMJ Open May 2023Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
OBJECTIVE
Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
DESIGN
Cross-sectional study (July 2019 to April 2020).
SETTING
Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens.
PARTICIPANTS
Patients aged between 6 months and 15 years with presumptive TB.
INTERVENTIONS
Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age.
RESULTS
A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen's kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9.
CONCLUSIONS
We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
TRIAL REGISTRATION NUMBER
NCT05364593.
Topics: Humans; Child; Female; Infant; Male; Cross-Sectional Studies; HIV Infections; Point-of-Care Systems; Guinea-Bissau; Tuberculosis; Ultrasonography; Malnutrition
PubMed: 37208138
DOI: 10.1136/bmjopen-2022-066937 -
BMJ Case Reports May 2018We report the case of a 41-year-old woman who presented with a unilateral exudative effusion with prominent eosinophils on pleural cytology. Carbimazole had been started...
We report the case of a 41-year-old woman who presented with a unilateral exudative effusion with prominent eosinophils on pleural cytology. Carbimazole had been started 4 weeks prior to presentation. No immediate cause was identified on imaging or laboratory testing. The effusion persisted at 2-month follow-up. Further investigation at this time, including autoimmune serology was negative. At 2-month follow-up, the effusion was loculated on ultrasound imaging and had a low fluid pH on diagnostic aspiration, in keeping with an empyema. The patient received treatment for pleural empyema, including antibiotics, intercostal drain insertion and video-assisted thoracoscopic pleural biopsy. Carbimazole was stopped, and following treatment for the empyema, the effusion did not reaccumulate.This case illustrates the diagnostic difficulties that pleural effusions may present. It demonstrates that drug reactions should be considered in the differential diagnosis following thorough investigation for other potential causes and also describes the complications that may occur.
Topics: Adult; Anti-Bacterial Agents; Antithyroid Agents; Carbimazole; Diagnosis, Differential; Empyema, Pleural; Eosinophils; Exudates and Transudates; Female; Humans; Pleura; Pleural Effusion; Streptococcus oralis; Thoracic Surgery, Video-Assisted; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography
PubMed: 29735508
DOI: 10.1136/bcr-2018-224701 -
BMC Infectious Diseases Aug 2019Pulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative... (Review)
Review
BACKGROUND
Pulmonary Cryptococcosis (PC) is diagnosed with increasing incidence in recent years, but it does not commonly involve the pleural space. Here, we report a HIV-negative case with advanced stage IIIB non-small cell lung cancer (NSCLC) treated with radiation therapy presented with dyspnea, a new PET-positive lung mass and bilateral pleural effusion suspecting progressive cancer. However, the patient has been diagnosed as pulmonary cryptococcal infection and successfully treated with oral fluconazole therapy.
CASE PRESENTATION
A 77-year-old male with advanced stage non-small cell lung cancer treated with combined chemo-radiation therapy who presented with progressive dyspnea, a new PET-positive left lower lobe lung mass and bilateral pleural effusions. Initial diagnostic thoracentesis and bronchoscopy yielded no cancer, but instead found yeast forms consistent with cryptococcal organisms in the transbronchial biopsies of the left lower lobe lung mass. Subsequent to this, the previously collected pleural fluid culture showed growth of Cryptococcus neoformans. The same sample of pleural effusion was tested and was found to be positive for crytococcal antigen (CrAg) by a lateral flow assay (LFA). The patient has been treated with oral fluconazole therapy resulting in gradual resolution of the nodular infiltrates.
CONCLUSION
PC should be considered in immunosuppressed cancer patients. Additionally, concomitant pleural involvement in pulmonary cryptococcal infections may occur. The incidence of false positive FDG-PET scans in granulomatous infections and the use of CrAg testing in pleural fluid to aid in diagnosis are reviewed.
Topics: Administration, Oral; Aged; Antifungal Agents; Carcinoma, Non-Small-Cell Lung; Cryptococcosis; Cryptococcus neoformans; Fluconazole; Humans; Immunocompromised Host; Lung Diseases, Fungal; Lung Neoplasms; Male; Pleural Effusion; Positron-Emission Tomography
PubMed: 31405376
DOI: 10.1186/s12879-019-4343-2 -
BMC Pulmonary Medicine Jul 2019Medical thoracoscopy is considered an overall safe procedure, whereas numbers of studies focus on complications of diagnostic thoracoscopy and talc poudrage pleurodesis....
BACKGROUND
Medical thoracoscopy is considered an overall safe procedure, whereas numbers of studies focus on complications of diagnostic thoracoscopy and talc poudrage pleurodesis. We conduct this study to evaluate the safety of medical thoracoscopy in the management of pleural diseases and to compare complications in different therapeutic thoracoscopic procedures.
METHODS
A retrospective study was performed in 1926 patients, 662 of whom underwent medical thoracoscopy for diagnosis and 1264 of whom for therapeutic interventions of pleural diseases. Data on complications were obtained from the patients, notes on computer system, laboratory and radiographic findings. Chi-square test was performed to compare categorical variables and Fisher's exact test was used for small samples.
RESULTS
The mean age was 51 ± 8.4 (range 21-86) years and 1117 (58%) were males. Diagnostic procedure was taken in 662 (34.4%) patients, whereas therapeutic procedure was taken in 1264 (65.6%) patients. Malignant histology was reported in 860 (44.6%) and 986 (51.2%) revealed benign pleural diseases. Eighty patients (4.2%) were not definitely diagnosed and they were considered as unidentified pleural effusion. One patient died during the creation of artificial pneumothorax, and the causes of death were supposed as air embolism or an inhibition of phrenic motoneurons and circulatory system. Complication of lung laceration was found in six patients (0.3%) and reexpansion pulmonary edema was observed in two patients (0.1%). Higher incidence of prolonged air leak was observed in bulla electrocoagulation group, in comparison with pleurodesis group. Moreover, pain and fever were the most frequently complications in pleurodesis group and cutaneous infection in entry site was the most frequently reported complication in pleural decortication of empyema group.
CONCLUSIONS
Medical thoracoscopy is generally a safe and effective method, not only in the diagnosis of undiagnosed pleural effusions, but also in the management of pleural diseases. Mastering medical thoracoscopy well, improving patient management after the procedure and attempts to reduce the occurrence of post-procedural complications are the targets that physicians are supposed to achieve in the future.
Topics: Adult; Aged; Aged, 80 and over; Biopsy; Chi-Square Distribution; Exudates and Transudates; Female; Humans; Male; Middle Aged; Patient Safety; Pleura; Pleural Effusion; Pleural Effusion, Malignant; Pleurodesis; Recurrence; Retrospective Studies; Talc; Thoracoscopy; Tuberculosis; Young Adult
PubMed: 31291926
DOI: 10.1186/s12890-019-0888-5 -
Respiratory Research Feb 2017Bacterial pleural infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive... (Comparative Study)
Comparative Study
BACKGROUND
Bacterial pleural infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial pleural infection.
METHODS
Consecutive patients presenting to a tertiary pleural service between 2008 and 2013 were recruited to a well-established pleural disease study. Consent was obtained to store pleural fluid and relevant clinical information. Serum CRP, WCC and PCT were measured. A diagnosis was agreed upon by two independent consultants after a minimum of 12 months. The study was performed and reported according to the STARD reporting guidelines.
RESULTS
80/425 patients enrolled in the trial had a unilateral pleural effusion secondary to infection. 10/80 (12.5%) patients had positive pleural fluid microbiology. Investigations for viral causes of effusion were not performed. ROC curve analysis of 425 adult patients with unilateral undiagnosed pleural effusions showed no statistically significant difference in the diagnostic utility of PCT (AUC 0.77), WCC (AUC 0.77) or CRP (AUC 0.85) for the identification of bacterial pleural infection. Serum procalcitonin >0.085 μg/l has a sensitivity, specificity, negative predictive value and positive predictive value of 0.69, 0.80, 0.46 and 0.91 respectively for the identification of pleural infection. The diagnostic utility of procalcitonin was not affected by prior antibiotic use (p = 0.80).
CONCLUSIONS
The study presents evidence that serum procalcitonin is not superior to CRP and WCC for the diagnosis of bacterial pleural infection. The study suggests routine procalcitonin testing in all patients with unilateral pleural effusion is not beneficial however further investigation may identify specific patient subsets that may benefit.
TRIAL REGISTRATION
The trial was registered with the UK Clinical Research Network ( UKCRN ID 8960 ). The trial was approved by the South West Regional Ethics Committee (Ethical approval number 08/H0102/11).
Topics: Aged; Aged, 80 and over; Bacterial Infections; Biomarkers; C-Reactive Protein; Calcitonin; Female; Humans; Incidence; Leukocyte Count; Male; Middle Aged; Pleural Effusion; Prognosis; Risk Factors; Survival Rate; United Kingdom
PubMed: 28158976
DOI: 10.1186/s12931-017-0501-5 -
International Journal of Infectious... Apr 2016Raoultella ornithinolytica is known to inhabit aquatic environments. The clinical features and outcomes of human infections caused by R. ornithinolytica have been... (Review)
Review
BACKGROUND
Raoultella ornithinolytica is known to inhabit aquatic environments. The clinical features and outcomes of human infections caused by R. ornithinolytica have been reported for only a limited number of cases.
METHODS
A retrospective study of cases of infection caused by R. ornithinolytica managed at four university hospital centres during the period before and after the introduction of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was performed. The aim was to describe the clinical and microbiological characteristics, treatments, and outcomes.
RESULTS
Among 187 R. ornithinolytica isolates identified for which clinical information was available, 71 were considered colonizers and 116 were pathogenic. A total of 112 cases of R. ornithinolytica infection were identified. Urinary tract infections, gastrointestinal infections, wound and skin infections, and bacteraemia were observed in 36%, 14%, 13%, and 5% of cases, respectively. Associated infections that have been poorly reported, such as respiratory infections, i.e. pneumonia and pleural effusion, were observed in 24% of cases. Additional diseases reported here for the first time included osteomyelitis, meningitis, cerebral abscess, mediastinitis, pericarditis, conjunctivitis, and otitis. The proportion of R. ornithinolytica isolates resistant to antibiotics was found to be relatively high: 4% of isolates were resistant to ceftriaxone, 6% to quinolones, and 13% to co-trimoxazole. The mortality rate related to infection was 5%.
CONCLUSIONS
R. ornithinolytica is an underreported, emerging hospital-acquired infection and is particularly associated with invasive procedures. R. ornithinolytica should never be considered simply a saprophytic bacterium that occasionally contaminates bronchial lavage or other deep respiratory samples or surgical sites. Physicians should be aware of the high rates of antimicrobial resistance of R. ornithinolytica isolates so that immediate broad-spectrum antibiotic treatment can be established before accurate microbiological results are obtained.
Topics: Anti-Bacterial Agents; Bacteremia; Cross Infection; Drug Resistance, Bacterial; Enterobacteriaceae; Enterobacteriaceae Infections; Female; Humans; Male; Retrospective Studies
PubMed: 26921549
DOI: 10.1016/j.ijid.2016.02.014 -
PLoS Neglected Tropical Diseases Aug 2019Lung disease is regularly reported in human filarial infections but the molecular pathogenesis of pulmonary filariasis is poorly understood. We used Litomosoides...
Lung disease is regularly reported in human filarial infections but the molecular pathogenesis of pulmonary filariasis is poorly understood. We used Litomosoides sigmodontis, a rodent filaria residing in the pleural cavity responsible for pleural inflammation, to model responses to human filarial infections and probe the mechanisms. Wild-type and Th2-deficient mice (ΔdblGata1 and Il-4receptor(r)a-/-/IL-5-/-) were infected with L. sigmodontis. Survival and growth of adult filariae and prevalence and density of microfilariae were evaluated. Cells and cytokines in the pleural cavity and bronchoalveolar space were characterized by imaging, flow cytometry and ELISA. Inflammatory pathways were evaluated by transcriptomic microarrays and lungs were isolated and analyzed for histopathological signatures. 40% of WT mice were amicrofilaremic whereas almost all mutant mice display blood microfilaremia. Microfilariae induced pleural, bronchoalveolar and lung-tissue inflammation associated with an increase in bronchoalveolar eosinophils and perivascular macrophages, production of mucus, visceral pleura alterations and fibrosis. Inflammation and pathology were decreased in Th2-deficient mice. An IL-4R-dependent increase of CD169 was observed on pleural and bronchoalveolar macrophages in microfilaremic mice. CD169+ tissue-resident macrophages were identified in the lungs with specific localizations. Strikingly, CD169+ macrophages increased significantly in the perivascular area in microfilaremic mice. These data describe lung inflammation and pathology in chronic filariasis and emphasize the role of Th2 responses according to the presence of microfilariae. It is also the first report implicating CD169+ lung macrophages in response to a Nematode infection.
Topics: Animals; Disease Models, Animal; Female; Filariasis; Filarioidea; Inflammation; Lung; Macrophages; Mice, Inbred BALB C; Receptors, Interleukin-4; Sialic Acid Binding Ig-like Lectin 1; Th2 Cells
PubMed: 31469835
DOI: 10.1371/journal.pntd.0007691 -
MBio Jun 2021Bacterial fatty acids are critical components of the cellular membrane. A shift in environmental conditions or in the bacterium's lifestyle may result in the requirement...
Bacterial fatty acids are critical components of the cellular membrane. A shift in environmental conditions or in the bacterium's lifestyle may result in the requirement for a distinct pool of fatty acids with unique biophysical properties. This can be achieved by the modification of existing fatty acids or via synthesis. Furthermore, bacteria have evolved efficient means to acquire these energy-rich molecules from their environment. However, the balance between fatty acid synthesis and exogenous acquisition during pathogenesis is poorly understood. Here, we studied the mouse fatty acid landscape prior to and after infection with Acinetobacter baumannii, a Gram-negative, opportunistic human pathogen. The lipid fluxes observed following infection revealed fatty acid- and niche-specific changes. Lipidomic profiling of A. baumannii isolated from the pleural cavity of mice identified novel A. baumannii membrane phospholipid species and an overall increased abundance of unsaturated fatty acid species. Importantly, we found that A. baumannii relies largely upon fatty acid acquisition in all but one of the studied niches, the blood, where the pathogen biosynthesizes its own fatty acids. This work is the first to reveal the significance of balancing the making and taking of fatty acids in a Gram-negative bacterium during infection, which provides new insights into the validity of targeting fatty acid synthesis as a treatment strategy. Acinetobacter baumannii is one of the world's most problematic superbugs and is associated with significant morbidity and mortality in the hospital environment. The critical need for new antimicrobial strategies is recognized, but our understanding of its behavior and adaptation to a changing environment during infection is limited. Here, we investigated the role of fatty acids at the host-pathogen interface using a mouse model of disease. We provide comprehensive insights into the bacterial membrane composition when the bacteria colonize the pleural cavity. Furthermore, we show that A. baumannii heavily relies upon making its own fatty acids when residing in the blood, whereas the bacterium favors fatty acid acquisition in most other host niches. Our new knowledge aids in understanding the importance of host fatty acids in infectious diseases. Furthermore, fatty acid synthesis is an attractive target for the development of new antimicrobial strategies, but our work emphasizes the critical need to understand microbial lipid homeostasis before this can be deemed suitable.
Topics: Acinetobacter Infections; Acinetobacter baumannii; Adaptation, Physiological; Animals; Cell Membrane; Fatty Acids; Homeostasis; Humans; Lipidomics; Mice; Phospholipids
PubMed: 34134515
DOI: 10.1128/mBio.00928-21 -
International Journal of Molecular... Oct 2019Thrombin is an essential procoagulant and profibrotic mediator. However, its implication in tuberculous pleural effusion (TBPE) remains unknown. The effusion thrombin...
Thrombin is an essential procoagulant and profibrotic mediator. However, its implication in tuberculous pleural effusion (TBPE) remains unknown. The effusion thrombin and plasminogen activator inhibitor-1 (PAI-1) levels were measured among transudative pleural effusion (TPE, = 22) and TBPE ( = 24) patients. Pleural fibrosis, identified as radiological residual pleural thickening (RPT) and shadowing, was measured at 12-month follow-up. Moreover, in vivo and in vitro effects of thrombin on PAI-1 expression and mesothelial-mesenchymal transition (MMT) were assessed. We demonstrated the effusion thrombin levels were significantly higher in TBPE than TPE, especially greater in TBPE patients with RPT > 10mm than those without, and correlated positively with PAI-1 and pleural fibrosis area. In carbon black/bleomycin-treated mice, knockdown of protease-activated receptor-1 (PAR-1) markedly downregulated α-smooth muscle actin (α-SMA) and fibronectin, and attenuated pleural fibrosis. In pleural mesothelial cells (PMCs), thrombin concentration-dependently increased PAI-1, α-SMA, and collagen I expression. Specifically, H37Ra (MTBRa) induced thrombin production by PMCs via upregulating tissue factor and prothrombin, and PAR-1 silencing considerably abrogated MTBRa-stimulated PAI-1 expression and MMT. Consistently, prothrombin/PAR-1 expression was evident in the pleural mesothelium of TBPE patients. Conclusively, thrombin upregulates PAI-1 and MMT and may contribute to tuberculous pleural fibrosis. Thrombin/PAR-1 inhibition may confer potential therapy for pleural fibrosis.
Topics: Adult; Aged; Aged, 80 and over; Animals; Disease Models, Animal; Exudates and Transudates; Female; Fibrosis; Follow-Up Studies; Humans; Male; Mesoderm; Mice; Mice, Inbred C57BL; Middle Aged; Mycobacterium tuberculosis; Phosphatidylinositol 3-Kinases; Plasminogen Activator Inhibitor 1; Pleura; Pleural Effusion; Receptor, PAR-1; Signal Transduction; Thrombin; Tuberculosis; Young Adult
PubMed: 31614900
DOI: 10.3390/ijms20205076 -
BMC Pulmonary Medicine Apr 2022To explored the clinical, pathological, and bacteriological characteristics of pleural-based masses occurred during anti-tuberculosis (TB) treatment in patients with... (Observational Study)
Observational Study
BACKGROUND
To explored the clinical, pathological, and bacteriological characteristics of pleural-based masses occurred during anti-tuberculosis (TB) treatment in patients with pleural TB.
METHODS
Patients referred with newly diagnosed pleural TB were prospectively enrolled into the study. Patients were followed up throughout the treatment, and clinical data were recorded. Percutaneous biopsy and surgical tissues from pleural-based masses were examined histologically and samples sent for PCR. Cytokines in the pleural effusions and clinical factors were collected and compared between different patients.
RESULTS
A total of 122 patients with pleural TB were enrolled, and 34.4% (42/122) displayed newly observed pleural-based mass during the treatment. Twelve cases underwent surgical resection at the 12 ± 0.5 months during the treatment course. Based on the surgical observation, 58.3% (7 /12) were located in pleura, 41.7% (5/12) were located in the lung parenchyma. Pathological observations showed that the pleural-based masses were typed as granulomatous inflammation, fibrous hyperplasia and necrosis. Mycobacterium tuberculosis PCR was positive in 57.1% of the cases (24/42). Any first-line anti-TB drug resistance gene mutations were positive in only 9.5% (4/42). Aside from 12 cases who underwent the surgical operation, 86.7% of the patients (26/30) still had a pleural-based mass at the end of 12 months treatment course. Patients with a pleural-based mass were younger, had a thicker pleural, a higher proportion of pleural adhesive, loculated pleural effusion and residual pleural effusion, and a higher level of LDH, ADA and lower glucose in pleural effusion than those without a pleural-based mass occurrence during the treatment (all Pcorr < 0.05).
CONCLUSIONS
Pleural-based masses were observed in about one-third of patients with pleural TB. The masses were in the lung or pleura and were divided into three pathological types.
Topics: Exudates and Transudates; Humans; Mycobacterium tuberculosis; Pleura; Pleural Effusion; Tuberculosis, Pleural
PubMed: 35379218
DOI: 10.1186/s12890-022-01910-6