الفهرس 
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Abstract
Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria. Tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections do not have symptoms, in which case it is known as latent tuberculosis. About 10% of latent infections progress to active disease which, if left untreated, kills about half of those affected (WHO, 2016).
Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs ¬known as alveoli. Typically, symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable (Roudsari et al., 2020).
Immune system status plays an important role in tuberculosis infection. Monocytes cells have been considered as the target cells of Mycobacterium tuberculosis, and lymphocytes are the main effector cells of TB immunity (Naranbhai et al., 2015).
Neutrophils are typically the earliest immune cells recruited to a site of inflammation, and are an essential component of innate immune resistance to respiratory pathogens (Grommes and Soehnlein, 2011).
We aimed in this study to evaluate the Neutrophil-to-Monocyte-Plus-Lymphocyte ratio as a diagnostic marker to differentiate pulmonary tuberculosis from pneumonia in comparison with other parameters, especially erythrocyte sedimentation rate and C-reactive protein.
This case control study conducted at Abbassia Chest Hospital, from March 2020 to October 2020, and included 60 patients with pulmonary TB (n=30) and community acquired bacterial pneumonia (n= 30), and 30 healthy controlled individuals.
All patients subjected to full history, physical examination, 2 cc of blood sample was collected for total and differential peripheral leucocytic count before starting antibiotic therapy by standard procedures on a Sysmex-2100 automated hematology analyzer, China machine, Neutrophil-to-Monocyte-Plus-Lymphocyte Ratio (NMLR) was calculated as the quotient of the absolute neutrophils, Monocyte and lymphocyte counts and Neutrophil-to-Lymphocyte Ratio (NLR) was calculated), skin test and Chest X-ray.
Inclusion criteria:
Patients were 18 years or older who presented with symptoms, signs and clinical finding in addition to radiological and laboratory diagnosis coinciding with pulmonary TB or pneumonia.
Exclusion criteria:
Airway disorders including asthma; bronchiectasis COPD; cystic fibrosis; pulmonary fibrosis; lung cancer, acute ischemic stroke, pregnancy, severe hepatic or renal diseases, immunocompromised (such as AIDS, cancer, diabetes, malnutrition, Active malignancy, hematologic disease and certain genetic disorders), immunosuppressed patients: e.g. steroid use, receiving immunosuppressive therapy, acute pulmonary embolism, acute coronary syndrome, hypertension, congestive heart failure and various systemic autoimmune diseases, including systemic lupus erythematosus, small vessel vasculitis and rheumatoid arthritis.
Our study involved 90 subjects, the age of TB patients was (29±8.17) years, which significantly lower than other with community acquired pneumonia (40.4±16.81) years.
Considering CRP and ESR, they were significantly higher in TB and pneumonia in comparing with control group, P < 0.001 for both while there was no significant difference between TB and pneumonia. Additionally, NLR and NMLR were significantly higher in pneumonia than TB or control group, P < 0.001 for both. There was positive correlation between blood indices (NLR and NMLR) and the regular inflammatory marker (CRP and ESR) r = 0.49 and 0.58 for CRP and 0.46 and 0.48 for ESR respectively.
The ability of all markers (NLR, NMLR, CRP and ESR) was excellent, the AUC were 92%, 92%, 98% and 100% respectively, P < 0.001 for all. Also, NLR > 2.96 and NMLR >2.385 cutoff values have sensitivity and specificity of 90% and 100% respectively for both.
We can concluded that NLR and NMLR are a good predictor for pneumonia and TB