Introduction: GeneXpert® MTB/RIF Ultra (Ultra) is a method for detecting the Mycobacterium tuberculosis complex (Mtb) with greater sensitivity compared to GeneXpert® MTB/RIF (Xpert). In Brazil, for children and for extrapulmonary tuberculosis (EPTB), "traces detected" results are considered positive for Mtb. Here, we describe the use of Ultra at a reference center for pediatric tuberculosis (TB) in Rio de Janeiro, Brazil. Methods: A cross-sectional study was conducted with children (0-9 years) and adolescents (10-18 years) with presumed EPTB or pulmonary TB (PTB) whose specimens were tested using Ultra. Data were analyzed using descriptive statistics, and Fisher's exact test (significance level p<0.05) was applied when appropriate. The study was approved by the Ethics Committee of IPPMG-UFRJ (CAAE: 02173518.2.0000.5264). Results: Ninety-three patients with presumed TB were included: 44% with PTB and 56% with EPTB. The final diagnoses revealed 63.4% PTB, 40.4% EPTB, and 49.5% other diagnoses. Among the PTB cases, 9/26 (34%) had positive results exclusively by Ultra. As for the EPTB cases, 11/21 (52%) were positive only by Ultra. For PTB, sensitivity was 50% and specificity was 100% (compared to culture). For EPTB, sensitivity was 85.7% and specificity was 100%. Conclusion: Ultra contributed to the diagnosis of both PTB and EPTB, especially in cases with negative culture results. The test demonstrated higher sensitivity in EPTB than in PTB.

Keywords: tuberculosis, real-time PCR, children, adolescents.

Objectives: To evaluate the contribution of Ultra to the diagnosis of pediatric pulmonary tuberculosis (PTB). Methods: We analyzed prospective data from children and adolescents with presumed PTB whose specimens were tested with Ultra between January 2020 and December 2022. Diagnosis was based on clinical-radiological criteria, clinical response after a two-month treatment period, and microbiological analysis. Ultra was considered positive with a result of 'Detected' and 'Traces' in children under 10 years and in HIV-infected individuals. Fisher's exact test was used for group comparisons, and McNemar's test was used to compare Ultra results with the diagnostic presumption. The study was approved by the Ethics Committee (CAAE No. 02173518.2.0000.5264). Results: A total of 41 patients were included, of whom 63% (26/41) were diagnosed with PTB. Among these, 9/26 (34%) had positive results only through Ultra, with negative AFB and culture. The sensitivity and specificity of Ultra were 50% (13/26) and 100% (15/15), respectively. The PPV was 100% (13/13), and the NPV was 54% (15/28). Of these 28 (68%) patients with negative Ultra results, 13 (46%) were diagnosed with PTB, mostly by MoH-SS. Considering culture as the reference, the PPV and NPV were 67% and 100%, respectively. Conclusions: Ultra significantly contributed to the diagnosis of pediatric PTB, proving to be a promising tool for paucibacillary forms of the disease. However, it should not be used alone. Integrating laboratory tests with clinical evaluation is essential to improving diagnostic accuracy and the management of pediatric TB.

Keywords: Pulmonary tuberculosis; children; adolescents; GeneXpert Ultra.

Objective: Pulmonary nontuberculous mycobacterial infections are caused by nontuberculous mycobacteria (NTM), the microbiological diagnosis of which involves the isolation and identification of the same species in at least two sputum samples, one BAL fluid sample, or one lung biopsy sample. The objective of the present study was to determine the frequency at which the various NTM species are identified among selected individuals and in potential cases of pulmonary nontuberculous mycobacterial infection. Methods: This was a retrospective analysis of the data on species isolated from respiratory specimens collected from 2,843 individuals between 2011 and 2014. Potential NTM infection cases were identified on the basis of the international microbiological criteria adopted in the state of São Paulo. Results: A total of 50 species were identified using the molecular method PCR-restriction enzyme analysis. Samples collected from 1,014 individuals were analyzed in relation to the microbiological criteria, and 448 (44.18%) had a presumptive diagnosis of pulmonary nontuberculous mycobacterial infection, the species identified most frequently being, in descending order, Mycobacterium kansasii, M. abscessus, M. intracellulare, M. avium, and M. szulgai. Conclusions: Although various NTM species were identified among the individuals studied, those presumptively identified most frequently on the basis of the microbiological criteria adopted in the state of São Paulo were the ones that are most commonly associated with pulmonary nontuberculous mycobacterial infection worldwide or in specific geographic regions.

Keywords: Nontuberculous mycobacteria/classification; Mycobacterium infections, nontuberculous/diagnosis; Lung.

Objective: Children are an important demographic group for understanding overall tuberculosis epidemiology, and monitoring of childhood tuberculosis is essential for appropriate prevention. The present study sought to characterize the spatial distribution of childhood tuberculosis notification rates in continental Portugal; identify high-risk areas; and evaluate the association between childhood tuberculosis notification rates and socioeconomic deprivation. Methods: Using hierarchical Bayesian spatial models, we analyzed the geographic distribution of pediatric tuberculosis notification rates across 278 municipalities between 2016 and 2020 and determined high-risk and low-risk areas. We used the Portuguese version of the European Deprivation Index to estimate the association between childhood tuberculosis and area-level socioeconomic deprivation. Results: Notification rates ranged from 1.8 to 13.15 per 100,000 children under 5 years of age. We identified seven high-risk areas, the relative risk of which was significantly above the study area average. All seven high-risk areas were located in the metropolitan area of Porto or Lisbon. There was a significant relationship between socioeconomic deprivation and pediatric tuberculosis notification rates (relative risk = 1.16; Bayesian credible interval, 1.05-1.29). Conclusions: Identified high-risk and socioeconomically deprived areas should constitute target areas for tuberculosis control, and these data should be integrated with other risk factors to define more precise criteria for BCG vaccination.

Keywords: Child; Poverty; Vaccination; Mycobacterium bovis.

Objective: The rapid differentiation between Mycobacterium tuberculosis and nontuberculous mycobacteria is fundamental for patients co-infected with tuberculosis and HIV. To that end, we use two methods in our laboratory: detection of cord factor and PCR-restriction enzyme analysis (PRA). The objective of this study was to evaluate the accuracy of a screening test on solid medium as a rapid method for the presumptive identification of M. tuberculosis complex, considering costs and turnover time. Methods: A total of 152 strains were submitted to a combined screening test, consisting of the detection of cord factor under microscopy (Ziehl-Neelsen staining) and evaluation of the macroscopic aspect of colonies, as well as to PRA, which was used as the gold standard. Costs were estimated by calculating the price of all of the materials needed for each test. Results: The overall accuracy of cord factor detection alone was 95.4% (95% CI: 90.7-98.1%), and that of the combined screening test was 99.3% (95% CI: 96.4-100%). Cord factor detection costs US$ 0.25, whereas the PRA costs US$ 7.00. Results from cord factor detection are ready in 2 days, whereas PRA requires 4 days to yield results. Conclusions: The presumptive identification of M. tuberculosis using the macroscopic evaluation of colonies combined with cord factor detection under microscopy is a simple, rapid and inexpensive test. We recommend the combined screening test to rapidly identify M. tuberculosis in resource-poor settings and in less well-equipped laboratories while awaiting a definite identification by molecular or biochemical methods.

Keywords: Tuberculosis; Mycobacterium/classification; Polymerase chain reaction; Diagnostic tests, routine.

Background: Tuberculin purified protein derivative is stored in vials of various sizes. Its adsorption to the vial can influence the results of tuberculin tests. Objective: To evaluate the effect of vial size on the results obtained in tuberculin tests. Methods: Sixty-four inpatients with active tuberculosis were submitted to two simultaneous tuberculin tests using the Mantoux technique. Patients were randomly allocated to receive two 0.1-ml injections, either one in the right forearm from a 1.5-ml vial and one in the left forearm from a 5-ml vial or vice versa. Induration was determined in a blinded fashion by a single, previously trained observer. Right arm-left arm differences of 2 mm or less were considered concordant results. Results: Twenty-one patients presented no induration and were excluded from analysis. Among the 42 remaining patients, mean induration diameters obtained in tuberculin tests using the larger vials were greater than those obtained in tests using the smaller vials. Concordance was achieved in 40.5% (17/42). The difference was negative (large-vial indurations smaller than small-vial indurations) in 16.7% (7/42) and positive in 42.9% (18/42). Conclusions: The size of the vial may influence tuberculin test results. Adsorption to the sides of the vial may explain this phenomenon. The authors caution others to be aware of the impact of these variations in epidemiological and operational studies.

Keywords: Key words: Tuberculin Skin Test. Tuberculin. Adsorption. PPD. Mantoux.

Tuberculosis continues to be a public health priority in many countries. In 2015, tuberculosis killed 1.4 million people, including 210,000 children. Despite the recent progress made in the control of tuberculosis in Brazil, it is still one of the countries with the highest tuberculosis burdens. In 2015, there were 69,000 reported cases of tuberculosis in Brazil and tuberculosis was the cause of 4,500 deaths in the country. In 2014, the World Health Organization approved the End TB Strategy, which set a target date of 2035 for meeting its goals of reducing the tuberculosis incidence by 90% and reducing the number of tuberculosis deaths by 95%. However, to achieve those goals in Brazil, there is a need for collaboration among the various sectors involved in tuberculosis control and for the prioritization of activities, including control measures targeting the most vulnerable populations. Children are highly vulnerable to tuberculosis, and there are particularities specific to pediatric patients regarding tuberculosis development (rapid progression from infection to active disease), prevention (low effectiveness of vaccination against the pulmonary forms and limited availability of preventive treatment of latent tuberculosis infection), diagnosis (a low rate of bacteriologically confirmed diagnosis), and treatment (poor availability of child-friendly anti-tuberculosis drugs). In this review, we discuss the epidemiology, clinical manifestations, and prevention of tuberculosis in childhood and adolescence, highlighting the peculiarities of active and latent tuberculosis in those age groups, in order to prompt reflection on new approaches to the management of pediatric tuberculosis within the framework of the End TB Strategy.

Keywords: Tuberculosis, pulmonary/prevention & control; Mycobacterium tuberculosis; Lung diseases/etiology; Child; Adolescent.

Objective: To analyze the relationship between one-minute sit-to-stand test (1MSTST) parameters and a diagnosis of post COVID-19 condition in a cohort of patients who previously had COVID-19. Methods: This was a prospective cohort study of patients with post COVID-19 condition referred for body plethysmography at a tertiary university hospital. Post COVID-19 condition was defined in accordance with the current WHO criteria. Results: Fifty-three patients were analyzed. Of those, 25 (47.2%) met the clinical criteria for post COVID-19 condition. HR was lower in the patients with post COVID-19 condition than in those without it at 30 s after initiation of the 1MSTST (86.2 ± 14.3 bpm vs. 101.2 ± 14.7 bpm; p < 0.001) and at the end of the test (94.4 ± 18.2 bpm vs. 117.3 ± 15.3 bpm; p < 0.001). The ratio between HR at the end of the 1MSTST and age-predicted maximal HR (HRend/HRmax) was lower in the group of patients with post COVID-19 condition (p < 0.001). An HRend/HRmax of < 62.65% showed a sensitivity of 78.6% and a specificity of 82.0% for post COVID-19 condition. Mean SpO2 at the end of the 1MSTST was lower in the patients with post COVID-19 condition than in those without it (94.9 ± 3.6% vs. 96.8 ± 2.4%; p = 0.030). The former group of patients did fewer repetitions on the 1MSTST than did the latter (p = 0.020). Conclusions: Lower SpO2 and HR at the end of the 1MSTST, as well as lower HR at 30 s after initiation of the test, were associated with post COVID-19 condition. In the appropriate clinical setting, an HRend/HRmax of < 62.65% should raise awareness for the possibility of post COVID-19 condition.

Keywords: COVID-19; Post-acute COVID-19 syndrome; Heart rate; Respiratory function tests.

Objective: To evaluate whether the use of inhaled albuterol via a metered-dose inhaler with a large-volume spacer with antistatic treatment modifies the bronchodilator test results when compared with the usual technique (no spacer). Methods: A prospective study involving 24 patients, 18-45 years of age, clinically suspected of having asthma, and under treatment at the Outpatient Pulmonary Clinic of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. All of the patients underwent two bronchodilator tests: one with and one without the use of a large-volume spacer. Results: There was no significant difference in the variation of FEV1 prior to and after bronchodilator use between the two techniques (mean FEV1 = 0.01 L; 95% CI: −0.05 to 0.06; p = 0.824). No statistically significant difference was found between the two techniques regarding the qualitative results on the bronchodilator test (p = 1.00). There was concordance between the techniques in terms of the bronchodilator test results (kappa coefficient = 0.909; p < 0.005). Conclusions: According to the results of this study, the use of large-volume spacers does not significantly modify bronchodilator test results.

Keywords: Asthma; Spirometry; Inhalation spacers.

Objective: To evaluate the performance of nested PCR (nPCR) in detecting the Mycobacterium tuberculosis complex in blood samples of patients suspected of having TB, in order to determine its potential for use as an auxiliary tool in the laboratory diagnosis of TB in children. Methods: Detection of the M. tuberculosis complex in blood samples using as a target the insertion sequence IS6110 of the genomic DNA of the bacillus. Blood samples of 120 patients were evaluated. All of the patients were under 15 years of age at the time of their treatment at public hospitals in the city of Recife, Brazil (between January of 2003 and August of 2005). Attending physicians at the hospitals diagnosed TB based on the criteria recommended by the American Thoracic Society. The nPCR amplified a 123-bp fragment with outer oligonucleotides (IS1/IS2) and, in the subsequent reaction, using inner oligonucleotides (IS3/IS4), generating an 81-bp amplicon. Results: Active or latent TB was found in 65 patients, TB was ruled out in 28 suspected cases, and 27 patients were TB-free (controls). The sensitivity of nPCR was 26.15% and was significantly higher for the extrapulmonary form of the disease (55.56%) than for the pulmonary form (18.18%). The specificity was 92.73%. Conclusions: Despite the difficulties in diagnosing TB in children and the low number of cases evaluated in the present study, nPCR in blood samples proved to be a rapid and specific technique, albeit one with low sensitivity. In order to establish its true usefulness in the diagnosis of paucibacillary forms, especially extrapulmonary TB, further studies need to be carried out with a larger sample of children and analyzing biological specimens other than blood.

Keywords: Tuberculosis; Diagnosis; Blood; Polymerase chain reaction.

Objective: To evaluate the accuracy of determining specific IgA to HspX recombinant antigen in pleural fluid and serum samples for the diagnosis of pleural tuberculosis in patients with pleural effusion. Methods: This was a cross-sectional study. Serum and pleural fluid samples of patients with pleural effusion and suspected of having pleural tuberculosis were tested with indirect ELISA in order to determine the optical density of specific IgA to HspX. Results: We evaluated serum and pleural fluid samples from 132 patients: 97 diagnosed with pleural tuberculosis (study group) and 35 diagnosed with pleural effusion due to other causes (control group). The determination of IgA in pleural fluid satisfactorily discriminated between pleural tuberculosis patients and control patients. The sensitivity of the test in pleural fluid and in serum was 69% and 30%, respectively, whereas the specificity was 83% and 84%, respectively. Conclusions: Our data suggest that this test can be used in the diagnosis of pleural tuberculosis. Further studies, involving larger patient samples and different epidemiological scenarios, are warranted.

Keywords: Pleural effusion; Tuberculosis/diagnosis; Enzyme-linked immunosorbent assay.

Objective: To evaluate the results of thoracoscopy for the treatment of pleural empyema in pediatric patients. Methods: A retrospective study of 117 patients who underwent mediastinoscopy or video-assisted thoracoscopy for pleural empyema treatment. General anesthesia and single-lumen oral intubation were used. Surgery was indicated when there was pleural effusion and no clinical and radiological response to clinical treatment (antibiotics, physiotherapy and thoracocentesis) or severe sepsis, together with loculated pleural effusion (confirmed through ultrasound or computed tomography of the chest). Results: Between February of 1983 and July of 2006, 117 thoracoscopies were performed in patients ranging in age from 5 months to 17 years (mean, 4 years). Mean time for thoracic drainage was 9 days (range, 2-33 days), and mean period of hospitalization was 16.4 days (range, 4 to 49 days). One patient (0.8%) died after surgery, and persistent fistula was observed in 33 patients (28%). In 7 cases (6%), open thoracotomy with pulmonary decortication was performed due to the disposition of the empyema. Conclusions: Management of pleural empyema in this age bracket is still controversial, and surgical indication is often delayed, particularly when there are multiple loculations or severe sepsis. Early thoracoscopy yields a better clinical outcome for pediatric patients with pleural empyema, with apparent decreased morbidity and mortality, earlier chest tube removal, earlier hospital discharge and improved response to antibiotic therapy.

Keywords: Empyema, pleural; Pediatrics/instrumentation; Thoracoscopy; Thoracic surgery, video-assisted.

Since the beginning of the use of anti-TNF in the treatment of rheumatoid arthritis and other inflammatory diseases, cases of pulmonary tuberculosis and extrapulmonary tuberculosis have been reported in patients receiving such treatment. In most cases, the disease develops by the time the patient has received the sixth infusion. Every patient should be evaluated for latent tuberculosis infection prior to the use of a TNF inhibitor. However, the diagnosis of latent tuberculosis infection is a challenge. The tuberculin test, which was the only test available to detect latent tuberculosis infection for nearly a century, presents a number of limitations. Tests based on the detection of the in-vitro production of IFN-γ by mononuclear cells activated by specific antigens appear to be more accurate and have been studied in patients with rheumatoid arthritis.

Keywords: Tuberculosis, pulmonary; Arthritis, rheumatoid; Tumor necrosis factor-alpha; Infection.

Objective: Although lean body mass (LBM) has been associated with mortality in patients with COPD, its influence on functional limitation is not clear. The objective of this study was to analyze the cardiopulmonary variables in COPD patients with or without LBM depletion, prior to and after the six-minute walk test (6MWT). Methods: We evaluated COPD patients, 32 with LBM depletion and 36 without. All patients underwent clinical evaluation, spirometry, evaluation of body mass composition and 6MWT, as well as completing questionnaires related to quality of life and perception of dyspnea. Results: No significant differences in the severity of airway obstruction, perception of dyspnea and quality of life scores were found between the groups. The distance covered on the 6MWT was similar in COPD patients with and without LBM depletion (470.3 ± 68.5 m vs. 448.2 ± 89.2 m). However, patients with LBM depletion presented significantly greater differences between baseline and final values in terms of heart rate and Borg scale index for lower limb fatigue. There was a significant positive correlation between distance covered on the 6MWT and FEV1 (r = 0.381, p = 0.01).Conclusions: In the patients studied, functional exercise tolerance and quality of life were unaffected by LBM depletion. However, the patients with LBM depletion presented more pronounced lower limb fatigue during the 6MWT, which underscores the importance of the evaluation and treatment of systemic manifestations in COPD patients.

Keywords: Body mass index; Pulmonary disease, chronic obstructive; Exercise tolerance.