BACKGROUND Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis, and the number of new cases of multidrug resistant TB (MDR-TB), pre extensively drug-resistant TB (pre-XDR-TB) and extensively drug-resistant TB (XDR-TB) has increased considerably worldwide. OBJECTIVES Herein, using 156 M. tuberculosis isolates from 106 patients previously classified as MDR or pre-XDR or XDR isolates, we investigated the genetic mutation profiles associated with phenotypic resistances in patients with MDR-TB, pre-XDR-TB and XDR-TB, treatment outcomes and resistance evolution. METHODS Molecular analyses were performed by partial sequencing of the rpoB, katG, gyrA, gyrB, rrs genes and analysis of the fabG-inhA promoter region. Clinical, epidemiologic and demographic data were obtained from the TB Notification database system of São Paulo (TB-WEB) and the Information System for Special Tuberculosis Treatments (SITE-TB). FINDINGS Drug resistance was attributed to previously known mutations and a novel Asp449Val mutation in gyrB was observed in four isolates from the same patient. Ten patients had more than one isolate evaluated and eight of these patients displayed resistance progression. MAIN CONCLUSIONS The present study is the first to report the frequency of mutations related to second-line drug resistance in MDR-TB, pre-XDR-TB and XDR-TB isolates. The results could lead to the improvement of available technologies for the rapid detection of drug resistant TB.

A single strain of Mycobacterium abscessus subsp. bolletii, characterised by a particular rpoB sequevar and two highly related pulsed field gel electrophoresis patterns has been responsible for a nationwide outbreak of surgical infections in Brazil since 2004. In this study, we developed molecular tests based on polymerase chain reaction restriction-enzyme analysis (PRA) and sequencing for the rapid identification of this strain. Sequences of 15 DNA regions conserved in mycobacteria were retrieved from GenBank or sequenced and analysed in silico. Single nucleotide polymorphisms specific to the epidemic strain and located in enzyme recognition sites were detected in rpoB, the 3' region of the 16S rDNA and gyrB. The three tests that were developed, i.e., PRA-rpoB, PRA-16S and gyrB sequence analysis, showed 100%, 100% and 92.31% sensitivity and 93.06%, 90.28% and 100% specificity, respectively, for the discrimination of the surgical strain from other M. abscessus subsp. bolletii isolates, including 116 isolates from 95 patients, one environmental isolate and two type strains. The results of the three tests were stable, as shown by results obtained for different isolates from the same patient. In conclusion, due to the clinical and epidemiological importance of this strain, these tests could be implemented in reference laboratories for the rapid preliminary diagnosis and epidemiological surveillance of this epidemic strain.

O desenvolvimento e a padronização de métodos confiáveis para a detecção de Mycobacterium tuberculosis em amostras clínicas é um objetivo importante nos laboratórios de todo o mundo. Neste trabalho, fragmentos de pulmão e baço de paciente que morreu com o diagnóstico de tuberculose miliar foram usados para avaliar a influência do tipo de fixador e dos protocolos de fixação e inclusão em parafina na performance da PCR. Fragmentos de tecido foram fixados por quatro h a 48 h, usando formalina não tamponada a 10% ou formalina tamponada a 10% e incluídos em parafina pura ou misturada a cera de abelha. As amostras foram submetidas a PCR para amplificação do gene da beta-actina humana e, separadamente, para amplificação da sequência de inserção IS6110, específica do complexo M. tuberculosis. O resultado da amplificação do gene da beta-actina foi positivo em todas as amostras. Não foram gerados amplicons na PCR-IS6110 em amostras de tecido pulmonar fixadas usando formalina não tamponada a 10% e incluídas em parafina com cera de abelha. Em conclusão, fatores inibitórios combinados interferiram na detecção de M. tuberculosis em material de arquivo. É importante controlar estes fatores inibitórios para poder implementar o diagnóstico molecular em laboratórios de patologia.

Development and standardization of reliable methods for detection of Mycobacterium tuberculosis in clinical samples is an important goal in laboratories throughout the world. In this work, lung and spleen fragments from a patient who died with the diagnosis of miliary tuberculosis were used to evaluate the influence of the type of fixative as well as the fixation and paraffin inclusion protocols on PCR performance in paraffin embedded specimens. Tissue fragments were fixed for four h to 48 h, using either 10% non-buffered or 10% buffered formalin, and embedded in pure paraffin or paraffin mixed with bee wax. Specimens were submitted to PCR for amplification of the human beta-actin gene and separately for amplification of the insertion sequence IS6110, specific from the M. tuberculosis complex. Amplification of the beta-actin gene was positive in all samples. No amplicons were generated by PCR-IS6110 when lung tissue fragments were fixed using 10% non-buffered formalin and were embedded in paraffin containing bee wax. In conclusion, combined inhibitory factors interfere in the detection of M. tuberculosis in stored material. It is important to control these inhibitory factors in order to implement molecular diagnosis in pathology laboratories.

Micobactérias não-tuberculosas isoladas no Laboratório Central de Saúde Pública de Mato Grosso do Sul em 2003 e 2004 foram identificadas usando métodos fenotípicos convencionais (TI) e PCR-Restriction Enzyme Analysis (PRA) tendo o gene hsp65 como alvo (PRA-hsp65). Em 15 dos 32 isolados analisados os resultados obtidos com ambos métodos foram concordantes, sendo 8 Mycobacterium avium, 3 M. fortutium, 1 M. kansasii, 1 M. flavescens, 1 M. peregrinum e 1 Nocardia brasiliensis. TI de 12 isolados não foi conclusiva. Perfis não descritos de PRA-hsp65 foram observados com 11 isolados. Dados dos prontuários médicos foram avaliados para inferir a relevância clínica dos isolados.

Non-tuberculous mycobacteria isolated at the Central Public Health Laboratory from Mato Grosso do Sul in 2003 and 2004 were identified by conventional phenotypic methods (TI) and by PCR-Restriction Enzyme Analysis (PRA) using the hsp65 gene as target (PRA-hsp65). With 15 of the 32 analysed isolates, results of both methods were concordant, being 8 Mycobacterium avium, 3 M. fortutium, 1 M. kansasii, 1 M. flavescens, 1 M. peregrinum and 1 Nocardia brasiliensis. TI of 12 isolates was inconclusive. Novel PRA-hsp65 patterns were observed with 11 isolates. Medical data were evaluated for inference of clinical relevance of these isolates.

As micobacterioses suínas são responsáveis por condenações de carcaças em abatedouro e uma das melhores formas de se conhecer os agentes envolvidos nos animais vivos é o isolamento a partir das fezes, pois em 94% das vezes, as lesões localizam-se no trato digestivo. Assim sendo, o presente estudo teve por objetivo comparar o desempenho de quatro métodos de descontaminação com semeadura em três diferentes meios de cultura, totalizando doze procedimentos na pesquisa de micobactérias a partir de amostras de fezes de suínos contaminadas experimentalmente. Amostras de fezes de suínos foram contaminadas artificialmente com 0,02g de Mycobacterium avium, estirpe de PIG-B, e submetidas à tentativa de isolamento de micobactérias, utilizando-se os seguintes protocolos de descontaminação: 1) Petroff modificado ou método básico; 2) Lowenstein-Jensen modificado ou método ácido; 3) Petroff modificado ou método básico e ressuspensão com anfotericina B; 4) Lowenstein-Jensen modificado ou método ácido e ressuspensão com anfotericina B; com subseqüente semeadura em meios de Petragnani, Lowenstein-Jensen e Lowenstein-Jensen com antibióticos (Penicilina G e Ácido nalidíxico). Houve diferença entre os percentuais de recuperação de micobactérias a partir das fezes de suínos (p<0,05) e o método ácido com ressuspensão em solução de anfotericina B e semeadura em meio de Lowenstein-Jensen com antibióticos apresentou os melhores resultados (87% de recuperação de micobactérias).

Swine mycobacteriosis is an important cause of carcass condemnation at abattoirs. One of the best ways to recognize the etiologic agent involved, in live animals, is the fecal isolation, as 94% of the lesions are located in the digestive tract. Therefore, the goal of the present study was to compare the performance of four decontamination methods followed by inoculation in three different culture media, totalizing twelve procedures of mycobacteria search from swine fecal samples experimentally contaminated. The swine feces were artificially contaminated with 0.02 g of Mycobacterium avium, PIG-B strain, and subjected to mycobacteria isolation trial. The protocols used were: 1) modified Petroff or basic method; 2) modified Lowenstein-Jensen or acidic method; 3) modified Petroff or basic method with re-suspension in Amphotericin B; 4) modified Lowenstein-Jensen or acid method with re-suspension in Amphotericin B, followed by inoculation in Petragnani, Lowenstein-Jensen and Lowenstein-Jensen medium with antibiotics (Penicillin G and Nalidixic acid). There was a difference (p<0.05) between the mycobacterial recovery percentages from swine feces. The acid method with re-suspension in Amphotericin B solution and inoculation in Lowenstein-Jensen medium with antibiotics showed the best results (87% of mycobacteria recovery).

O objetivo do caso é descrever a presença de micobactérias viáveis em pacientes com ceratite, 6 meses após tratamento intensivo. A identificação de espécies, foi efetuada usando método PRA (polymerase chain reaction seguida pela restriction endonuclease analysis). Clonalidade foi avaliada pelos métodos RAPD (randomly amplified polymorphic DNA) e ERIC-PCR (enterobacterial repetitive intergenic consensus - polymerase chain reaction). Paciente refere trauma com corpo estranho metálico há 3 semanas. A cultura da córnea revelou Mycobacterium abscessus. Após 6 meses de tratamento tópico e sistêmico, paciente apresentava-se sem inflamação, sendo considerado clinicamente curado. Realizou-se então, uma ceratoplastia penetrante com intuitos ópticos. A cultura da córnea transplantada revelou micobactérias de mesma origem clonal. O achado mais interessante neste relato, foi a positividade da cultura da córnea transplantada após 6 meses de intenso tratamento específico. Ao nosso conhecimento, esse é o primeiro caso relatado na literatura mostrando essa possibilidade em tratamento de ceratites por micobactérias. Assim, os pacientes com ceratite por Mycobacterium abscessus podem apresentar bactérias viáveis após longo tempo de tratamento específico e precisam ser seguidos cuidadosamente por um longo período de tempo.

To report the presence of viable mycobacteria in a patient with keratitis treated for 6 months. Species identification was performed using the PRA method (polymerase chain reaction followed by restriction endonuclease analysis). Clonality was evaluated with RAPD (randomly amplified polymorphic DNA) and ERIC-PCR (enterobacterial repetitive intergenic consensus - polymerase chain reaction) methods. The patient reported trauma due to a metallic foreign body 3 weeks prior to presentation. Initial corneal scraping cultures revealed Mycobacterium abscessus. After 6 months of topical and systemic treatment the patient presented with no active inflammation and was considered clinically cured. An optic penetrating keratoplasty was performed. Culture of the excised cornea revealed Mycobacterium abscessus. Both isolates had the same clonal origin. The most interesting finding of this case report was the positive culture of the excised cornea after 6 months of intensive specific topical therapy. To our knowledge, this is the first report in the literature showing this possibility in the treatment of Mycobacterial keratitis. Thus, Mycobacterium abscessus may present viable bacteria after long-term treatment and should be followed carefully for a long period of time after tapering the medication.

Mycobacterium tuberculosis complex (MTBC) members are causative agents of human and animal tuberculosis. Differentiation of MTBC members is required for appropriate treatment of individual patients and for epidemiological purposes. Strains from six MTBC species - M. tuberculosis, M. bovis subsp. bovis, M. bovis BCG, M. africanum, M. pinnipedii, and "M. canetti" - were studied using gyrB-restriction fragment length polymorphism (gyrB-RFLP) analysis. A table was elaborated, based on observed restriction patterns and published gyrB sequences. To evaluate applicability of gyrB-RFLP at Instituto Adolfo Lutz, São Paulo, Mycobacterial Reference Laboratory, 311 MTBC clinical isolates, previously identified using traditional methods as M. tuberculosis (306), M. bovis (3), and M. bovis BCG (2), were analyzed by gyrB-RFLP. All isolates were correctly identified by the molecular method, but no distinction between M. bovis and M. bovis BCG was obtained. Differentiation of M. tuberculosis and M. bovis is of utmost importance, because they require different treatment schedules. In conclusion, gyrB-RFLP is accurate and easy-to-perform, with potential to reduce time needed for conventional differentiation methods. However, application for epidemiological studies remains limited, because it cannot differentiate M. tuberculosis from M. africanum subtype II, and "M. canetti", M. africanum subtype I from M. pinnipedii, and. M. bovis from M. bovis BCG.

Tendo sido comprovada a existência de quatro famílias molecularmente distintas de M. avium (PIG-A, B, C e D) circulando em suínos da região sul do Brasil, e havendo dúvidas a respeito da importância da transmissão horizontal como mecanismo de manutenção da doença, o presente teve por objetivo estudar a virulência dessas estirpes, informação importante para o aperfeiçoamento dos métodos de controle. Uma estirpe representante de cada família foi inoculada pela via intra-peritoneal em 48 hamsters com uma dose de 30.000 U.F.C. por animal. Após 2, 13, 26 e 40 dias da inoculação (T1 a T4), 12 hamsters inoculados de cada família foram anestesiados, sacrificados e os agentes foram quantificados no fígado, baço e pulmão. Os resultados foram expressos em número de U.F.C./g de órgão. A presença das estirpes foi pesquisada no sangue e também foram realizados exames histológicos. As estirpes PIG-A, B, C e D induziram a formação de lesões granulomatosas no fígado e baço a partir do segundo dia pós-inoculação e disseminaram-se pela via hemática, alcançando os pulmões. O baço sempre apresentou maiores contagens de U.F.C., seguido pelo figado e pulmões. Diferenças entre as estirpes foram constatadas através de análises das contagens de U.F.C de baço (T1: p<0,001; T2: p<0,001; T3: p<0,001 e T4: p<0,001), permitindo a construção da seguinte escala de virulência: PIG-B> PIG-A> PIG-D> PIG-C.

The finding of four clusters of M. avium (PIG-A, B, C and D), typed by the IS1245-RFLP method, infecting the swine population of the south region of Brazil, the possible existence of virulence differences among them, the role of the virulence in the transmission mechanisms of infections and the existence of reasonable doubts regarding the importance of horizontal transmission for swine micobacteriosis, the virulence of these four strains of M. avium were compared. Bacteria from each cluster were inoculated in 48 hamsters by intra-peritoneal route. On the 2nd, 13th, 26th, and 40th days after inoculation, (T1 to T4), 12 animals of each cluster were sacrificed with vapors of ethyl ether and the bacteria were quantified in the liver, spleen and lung. Results were expressed as cfu/g of organ. The presence of the strains was verified in the blood and histological exams were also accomplished. The four strains induced granulomatous lesions in the liver and spleen since 2 days after inoculation and were disseminated to the lungs through the blood stream. The cfu counts from spleen were always bigger them that obtained from liver and lungs. Differences among strains were observed through the analysis of cfu counts from spleen (T1: p<0,001; T2: p<0,001; T3: p<0,001 and T4: p<0,001), allowing the construction of the following virulence scale: PIG-B> PIG-A> PIG-D> PIG-C.

Mais de 70 espécies de micobactérias já foram definidas e algumas delas podem causar enfermidade em humanos, especialmente em pacientes imunocomprometidos. A identificação de espécie, na maioria dos laboratórios clínicos, se baseia em características fenotípicas e testes bioquímicos e resultados definitivos só são obtidos após duas a quatro semanas. Métodos rápidos de identificação reduzem o tempo necessário para o diagnóstico e podem antecipar a instituição do tratamento específico, aumentando as chances de sucesso. A análise de padrões de restrição do gene hsp65 amplificado por PCR (PRA) foi utilizada como método rápido de identificação em 103 isolamentos clínicos. Os padrões de bandas foram interpretados por comparação com tabelas publicadas e padrões disponíveis em um site de Internet (<a HREF="http://www.hospvd.ch:8005/">http://www.hospvd.ch:8005</a>). Resultados concordantes de PRA e identificação bioquímica foram obtidos em 76 de 83 isolamentos (91,5%). Os resultados de 20 isolamentos não puderam ser comparados porque a identificação fenotípica ou por PRA foi inconclusiva. Os resultados deste trabalho mostram que PRA pode ser útil para identificação de rotina de micobactérias por ser um método acurado, rápido e mais econômico do que a identificação convencional.

More than 70 species of mycobacteria have been defined, and some can cause disease in humans, especially in immunocompromised patients. Species identification in most clinical laboratories is based on phenotypic characteristics and biochemical tests and final results are obtained only after two to four weeks. Quick identification methods, by reducing time for diagnosis, could expedite institution of specific treatment, increasing chances of success. PCR restriction-enzyme analysis (PRA) of the hsp65 gene was used as a rapid method for identification of 103 clinical isolates. Band patterns were interpreted by comparison with published tables and patterns available at an Internet site (http://www.hospvd.ch:8005). Concordant results of PRA and biochemical identification were obtained in 76 out of 83 isolates (91.5%). Results from 20 isolates could not be compared due to inconclusive PRA or biochemical identification. The results of this work showed that PRA could improve identification of mycobacteria in a routine setting because it is accurate, fast, and cheaper than conventional phenotypic identification.

A identificação bioquímica de micobactérias não permite a discriminação das espécies do complexo Mycobacterium avium (MAC). Este estudo mostrou que a amplificação por PCR de DT1 e DT6, duas sequências de cópia única identificadas no genoma de M. avium sorotipo 2, da sequência de inserção IS1245, encontrada consistentemente em cepas de M. avium e de um fragmento do gene da proteína de choque térmico hsp65, seguida da análise do polimorfismo de restrição, são testes rápidos e acurados para a diferenciação das espécies M. avium, M. intracellulare e M. scrofulaceum.

Mycobacterium avium complex (MAC) species cannot be discriminated by the usual methods of biochemical identification of mycobacteria. This study showed that amplification by PCR of DT1 and DT6, two single copy sequences identified in the genome of M. avium serotype 2, the insertion sequence IS1245, found to be consistently present in M. avium strains and the heat-shock protein gene hsp65, followed by restriction polymorphism analysis, are rapid and accurate tests for the differentiation of the species M. avium, M. intracellulare, and M. scrofulaceum.