背景:心包积液是心包腔中液体的积聚。在结核病(TB)负荷高的国家,TB是心包积液的最常见原因。1-2%的肺结核患者在全世界发展为心包结核。耐多药(MDR)结核病,包括肺外结核(EPTB)病例,数量在上升。腺苷脱氨酶(ADA)是淋巴细胞和骨髓细胞中的一种酶,在体内具有一定的免疫功能。在炎症条件下ADA水平升高,像胸膜,心包,或关节积液,细菌病因,肉芽肿状况,肿瘤,和自身免疫性疾病。TB是涉及ADA水平升高的疾病的唯一淋巴细胞增多症。MDREPTB很罕见,但是案件在增加,结核性心包积液就是这样一个例子。因此,重要的是要知道可以通过基于盒的核酸扩增测试(CBNAAT)识别的培养物检测到的病例百分比,他们的抵抗模式,并识别像ADA这样的潜在标记,这可以帮助早期识别病例。本研究的目的是鉴定培养物中的结核分枝杆菌(MTB),并将它们与基于药筒的核酸扩增测试(CBNAAT)结果及其耐药性相关联,心包结核性积液,并确定腺苷脱氨酶(ADA)水平是否可以用作心包液中MTB存在的预测指标。
方法:我们招募了52例中度至重度结核性心包积液患者,基于心包液分析,CBNAAT,和文化方法,2021年1月至2021年12月。
结果:患者的平均年龄为41.85+17.88岁,中位数为38岁。男性占患者总数的57.7%。在CBNAAT评估中,16例(30.8%)患者检测到MTB。14例(87.5%)CBNAAT阳性结核病患者对利福平敏感,而其余2例(12.5%)对CBNAAT的利福平耐药。发现MTB在8种(15.38%)药物敏感性测试培养物中生长。在这8个中,6个对一线药物敏感,而2对异烟肼和利福平均有抗性。发现咳嗽的存在在CBNAAT检测到的MTB阳性和阴性患者之间有显着差异(p=0.020),而对于高血压的存在,发现了微不足道的差异,糖尿病,肥胖,呼吸困难,或发烧。Tuberculin皮肤试验阳性的患者人数之间也有无足轻重的差异,两组之间。在MTB检测到的CBNAAT组中,ADA显着升高(85.9137.60U/Lvs39.7824.31U/L,p=0.005),而白细胞总数,淋巴细胞,中性粒细胞,随机血糖水平,与血清蛋白水平无显著差异。接收器操作曲线下的面积(CBNAAT阳性:因变量;ADA:测试结果变量)为0.854(原假设被拒绝),标准误差为0.078。
结论:培养是诊断结核病的金标准方法。在心包液培养中检测MTB是非常罕见的,虽然在我们的研究中,16%的患者出现文化阳性,4%对利福平和异烟肼耐药。心包液中较高的ADA水平是结核性心包积液的指标。
BACKGROUND: Pericardial effusion is the accumulation of fluid in the pericardial cavity. In nations with high tuberculosis (TB) load, TB is the most common cause of pericardial effusion. 1-2% of patients with pulmonary TB develop Pericardial TB worldwide. Multi-drug-resistant (MDR) TB, including extrapulmonary TB (EPTB) cases, are rising in number. Adenosine Deaminase (ADA) is an enzyme in lymphocytes and myeloid cells, which has certain immune functions in the body. ADA levels are increased in inflammatory conditions, like pleural, pericardial, or joint effusions, of bacterial etiology, granulomatous conditions, neoplasms, and autoimmune pathologies. TB is the only lymphocytosis involving disease with increased ADA levels. MDR EPTB is rare, but cases are on the rise, and tuberculous pericardial effusion is one such example. Hence, it is important to know the percentage of cases detected by a culture that can be identified by cartridge-based nucleic acid amplification test (CBNAAT), their resistance patterns, and to identify potential markers like ADA, which can help in early identification of cases. The objectives of this study were to identify the Mycobacterium tuberculosis (MTB) bacilli in culture, and correlate them with cartridge-based nucleic acid amplification test (CBNAAT) results and their drug-resistance, in the Pericardial tubercular effusion, and to find if Adenosine Deaminase (ADA) levels can be used as a predictor of the presence of MTB in pericardial fluid.
METHODS: We enrolled 52 patients with moderate to large tuberculous pericardial effusion, based on pericardial fluid analysis, CBNAAT, and culture methods, between January 2021 and December 2021.
RESULTS: The mean age of the patients was 41.85 + 17.88 years, with a median of 38 years. Males made up 57.7% of the total patients. MTB was detected in 16 (30.8%) patients in the CBNAAT evaluations. 14 (87.5%) of the CBNAAT-positive TB patients were sensitive to Rifampicin, whereas the remaining 2 (12.5%) were resistant to Rifampicin on CBNAAT. MTB was found to be growing in 8 (15.38%) drug sensitivity test cultures. Out of these 8, 6 were sensitive to first-line drugs, whereas 2 were resistant to both Isoniazid and Rifampicin. The presence of cough was found to have a significant difference between CBNAAT-detected MTB positive and negative patients (p = 0.020), whereas an insignificant difference was found for the presence of hypertension, diabetes mellitus, obesity, dyspnea, or fever. There was also an insignificant difference between the number of patients positive for the Tuberculin skin test, between the two groups. ADA was significantly higher in the MTB-detected CBNAAT group (85.91 + 37.60U/L vs 39.78 + 24.31U/L, p = 0.005), whereas the total leukocyte count, lymphocytes, neutrophils, random blood sugar levels, and serum protein levels had no significant difference. The area under the Receiver Operator Curve (CBNAAT positive: dependent variable; ADA: test result variable) was 0.854 (null hypothesis rejected), with a standard error of 0.078.
CONCLUSIONS: Culture is the gold standard method to diagnose tuberculosis. Detection of MTB on pericardial fluid culture is very uncommon, though in our study, culture came out positive in 16% of patients, and 4% were resistant to rifampicin and isoniazid. Higher ADA levels in pericardial fluid are an indicator of tuberculous pericardial effusion.