8 million new cases of extrapulmonary tuberculosis (EPTB) were observed in 2010 worldwide (WHO, 2011). EPTB Enzalutamide clinical trial has become more common since the advent of human immunodeficiency virus (HIV) infection (Cabandugama et al., 2011; WHO, 2011). EPTB constitutes about 15–20% of TB cases and can constitute up to 50% of TB cases in HIV-infected individuals (Noussair et al., 2009; Peto
et al., 2009; Cortez et al., 2011). As India has high burden of TB cases, thus proportionately higher number of EPTB cases are also observed in this country (WHO, 2011). The diagnosis of smear-positive PTB has been considerably established, but the diagnosis of smear-negative PTB, TB–HIV co-infection and EPTB poses serious challenges (Golden & Vikram, 2005; Chang, 2007). Diagnosis of EPTB, in particular, is difficult owing to paucibacillary nature of the specimens, lack of adequate clinical sample volumes and nonuniform distribution of bacteria in those specimens as well as the disease localized in sites that are difficult to access (Chakravorty et al., 2005; Cheng et al., 2005; Galimi, 2011). Various methods are employed for the diagnosis of EPTB such as smear microscopy, culture identification, histopathology, tuberculin skin test (TST), serological assays, interferon-gamma release assays (IGRAs) and nucleic acid amplification (NAA) tests (Katoch, 2004; Lange & Mori, 2010). Smear microscopy is widely used in the diagnosis
of EPTB but has drawbacks owing to Phospholipase D1 low and variable sensitivity values (0–40%) and could not differentiate between Mycobacterium tuberculosis CCI-779 concentration and nontuberculous mycobacteria (NTM; Liu et al., 2007; Haldar et al., 2011; Derese et al., 2012). Culture identification for M. tuberculosis also has variable sensitivities (0–80%) in different extrapulmonary specimens (Padmavathy et al., 2003; Sharma & Mohan, 2004; Takahashi et al., 2008; Abbara & Davidson, 2011) with turnaround time of 4–8 weeks and requires skilful technicians (Mehta et al., 2012). Diagnosis of EPTB from tissue samples is usually made by histopathological examination that depends on the presence of granulomatous inflammation and caseous
necrosis (Liu et al., 2007; Almadi et al., 2009). However, histology does not distinguish between EPTB and infections from other granulomatous diseases such as NTM, sarcoidosis, leprosy and systemic lupus erythematosus (except for the presence of acid-fast bacilli; AFB; Bravo & Gotuzzo, 2007; Chawla et al., 2009). The TST is useful for the diagnosis of EPTB; however, false-positive reactions occur as a result of previous Bacille Calmette–Guérin (BCG) vaccination or sensitization to NTM, and false-negative results occur in the immunocompromised patients, elderly persons or overt forms of TB (Lange & Mori, 2010). The in vitro T-cell-based IGRAs have been used for the diagnosis of both latent and active TB, but these assays do not differentiate between latent and active TB infection (Pai & O’Brien, 2008).