Original articleEarly diagnosis of tuberculosis by fibreoptic bronchoscopy
Abstract
We carried out a retrospective study of the methods used to achieve an early diagnosis of 67 patients with pulmonary tuberculosis treated at our institute between 1984 and 1989.
Sputum bacteriology was positive in 56 of the 67 patients, 22 were positive on microscopical examination of smears and on culture and 34 on culture alone. The 11 patients with negative sputum bacteriology were all diagnosed by fibreoptic bronchoscopy. In addition, 21 of the 34 smear-negative/culture-positive patients were examined by fibreoptic bronchoscopy and the initial diagnosis was made in 7 of these. Thus the initial diagnosis was made by sputum bacteriology in 49 cases and by fibreoptic bronchoscopy in 18 cases.
The median number of days between obtaining a specimen and starting therapy was 7 days for sputum microscopy, 41 days for sputum culture, 7 days for microscopic examination of bronchoscopy specimens, 51 days for culture of the same and 19 days for biopsy.
Fibreoptic bronchoscopy is therefore useful for the diagnosis of cases of tuberculosis in which tubercle bacilli are not detected in sputum and, in some instances, for an earlier diagnosis of smear-negative/culture-positive patients.
Résumé
Une étude rétrospective (1984–1989) portant sur les méthodes utilisées pour un diagnostic précoce chez 67 patients atteints de tuberculose pulmonaire a été effectuée dans l'institut de medicine interne de la Showa Université School of Medicine (Tokyo), où ils avaient été traités. La bactériologie des crachats était positive dans 56 des 67 malades, dont 22 étaient positifs sur examen direct des frottis sous microscope et à la culture, et 34 seulement à la culture. Les 11 malades dont la bactériologie était négative étaient tous diagnostiqués grâce à la broncho-fibroscopie. De plus, 21 des 34 cas négatifs à la bacilloscopie mais positifs à la culture ont été examinés par broncho-fibroscopie, et le diagnostic initial a été fait dans 7 de ces cas. Ainsi le diagnostic initial a été fait par une bactériologie des crachats dans 49 cas et par une broncho-fibroscopie dans 18 cas. Les délais moyens entre l'obtention d'un échantillon et le début du traitement ont été de 7 jours pour la microscopie des crachats, de 41 jours pour la culture des crachats, de 7 jours pour l'examen sous microscope des échantillons de bronchoscopie, de 51 jours pour leur culture, et de 19 jours pour la biopsie. La bronchofibroscopie est donc utile pour le diagnostic des cas de tuberculose où les bacilles tuberculeux ne sont pas mis en évidence dans les crachats et, dans certains des cas, pour un diagnostic plus rapide des malades négatifs à l'examen direct mais positifs à la culture.
Resumen
Llevamos a cabo un estudio retrospectivo de los métodos utilizados para obtener un diagnóstico precoz de 67 pacientes con tuberculosis pulmonar tratados en nuestro Instituto entre 1984 y 1989.
La bacteriología del esputo era positiva en 56 de los 67 pacientes; 22 presentaban una positividad tanto de los frotis como de los cultivos, en tanto que 34 tenían exclusivamente un cultivo positivo. Los 11 pacientes con bacteriologia de esputo negativa fueron diagnosticados mediante broncoscopía en fibra óptica. Además, 21 de 34 pacientes con baciloscopia negativa, pero cultivo positivo, fueron examinados mediante broncoscopía en fibra óptica, efectuándose en 7 de ellos el diagnóstico inicial. De esta forma, en 49 casos el diagnóstico inicial se obtuvo gracias a la bacteriología de esputo y en 18 casos gracias a la broncoscopía en fibra óptica.
La mediana del número de días transcurridos entre la obtención de la muestra y el comienzo del tratamiento fue de 7 dias para la baciloscopia, de 41 días para el cultivo de esputo, de 7 días para el examen microscópico de las muestras broncoscópicas, de 51 días para el cultivo de las mismas y de 19 días para la biopsia. Por tanto, la broncoscopía en flbra óptica es útil para el diagnóstico de los casos de tuberculosis en los cuales no son detectados bacilos tuberculoses en el esputo y, en algunos casos, para el diagnóstico más precoz de los pacientes con baciloscopia negativa y cultivo positivo.
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Cited by (30)
The diagnosis of tuberculosis
2005, Clinics in Chest MedicineAdequately washed bronchoscope does not induce false-positive amplification tests on bronchial aspirates in the diagnosis of pulmonary tuberculosis
2002, ChestCitation Excerpt :However, even these amplification techniques are relatively insensitive in smear-negative pulmonary tuberculosis.19 Therefore, because bronchoscopic procedures have increased diagnostic potential,2,20,21 some researchers have used bronchoscopic specimens for the amplification of M tuberculosis DNA in the diagnosis of tuberculosis.3 Endoscopic procedures, however, have the potential for cross-contamination of pathogens.
To investigate the clinical usefulness of amplification (COBAS AMPLICOR; Roche Diagnostics Systems; Branchburg, NJ) on bronchoscopic aspirate specimens in the diagnosis of pulmonary tuberculosis, with particular regard to the possibility of false-positive results in subsequent specimens due to residual Mycobacterium tuberculosis DNA.
A prospective clinical study at a tertiary referral medical center.
Four hundred fiberoptic bronchoscopic procedures were performed, using seven bronchoscopes on 335 consecutive patients, for therapeutic or diagnostic purposes. Serial bronchial aspirates were collected and tested for M tuberculosis, using COBAS AMPLICOR (CA). Bronchoscopes were cleaned and disinfected automatically, between patient use, by the same endoscope washer. The name of each bronchoscope and the sequence of its use were recorded, together with the sequence of washing. The CA results were compared with the bacteriologic and histologic results for M tuberculosis infection. When there was a suspicion of contamination, outward polymerase chain reaction analysis was performed.
Of 392 specimens (332 subjects), excluding the 8 specimens (4 subjects) in which bacteriologic and histologic analyses were omitted, a smear-positive result for acid-fast bacilli (AFB), culture-positive or biopsy-positive results, and CA-positive results were obtained in 16, 49, and 32 specimens, respectively. In AFB smear-positive subjects, the sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs) were 92%, 67%, 92%, and 67%, respectively. In AFB smear-negative subjects, the sensitivity, specificity, PPV, and NPV values were 38%, 99%, 74%, and 94%, respectively. The CA test was more sensitive than the AFB smears for the diagnosis of pulmonary tuberculosis (53% vs 27%, respectively; p < 0.05). False-positive CA results were seen in only six specimens. Three of these six subjects received a diagnosis of pulmonary tuberculosis on clinical and radiologic grounds, and none of the six results seemed to be associated with bronchoscopic cross-contamination.
Adequately cleaned and disinfected bronchoscopes did not cause false-positive amplification test results for M tuberculosis on bronchial aspirates by cross-contamination. Furthermore, sensitivity was greater with the CA tests. Therefore, CA tests on bronchial aspirates seem to be useful in the diagnosis of pulmonary tuberculosis.
Role of bronchoscopy in AIDS
1999, Clinics in Chest MedicineInfection with human immunodeficiency virus (HIV) is considered to be the most important public health problem of the twentieth century. HIV-associated respiratory tract infections, including tuberculosis and bacterial pneumonia, are the most important causes of morbidity and mortality in AIDS in the world, and Pneumocystis carinii pneumonia (PCP) is the most common AIDS-defining opportunistic infection in the United States. Many infectious, neoplastic, and other disorders have been linked with HIV infection. A list of HIV-associated respiratory disorders follows:
Bacterial Infections
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Pseudomonas aeruginosa
Staphylococcus aureus
Moraxella catarrhalis
Rhodococcus equi
Mycobacterium tuberculosis
Mycobacterium avium-intracellulare
Other nontuberculous mycobacteria
Protozoal Infections
Pneumocystis carinii (fungus?)
Strongyloides stercoralis
Toxoplasma gondii
Viral infections
Cytomegalovirus
Adenovirus
Herpes simplex
Measles
Fungal infections
Cryptococcus neoformans
Histoplasma capsulatum
Aspergillus fumigatus
Coccidioides immitis
Blastomyces dermatitides
Malignancies
Kaposi's sarcoma
Non-Hodgkin's lymphoma
Carcinoma of the lung
Other Disorders
Sinusitis
Bronchitis/bronchiectasis
Lymphocytic interstitial pneumonitis
Nonspecific interstitial pneumonitis
Bronchiolitis obliterans organizing pneumonia
Primary pulmonary hypertension
The risk of developing each of these disorders is influenced by genetic factors, place of residence, route of transmission of HIV, prior infections, severity of immunosuppression, and use of prophylactic and antiretroviral medications.1, 19, 27, 33, 46, 71
Since the beginning of the AIDS epidemic, flexible bronchoscopy (FB) has been invaluable in the diagnosis of these disorders. Rigorous assessment of the diagnostic usefulness of bronchoscopy in HIV-infected patients is difficult because large studies comparing the yield of bronchoscopic procedures with the gold standard of open lung biopsy (OLB) or autopsy are lacking; most patients with nondiagnostic bronchoscopic procedures are treated empirically. Nevertheless, a wealth of clinical experience supports the use of the procedure.12, 72, 75, 81
In this article, the usefulness of bronchoscopy in diagnosing the common pulmonary complications associated with HIV infection is discussed. Alternatives to bronchoscopy are briefly reviewed. The information provided is likely to help the clinician plan a diagnostic approach to pulmonary complications of HIV disease.
Rapid diagnosis of smear-negative pulmonary tuberculosis via fibreoptic bronchoscopy: Utility of polymerase chain reaction in bronchial aspirates as an adjunct to transbronchial biopsies
1998, Respiratory MedicineFibreoptic bronchoscopy was performed on 190 patients with chest radiographic lesions and negative sputum smears for acid-fast bacilli. Aside from obtaining transbronchial biopsies for histological examination, bronchial aspirate specimens were also tested for Mycobacterium tuberculosis complex DNA by a conventional polymerase chain reaction (PCR) technique. Of 177 transbronchial biopsies performed, a diagnosis was found in 64 cases [43 cases of tuberculosis (TB), 17 cases of lung carcinoma and four cases of other infective/inflammatory diseases] giving a diagnostic yield of 36·2%. PCR was positive in 105 of 108 finally diagnosed cases of TB and 22 of 82 non-TB cases. The sensitivity, specificity, positive predictive value and negative predictive value of PCR when applied to bronchial aspirate specimens for diagnosing smear-negative pulmonary TB were 97·2%, 73·2%, 82·7% and 95·2% respectively. Therefore, detection of M. tuberculosis complex DNA in bronchial aspirates by PCR might have an adjunctive place to transbronchial biopsies in the rapid diagnosis of smear-negative pulmonary tuberculosis.
The diagnosis of tuberculosis
1997, Disease-a-MonthValue of bronchoalveolar lavage and gastric lavage in the diagnosis of pulmonary tuberculosis in children
1995, Tubercle and Lung DiseaseThe diagnosis of pulmonary tuberculosis in children is based mainly on clinical and radiographic features because of the difficulty in bacteriologic confirmation.
The aim of our study was to find out if bronchoalveolar lavage (BAL) would be better than gastric lavage for the isolation of Mycobacterium tuberculosis from paediatric patients with suspected pulmonary tuberculosis.
50 children with suspected pulmonary tuberculosis at a mean age of 5.1 years (range 7 months to 12 years) were studied. Early morning gastric lavage was collected. Flexible bronchoscopy and bronchoalveolar lavage was performed under local anaesthesia after obtaining informed consent from the parents. The BAL fluid and gastric lavage specimens were subjected to smear examination for acid-fast bacilli (AFB) and culture for mycobacteria using established methods.
Of the 50 cases, M. tuberculosis was grown in 6 BAL samples (12%) and 16 gastric lavage samples (32%) making a total of 17 culture proven cases (34%). Out of the 6 BAL positive cases, gastric lavage was also positive in 5 cases.
We conclude that gastric lavage is better than BAL for bacteriologic confirmation of pulmonary tuberculosis in children. The overall bacteriologic yield combining both procedures was 34% while gastric lavage alone was positive in 32% of the cases.
Le diagnostic de la tuberculose pulmonaire chez l'enfant est fondé principalement sur les aspects cliniques et radiographiques, en raison des difficultés liées à la confirmation bactériologique.
Le but de cette étude était de déterminer si le lavage bronchiolo-alvéolaire était supérieur au lavage gastrique pour l'isolement de Mycobacterium tuberculosis chez des enfants soupçonnés d'être atteints de tuberculose pulmonaire.
50 enfants soupçonnés d'être atteints de tuberculose pulmonaire et âgés de 5,1 ans en moyenne (extrêmes : 7 mois à 12 ans) ont été étudiés. Un lavage gastrique recueilli en début de matinée, et une bronchoscopie par tube flexible avec lavage bronchiolo-alvéolaire (LBA) ont été effectués sous anesthésie locale avec le consentement éclairé des parents. Les échantillons du liquide de LBA et du lavage gastrique ont été soumis à un examen des frottis pour déceler des bacilles acido-alcoolo-résistants et à une culture pour déceler des mycobactéries, à l'aide des méthodes établies.
Parmi les 50 cas, M. tuberculosis a été cultivé dans 6 échantillons provenant du LBA (12%) et dans 16 échantillons provenant du lavage gastrique (32%), soit un total de 17 cas confirmés par culture (34%). 5 des 6 cas positifs au LBA ont également été vérifiés par lavage gastrique.
Nous concluons que le lavage gastrique possède une efficacité supérieure à celle du LBA pour une confirmation bactériologique de la tuberculose pulmonaire chez l'enfant. Le rendement bactériologique combinant les deux processus était de 34%, tandis que pour le lavage gastrique seul il était de 32%.
El diagnóstico de la tuberculosis pulmonar en niños se basa principalmente en los aspectos clínicos y radiográficos, debido a las dificultades para la confirmación bacteriológica.
El propósito de nuestro estudio fue de investigar si el lavado broncoalveolar (LBA) sería mejor que el lavado gástrico para el aislamiento de Mycobacterium tuberculosis en pacientes pediátricos con sospecha de tuberculosis pulmonar.
Se estudió 50 niños con sospecha de tuberculosis pulmonar, con edad promedio de 5,1 años (extremos : 7 meses — 12 años). Se practicó un lavado gástrico en la mañana temprano. Se practicó una broncoscopía flexible y un lavado broncoalveolar bajo anestesia local, después de haber obtenido la autorización formal de los padres. Las muestras de líquido de LBA y gástrico fueron sometidas a examen directo para bacilos ácido-alcohol resistentes y cultivo de micobacterias utilizando los métodos establecidos.
De los 50 casos, M. tuberculosis se cultivó en 6 muestras de LBA (12%) y en 16 muestras de lavado gástrico (32%) haciendo un total de 17 casos confirmados por cultivo (34%). De los 6 casos con LBA positivo, el lavado gástrico también fue positivo en 5 casos.
Concluimos que el lavado gástrico es mejor que el LBA para la confirmación bacteriológica de la tuberculosis pulmonar en niños. El rendimiento bacteriológico total, combinando los dos procedimientos, fue de 34% mientras que la del lavado gástrico solo fue de 32% de los casos.