This protocol describes a study in which we would assess the effect of using community lay counselors, self-help groups (SHGs), and trained frontline health workers to reduce mental disorders and improve quality of life (QOL) of persons affected by leprosy or Buruli ulcer (BU). A cluster randomized controlled study design will be employed. The study will involve persons affected by leprosy or BU. Ten local government areas (clusters) with the highest number of notified leprosy or BU cases between 2014 and 2018 in Southern Nigeria will be purposively selected. The clusters will be randomized into intervention and control groups using a computer-generated list of random numbers. At baseline, data were collected using the following validated questionnaires, Patient Health Questionnaire, Generalized Anxiety Disorder questionnaire, Stigma Assessment and Reduction of Impact Scale, World Health Organization QOL BREF and Warwick-Edinburgh Mental Well-being scale among persons affected by leprosy or BU. The intervention will last for 2 years and will involve use of community lay counselors, SHGs, and appropriately trained frontline health workers in reducing mental disorders and improving QOL of persons affected by leprosy or BU. This project postulates that the reduction of burden of mental health problems and improved QOL among persons affected by leprosy or BU could be achieved through a holistic approach involving SHGs, appropriately trained community opinion leaders, and general health-care workers as well as a functional referral system. If successful, the model will be integrated into the activities of the National Tuberculosis and Leprosy Control Programme and scaled up nationwide. Trial registration: ISRCTN Registry: ISRCTN 83649248. https://trialsearch. who.int/Trial2.aspx? TrialID % ISRCTN83649248 Prospectively registered.

Background: Post tuberculosis (TB) sequelae are faced by many individuals who survive TB. The most common of all is post-TB chronic lung disease (CLD) and pulmonary impairment. We reviewed studies that estimated the prevalence of post-TB CLD in patients with TB only and those with TB-HIV coinfection. Methods: Searched Google scholar, PubMed, African journals online, Embase, and Cochrane Central Register of Clinical Trials from the year 2000 to 01 March 2022 for all designs of studies that examined the impact of post on lung impairment or damage. The protocol was registered in PROSPERO, ID: chronic respiratory disease 42022304628. Results: Three hundred and thirty-six studies were identified and five studies were identified through other sources, four were finally in the meta-analysis with a total of 4382 enrolled participants. All the studies had a low risk of bias; The prevalence of CLD between the TB HIV coinfection and those with TB only was of no statistical significance between the three of the four studies – new statement: the prevalence of CLD in the TB-HIV coinfected group when compared to the group of participants with TB only was not statistically significant in the study. This was seen in three of the four studies. One study was in favor of the high prevalence of CLD in HIV coinfection participants (relative risk [RR] = 0.75 [0.61–0.89] with 95% confidence interval [0.61–0.89]). Conclusions: Post-TB lung disease is still a burden that needs advocation and an increase of awareness is necessary from the health-care level to the communities and societies, especially in regions of high prevalence. Development of guidelines for health-care workers to aid the management of individuals, multi-disciplinary advocacy is necessary for those whom prevention is not too late.

Aims: Rapid and accurate identification of mycobacteria is important for the species-specific treatment of the disease. The aim of this study was the identification at the species level of 34 nontuberculous mycobacteria strains isolated from respiratory tract samples and 14 reference strains as by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Materials and Methods: Isolates derived from clinical specimens were subcultured in the Lowenstein–Jensen medium. Deoxyribonucleic acid isolation was carried out using the boiling method. PCR amplification was performed using primers specific to the hsp65 gene region. The PCR products were digested BstEII and HaEIII enzymes. All samples were studied comparatively by two different centers. Results: In our study, the most common species were found to be Mycobacterium intracellulare in 23.52% (8/34). The performance of the PCR-RFLP method in detecting mycobacteria was found to be 82.35%. Conclusions: The PCR-RFLP method is a rapid, cheap, and practical method for the identification of mycobacteria.

Background: The antibiotic-exposed bacteria often contain the reactive oxygen species (ROS), hydroxyl radical, which inflicts genome-wide mutations, causing the de novo formation of antibiotic-resistant strains. Hydroxyl radical is generated by Fenton reaction of Fe (II) with the ROS, H₂O₂, which, in turn, is formed by the dismutation of the ROS, superoxide. Therefore, for the emergence of bacterial strains genetically resistant to antibiotics, increased levels of superoxide, H₂O₂, hydroxyl radical, and Fe (II) should be present in the antibiotic-exposed bacteria. Here, we verified this premise by finding out whether the in vitro cultures of M. smegmatis, exposed to MBC of moxifloxacin for a prolonged duration, contain significantly high levels of superoxide, H₂O₂, hydroxyl radical, and Fe (II). Methods: Biological triplicate cultures of M. smegmatis, were exposed to MBC of moxifloxacin for 84 h. The colony-forming units (CFUs) of the cultures were determined on moxifloxacin-free and moxifloxacin-containing plates for the entire 84 h at a regular interval of 6 h. The cultures were analyzed at specific time points of killing phase (KP), antibiotic-surviving phase (ASP), and regrowth phase (RGP) for the presence of superoxide, H₂O₂, hydroxyl radical, and Fe (II) using the ROS- and Fe (II)-detecting fluorescence probes. The experimental cultures were grown in the presence of ROS and Fe (II) quenchers also and determined the levels of fluorescence corresponding to the ROS- and Fe (II)-specific probes. This was performed to establish the specificity of detection of ROS and Fe (II). Biological triplicate cultures, unexposed to moxifloxacin but cultured for 84 h, were used as the control for the measurement of ROS and Fe (II) levels. The CFUs of the cultures were determined on moxifloxacin-free and moxifloxacin-containing plates for the entire 84 h at regular intervals of 6 h. Flow cytometry analyses were performed for the detection and quantitation of the levels of fluorescence of the ROS-and Fe (II)-specific probes. The experimental cultures were grown in the presence of thiourea and bipyridyl as the ROS and Fe (II) quenchers, respectively, for the determination of the levels of fluorescence corresponding to the ROS- and Fe (II)-specific probes. Paired t-test was used to calculate statistical significance (n = 3). Results: The moxifloxacin-exposed cultures, but not the cultures unexposed to moxifloxacin, showed a triphasic response with a KP, ASP, and RGP. The cells in the late KP and ASP contained significantly elevated levels of superoxide, H₂O₂, hydroxyl radical, and Fe (II). Thus, high levels of the ROS and Fe (II) were found in the small population (in the ASP) of M. smegmatis cells that survived the moxifloxacin-mediated killing. From this moxifloxacin-surviving population (in the ASP), moxifloxacin-resistant genetic resisters emerged de novo at high frequency, regrew, divided, and populated the cultures. The levels of these ROS, Fe (II), and the high moxifloxacin resister generation frequency were quenched in the cultures grown in the presence of the respective ROS and Fe (II) quenchers. The cultures unexposed to moxifloxacin did not show any of these responses, indicating that the whole response was specific to antibiotic exposure. Conclusions: Significantly high levels of superoxide, H₂O₂, hydroxyl radical, and Fe (II) were generated in the M. smegmatis cultures exposed to moxifloxacin for a prolonged duration. It promoted the de novo emergence of genetic resisters to moxifloxacin at high frequency.

Background: Mycobacterial fatty acid synthase Type-II (FAS-II) components are major virulence factors exploited as potential targets for developing novel antimycobacterial drugs. The FAS-II enzyme 3-hydroxyacyl-ACP dehydratase (HadC) is important for biofilm development and pathogenesis of Mycobacterium tuberculosis and other mycobacterial species. Methods: Literature review and homology search led to the identification of Mycobacterium fortuitum MFhadC gene. Functional interaction study of MFHadC protein was done using STRING. M. fortuitum MFhadC over-expressing (HS) and knockdown (HA) strains were constructed and validated by expression analysis using quantitative polymerase chain reaction. The strains were analyzed for growth behavior and surface spreading ability. Biofilm formation was assayed through crystal violet assay, viability count, and basic fuchsin staining. In addition, survival of the strains was studied under in vitro nutrient starvation and detergent stress. Results: STRING analysis showed the interaction of HadC with proteins involved in biofilm formation. The strains HS and HA showed spreading ability on the agarose surface, exhibiting translocation patterns similar to the vector control strain. All three strains showed a similar amount of biofilm formation when analyzed using crystal violet assay, viability count, and basic fuchsin staining. The strains showed no deviation in survival when incubated under nutrient starvation and detergent stress. Conclusion: Our results suggest that MFhadC may not be important for the formation and maintenance of biofilm, a factor critically important in M. fortuitum pathogenicity. However, not essential for survival and growth, MFhadC maintains the viability of M. fortuitum under a nutrient-starved environment. Collectively, MFhadC may not be used as a biofilm-specific marker for M. fortuitum.

Background: Nontuberculous mycobacteria (NTM) are on the rise worldwide. The diagnosis and treatment of NTM disease create a dilemma for physicians as their clinical features often overlap with that of tuberculosis (TB). The present study aims to report a series of NTM infections presenting as suspected TB. Methods: It was a prospective observational study starting from December 2018 to January 2022. A total of 1850 suspected TB patients (pulmonary = 522 and extrapulmonary = 1328) were included in this study. Clinical features, radiological findings, microbiological diagnosis, treatment, and outcome were recorded. Clinical specimens were processed for Ziehl–Neelsen staining, GeneXpert MTB/Rif assay by cartridge-based nucleic acid amplification test, and culture. The culture-positive isolates were categorized as Mycobacterium tuberculosis complex or NTM depending on the detection of MPT64 antigen by immunochromatographic test. The NTM isolates were speciated by line probe assay using GenoType® Mycobacterium common mycobacteria kit. The criteria of the American Thoracic Society/Infectious Diseases Society of America were applied to confirm NTM disease. Results: Of 1850 suspected TB patients, NTM disease was diagnosed in 20 patients (pulmonary = 9, nonpulmonary = 11). Eight NTM cases presented as suspected drug-resistant-TB with a history of antitubercular therapy. Among pulmonary NTM cases, Mycobacterium scrofulaceum (n = 7) was the most common species followed by Mycobacterium kansasii (n = 1) and Mycobacterium intracellulare (n = 1). In nonpulmonary cases, Mycobacterium abscessus (n = 8) was involved in majority of cases followed by Mycobacterium fortuitum (n = 3). Cavitary lung disease and laparoscopic port site infections were most frequent pulmonary and non-pulmonary manifestations respectively. Conclusion: Hence, there is an urgent need for better diagnostic and drug susceptibility testing facility along with standardized treatment protocol for NTM disease.

Background: The aim of this study was to evaluate the prevalence of active tuberculosis (TB) infection in Moroccan patients with rheumatic diseases under biologic therapy, and to describe the demographic characteristics of these patients as well as to explore potential risk factors. Methods: This 14-year nationally representative multicenter study enrolled Moroccan patients with rheumatic diseases who had been treated with biologic therapy. Patient medical records were reviewed retrospectively for demographic characteristics, underlying rheumatic diseases, associated comorbidities, and TB-related data. Results: In total, 1407 eligible patients were studied, detailed records were obtained for only 130 patients; 33 cases with active TB were identified at an estimated prevalence rate of 2.3%. The mean age was 42.9 ± 12 years and 75.8% were males. Ankylosing spondylitis accounted for 84.8% of active TB cases, and the majority of the cases (31/33) occurred among antitumor necrosis factor-alpha (TNF-α) users. A total of 8 out of 33 patients were positive at initial latent TB infection (LTBI) screening by tuberculin skin test and/or interferon-gamma release assay. Consumption of unpasteurized dairy products (odds ratio [OR], 34.841; 95% confidence interval [CI], 3.1–389.7; P = 0.04), diabetes (OR, 38.468; 95% CI, 1.6–878.3; P = 0,022), smoking (OR, 3.941; 95% CI, 1–159.9; P = 0.047), and long biologic therapy duration (OR, 1.991; 95% CI, 1.4–16.3; P = 0.001) were identified as risk factors for developing active TB. Conclusion: Moroccan patients with rheumatic diseases under anti-TNF-α agents are at an increased TB risk, especially when risk factors are present. Strict initial screening and regular monitoring of LTBI is recommended for patients living in high TB prevalence areas.

Background: Recently, moxifloxacin (MFX)-resistant results of Mycobacterium tuberculosis (Mtb) obtained by GenoType MTBDRsl (second-line line probe assay [SL-LPA]) have been stratified to determine their resistance level; however, its accuracy has not been well studied. Therefore, the study aimed to evaluate the diagnostic accuracy of SL-LPA, with phenotypic drug susceptibility testing (pDST) and whole-genome sequencing (WGS) for the detection of MFX-resistant Mtb and their resistance level. Methods: A total of 111 sputum samples were subjected to SL-LPA according to the diagnostic algorithm of the National Tuberculosis Elimination Program. Results were compared with pDST of MFX (at critical concentration [CC, 0.25 μg/ml] and clinical breakpoint [CB, 1.0 μg/ml] using BACTEC mycobacterial growth indicator tube-960), and WGS. Results: At CC, SL-LPA and pDST yielded concordant results of MFX for 104 of 111 (94%). However, at CB, 23 of 30 (77%) isolates carrying gyrA mutation known to confer low-level resistance to MFX were scored as susceptible by pDST. Among 46 Mtb isolates carrying gyrA mutations known to confer high-level resistance to MFX, 36 (78%) isolates yielded concordant results, while 10 (22%) isolates were scored as susceptible at CB by pDST. WGS identified gyrA mutations in all isolates suggested by SL-LPA. Conclusion: It is concluded that the stratification of MFX-resistant results by SL-LPA/genotypic method is not very well correlated with pDST (at CB), and hence, pDST may not be completely replaced by SL-LPA. gyrA D94G and gyrAA90V are the most prevalent mutations in MFX-resistant Mtb.

Background: Bovine tuberculosis (bTB) is still a prominent threat to animal health; lacking an efficient vaccine, other than BCG to get rid of tuberculosis, the most effective way for this is culling and slaughtering the infected animals. There are several cellular, serological, and molecular tests for the diagnosis of the disease but the most practical one at the field level is the double skin testing with bovine and aviary tuberculins. This is not a very specific test but is sensitive enough to identify most diseased animals; adjunct practical tests are desirable to strengthen the utility of skin tests. All lymphoid and myeloid cells participate, in diverse grades, in the immune response to tuberculosis with neutrophils playing an unintended pathologic role. The study aimed to investigate the response of neutrophils to agents present in the sera of tuberculous cows. Methods: We have developed a neutrophil-based test (N BT) to identify diseased cows within a herd suspected of having tuberculosis; a positive N BT correlates with a positive double skin test. In this test, healthy neutrophils are incubated with the sera of healthy or tuberculous cows for 3 and 6 h, and the nuclear morphologic changes are recorded and analyzed. Results: Sera from tuberculous but not from healthy cows induce nuclear alterations including pyknosis, swelling, apoptosis, and sometimes NETosis, in healthy neutrophils, and CFP 10 and ESAT 6 participate in the phenomenon. Conclusion: We propose the N BT as an auxiliary tool for substantiating the diagnosis of bTB reinforcing the PPD test outcome to help decide whether or not a cow should be sacrificed.

Spontaneous hydropneumothorax (HP) and mediastinal emphysema (ME) are infrequently presented complications of pulmonary tuberculosis (TB). A-34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic chest pain. He had no history of any surgery, TB, comorbid disease, or other serious pulmonary diseases. Chest radiography revealed a right-sided HP and parenchymal infiltration. The laboratory results of pleural effusion showed elevated adenosine deaminase levels with the empyema features. Acid-fast bacilli were detected and Mycobacterium tuberculosis without any drug resistance grew in the culture both in the sputum and pleural fluid. A chest tube was inserted immediately. A prolonged airway leak was detected. Hepatotoxicity protocol has been initialized (due to increased hepatic enzymes in the initial presentation) and followed without observing any complications associated with the treatment. On the 25^th day of the standard TB treatment protocol, we observed hepatic enzymes in the normal range. Around 40-days of a hospitalization period, he started developing fever and methicillin-resistant Staphylococcus aureus was detected in the pleural fluid culture. We introduced linezolid to the treatment regimen in addition to the antituberculosis protocol. Although spontaneous ME is a benign disease, it might be life-threatening and difficult to manage when complicated with HP and active TB infection. Active TB should be considered a differential diagnosis once ME or HP was detected, and treatment should be started immediately for both diseases.

Tuberculosis (TB) and lung cancer are the leading causes of mortality and morbidity in the world. The burden of TB is significantly high in developing countries causing serious public health concern, and the incidence of lung cancer is also increasing all around the world with high mortality. Pulmonary TB coexisting with lung cancer can mask the underlying disorder producing diagnostic dilemma resulting in a delay in diagnosis leading to decreased survival of the patients. Here, we report a rare case of a 66-year-old male diagnosed with microbiologically confirmed TB along with coexisting small cell neuroendocrine carcinoma of the lung presenting with syndrome of inappropriate antidiuretic hormone.

Weil's syndrome, a severe form of the disease, may present with symptoms such as jaundice, renal dysfunction, and hemorrhagic diathesis and it can progress to multi-organ failure leading to death. In patients with coinfection of tuberculosis with leptospirosis, there may be severe hepatic and renal dysfunction rendering the standard antitubercular therapy (ATT) regimen useless, thus requiring alternate drug selection and dose modification of antitubercular drugs. We present a case of a 57-year-old female who presented with high-grade fever and yellowish discoloration of the eyes. She was diagnosed with Weil's disease and started on treatment. She later developed altered sensorium and lumbar puncture was suggestive of tubercular meningitis. Due to her deranged renal and hepatic function tests, she was started on a modified regimen of ATT with intermittent dialysis. The patient responded to treatment and was shifted to the standard Isoniazid, Rifampicin, Pyrazinamide, Ethambutol (HRZE) regimen once renal and hepatic functions returned to normal.

Tuberculosis verrucous cutis (TBVc) is a skin infection caused by M. tuberculosis, characterized by the presence of a solitaire verrucous plaque but may present as a varies of different clinical morphologies on the finger and or feet. The diagnosis is often late because of its mimicking other diseases with different etiology. Bacterial culture examination is negative because there are few pathogens in the lesion. Meanwhile, other diagnostic methods provide lower sensitivity and specificity which add further diagnostic challenges. We presented one case report of TBVc mimicking chromoblastomycosis. A 26-year-old man complain a multiple papule-plaque verrucose on the dorsum of the right foot and extending to all of fingers for 2 years ago. The first lesion appears as a small papule verrucous then progressively to form plaque with curst yellow-red and central healing. Examination of bacterial culture with Ziehl–Neelsen stain and GeneXpert did not find M. tuberculosis but could not rule out the diagnosis of TBVc. The diagnosis was established based on the correlation of clinical manifestations and dermoscopy with histopathological examination. To date, there is no gold standard for TBVc testing. Correlation analysis of clinical manifestations, dermoscopy, and histopathology can be considered to establish the diagnosis of TBVc, especially if the culture is negative and the limitations of polymerase chain reaction tools.

Intramedullary tuberculoma (IMT) is considered to be a rare form of spinal tuberculosis (TB). Overall, TB of the central nervous system accounts for approximately 1% of all cases of TB and 50% of these involve the spine. The clinical presentation of spinal intramedullary TB is similar to an intramedullary spinal cord tumor mass. The factors attributable could be malnutrition, poor socioeconomic conditions, and immunodeficiency syndromes. As per the reports, the incidence of primary intramedullary TB is 2 in 100,000 cases among patients with TB. We describe one such patient who presented with progressive asymmetrical paraparesis due to histologically confirmed intraspinal tuberculoma. Paraparesis in spinal IMT is considered to be rare. Hereby, we present the case of a 29-year-old female who presented with asymmetric onset paraparesis of 6 months with associated numbness and tingling began in the left foot 3 months which was ascending in nature. There was no history of stiffness, involuntary movements, flexor spasms, thinning, or fasciculations of muscles. There was a loss of sensation pain, touch, and temperature below L3 with normal reflexes. Power in both the lower limbs was 1/5 as per Medical Research Council (MRC) grading. She underwent a contrast magnetic resonance imaging spine which was suggestive of an intramedullary SOL at D12 vertebral level. The patient underwent surgical intervention with resection of the SOL. Histopathology was confirmed to be an IMT. She was started on Category 1 (antitubercular drugs) and further investigated for primary source, which was found to be negative. We want to emphasize that TB can involve any part of the body. It should be kept as a differential diagnosis of any chronic inflammatory lesion involving the bony skeleton, especially in endemic countries where combined surgical and medical treatment is usually sufficient to provide a cure.

This is a case report of patient suffering from multiple central nervous system tuberculoma which progressed to tubercular abscess. Patient developed signs and symptoms of mass effect and compression. Computed tomography of brain and magnetic resonance spectroscopy confirmed the diagnosis. Patient underwent left temporal craniotomy with evacuation of pus. The abscess wall and the pus sent for histopathological and microbiological examination which confirmed the etiological agent – Mycobacterium tuberculosis. Appropriate treatment was started and discharged. Hence, early diagnosis and treatment of intracranial tuberculoma are pivotal in preventing morbidity and mortality of the condition.

Histoid leprosy is an expression of multibacillary leprosy with unique histopathology and characteristic bacterial morphology. It is characterized by the occurrence of asymptomatic firm, dome-shaped succulent papulonodules on apparently normal skin, or subcutaneous tissues. There are very few reports of the detection of Mycobacterium leprae in the epidermis in leprosy, which may have a possible role in transmission. We report five de novo cases of histoid leprosy with transepidermal elimination.