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P6 Ocular tuberculosis: a survey of uk clinical practice

Background Ophthalmic manifestations of tuberculosis (TB) are described as inflammatory events in one or both eyes involving the uvea, optic nerve or orbit. The diagnosis is almost always presumptive as mycobacterium are rarely cultured from ocular/periocular tissues. Ocular TB is rare in the developed world and there is a general lack of consensus regarding diagnosis and treatment duration. We surveyed UK specialists involved in the diagnosis and treatment of tuberculous uveitis to examine current clinical practice. Method A previously validated survey based on two clinical cases (one more likely to have TB, one less likely to have TB) was used to examine diagnostic and treatment practices amongst consultants from three different specialities across different institutions in the UK: ophthalmologists with an interest in uveitis, respiratory, and infectious disease (ID) physicians with a TB interest. Results Ten ophthalmologists, 24 ID and 29 respiratory physicians completed the survey. Responses varied greatly within the same specialty as well as between different specialities. For example, in a patient with chronic granulomatous panuveitis and a known TB risk factor, the pre-test likelihood of having ocular TB varied significantly within the groups: ophthalmologists (range 5%–95%), respiratory (range 20%–99%), ID (range 9%–90%). Similarly, for the same scenario, there was disagreement in the optimal duration of treatment. Whilst the majority of clinicians would treat for 6 months, 17 clinicians (24%) – ophthalmologists [3], respiratory [5], ID [9] – would treat for longer than 6 months. All 10 ophthalmologists (100%) would defer antibiotic treatment decisions to a TB specialist rather than initiate treatment themselves. All ID and respiratory physicians would screen for HIV if ocular TB was suspected, whereas only 6 (60%) of ophthalmologists would. Conclusion Diagnosis of ocular TB is challenging due to lack of a gold standard test. Expert consensus is therefore important to ensure the right patients are treated appropriately. This is the first multidisciplinary survey within the UK capturing a spectrum of opinions regarding ocular TB. The Results highlight a lack of consensus both within and between different specialties in the field. An open dialogue between relevant stakeholders is key to harmonising diagnostic and treatment strategies.

S39 Preliminary Results of a Latent Tuberculosis Screening and Treatment Project and the Role of TB Services in Secondary Care

Introduction Since July 2014, the London Borough of Newham has offered latent tuberculosis (TB) screening to all recent migrants (residing in the UK less than 5 years), aged 16–50 years, from countries with a TB incidence of greater than 150/100 000 cases/year. All migrants are offered an interferon gamma-release assay (IGRA) when registering with a general practitioner. Active TB is excluded by the GP using chest radiography, blood tests and clinical examination. All IGRA positive patients are tested for HIV, Hepatitis B and C. All patients without underlying liver disease, Hepatitis B, C or HIV infection and those who are not immunosuppressed are offered treatment for LTBI with Rifampicin and Isoniazid for 3 months in primary care. Patients with positive results not meeting the above exclusion criteria are referred to the local secondary care service using a standardised referral protocol. We conducted a retrospective study reviewing records of all patients referred to secondary care from the LTBI screening programme. Results From July 2014 to March 2015, a total of 5683 patients were offered screening. 3272 proceeded to IGRA testing of which 866 were positive. Of these patients, 138 were referred to the TB clinic. The most common reasons for referral were symptoms suggestive of active TB (26%), abnormal liver function tests (19%) before and after initiation of treatment, an abnormal chest radiograph (CXR) (10%), Pregnancy or breastfeeding (9%), Hepatitis B or C infection (7%) or previously treated latent or active TB (7%). Of those referred, 11 patients were found to have active disease. 6 patients had mediastinal lymphnode TB, 4 pulmonary and one patient had TB of the knee. Conclusion Screening for latent tuberculosis in primary care has identified a significant of number of cases of active Tuberculosis, particularly mediastinal TB.

P253 Isoniazid and Multi-Drug Resistant Mycobacterium Tuberculosis: The East London Experience

Introduction East London has one of the UK’s largest cohorts of Drug Resistant Tuberculosis (DR-TB). This paper aims to provide insight into the recent behaviour of DR-TB in a multi-ethnic urban TB clinic. Methods A retrospective study was conducted on all patients with DR-TB between 2007 and 2013. Statistical analysis was performed using Fisher’s Exact Test. Results 179 cases were identified: 126 patients had Isoniazid mono-resistance (H-Mono), 3 had poly-resistance including Isoniazid, and 37 patients had multi-drug resistant TB (MDR-TB). There were 6 cases of Rifampicin mono-resistance, 1 Ethambutol mono-resistance, and 6 Pyrazinamide mono-resistance. H-Mono and MDR-TB were more prevalent in males (58% and 57% respectively). H-Mono predominated in younger age groups (mode age group 25–29) whilst MDR-TB had a more uniform age distribution (Figure 1). The ethnicities of patients with DR-TB reflected the local population (Indian Subcontinent: 57% of H-Mono and 52% MDR-TB; Africa: 16% for both; Caucasian: 11% and 16% respectively; Other: 16% for both).Abstract P253 Figure 1 The majority were non-UK born, however a meaningful proportion were UK-born (H-Mono 17% and MDR-TB 14%). Patients from all WHO world regions with DR-TB were more likely to have H-Mono, apart from Eastern Europe, where MDR-TB was more common (p = 0.005). The proportion of patients with pulmonary TB was similar in both cohorts (54% H-Mono and 65% MDR-TB, p = 0.26), as was the proportion of patients who were sputum smear-positive (46% and 38% respectively, p = 0.64). More patients with MDR-TB had a history of previous TB diagnosis compared to patients with H-Mono (p = 0.0005). Of note, the 5 UK-born patients with MDR-TB were all under the age of 40 with no specific risk factors or previous TB treatment. The number of TB notifications fell during this period, however the proportion of patients with MDR-TB remained stable at approximately 1%. In contrast, cases with any drug resistance reduced. Conclusion H-mono and MDR-TB shared many demographical features, but in this cohort there were significant differences in age distribution, previous diagnosis of TB and country of origin. A significant proportion of patients did not match the typical profile of DR-TB, highlighting the importance of culture to exclude drug-resistance in all individuals.

P257 Modern Day Scrofulous Swellings: Breast Tuberculosis in East London

Introduction Breast tuberculosis (TB) is rare and diagnosis may be delayed. It was first described in 1829. Incidence is highest in TB endemic areas. Here we describe a series of cases diagnosed in East London (UK). Methods We conducted a retrospective study of all patients treated at our institution for breast TB between 2005 – 2015. Data including demographics, symptoms, microbiological, histological diagnoses and treatment outcomes were recorded. Results 35 cases of breast TB were identified (1 male). Mean age at diagnosis was 33 years (range 16 – 63). 24 patients were from the Indian subcontinent, 3 Asian other, 7 Black-African and 1 Middle Eastern; no patients were Caucasian. Three patients were lactating, two were pregnant. Four patients had a previous history of TB and one was HIV positive. All patients presented with a breast lump, 58% in the upper outer quadrant. 25 patients initially presented to their general practitioner (GP), of which 24 were referred to breast clinic and 1 directly to TB clinic. Eight cases presented to hospital. In two cases there was insufficient data. The breast lump was associated with skin changes in six cases, inverted nipple in three, discharge in one, and 49% had ipsilateral axillary lymphadenopathy. Erythrocyte sedimentation rate and C-reactive protein was raised in 84% and 53% cases respectively. Thirty percent of patients had abnormal mammography, 68% abnormal ultrasound breast findings. 25 out of 35 cases had biopsies/fine needle aspirations (FNA), all of these were sent for culture; 17 were culture positive with 3 drug resistant cases. Nine cases had necrotising granulomatous changes on histology, of which 1 was positive for Ziehl-Neelson (ZN) stain, 9 cases had non-necrotising granulomas, of which 2 were ZN positive, and 7 cases had inflammatory changes only (none were ZN positive). All patients received at least three anti-tuberculous drugs. Median treatment duration was six months, leading to complete resolution of breast TB. Conclusion This case series highlights the difficultly in diagnosing breast TB. Raising awareness of the classical presentation of breast TB amongst GPs and breast services may improve diagnosis and treatment of this rare disease.