结核分枝杆菌抗原检测研究进展

结核病仍然是一个严重的全球性公共卫生问题,有效控制结核病的障碍在于缺乏早期、准确的诊断方法。机体受到结核分枝杆菌感染后,体内首先出现的是结核分枝杆菌特异性抗原。因此,结核分枝杆菌抗原检测作为结核病早期诊断的方法可能具有很高的诊断价值。我们简要综述了结核分枝杆菌抗原检测的相关研究进展。     

一种随机引物联合多特异性DNA片段检测结核分支杆菌的新方法

目的:针对目前结核性疾病实验室诊断的局限性,探索一种更为敏感和特异的结核分枝杆菌DNA检测新方法。方法:选取10株江苏地区流行的结核分支杆菌(MTB)菌株,选取临床其他常见菌株及分枝杆菌菌株作为对照组,分别提取DNA作为随机引物的模板。参考国内、外文献设计12条随机引物,并分别对MTB及对照菌株进行单个引物随机扩增,2%的琼脂糖凝胶电泳对扩增产物进行分离并切胶纯化,通过TA克隆将纯化片段连接到质粒pEASYTM-T5 Zero并进行测序,通过BLAST-nr比对验证是否为MTB DNA片段。按照所确定的MTB片段序列,在其内部设计、合成一对特异性引物。用此特异性引物扩增对应的随机引物扩增产物,获得MTB特异性条带图谱。并将该方法检测的敏感性和特异性与临床上常用的real-time PCR进行比较。结果:经BLAST-nr比对,随机引物IS986F,S535及IS986R扩增的条带与MTB DNA有高度同源性(均为99%)。随机引物IS986F、S535和IS986R分别联合其特异性引物可以检测稀释105倍、105倍和103倍的MTB DNA,其特异性分别为100%、90%和80%。常规real-time PCR可检测出稀释104倍的MTB DNA。结论:随机引物IS986F联合其特异性引物检测结核分枝杆菌的灵敏度和特异性优于S535、IS986R两组,特异性为100%,且灵敏度优于常规real-time PCR法。     

Rapid and simple identification of Beijing genotype strain of Mycobacterium tuberculosis using a loop‐mediated isothermal amplification assay

Beijing genotype strains of Mycobacterium tuberculosis are geographically widespread and pose a notorious public health problem, these strains causing outbreaks of multidrug‐resistant tuberculosis (TB); some studies have reported an association with drug resistance. Because the prevalence of Beijing strain has a substantial impact on TB control programs, the availability of a rapid and reliable method for detecting these strains is important for epidemiological monitoring of their circulation. The main methods currently used to identify Beijing genotype strains are IS6110 DNA fingerprinting, spoligotyping and PCR to detect specific deletions such as region of difference (RD)207. More recently, multiplex PCR assay using a Beijing‐specific single nucleotide polymorphism (SNP) has been developed for detecting Beijing lineage strains. However, these methods are time‐consuming and technically demanding. In the present study, a loop‐mediated isothermal amplification (LAMP) assay that allows specific identification of Beijing genotype strain was developed. This Beijing genotype strain‐identifying LAMP assay was performed 214 clinical isolates and the results compared with those of conventional PCR that targeted RD207 and Rv0679c‐targreting multiplex PCR for Beijing lineage identification. LAMP assay showed 100% sensitivity and specificity compared with RD207‐PCR. Furthermore, the sensitivity and specificity were 99.3% and 100%, respectively, compared with Rv0679c‐multiplex PCR. This LAMP assay could be used routinely in local laboratories to monitor the prevalence of the Beijing genotype strain and thereby used to help control the spread of these potentially highly virulent and drug resistant strains.     

Rapid detection of Phytophthora nicotianae by simple DNA extraction and real‐time loop‐mediated isothermal amplification assay

Phytophthora nicotianae is a phytopathogenic oomycete with a wide host range and worldwide distribution. Rapid detection and diagnosis at the early stages of disease development are important for the effective control of P. nicotianae. In this study, we designed a simple and rapid loop‐mediated isothermal amplification (LAMP)‐based detection method for P. nicotianae. We tested three DNA extraction methods and selected the Kaneka Easy DNA Extraction Kit version 2, which is rapid and robust for LAMP‐based detection. The designed primers were tested using mycelial DNA from 35 species (81 isolates) of Phytophthora, 12 species (12 isolates) of Pythium, one isolate of Phytopythium and one isolate each from seven other soil‐borne pathogens. All of the 42 P. nicotianae isolates were detected by these primers, and no other isolates gave positive results. Three isolates were tested for the sensitivity of the reaction, and the lowest amounts of template DNA that could be detected were 10 fg for two isolates and 1 fg for the third. The target was detected within 25 min in all tested samples, including DNA extracted from both inoculated and naturally infected plants. In contrast, PCR assays with P. nicotianae‐specific primers failed or showed weakened detection in several samples. Thus, we found that the rapid DNA extraction and LAMP assay methods developed in this study can be used to detect P. nicotianae with high sensitivity, specificity and stability.     

Loop‐mediated isothermal amplification method for rapid detection of Vibrio alginolyticus,the causative agent of vibriosis in mariculture fish

Aims: The purpose of this study was to develop a loop‐mediated isothermal amplification (LAMP) method for the rapid, sensitive and simple detection of Vibrio alginolyticus in mariculture fish. Methods and Results: LAMP primers were designed by targeting the gyrB gene. With Bst DNA polymerase, the target DNA can be clearly amplified for 60 min at 64°C in a simple water bath. The detection sensitivity of the LAMP assay for the detection of V. alginolyticus is about 3·7 × 10² CFU ml^?1 (3·7 CFU per reaction). LAMP products could be judged with agar gel or naked eye after the addition of SYBR Green I. There were no cross‐reactions with other bacterial strains indicating a high specificity of the LAMP. The LAMP method was applied to detect V. alginolyticus‐infected fish tissues effectively. Conclusions: The LAMP established in this study is a simple, sensitive, specific, inexpensive and rapid protocol for the detection of V. alginolyticus. Significance and Impact of the Study: This LAMP method provides an important diagnostic tool for the detection of V. alginolyticus infection both in the laboratory and field.     

结核分枝杆菌/利福平耐药实时荧光定量核酸扩增检测技术对肺外结核性脓肿的诊断价值分析

摘要 目的：探讨结核分枝杆菌/利福平耐药实时荧光定量核酸扩增检测技术（Xpert MTB/RIF）对肺外结核性脓肿的诊断价值。方法：收集2020年1月至2021年12月无锡市第五人民医院住院的122例高度疑似肺外结核性脓肿患者为研究对象,在超声引导下对脓肿病灶进行针吸穿刺活检,脓液标本分别进行Xpert MTB/RIF检测、结核杆菌脱氧核糖核酸（TB-DNA）检测、MGIT 960培养以及涂片抗酸染色。以临床综合诊断作为参考标准,比较Xpert MTB/RIF检测、TB-DNA检测、MGIT 960培养以及涂片抗酸染色四种方法对肺外结核性脓肿的诊断效能。对比Xpert MTB/RIF检测和MGIT 960药敏试验对利福平的耐药性。观察各类肺外结核性脓肿患者的诊断延迟时间。结果：122例疑似患者中,最终确诊肺外结核性脓肿患者73例,非结核性脓肿者49例。Xpert MTB/RIF检测、MGIT 960培养、TB-DNA检测以及涂片抗酸染色四种方法在肺外结核性脓肿标本中的阳性检出率结果分别为89.04%、20.55%、58.90%、36.99%,四种方法的阳性检出率整体比较差异有统计学意义（P<0.01）,Xpert MTB/RIF检测的阳性检出率明显高于MGIT 960培养、TB-DNA检测以及涂片抗酸染色法,差异均有统计学意义（P<0.05）。以临床综合诊断作为参考标准,Xpert MTB/RIF检测诊断肺外结核性脓肿者的临床诊断价值最高,其敏感度、特异度、阳性预测值、阴性预测值分别为89.04%、100.00%、100.00%、85.96%。Xpert MTB/RIF检测与MGIT 960药敏试验对利福平耐药率之间差异无统计学意义（P>0.05）。肺外结核性脓肿诊断存在明显延迟,尤其以关节结核性脓肿诊断延迟时间最长,平均为103.5天;但在结核性脓胸患者中诊断延迟时间最短,平均为7.6天。结论：与MGIT 960培养、TB-DNA检测以及涂片抗酸染色比较,Xpert MTB/RIF在肺外结核性脓肿中的阳性检出率较高,临床诊断价值最佳,表明其可用作为疑似结核性脓肿患者的快速诊断工具,同时在结核耐药性方面亦可以做到快速筛查。     

Development of an antimicrobial formulation for control of specimen-related contamination in phage-based diagnostic testing for tuberculosis

AIMS: To develop and evaluate an antimicrobial supplement for use with phage-based tests for rapid detection of drug resistance of tuberculosis (TB). METHODS AND RESULTS: An antimicrobial formulation containing nystatin, oxacillin and aztreonam (NOA) (final concentrations of 50,000 IU l(-1), 2 mg l(-1), and 30 mg l(-1) respectively) was developed. This formulation was tested for its influence on detection of a number of Mycobacterium tuberculosis (MTB) strains using the phage amplification (FASTPlaque) assay. Addition of the supplement did not lead to significant reduction in assay sensitivity. Antimicrobial efficacy was assessed with a range of Gram-positive and -negative organisms. The NOA supplement had a broad antimicrobial effect. The supplement was tested for its effect on growth of MTB culture, and on determination of rifampicin resistance using the phage-based methodology (FASTPlaque-Response). NOA did not significantly affect the growth of a range of rifampicin susceptible and resistant MTB strains, nor did it have an adverse effect on the number of interpretable results, nor the ability to discriminate between rifampicin susceptibility and resistance. CONCLUSION, SIGNIFICANCE AND IMPACT OF STUDY: Use of NOA antimicrobial supplement with rapid phage-based tests for TB will increase the proportion of interpretable results obtained, and enable their wider implementation in disease-endemic countries by improved control of specimen-related contamination.     

结核病实验诊断技术

结核病诊断一直是控制结核病疫情的关键,快速准确、敏感特异、简便低廉的诊断方法是目前迫切需要的.从结核分枝杆菌快速诊断噬菌体法、AMPLICOR(R) MTB试验、Gen-Probe分子生物学诊断方法到T-SPOT.TB和QuantiFeron-Gold Test免疫学检测方法,结核病实验诊断方法在不断改进和完善.近年来...     

Comparison of loop-mediated isothermal amplification and real-time PCR for the diagnosis of tuberculous pleurisy

Aims: Tuberculous pleurisy is an important cause of pleural effusions in areas with a high incidence of tuberculosis. In this study, we developed an IS1081‐based LAMP for the detection of Mycobacterium tuberculosis complex and investigated its usefulness in the diagnosis of tuberculous pleurisy. Methods and Results: Investigation of pleural effusion samples from patients with tuberculous pleurisy, majority of them smear‐/culture‐negative, and control individuals with non‐TB diseases showed that the LAMP assay with incubation time of 60 min has much higher specificity and the LAMP assay with incubation time of 90 min has significantly higher sensitivity in the diagnosis of tuberculous pleurisy, as compared with fluorescent real‐time PCR. Conclusions: The MTBC–LAMP is a useful assay for the diagnosis of tuberculous pleurisy, especially in pleural effusion smear‐/culture‐negative patients. Significance and Impact of the Study: Tuberculous pleural effusion usually contains low number of mycobacteria, which leads to low diagnostic sensitivity of acid‐fast staining and mycobacterial culture methods. In this study, we developed a simple and sensitive LAMP assay for the diagnosis of tuberculous pleurisy. This assay should have broad application in resource‐limited settings.     

用于结核分枝杆菌与非结核分枝杆菌鉴定的4种方法效能比较

比较硝基苯甲酸/噻吩−2−羧酸肼（PNB/TCH）生长试验、胶体金法、荧光PCR法和基因芯片法用于结核分枝杆菌（MTB）和非结核分枝杆菌（NTM）鉴定的效能,从而为临床选择鉴别MTB和NTM的实验室方法提供参考依据。

收集2021—2022年疑似肺结核患者痰液和肺泡灌洗液样本,选择经BACTEC MGIT 960全自动快速分枝杆菌培养鉴定药敏仪液体培养阳性的440份标本,分别采用PNB/TCH生长试验、胶体金法、荧光PCR法和基因芯片法鉴定MTB和NTM。以16S rRNA基因测序法为金标准,比较4种方法的效能。

440份分枝杆菌阳性标本,16S rRNA基因测序法鉴定出MTB和NTM分别为316株和124株。PNB/TCH生长试验、胶体金法、荧光PCR法和基因芯片法鉴定MTB的敏感度分别为96.5%、97.8%、100.0%和99.7%,差异具有统计学意义（χ² = 17.261,P = 0.012）;特异度分别为90.3%、100.0%、100.0%和98.4%,差异具有统计学意义（χ² = 29.110,P＜0.001）;符合率分别为94.8%、98.4%、100.0%和99.3%,κ值分别为0.87、0.96、1.00和0.98。

PNB/TCH生长试验、胶体金法、荧光PCR法和基因芯片法均可用于MTB和NTM鉴定。胶体金法和荧光PCR法鉴定MTB时效性较好,但胶体金法经济、便捷,更适合于基层临床实验室MTB快速鉴定;基因芯片法对软、硬件均有一定要求、检测成本较高,在一定程度上限制了临床的普及应用。

     

肺外结核病微生物学诊断方法的研究和应用进展

肺外结核病指由结核分枝杆菌（Mycobacterium tuberculosis, MTB）感染所引起的发生在肺部以外器官和部位的结核病。近年来肺外结核的发病率逐渐升高,未能得到早期有效治疗的肺外结核病患者可能并发畸形、截瘫甚至死亡等严重后果。微生物学检测方法对从病原学角度诊断肺外结核病至关重要。基于此,总结了近年来肺外结核病细菌学检查方法、结核分枝杆菌的抗原检测与分子生物学检测等微生物学诊断方法的概况及应用进展,并对这些检测方法的优缺点及适用范围进行了分析、比较,以期为今后肺外结核病病原学诊断的研究提供相关信息。     

A simple and sensitive method for detection of Bacillus anthracis by loop‐mediated isothermal amplification

Aims: To develop a rapid and simple system for detection of Bacillus anthracis using a loop‐mediated isothermal amplification (LAMP) method and determine the suitability of LAMP for rapid identification of B. anthracis infection. Methods and Results: A specific LAMP assay targeting unique gene sequences in the bacterial chromosome and two virulence plasmids, pXO1 and pXO2, was designed. With this assay, it was possible to detect more than 10 fg of bacterial DNA per reaction and obtain results within 30–40 min under isothermal conditions at 63°C. No cross‐reactivity was observed among Bacillus cereus group and other Bacillus species. Furthermore, in tests using blood specimens from mice inoculated intranasally with B. anthracis spores, the sensitivity of the LAMP assay following DNA extraction methods using a Qiagen DNeasy kit or boiling protocol was examined. Samples prepared by both methods showed almost equivalent sensitivities in LAMP assay. The detection limit was 3·6 CFU per test. Conclusions: The LAMP assay is a simple, rapid and sensitive method for detecting B. anthracis. Significance and Impact of the Study: The LAMP assay combined with boiling extraction could be used as a simple diagnostic method for identification of B. anthracis infection.     

Binding of Leishmania spp with gold nanoparticles supported polyethylene glycol and its application for the sensitive detection of infectious photogenes in human plasma samples: A novel biosensor

The management of pathogen detection using a rapid and cost‐effective method presents a major challenge to the biological safety of the world. The field of pathogen detection is nascent and therefore, faces a dynamic set of challenges as the field evolves. Visceral leishmaniasis (VL), or kala‐azar is the most severe form of leishmaniasis. Delay to the accurate diagnosis and treatment is likely to lead to fatality. The reliable, fast and sensitive detection is closely linked to safe and effective treatment of Leishmania spp. Despite several routine and old method for sensitive and specificity detection of Leishmania spp, there is highly demand for developing modern and powerfully system. In this study a novel ultra‐sensitive DNA‐based biosensor was prepared for detection of Leishmania spp. For the first time, the specific and thiolated sequences of the Leishmania spp genome (5′‐SH‐[CH₂]₆ ATCTCGTAAGCAGATCGCTGTGTCAC‐3′) were recognized by electrochemical methods. Also, selectivity of the proposed bioassay was examined by three sequences that were mismatched in 1, 2, and 3 nucleotides. The linear range (10^?6 to 10^?21 M) and limit of detection (LLOQ = 1 ZM) obtained are remarkable in this study. Also, simple and cost‐effective construction of genosensors was another advantage of the proposal DNA‐based assay. The experimental results promise a fast and simple method in detection of kala‐azar patients with huge potential of the nanocomposite‐based probe for development of ideal biosensors.     

Xpert MTB/RIF在人类免疫缺陷病毒感染/艾滋病患者中诊断结核病的价值

为探讨利福平耐药结核分枝杆菌实时荧光定量核酸扩增检测技术(Xpert Mycobacterium tuberculosis/rifampicin,Xpert MTB/RIF)在人类免疫缺陷病毒感染/艾滋病(human immunodeficiency virus infection/acquired immunodeficiency syndrome,HIV/AIDS)患者中诊断结核病的价值,本研究回顾性分析了2018年1月1日—2020年12月31日复旦大学附属公共卫生临床中心感染与免疫科收治的801例HIV/AIDS合并疑似结核病患者的临床资料。801例患者中,657例进行了Xpert MTB/RIF、外周血结核感染T细胞斑点试验(tuberculosis T cell spot test,T-SPOT.TB)、抗酸染色涂片镜检和BACTEC MGIT 960液体培养等检测。以液体培养及菌型鉴定结果作为结核病诊断的“金标准”,确诊结核病92例,Xpert MTB/RIF、T-SPOT.TB、抗酸染色涂片镜检在HIV/AIDS患者中诊断结核病(包括肺结核和肺外结核)的灵敏度分别为72.8%、55.4%和69.6%,特异度分别为96.8%、90.3%和84.4%,与“金标准”行一致性检验,Kappa值分别为0.719 (P<0.01)、0.430(P<0.01)和0.424(P<0.01)。Xpert MTB/RIF检测502份呼吸道样本,结果显示其诊断肺结核的灵敏度和特异度分别为66.7%和96.0%;在痰涂片阳性和阴性的患者中,Xpert MTB/RIF诊断肺结核的灵敏度分别为77.4%和35.2%,特异度分别为87.7%和 97.8%。采用Xpert MTB/RIF检测343份肺外标本,结果显示其诊断肺外结核的灵敏度和特异度分别为63.3%和95.2%。以上结果提示,Xpert MTB/RIF在HIV/AIDS患者中诊断结核病(包括肺结核和肺外结核)具有较高的灵敏度和特异度,诊断肺结核的灵敏度高于肺外结核,因此推荐将其作为HIV/AIDS患者疑似结核病的首选检测方法。     

Co‐amplification of cytochrome b and D‐loop mtDNA fragments for the identification of degraded DNA samples

We propose a simple and effective approach to simultaneously co‐amplify both cytochrome b and D‐loop fragments to evaluate DNA preservation and to monitor possible contaminations in the analysis of degraded animal DNA samples. We have applied this approach to over 200 ancient salmon samples and 25 ancient whale DNA samples, clearly demonstrating its multiple benefits for analysis of degraded DNA samples, and the ease in which co‐amplification can be optimized for different taxa. This simple, cost‐efficient and genomic DNA‐saving approach can be used routinely in the analysis of minute and degraded DNA samples in wildlife forensics, food inspection, conservation biology and ancient faunal remains.     

Rapid and simple detection of the invA gene in Salmonella spp. by isothermal target and probe amplification (iTPA)

Aims: Salmonella spp. are an important cause of food‐borne infections throughout world, and the availability of rapid and simple detection techniques is critical for the food industry. Salmonella enterica serovars Enteritidis and Typhimurium cause the majority of human gastroenteritis infections, and there are a reported 40 000 cases of salmonellosis in the United States each year. Methods and Results: A novel rapid and simple isothermal target and probe amplification (iTPA) assay that rapidly amplifies target DNA (Salmonella invA gene) using a FRET‐based signal probe in an isothermal environment was developed for detection Salmonella spp. in pre‐enriched food samples. The assay was able to specifically detect all of 10 Salmonella spp. strains without detecting 40 non‐Salmonella strains. The detection limit was 4 × 10¹ CFU per assay. The iTPA assay detected at an initial inoculum level of <10 CFU in the pre‐enriched food samples (egg yolk, chicken breast and peanut butter). Conclusions: This detection system requires only a water bath and a fluorometer and has great potential for use as a hand‐held device or point‐of‐care‐testing diagnostics. The iTPA assay is sensitive and specific and has potential for rapid screening of Salmonella spp. by food industry.     

Rapid detection of Mycobacterium tuberculosis based on antigen 85B via real-time recombinase polymerase amplification

Tuberculosis (TB), as a common infectious disease, still remains a severe challenge to public health. Due to the unsatisfied clinical needs of currently available diagnostic vehicles, it is desired to establish a new approach for universally detecting Mycobacterium tuberculosis. Herein, we designed a real-time recombinase polymerase amplification (RPA) technology for identifying M. tuberculosis within 20 min at 39°C via custom-designed oligonucleotide primers and probe, which could specifically target antigen 85B (Ag85B). Particularly, the primers F4-R4 produced the fastest fluorescence signal with the probe among four pairs of designed primers in the RPA assays. The optimal primers/probe combination could effectively identify M. tuberculosis with the detection limit of 4·0 copies per μl, as it could not show a positive signal for the genomic DNA from other mycobacteria or pathogens. The Ag85B-based RPA could determine the genomic DNA extracted from M. tuberculosis with high reliability (100%, 22/22). More importantly, when testing clinical sputum samples, the real-time RPA displayed an admirable sensitivity (90%, 95% CI: 80·0-96·0%) and specificity (98%, 95% CI: 89·0-100·0%) compared to traditional smear microscopy, which was similar to the assay of Xpert MTB/RIF. This real-time RPA based Ag85B provides a promising strategy for the rapid and universal diagnosis of TB.     

重组酶聚合酶扩增技术检测结核分枝杆菌

目的 利用重组酶聚合酶扩增（Recombinase Polymerase Amplification,RPA）技术检测结核分支杆菌。方法 采用Axxin T8-ISO扩增仪（TwistDX公司）,反应温度设置为39℃,反应时间20 min。检测分为实验组、阳性对照组和空白对照组。实验组模板DNA从痰液中提取。阳性对照模板DNA为H37Rv标准菌株样本DNA及卡介苗提取的DNA。空白对照为蒸馏水。结果 RPA技术可在20 min内明显区分103~106 copies/mL的阳性质粒与阴性对照。对分离培养的结核杆菌（H37Rv）DNA及卡介苗提取的DNA,阳性克隆质粒进行等温扩增,结果结核杆菌分离株DNA、卡介苗DNA、阳性克隆质粒均有阳性扩增反应,而非结核分枝杆菌分离株和阴性对照无阳性扩增反应。灵敏度为100%,特异性为82%。结论 RPA技术利用了重组酶、单链结合蛋白、DNA聚合酶代替了传统PCR变性、退火、延伸的热循环过程,在常温25℃~42℃、15~30 min内即可实现痕量核酸的快速扩增,可应用于快速检测人结核分枝杆菌,是一种全新的检测方法。     

Thyroid tuberculosis – role of PCR in diagnosis of a rare entity

N. Gupta, K. Sharma, A. Barwad, M. Sharma, A. Rajwanshi, P. Dutta and A. Sharma
Thyroid tuberculosis – role of PCR in diagnosis of a rare entity Background: Tuberculosis is a rare cause of granulomatous thyroiditis, whose diagnosis may be difficult with routine cytopathology and staining for acid‐fast bacilli (AFB). Study design: Amongst 7962 cases of various thyroid lesions subjected to fine needle aspiration cytology (FNAC) over a period of 12 years, 34 cases (0.43%) were found to have cytological features of granulomatous inflammation with or without necrosis, which could be due to tuberculosis, granulomatous thyroiditis or other causes of granulomatous inflammation such as sarcoidosis or fungal infections. DNA was extracted from the material available on May‐Grünwald–Giemsa‐stained smears from the archival material. PCR for Mycobacterium tuberculosis was performed for insertion sequence IS6110. Results: The age of the patients ranged from 32 to 58 years (median 48 years); 24 were female and 10 male. FNAC from thyroid swellings showed epithelioid granulomas with giant cells and/or necrosis. Although acid‐fast bacilli were only seen in smears in two cases, 19/34 (55.9%) showed the presence of 123 bp DNA band under ultraviolet transillumination. Five control cases were negative. Conclusion: Our study of archival cytological material illustrates the importance of PCR as a potentially useful tool for the detection of M. tuberculosis DNA from FNAC of thyroid lesions, which could provide an alternative for rapid diagnosis of thyroid tuberculosis in AFB‐negative cases.