Bronchial wash Gene Xpert MTB/RIF in lower lung field tuberculosis: Sensitive, superior, and rapid in comparison with conventional diagnostic techniques

BackgroundLower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB.Materials and MethodsThe prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test.ResultsIn the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P< 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P< 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P< 0.00001).ConclusionLLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.

9 The Bone Bed(Lam)

The Bone Bed was composed of the skeletons, parts of skeletons, and isolated bones, of about 190 bison (Fig. 1). During our excavations, we recorded a total of 143 skulls. While Olsen and Chubbuck kept no record during their excavations, they estimate that they found about 50 skulls, a figure which appears reasonable in view of the volume they dug and the area in which their excavations were centered. Hence the suggested total of about 190 animals.Five hundred three bone units were recorded during our 2 seasons of excavation at the Olsen-Chubbuck site (Table 1). A proportionate number of units must also have occurred in that part of the site dug by Olsen and Chubbuck, so that, using the ratio estimated above, somewhere near 670 units probably comprised the total bone bed.As previously explained (see Recording), each articulated skeleton or segment of a skeleton was recorded as a single unit. In addition, skulls were also recorded as units. We did this because, from early in our first season of excavation, we believed that most, if not all, such articulated segments represented those parts that had been cut off by the Indians during the butchering. That is to say, that the Indians followed a fairly standard procedure in cutting up a bison, and that when the meat had been removed, the bones were discarded, still held together by sinews. We believed that an analysis of such units would provide direct information on the butchering techniques of the Indians, on the selection of choice parts, and perhaps on the use made of the parts. To a large extent, these hypotheses have been validated.

The Bacteriological Examination of Surface Wells

1. Numerical counts on gelatin media are of very limited value for surface well examinations and are quite useless for open draw-wells. The blood-heat enumeration is of use, but still of but limited value.2. The influence of rainfall and local conditions generally is marked for this class of waters with regard to their bacterial content.Whether the well is uncovered, or covered and provided with a pump has a very important influence upon the bacteriological results. For a good many wells which show very bad bacteriological findings the cause of pollution is frequently due to surface pollution rather than to pollution of the ground water through the soil. If these wells are properly protected they will become suitable sources of drinking supply.3. The results obtained confirm the value of B. coli and streptococci estimations as the best tests by which to judge the freedom from pollution of such waters.The streptococci results are of great value, only second in importance to the B. coli determinations. In numerical distribution these two organisms closely agree. The presence of streptococci is more reliable as evidence to deduce pollution than their absence is to exclude it.4. An opinion regarding the freedom of surface wells from pollution is best formed on the basis of combined topographical and bacteriological investigation.5. Inspection alone is frequently quite insufficient for the purpose of determining if a well is contaminated and if it should be closed.Of the 50 wells examined no less than 31 had to be classed as doubtful (Series C), topographical examination alone affording insufficient data for the expression of a decided opinion.In view of the fact that pure water supplies are not easy to obtain in many rural districts, a water supply, which may have been in use for many years, cannot be condemned in the absence of clear evidence that it is unsatisfactory and dangerous.6. In surface well waters a large proportion of the coli-like organisms isolated are atypical in one or more particulars.7. Typical B. coli implanted into soil showed some alteration of character, but the changes were not extensive and no evidence was obtained that the widely aberrant organisms met with in different soils and waters ever represent typical B. coli altered by unfavourable environment.8. Organisms closely allied to B. coli, but differing in one or more characters, possess significance as indicators of faecal contamination.The more nearly the organism isolated resembles an “excretal” B. coli the greater is its significance as an indicator of pollution. Consequently the fewer the number required to condemn a sample water in which they occur. Stated as a working proposition, the more the characters of the coli-like organisms deviate from that which for convenience may be spoken of as the typical form, the greater the proportionate number of them required to condemn the water.9. The presence of ‘excretal’ B. coli in 10 c.c. or less of a surface well water points to undesirable pollution and is sufficient to condemn the water.