Oral Tuberculosis with Advanced Diagnostic Trends - Jaypee Journals

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CASE REPORT

10.5005/jp-journals-10015-1397 Oral Tuberculosis with Advanced Diagnostic Trends

Oral Tuberculosis with Advanced Diagnostic Trends 1 6

V Pavithra, 2Shwetha Nambiar, 3Dominic Augustine, 4SV Sowmya, 5K Vineeth Kumar Kavitha Prasad, 7Roopa S Rao

ABSTRACT Tuberculosis (TB) is a universally known chronic infectious disease that can affect any part of the body including oral cavity. Though usually affects the lungs, tubercle bacilli can spread hematogenously to involve other parts of the body. Oral lesions, although rare, are very important for early diagnosis and interception of primary TB. Here, we report a case of oral TB that manifested as painless extraoral swelling on the right side of the mandible which was initially small, later increased in size within 3 months. The patient was asymptomatic for pulmonary TB. Excisional biopsy was done. The histopathological section showed granulomatous lesion, and Ziehl–Neelsen (ZN) stain showed acid-fast magenta color rods suggesting tuberculous infection. This prompted us to validate with other advanced diagnostic technique, such as polymerized chain reaction (PCR) for tubercle bacilli. Thus, we emphasize on few advanced diagnostic techniques in the detection of the TB. Keywords: Advanced diagnostic aids, Oral tuberculosis, Tubercle bacilli, Ziehl–Neelsen stain. How to cite this article: Pavithra V, Nambiar S, Augustine D, Sowmya SV, Kumar KV, Prasad K, Rao RS. Oral Tuberculosis with Advanced Diagnostic Trends. World J Dent 2016;7(4):203-207. Source of support: Nil. Conflicts of interest: None

INTRODUCTION Tuberculosis (TB) is caused by Mycobacterium tuberculosis, by direct person-to-person spread through airborne droplets, and less frequently, by intake of infected, unpasteurized cow milk by Mycobacterium bovis or by other atypical mycobacteria.1 Tuberculosis is a major cause of morbidity and mortality worldwide. The risk of infection is much greater among people in lower socioeconomic groups.2 Oral TB lesions are extremely rare and usually observed in children but may also be seen in adults. Tubercle bacilli are most likely carried through sputum or unpasteurized

1 Postgraduate Student, 2Tutor, 3Assistant Professor, 4,5Associate Professor, 6,7Professor and Head 1-7

Department of Oral and Maxillofacial Pathology, Faculty of Dental Sciences, MS Ramaiah University of Applied Sciences Bengaluru, Karnataka, India Corresponding Author: V Pavithra, Postgraduate Student Department of Oral and Maxillofacial Pathology, Faculty of Dental Sciences, MS Ramaiah University of Applied Sciences Bengaluru, Karnataka, India, Phone: +917406027039, e-mail: [email protected]

World Journal of Dentistry, October-December 2016;7(4):203-207

milk which enter the mucosal tissue through a small breach in the oral mucosa.3 Pulmonary TB incidence is increasing due to incidence of HIV infection and emergence of multidrug-resistant (MDR) organisms.4 There is a synergistic relationship between TB and HIV. World Health Organization reports that if TB is left untreated, each person with active TB will infect about 10 to 15 new individuals annually.5 Therefore, effective control of TB is essential, which in turn requires early and accurate detection and diagnosis along with the treatment. Advanced diagnostic aids helps in early detection of TB. If these aids are employed in the primary health care centers, early detection and complete eradication may be possible.

CASE report A 32-year-old female patient reported with a painless swelling on the right side of the lower jaw since 3 months. The swelling was small in size initially, progressed over 2 months to the present size of 2 × 2 cm. There was no history of fever, toothache, weight loss, cough, or previous history of TB. On examination, there was a diffuse swelling in the right lower border of the mandible, ovoid in shape (Figs 1A and B), associated with local raise in temperature, and the swelling was mobile and firm in consistency. The overlying skin was normal. Intraoral findings were normal. Fine-needle aspiration cytology (FNAC) from the lesion and radiograph did not provide any significant findings. Excisional biopsied tissue was received (Fig. 1C). On histopathological examination, the H and E stained section showed well circumscribed lesion with numerous noncaseating granulomas interspersed with fibrous stroma. The granulomas composed of macrophages, epithelioid cells, Langhans type, and foreign body type of multinucleated giant cells with scanty lymphocytic infiltrate (Figs 2A and B). The Ziehl–Neelsen (ZN) stained section showed numerous granulomas with few foci of 10 to 50 rodshaped acid-fast magenta colored bacilli per oil immersion field (Fig. 2C). Polymerized chain reaction (PCR) did not yield a positive result for M. Tuberculosis (Graph 1). Diagnosis of tuberculous granuloma was given based on the special stain.

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A

B

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Figs 1A to C: (A) Clinical photograph showing extraoral swelling of 2 × 2 cm in the right side of the mandible; (B) clinical photograph showing the lesion with irregular nodular surface; and (C) gross specimen of 2 × 1.3 × 1 cm size, ovoid in shape, irregular nodular surface

A

B

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Figs 2A to C: (A) Photomicrograph showing numerous noncaseating granulomas inset shows mature Langhans giant cell (100× H&E); (B) photomicrograph showing granuloma with giant cell, surrounded by epithelioid cells and scanty lymphocytic infiltrate (400× H&E); and (C) Ziehl–Neelsen stain showing magenta colored acid-fast bacilli 10 to 50 rods per oil immersion field

Graph 1: Polymerized chain reaction graph showing negative results in comparison with control taken

DISCUSSION Tuberculosis is a chronic infectious disease caused by Mycobacterium species. Tuberculosis remains a major global health problem and ranks as the second leading cause of death worldwide. The incidence of TB is 9 million, and mortality rate is around 1.5 million cases worldwide every year. India accounts for about 29% of burden of TB in the world.5

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Oral TB accounts for 0.2 to 5% of all the TB infections.6 Mycobacterium tuberculosis infects all parts of the mouth: Soft and hard palate, uvula, buccal mucosa, gingivae, lips, tongue, jaw bones, and can also involve extraction sockets. Clinically the lesions present with solitary ulcers, indurated and ill-defined margins, and a hard necrotic base.7 Robert Koch, in 1882, first isolated the mammalian tubercle bacilli and proved the causative role in TB and described two types of bacillus, M. tuberculosis and M. bovis.8 Humans can be infected both by drinking unpasteurized milk from infected cattle and by inhaling infective droplets.9 Tuberculous infection in the oral cavity is an extremely rare development. The resistance to infection is due to the integrity of the oral epithelium and the cleansing action of saliva.10 Oral lesions occur when the organisms enter the mucosa through a small break in the surface epithelium. The factors that may facilitate the invasion of oral mucosa includes oral ulcers, poor oral hygiene, oral potentially malignant disorders, jaw fractures, dental caries, periapical granulomas, cysts, periodontitis, ill-fitting dentures, etc.11 Here in our case, the lesion presented as an extraoral swelling at the right lower border of the mandible. The oral hygiene was fair, and there were no supportive

WJD Oral Tuberculosis with Advanced Diagnostic Trends

clinical findings of swelling that could be linked to an odontogenic cause, cyst, or neoplasm. Secondary manifestations are caused by autoinoculation of infected sputum by the patient by expectoration or by hematogenous or lymphatic dissemination.10 Hence, both local and systemic factors predispose for the occurrence of the oral lesion. Tuberculosis is caused by M. tuberculosis and M. bovis, which is both acid- and alcohol-fast organism. Histopathology is characterized by the presence of caseating granuloma with epithelioid cells, Langhans giant cells, and dense lymphocytic infiltration. In response to the infection, the activated macrophages, cytokine interferon (IFN), and T cell activity produces a type IV reaction.12 In our case, the histopathology revealed numerous noncaseating granulomas with epithelioid cells, Langhans giant cells with scanty lymphocytic infiltrate. The absence of necrosis is probably due to the early stage of the lesion. Jones and Campbell classified peripheral TB into five clinical stages, where our case presents the clinical features of Stage 1 with enlarged, firm, mobile, discrete mass showing nonspecific reactive hyperplasia without abscess.14

Granulomas with Langhans giant cells and epithelioid cells are the features of granulomatous lesions. This raised the possibility of granulomatous infection, including TB and sarcoidosis. Hence, we employed ZN stain to rule out tuberculous infection.14 In our case, there was a foci of collection of 10 to 50 slender rod-shaped acidfast magenta colored bacilli. Demonstration of acid-fast bacilli in histological section is low, as there is relative scarcity of tubercle bacilli in oral biopsies and only 7.8% of histopathology specimens stain positive for acid-fast bacilli.4 Immunofluorescence staining using auraminerhodamine was used earlier.13 Recent advances for detection of mycobacteria in aspirate samples and tissues is PCR which is said to be fast and reliable.14 We further employed PCR technique for confirmation of the Mycobacteria, but PCR did not yield a positive result, the possible reason for the negative result could be uneven distribution of mycobacteria in tissue samples, inadequate samples sent for PCR, presence of inhibitors or human genomic DNA, loss of DNA during extraction, and absence of IS6110 gene.14 Other few recent advances in diagnosing TB have been described in Table 1.

Table 1: Describing the review on few advanced diagnostic techniques in diagnosing tuberculosis Marker Tuberculin skin test

Interferon gamma release assay

Lymphocyte proliferation assay

Principle Based on Koch’s phenomenon

Advantages For diagnosing pediatric TB Used as screening test Valuable tool in suspected cases of BCG vaccinated cases Beneficial in patients with Measures the Interferon-γ cytokine released by T-cells obtained from blood high risk of developing active sample following restimulation with MTB TB antigens High specificity Compares the reactivity of peripheral Eliminates the cross-reacting lymphocytes to tuberculin purified antigens of nonpathogenic protein derivative (PPD)-B and PPD-A species

MIRU-VNTR: Mycobacterial interspersed repetitive unit (MIRU); variable number tandem repeat (VNTR)

Based on polymorphisms of MIRU loci Set of 15 loci used for molecular epidemiology studies Set of 24 for phylogenetic studies

Good discriminatory power Data format can be exchangeable format

Detection of Lipoarabinomannan (LAM)

Detection of Lipoarabinomannan which is a cell wall liposaccharide antigen of the MTB through ELISA (LAM-ELISA)

Polymorphic GC-rich repetitive sequence (PGRS)-Restriction fragment length polymorphism (RFLP)

Based on number, location and variability in the glycine rich proteins regions

Used in the diagnosis of HIV-associated TB Test is applied on urine sample High specificity Highly significant


Disadvantages False-positive results14

Cannot distinguish an active TB and latent TB15

Time-consuming Logistics and laboratory execution is complicated Expensive15 Set of 12 loci low discriminatory power than IS6110 RFLP Electrophoresis method: Reproducibility is less with band size than the sequencer-based method Expensive15 Sensitivity to HIV-negative patient is low16

Limited data using this technique Time-consuming Analysis is difficult17 Contd…

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V Pavithra et al Contd… Marker IS6110-RFLP IS-Insertion element

Principle Based on number of copies of IS6110 Molecular weights of DNA fragments in which the insertions are found

Spoligotyping

Based on polymorphism in the direct repeat locus which is a member of the CRISPRs (clustered regularly interspaced short palindromic repeats) Culture with enriched media

Septi-chek AFB

Chromatography

Drug-resistance mutations

Large-sequence polymorphism Multilocus sequence typing

Separation of complex mixtures based on the differential affinities of substances for two different media Mutations associated with strains of drug resistance

Presence or absence of specific DNA segments DNA sequences of multiple loci

Whole-genome sequencing Analysis of the whole-genome sequence results

CONCLUSION Primary and secondary TB of the oral cavity is relatively rare and has largely become a forgotten diagnosis in oral lesions. Dental practitioners need to be aware that TB may occur in the oral cavity. Tuberculosis should be considered in the differential diagnosis of oral lesions. Clinical manifestation of reported cases in the literature has been presented as an indurated nonhealing ulcer in the different areas of the oral cavity. In the present case, the lesion manifested as an extraoral swelling in the lower jaw. Polymerized chain reaction has limitations to detect the infectious organisms in the tissue because of the uneven distribution of the organism. Hence, early diagnosis of TB with the help of advanced diagnostic aids should be implemented for improvement of the overall quality of life of individuals.

REFERENCES 1. Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK, Jesudason MV. Primary oral tuberculosis report of two cases. Indian J Dent Res 2006 Jan-Mar;17(1):41-44.

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Advantages Highly significant results with low bias Frequently and widely used

Disadvantages Limited discriminatory power in isolates with five or less IS6110 bands Time-consuming Comparison of results is difficult between the laboratories17 Can be done in sputum sample Low power of discrimination18 Data can be exchanged Good reproducibility Simultaneous detection of M. tuberculosis, nontuberculosis mycobacteria and contaminants Used in epidemiological studies

Long incubation time18

Used to determine the specific mutations on drug-resistant strains Combined with other genetic markers provide high discrimination power Robust marker for phylogenetic classification Robust marker for phylogenetic classification

Only to detect isolates with drug resistance19

Considered to be the gold standard for phylogenetic classification

Initial cost of the equipment is high18

Specific strains cannot be tracked19 Expensive Depending on the loci used, probably limited discriminatory power to be used to track specific strains in the community19 Expensive Need advanced equipments and technology19

2. Aoun N, El-Hajj G, El Toum S. Oral ulcer: An uncommon site in primary tuberculosis. Aust Dent J 2015 Mar;60(1):119-122. 3. Saeed S, Hasan S. Tuberculosis: a public health challenge: brief overview of literature. Int Res Pharm 2016;7(1):1-4. 4. Kapoor S, Gandhi S, Gandhi N, Singh I. Oral manifestations of tuberculosis. CHRISMED J Health Res 2014;1(1):11-14. 5. Saleem A, Azher M. The next pandemic-tuberculosis: the oldest disease of mankind rising one more time. BJMP 2013;6(1). 6. Pai NP, Pai M. Point-of-care diagnostics for HIV and tuberculosis: Landscape, pipeline, and unmet needs. Discov Med 2012 Jan;13(68):35-45. 7. Kakisi OK, Kechagia AS, Kakisis IK, Rafailidis PI, Falagas ME. Tuberculosis of the oral cavity: A systematic review. Eur J Oral Sci 2010 Apr;118(2):103-109. 8. Jain P, Jain I. Oral manifestations of tuberculosis: step towards early diagnosis. J Clin Diagn Res 2014 Dec;8(12):18-21. 9. Ayele WY, Neill SD, Zinsstag J, Weiss MG, Pavlik I. Bovine tuberculosis: an old disease but a new threat to Africa. Int J Tuberc Lung Dis 2004 Aug;8(8):924-937. 10. Kishore DN, Geetha NT, Umashankara KV, Rai KK. Submasseteric tuberculous lesion of mandible: Report of a case and review of the literature. Case Rep Dent 2014.

WJD Oral Tuberculosis with Advanced Diagnostic Trends 11. Kumar B. Tuberculosis of the oral cavity affecting alveolus: a case report. Case Rep Dent 2011;2011:945159. 12. Kumar SN, Prasad TS, Narayan PA, Muruganandhan J. Granuloma with Langhans giant cells: an overview. J Oral Maxillofac Pathol 2013 Sep;17(3):420-423. 13. Mohapatra PR, Janmeja AK. Tuberculous lymphadenitis. J Assoc Physicians India 2009 Aug;57:585-590. 14. Chawla K, Gupta S, Mukhopadhyay C, Rao PS, Sudha S, Bhat SS. PCR for M. tuberculosis in tissue samples. J Infect Dev Ctries 2009 Mar;3(2):83-87. 15. Tadesse B, Ejeta E. Review on convectional and advanced diagnostic techniques of human tuberculosis (TB) in Ethiopia. J Med Lab Diagn 2015 Jan;6(2):9-16.

16. Hamasur B, Bruchfeld J, van Helden P, Källenius G, Svenson S. A sensitive urinary lipoarabinomannan test for tuberculosis. PLoS One 2015 Apr;10(4):e0123457. Doi:10.1371/journal. pone.0123457. 17. Maeda MK, Metcalfe JZ, Flores L. Genotyping of Mycobacterium tuberculosis: application in epidemiologic studies. Future Microbiol 2011 Feb;6(2):203-216. 18. Anochie PI, Onyeneke EC, Ogu AC, Onyeozirila AC, Aluru S, Onyejepu N, Zhang J, Efere L, Adetunji MA, Sanchez JGB. Recent advances in the diagnosis of Mycobacterium tuberculosis. Germs 2015;2(3):110-120. 19. Katoch VM. Newer diagnostic techniques for tuberculosis. Indian J Med Res 2004 Oct;120(4):418-428.


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