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Letter to the Editor
Is Multidrug-resistant Extrapulmonary Tuberculosis Important? If So, What Is Our Strategy? ENG
Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
Correspondence to:This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Ewha Med J 2021; 44(4): 148-149
Published October 31, 2021 https://doi.org/10.12771/emj.2021.44.4.148
Copyright © Ewha Womans University School of Medicine.
I read the manuscript entitled “Differentiating between intestinal tuberculosis and Crohn’s disease may be complicated by multidrug-resistant
In the current paper, I summarize the literature on the prevalence of and diagnostic strategies for extrapulmonary MDR TB, including ITB.
MDR TB is diagnosed on the basis of resistance to both rifampin and isoniazid [5]. According to the World Health Organization global TB report, about 2.7% of all TB infections are caused by MDR TB [2]. As drug resistance is a ‘man-made’ problem, MDR TB is also not unrelated to the issues of
The most common sites for extrapulmonary MDR TB are the lymph nodes, followed by bones. Although MDR ITB is rare, it occurs more commonly than has been previously assumed. A Korean retrospective study of 400 ITB patients reported a sensitivity of 44.1% for mycobacterial culture of colonoscopic biopsy samples. The prevalence of MDR and single drug-resistance ITB were 2.7% and 17.6%, respectively [8]. In India, where ITB is endemic, 13.9% of patients had MDR ITB and required second-line anti-TB therapy on the basis of the drug sensitivity pattern. Resistance to at least one first-line anti-TB drug was found in 23.2% of ITB patients. Resistance to isoniazid was the most common, followed by rifampin [7].
Although mycobacterial culture is the gold standard diagnostic test for ITB, its yield for
In areas where the prevalence of TB is still high, and the prevalence of CD is also on the rise, such as Korea, misdiagnosis of the two diseases can often occur, and the resulting incorrect treatment can lead to a problem that delays the recovery of the patient’s true disease. A trial of anti-TB treatment is recommended to differentiate between TB and CD when the diagnosis is not clear [9]. However, the problem with this differentiation method is that if empirical first-line anti-tubercular therapy fails, the conversion to CD treatment is made without much thought, but the actual patient could be MDR ITB.
No diagnostic method can rapidly and accurately identify extrapulmonary MDR TB, including MDR ITB, at the early disease stage. Therefore, mycobacterial culture should be performed at the time of diagnosis of TB to exclude MDR TB, especially in Korea, where the prevalence of TB is higher than that in the West. According to the Korean TB practice guidelines published in 2020, culture of the initial tissue biopsy sample should be performed to increase the diagnostic yield and determine the presence of MDR TB. If the culture is positive for TB, a drug susceptibility test should be performed [5].
Although TB has been studied extensively, there is still much to learn about it. The importance of extrapulmonary MDR TB has been overlooked and data on extrapulmonary MDR TB are sparse. However, the elimination of TB requires overcoming the challenge of extrapulmonary MDR TB. Despite the limitations, diagnostic tests for MDR TB, including TB culture and drug susceptibility testing, should be routinely performed. Additionally, patients with TB should be treated with the appropriate drugs for an adequate duration.
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