Diagnosis of  Female Genital TB Anuj Sharma
TB <ul><li>One third of world population infected </li></ul><ul><li>Life time risk of TB following infection ~5-10% </li><...
GUTB <ul><li>Common site of extrapulmonary TB </li></ul><ul><li>15-20% of extrapulmonary cases of TB (developing countries...
GUTB <ul><li>Mycobacterium sp </li></ul><ul><ul><li>M. tuberculosis  complex </li></ul></ul><ul><ul><ul><li>M. tuberculosi...
M. tuberculosis <ul><li>Aerobic bacillus </li></ul><ul><li>Non-spore forming </li></ul><ul><li>Non-motile </li></ul><ul><l...
GTB <ul><li>Still rampant in India </li></ul><ul><li>Genital TB used to be the commonest cause of tubal infertility in the...
Pathogenesis <ul><li>FGTB is usually secondary to pulmonary TB; although in some cases, cervical TB - primary infection </...
Diagnostic   criteria  Genital tuberculosis <ul><li>E ndometrial   adhesions with deformity , and  obliteration of the end...
HSG - GTB <ul><li>Rigid pipe-stem tubes </li></ul><ul><li>A clubbed ampula with retort-shaped hydrosalpingx </li></ul><ul>...
Investigations <ul><li>CBC, ESR, KFT, CRP </li></ul><ul><li>CXR </li></ul><ul><li>Pelvic ultrasound / hystero-salpingograp...
Genital tuberculosis A diagnostic dilemma* <ul><li>Varied clinical presentations </li></ul><ul><li>Diverse results on imag...
GTB <ul><li>Chest radiographs, urine, and sputum cultures are not specific for FGTB </li></ul><ul><li>But, helpful to rule...
New approaches <ul><li>LTBI – QFTG, T spot TB </li></ul><ul><li>NAA </li></ul><ul><ul><ul><li>Amplicor MTB test (Roche, PC...
Outline <ul><li>Mantoux </li></ul><ul><li>QuantiFERON-TB Gold </li></ul><ul><li>Microscopy </li></ul><ul><li>Culture </li>...
Mantoux <ul><li>Diagnostic role of a positive Mantoux (PPD) is controversial </li></ul><ul><li>Almost 45% of infertile wom...
QuantiFERON-TB Gold QFTG <ul><li>I n vitro  laboratory diagnostic test (May ’05) </li></ul><ul><li>Indirect test for  M. t...
QFTG <ul><li>IFN-g release assay (IGRA) Fresh heparinised whole blood from sensitised persons incubated with mixtures of s...
QFTG <ul><li>Single patient visit - whole blood sample - 4 ml of heparinised whole blood </li></ul><ul><li>Must be transpo...
QFTG Test not interpretable Indeterminate M. tuberculosis  infection unlikely,  but cannot be excluded in immunocompromise...
Microscopy <ul><li>Ziehl-Neelsen, Kinyoun </li></ul><ul><li>Fluorochrome - Auramine-rhodamine (direct fluorescence) </li><...
Culture <ul><li>Decisive step for diagnosis, treatment & control of TB </li></ul><ul><li>Combination of solid & liquid med...
BacT/ALERT 3D MB <ul><li>Fully automated </li></ul><ul><li>Non-invasive </li></ul><ul><li>Continuously monitored non-radio...
BacT/ALERT 3D The first BacT/ALERT 3D 960 in India
BacT/ALERT MP <ul><li>10 ml Middlebrook 7H9 Broth </li></ul><ul><ul><li>BSA, Catalase </li></ul></ul><ul><li>Decontaminate...
BacT/ALERT MB <ul><li>30 ml  Middlebrook 7H9 Broth </li></ul><ul><ul><li>SPS, Glycerol </li></ul></ul><ul><li>For blood an...
BacT/ALERT 3D MB <ul><li>CO 2  released by mycobacteria detected by sensor </li></ul><ul><li>Colour changes -  increase in...
Mean detection time 36.2 12.7 NTM  36.2 21 <ul><li>Smear  – ve  </li></ul>28.5 11.8 <ul><li>Smear  + ve  </li></ul>MTB Ita...
SGRH Experience 21 10.45 AFB S/T 22 11.95 Mean detection time   (days) LJ medium BacT/Alert 3D
Molecular diagnosis of TB <ul><li>DNA probes </li></ul><ul><ul><li>From cultures </li></ul></ul><ul><ul><li>Direct samples...
PCR AMPLICOR M. tb test <ul><li>Uses </li></ul><ul><ul><li>Rapid diagnosis in smear negative samples </li></ul></ul><ul><u...
Gen-Probe – MTD test Amplified M. tb direct ( MTD ) test <ul><li>TMA - isothermal amplification of  M. tb  complex 16s rRN...
MTD Test Performance Smear-Positive Patients  37 87.5% 100% 100% 96.7% 7H10/7H11 39 63.6% 100% 100% 87.5% LJ 39 87.5% 100%...
MTD Test Performance Smear-Negative Patients  Number of Patients NPV PPV Specificity Sensitivity   167 93.4% 100% 100% 60%...
Evaluation of women with infertility and genital TB <ul><li>Biopsy or curettage samples from 65 women clinically suspected...
Improved diagnostic value of PCR in the diagnosis of FGTB leading to infertility <ul><li>Double-blind study; 25 women suff...
Meta-analyses / systematic review Accuracy of NAA test for TB <ul><li>> 40 studies; Pulm & extrapul TB </li></ul><ul><li>C...
Accuprobe <ul><li>Gen-probe’s culture identification tests </li></ul><ul><li>Definitive identification of common mycobacte...
AccuProbe tests <ul><li>Based on hybridisation of nucleic acids </li></ul><ul><li>4 steps </li></ul><ul><ul><li>Sample pre...
 
FASTPlaque TB <ul><li>Mycobacteriophage detection system </li></ul><ul><li>M. smegmatis  lytic cycle: 90 mins </li></ul><u...
Diagnosis of TB SGRH Microbiology <ul><li>Microscopy SGRH charges  (NH/PvtOPD) </li></ul><ul><ul><li>ZN 170 </li></ul></ul...
 
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Diagnosis of Female Genital TB

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Role of Microbiology techniques in diagnosis of TB in the female gential tract

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Diagnosis of Female Genital TB

  1. 1. Diagnosis of Female Genital TB Anuj Sharma
  2. 2. TB <ul><li>One third of world population infected </li></ul><ul><li>Life time risk of TB following infection ~5-10% </li></ul><ul><li>Global emergency </li></ul><ul><ul><li>10 million new cases per year </li></ul></ul><ul><ul><li>3 million deaths every year </li></ul></ul><ul><li>India </li></ul><ul><ul><li>14 million people </li></ul></ul><ul><ul><li>5-16% cases of infertility </li></ul></ul><ul><li>Drug resistant TB </li></ul><ul><li>HIV co-infection </li></ul>
  3. 3. GUTB <ul><li>Common site of extrapulmonary TB </li></ul><ul><li>15-20% of extrapulmonary cases of TB (developing countries); M:F = 5:3 </li></ul><ul><li>Kidneys, ureter, bladder, or genital organs </li></ul><ul><li>Clinical symptoms develop 10-15 yrs after primary infection </li></ul><ul><li>~25% GUTB patients have known h/o TB; about half of these patients have normal CXR </li></ul>
  4. 4. GUTB <ul><li>Mycobacterium sp </li></ul><ul><ul><li>M. tuberculosis complex </li></ul></ul><ul><ul><ul><li>M. tuberculosis – most common </li></ul></ul></ul><ul><ul><ul><li>M. bovis ( M. microti, M. africanum, M. canetti) </li></ul></ul></ul><ul><ul><li>MOTT/NTM </li></ul></ul><ul><ul><ul><li>Mycobacterium kansasii </li></ul></ul></ul><ul><ul><ul><li>Mycobacterium fortuitum </li></ul></ul></ul><ul><ul><ul><li>Mycobacterium avium-intracellulare </li></ul></ul></ul><ul><ul><ul><li>Mycobacterium xenopi </li></ul></ul></ul><ul><ul><ul><li>Mycobacterium celatum </li></ul></ul></ul>
  5. 5. M. tuberculosis <ul><li>Aerobic bacillus </li></ul><ul><li>Non-spore forming </li></ul><ul><li>Non-motile </li></ul><ul><li>Generation time: 12-20 hours </li></ul><ul><li>Culture </li></ul><ul><ul><li>3-6 weeks </li></ul></ul><ul><ul><li>1-2 weeks </li></ul></ul>
  6. 6. GTB <ul><li>Still rampant in India </li></ul><ul><li>Genital TB used to be the commonest cause of tubal infertility in the past </li></ul><ul><li>Today genital TB much less common </li></ul><ul><li>But, often misdiagnosed in infertile women, leading to a lot of heartbreak and distress </li></ul><ul><li>Infection / Disease </li></ul>
  7. 7. Pathogenesis <ul><li>FGTB is usually secondary to pulmonary TB; although in some cases, cervical TB - primary infection </li></ul><ul><li>Begins with a focus in the endosalpinx </li></ul><ul><ul><li>Fallopian tubes - 100% </li></ul></ul><ul><ul><li>Endometrium - 50% </li></ul></ul><ul><ul><li>Ovaries - 20% </li></ul></ul><ul><ul><li>Cervix - 5% </li></ul></ul><ul><ul><li>Vagina and vulva - <1% </li></ul></ul>
  8. 8. Diagnostic criteria Genital tuberculosis <ul><li>E ndometrial adhesions with deformity , and obliteration of the endometrial cavity, </li></ul><ul><li>O bstruction of the fallopian tubes with multiple areas of constriction, and calcified lymph nodes in the adnexal region </li></ul><ul><li>Advanced tuberculous endometritis may mimic severe uterine adhesions as seen in Asherman syndrome </li></ul>
  9. 9. HSG - GTB <ul><li>Rigid pipe-stem tubes </li></ul><ul><li>A clubbed ampula with retort-shaped hydrosalpingx </li></ul><ul><li>Vascular or lymphatic intravasation of contrast </li></ul><ul><li>Small shrunken uterine cavity with filling defects </li></ul><ul><li>Long and dilated cervical canal & dye in cervical crypts </li></ul><ul><li>Bilateral cornual block </li></ul><ul><li>Punctate opacification of crypts and diverticulae in lumen of tubes </li></ul>
  10. 10. Investigations <ul><li>CBC, ESR, KFT, CRP </li></ul><ul><li>CXR </li></ul><ul><li>Pelvic ultrasound / hystero-salpingography </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Histopathology </li></ul><ul><li>Microbiology </li></ul><ul><ul><li>Mantoux test </li></ul></ul><ul><ul><li>QTG-T </li></ul></ul><ul><ul><li>Serology </li></ul></ul><ul><ul><li>AFB microscopy / culture </li></ul></ul><ul><ul><ul><li>EA / EB / EC / menstrual blood </li></ul></ul></ul><ul><ul><ul><li>Urine – 3 consecutive days (smear vs culture - St: 52% / 65%; Sp: 89-96 / 100%) </li></ul></ul></ul><ul><ul><li>Molecular tests </li></ul></ul><ul><ul><li>HIV </li></ul></ul>
  11. 11. Genital tuberculosis A diagnostic dilemma* <ul><li>Varied clinical presentations </li></ul><ul><li>Diverse results on imaging and laparoscopy </li></ul><ul><li>Mixed lab tests </li></ul><ul><li>Pelvic ultrasound - initial screening test </li></ul><ul><ul><ul><li>Ascites / loculated fluid (100%) </li></ul></ul></ul><ul><ul><ul><li>Adnexal mass (93%) </li></ul></ul></ul><ul><ul><ul><li>Peritoneal thickening(69%) </li></ul></ul></ul><ul><ul><ul><li>Omental thickening(61%) </li></ul></ul></ul><ul><ul><ul><li>Endometrial involvement (83%) </li></ul></ul></ul><ul><ul><ul><li>Peritoneal tubercles and adhesions </li></ul></ul></ul><ul><li>MRI, hysterosalpingography, and endoscopy </li></ul><ul><li>Diagnosed on the collective evidence from imaging techniques, endoscopy, histopathology and microbiology </li></ul>*J Obstet Gynecol India 2006; Vol. 56, No. 3: 203-204
  12. 12. GTB <ul><li>Chest radiographs, urine, and sputum cultures are not specific for FGTB </li></ul><ul><li>But, helpful to rule out dissemination to other organs </li></ul><ul><li>Infertile women with a positive PPD skin test - early laparoscopy </li></ul><ul><ul><li>direct visualisation of fallopian tubes </li></ul></ul><ul><ul><li>collection of specimens for histopathology and microbiology </li></ul></ul>
  13. 13. New approaches <ul><li>LTBI – QFTG, T spot TB </li></ul><ul><li>NAA </li></ul><ul><ul><ul><li>Amplicor MTB test (Roche, PCR) </li></ul></ul></ul><ul><ul><ul><li>Amplified MTD (Gen-Probe, TMA) </li></ul></ul></ul><ul><ul><ul><li>ProbeTec ET (BD, SDA) </li></ul></ul></ul><ul><ul><li>High specificity / PPV; low sensitivity / NPV </li></ul></ul><ul><ul><li>To be used in conjunction with conventional tests and clinical data </li></ul></ul><ul><li>Rapid detection of drug resistance </li></ul><ul><ul><li>Molecular beacons – Rif / INH </li></ul></ul><ul><ul><li>Line probe assays – INNO-LiPA Rif TB kit </li></ul></ul><ul><ul><li>Phage based assays – FASTPlaque TB, FASTPlaque TB MDRi kit, FASTPlaque TB-Response </li></ul></ul>Proc Am Thorac Soc 2006; Vol 3: 103-10
  14. 14. Outline <ul><li>Mantoux </li></ul><ul><li>QuantiFERON-TB Gold </li></ul><ul><li>Microscopy </li></ul><ul><li>Culture </li></ul><ul><li>Molecular tests – Gen-probe / PCR </li></ul><ul><li>Identification by Accuprobe </li></ul><ul><li>FASTPlaque TB </li></ul>
  15. 15. Mantoux <ul><li>Diagnostic role of a positive Mantoux (PPD) is controversial </li></ul><ul><li>Almost 45% of infertile women with strong indirect evidence of pelvic TB, such as laparoscopic findings (thickened tubes, areas of caseation, etc) - negative Mantoux </li></ul><ul><li>In 27 infertile women with a positive Mantoux, only 11 had clear laparoscopic findings suggestive of FGTB </li></ul><ul><li>Mantoux test in women with laparoscopically diagnosed tuberculosis </li></ul><ul><ul><li>sensitivity - 55% </li></ul></ul><ul><ul><li>specificity - 80% </li></ul></ul>* Raut VS, Mahashur AA, Sheth SS: The Mantoux test in the diagnosis of genital tuberculosis in women. Int J Gynaecol Obstet 2001, 72: 165-169
  16. 16. QuantiFERON-TB Gold QFTG <ul><li>I n vitro laboratory diagnostic test (May ’05) </li></ul><ul><li>Indirect test for M. tuberculosis complex </li></ul><ul><ul><li>M. tuberculosis </li></ul></ul><ul><ul><li>M. bovis, M. africanum, M. microti, M. canetti infection </li></ul></ul><ul><li>Tuberculosis disease OR latent tuberculosis infection (LTBI)- cannot distinguish between them </li></ul><ul><li>Intended for use in conjunction with risk assessment, radiography, and other medical and diagnostic evaluations </li></ul>
  17. 17. QFTG <ul><li>IFN-g release assay (IGRA) Fresh heparinised whole blood from sensitised persons incubated with mixtures of synthetic peptides (two proteins present in M. tuberculosis) </li></ul><ul><ul><li>ESAT-6 (early secretory antigenic target-6) </li></ul></ul><ul><ul><li>CFP-10 (culture filtrate protein-10) </li></ul></ul><ul><li>Lymphocytes in blood of TB patients recognize these mycobacterial antigens - generation and secretion of interferon-γ (IFN-γ) </li></ul><ul><li>Detection and subsequent quantification of IFN-γ by ELISA </li></ul><ul><li>These proteins are absent in BCG strains and from most NTMs (except M. kansasii , M. szulgai and M. marinum ) </li></ul><ul><li>Higher specificity than with PPD (Mantoux) </li></ul>
  18. 18. QFTG <ul><li>Single patient visit - whole blood sample - 4 ml of heparinised whole blood </li></ul><ul><li>Must be transported to lab to allow initiation of testing within 12 hours (viable lymphocytes) </li></ul><ul><li>Rapid results (within 24 hours) </li></ul><ul><li>No booster response (measured by subsequent tests - which can happen with Mantoux) </li></ul><ul><li>No reader bias (cf Mantoux) </li></ul><ul><li>Not affected by prior BCG vaccination </li></ul><ul><li>Impaired or altered immune function </li></ul><ul><li>ST: 80-95% (Mantoux 75-90%) </li></ul><ul><li>SP: 95-100% (Mantoux 70-95%) </li></ul>
  19. 19. QFTG Test not interpretable Indeterminate M. tuberculosis infection unlikely, but cannot be excluded in immunocompromised patients, or highly probable cases Negative (No ESAT-6 or CFP-10 responsiveness detected) M. tuberculosis infection likely Positive (ESAT-6 and/or CFP-10 responsiveness detected) Interpretation Result
  20. 20. Microscopy <ul><li>Ziehl-Neelsen, Kinyoun </li></ul><ul><li>Fluorochrome - Auramine-rhodamine (direct fluorescence) </li></ul><ul><ul><li>Higher sensitivity; faster screening </li></ul></ul><ul><li>ST: 22-78% (cf culture) </li></ul><ul><li>MC Detection limit in sputum: 5000-10000 orgs/ml Culture: 100 orgs/ml </li></ul><ul><li>Presumptive identification; confirmation by culture / NAA test </li></ul>
  21. 21. Culture <ul><li>Decisive step for diagnosis, treatment & control of TB </li></ul><ul><li>Combination of solid & liquid media- “ gold standard ” for primary isolation </li></ul><ul><li>Recommended turn around time (CDC) </li></ul><ul><ul><li>14 days (culture) </li></ul></ul><ul><ul><li>21-30 days (identification & susceptibility) </li></ul></ul>
  22. 22. BacT/ALERT 3D MB <ul><li>Fully automated </li></ul><ul><li>Non-invasive </li></ul><ul><li>Continuously monitored non-radiometric system </li></ul><ul><li>Revised antibiotic supplement kit </li></ul><ul><li>Medium - modified Middlebrook 7H9 broth with supplements </li></ul>
  23. 23. BacT/ALERT 3D The first BacT/ALERT 3D 960 in India
  24. 24. BacT/ALERT MP <ul><li>10 ml Middlebrook 7H9 Broth </li></ul><ul><ul><li>BSA, Catalase </li></ul></ul><ul><li>Decontaminated clinical specimen and sterile body fluid specimen (other than blood) </li></ul><ul><li>MB/BacT Antibiotic Supplement Kit </li></ul><ul><ul><li>Ampho B, Azlocillin, NA, Polymyxin B, Trimethoprim and Va </li></ul></ul>
  25. 25. BacT/ALERT MB <ul><li>30 ml Middlebrook 7H9 Broth </li></ul><ul><ul><li>SPS, Glycerol </li></ul></ul><ul><li>For blood and sterile body fluids </li></ul><ul><li>Direct inoculation </li></ul><ul><li>No processing </li></ul>
  26. 26. BacT/ALERT 3D MB <ul><li>CO 2 released by mycobacteria detected by sensor </li></ul><ul><li>Colour changes - increase in reflectance units </li></ul><ul><li>Positive broth - 10 6 -10 7 orgs/ml </li></ul><ul><ul><li>Higher biomass - direct inoculation of identification panels & susceptibility tests </li></ul></ul>
  27. 27. Mean detection time 36.2 12.7 NTM 36.2 21 <ul><li>Smear – ve </li></ul>28.5 11.8 <ul><li>Smear + ve </li></ul>MTB Italy 1999 27.8 19.6 NTM 32.1 19.9 <ul><li>Smear – ve </li></ul>20.6 11.5 <ul><li>Smear + ve </li></ul>MTB Italy 2001 LJ ( days ) BacT/ALERT - 3D ( days )
  28. 28. SGRH Experience 21 10.45 AFB S/T 22 11.95 Mean detection time (days) LJ medium BacT/Alert 3D
  29. 29. Molecular diagnosis of TB <ul><li>DNA probes </li></ul><ul><ul><li>From cultures </li></ul></ul><ul><ul><li>Direct samples > 10,000 organisms </li></ul></ul><ul><li>rRNA probes </li></ul><ul><li>Gene amplification </li></ul><ul><ul><li>PCR </li></ul></ul><ul><ul><li>Isothermal amplification </li></ul></ul><ul><ul><ul><li>Gen-probe AMTD, NASBA , SDA (IS6110), QB replicase </li></ul></ul></ul>
  30. 30. PCR AMPLICOR M. tb test <ul><li>Uses </li></ul><ul><ul><li>Rapid diagnosis in smear negative samples </li></ul></ul><ul><ul><ul><li>65 kDA protein encoding gene </li></ul></ul></ul><ul><ul><ul><li>mpt64 gene </li></ul></ul></ul><ul><ul><li>Differentiate M. tb / NTM </li></ul></ul><ul><ul><ul><li>Species specific IS6110 </li></ul></ul></ul><ul><ul><li>Genetic markers for drug resistance </li></ul></ul><ul><ul><ul><li>Rifampicin – rpoB </li></ul></ul></ul><ul><ul><ul><li>INH – codon 315 of katG </li></ul></ul></ul><ul><li>False positives & false negatives (inhibitors) </li></ul><ul><li>Negative result cannot rule out TB & positive result is not always confirmatory </li></ul>
  31. 31. Gen-Probe – MTD test Amplified M. tb direct ( MTD ) test <ul><li>TMA - isothermal amplification of M. tb complex 16s rRNA </li></ul><ul><li>>1 billion copies of RNA amplicons; Hybridisation Protection assay (HPA); Single tube </li></ul><ul><li>Detection of amplicons with acridinium ester-labelled DNA probe </li></ul><ul><li>St – 91-95% </li></ul><ul><li>Sp - 99-100% </li></ul><ul><li>PPV - 84-100% </li></ul><ul><li>NPV - 98.4-99.6% </li></ul>
  32. 32. MTD Test Performance Smear-Positive Patients 37 87.5% 100% 100% 96.7% 7H10/7H11 39 63.6% 100% 100% 87.5% LJ 39 87.5% 100% 100% 96.9% BACTEC 39 87.5% 100% 100% 96.9% MTD Number of Patients NPV PPV Specificity Sensitivity  
  33. 33. MTD Test Performance Smear-Negative Patients Number of Patients NPV PPV Specificity Sensitivity   167 93.4% 100% 100% 60% 7H10/7H11 160 95.1% 100% 100% 72% LJ 167 94.7% 100% 100% 68% BACTEC 167 95.3% 94.7% 99.3% 72% MTD
  34. 34. Evaluation of women with infertility and genital TB <ul><li>Biopsy or curettage samples from 65 women clinically suspected to have genital tuberculosis were investigated with smear microscopy, histopathology, culture, and PCR for mycobacteria </li></ul><ul><li>Of the 65 clinically suspected patients investigated </li></ul><ul><ul><li>8 were acid fast bacilli (AFB) smear positive </li></ul></ul><ul><ul><li>12 were culture positive </li></ul></ul><ul><ul><li>17 were histology positive </li></ul></ul><ul><ul><li>28 were positive by PCR </li></ul></ul><ul><li>A combination of PCR with the other available techniques is the best method of achieving sufficient sensitivity and specificity for the diagnosis of female genital tuberculosis </li></ul>J Obstet Gynecol India 2006, Vol. 56, No. 5: 423-426
  35. 35. Improved diagnostic value of PCR in the diagnosis of FGTB leading to infertility <ul><li>Double-blind study; 25 women suffering from infertility </li></ul><ul><li>61 samples, consisting of EAs, EBs and fluid from POD </li></ul><ul><li>PCR - mpt64 gene of Mycobacterium tuberculosis 14 out of 25 patients (56.0 %) compared to 1 smear with acid-fast bacilli (1.6%) and 2 culture-positive samples (3.2 %) </li></ul><ul><li>53.3%of EBs, 47.6% of EAs and 16% of POD fluid samples </li></ul><ul><li>All patients with laparoscopy suggestive of tuberculosis 60% of those with a probable diagnosis and 33% of those with incidental findings, were positive by PCR 1 EA sample from an infertile patient with normal laparoscopy was also positive </li></ul><ul><li>Multiple sampling from different sites and amplification of the mpt64 gene segment by PCR offered increased sensitivity in determining tuberculous aetiology in female infertility </li></ul>Journal of Medical Microbiology (2005), 54, 927–931
  36. 36. Meta-analyses / systematic review Accuracy of NAA test for TB <ul><li>> 40 studies; Pulm & extrapul TB </li></ul><ul><li>Commercial tests </li></ul><ul><li>High Specificity; St lower / variable </li></ul><ul><li>NAA to be done in conjunction with smears / cultures </li></ul><ul><li>Clinical value depends on pretest probability </li></ul>J Clin Microbiol 2003; 41: 5355-65
  37. 37. Accuprobe <ul><li>Gen-probe’s culture identification tests </li></ul><ul><li>Definitive identification of common mycobacteria </li></ul><ul><li>Specificity of DNA probe / convenience/speed of HPA </li></ul>99.0% 99.2% Mycobacterium tuberculosis complex 100% 92.8% Mycobacterium kansasii 99.7% 98.8% Mycobacterium gordonae 100% 99.9% Mycobacterium avium complex 100% 100% Mycobacterium intracellulare 100% 99.3% Mycobacterium avium Specificity Sensitivity Mycobacterial Identification
  38. 38. AccuProbe tests <ul><li>Based on hybridisation of nucleic acids </li></ul><ul><li>4 steps </li></ul><ul><ul><li>Sample preparation </li></ul></ul><ul><ul><li>Hybridisation </li></ul></ul><ul><ul><li>Selection of the hybrid </li></ul></ul><ul><ul><li>Detection of the hybrid </li></ul></ul>
  39. 40. FASTPlaque TB <ul><li>Mycobacteriophage detection system </li></ul><ul><li>M. smegmatis lytic cycle: 90 mins </li></ul><ul><li>Not expensive; safe </li></ul><ul><li>Viable bacilli, intact phage receptors </li></ul><ul><li>Affected by effective ATT – monitor trt success </li></ul><ul><li>Phage inhibitory substances </li></ul><ul><li>Analytical ST: 100-300 bacilli/ml </li></ul><ul><li>Mixed results </li></ul><ul><ul><li>Good sp (96-99%) </li></ul></ul><ul><ul><li>Less st (70-87%) </li></ul></ul>
  40. 41. Diagnosis of TB SGRH Microbiology <ul><li>Microscopy SGRH charges (NH/PvtOPD) </li></ul><ul><ul><li>ZN 170 </li></ul></ul><ul><ul><li>DF (Auramine-Rhodamine) 500 </li></ul></ul><ul><li>Culture, Identification & Sensitivity </li></ul><ul><ul><li>AFB Culture (manual)/ST 900 </li></ul></ul><ul><ul><li>AFB Culture (automated - BacT/ALERT-3D) MB3DNAI </li></ul></ul><ul><ul><li>Accuprobe nil </li></ul></ul><ul><li>NAA </li></ul><ul><ul><li>NASBA - </li></ul></ul><ul><ul><li>Gen-probe – TMA 2000 </li></ul></ul><ul><li>Serology / Mantoux / QFT-G 1200 / 80 / 2500 </li></ul><ul><li>3DNAI – DF, rapid culture, NA Id and ST 2200 </li></ul>
  41. 43. Thank you
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