Surveillance of Elderly Hospital Patients for Pulmonary Tuberculosis

A restrospective study of pulmonary tuberculosis in a general hospital showed that the diagnosis had been frequently overlooked in the middleaged or elderly because the patient also suffered from a more acute condition which preoccupied the attention of the doctor. The commonest error was to discount chest x-ray abnormalities by omitting sputum culture or serial radiography.Surveillance was carried out on all patients aged 60 or over admitted to a large general hospital whose routine chest radiograph showed signs of possible pulmonary tuberculosis whether apparently active or inactive. Three sputum samples from each patient were examined for Mycobacterium tuberculosis without reference to the clinical presentation. In a nine-month period six out of 81 patients proved to have active pulmonary tuberculosis (7·4%). It is suggested that this may be a useful method of screening the elderly hospital population for pulmonary tuberculosis.     

DNA Methylation as a Biomarker for Cardiovascular Disease Risk

Background

Elevated serum homocysteine is associated with an increased risk of cardiovascular disease (CVD). This may reflect a reduced systemic remethylation capacity, which would be expected to cause decreased genomic DNA methylation in peripheral blood leukocytes (PBL).

Methodology/Principal Findings

We examined the association between prevalence of CVD (myocardial infarction, stroke) and its predisposing conditions (hypertension, diabetes) and PBL global genomic DNA methylation as represented by ALU and Satellite 2 (AS) repetitive element DNA methylation in 286 participants of the Singapore Chinese Health Study, a population-based prospective investigation of 63,257 men and women aged 45–74 years recruited during 1993–1998. Men exhibited significantly higher global DNA methylation [geometric mean (95% confidence interval (CI)): 159 (143, 178)] than women [133 (121, 147)] (P = 0·01). Global DNA methylation was significantly elevated in men with a history of CVD or its predisposing conditions at baseline (P = 0·03) but not in women (P = 0·53). Fifty-two subjects (22 men, 30 women) who were negative for these CVD/predisposing conditions at baseline acquired one or more of these conditions by the time of their follow-up I interviews, which took place on average about 5·8 years post-enrollment. Global DNA methylation levels of the 22 incident cases in men were intermediate (AS, 177) relative to the 56 male subjects who remained free of CVD/predisposing conditions at follow-up (lowest AS, 132) and the 51 male subjects with a diagnosis of CVD or predisposing conditions reported at baseline (highest AS 184) (P for trend = 0.0008) No such association was observed in women (P = 0.91). Baseline body mass index was positively associated with AS in both men and women (P = 0·007).

Conclusions/Significance

Our findings indicate that elevated, not decreased, PBL DNA methylation is positively associated with prevalence of CVD/predisposing conditions and obesity in Singapore Chinese.     

Compass: Clinical Evaluation of a New Instrument for the Diagnosis of Glaucoma

Aims

To evaluate Compass, a new instrument for glaucoma screening and diagnosis that combines scanning ophthalmoscopy, automated perimetry, and eye tracking.

Materials and Methods

A total of 320 human subjects (200 normal, 120 with glaucoma) underwent full ophthalmological evaluation and perimetric evaluation using the Humphrey SITA standard 24° test (HFA), and the Compass test that consisted of a full-threshold program on the central 24° with a photograph of the central 30° of the retina. A subgroup of normal subjects and glaucoma patients underwent a second Compass test during the same day in order to study test-retest variability. After exclusion of 30 patients due to protocol rules, a database was created to compare the Compass to the HFA, and to evaluate retinal image quality and fixation stability.

Results

The difference in mean sensitivity between Compass and HFA was -1.02 ± 1.55 dB in normal subjects (p<0.001) and -1.01 ± 2.81 dB in glaucoma (p<0.001). Repeatability SD for the average sensitivity was 1.53 for normal subjects and 1.84 for glaucoma. Test time with the Compass was 634±96 s (607±78 for normals, 678±108 for glaucoma). Compass analysis showed the percentage of fixation within the central 1° was 86.6% in normal subjects, and 79.3% in glaucoma patients. Color image quality was sufficient for diagnostic use in >65% of cases; Image-based diagnosis was in accordance with the initial diagnosis in 85% of the subjects.

Conclusions

Based on preliminary results, Compass showed useful diagnostic characteristics for the study of glaucoma, and combined morphological information with functional data.     

Asthma as a link between chest illness in childhood and chronic cough and phlegm in young adults

The link between chest illnesses in childhood to age 7 and the prevalence of cough and phlegm in the winter reported at age 23 was investigated in a cohort of 10 557 British children born in one week in 1958 (national child development study). Both pneumonia and asthma or wheezy bronchitis to age 7 were associated with a significant excess in the prevalence of chronic cough and phlegm at age 23 after controlling for current smoking. This excess was largely attributable to the association of cough and phlegm at age 23 with a history of asthma or wheezy bronchitis from age 16. When adjustment was made for recent wheezing, current cigarette consumption, previous smoking habit, and passive exposure to smoke the relative odds of cough or phlegm, or both, in subjects with a history of childhood chest illness was 1·11 (95% confidence interval 0·97 to 1·27). When analysed separately asthma, wheezy bronchitis, and pneumonia up to age 7 did not significantly increase the prevalence of either cough or phlegm.The explanation for the observed continuity between chest illness in childhood and respiratory symptoms in later life may lie more in the time course of functional disturbances related to asthma than in the persistence of structural lung damage.     

Epidemiology and Course of Gastrointestinal Haemorrhage in North-east Scotland

A prospective study was made of 817 consecutive episodes of major gastrointestinal haemorrhage in patients admitted to hospital during 1967-8 from the defined population of North-East Scotland. The yearly admission rate was 116 per 100,000 population. Comparison of the data for city and country residents showed no appreciable differences. In the duodenal ulcer group there was an undue incidence of bleeding among foremen and skilled workers and among those who were unmarried or widowed.Both the clinical history and the results of any previous barium meal examinations were unreliable guides to the source of the current haemorrhage. Prognosis was worse for patients who did not have a dyspeptic history and was better for those who had bled on a previous occasion. The simultaneous ingestion of alcohol and aspirin had an adverse effect on the occurrence of bleeding. Forty-seven per cent. of the patients had another major coincidental disease.Mortality was 13·7% in the whole series and 8·6% in those with peptic ulcer (duodenal ulcer 7·1%, gastric ulcer 16·9%). In 28% of the patients further haemorrhage occurred after admission to hospital and caused a 28·8% mortality. Seventy-four patients were already in hospital when they first bled and 44% of them died.     

Fabry Disease – Underestimated in the Differential Diagnosis of Multiple Sclerosis?

Objective

Fabry disease is a rare X-linked inherited lysosomal storage disorder affecting multiple organ systems. It includes central nervous system involvement via micro- and macroangiopathic cerebral changes. Due to its clinical symptoms and frequent MRI lesions, Fabry disease is commonly misdiagnosed as multiple sclerosis. We present an overview of cases from Fabry centres in Germany initially misdiagnosed with multiple sclerosis and report the clinical, MR-tomographical, and laboratory findings.

Methods

Eleven Fabry patients (one male, ten females) initially diagnosed with multiple sclerosis were identified from 187 patient records (5.9%) and analyzed for presenting symptoms, results of the initial diagnostic workup, and the clinical course of the disease.

Results

Four patients were identified as having a “possible” history of MS, and 7 patients as “definite” cases of multiple sclerosis (revised McDonald criteria). On average, Fabry disease was diagnosed 8.2 years (±9.8 years) after the MS diagnosis, and 12.8 years after onset of first symptoms (±10.3 years). All patients revealed white matter lesions on MRI. The lesion pattern and results of cerebrospinal fluid examination were inconsistent and non-specific. White matter lesion volumes ranged from 8.9 mL to 34.8 mL (mean 17.8 mL±11.4 mL). There was no association between extra-neurological manifestations or enzyme activity and lesion load.

Conclusion

There are several anamnestic and clinical hints indicating when Fabry disease should be considered a relevant differential diagnosis of multiple sclerosis, e.g. female patients with asymmetric, confluent white matter lesions on MRI, normal spinal MR imaging, ectatic vertebrobasilar arteries, proteinuria, or lack of intrathecally derived immunoglobulin synthesis.     

Streptokinase in Recent Myocardial Infarction: A Controlled Multicentre Trial

In this controlled multicentre trial treatment with either streptokinase or heparin was allocated at random to patients suffering from myocardial infarction of less than 24 hours'' duration. Treatment with either drug was standardized and lasted for 24 hours. A total of 764 patients entered the trial; 34 patient charts were rejected (including all 28 charts from one centre) because of data failure. On retrospective analysis of the 730 remaining patients the two groups were found to have been comparable at the start.The total hospital mortality was 18·5% of 373 patients allotted to streptokinase treatment and 26·3% of 357 given herapin. The mortality after infusion (24 hours) was 10·6% of 340 patients treated with streptokinase and 17·8% of 320 given herapin (P=0·011). Reinfarction in hospital after the 24-hour period of infusion occurred significantly less often in patients treated with streptokinase (P=0·036). Bleeding from puncture sites and pyrexia occurred more frequently during streptokinase treatment.After exclusion of those patients whose diagnosis was unconfirmed on retrospective assessment, the total hospital mortality rate was 19·0% of 357 patients treated with streptokinase and 27·4% of 339 treated with heparin (P=0·011). These results indicate that in recent myocardial infarction streptokinase was superior to heparin in reducing mortality and reinfarction rate during an average period of six weeks in hospital.     

Emergency geriatric surgical admissions

The emergency surgical work load created by patients aged 80 and over in a district hospital was assessed and the results of treatment examined. Over one year 248 patients aged 80 or over were admitted as emergencies, and the overall mortality rate was 21·8%. When terminal disease was excluded mortality rate was 12·5%. These elderly patients had an average length of stay in the acute surgical ward of 14·7 days compared with a mean of 8·4 days for all patients, and all but seven patients were discharged to their original place of referral.Elderly patients do exacerbate the bed shortage in acute surgical wards because they tend to stay longer than younger patients, but these elderly surgical patients imposed only a small load on the inpatient geriatric services, as 78% were discharged straight to their own homes and a further 17% went home after a period on the surgical convalescent wards.     

Comparison of community based service with hospital based service for people with acute,severe psychiatric illness.

OBJECTIVE--To compare the burden on relatives and outcome of people treated for severe acute psychiatric illness by a community service and a traditional hospital based service. DESIGN--Follow up of patients aged 16-65 who required admission to hospital or home treatment for psychiatric illness during January 1990 to February 1991. SETTING--Two Birmingham electoral wards, Sparkbrook and Small Heath; Sparkbrook has a community based service and Small Heath a traditional hospital based service. SUBJECTS--69 patients from Sparkbrook and 55 from Small Health. MAIN OUTCOME MEASURES--Scores on present state examination, social behaviour assessment schedule, and general health questionnaire. RESULTS--24 (35%) of Sparkbrook patients received some treatment in hospital during the initial episodes. Relatives of Sparkbrook patients were less distressed by their burden at the initial assessment than relatives of Small Health patients (mean score 0.11 v 0.29, p < 0.01). Relatives were also more satisfied with the support they received and the treatment received by patients. More patients from Sparkbrook than Small Health were in contact with a psychiatrist (81% (95% confidence interval 71% to 91%) v 62% (44% to 68%)) and community nurse (56% (44% to 68%) v 14% (13% to 24%)) one year after the initial episode. Sparkbrook patients spent significantly fewer days in hospital during the initial episode (8 days v 59 days) and the first year (20.6 v 67.9 days). CONCLUSION--The community based service is as effective as the hospital based service and is preferred by relatives. It is more effective in keeping people in long term contact with psychiatrists.     

ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review

Aim

To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.

Methods

Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.

Results

Until July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.

Conclusion

The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.     

Predisposing Risk Factors for Delirium in Living Donor Liver Transplantation Patients in Intensive Care Units

Background

Delirium is one of the main causes of increased length of intensive care unit (ICU) stay among patients who have undergone living donor liver transplantation (LDLT). We aimed to evaluate risk factors for delirium after LDLT as well as to investigate whether delirium impacts the length of ICU and hospital stay.

Methods

Seventy-eight patients who underwent LDLT during the period January 2010 to December 2012 at a single medical center were enrolled. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scale was used to diagnose delirium. Preoperative, postoperative, and hematologic factors were included as potential risk factors for developing delirium.

Results

During the study period, delirium was diagnosed in 37 (47.4%) patients after LDLT. The mean onset of symptoms occurred 7.0±5.5 days after surgery and the mean duration of symptoms was 5.0±2.6 days. The length of stay in the ICU for patients with delirium (39.8±28.1 days) was significantly longer than that for patients without delirium (29.3±19.0 days) (p<0.05). Risk factors associated with delirium included history of alcohol abuse [odds ratio (OR) = 6.40, 95% confidence interval (CI): 1.85–22.06], preoperative hepatic encephalopathy (OR = 4.45, 95% CI: 1.36–14.51), APACHE II score ≥16 (OR = 1.73, 95% CI: 1.71–2.56), and duration of endotracheal intubation ≥5 days (OR = 1.81, 95% CI: 1.52–2.23).

Conclusions

History of alcohol abuse, preoperative hepatic encephalopathy, APACHE II scores ≥16 and endotracheal intubation ≥5 days were predictive of developing delirium in the ICU following liver transplantation surgery and were associated with increased length of ICU and hospital stay.     

One Year's Experience in a Ministry of Health Dialysis Centre

A 10-bed dialysis unit, opened at the London Hospital in 1968, admitted 37 patients during its first year of operation. The aims of the unit were to prepare patients for renal transplantation and to provide instruction for dialysis treatment at home. A total of 2,012 days were spent in hospital, the average intervals between admission, the first dialysis, and discharge being 23·8 and 20 days, respectively. The overall number of readmissions was 1·5 per patient. These figures, together with the increasing number of patients accepted for such treatment, indicate the considerable number of supporting hospital beds, as well as medical and technical staff, required to maintain a dialysis unit.     

The Value of Serum Prealbumin in the Diagnosis and Therapeutic Response of Tuberculosis: A Retrospective Study

Objective

The aim of this study was to examine serum prealbumin (PA) levels in patients with tuberculosis and lung cancer, and to evaluate the correlations of serum PA levels with clinicopathological characteristics.

Method

Total 760 patients were included in the study: 320 patients with tuberculosis, 320 patients with lung cancer, and 120 healthy subjects. Serum PA was detected using a biochemical analyzer to determine the value of serum PA in the diagnosis and therapeutic response of tuberculosis.

Results

Compared to lung cancer and healthy individuals, TB patients were more frequent in suffering from low serum PA (75.0% vs.30.9% vs.6.7%,P<0.01), and the serum PA levels of TB patients were significantly reduced (137.5±42.4 mg/L vs. 183.5±49.1 mg/L vs. 240.0±43.9 mg/L, P<0.01). Among various clinical characteristics, type (with pleuritis), age (≥60), ESR (>20 mm/h) and smoking status (≥20 pack×years) were associated with low serum PA levels of TB patients, while ECOG performance status (≥2) was associated with low serum PA levels of lung cancer patients. The change of serum PA levels was in accordance with the therapeutic effects of anti-TB drugs, which might present a valuable and objective indicator for monitoring the therapeutic effects of TB drugs on TB patients.

Conclusion

Low serum prealbumin levels are very common in TB patients and can be served as a potential indicator for differential diagnosis of lung cancer and monitoring the therapeutic effects of TB drugs.     

The Significance of Sensitive Interferon Gamma Release Assays for Diagnosis of Latent Tuberculosis Infection in Patients Receiving Tumor Necrosis Factor-α Antagonist Therapy

Objective

We compared two interferon gamma release assays (IGRAs), QuantiFERON-TB Gold In-Tube (QFT-GIT) and T-SPOT.TB, for diagnosis of latent tuberculosis infection (LTBI) in patients before and while receiving tumor necrosis factor (TNF)-α antagonist therapy. This study evaluated the significance of sensitive IGRAs for LTBI screening and monitoring.

Methods

Before starting TNF-α antagonist therapy, 156 consecutive patients with rheumatic diseases were screened for LTBI using QFT-GIT and T-SPOT.TB tests. According to our study protocol, QFT-GIT-positive patients received LTBI treatment. Patients positive by any IGRAs were subjected to follow-up IGRA tests after completing LTBI-treatment and/or during TNF-α antagonist therapy.

Results

At the initial LTBI screening, 45 (28.9%) and 70 (44.9%) patients were positive by QFT-GIT and T-SPOT.TB, respectively. The agreement rate between IGRA results was 78.8% (k = 0.56; 95% confidence interval [95% CI] = 0.43 to 0.68). Of 29 patients who were positive only by T-SPOT.TB in the initial screening, 83% (19/23) were persistently positive by T-SPOT.TB, while QFT-GIT testing showed that 36% (9/25) had conversion during TNF-α antagonist therapy. By the end of the follow-up period (218 to 1,264 days), four patients (4/137, 2.9%) developed active tuberculosis (TB) diseases during receiving TNF-α antagonist therapy. Among them, one was Q-T+, one was Q+T-, and the remaining two were Q-T- at the initial screening (Q, QuantiFERON-TB Gold In-Tube; T, T-SPOT.TB; +, positive; -, negative). Two (2/4, 50%) patients with TB reactivation had at least one prior risk factor consistent with previous TB infection.

Conclusion

This study demonstrated the need to capitalize on sensitive IGRAs to monitor for LTBI in at-risk patients for a more sensitive diagnosis in countries with an intermediate TB burden.     

Use of Radiological Facilities by General Practitioners

The 11,360 direct referrals to diagnostic radiological facilities by general practitioners in the Aberdeen area during 1973 were studied. These represented about 12% of the adult radiology performed in the main x-ray departments of the city, and barium meal examinations amounted to half of all such outpatient contrast examinations. Chest x-ray and barium meal examinations were the most frequently used procedures.Some abnormality was detected at 34% of all examinations, and the barium meal examinations requested by general practitioners showed a similar percentage of abnormal findings to those requested by Aberdeen hospital doctors.The average referral rate for all practices was 24·6 per 1,000 practice population per year. Singlehanded general practitioners referred fewer patients for diagnostic radiology than those working in group practices, and rural practitioners referred fewer than urban general practitioners. This trend was emphasized at a distance greater than 15 miles from the city.     

Developmental history affects the susceptibility of spinach leaves to in vivo low temperature photoinhibition

Room temperature chlorophyll a fluorescence was used to determine the effects of developmental history, developmental stage, and leaf age on susceptibility of spinach to in vivo low temperature (5°C) induced photoinhibition. Spinach (Spinacia oleracea cv Savoy) leaves expanded at cold hardening temperatures (5°C day/night), an irradiance of 250 micromoles per square meter per second of photosynthetic proton flux density, and a photoperiod of 16 hours were less sensitive than leaves expanded at nonhardening temperatures (16 or 25°C day/night) and the same irradiance and photoperiod. This differential sensitivity to low-temperature photoinhibition was observed at high (1200) but not lower (500 or 800 micromoles per square meter per second) irradiance treatment. In spite of a differential sensitivity to photoinhibition, both cold-hardened and nonhardened spinach exhibited similar recovery kinetics at either 20 or 5°C. Shifting plants grown at 16°C (day/night) to 5°C (day/night) for 12 days after full leaf expansion did not alter the sensitivity to photoinhibition at 5°C. Conversely, shifting plants grown at 5°C (day/night) to 16°C (day/night) for 12 days produced a sensitivity to photoinhibition at 5°C similar to control plants grown at 16°C. Thus, any resistance to low-temperature photoinhibition acquired during growth at 5°C was lost in 12 days at 16°C. We conclude that leaf developmental history, developmental stage, and leaf age contribute significantly to the in vivo photoinhibitory response of spinach. Thus, these characteristics must be defined clearly in studies of plant susceptibility to photoinhibition.     

Tick-borne Relapsing Fever in the Pacific Northwest: An Underdiagnosed Illness?

Some 30 cases of tick-borne relapsing fever due to Borrelia are known to have occurred between 1965 and 1978 in the Pacific Northwest. This disease was found more frequently in young men with a history of wilderness exposure during the summer months. Recurrent fever was the most common symptom with temperatures reaching higher than 39.5° C (103.1° F) in all cases, and many patients had three or more febrile episodes. Splenomegaly was the second most common finding reported. Diagnosis of relapsing fever was made in 20 cases by identifying spirochetes on peripheral blood smears. In ten remaining cases the diagnosis was made on clinical and epidemiologic grounds.Information regarding therapy was available in 21 cases. Ten patients received a tetracycline drug and all had a prompt response without relapse. Two of the patients died, a 68-year-old woman with possible myocardial involvement and a newborn infant with infection acquired in utero and meningeal involvement.The diagnosis was often delayed in spite of outpatient evaluation and admittance to hospital, probably because borreliosis was not considered in the differential diagnosis. Because tick-borne relapsing fever is eventually a self-limited disease in most patients, it is probably not recognized often enough. Awareness of this disease and examination of the peripheral blood smear for spirochetes will lead to earlier diagnosis. Prompt initiation of tetracycline therapy should reduce morbidity associated with borreliosis.     

Outcomes and Treatment of Lumbosacral Spinal Tuberculosis: A Retrospective Study of 53 Patients

Study Strategy

A retrospective clinic study.

Purpose

To evaluate the efficacy of conservative and surgical treatment for lumbosacral tuberculosis.

Methods

This study retrospectively reviewed 53 patients with lumbosacral tuberculosis who were treated in our institution between January 2005 and January 2011. There were 29 males and 24 females with average ages of 37.53 ± 17.28 years (range 6–72 years). 11 patients were given only anti-TB drugs; the remainder underwent anterior debridement, interbody fusion with and without instrumentation, or one-stage anterior debridement combined with posterior instrumentation. Outcome data for these patients included neurologic status, lumbosacral angle, erythrocyte sedimentation rate value(ESR) and C-reactive protein value(CRP) were assessed before and after treatment.

Results

The mean lumbosacral angles were 23.00°± 2.90°in the conservatively treated patients and 22.36°± 3.92o in the surgically treated patients. At the final follow-up, this had improved to 24.10o ± 2.96°in the conservatively treated patients and 28.13° ± 1.93°in the surgically treated patients (all P < 0.05). There were statistically significant differences before and after treatment in terms of ESR and CRP (all P < 0.05). All patients achieved bone fusion. The mean follow-up period was 32.34 ± 8.13 months (range 18 to 55 months). The neurological deficit did not worsen in any of the patients.

Conclusions

It has been proven that conservative and surgical treatments are safe and effective and produce good clinical outcomes for patients with lumbosacral tuberculosis. The advantages of operation include thoroughness of debridement, decompression of the spinal cord, and adequate spinal stabilization.     

Clinical Deterioration during Antitubercular Treatment at a District Hospital in South Africa: The Importance of Drug Resistance and AIDS Defining Illnesses

Background

Clinical deterioration on drug therapy for tuberculosis is a common cause of hospital admission in Africa. Potential causes for clinical deterioration in settings of high HIV-1 prevalence include drug resistant Mycobacterium tuberculosis (M.tb), co-morbid illnesses, poor adherence to therapy, tuberculosis associated-immune reconstitution inflammatory syndrome (TB-IRIS) and subtherapeutic antitubercular drug levels. It is important to derive a rapid diagnostic work-up to determine the cause of clinical deterioration as well as specific management to prevent further clinical deterioration and death. We undertook this study among tuberculosis (TB) patients referred to an adult district level hospital situated in a high HIV-1 prevalence setting to determine the frequency, reasons and outcome for such clinical deterioration.

Method

A prospective observational study conducted during the first quarter of 2007. We defined clinical deterioration as clinical worsening or failure to stabilise after 14 or more days of antitubercular treatment, resulting in hospital referral. We collected data on tuberculosis diagnosis and treatment, HIV-1 status and antiretroviral treatment, and investigated reasons for clinical deterioration as well as outcome.

Results

During this period, 352 TB patients met inclusion criteria; 296 were admitted to hospital accounting for 17% of total medical admissions (n = 1755). Eighty three percent of TB patients (291/352) were known to be HIV-1 co-infected with a median CD4 count of 89cells/mm³ (IQR 38–157). Mortality among TB patients admitted to hospital was 16% (n = 48). The median duration of hospital admission was 9.5 days (IQR 4–18), longer than routine in this setting (4 days). Among patients in whom HIV-1 status was known (n = 324), 72% of TB patients (n = 232) had an additional illness to tuberculosis; new AIDS defining illnesses (n = 80) were the most frequent additional illnesses (n = 208) in HIV-1 co-infected patients (n = 291). Rifampin-resistant M.tb (n = 41), TB-IRIS (n = 51) and drug resistant bacterial infections (n = 12) were found in 12%, 14% and 3.4% of the 352 cases, respectively.

Interpretation

In our setting, new AIDS defining illnesses, drug resistant M.tb and other drug resistant bacteria are important reasons for clinical deterioration in HIV-1 co-infected patients receiving antitubercular treatment. HIV-1 co-infected patients may be at increased risk of acquiring nosocomial drug resistant pathogens because profound immune suppression results in co-morbid illnesses that require prolonged inpatient admissions. Routine infection control is essential and needs to be strengthened in our setting.