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Setting Breast tuberculosis (TB) is rare in Western Europe, and its diagnosis may be delayed through lack of awareness of presenting features. Our institution serves a large East London population with a high incidence of TB. Objective To characterize presenting features and avoidable diagnostic delay in breast TB patients. Design We conducted a 13‐year retrospective study of breast TB patients treated at our institution including demographic, clinical, microbiology, and pathology data. Results Forty‐seven cases were included; 44 (94%) were female, with a median age of 33 years (IQR 28.5‐39.5). The main presenting feature was a breast lump in 41 cases (87%); which were predominantly solitary unilateral lesions (25, 61%) and frequently located in the upper outer quadrant (28, 68%). Where performed, Mycobacterium tuberculosis was cultured in 15/36 (42%) cases. Granulomata were present on biopsy or aspirate in 21 (47%) and 17 (36%) cases, respectively. The median duration between symptom onset and treatment was 20 weeks (IQR 15‐30). Forty‐six (98%) completed treatment successfully and one relapsed. Conclusion A high index of suspicion for TB is required for individuals presenting with breast symptoms from countries where TB is endemic. Development of standardized pathways may improve detection and management of breast TB may reduce diagnostic delay.

Background Acute myopericarditis can be caused by a myriad of infectious and non-infectious aetiologies, however, it is often considered to be due to self-limiting viral infection. Salmonella spp. myopericarditis is rare and the few cases in the literature suggest significant associated morbidity and mortality. Case summary A 44-year-old man presented with fever, dyspnoea, and chest pain. He was found to have a large pericardial effusion with clinical signs of tamponade and sepsis. Therapeutic pericardiocentesis was performed and ceftriaxone and levofloxacin were administered. Fully sensitive Salmonella enterica serovar Enteritidis (S. Enteritidis) was isolated in his pericardial fluid and he made a full recovery after a 4-week course of ciprofloxacin. A new diagnosis of type 2 diabetes mellitus was made on admission. A follow-up cardiac magnetic resonance (CMR) scan was suggestive of myocarditis which was unexpected given a normal Troponin T level on presentation. Discussion We report a rare case of S. Enteritidis myopericarditis. Our case is notable as the patient was immunocompetent apart from newly diagnosed diabetes. This case highlights the value of CMR imaging in assessing for myocarditis and ventricular function.

Background Public health guidance recommending isolation of individuals with group A streptococcal (GAS) infection or carriage for 12–24 h from antibiotic initiation to prevent onward transmission requires a strong evidence base. Aim To estimate the pooled proportion of individuals who remain GAS culture-positive at set intervals after initiation of antibiotics through a systematic literature review (PROSPERO CRD42021290364) and meta-analysis. Methods We searched Ovid MEDLINE (1946–), EMBASE (1974–) and Cochrane library. We included interventional or observational studies with ≥ 10 participants reporting rates of GAS throat culture positivity during antibiotic treatment for culture-confirmed GAS pharyngitis, scarlet fever and asymptomatic pharyngeal GAS carriage. We did not apply age, language or geographical restrictions. Results Of 5,058 unique records, 43 were included (37 randomised controlled studies, three non-randomised controlled trials and three before-and-after studies). The proportion of individuals remaining culture-positive on day 1, day 2 and days 3–9 were 6.9% (95% CI: 2.7–16.8%), 5.4% (95% CI: 2.1–13.3%) and 2.6% (95% CI: 1.6–4.2%). For penicillins and cephalosporins, day 1 positivity was 6.5% (95% CI: 2.5–16.1%) and 1.6% (95% CI: 0.04–42.9%), respectively. Overall, for 9.1% (95% CI: 7.3–11.3), throat swabs collected after completion of therapy were GAS culture-positive. Only six studies had low risk of bias. Conclusions Our review provides evidence that antibiotics for pharyngeal GAS achieve a high rate of culture conversion within 24 h but highlights the need for further research given methodological limitations of published studies and imprecision of pooled estimates. Further evidence is needed for non-beta-lactam antibiotics and asymptomatic individuals.

The global incidence of tuberculosis (TB) infection was estimated by the WHO to be 10 million cases in 2018, 85% of whom had pulmonary TB (pTB) infection (WHO 2019). In Europe, the extrapulmonary TB (EPTB) incidence is increasing, accounting for 22.6% of new cases reported in 2017 (ECDC 2019). Furthermore, the incidence of articular TB infections has risen in Europe (Jutte 2004, Lesic 2010. This is reflected in UK surveillance data, where in 2017, 2.2% of new TB cases presented with non-spinal bone infections (Kruijshaar 2009, PHE 2018. Globally, this rise in EPTB infections has largely been ascribed to a growing population of immunosuppressed patients including those on long-term steroids and biologic therapies, as well as to an ageing population (Pigrau-Serrallach 2013, Byng-Maddick 2016). However, in low-incidence countries in Europe the rise in articular TB infections has also been attributed to increasing rates of migration (Jutte 2004, Krujishaar 2009. EPTB infection is thought to occur through haematogenous, contiguous or lymphatic spread in the primary infection stage, when mycobacteria can spread to any organ or tissue and remain dormant for years. Articular infection most commonly affects weight-bearing large joints such as the spine, knees and hips. Infection is often slowly progressing with joint effusions and pain, progressing to the formation of sinus tracts and eventually to complete joint destruction (Hogan 2017). Initial symptoms are vague and may mimic other conditions such as bacterial osteoarticular infection. This can result in significant diagnostic delay, especially in settings where TB is non-endemic and clinical suspicion is low (Erdem 2005, Broderick 2018). Most studies describing osteoarticular TB have focused on paediatric populations or on spinal TB with only a few published case series of extra-