Design and protocol for a cluster randomised trial of enhanced diagnostics for tuberculosis screening among people living with HIV in hospital in Malawi (CASTLE study)

Background People living with HIV (PLHIV) have a high risk of death if hospitalised in low-income countries. Tuberculosis has long been the leading cause of admission and death, in part due to suboptimal diagnostics. Two promising new diagnostic tools are digital chest Xray with computer-aided diagnosis (DCXR-CAD) and urine testing with Fujifilm SILVAMP LAM (FujiLAM). Neither test has been rigorously evaluated among inpatients. Test characteristics may be complementary, with FujiLAM especially sensitive for disseminated tuberculosis and DCXR-CAD especially sensitive for pulmonary tuberculosis, making combined interventions of interest. Design and methods An exploratory unblinded, single site, two-arm cluster randomised controlled trial, with day of admission as the unit of randomisation. A third, smaller, integrated cohort arm (4:4:1 random allocation) contributes to understanding case-mix, but not trial outcomes. Participants are adults living with HIV not currently on TB treatment. The intervention (DCXR-CAD plus urine FujiLAM plus usual care) is compared to usual care alone. The primary outcome is proportion of participants started on tuberculosis treatment by day 56, with secondary outcomes of mortality (time to event) measured to to 56 days from enrolment, proportions with undiagnosed tuberculosis at death or hospital discharge and comparing proportions with enrolment-day tuberculosis treatment initiation. Discussion Both DCXR-CAD and FujiLAM have potential clinical utility and may have complementary diagnostic performance. To our knowledge, this is the first randomised trial to evaluate these tests among hospitalised PLHIV.

Warty cutaneous tuberculosis of the nose: A rare localization

Cutaneous tuberculosis is a rare, extra-pulmonary form of tuberculosis caused by mycobacteria of the tuberculosis complex. It is characterized by clinical polymorphism often posing a difficult diagnostic challenge. Herein, we report a case of cutaneous tuberculosis in its warty form located on the nose. This was a 57-year-old patient who was infected in the classroom three months previously while taking lessons from a woman with pulmonary tuberculosis. A facial examination revealed a blackish, papillomatous patch invading almost the entire nose, with a keratotic surface spreading over the wings of the nose. The diagnosis of verrucous tuberculosis was reached on the basis of epidemiological, clinical, and paraclinical arguments. Under anti-tuberculosis treatment for six months, the lesion had healed without sequelae. The diagnosis of verrucous cutaneous tuberculosis must be established in the presence of any chronic and crusty lesion. The management responds to the treatment protocol for all forms of tuberculosis.

The Prevalence of Pulmonary Aspergillosis Among Clinically Suspected and Undertreated Tuberculosis Patients in Khartoum State, Sudan

Background Respiratory tract aspergillosis is a pulmonary disease cause by aspergillus species which are opportunistic fungi that mainly infect immuno-compromised patients . Objective(s) The present study aimed to detect the frequency of pulmonary aspergillosis among clinically suspected and under follow up tuberculosis patients conducted at Tropical Diseases Teaching Hospital, Omdurman, Khartoum State , Sudan during the period from December 2019 to November 2020. Materials and Methods One hundred and fifty sputum samples were collected from suspected cases of pulmonary tuberculosis and under follow up tuberculosis patients. All specimens were examined using 20% KOH and cultured on two sets of Sabouraudʹs Dextrose agar slope media with chloramphenicol. Results Asperigillus species were isolated from 9/150 (6%) patients. They represented 5(3.3%) A.fumigatus, 3 (2%) A. niger and 1 (0.6%) A. Flavus. It was found that all Aspergillus isolates were revealed from Non acid fast bacilli (Non AFB) patients 9/137(6.6%) with the most common frequency among asymptomatic patients 3/35(8.6%) , patients who were under tuberculosis treatment (8.5%), those who were under Rifampicin (RIF) and Isonizide (INH) treatment (10%) and with duration of less than three month. Also the higher percentage (13%) was represented among the age group range from 61-80 year and slightly among males 6/97 (6.2 %) than females 3/53 (5.7%). There was statistically non-significant association between the frequency of aspergillosis and the studied variables in this study. Conclusion The frequency of pulmonary aspergillosis among patients with anti-tuberculosis treatment reflects the need for routine screening and diagnosis of those patients since the use of anti- tuberculosis treatment can promote the growth and reproduction of fungi. Keywords Pulmonary aspergillosis, tuberculosis, follow up patients.