International Journal of Infectious Diseases
Volume 14, Issue 8 , Pages e659-e666, August 2010

Is spinal tuberculosis contagious?

  • Patricia Schirmer

      Affiliations

    • VA Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304, USA
    • Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
    • Corresponding Author InformationCorresponding author. Tel.: +1 650 852 3408; fax: +1 650 858 3978.
    • ,
  • Cybèle A. Renault

      Affiliations

    • VA Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304, USA
    • Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
    • ,
  • Mark Holodniy

      Affiliations

    • VA Palo Alto Health Care System, 3801 Miranda Avenue (132), Palo Alto, CA 94304, USA
    • Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA

Received 3 July 2009; received in revised form 18 July 2009; accepted 4 November 2009. published online 24 February 2010.

Corresponding Editor: William Cameron, Ottawa, Canada

Article Outline

Summary 

While pulmonary Mycobacterium tuberculosis infections are recognized for their public health implications, less is known about the infectiousness of extrapulmonary tuberculosis, specifically, spinal tuberculosis or Pott's disease. We present a case of spinal tuberculosis with concomitant active pulmonary tuberculosis in the absence of chest radiographic abnormalities or symptoms, and review the literature regarding infectiousness of concomitant spinal and pulmonary tuberculosis.

Keywords: Mycobacterium tuberculosis, Osteomyelitis, Pott's disease, Pulmonary tuberculosis, Spinal tuberculosis

 

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1. Introduction 

Mycobacterium tuberculosis (MTB) has infected an estimated 2 billion persons worldwide and remains a leading cause of global mortality.1 In 2007, over 13 000 tuberculosis (TB) cases were reported in the USA.1 Nearly 20% of patients with TB develop extrapulmonary manifestations. Skeletal TB accounts for 10–20% of all extrapulmonary TB, with spinal involvement in 50–60% of all skeletal TB cases or in <1% to 5% of all TB cases.2, 3, 4, 5, 6, 7, 8, 9 Pott's disease, first described by Percival Pott, is MTB infection of the vertebral spine and typically involves thoracic and lumbar anterior vertebral bodies. Complications can include vertebral collapse, paraplegia and paraspinal abscesses.3, 10, 11, 12

Between 50% and 75% of patients with osteoarticular TB and approximately 33–50% of patients with spinal TB have an associated primary lung focus or have a reported history of pulmonary TB.3, 9, 13, 14 In one study of spinal TB, MTB was found elsewhere in the body in approximately 40% of cases, and 50% of those cases had pulmonary involvement.15 Most reports suggest that spinal TB results from a primary focus outside of the spine, and spread is postulated to be via hematogenous or lymphatic dissemination.2, 7, 16

While it is common practice to obtain a chest X-ray (CXR) when a patient is diagnosed with extrapulmonary TB, sputum examination is typically reserved for those with respiratory symptoms and/or abnormal chest imaging.17 Although TB treatment may not differ if the sputum is positive for TB, the contact investigation and isolation procedures may vary significantly.17, 18, 19, 20, 21 We present a case of a patient diagnosed with spinal TB in whom sputum cultures grew MTB despite a normal CXR. We also review the literature and discuss the infection control implications and management.

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2. Case report 

A 62-year-old man was seen in November 2007 reporting a two-month history of lower back pain, which he attributed to lifting a heavy object. He was prescribed physical therapy. In February 2008, he reported having persistent back pain and night sweats for four months; and because he refused further workup, physical therapy alone was continued. He was seen several times in the mental health clinic over the following months where he continued to report night sweats, which were attributed to post-traumatic stress disorder. In July, he saw his primary care physician and reported approximately one month of chills, left-sided mid-abdominal pain associated with movement, a bloody bowel movement, and a 9kg weight loss over eight months. A history of a positive tuberculin skin test (TST) was noted, although it was unknown whether he had received treatment for latent TB. An HIV ELISA test was negative. CXR findings were unremarkable except for a possible T4 osteophyte. An abdominal and pelvic computed tomography (CT) scan was ordered, but the patient postponed the study until after his vacation. In August, the patient was seen in the emergency room for his abdominal pain. An abdominal and pelvic CT scan revealed a mass extending from T10 to L2, a destructive process involving the T9, L3, L4 vertebral bodies causing severe cord compression, and a large rim-enhancing fluid collection in the right psoas muscle.

The patient was admitted with presumptive Pott's disease. Notably, he did not complain of respiratory symptoms. An admission CXR demonstrated a stable circumscribed opacity in the right paratracheal region; differential diagnosis included a prominent right costovertebral junction at the T4 level, an osteophyte, a mediastinal lymph node, or a soft tissue prominence (Figure 1). He was placed in respiratory isolation because of this abnormal CXR finding in the setting of presumptive Pott's disease. Three induced sputums for mycobacterial smear and culture were obtained over consecutive days. All acid-fast bacilli (AFB) smears were negative, and airborne isolation was discontinued. A repeat TST was negative. After a magnetic resonance imaging (MRI) scan confirmed the CT scan findings, he underwent abscess drainage and bone biopsy, performed at the local academic medical center. Samples from abscess drainage and bone biopsy were AFB smear-negative, but one week later grew pan-sensitive MTB. Bone histology demonstrated necrotizing granulomas, consistent with Pott's disease. The day after biopsy, empiric four-drug TB therapy (isoniazid 300mg daily, ethambutol 20mg/kg daily, pyrazinamide 25mg/kg daily, and rifampin 600mg daily, with pyridoxine 25mg daily) was begun.

Three days after starting TB therapy, he developed urinary retention. A repeat MRI scan demonstrated no interval change. However, because of changed neurologic exam findings, emergent thoracolumbar decompression was performed. Spinal fusion and further debridement of necrotic bone was performed four days later. A follow-up CXR demonstrated that the previously noted right upper lung abnormality was consistent with anterior rib markings and an osteophyte. Once MTB drug susceptibilities from the psoas abscess culture were known (one month after starting treatment), ethambutol was discontinued. Two weeks later, admission sputum cultures grew pan-sensitive MTB. He was not in respiratory isolation at this time, since he had been on four-drug TB therapy for over one month and because his initial sputum AFB smears were negative. As he was nearing discharge after approximately three months of TB therapy, the local county TB control officer requested three additional mycobacterial sputum smears and cultures. Two of three sputum samples revealed rare AFB on smear. A repeat CXR and chest CT scan were not suggestive of active pulmonary disease. Although he had received directly-observed therapy, the possibility of drug-resistant MTB was entertained. He was again placed in airborne isolation until three additional sputum AFB smears returned negative. All six mycobacterial sputum cultures were negative; therefore, it was thought that the AFB smear-positive samples likely represented dead organisms. Because he was symptomatically improved, his TB regimen was not changed. Pyrazinamide was continued for four months until an MRI scan demonstrated improvement. Currently, he is clinically improved on isoniazid, rifampin, and pyridoxine.

Although infection control staff had followed the case since admission, an exposure investigation was initiated when the AFB smears returned positive. It was determined that the staff wore N-95 respirators during his abscess drainage and bone biopsy (performed at another institution). There was approximately one week when he was not in respiratory isolation prior to starting anti-TB treatment and before the MTB-positive culture results returned. A total of 69 employees and four patients were evaluated at our institution for possible TB exposure. One patient had a negative Quantiferon test result (performed because he was unable to return for follow-up reading). All others had negative symptom review, TST, and CXR with the exception of one patient, who demonstrated a new TST conversion, had a normal CXR and whose mycobacterial sputum culture grew Mycobacterium avium complex.

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3. Discussion 

Although TB has declined in the USA due to effective public health surveillance and infection control practices, the public health ramifications of undiagnosed pulmonary TB are substantial.1 Our patient presents an interesting question about the prevalence of spinal TB and concomitant active pulmonary TB. The prevalence of both spinal and pulmonary TB (both active and inactive) occurs at a surprisingly high rate (Table 1, Table 2). A total of 29 individual cases of concomitant pulmonary and spinal TB have been presented in the literature (Table 1); unfortunately, the quality of information presented in case reports and case series varies greatly, with many lacking critical information such as mycobacterial sputum smear and culture results. Retrospective studies describing over 3000 patients with spinal TB have noted that 2–80% of these cases also have evidence of pulmonary TB (either active or inactive), indicating that further consideration of this clinical dogma should be entertained (Table 2). However, other studies suggest a low prevalence of concomitant extrapulmonary and pulmonary TB. One prospective study from Malawi reported that 1.7% of patients with extrapulmonary TB (>3% in patients with miliary disease, lymphadenitis or meningitis) had AFB smear-positive sputum.22 Although no cases of AFB smear-positive sputum were identified in the skeletal TB patients, only 42% submitted sputum samples.22 Unfortunately, information in many of these studies is incomplete and often does not differentiate active from inactive disease or provide information about culture positivity and radiographic findings.

Table 1. Individual reported cases of pulmonary tuberculosis and spinal tuberculosis in the literature
Age/sexAFB sputum smear and cultureCXR/CT scanPathologyTissue for AFBaTherapyComments/outcomeRef.
SmearCulture/PCRMedicalSurgical/site of spinal disease
23FNRMiliary TBNRPositiveNegativeINH, EMB, RIF (5 mo); INH, EMB (19 mo)Anterior spinal fusion and drainage of abscess (T6)Died of unrelated cause (heroin overdose)10
47FNRHealed TBCaseation necrosisPositiveNegativeINH, EMB, RIF, CY (6 mo); INH, EMB (19 mo)Debridement and drainage (T12–L1)Minimal residual weakness10
32MNRHealed TBCaseation necrosis, granulomasNegativeNegativeINH, EMB, RIF (4 mo); INH, EMB (18 mo)Debridement and anterior spinal fusion, bone graft (C6–7)Cured10
62FNRMiliary TBGranulomasNegativeMTBINH, EMB, SM (2 mo); INH, EMB (36 mo)Anterior spinal fusion (T7–8)Marked residual weakness (wheelchair bound)10
42FNRHealed TBCaseation necrosis, granulomaNegativeMTBINH, EMB, RIF or SM (11 mo); INH, EMB (20 mo)Anterior spinal fusion, bone graft, debridement (T12–L1)Cured10
53FNRHealed TBNDNDNDINH, RIF (24 mo)NoneCured10
26MRefused bronchoscopy and unable to provide sputumReticulo-nodular infiltration in RUL with right hilar enlargedEpithelioid granulomata with Langhans giant cells and lymphohistiocytic aggregatesNRNR4-drug therapy – not further specifiedVATS; multiple thoracic and vertebral involvedImprovement in bone lesions2
19MNRHeterogeneous density increase in left apex; many nodules with smooth edges and a cavitary lesion on CT scanSkin: micro-granuloma, many Langhans-type giant cell formation and dense mononuclear inflammatory cellsSkin lesion: negativeSkin lesion culture: negative; PCR: positiveRIF, INH, SM, EMB (18 mo)NR; T4–T5 diseaseAlso with cutaneous lesions. Improved with healing of skin lesions by 5th week59
79MSmear: positive; culture: positiveBilateral pseudo-tumoral infiltration with cavitation in the RUL; multiple calcified hilar lymph nodesNRNRNRNRNR; T9 diseaseNR60
66FNRMiliary nodules bilaterally on CT scanIntramedullary lesion: fibrous, diffuse chronic inflammatory cell infiltration with granulation tissue and focal abscess formationNRCulture: NR; PCR: positiveRIF, INH, PZA, EMBLaminectomy of L1–L2 and subtotal laminectomy of T10–T11, myelotomies followed at T10 and T11Intramedullary tuberculomas: spine and brain with involvement of L1–2 bone marrow and end plates. Improved movement and decreased size of tuberculomas61
25MNRLeft pleural effusion; repeat CXR with right pleural effusionPleural tissue: thickened pleural tissue, infiltration of lymphocytes; right psoas abscess caseous necrosis with Langhans giant cells and epithelioid cellsNRRight psoas abscess: MTBINH, RIF, SMDebridement of T11–12; anterior spinal fusion, bone graftImproved11
25MBronchoscopy and sputum AFB: negativeRight hilar enlarged, perihilar infiltration and lytic expansile lesion of the left 8th rib; CT: multiple mediastinal and right hilar LAD and RUL consolidation and vertebral and rib lytic lesionsLung and mediastinal lymph nodes: small necrotizing granulomas with multinucleated giant cellsLung and lymph node tissue: positiveLung and lymph node tissue: MTBINH, RIF, PZA, EMBVATS; L2–L3 diseaseImproved9
20MSmear: positiveApical lesion in RULNDNDNDINH, EMBNo surgical intervention of T11–12 diseaseImproved15
24MCulture: MTBLUL infiltrateNRNRMTBINH, RIF, PZA, EMB (2 mo); INH, RIF (10 mo)NR; T7–T9 lesionHIV-pos; improved62
59MCulture: MTBRUL cavityNRNRMTBINH, RIF, PZA, EMB (2 mo); INH, RIF (10 mo)NR; L4 lesionHIV-pos; improved62
18FCulture: MTBNRLung tissue: caseating granulomas; spinal tissue: caseating granulomaNRSpinal tissue: MTBNRLaminectomy; C6, L1–L2 diseasePatient died56
21MNegativeNegativeLung tissue: granulomatous cavitation with Candida and Aspergillus seen in tissueSpinal: positiveSpinal: negativeNRNR; T2–T3 diseasePatient died56
26MNegativeMediastinal fusiform shadow and left axillary pleural thickeningPatient refused biopsyNDNDINH, RIF, PZA, EMB (2 mo); INH, RIF, PZA (7 mo)Patient refused; T7–T8 and L4–L5 diseaseImproved63
25MNRRetrocardiac mediastinal shadowNRRetro-pharyngeal abscess: positiveRetro-pharyngeal abscess culture: MTB; retro-pharyngeal abscess
PCR: positive		INH, RIF, PZA, EMB (2 mo); INH, RIF (7 mo)Abscess aspirations. C2–C3, T8–T9 diseaseImproved63
37MNegativeLeft apical thickening of the pleura Left psoas abscess: negativeLeft psoas abscess: MTBINH, RIF, PZA, EMB (5 mo); INH, RIF (7 mo)Psoas abscess aspiration; L2–L3 diseaseImproved63
24MGastric aspirate: positiveLeft pleural effusion and retro-cardiac massNRSpinal: positiveSpinal: MTBINH, SM, para-aminosalicylateNR; T8–T10 diseaseUnknown64
26MNegative2cm opacity in LULNRAbscess: positiveAbscess: MTBINH, SM, para-aminosalicylateNR; lumbar diseaseUnknown64
73FNegative; bronchoscopy culture: positiveCT: pulmonary infiltrates and fibrosis of the right lungSpinal: caseating granulomas with multinucleated cellsSpinal: positiveNRINH, PZA, RIF (12 mo)NR; mid-thoracic diseaseImproved65
51MNRCT: tiny nodules consistent with miliary diseaseSpinal: necrotizing granulomatous inflammation; extramedullary mass: granulomatous inflammationSpinal: positive; extra-medullary lesion: negativeSpinal: culture MTB; PCR positiveINH, ETH, RIF, SM (2 mo); INH, RIF (2 mo); INH, ETH, RIF, SM (restarted for unknown duration)T12–L1 laminectomy.Returned due to worse symptoms and found to have extramedullary mass, subsequently improved66
37MNRLLL infiltrateChest wall: caseating granulomas with AFBChest wall: positiveChest wall: MTBINH, RIF, PZAAbscess aspiration around C1–4Died of respiratory distress67
31MSmear: positive; culture: MTBThickened pleura, fibrotic stranding, RUL infiltrate with early cavitationSpinal: caseating necrosis and necrotic bonePositiveNegativeSM, INH, EMBDebridement and fusion of L2–3Improved3
27MSputum and gastric aspirates smear and culture: positive (MTB)Bilateral apical thickening and periapical fibrosisNDNegativeNegativeINH, RIFNR; L3–5 diseaseImproved3
56FNegativeBilateral small pleural effusionsSpinal: fibrosis, new bone formation, multinucleated cells, plasma cell infiltrateNegativeNegativeINH, EMBDebridement of T8–9Improved3
36MNRMediastinal widening right apical pleural thickeningSpinal: granulomas with caseation necrosis and Langhans giant cellsPositiveNegativeINH, EMB, RIFT2–6 laminectomyImproved3

AFB, acid-fast bacilli; CXR, chest X-ray; CT, computed tomography; PCR, polymerase chain reaction; NR, not reported; ND, not done; mo, months; TB, tuberculosis; MTB, Mycobacterium tuberculosis; RUL, right upper lobe; LUL, left upper lobe; LLL, left lower lobe; LAD, lymphadenopathy; VATS, video-assisted thoracoscopic surgery; INH, isoniazid; EMB, ethambutol; RIF, rifampicin; SM, streptomycin; CY, cycloserine; PZA, pyrazinamide.

aSpinal tissue unless otherwise stated.

Table 2. Studies noting concomitant pulmonary and spinal tuberculosis
Study locationNumber of patients with spinal TBNumber of patients also with a form of pulmonary TB (%)Based on CXRBased on positive sputum culturesNo further details on lung diseaseActive vs. inactive vs. combined pulmonary TBCommentsRef.
England500284/500 (57)XX ActiveKnown cases of active pulmonary TB (sputum-positive) were excluded68
England914175/914 (19) XXActive443 with additional active TB focus69
France10316/103 (16) XXCombined28 extraskeletal TB70
India151/15 (7)XX InactivePrimarily intramedullary TB; one of these patients with Pott's (not the one with pulmonary disease); no sputum AFBs sent71
India and Iran489/48 (19)XX CombinedNo definition of ‘a primary pulmonary focus’72
Iran10018/100 (18)XXXX CombinedAll patients got a CXR and sputum smear and culture73
Korea244116/244 (48)XX Combined69 (28%) active disease; 47 (20%) inactive74
Nigeria349/34 (27) XXActive 75
Philippines88 children88/88 (100) XXActiveAll had to have spinal TB associated with active pulmonary TB to be included; 2 miliary disease, 3 pleural effusion, 8 had residue of acute pleuritis16
Saudi Arabia3912/39 (31)XX CombinedTB of the nervous system; 8 with bony disease (unclear if any of these had pulmonary disease as well); 7 with abnormal CXR: 4 old TB, 3 miliary TB76
Tanzania22 children2/22 (9)XXXX ActiveAFB sputums were done and positive only on the 2 with positive CXR findings77
Turkey694; 35 with multifocal disease16/694 (2) XXCombinedOf the 35 with multifocal TB 45% had pulmonary involvement8
USA7010/70 (14) XXActive9 active; 1 pleurisy; inner city patients78
USA126/12 (50) XXCombinedInner city patients14
USA62 (48 with CXR; 56 with cultures)40/48 (83) based on CXR; 20/56 (37) based on AFBXXXX Combined5 with miliary; combination of sputum and gastric aspirates 37%56
USA (immigrants from Asia and Central America)198/19 (42)XX Combined3 inactive, 3 miliary, 1 diffuse infiltrates, 1 pleural effusion; 15 AFB smear/cultures done but the source of specimen is unclear79
USA2010/20 (50)XX Combined7 with calcified adenopathy and pleural thickening, 3 had pulmonary infiltrates; 1 with a positive AFB sputum (unclear if others were tested)80
USA262/26 (8)XXXX Active1 with a left upper lobe infiltrate and the other with right upper lobe cavity. HIV-pos patients. Sputum AFBs only reported on 2 patients with abnormal CXR62
USA230 skeletal TB patients (138 with spinal TB)139/230 (60) XXCombinedPatients were chosen from a sanatorium; 117 (51%) active; 22 (10%) inactive; unclear how many of these had spinal involvement81

TB, tuberculosis; CXR, chest X-ray; AFB, acid-fast bacilli.

While physicians often use the presence of respiratory symptoms or abnormal radiographic findings in detecting those at risk for having pulmonary TB, this can be misleading. Our patient had no pulmonary symptoms and had a normal chest radiograph, despite having positive sputum cultures for MTB. Culture-positive pulmonary TB has been found in patients with extrapulmonary TB or with HIV infection who have normal CXR findings.17, 23, 24, 25, 26 A recent study found a significant difference in HIV-negative versus HIV-positive patients with normal CXR findings in the setting of active pulmonary TB (5% vs. 22%).26 HIV-infected patients with normal or atypical CXR findings in culture-positive pulmonary TB were similar to those reported in other studies (2–32%).27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42 In one study of patients (HIV-positive and -negative) with normal CXR findings, 48 of 53 had sputum AFB smears performed, of which 21 of 48 were smear-positive.26 Patients with normal CXR findings were also significantly less likely to report respiratory symptoms on presentation (32% vs. 13%).26 Published series prior to the HIV epidemic, or studies not indicating HIV status, have reported a range of 1–32% of patients with normal CXR findings who were found to have MTB culture-positive sputum.23, 25, 32, 33, 34, 41, 43, 44, 45, 46, 47, 48, 49 HIV-infected patients with pulmonary TB also have an increased probability of presenting with AFB smear-negative sputum and normal CXR findings compared to non-HIV-infected individuals.28, 50 This likely contributes to delayed TB diagnosis and treatment in HIV-infected patients.28, 50 In summary, little quality data has been published about the correlation between extrapulmonary TB, culture-positive pulmonary TB and normal CXR findings.

Importantly, respiratory transmission of TB has been documented in patients with AFB smear-negative sputum.17, 51, 52, 53, 54, 55 Two studies suggest that approximately 17% of transmission occurred from persons with sputum smear-negative TB.51, 52 One study found that those with extrapulmonary TB increased the TB transmission rate, suggesting that the infectiousness of extrapulmonary TB has previously been underestimated.51 We found no evidence of transmission in our case. Although evidence of transmission (other than direct inoculation) of MTB from extrapulmonary sources is lacking in the current literature, in-depth evaluations of the infectiousness and risk of transmission from extrapulmonary TB have not been adequately documented in the literature.

Unfortunately, current guidelines offer no clear guidance on whether or not all patients with extrapulmonary TB should be evaluated for concurrent pulmonary involvement nor is there an appropriate infection control strategy delineated for these patients. Several sources suggest a conservative approach, such as obtaining cultures from all body fluids and tissues that are suspected of being involved with MTB.56 The Centers for Disease Control and Prevention recommends that “persons diagnosed with extrapulmonary TB disease should be evaluated for the presence of concurrent pulmonary TB disease”; however, further description of the extent of that evaluation is lacking.57 According to Mandell's Principles and practice of infectious diseases, a CXR should be routinely obtained in Pott's disease since abnormal radiographs can have important health ramifications.58

The cost of respiratory isolation and obtaining mycobacterial sputum cultures on all patients with extrapulmonary TB would not be trivial. However, cost could be minimized by appropriately identifying patients who are at risk of having pulmonary TB. At our institution, routine isolation and subsequent AFB sputum examination from extrapulmonary TB cases does not always occur unless pulmonary symptoms or abnormal CXR findings are noted. From our literature review and weighing public health considerations of TB transmission, we suggest that airborne isolation of patients with suspected extrapulmonary TB, including spinal TB, is justified until CXR and AFB sputum smear results are known and cultures have been obtained. Even though there is documentation of AFB smear-negative transmission of pulmonary TB, it is customary to discontinue isolation once negative AFB sputum smear results are known.

Advantages of taking an aggressive approach to isolation and documentation of active pulmonary TB include minimizing healthcare worker and patient exposure to a potentially infectious patient, as well as providing an additional source for MTB culture and susceptibility testing . Future investigations and publications require clear definitions of a pulmonary primary focus as well as active versus inactive pulmonary TB to help guide appropriate infection control practices. Finally, better guidance with respect to isolation practices and appropriate evaluation of extrapulmonary TB cases, particularly spinal TB, is needed.

Conflict of interest: No conflict of interest to declare.

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PII: S1201-9712(10)00021-4

doi:10.1016/j.ijid.2009.11.009

International Journal of Infectious Diseases
Volume 14, Issue 8 , Pages e659-e666, August 2010

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