Diagnosis of Genitourinary Tuberculosis

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Diagnosis of Genitourinary Tuberculosis
Dr. Jayesh Dhabalia Dr. Ulhas
Sathe Consultant Urologist
Consultant Urologist Professor Head
Sahyog Speciality Hospital Department of
Urology, Lithotripsy
Centre LTMG Hospital , Mumbai
Jhamnagar
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INTRODUCTION

• General Incidence India1
• One fifth of world TB population
• 1.8 million new cases / year
• 8 lac infectious cases
• One death every 90 sec , 45 / hour , 1080 / day ,
  3.88 lack /year

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INTRODUCTION

• General Incidence India GUTB1
• Most common extra pulmonary TB
• 30 of all extrapulmonary TB
• 18 of infertile women
• 11 of hematospermia
• 5-25 year after primary pulmonary TB
• Primary GUTB - anecdotal cases in females

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MICROBIOLOGICAL BACKGROUND
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MICROBIOLOGICAL BACKGROUND

• Bacterial characteristics diagnostic
  difficulties
• Slow growing - divides every 1520 hours
• - Delayed growth on culture
• Can survive in a dry state for weeks
• - Infectivity contamination
• Obligate aerobic
• Acid-fast -waxy coating on the cell surface makes
  the cells impervious to Gram staining

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GUTB - DIAGNOSTIC DIFFICULTIES

• Characteristics of M. tuberculosis bacteria
• Difficult and delayed lab diagnosis
• Index of suspicion not high enough

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GUTB - DELAYED DIAGNOSIS

• After significant irreversible anatomical changes
  -
• major surgical procedure
• ( thimble bladder , multiple ureteric
  strictures, multiple infundibular stenosis)
• Irreversible loss of kidney function
• Infertility in both gender
• Early diagnosis in India high index of suspicion

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GUTB DIAGNOSTIC MODALITIES
CLINICAL RADIOLOGICAL LABORATORY
Reliability increases with Progression of disease Multisystem involvement Early changes Needs confirmation Advanced disease Almost diagnostic Valuable for Early disease diagnosis Rapid diagnosis Drugs sensitivity
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GUTB - CLINICAL EVALUATION

• SPECIFIC - Genitourinary tract
• Lower urinary tract 50 to 80
• Burning , frequency , urgency , urge incontinence
• Dysuria , hematuria
• Suprapubic pain / perineal discomfort
• Decreased stream , straining, ineffective voiding
• Slough in urine

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GUTB - CLINICAL EVALUATION

• Upper urinary tract symptoms
• Pain - kidney and ureter region
• Gross hematuria- 10
• Genital Male
• Hematospermia - 10
• Azoospermia
• S/S of chronic
• epididymorchitis

• Genital Female
• Menstrual irregularities
• Pelvic pain syndrome
• Infertility 18

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GUTB - CLINICAL EVALUATION

• Other systems
• Respiratory - 12 patients
• Gastrointestinal - 10
• Lymphoreticular
• Constitutional - 10 to 15 1
• Evening rise of temperature
• Weight loss
• Anorexia

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GUTB - LABORATORY DIAGNOSIS
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GUTB - PROBLEMS IN LAB DIAGNOSIS

• Paucibacillary
• Intermittent bacterial shedding
• Fastidious / slow growth difficult to culture
• Diagnostic difficulty due to atypical
  mycobacteria / MOTT / NTM
• Sensitivity of all tests - extra pulmonary TB

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GUTB - LAB DIAGNOSIS SUPPORTIVE TESTS

• Urine routine and microscopy
• Acidic urine , sterile pyuria , microscopic
  hematuria
• Guide for further investigation, especially in
  pauci-symptomatic patients
• Montaux Test (Robert Koch in 1890)
• If Positive supports the diagnosis
• If Negative can not exclude extrapulmonary TB
• Response HIV, Immunocompromised ,
  Post-transplant pts
• Problems in India
• Invariably positive - Exposure in childhood ,
  BCG vaccination

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GUTB SERODIAGNOSIS

• Basis by detecting
• I. Specific immunological host response
• Humoral (serological) antibody immune response
  to M. tb 
• Ig G High levels in active TB
• Ig M Immediate appearance, disappears later on
• Commercial ELISA test kit available
• T cellbased cellular immune response
• Different antigens detects different types of
  TB
• Test kit not available
• II. Direct detection of bacterial antigens
  metabolites
• Test kit not available

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GUTB SERODIAGNOSISPROBLEMS

• Low sensitivity and specificity
• At present supportive at best
• Potential role in future
• Early diagnosis
• Response measurement to treatment
• Early detection of relapse
• LITTLE OR NO ROLE IN DIAGNOSIS

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GUTB - POTENTIALLY DIAGNOSTICLAB TESTS

• COLLECTION OF SAMPLES
• Urine
• Physiologically pooled ( overnight) early morning
  1stsample
• Three consecutive days , ? 5 days
• Volume 10 ml for AFB, culture , PCR
• Immediate processing if not feasible
  refrigerate at 4-8o C
• Alkalinisation of urine - ? Increased yield2

• Tissue
• In neutral transport media avoids dessication
• Swab specimen not suitable

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GUTB - POTENTIALLY DIAGNOSTIC LAB TESTS
TEST UTILITY EVALUATION CRITERIAS
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GUTB - DIAGNOSTIC LAB TESTS ZN / AFB SMEAR
EXAMINATION

• First described by Franz Ziehl (1859 to 1926), a
  bacteriologist and Friedrich Neelsen (1854 to
  1894)
• Requiring 104 bacilli ml-1 of sample to achieve
  a positive result3
• Can not differentiate between live versus dead
  bacteria

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GUTB - DIAGNOSTIC LAB TESTS ZN / AFB SMEAR
EXAMINATION

• 1. Take sediment and make a smear
• 2. Carbol-fuchsin solution - allow slides to
  stand in hot solution for 5 minutes.
• 3. Wash in running tap water.
• 4. 1 Acid alcohol until light pink and color
  stops running.
• 5. Wash in running tap water for 5 minutes...
• 7. Working methylene blue for 30 seconds.
• 8. Rinse in water.
• 9. Dehydrate, clear, and cover slip.
• RESULTS
• Acid-fast bacilli bright red
• Background blue

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ZN - AFB STAIN TEST UTILITY EVALUATION

• Availability - Universal
• Sensitivity - 30 40 4
• Specificity - 95 4
• Processing time - 45 mins
• Cost - Cheap
• Antibiotic sensitivity - NA

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GUTB - DIAGNOSTIC LAB TESTS FLUORESCENCE
MICROSCOPY

• Microscopy with fluorochrome dyes such as
  auramine O or auramine-rhodamine
• To increase sensitivity over
• ZN AFB staining

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TEST UTILITY EVALUATION

• Availability - Poor
• Sensitivity - 10 gt ZN
  staining5
• Specificity - Similar
• Processing time - Less than ZN
  staining
• Cost - Significantly gt
  ZN staining
• Antibiotic sensitivity - NA

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MOLECULAR TECHNOLOGY POLYMERASE CHAIN REACTION
(PCR)

• Principle- by detection of species
  specific DNA
• Technique to amplify a single or few copies of
  a piece of DNA to generate millions of copies of
  a particular DNA sequence
• Targeting different gene sequences of M.
  tuberculosis , showed different positivity
• IS6110 - 77 - Most commonly targeted6
• 65kDa - 75, 38 kDa - 72 ,85B protein - 73

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MOLECULAR TECHNOLOGY POLYMERASE CHAIN REACTION
(PCR)

• Diagnostic Problems
• Few Indian strains lack copy of IS 6110
• IS 6110- present in M.tb complex bacteria
• ( tuberculous / africanum / microti / bovis)
• False positive old cases of TB, contamination
• False negative extremely paucibacillary cases
• ( detection limit up to 10 copies / ml )
• Cannot differentiate dead from live bacteria

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MOLECULAR TECHNOLOGY - PCR

• Universal Sample Processing (USP) Technology
• AIM - To false negative rate by removing
  inhibitors of DNA amplification
• Potent inhibitor-heparin, hemoglobin, phenol
  sodium dodecyl sulfate4
• Detected in 0 to 20 of the clinical specimen4

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MOLECULAR TECHNOLOGY - PCR TECHNICAL PROCESSING
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MOLECULAR TECHNOLOGY - PCR
TEST UTILITY EVALUATION

• Availability - Limited
• Sensitivity - 75 - 956
• Specificity - 95 - 97 6
• Processing time - One day
• Cost - Rs 1600
• Antibiotic sensitivity - NA

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MOLECULAR TECHNOLOGY RNA PCR

• DNA PCR cannot differentiates dead from live
  organisms
• Principle Reverse transcriptase copies the RNA
  target from DNA into a transcription complex,
  which is then amplified by RNA polymerase

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MOLECULAR TECHNOLOGY TISSUE PCR

• Sampling limitations
• Availability - Limited
• Sensitivity - 95
• Specificity - 95 to 97
• Processing time - One day
• Cost - Rs 1600
• Antibiotic sensitivity - NA

TEST UTILITY CRITERIA
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M.TUBERCULOSIS CULTURE

• Gold standard ????
• Highly specific and sensitive
• Detects presence of live bacteria
• Can differentiate between typical and atypical
• Antimicrobial sensitivity
• Biggest drawback time required

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M.TUBERCULOSIS CULTUREMEDIA

• Solid
• Egg-based - Petragnini medium and Dorset medium
• Middlebrook 7H10 Agar
• Middlebrook 7H11 Agar
• Blood based -Tarshis medium
• Serum based - Loeffler medium
• Potato based - Pawlowsky medium
• LJ media

• Liquid
• Dubos' medium
• Middlebrook 7H9 Broth
• Proskauer and Beck's medium
• Sula's medium
• Sauton's medium
• Radiometric Bactec
• Nonradiomaetric MGIT / MB Redox

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M.TUBERCULOSIS CULTURE
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M.TUBERCULOSIS CULTURESOLID MEDIA
LOWENSTEIN-JENSEN MEDIUM

•  Growth medium specially used for culture
  of Mycobacterium
• Processing time 2-8 weeks
• Time increases in pauci bacillary specimen
• Further 2-8 weeks in typical v/s atypical -?
  Simultaneous culture with inhibition of M.tb
• Further 2-8 weeks for drug susceptibility

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M.TUBERCULOSIS CULTURE LOWENSTEIN-JENSEN MEDIUM

• Composition
• Malachite green ,Glycerol, Asparagine , Potato
  starch, Coagulated eggs, Mineral salt solution
  (Potassium dihydrogen phosphate, Magnesium
  sulfate, Sodium citrate )
• Penicillin and nalidixic acid -Inhibit growth
  of gram positive and gram negative bacteria, .
  Presence of malachite green in the medium
  inhibits most other bacteria.

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M.TUBERCULOSIS CULTURE
LIQUID CULTURE MEDIA

• More sensitive and specific
• Shorter processing time
• Variable availability
• Simultaneous differentiation of atypical v/s
  typical

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M.TUBERCULOSIS CULTURE RADIOMETRIC

• BACTEC 460 TB system
• Principle
• Detection of the metabolism of the bacteria
• Detects 14CO2 liberation during the
  decarboxylation of 14C labelled substrates
  palmitic acid
• Differentiates typical and atypical mycobacteria
  4
• p-nitro benzoic acid (PNBA) test
• The BACTEC NAP test

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M.TUBERCULOSIS CULTURE NONRADIOMETRIC

• Principle detection of metabolism of bacteria
• Types
• Mycobacteria Growth Indicator Tube (MGIT)
• MB Redox

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M.TUBERCULOSIS CULTURELIQUID MEDIA
Nonradiometric Liquid Culture Media

• (1) Mycobacteria Growth Indicator Tube (MGIT)
• Sensor Contains 4 ml of modified Middlebrook 7H9
  broth with an oxygen quenching- based fluorescent
  sensor.

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M.TUBERCULOSIS CULTURELIQUID MEDIA
Nonradiometric Liquid Culture Media

• (2) MB Redox Tube
• Four ml of modified, serum-supplemented Kirchner
  medium with a colourless tetrazolium salt as a
  growth indicator.
• During bacterial growth, the tetrazolium salt is
  reduced to a pink-, red-, or violet-colored
  formazan.
• Contains a special vitamin complex which provides
  for a considerable acceleration of the growth of
  mycobacteria

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M.TUBERCULOSIS CULTURE SOLID V/S LIQUID MEDIA
Solid media Liquid media
Availability Good Variable
Sensitivity 40-70 80-95
Specificity 95 - 97 95 - 97
Processing time 4-8 weeks 12-15 days
Cost 1500 1500
Antibiotic sensitivity
Hence liquid media is preferred
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TEST UTILITY EVALUATION RADIOMETRIC V/S
NONRADIOMETRIC
Radiometric Non radiometric Non radiometric
Bactec MGIT MB redox
Availability Variable Most common Uncommon
Sensitivity 90-95 70 - 80 80
Specificity 95-97 95-97 95-97
Processing time 12-14 days 17 days 16 days
Cost 1600 1600 -
Antibiotic sensitivity
Technical difficulty Labor intensive Radiation hazards
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GUTB DIAGNOSISENDOSCOPY BIOPSY

• Indications
• Suspected GU Koch's with equivocal radiology
  and lab test
• Ureteric evaluation ( RGP) and stenting
• Risks
• Bladder perforation, septicemia
• Problems
• - Morphology - If normal no biopsy
• - Changes - specific / nonspecific
  biopsy
• ? Need Highly suggestive radiological findings

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VIDEO
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GUTB - ENDOSCOPY BIOPSY

• Classical Histological features
• Granuloma formation
• Caseous necrosis
• Cavitation
• Chronic inrterstital inflammation

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HISTOPATHOLOGY
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GUTB DIAGNOSIS ENDOSCOPY BIOPSY

• Differential diagnosis -
• Fungal infection histoplasmosis cryptococcus
• Infections
• Cat-scratch fever (caused by bartonella henselae)
  
• Chronic pyelonephritis , sarcoidosis
• Wegener's granulomatosis
• Drugs
• Very rare compared to M.tb infection

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GUTB DIAGNOSIS ENDOSCOPY BIOPSY

• Availability - Universal
• Sensitivity - 18 to 56 6,12,13
• Specificity - 95 to 97
• Processing time - four days
• Cost - Rs 500
• Antibiotic sensitivity - NA

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GUTB DIAGNOSIS ENDOSCOPY BIOPSY

• Bivalved resected specimen shows two foci of
  caseous necrosis in the upper pole (arrows).

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DIAGNOSTIC LAB TESTSCOMPARISON
AFB Stain PCR LJ Culture Bactec MGIT MB redox
Availability Universal Limited Common Limited Limited Uncommon
Sensitivity 40 60 95 40-70 80-95 70 - 80 80
Specificity 95 - 97 95 - 97 95 - 97 95 - 97 95 - 97 95 - 97
Processing time 45 mins one day 4-8 weeks 12-14 days 17 days 16 days
Cost Rs 500 Rs 1600 Rs 1600 Rs 1500 Rs 1500 -
Antibiotic sensitivity NA NA
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GUTB LAB DIAGNOSIS

• PROBLEMS - No Gold Standards
• Current Literature
• - Not all test done in all patients
• - Different samples from different systems
• Sensitivity Specificity
• - Maximum with combination of tests
• Recommendation PCR with Bactac
• Radiometric Culture

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DIAGNOSTIC ALGORITHM

• Persistent Irritative voiding /OR genital
  symptoms
• History of recurrent UTI, past H/O TB, Failed
  symptomatic t/t
• Urine sterile pyuria, acidic , microscopic
  hematuria

USG
NonSpecific
Urine-PCR/AFB stain Culture
?
Specific
Positive
Negative
IVP
Endoscopy
AKT
Morphology
Specific / Non-Specific
Biopsy HPE Tissue PCR
Normal
Clinical Decision
Negative
No Biopsy
Positive
AKT
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