American Journal of Infectious Diseases and Microbiology, 2014, Vol. 2, No.

1, 17-21
Available online at http://pubs.sciepub.com/ajidm/2/1/4
© Science and Education Publishing
DOI:10.12691/ajidm-2-1-4

Evaluation of Microscopy, Culture and PCR Methods in

the Laboratory Diagnosis of Genito-urinary
Tuberculosis
Pranali Pingle1,*, Pradeep Apte2, Rakesh Trivedi3
1
Microbiologist, Medicare Hospital and Research Centre, Indore
2
Biochemist and Lab incharge, Medicare Hospital and Research Centre, Indore
3
Principal, P.M.B.Gujarati Science College, Indore
*Corresponding author: pranalispingle@yahoo.com

Received December 09, 2013; Revised January 04, 2014; Accepted January 09, 2014
Abstract Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary tuberculosis,
with more than 90% of cases occurring in developing countries. In GUTB, the kidneys are the most common sites of
infection and are infected through hematogenous spread of the bacilli, which then spread through the renal and
genital tract. Diagnosis of TB is often delayed owing to the nonspecific nature of its presentation; therefore, a high
degree of suspicion should be exercised and a systematic approach should be taken during investigation. The aim of
this study was to apply bleach concentration method for detection of AFB in 5-day morning urine samples obtained
from the suspects of urinary tuberculosis and to correlate the results with conventional Zeihl Neelsen (ZN) staining,
TB culture and TB-PCR. A total of 46 samples were studied from clinically suspected cases of urinary tuberculosis.
All the samples were processed for conventional ZN staining, Bleach concentration followed by ZN staining, TB
culture on LJ media and TB-PCR (IS 6110) by standard protocols. Out of the 46 samples evaluated all were negative
(0%) by conventional ZN staining, while the positivity increased to 7(15.22%) by bleach concentration method, the
gold standard i.e. TB culture had 9(19.56%) positive and the TB-PCR gave 4(8.69%) positive. The results revealed
that bleach concentration method was superior to conventional ZN staining method and TB-PCR. Though TB
culture was found to be the best method, but it takes a long time for the diagnosis.
Keywords: Genito-urinary tuberculosis, M.tuberculosis, conventional ZN staining, bleach method, PCR, TB
culture
Cite This Article: Pranali Pingle, Pradeep Apte, and Rakesh Trivedi, “Evaluation of Microscopy, Culture and
PCR Methods in the Laboratory Diagnosis of Genito-urinary Tuberculosis.” American Journal of Infectious
Diseases and Microbiology 2, no. 1 (2014): 17-21. doi: 10.12691/ajidm-2-1-4.

prevailing in individual countries and on the resources

available. In most low income countries, the only
1. Introduction practically available bacteriological method for
diagnosing extrapulmonary tuberculosis is direct smear
Tuberculosis (TB) remains one of the leading infectious microscopy for AFB.Drawbacks of smear microscopy
diseases throughout the world accounting for about 8.8 include low and variable sensitivity values (0-40%) and
million cases in 2010 [1]. India alone accounted for 2.0- cannot differentiate between Mycobacterium tuberculosis
2.5 million cases in 2010, thus contributing approximately and non-tuberculous mycobacteria (NTM) [6,7,8].Culture
26% of all TB cases worldwide [2]. According to National identification for M. tuberculosis also has variable
Tuberculosis Control Programmes (NTPs), 2.6 million sensitivities (0-80%) in different extrapulmonary
new cases of sputum smear-positive pulmonary TB (PTB), specimens [9,10,11,12] with turnaround time of 4-8 weeks
2.0 million new cases of sputum smear-negative PTB and and requires skillful technicians [13].
0.8 million new cases of extrapulmonary tuberculosis The TST is useful for the diagnosis of EPTB, however,
(EPTB) were observed in 2010 worldwide [3]. EPTB has false-positive reactions occur due to previous Bacille
become more common since the advent of human Calmette-Guérin (BCG) vaccination or sensitization to
immunodeficiency virus (HIV) infection [3]. Various NTM and false-negative results occur in the
methods are employed for the diagnosis of EPTB such as immunocompromised patients, elderly persons or overt
smear microscopy, culture, histopathology, tuberculin skin forms of TB [5]. The in vitro T-cell based IGRAs have
test (TST), interferon-gamma release assays (IGRAs) and been used for the diagnosis of both latent and active TB
nucleic acid amplification (NAT) tests [4,5]. The but these assays do not differentiate between latent and
usefulness, priority and scope of various techniques used active TB infection [14]. Therefore, these assays have no
in TB diagnosis depend on the epidemiological situation utility in disease diagnosis and treatment in highly
18 American Journal of Infectious Diseases and Microbiology

endemic countries [15]. The analysis of cytokine profiles result into false positivity [33,34]. The false positivity of
in M. tuberculosis-specific CD4+ T cells by PCR reports in absence of clinical findings poses serious
polychromatic flow cytometry could differentiate between challenges these days in diagnosing EPTB cases [25].
active and latent TB [16]. The use of flow cytometry as Various studies have shown bleach concentration
part of the diagnostic algorithm has been exploited for method is cost effective, sensitive, versatile and safe
EPTB infection (e.g. pleural TB), however, due to high procedure for demonstration of tubercle bacilli and is very
cost, its use as a rapid diagnostic test is limited in the valuable in diagnosing case of extra pulmonary
resource-poor settings [17]. The serological antibody tuberculosis [35,36,37,38] and would benefit the patients
detection tests have been widely used and the tools of to receive an early and specific treatment, although it is
genomics and proteomics have led to the use of several not confirmed by WHO experts[39].
antigens for the diagnosis of both PTB and EPTB patients We have used the bleach concentration method in
[18]. Due to inconsistent and imprecise estimates, the urinary samples which is in its type the first study. Using
World Health Organization (WHO) Expert Group Meeting 5 day morning urine samples as a source, the bleach
convened in 2010 has strongly recommended against the concentration prior to Zeihl-Nelson (ZN) staining was
use any of these serological tests for the diagnosis of both evaluated to see the increase in positivity of AFB as
PTB and EPTB cases [19]. Newer molecular techniques, compared to direct ZN staining. Further the results were
such as polymerase chain reaction (PCR), although rapid ; also compared by culture on Lowenstein-Jensen (LJ)
are too costly to be routinely used in the settings where media and TB-PCR.
most TB cases occur.[20] The reason for widely used
IS6110 in PCR tests is the presence of its multiple copies
in M. tuberculosis complex genome which is believed to 2. Materials and Methods
confer higher sensitivity [21,22,23]. However, few studies
from different geographical regions of the world have A study of 46 cases of suspected Genitourinary TB was
reported that some clinical isolates have either a single done. This study was performed between 1st January
copy or no copy of IS6110 which leads to false negative 2012-31st December 2012. This included cases of
results [24,25]. For avoiding the contamination during genitourinary TB. The samples included were 5 days
amplification and increasing the sensitivity, new morning urine sample which were collected from the
approaches such as nested PCR (two step amplification) patients attending various out –patient and in-patient
[26,27] and multiplex PCR (amplification of two or more departments at the Medicare hospital, Indore. The
gene targets simultaneously) [28,29,30,31] have been selection of cases on basis of "sterile pyuria" with WBC's
exploited for EPTB diagnosis. present and with or without haematouria in urine but a
During PCR amplification, several inhibitors such as negative routine bacterial culture(in renal TB). The cases
host proteins, blood and even eukaryotic DNA in included belonged to the age groups from 40 to 65. There
extrapulmonary specimens are known to interfere with the were 29 males (63.04%) and 17 females (37.77%). The
sensitivity of PCR and give false negative results details of the samples and the various test findings are
[7,32,33]. Due to extremely high sensitivity of PCR, the indicated in the Table 1. All the samples were processed
carryover contamination of amplicon, previous infection for direct microscopy using conventional ZN staining,
or asymptomatic EPTB infection at another site could bleach concentration method, TB culture, and PCR.
Table 1. Comparison of urine samples treated by direct ZN staining, bleach concentration method, AFB culture and PCR
Findings (positive)
samples sex No of patients
ZN Bleach concentration LJ culture PCR
male 29 0 4 4 2
5 day morning urine samples
female 17 0 3 5 2
Total 46 0 7 9 4
Five early morning specimens were collected on with 1ml of commercially available 4% sodium
consecutive days and the urine was allowed to settle at hypochlorite (merck). After thorough mixing the mixture
4°C. The resulting samples were pooled and centrifuged at was incubated for 15minutes at room temperature with
3000g for 20 min and the final volume was adjusted to 3 to 6 frequent mixing at intervals. (a prolonged exposure to
ml depending on the pellet size. The sediment were divided bleach and a higher concentration of bleach solution
into three equal portions and were then used for analysis. reduces the possibility to detect AFB [41]. An equal
The first portion was used for direct ZN staining and volume of commercially available distill water was then
bleach concentration followed by ZN staining. added and mixed thoroughly using vortex mixer or
disposable sterile plastic pipette and then centrifuged at
2.1. ZN Staining 3000g for 15minutes. The supernatant was discarded, and
smears were prepared using one drop of the sediment, air
ZN staining was performed by conventional method. dried, heat fixed and stained by ZN staining technique. As
a control 2ml of distilled water was centrifuged and the
2.2. Bleach Concentration Method sediment was stained by ZN staining to rule out any error
It was performed using slight modification of the due to contamination while testing each specimen. After
original method [40]. Sterile, disposable test tubes were conventional ZN staining and bleach concentration
used for bleaching. In this approximately 1ml of the methods the smears were examined under 100 oil fields
centrifuged material of 5 days morning sample was mixed for the presence of AFB which is the standard procedure.
 American Journal of Infectious Diseases and Microbiology 19

2.3. LJ Culture AFB culture, three were positive by PCR but all were
negative by conventional ZN staining [Table 2].
The second portion was used for culture in which the Except the 7 samples which were positive by bleach
deposits were decontaminated by adding an equal volume method, there were two other samples (n = 9) (19.56%)
of molar sodium hydroxide and mixed for 30 min. After which were detected by AFB culture which is considered
centrifugation the sample were neutralized by 8% HCl to be a gold standard in TB diagnosis, while both the AFB
with the help of neutral red and then cultured on LJ slant. culture positive samples were negative by PCR [Table 3].

2.4. PCR Table 3. Distribution of patients according to LJ culture

Total Number of
The third portion was used for DNA extraction by Findings (positive)
samples patients
Percentage
Qiagen kit and followed by multiplex PCR for the IS6110 OnlyLJ culture 46 2 4.34%
gene specific for M.tuberculosis.
LJ culture + AFB smear 46 0 0.00%
2.4.1. DNA Extraction LJ culture + Bleach conc 46 7 15.21%
Urine specimens were treated with NALC-NaOH LJ culture + PCR 46 3 6.52%
method for the decontamination and liquefaction to obtain Total LJ culture 46 9 19.53%
the pellet for DNA extraction.[24] The bacterial pellet was
By PCR there were only four samples (8.69%) positive
resuspended in 180 ul buffer ATL (supplied in QIAamp
for AFB, from which three samples were positive by all
Tissue Kit, QIAGEN GmbH, Hilden, Germany). The
the methods except conventional ZN staining and there
extraction of TB DNA was performed according to
was only one sample which was positive by PCR and all
QIAGEN kit protocol. The eluted DNA can be stored at-
other methods were negative [Table 4].
20C until use in PCR.
Table 4. Distribution of patients according to PCR
2.4.2. PCR Assay Total Number of
Findings (positive) Percentage
The SeeplexR MTB ACE detection uses multitarget samples patients
(IS6110 and MPB64) and carries out both IS6110 and Only PCR 46 1 2.17%
MPB64 PCR. The PCR mastermix was prepared PCR + AFB smear 46 0 0.00%
according to standard protocol of the kit which contained
PCR + Bleach conc 46 3 6.52%
primer pairs, DNA polymerase, buffer containing dNTPs,
MgCl2 and stablizersand 8-MOP solution (which prevents PCR + LJ culture 46 3 6.52%
carry over contamination). This 15µl of mastermix is Total PCR 46 4 8.69%
mixed with 5µl of sample’s nucleic acid. The PCR Out of 46 samples 10 were reported as positive for TB while rest as
conditions for DNA amplification were an initial negative.
denaturation step of 94C for 15 min, followed by 40 When results of bleach concentration were compared to AFB culture by
Z test the P value is > 0.05 which in turn shows a close resemblance in
cycles of 94C for 0.5 min, 62C for 1.5 min, 72C for 1.5 between them.
min. and a final extension step at 72C for 10 min. The
PCR procedure was accomplished with a thermocycler TC
9600 (Perkin-Elmer Cetus). After detection step, irradiate 4. Discussion
UV light(365nm) onto PCR product for 20 min to prevent
carry over contamination. Each experiment included Genitourinary tuberculosis is one of the most common
positive and negative control tubes. The products of manifestations of extrapulmonary tuberculosis and
amplification were then analyzed by agarose gel represents 15% of all extrapulmonary tuberculosis cases
electrophoresis. [42]. Renal TB occurs up to 20 times more frequently in
kidney transplant recipients than in the general population.
The early diagnosis of renal TB is very important in
3. Results preventing progressive destruction of the kidney [43].
In the present study all the samples were negative for
Out of the sample processed, AFB smears by Acid fast bacilli by ZN staining which was contradicting
conventional ZN staining were negative for all the the study of Warren D et.al, where they found Acid-fast
samples (0%) [Table 1]. staining as the most reliable test, with a sensitivity of 22%
to 81% [44]. A study by A.Webster and D J Wright
Table 2. Distribution of patients according to Bleach concentration showed only 0.2% positive results on ZN
method
Total Number of staining.[45].Khaled G et al reported genitourinary TB
Findings (positive) Percentage from the samples obtained from 300 symptomatic patients
samples patients
Only Bleach concentration 46 0 0.00% in 0.66% on ZN staining [46]. However, the results of our
Bleach +AFB smear 46 0 0.00%
study were just contradicting the study of Fazal-ur-
Rehman et al where they had AFB in 13 patients i.e.
Bleach + LJ Culture 46 7 15.21% sensitivity of 51.5% from 50 symptomatic patients of
Bleach + PCR 46 3 6.52% genitourinary TB [47].
Total Bleach positive 46 7 15.21% A study by Mete C et al showed that detection of acid-
fast bacilli from urine samples by microscopy (Ziehl-
Now when the samples were processed for bleach and
Neelsen acid fast stain) is not reliable, because of the
then stained by ZN it detected AFB in 7 samples (15.21%).
possible presence of M. smegmatis, which may be present
Among the 7 bleach positive samples all were positive on
20 American Journal of Infectious Diseases and Microbiology

as Commensals and that decolourization with acid-alcohol [8] Derese Y, Hailu E, Assefa T, Bekele Y, Mihret A, Aseffa A,
should be used [48]. Hussien J, Ali I & Abebe M Comparison of PCR with standard
culture of fine needle aspiration samples in the diagnosis of
Our study revealed low positivity by LJ culture tuberculosis lymphadenitis. J Infect Dev Ctries 2012; 6: 53-7.
(19.53%) when compared to studies by Hemal A K et al [9] Padmavathy L, Rao L & Veliath A, Utility of polymerase chain
(30.95%), SS Negi (48.9%) [49,50]. Gracia R. et al stated reaction as a diagnostic tool in cutaneous tuberculosis. Indian J
that, the rate of positive results on culture can be as low as Dermatol Venereol Leprol 2003; 69: 214-16.
10.7% or as high as 80%, depending on the disease [10] Sharma SK & Mohan A Extrapulmonary tuberculosis. Indian J
Med Res 2004; 120: 316-353.
severity and how the disease is defined [51]. Khaled G et [11] Takahashi T, Tamura M, Asami Y et al. Novel wide-range
al diagnosed a very less i.e. 0.66% patients on LJ culture quantitative nested real-time PCR assay for Mycobacterium
[46]. tuberculosis DNA: clinical application for diagnosis of
PCR positive patients in our study were 8.69% which is tuberculous meningitis. J Clin Microbiol 2008; 46: 1698-1707.
very less as compared to the study by Negi S et al (74.4%), [12] Abbara A & Davidson RN Etiology and management of
genitourinary tuberculosis. Nat Rev Urol 2011; 8: 678-88.
Hemal A K et al (80.95%), and Bhanu et al. (53.3%) [13] Mehta PK, Kalra M, Khuller GK, Behera D & Verma I,
[49,50,52]. Development of an ultrasensitive polymerase chain reaction-
The study by Leonardo A. Sechi et al (6.3%) showed amplified immunoassay (Immuno-PCR) based on mycobacterial
low positivity as compared with the present study[53]. RD antigens: implications for the serodiagnosis of tuberculosis.
Diag Microbiol Infect Dis 2012; 72: 166-74.
The patients showing positive results on bleach [14] Pai M & O’Brien R New diagnostics for latent and active
concentration method, TB culture and PCR were treated tuberculosis: state of the art and future prospects. Semin Respir
with anti- tubercular drugs (ATT). Crit Care Med 2008; 29: 560-8.
In the present study TB culture method followed by [15] Dyrhol-Riise AM, Gran G, Wentzel-Larsen T, Blomberg B,
Bleach concentration microscopy diagnosed the majority Haanshuus CG & Mørkve O, Diagnosis and follow-up of
treatment of latent tuberculosis; the utility of the QuantiFERON-
cases of GUTB tuberculosis even when other diagnostic TB Gold In-tube assay in outpatients from a tuberculosis low-
modalities were negative demonstrating these as useful endemic country. BMC Infect Dis 2010; 10: 57.
techniques in the diagnosis of extra pulmonary [16] Harari A, Rozot V, Enders FB et al. Dominant TNF-α+
tuberculosis. Mycobacterium tuberculosis-specific CD4+ T cell responses
discriminate between latent infection and active disease. Nat Med.
The limitation of this study was that BACTEC TB 2011; 17: 372-6.
culture were not performed. [17] Sutherland JS, Garba D, Fombah AE, Mendy-Gomez A, Mendy
FS, Antonio M, Townend J, Ideh RC, Corrah T & Ota MO Highly
accurate diagnosis of pleural tuberculosis by immunological
5. Conclusion analysis of the pleural effusion. PLoS One 2012; 7: e30324.
[18] Steingart KR, Flores LL, Dendukuri N, Schiller I, Laal S, Ramsay
A, Hopewell PC & Pai M Commercial serological tests for the
Genitourinary tuberculosis is not very common but it is diagnosis of active pulmonary and extrapulmonary tuberculosis:
considered as a frequent presentation of extra-pulmonary an updated systematic review and meta-analysis. PloS Med 2011;8:
tuberculosis. On basis of the increased positivity observed e1001062.
by the bleach concentration prior to ZN staining it can be [19] Morris K, WHO recommends against inaccurate tuberculosis tests.
Lancet 2011; 377: 113-114.
recommended as an initial step in the diagnosis of renal
[20] Angeby KA, Hoffners SE, Diwan VK. Should the ‘bleach
TB rather than conventional ZN staining. Conventional microscopy method’ be recommended for improved case detection
methods of diagnosing renal TB i.e. HPE and LJ culture of tuberculosis? Literature review and key person analysis. Int J
also have a place, especially in government set ups where Tuber Lung Dis 2004;8: 806-15.
BACTEC and PCR are not done routinely due to lack of [21] Lima DM, Colares JK, & da Fonseca BA Combined use of the
polymerase chain reaction and detection of adenosine deaminase
resources. Though culture remains the gold standard for activity on pleural fluid improves the rate of diagnosis of pleural
the diagnosis of TB, Bleach concentration method should tuberculosis. Chest. 2003; 124:909-14.
also be collaborated with PCR, culture or histopathology [22] Rafi W, Venkataswamy MM, Ravi V & Chandramuki A, Rapid
before starting the treatment. A large case- control studies diagnosis of tuberculous meningitis: a comparative evaluation of
in-house PCR assays involving three mycobacterial DNA
are required to suggest the most appropriate and cost sequences, IS6110, MPB-64 and 65 kDa antigen. J Neurol Sci
effective test for the diagnosis of Renal TB. 2007;252: 163-8.
[23] Jin XJ, Kim JM, Kim HK et al. Histopathology and TB-PCR kit
analysis in differentiating the diagnosis of intestinal tuberculosis
References and Crohn's disease. World J Gastroenterol 2010;16: 2496-2503.
[24] Dale JW, Al-Ghusein H, Al-Hashmi S et al Evolutionary
relationships among strains of Mycobacterium tuberculosis with
[1] Griffiths G, Nystrom B, Sable SB, Khuller GK. Nanobead-based
few copies of IS6110. J Bacteriol 2003;185: 2555-62.
interventions for the treatment and prevention of Tuberculosis. Nat
Rev Microbiol 2010; 8: 827-34. [25] Thangappah RB, Paramasivan CN & Narayanan S, Evaluating
PCR, culture & histopathology in the diagnosis of female genital
[2] WHO. The sixteenth global report on Tuberculosis:2011.
tuberculosis. Indian J Med Res 2011; 134: 40-46.
[3] World Health Organization Global tuberculosis control. WHO
report, 2011.
[26] Torrea G, Van de Perre P, Ouedraogo M et al. PCR-based
detection of the Mycobacterium tuberculosis complex in urine of
[4] Katoch VM. Newer diagnostic techniques for tuberculosis. Indian HIV-infected and uninfected pulmonary and extrapulmonary
J Med Res2004; 120: 418-428. tuberculosis patients in Burkina Faso. J Med Microbiol 2005;54:
[5] Lange C & Mori T Advances in the diagnosis of tuberculosis. 39-44.
Respirology 2010; 15: 220-240. [27] Agashe V, Shenai S, Mohrir G, Deshmukh M, Bhaduri A,
[6] Liu KT, Su WJ & Perng RP Clinical utility of polymerase chain Deshpande R, Mehta A & Rodrigues C Osteoarticular
reaction for diagnosis of smear-negative pleural tuberculosis. J tuberculosis-diagnostic solutions in a disease endemic region. J
Chin Med Assoc 2007; 70:148-51. Infect Dev Ctries 2009; 3: 511-16.
[7] Haldar S, Sharma N, Gupta VK & Tyagi JS Efficient diagnosis of [28] Okazaki T, Ebihara S, Takahashi H, Asada M, Sato A, Seki M,
tuberculous meningitis by detection of Mycobacterium Ohto H & Sasaki H, Multiplex PCR-identified cutaneous
tuberculosis DNA in cerebrospinal fluid filtrates using PCR. J tuberculosis evoked by Mycobacterium bovis BCG vaccination in
Med Microbiol 2009; 58: 616-24. a healthy baby. J Clin Microbiol 2005; 43: 523-5.
 American Journal of Infectious Diseases and Microbiology 21

[29] Colmenero JD, Morata P, Ruiz-Mesa JD, Bautista D, Bermudez P, for Pulmonary Tuberculosis in Ethiopia. Int. J. Tuberc Lung Dis.
Bravo MJ & Queipo-Ortuño MI Multiplex real-time polymerase 2003; 7:678-83.
chain reaction: a practical approach for rapid diagnosis of [42] Raviglione MC, O’Brien RJ. Tuberculosis. In: Fauci AS,
tuberculous and brucellar vertebral osteomyelitis. Spine 2010; 35: Braunwald E, Kasper DL, eds. Harrison’s principles of internal
E1392-6. medicine Vol 1. 17th ed. New York: McGraw-Hill; 2008: 1006-20.
[30] Sharma K, Sharma A, Ray P, Sharma SK, Modi M, Prabhakar [43] Wise GJ Urinary tuberculosis: modern issues. Curr Urol Rep 2009;
S,Varma S & Sharma M, Multiplex PCR for rapid diagnosis of 10: 313-318.
tuberculous meningitis. J Neurol 2011a; 258: 1781-1787. [44] Warren D, Johnson JR, JohnsonCW, Franklin C. Lowe:
[31] Sharma K, Sharma A, Sharma SK, Sen RK, Dhillon MS & Genitourinary Tuberculosis Campbell’s Urology. 8th ed. Saunders;
Sharma M, Does multiplex Polymerase Chain Reaction increase 2002.
the diagnostic percentage in osteoarticular tuberculosis? A [45] Webster A. and Wright D J Ziehl-Neelsen staining of urine
prospective evaluation of 80 cases. Int Orthop 2011b; 36: 255-259. deposits in the diagnosis of genitourinary tuberculosis. J Clin
[32] Gan HT, Chen YQ, Ouyang Q, Bu H & Yang XY, Differentiation Pathol. 1985; 38: 236.
between intestinal tuberculosis and Crohn's disease in endoscopic [46] Khaled Ghaleb,Magdy Afifi, and Mohamad El-Gohary
biopsy specimens by polymerase chain reaction. Am J Assessment of Diagnostic Techniques of Urinary Tuberculosis
Gastroenterol 2002; 97: 1446-1451. Mediterr J Hematol Infect Dis. 2013; 5:1.
[33] Sun YS, Lou SQ, Wen JM, Lv WX, Jiao CG, Yang SM & Xu HB, [47] FAZAL-UR-REHMAN KHAN, FARHAN ARSHAD CHEEMA,
Clinical value of polymerase chain reaction in the diagnosis of MOHAMMAD USMAN KHAN Accuracy of Urinary PCR as
joint tuberculosis by detecting the DNA of Mycobacterium Compared with Urine Culture for Early Diagnosis of
tuberculosis. Orthop Surg 2011; 3: 64-71. Genitourinary Tuberculosis 2013.
[34] Honore-Bouakline S, Vincensini JP, Giacuzzo V, Lagrange PH & [48] Mete C¸ ek*, Severin Lenk, Kurt G. Naber, Michael C. Bishop,
Herrmann JL, Rapid diagnosis of extrapulmonary tuberculosis by Truls E. Bjerklund Johansen, Henry Botto, Magnus Grabe,
PCR: impact of sample preparation and DNA extraction. J. Clin. Bernard Lobel, Juan Palou Redorta, Peter Tenke: EAUGuidelines
Microbio. 2003; 41: 2323-29. for the Management of Genitourinary Tuberculosis European
[35] Khubnani H, Munjal K. Application of bleach method in diagnosis Urology 2005;48 : 353-362
of extra-pulmonary tuberculosis.Indian J Pathol Microbiol. 2005; [49] A K Hemal, N P Gupta, T P Rajeev, R Kumar, L Dar, P Seth
48: 546-50. Polymerase chain reaction in clinically suspected genitourinary
[36] Gangane N, Anshu, Singh R. Role of modified bleach method in tuberculosis: comparison with intravenous urography, bladder
staining of acid-fast bacilli in lymph node aspirates. Acta Cytol. biopsy, and urine acid fast bacilli culture Urology (Impact Factor:
2008; 52: 325-8. 2.42) 2000; 56:570-4.
[37] Annam V, Karigoudar MH, Yelikar BR India Improved [50] Negi SS, Khan SF, Gupta S, Pasha ST, Khare S, Lal S.
microscopical detection of acid-fast bacilli by the modified bleach Comparison of the conventional diagnostic modalities, bactec
method in lymphnode aspirate Indian J Pathol Microbiol. 2009; culture and polymerase chain reaction test for diagnosis of
52:349-52. tuberculosis. Indian J Med Microbiol. 2005; 23:29-33.
[38] Chandrasekhar B, Prayaga AK. Utility of concentration method by [51] Garcia-Rodrigues, J. A. et al. Genitourinary Tuberculosis in Spain:
modified bleach technique for the demonstration of acid-fast review of 81 Cases. Clin. Infect. Dis. 1994; 18:557-561.
bacilli in the diagnosis of tuberculous lymphadenopathy. J Cytol. [52] Bhanu NV, Singh UB, Chakrabotty M, Suresh N, Arora J, Rana T
2012; 29:165-8. et al. Improved diagnostic value of PCR in the diagnosis of female
[39] A. Cattamanchi, J. L. Davis, M. Pai, L. Huang, P. C. Hopewell, genital tuberculosis leading to infertility. J Med Microbiol 2005;
and K. R. Steingart Does Bleach Processing Increase the Accuracy 54:927-31.
of Sputum Smear Microscopy for Diagnosing Pulmonary [53] Leonardo A. Sechi, Maria Piera Pinna, Alberto Sanna, Piero Pirina,
Tuberculosis? J. Clin. Microbiol. 2010; 48: 2433-243. Franco Ginesu, Franca Saba, Antonio Aceti, Franco Turrini,
[40] Aber VR, Allen BW, Mitchinson DA, Ayuma P, Edwards EA, Stefania Zanetti, Giovanni Fadda. Detection of Mycobacterium
Keyes AB. Quality control in Tuberculosis bacteriology. tuberculosis by PCR analysis of urine and other clinical samples
Laboratory studies on isolated positive cultures and the Efficiency from AIDS and non-HIV-infected patients Molecular and Cellular
of direct smear examination. Tubercle.1980; 61: 123-33. Probes 1997;11: 281-285.
[41] Yassin M, Cuveas AEL, Gebrexabher H, Squire SB. Efficacy and
safety of short – term Bleach digestion of sputum in case finding