Tuberkulosis

1. Strategy to Diagnose
Difficult Case of Tuberculosis
Heni Retnowulan
Pulmonary Division, Internal Medicine Departement
Medicine Faculty, Sardjito Hospital
Gadjah Mada University, Yogyakarta

2. Subtitle
• Diagnostic Approach Testing For Suspected Pulmonary TB
• Diagnostic Approach Testing For Suspected Extrapulmonary
TB
• Other Test

3. DIAGNOSTIC APPROACH
TESTING FOR SUSPECTED PULMONARY TB

4. AFB smear microscopy
Recommendation
It is highy recommended that AFB smear microscopy
be performed, rather than no AFB smear microscopy, in all
patients suspected of having pulmonary TB (strong
recommendation, moderate-quality evidence)
(Lewinsohn et al, 2017)

5. Liquid and solid mycobacterial cultures
Recommendation
Both liquid and solid mycobacterial cultures be
performed, for every specimen obtained from an
individual with suspected TB disease (conditional
recommendation, low-quality evidence)
(Lewinsohn et al, 2017)

6. Nucleic acid amplification test
(NAAT-TB)
Recommendation
It is suggested performing a diagnostic NAAT, rather
than not performing a NAAT, on the initial respiratory
specimen from patients suspected of having
pulmonary TB conditional recommendation, low-
quality evidence).
(Lewinsohn et al, 2017)

7. Nucleic acid amplification test,
resistance markers (NAAT-R)
Recommendation
• It is recommended to perform rapid molecular DST for rifampin
with or without isoniazid using the respiratory specimens of
persons who are either AFB smear positive or Hologic Amplified
MTD positive
• And anybody meet one of the following criteria: (1) have been
treated for tuberculosis in the past, (2) were born in or have lived
for at least 1 year in a foreign country with at least a moderate
tuberculosis incidence (≥20 per 100 000) or a high primary MDR-
TB prevalence (≥2%), (3) are in contacts with MDR-TB patients, or
(4) are HIV infected (strong recommendation, moderate-quality
evidence).
(Lewinsohn et al, 2017)

8. Sputum induction
or
Flexible bronchoscopic sampling?
Recommendation
• It is suggested doing sputum induction rather than flexible
bronchoscopic sampling as the initial respiratory sampling method for
adults with suspected pulmonary TB who are either unable to
expectorate sputum or whose expectorated sputum is AFB smear
microscopy negative (conditional recommendation, low-quality
evidence).
(Lewinsohn et al, 2017)

9. Flexible bronchoscopic sampling
Recommendation
• It is suggested having flexible bronchoscopic sampling, rather than no
bronchoscopic sampling, in adults with suspected pulmonary TB from
whom a respiratory sample cannot be obtained via induced sputum
(conditional recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

10. Postbronchoscopy Sputum Specimens
Recommendation
• It is suggested that postbronchoscopy sputum specimens
be collected from all adults with suspected pulmonary TB
who undergo bronchoscopy (conditional recommendation,
low-quality evidence).
(Lewinsohn et al, 2017)

11. Flexible bronchoscopic sampling be performed
in adults with suspected miliary TB
Recommendation
• It is suggested having flexible bronchoscopic sampling, rather than no
bronchoscopic sampling, for adults with suspected miliary TB and no
alternative lesions that are accessible for sampling , whose induced
sputum is AFB smear microscopy negative or from whom a
respiratory sample cannot be obtained via induced sputum
(conditional recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

12. DIAGNOSTIC APPROACH
TESTING FOR SUSPECTED EXTRAPULMONARY TB

13. Cell counts and chemistries
Recommendation
• It is suggested that cell counts and chemistries be
performed on affordable fluid specimens collected from
sites of suspected extrapulmonary TB (conditional
recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

14. Adenosine deaminase (ADA) and free IFN-γ
Recommendation
• It is suggested that ADA levels be measured, rather than not
measured, on fluid collected from patients with suspected pleural
TB, meningitis TB, peritoneal TB, or pericardial TB (conditional
recommendation, low-quality evidence).
• It is suggested that free IFN-γ levels be measured, rather than not
measured, on fluid collected from patients with suspected pleural
TB or peritoneal TB (conditional recommendation, low-quality
evidence).
(Lewinsohn et al, 2017)

15. AFB smear microscopy
Recommendation
It is suggested that AFB smear microscopy be performed,
rather than not performed, on specimens collected from
sites of suspected extrapulmonary TB (conditional
recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

16. Mycobacterial cultures
Recommendation
It is suggested that mycobacterial cultures be performed,
rather than not performed, on specimens collected from
sites of suspected extrapulmonary TB (strong
recommendation, low-quality evidence
(Lewinsohn et al, 2017)

17. NAAT
Recommendation
• It is suggested that NAAT be performed, rather than
not performed, on specimens collected from sites of
suspected extrapulmonary TB (conditional
recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

18. Histological examination
Recommendation
It is suggested that histological examination be performed,
rather than not performed, on specimens collected from sites
of suspected extrapulmonary TB (conditional
recommendation, very low-quality evidence).
(Lewinsohn et al, 2017)

19. Other Tests

20. Ag 85B
• A study to evaluate the predictive role of M. tuberculosis Ag 85 complex
by a sensitive and specific indirect ELISA as diagnostic tools for
pulmonary tuberculosis (PTB).
• Index test
TB Ag 85 complex by a sensitive and specific indirect ELISA > 0.18
• Reference standard
sputum smear for AFB
sputum for MTB cuture (LJ)

21. Box plot demonstrating Ag 85 complex in sera from confirmed
and clinically diagnosed TB patients, non-TB disease
patients and healthy control group.

22. Ag 85 complex in sera from tuberculosis and
non-tuberculosis patients by indirect ELISA
#
*
# p < 0.001, TB group vs Nob TB group
* p < 0.001 confirmed TB vs Clinically diagnosed
Sn 82% Sp 86%
PLR 5.86 NLR 0.21
(Kashyap et al, 2007)

23. Ag 85 complex in sera from tuberculosis and
non-tuberculosis patients by indirect ELISA
#
*
# p < 0.001, TB group vs Nob TB group
* p < 0.001 confirmed TB vs Clinically diagnosed
Sn 82% Sp 86%
PLR 5.86 NLR 0.21
(Kashyap et al, 2007)

24. The MicroRNA
• A study to identify miRNA profiles associated with the different
phases of M. tuberculosis infection (PTB, EPTB, LTBI), and non-
tubercular lung infection
• Index test serum miRNA
• Reference standard
PTB, PTB-HIV sputum smear for AFB
xpert
sputum for MTB culture
LTBI, OPI, Healthy IGRA
TST

25. Summary of candidate serum miRNAs selected
as relevant to discriminate among the categories

26. Summary of putative serum miRNA signatures discriminating
among relevant clinical categories

27. Twenty miRNAs
resulted to be significantly different between H and PTB
• miR-10b
• miR-127-5p
• miR-146a
• miR-148a
• miR-16,
• miR-185
• miR-192
• miR-193a-5p
• miR-25
• miR-365
• miR-451
• miR-518d-3p
• miR-532-5p
• miR-590-5p
• miR-660
• miR-885-5p
• miR-223
• miR-30a
• miR-30e

28. The MicroRNA
• A study to identifying miRNA profiles associated with
the different phases of M. tuberculosis infection
(PTB, EPTB, LTBI), and non-tubercular lung infection
• Sn 72.22 % Sp 88.89%
• PLR 6.5 NLR 0.3125
• Accuracy 80.56 %
(Miotto et al, 2013)

29. Serum Protein Profiling
m/z 4821.45
• A study to evaluate the serum protein profiling by using SELDI
as daagnostic tools for pumonary TB
• Index test protein profiling (SELDI-TOF MS)
• Reference standard  SPPTB, SNPTB, non-TB
sputum AFB
sputum PCR
sputum MTB culture (liquid)

30. SELDI analysis for sera proteomic patterm
(the m/z 4792 and the m/z 4821)

33. Serum Protein Profiling
m/z 4821.45
• A study to screen sera biomarker, establish respective diagnostic
models for identifyng them with SELDI and explore their potential
value in the early diagnosis of SNPTB.
SPPTB and SNPTB vs non-TB controls
• Sn 86.36% Sp 85.71%
• PLR 6.04 NLR 0.16
• Accuracy 85.94%
(Liu et al, 2010)

34. The Serum Protein Profiling
(serum amyloid A protein, transthyretin, neoptherin, CRP)
• A study to evaluate the proteomic finger printing as diagnostic
tools for pulmonary tuberculosis (PTB).
• Index test
serum amyloid A protein
transthyretin
neoptherin
CRP
• Reference standard
sputum for MTB culture (liquid)

35. Performance of SVM classifiers
based on subsets of peak clusters
1g=transthyretin.
2g=CRP.
3g=neopterin.
4g=SAA
Sn 81% Sp 88%
PLR 6.75 NLR 0.21
Accuracy 85.94%
(Fernadez Reyes, et al 2006)

36. Performance of SVM classifiers
based on subsets of peak clusters
1g=transthyretin.
2g=CRP.
3g=neopterin.
4g=SAA
Sn 81% Sp 88%
PLR 6.75 NLR 0.21
Accuracy 85.94%
(Fernadez Reyes, et al 2006)

37. The Volatile Organic Compounds in breath
(VOCs)
• A study to evaluate the mass spectrometric serum profiling
as diagnostic tools for pulmonary tuberculosis (PTB).
• Index test Volatile Organic Compounds
• Reference standard
sputum induction or BAL for AFB
sputum induction or BAL for MTB cuture (liquid)

38. The Volatile Organic Compounds in breath
(VOCs)
Sn 84% Sp 64.7%
PLR 2.3 NLR 0.24
Accuracy 85%,
(Phillips et al, 2010)
■
■

39. Ca 125
• A study to evaluate the predictive role of serum CA125 as
diagnostic tools for pulmonary tuberculosis (PTB).
• Index test Ca 125
• Reference standard
Sputum smear
Xpert
Mycobactrium culture

40. Ca 125
• ROC 0.966 (95% CI 0.951-0.981)
• Cut off point is 10.30
• Sn 95.6% Sp 85.0%
• PLR 6.37 NLR 0.052
Jingjing etal (2016)

41. The C-Reactive Protein
(CRP)
A systematic review to determine whether CRP is an adequate
screening test for pulmonary TB
5 studies (1723 patients)
Index test CRP > 10 mg/ L
Reference standard
Mycobacterial culture (LJ and or MGT)
Clinical criteria

42. Diagnostic accuracy of CRP
for pulmonary tuberculosis among outpatients
Pooled sensitivity 93% (95% CI: 85–97); test for heterogeneity I2 = 39%, p=0.16
Pooled specificity 62% (95% CI: 42–79); test for heterogeneity I2 = 96%,
p<0.0001
Sn 93% Sp 62%
PLR 2.44 NLR 0.11

43. Diagnostic accuracy of CRP
for pulmonary tuberculosis among ambulatory
patients with confirmed HIV infection
Pooled sensitivity 93% (95% CI: 85–97); test for heterogeneity I2 = 40%, p=0.16
Pooled specificity 64% (95% CI: 42–81); test for heterogeneity I2 = 96%,
p<0.0001
Sn 93% Sp 64%
PLR 2.58 NLR 0.11

44. TB HIV seronegative
• Sn 93% Sp 62%
• PLR 2.44 NLR 0.11
TB HIV seropositive
• Sn 93% Sp 64%
• PLR 2.58 NLR 0.11
(Yoon et al, 2017)
C -Reactive Protein

45. TB HIV seronegative
• Sn 93% Sp 62%
• PLR 2.44 NLR 0.11
TB HIV seropositive
• Sn 93% Sp 64%
• PLR 2.58 NLR 0.11
(Yoon et al, 2017)
C -Reactive Protein

46. TB HIV seronegative
• Sn 93% Sp 62%
• PLR 2.44 NLR 0.11
TB HIV seropositive
• Sn 93% Sp 64%
• PLR 2.58 NLR 0.11
(Yoon et al, 2017)
C -Reactive Protein

47. similar
TB HIV seronegative
• Sn 93% Sp 62%
• PLR 2.44 NLR 0.11
TB HIV seropositive
• Sn 93% Sp 64%
• PLR 2.58 NLR 0.11
(Yoon et al, 2017)
C -Reactive Protein

48. Conclusion
• Diagnostic Approach Testing For Suspected Pulmonary TB
• Diagnostic Approach Testing For Suspected Extrapulmonary
TB
• Other Test