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Diagnostic and Treatment Monitoring Potential of A Stool-Based Quantitative Polymerase Chain Reaction Assay for Pulmonary Tuberculosis

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  • 1 The Global TB Program, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas;
  • | 2 Internal Medicine-Infectious Diseases, Baylor College of Medicine, Houston, Texas;
  • | 3 The Baylor-Swaziland Children’s Foundation, Mbabane, Swaziland;
  • | 4 Ministry of Health, Mbabane, Swaziland;
  • | 5 Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas;
  • | 6 The National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas
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A quantifiable, stool-based, Mycobacterium tuberculosis (Mtb) test has potential complementary value to respiratory specimens. Limit of detection (LOD) was determined by spiking control stool. Clinical test performance was evaluated in a cohort with pulmonary tuberculosis (TB) (N = 166) and asymptomatic household TB child contacts (N = 105). Stool-quantitative polymerase chain reaction (qPCR) results were compared with sputum acid-fast bacilli (AFB) microscopy, GeneXpert MTB/RIF (Xpert MTB/RIF), and cultures. In Mtb stool-spiking studies, the LOD was 96 colony-forming units/50 mg of stool (95% confidence interval [CI]: 84.8–105.6). Among specimens collected within 72 hours of antituberculosis treatment (ATT) initiation, stool qPCR detected 22 of 23 (95%) of culture-positive cases. Among clinically diagnosed cases that were Xpert MTB/RIF and culture negative, stool qPCR detected an additional 8% (3/37). Among asymptomatic, recently TB-exposed participants, stool PCR detected Mtb in two of 105 (1.9%) patients. Two months after ATT, the Mtb quantitative burden in femtogram per microliters decreased (Wilcoxon signed-rank P < 0.001) and persistent positive stool PCR was associated with treatment failure or drug resistance (relative risk 2.8, CI: 1.2–6.5; P = 0.012). Stool-based qPCR is a promising complementary technique to sputum-based diagnosis. It detects and quantifies low levels of stool Mtb DNA, thereby supporting adjunct diagnosis and treatment monitoring in pulmonary TB.

Author Notes

Address correspondence to Anna M. Mandalakas, Baylor College of Medicine, One Baylor Plaza, Mail Stop BCM286, Houston, TX 77030. E-mail: anna.mandalakas@bcm.edu

Financial support: This work was supported by Early Career Grants by ASTMH/ Burroughs Wellcome Fund and the Thrasher Research Fund (A. R. D.). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. R. M. reports grants and other from Romark Laboratories outside the submitted work.

Conflicts of interest: The authors do not have a commercial or other association that would be a conflict of interest. Aspect of these data was presented at the International Union Conference of Tuberculosis and Lung Disease, Liverpool, United Kingdom, 2016. No authors have changed address since completion of the study.

Authors’ addresses: Andrew R. DiNardo, Department of Global and Immigrant Health, Baylor College of Medicine, Houston, TX, E-mail: andrew.dinardo@bcm.edu. Alexander W. Kay, Celia Fung, and Pilar Ustero, Global TB department, The Baylor-Swaziland Children’s Foundation, Mbabane, Swaziland, E-mails: alexander.kay@bcm.edu, celiafung2015@gmail.com, and pustero@yahoo.es. Gugu Maphalala and Sindisiwe Dlamini, National Reference Laboratory, Swaziland Ministry of Health, Mbabane, Swaziland, E-mails: gpmaph@hotmail.com and sindydlamini36@yahoo.com. Nadine M. Harris, Internal Medicine-Infectious Diseases, Baylor College of Medicine, Houston, TX, E-mail: nmharris09@gmail.com. Godwin Mtetwa, Global TB Department, Baylor-Swaziland Children’s Foundation, Mbabane, Swaziland, E-mail: gmtetwa@baylorswaziland.org.sz. Ngan Ha and Edward A. Graviss, Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, E-mails: npha@houstonmethodist.org and eagraviss@houstonmethodist.org. Rojelio Mejia, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, E-mail: rojelio.mejia@bcm.edu. Anna M. Mandalakas, Global TB Program, Baylor College of Medicine, Houston, TX, E-mail: anna.mandalakas@bcm.edu.

Reprint requests: Patricia Dorman, Baylor College of Medicine and Texas Children’s Hospital, 1102 Bates St., Houston, TX 77030, E-mail: padorman@texaschildrens.org, Phone: 832-822-133, Fax: 832-825-1281.

These authors contributed equally to this work.

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