Download 165. From bench to bedside: diagnosis of tuberculosis

E-Communication Session
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M ONDAY, S EPTEMBER 14 TH 2009
165. From bench to bedside: diagnosis of
tuberculosis
E1683
New skin testing with DIASKINTEST® (recombinant protein CFP10-ESAT6)
in TB diagnosis
Ludmila Slogotskaya 1 , Vitaly Litvinov 1 , Peter Seltsovsky 1 , Alexander Shuster 2 ,
Vitaly Martyanov 2 , Alexander Demin 2 , Alexey Filippov 1 , Ludmila Stakheeva 1 ,
Yakov Kochetkov 1 . 1 Clinical Research, Scientific and Clinical Antituberculosis
Center of Moscow Government Health Department, Moscow, Russian
Federation; 2 Clinical Research, JSC “Masterklon”, Moscow, Russian Federation
The Russian JSC “Masterklon” has developed a preparation called DIASKINTEST® (DST) to detect delayed-type hypersensibility to Mycobacterium tuberculosis.
The aim of the study was to evaluate sensitivity and specificity of new skin testing
with DIASKINTEST® (DST).
345 adults and children were tested with DST.
Phase I-III of the clinical trial involved 120 subjects. Healthy controls, TB patients
and newly-infected individuals allowed simultaneous testing of DST (0.2μg/0.1
ml) and TST (2 ÒU PPD-L) in the right and left arms.
The results: Practically all TB and newly-infected patients were DST positive,
healthy controls – DST-negative, though TST positive (induration of 5.93±0.90
mm).
In phase IV 225 subjects allowed DST testing: 81 newly-detected TB cases, 27
completed TB treatment course, 19 newly-infected TB cases, 27 healthy controls,
12 cases with indeterminate process and 59 TB/AIDS cases. The results: newlydetected TB patients had induration of 14.38±0.77 mm, patients which received
treatment – 3.63±1.34 mm (p<0.001), and cured individuals were DST negative.
Newly-infected children (19) – 16.26±1.23 mm. BCG vaccinated TST positive
children were DST negative.
Out of 59 TB/AIDS cases, 38 were DST negative. The latter had 179.6±29.4
CD4 T-lymphocytes, while 21 cases with induration ≥5 mm had 448.5±65.1 these
cells (p<0.001). The CD4/CD8 ratio was 0.28±0.04 and 0.62±0.13 respectively
(p<0.005). In cases with CD4<200 negative DST reactions were more frequent
than in those with CD4>200 (82.1±7.2% and 48.4±9.0% respectively). Thus, DST
demonstrated high sensitivity and specificity in individuals without AIDS. It might
be used for TB detection, evaluation of TB activity and treatment effectiveness.
E1684
Evaluation of rapid test device based on detection of antibodies against 6,16
and 38 kDa antigens of Mycobacterium tuberculosis
Parvaneh Baghaei Shiva, Payam Tabarsi, Majid Marjani, Shokufe Dehghani,
Mohammad Reza Masjedi. Mycobacteriology Research Center, National Research
Center of Tuberculosis and Lung Disease, Tehran, Islamic Republic of Iran
Background: Serological assays for diagnosis of tuberculosis are very attractive because they are inexpensive, non invasive and simple. Present study was
conducted to evaluate the Tuberculosis rapid test device in Iran.
Methods: The tuberculosis rapid test device based on detection of IgM, IgA and
IgG antibodies against 6,16 and 38-kDa antigens of mycobacterium tuberculosis
via chromatography was used in 96 cases of pulmonary and extra pulmonary TB.
54 patients other than TB were selected as control group. Tuberculin skin test was
performed in two groups. None of patients were immune deficient. All of them
were evaluated concerning presence of BCG scar.
Results: Tuberculosis rapid test was positive in 75 patients (78.1%) from case
group and 15 from control group (27.8%). This difference was statistically meaningful (p-value < 0.001). TST was positive in 66 patients (68.8%) with tuberculosis
and 10 (18.5%) among control group without any statistically difference. (p-value
= 0.065).
Sensitivity, specificity, Positive and negative predictive value of the tuberculosis
rapid test for diagnosis of tuberculosis were 78.1%, 72.2%, 83.3% and 65%
respectively.
These parameters for TST were 31.3%, 81.5% 75% and 40% respectively.
Comparison between TST and Rapid serologic assay
TST
Rapid serologic assay
1
Sensitivity
Specificity
PPV1
NPV2
31.3%
78.1%
81.5%
72.2%
75%
83.3%
40%
65%
PPV: Positive predictive value; 2 NPV: Negative predictive value.
Conclusion: Tuberculosis rapid test has better sensitivity than TST and may be
helpful in diagnosis of tuberculosis as a complementary test or in epidemiological
investigations.
280s
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E1685
Usefulness of CT, whole-blood interferon-g assay and sputum TB-PCR in the
diagnosis of smear-negative pulmonary tuberculosis
Jae Chol Choi, Jae Yeoul Kim, In Won Park, Byoung Whui Choi, Jong
Wook Shin. Division of Pulmonary and Critical Care Medicine - Department of
Internal Medicine, Chung-Ang University School of Medicine, Seoul, Korea
Background: To diagnose sputum smear-negative pulmonary tuberculosis (PTB)
is difficult.
Aim of study: To evaluate the usefulness of clinical findings, high-resolution computed tomography (HRCT), interferon-g release assay (IGRA) and polymerase
chain reaction (PCR) of sputum in the diagnosis of smear-negative PTB.
Methods: We reviewed data of the patients who had been suspected as active PTB
with negative of AFB smear from June 2006 to September 2008. During these
periods, 178 patients were visited our institute with suspicion of having PTB. After
exclusion of smear-positive (n=77) and inconclusive diagnosis cases (n=17), we
conducted our study in 84 patients.
Results: Active PTB was diagnosed in 40 (48%) of 84 participants. Lack of
sputum and young age was significantly associated with an increase of risk of
PTB. The sensitivity of sputum PCR, IGRA and HRCT was 43.2%, 84.4% and
87.5%, respectively. The specificity of sputum PCR, IGRA and HRCT was 97.7%,
82.9% and 65.9%, respectively. Among patients who suggested as PTB by HRCT,
the 24 patients showed positive IGRA results, and 23 of them were diagnosed as
active PTB. Among patients who suggested as not-TB by HRCT, the 23 patients
showed negative result of IGRA, and 22 (96%) of them were diagnosed as not-TB.
Conclusion: Combined results of HRCT and IGRA could help decision-making
for early initiation of treatment in smear-negative patients.
E1686
Exhaled nitric oxide measurement in the diagnosis and management of
pulmonary tuberculosis
Sang-Heon Kim, Tae Hyung Kim, Jang Won Sohn, Ho Joo Yoon, Dong Ho Shin,
Sung Soo Park. Department of Internal Medicine, Hanyang University College of
Medicine, Seoul, Republic of Korea
The measurement of the fraction of NO in exhaled breath (FE NO) provides the
activity of airway inflammation and used as a marker of airway inflammation in
respiratory diseases, such as asthma. The role of measurement of FE NO in the
diagnosis and management of pulmonary tuberculosis (TB) is not well evaluated.
This study is to assess if levels of FE NO is elevated in patients with pulmonary
TB and if FE NO could be a useful biomarker of pulmonary TB. We enrolled 35
patients with newly diagnosed pulmonary TB and 121 healthy controls. Measurement of FE NO was performed at the time of diagnosis of pulmonary TB and two
months after the initiation of treatment. FE NO was measured using a NO analyzer
(NOA280i; Bouler, Co, USA) according to the recommendations by ATS and ERS.
We compared levels of FE NO between patients with pulmonary TB and healthy
controls. In patients with pulmonary TB, levels of FE NO were compared between
before treatment and at two months of treatment. The patients with pulmonary TB
showed significantly higher levels of FE NO before treatment compared to healthy
controls (35.8±18.1 versus 28.4 ± 13.5, P < 0.05). In addition, levels of FE NO
were decreased after two months of treatment (35.2±20.7 versus 27.5 ± 11.4, P
< 0.05). These findings suggest FE NO measurement could be used as a useful
marker in the diagnosis and management of pulmonary TB.
E1687
Diagnostic value of bronchoalveolar lavage (BAL) in sputum smear negative
pulmonary tuberculosis
Dorin Vancea, Adriana Socaci, Ionela Iovan, Zeno Ioan Fratila. Department of
Pneumology, Clinical Hospital “Dr.V Babes”, Timisoara, Timis, Romania
Introduction: Although the initial approach for the diagnosis of pulmonary TB
is the detection of acid-fast bacilli (AFB) in respiratory specimens (sputum or
bronchoscopic smears), there are various opinions regarding the use of fiberoptic
bronchoscopy (FOB) as a routine diagnostic technique in this disease.
Aims and objectives: To assess the bacteriological diagnostic yield of specimens
collected by FOB, in patients suspected to have pulmonary TB, whose sputum
smears were negative, in an area with a high prevalence of tuberculosis (124‰00).
Methods: FOB with BAL was performed in 74 sputum smears negative for AFB,
collected from X-ray positive pulmonary TB patients. The microbiological studies
involved Ziehl-Nielson staining and culture on Lowenstein-Jensen medium. The
BAL (AFB smear and culture) results were compared with those obtained for
sputum taken before and after FOB. Data regarding age, gender, pathological
findings on thorax imaging and endoscopy were collected.
Results: BAL smear was positive in 8 patients (10.8% of the 74 patients who
completed all tests), post-bronchoscopy sputum was positive in 9 patients (12.1%),
with a total immediate positive yield for AFB in 17 patients (23.9%). The yield for
BAL cultures was 74.3% (55 patients), better than the 51.3% (38 patients) recorded
in cultures of pre-bronchoscopy and 59.4% (44 patients) in post-bronchoscopy
sputum cultures. Non-TB conditions were diagnosed by FOB in six patients (8.1%).
Conclusions: Bronchoscopic procedures like BAL are useful for early diagnosis
of TB in nearly 1/4 of sputum smear negative patients, for confirming TB (positive
cultures in 3/4 of cases) and also for establishing diagnosis of non-TB pathology.
E1688
Characterization of regulatory T-cells identified as CD4+ CD25high CD39+ in
patients with active tuberculosis
Teresa Chiacchio 1 , Rita Casetti 2 , Ornella Butera 1 , Valentina Vanini 1 ,
Elisa Petruccioli 1 , Stefania Carrara 1 , Enrico Girardi 1 , Diletta Di Mitri 3 ,
Luca Battistini 3 , Federico Martini 2 , Giovanna Borsellino 3 , Delia Goletti 1 .
1
Translational Research Unit, Department of Epidemiology and Preclinical
Research, National Institute for Infectious Diseases Lazzaro Spallanzani, Rome,
Italy; 2 Cellular Immunology Laboratory, Department of Epidemiology and
Preclinical Research, National Institute for Infectious Diseases Lazzaro
Spallanzani, Rome, Italy; 3 Laboratory of Neuroimmunology, Santa Lucia
Foundation, Rome, Italy
Introduction: FoxP3 is a transcription factor whose expression characterizes regulatory T-cells (Treg), but it is present also on activated T-cells, thus hindering
correct Treg identification. Using classical markers for Treg recognition, discordant results were found in terms of Treg expansion during active tuberculosis
(TB) disease. Recently CD39 has been shown to be an accurate marker for Treg
detection.
Objectives of this study were: 1) to identify Treg expressing CD39 in patients with
TB and to compare the results with those obtained by the standard phenotypic
markers; 2) to evaluate if Treg are expandedin vitro by exogenous interleukin
(IL)-2 or by antigen-specific stimulation; 3) to characterize Treg function on the
modulation of antigen-specific responses.
Methods and Results: We enrolled 13 patients with pulmonary TB and 12 healthy
controls. Treg were evaluated by flow cytometry ex vivo and after antigen-specific
in vitro stimulation using CD25, FoxP3, CD127 and CD39 markers.
Results indicate that CD39+ cells within the CD4+ CD25high cells have Treg properties [absence of Interferon (IFN)-γ production and Transforming Growth Factor
(TGF)-β1 release upon stimulation]. Ex vivo analysis did not show significant differences between TB patients and controls of Treg by classical or novel markers.
In contrast, a significantly higher percentage of Treg was found in TB patients after
antigen-specific stimulation both in the presence or absence of IL-2. Depletion of
CD39+ Treg significantly increased RD1-specific responses.
Conclusions: CD39 properly identifyies Treg in TB. These results can be useful
for future studies to monitor M. tuberculosis-specific response during TB.
E1689
Loss of receptors CD27 and CCR7 on Mycobacterium tuberculosis-specific
interferon-γ producing T cells marks active tuberculosis
Johannes Nemeth 1 , Ralf-Harun Zwick 2 , Heide-Maria Winkler 1 ,
Rudolf Rumetshofer 2 , Otto C. Burghuber 2 , Stefan Winkler 1 . 1 Department of
Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical
University of Vienna, Vienna, Austria; 2 Department of Respiratory and Critical
Care Medicine, Otto Wagner Hospital, Vienna, Austria
Background: Enumeration of early secretory antigenic target (ESAT)-6 specific,
interferon (IFN)-γ expressing T cells at the site of infection accurately identifies
active tuberculosis (TB). To find additional markers for immune-diagnosis, T
cell differentiation markers CD27 and CCR7 were studied on T cells from both
peripheral blood and the site of infection of patients with suspected active TB.
Methods: 12 patients with lymphocytic exudates (10 pleural, 2 ascites) suspected
for TB were prospectively studied. Flow cytometry for intracellular detection
of IFN-γ in CD4+ T cells as well as surface receptor staining (CD27, CCR7
and CD45RO) were performed after overnight stimulation of peripheral blood
mononuclear cells and lymphocytes from the site of disease with ESAT-6.
Results: In 5 patients active TB was confirmed. As expected, TB patients were
shown to enrich MTB-specific IFN-γ expressing CD4+ T cells at the site of
infection when compared to blood (p < 0.05). No enrichment of MTB-specific
T cells was found in 7 patients with non-TB disease. Both CD27 and CCR7
significantly decreased on CD4+ T cells in TB patients (CD27, median: blood
94.7%, site of infection: 70.1%, CCR7, median: blood 81.3%, site of infection:
50.7%; p < 0.05, respectively). This finding was even more striking within the
memory (CD4/CD45RO+) subset. In contrast, in the non-TB group an increase of
CD27 and CCR7 on the CD4+ and CD4/CD45RO+ subset in the exudates was
noted (p < 0.05, respectively).
Conclusions: Active TB can not only be diagnosed by the enumeration of MTBspecific, IFN-γ expressing T cells but also by the concomitant decrease of CD27
and CCR7 at the site of infection.
E1690
Clinical evaluation of QuantiFERON TB-2G test for patients with active
tuberculosis disease stratified by age groups
Yoshihiro Kobashi, Keiji Mouri, Yasushi Obase, Naoyuki Miyashita, Mikio Oka.
Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical
School, Kurashiki, Okayama, Japan
Objective: We evaluated the usefulness of QuantiFERON TB-2G (QFT-2G) test
and tuberculin skin test (TST) in patients with active tuberculosis (TB) stratified
by age groups.
Methods: Two hundred seventy patients wuth active TB disease that was confirmed
by positive culture of any specimen were enrolled in this study and stratified by
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age in ten year increments. The QFT-2G test and TST were performed for all
patients.
Results: Although the positive rate on TST is over 80% in younger patients below
nine years of age, it has decreased to 55% in patients of 70-79years old and 34%
in patients of over 80 years old. However, the positive rate on QFT-2G test is over
80% between 10-19 years old and 60-69 years old, excluding younger patients
below nine years. Furthermore, the rate is 77% in patients aged 70-79 years old
and 72% in patients over 80 years old. The positive response rate of QFT-2G
test was significantly higher than that of TST in patients over 50 years old. The
indeterminate result of QFT-2G test has increased with aging and this result was
suggested to be concerned with the severity of underlying diseases in patients with
active TB disease.
Conclusions: Although the positive rate on QFT-2G test decreases with agein
adults, it is thought to be a useful supportive diagnostic method for active TB
diease compared with TST, except in younger patients below nine years old.
E1691
The diagnosis value of QuantiFERON-TB gold test at patients with active
tuberculosis
Vladimir-Mihail Macavei 1 , Ionela Muntean 2 , Valeria Sandru 2 , Raluca Macavei 1 ,
Carmen Macavei 2 . 1 Ist Section, Pneumology Institute ”Marius Nasta”,
Bucharest, Romania; 2 Ist Section, Pneumology Hospital, Brasov, Romania
Background: Brasov is a central county in Romania with a Tuberculosis (TB)
incidence of 55, 6%000 in 2007.
Objectives: The study’s main aim was the diagnosis significance of Quantiferon Tb Gold Test (QFT) among patients with pulmonary/extrapulmonary active
tuberculosis.
Methods: The prospective study included 56 pulmonary active tuberculosis patients, with confirmed positive culture by Lowenstein-Jensen method, at which
QFT was performed at the beginning of the anti-tuberculosis treatment.
Results: 56 cases were analyzed, of which 57, 1% were men, 80, 4% had been
registered in urban areas, with the medium age of 41, 9±18, 3 years and ranges
between 18 and 78 years. From the total of 56 cases, 2 were confirmed with extra
pulmonary tuberculosis. The QFT results: 62, 5% (35/56) positive cases, 12, 5%
(7/56) negative cases and 25% (14/56) indetermined.
Conclusion: Because of a low sensitivity (62, 5%), the QFT can not be used alone
for excluding the active tuberculosis diagnosis.
E1692
Sequential analysis of interferon-gamma release assay results in active
tuberculosis patients
Kazue Higuchi 1 , Kiyoko Takayanagi 2 , Satoshi Mitarai 1 , Misako Aoki 2 ,
Nobuyuki Harada 1 , Masao Okumura 2 , Takashi Yoshiyama 2 , Hideo Ogata 2 ,
Yukie Sekiya 1 , Toru Mori 3 . 1 Department of Mycobacterium Reference and
Research, The Research Institute of Tuberculois, Kiyose, Tokyo, Japan;
2
Department of Respiratory Medicine, Fukujuji Hospital, Kiyose, Tokyo, Japan;
3
Leprosy Research Center, National Institute of Infectious Diseases,
Higashimurayama, Tokyo, Japan
To test the hypothesis that Interferon-gamma release assays (IGRAs) could be
a good monitor of the progress of chemotherapy for tuberculosis (TB), the systematic and long-term changes in IGRAs responses during and after a course of
chemotherapy in a group of active TB patients were observed. Informed consent
for this study was obtained from all the TB patients at enrolment. Follow-up
observation of interferon-gamma (IFN-g) response was conducted in 50 active TB
patients during and after treatment up to 120 weeks. The proportion of patients
with positive QFT-G test results prior to treatment, or at the time of admission,
was 76.0% (38/50). Of these 12 subjects, seven (67%) exhibited positive tests after
the start of treatment, but five remained non-positive throughout. After the start
of chemotherapy, a clear decline of positive rate continued until 48 weeks, when
almost all of the cases completed the treatment. This downward trend of positive
rate between the start and 48 weeks was statistically significant (Chi-squared for
trend = 20.23, p = 0.0001). After 48 weeks, a slight and irregular rise of positive
rate was observed toward 120 weeks, but failed to reach statistical significance
(Chi-squared = 0.851, p = 0.3563). This study demonstrates the change of IFN-g
response along with the progress of chemotherapy in TB patients and after the
completion of treatment, apparently reflecting a change in mycobacterial load in
the disease lesion. With some reservations, it was concluded that IGRAs can be a
useful monitor of the progress of chemotherapy of TB.
E1693
Short-term reproducibility of the QuantiFERON-TB gold in-tube assay
Monica Losi 1 , Fabrizio Luppi 1 , Mario Luppi 2 , Barbara Maria Bergamini 3 ,
Mauro Codeluppi 4 , Roberto D’Amico 5 , Cinzia Del Giovane 5 , Pietro Roversi 1 ,
Fabio Rumpianesi 6 , Marisa Meacci 6 , Giuseppe Torelli 2 , Leonardo Fabbri 1 ,
Luca Richeldi 1 . 1 Section of Respiratory Diseases, Department of Oncology,
Haematology and Respiratory Diseases, University of Modena and Reggio
Emilia, Modena, Italy; 2 Section of Haematology, Department of Oncology,
Haematology and Respiratory Diseases, University of Modena and Reggio
Emilia, Modena, Italy; 3 Pediatrics Unit, University of Modena and Reggio
Emilia, Modena, Italy; 4 Infectious Diseases, University of Modena and Reggio
Emilia, Modena, Italy; 5 Section of Statistics, Department of Oncology,
Haematology and Respiratory Diseases, University of Modena and Reggio
Emilia, Modena, Italy; 6 Microbiology and Virology Laboratory,
University-Policlinico Hospital, Modena, Italy
Background: interferon-gamma (IFN-γ) release assays (IGRAs) are a promising
alternative to the tuberculin skin test (TST), but some aspects of their performance
are still unclear: short-term within-person reproducibility is particularly relevant
in the context of serial testing and to interpret reversions and conversions of IGRA
results beyond non-specific biological variations of the assays over time.
Methods: we retrospectively collected QuantiFERON-TB Gold In-Tube (QFT-IT)
assays repeated within 2 months (mean 28.1±21.6 days) after first testing in 223
patients (mean age 46.7±21.4 years, 14% foreign-born, 8% BCG-vaccinated): most
(90%) also received TST at first QFT-IT testing. None received anti-tuberculosis
treatment before second QFT-IT testing.
Results: at first evaluation 156 (70.0%) patients were QFT-IT-negative, 41 (18.4%)
positive and 26 (11.7%) indeterminate; at subsequent testing, 164 (73.5%) tested
negative, 42 (18.8%) positive and 17 (7.6%) indeterminate. Test-retest reproducibility of dichotomous test results showed a moderate agreement (concordance
78.92%, k=0.52). When examining reproducibility of the continuous QFT-IT IFNγ values, discordance occurred most frequently in patients with QFT-IT responses
around the cut-off for a positive result: 5/8 (62.5%) positive switched to negative
and 5/28 (17.8%) changed from negative to positive.
Discussion: these findings suggest that QFT-IT may have some degree of shortterm variability, in particular in persons with results around the cut-off value.
E1694
Performance of a commercial IFN-gamma blood assay for monitoring
treatment efficacy in active pulmonary tuberculosis
Marialuisa Bocchino 1 , Patrizia Chiaradonna 2 , Alessandro Matarese 1 ,
Mariella Salvatores 3 , Mario G. Alma 4 , Alessandro Sanduzzi 1 , Alfonso
M. Altieri 4 . 1 Dipartimento di Medicina Clinica e Sperimentale, Università
Federico II, Naples, Italy; 2 UOC di Microbiologia e Virologia, AO
S.Camillo-Forlanini, Rome, Italy; 3 Divisione di Tisiologia, AO Monaldi, Naples,
Italy; 4 UOC Bronco-pneumologia e Tisiologia, AO S.Camillo Forlanini, Rome,
Italy
Setting: Prospective study at two tertiary care hospitals.
Aim: To assess performance of QuantiFERON TB Gold in-Tube (QFT-IT, Cellestis,
Australia) for monitoring efficacy of anti-tuberculosis (TB) treatment.
Patients and study design: Sixty-one HIV-negative patients affected by active
pulmonary TB (M:F=36/25; mean age±SD: 39.6±15 yrs; Italians= 29) were serial
tested by QFT-IT at baseline, and after 2 and 6 months of treatment. TB diagnosis
was culture confirmed in 96% of cases (64% of smear-positive cases).Single-drug
resistance was recorded in 6 cases (10%). QFT-IT performance was compared
with sputum culture and chest X-ray status.
Results: Sputum conversion occurred within the first 30 days of therapy in 80%
of cases. Standard therapy was successfully completed by all susceptible patients.
Overall, the 86% of patients was QFT-IT positive at baseline (T0). Compared
to T0, the 81% of cases showed persistent interferon (IFN)-gamma responses at
6 months (similar results also recorded at 2 months), whereas conversion to a
negative response occurred in 10 out of 50 re-tested cases. Conversion was mainly
found in patients with low baseline IFN-gamma responses (close to the cut-off
value). Interestingly, IFN-gamma concentrations were significantly higher among
Italian patients compared to foreign-born cases, both at baseline and at 6 months
(p<0.05 in all instances). QFT-IT performance was not correlated with culture and
X-ray status.
Conclusions: Our results suggest that QFT-IT adds no significant information to
clinicians for treatment monitoring. Variability of IFN-gamma responses among
patients of different geographic origin is an issue to be investigated further.
E1695
The value of interferon-γ assay for the diagnosis of TB meningitis in children
Olga-Adriana Caliman-Sturdza 1,2 , Doina Mihalache 2 , Mihaela-Catalina Luca 3 .
1
Infectious Diseases, Emergency County Hospital“New St.John”, Suceava,
Romania; 2 Clinic of Infectious Diseases, University of Medicine and Pharmacy
“New St.John”, Iasi, Romania
Objectives: We investigated whether a rapid diagnosis of TB meningitis at children
can be established by interferon-γ blood and CSF tests.
Methods: The patients have been separated in two groups: first group, where the
diagnosis of TB meningitis has been confirmed (13 patients) and second group
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with non-TB meningitis (15 cases). We performed QuantiFERON-TB Gold in
Tube (QFT-G) in blood and CSF at all patients.
Results: A total of 28 children were enrolled, M:F=18:10; mean of age was 10.75.
The symptoms at the admission may suggest TB meningitis: fever, headache and
vomiting at 10, cranial nerve palsies at 1, hemi paresis at 2, altered mental status at
9 and seizures at 3 subjects.TST was positive at 7 patients in the first group and at
3 in the second. The CSF analyses were suggestive for TB at 9 patients: moderate
pleocytosis, high CSF protein level and low CSF glucose. All patients had negative
smear and only 4 (30.7%) had positive culture.In the first group, the results of
QFT-G in blood samples were: 10 (76.9%) subjects had QFT-G positive and 3
(23.1%) had negative. In CSF, 10 (76.9%) patients had positive results, 1 (7.7%)
negative and 2 (15.4%) indeterminate. In group of non TB, 14 (93.3%) had QFT-G
negative in blood and 1 (6.7%) positive; in CSF, 12 (80%) had negative results
and 3 (20%) indeterminate.The interval required for the results of QFT-G was
48 hours. We diagnosed with TB meningitis 13 patients: 3 had both QFT-G and
culture positive and 7 only QFT-G positive. The interval between the admission
and diagnosis confirmation was 3.15 days.
Conclusions: The determination of INF-γ in serum and CSF is useful diagnostic
marker of tuberculosis who could improve the management of TB meningitis.
E1696
Evaluation of QuantiFERON TB test (QFT-TB) in detection of children
infected with Mycobacterium tuberculosis
Soheila Khalilzadeh, Maryam Hasanzad, Mohammad Reza Bloorsaz,
Nooshin Baghaie. Pediatric Pulmonary, NRITLD, Tehran, Islamic Republic of
Iran
Introduction: Recently a new diagnostic test (Quantiferon-TB Gold) which measures the production of interferon gamma in whole blood upon stimulation of
Mycobacterium tuberculosis has been introduced. The aim of this study is to
compare the performance of the IFN-gamma assay with TST for the identification
of latent TB infection in childhood contacts with active TB.
Material & Methods: The present cross-sectional study was conducted on 100
children, aged 2months – 15 years admitted in the Pediatric ward of NRITLD during 2007-2008. Whole blood was collected for measuring Interferon-gamma using
Quantiferon-TB Gold kit (QFT-Cellestis Comp). In this procedure, Mycobacterium
tuberculosis specific antigens (ESAT-6 and CFP-10), were used. 100 children were
divided into three groups of Case (TB), Contact and Control.
Result: Smear of the gastric washing (3×) was prepared in Contact groups and
Cases (TB); 30% of the Cases (TB) were AFB positive, while all of the Contact
groups had negative smears.
Positive PPD test (PPD≥ 10 mm) was observed in 90% of the Cases and 24% of
the Contacts. PPD test was negative in the Control group.
Out of 50 contact cases 18 (36%) showed positive QFT test, and in 20 TB patients
18 (90%) had positive test. Regarding the age groups, children with the positive
QFT test were in older range group.
Conclusion: Considering the result of this research, in predominantly well children at high risk of latent TB infection, there is fair correlation between the TST
and the whole blood IFN-γ assay. Our study has high lighted fair and moderate
agreement in contact and TB group respectively between the TST and QFT –TB
test in children at high risk for latent TB infection.
E1697
Clinical evaluation of QuantiFERON TB -2g test in patients with
nontuberculous mycobacterial disease
Yoshihiro Kobashi, Keiji Mouri, Yasushi Obase, Naoyuki Miyashita, Mikio Oka.
Division of Respiratory Diseases, Deaprtment of Medicine, Kawasaki Medical
School, Kurashiki, okayama, Japan
Background: Clinical usefulness of QuantiFERON TB-2G (QFT-2G) test in
patients with NTM disease was evaluated.
Methods: The subjects consisted of 100 healthy volunteers and 255 patients with
NTM disease who satisfied the diagnostic guidelines of the American Thoracic Society and were treated between January 2005 and December 2008. The tuberculin
skin test (TST) and the QFT-2G test were performed for all subjects.
Results: The causative microorganism was Mycobacterium avium in 103 patients,
Mycobacterium intracellulare in 98, Mycobacterium kansasii in 35, Mycobacterium marinum in 12, Mycobacterium szulgai in 3, Mycobacterium chelonei in 2
and Mycobacterium abssessus in 2. Concerning the TST results of patients with
NTM disease, 60% had a positive result and there was no significant difference
between the positive response rate for Mycobacterium avium complex (MAC) and
that of other NTM excluding MAC. The positive response rate of QFT-2G test
result was 6% in 210 patients with MAC disease. 51% in 35 with M.kansasii
disease, 58% in 12 with M.marinum disease, 33% in 3 with M.szulgai disease,
0% in 2 with M.chelonei and M.abssessus disease. The positive response rate of
QFT-2G test result was 52% in patients with NTM disease which was thought
to show the positive response because NTM possessed common Mycobacterium
tuberculosis (MTB)-specific antigens.
Conclusions: Although QFT-2G test may be a useful diagnostic method to differentiate tuberculosis disease from MAC disease, there are several problems to
be resolved before it can become a useful diagnostic method for NTM disease
such as M.kansasii disease including differentiation of the positive cut-off level
for QFT-2G test.
E1698
Ifn-γ response on T-cell based assays for the diagnosis of tuberculosis
infection in rheumatic patients undergoing anti-TNF-α treatment
Irene Latorre 1,3 , Lourdes Mateo 2 , Sonia Mínguez 2 , Cristina Prat 1,3 ,
Alicia Lacoma 1,3 , Anna Moltó 2 , Vicente Ausina 1,3 , Jose Domínguez 1,3 . 1 Servei
de Microbiologia, Hospital Universitari germans Trias i Pujol. Fundació Institut
d’Investigació en Ciències de la Salut Germans Trias i Pujol. Universitat
Autònoma de Barcelona, Badalona, Spain; 2 Servei de Reumatologia, Hospital
Universitari germans Trias i Pujol. Universitat Autònoma de Barcelona,
Badalona, Spain; 3 Centro de Investigación Biomédica en Red de Enfermedades
Respiratorias (CIBERES), Instituto de Salud Carlos III, Badalona, Spain
Objective: Determination of IFN-γ response for the detection of tuberculosis
infection with QuantiFERON-TB GOLD In Tube (QFN) and T-SPOT.TB (TS.TB)
in patients undergoing anti-TNF-α treatment, comparing the results with tuberculin
skin test (TST).
Material and methods: We enrolled 23 patients with rheumatic diseases (7
rheumatoid arthritis, 4 ankylosing spondilytis, 5 psoriatic arthritis, 3 seronegative
arthritis, 2 LES, 1 undifferenciated spondiloarthritis and 1 SAPHO). Sixteen patients received previous therapy with DMARD and corticosteroids before starting
anti-TNF- α treatment. TST was done in all cases and it was repeated after two
weeks if it was negative the first time. We determined the IFN-γ production with
QFN and TS.TB assays.
Results: TS.TB and QFN were positive in 30.4% (7/23) and 21.7% (5/23) respectively, otherwise, TST was positive in 13% (3/23). We obtained 3 indeterminate
results with QFN, two of them corresponded with patients receiving corticosteroids therapy. Global concordance (κ) between TS.TB and QFN-IT was 0.562.
Concordance of TS.TB and QFN with TST was 0.470 and 0.641, respectively. Five
patients started chemoprophylaxis for tuberculosis infection, two of them had a
negative TST and positive IFN-γ tests.
Conclusions: TS.TB detects more positive results than QFN for the diagnosis of
tuberculosis infection.
QFN has more indeterminate results than TS.TB.
Concordance between TST and IFN-γ assays is poor in these kind of patients.
The use of IFN-γ tests could avoid unnecessary chemoprophylaxis treatments in the
diagnosis of tuberculosis infection in rheumatic patients undergoing anti-TNF-α
treatment.
E1699
Quantiferon-TB gold in tube method in sarcoidosis patients
Irini Gerogianni 1 , Maria Papala 1 , Foteini Malli 1 , Efi Petinaki 2 ,
Konstantinos Gourgoulianis 1 , Zoi Daniil 1 . 1 Respiratory Medicine, University of
Thessaly, Larisa, Greece; 2 Microbiology, University of Thessaly, Larisa, Greece
Background: High percentage of sarcoidosis patients present suppressed immune
response to tuberculin. The exact mechanisms underlying this “immune paradox”
are not yet clarified.
Objectives: This study aimed to examine whether the QuantiFeron-TB Gold
(QFT-G) method is suitable for detecting tuberculosis infection (TBI) in sarcoidosis patients.
Methods: Forty patients (28 females, 52±13.6 years), with sarcoidosis were included in the study. The presence of active tuberculosis infection was excluded
at the time of diagnosis. Clinical, radiological and microbiological data were
collected and TST and QFT-G method were performed in all subjects. BCG status
was obtained in all patients. None of the patients received corticosteroid or other
immunosuppressive therapy.
Results: All patients had pulmonary sarcoidosis. The QFT-G method was positive
in 2 (5%) of the 40 patients tested and TST was negative in all patients. The
overall agreement between the two methods was 96.4%. The effect of BCG, and
the medical history of active tuberculosis did not reveal significant effect on the
result of QFT-G method neither in the univariate nor in multivariate analysis.
Conclusions: The present study showed an overall high agreement between the
two methods. In conclusion, improvement of sensitivity of the test and studies
in various areas are required to clarify the involvement of M.tuberculosis in the
pathogenesis of sarcoidosis and retrace possible latent infection in sarcoidosis
patients.
E1700
Number of peripheral blood lymphocyte affects sensitivity of QuantiFERON
TB -gold
Megumi Tarui, Haruyuki Ariga, Hideaki Nagai, Hirotoshi Matsui,
Shunsuke Shoji, Yutsuki Nakazima, Hideki Yotsumoto. Department of
Respiratory Medicine, National Hospital Organization, Tokyo National Hospital,
Kiyose-City, Tokyo, Japan
Objective: QuantiFERON TB-Gold (QFT-G) is utilized to detect patients infected
with M. tuberculosis (TB). Since QFT-G measures IFN-γ before and after stimulating T-cells with TB specific antigens, decrease of peripheral blood lymphocytes
(PBL) may reduce sensitivity of QFT-G. Therefore, we tested the sensitivity of
QFT-G focusing on the PBL count of TB patients.
Methods: From Jan 2006 to Oct 2008, QFT-G tests were performed with 728
patients who were diagnosed as TB based on positive cultures, within 2 weeks
after initiation of treatment. Those patients were divided into 3 groups; group A
283s
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with lymphocyte count ≥ 1500 (normal), group B with 700≤ lymphocyte count
<1500 (slightly decreased), and group C with lymphocyte count<700 (severely
decreased). Supernatant concentration of IFN-γ was measured after stimulation
with non-specific mitogens (M value) or TB specific antigens, ESAT-6 (E value)
or CFP10 (C value).
Results: QFT-G test revealed positive in 69.2% and indeterminate in 3.6% of the
728 TB patients (aged 15-97, mean=60). In the group A (n=182, aged 15-94,
mean=51yo), 84.6% was positive and 0.5% indeterminate; in the group B (n=364,
aged 18-95, mean=60yo), 71.4% positive and 1.1% indeterminate; in the group C
(n=182, aged 21-97, mean=71), 49.5% positive and 11.5% indeterminate. Positive
rate of QFT-G was significantly decreased in the group C compared with group
A (P<0.0001). M value, and “E or C” value, higher of either E or C value, were
significantly decreased in the group C (M=4.71, E or C =1.11) compared with that
in the group A (M=12.2, E or C =2.85).
Conclusion: In patients with decreased PBL, QFT-G test results should be interpreted carefully since false negative rate might be increased.
E1701
Effect of different positive cut-off values on T-spot.TB results
Monica Losi 1 , Cinzia Del Giovane 2 , Fabrizio Luppi 1 , Roberto D’Amico 2 ,
Pietro Roversi 1 , Leonardo Fabbri 1 , Luca Richeldi 1 . 1 Section of Respiratory
Diseases,Department of Oncology, Haematology and Respiratory Diseases,
University of Modena & Reggio Emilia, Modena, Italy; 2 Section of
Statistics,Department of Oncology,Haematology and Respiratory Diseases,
University of Modena & Reggio Emilia, Modena, Italy
Background: commercially available interferon-gamma (IFN-γ) release assays
(IGRA) have high diagnostic specificity for latent tuberculosis infection (LTBI),
being unaffected by BCG vaccination; sensitivity data are not completely consistent
across different studies, although T-SPOT.TB (TS.TB) seems to be more sensitive
than both generations of QuantiFERON-TB (QFT) tests in meta-analyses. It has
been questioned that the cut-off value set for TS.TB might account for this finding.
We wanted to explore the impact of different cut-off values (as approved in Europe
and in US) on TS.TB results.
Methods: we retrospectively evaluated TS.TB results of 939 consecutive individuals tested between 1 November 2004 and 30 June 2008 at the Policlinico Hospital
of Modena (Italy): 368 (39.2%) were also tested with QuantiFERON-TB Gold
(QFT-G) and 564 (60.1%) with QuantiFERON-TB Gold In-Tube (QFT-IT).
Results: considering TS.TB as a dichotomous test result, 295 (31.4%) individuals
were TS.TB-positive with a cut-off value of ≥6 (as approved in Europe) and 273
(29.1%) with a cut-off of ≥8 (as approved in US) SFUs/250,000 cells. Agreement
of TS.TB results using the two different positive thresholds was high (concordance
97.6%, k=0.94). In persons with TS.TB and QFT tests available, concordance
between the two assays was similar at both cut-off values (k=0.51 and k=0.52). Of
the 22 individuals with discordant TS.TB results using the two different cut-off
values, most (n=13, 59.1%) were negative with both QFT-G and QFT-IT.
Discussion: these retrospective findings on a large cohort of patients indicate that
using European or US cut-off values does not significantly affect the rates of
positive TS.TB results.
E1702
Negative predictive value of serum-procalcitonin (PCT) for active pulmonary
tuberculosis (pTB)
Alan Strassburg 1 , Gunar Guenther 1 , Hany Sahly 2 , Christoph Lange 1 . 1 Div. of
Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany;
2
IPM-Biotech (Institute for Immunology, Clinical Pathology and Molecular
Medicine), Labor Lademannbogen, Hamburg, Germany
Background: PCT, a propeptide of calcitonin, has been used to discriminate
between bacterial infectious and non-infectious causes of inflammation, and as a
marker of severe sepsis. In patients with pulmonary infiltrates pTB should always
be considered as one of the differential diagnosis.
Hypothesis: As defence mechanisms against pTB are lymphocyte-driven, elevated
serum levels of PCT may not to be expected compared to patients with other
infectious or non-infectious pulmonary diseases.
Methods: Prospective case control study of all individuals admitted with suspected
pTB from 1/2008 until 2/2009. PCT, CRP and WBC were measured on the day of
admission.
Results: At submission’s date of the abstract 77 individuals were enrolled. 35
patients were diagnosed with pTB by cultural proof from bronchopulmonary or
pleural specimens. 42 patients were diagnosed with diseases different from pTB,
including FUO, CAP, HAP, AECOPD, idiopathic fibrosis, bronchopulmonary
malignancies and sarcoidosis. Except for 3 patients suffering from miliary pTB
revealing PCT levels between 0,3 and 0,4 ng/ml, all other 32 pTB patients exhibited PCT values below 0,1 ng/ml. While there were no differences regarding
CRP concentrations and WBC count, PCT was significantly elevated in the 42
patients with pulmonary diseases other than pTB (0.0±0.0 ng/ml vs. 0.3±1.1
ng/ml; p<0,02).
Conclusion: Compared to pulmonary diseases other than pTB, median PCT concentrations were not elevated in pTB. PCT might serve as a useful additional
negative predictive marker for the rapid exclusion of pTB not accompanied by
other pulmonary disorders. Probable exceptions such as miliary pTB should be
further investigated.
284s
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