Tuberculosis: Hospitalization and Outpatient Treatment

Initial hospitalization terminated by discharge upon medical advice to continue with chemotherapy on an outpatient basis represents the treatment of choice for most patients with active pulmonary tuberculosis. Any departure from this plan for any patient should be accepted only after careful consideration of all the circumstances. Patients with active pulmonary tuberculosis who are to receive outpatient chemotherapy without adequate initial hospitalization should be carefully selected by the local or provincial department of public health. Approval in writing should be required from the appropriate public health authority before antituberculosis chemotherapy is provided at public expense for any such patient, except possibly for a limited period while awaiting formal approval. In all instances, the clinic which dispenses the antituberculosis drugs should have the patient under supervision with recall for follow-up examinations as required. Prophylactic antituberculosis chemotherapy may be provided to certain groups of persons without hospitalization.     

Short course chemotherapy for tuberculous lymphadenitis in children.

OBJECTIVE--To assess the efficacy of a short course chemotherapy regimen for treating tuberculosis of the lymph nodes in children. DESIGN--Open, collaborative, outpatient clinical trial. SETTING--Outpatient department of the Tuberculosis Research Centre, paediatric surgery departments of the Institute of Child Health and Hospital for Children and the Government Stanley Hospital, Madras, South India. PATIENTS--Children aged 1-12 years with extensive, multiple site, superficial tuberculous lymphadenitis confirmed by biopsy (histopathology or culture). INTERVENTIONS--Patients were treated with a fully supervised intermittent chemotherapy regimen consisting of streptomycin, rifampicin, isoniazid, and pyrazinamide three times a week for two months followed by streptomycin and isoniazid twice a week for four months on an outpatient basis. Surgery was limited to biopsy of nodes for diagnosis and assessment. MAIN OUTCOME MEASURES--Response to chemotherapy was assessed by regression of lymph nodes and healing of sinuses and abscesses during treatment and follow up. Compliance with treatment and frequency of adverse reactions were also estimated. RESULTS--197 Patients were admitted to the study and 168 into the analysis. The regimen was well tolerated and compliance was good with 101 (60%) patients receiving the prescribed chemotherapy within 15 days of the stipulated period of six months. Those whose chemotherapy extended beyond that period received the same total number of doses. Clinical response was favourable in most patients at the end of treatment. Sinuses and abscesses healed rapidly. Residual lymphadenopathy (exceeding 10 mm diameter) was present in 50 (30%) patients at the end of treatment; these nodes were biopsied. Fresh nodes, increase in size of nodes, and sinuses and abscesses occurred both during treatment and follow up. After 36 months of follow up after treatment only 5 (3%) patients required retreatment for tuberculosis. CONCLUSION--Tuberculous lymphadenitis in children can be successfully treated with a short course chemotherapy regimen of six months.     

纤维支气管镜局部注药治疗耐药支气管内膜结核

目的:探讨和评价经纤维支气管镜局部注药对耐药肺结核合并支气管内膜结核患者的可行性和疗效.方法:对120例确诊为耐药肺结核合并支气管内膜结核患者,在进行全身抗结核治疗的同时依据患者志愿,随机分为两组,一组即单纯化疗者,另一组化疗+支气管镜注药组.比较两组病人在临床症状、痰菌阴转、影像学及纤维支气管镜下的疗效差异.结果:耐药肺结核合并支气管内膜结核经全身抗结核治疗辅以支气管镜局部给药,疗效显著优于单纯全身抗结核治疗.结论:使用支气管镜治疗耐药支气管内膜结核,可明显提高疗效、缩短病程,值得在临床上广泛应用.     

Lymphadénite tuberculeuse cervicale simulant une métastase ganglionnaire d’un carcinome papillaire de la thyroïde. À propos d’un cas

Cervical lymph nodes represent one of the most frequent clinical symptoms of extrapulmonary tuberculosis. Their appearance in a neoplastic suggests lymph node metastasis. We report an atypical tuberculous lymphadenetis mimicking lymph node metastasis in a 42-year-old patient followed for papillary thyroid carcinoma operated and treated by iodine 131 therapy. Evolution was marked by the appearance of left cervical adenopathies suggesting lymph node metastatic extension on echographic criteria. A lymph node excision was undertaken and the pathologic study revealed a tuberculous lymphadenitis. The patient was put under antibacillary treatment and evolution was satisfactory. We also expose, through this work, a certain number of techniques of exploration likely to ascertain the diagnosis of a tuberculous lymphadenitis and to monitor the therapeutic strategy.     

Changes in serum selenium, copper, zinc levels and Cu/Zn ratio in patients with pulmonary tuberculosis during therapy

The effectiveness and success of antituberculosis therapy is mainly measured by its ability to identify the organism in the sputum. In certain cases, available tuberculosis tests are not satisfactory and do not provide enough information on the effectiveness of antituberculosis therapy. Copper (Cu), zinc (Zn), and selenium (Se) are the essential elements that play a crucial role in the immune system. The serum levels of these elements vary in many diseases including tuberculosis. In this study, we investigate whether the serum levels of Cu, Zn, and Se change during antituberculosis therapy. We have included 22 pulmonary tuberculosis cases that were newly diagnosed with positive sputum and 18 healthy subjects. At the beginning and 2 mo after therapy, serum levels of Cu, Zn, and Se were measured by atomic absorption spectrometry. Despite Se and Cu levels not being affected during the treatment, we found that there was a significant increase in the levels of Zn and a decrease in the Cu/Zn ratio. Serum Zn levels and the Cu/Zn ratio could be used as a valuable laboratory tool for the clinicians to assess response to therapy or effectiveness of the ongoing antituberculosis therapy.     

Management of extra-pulmonary tuberculosis (excluding miliary and meningeal) in south and west Wales (1976-8).

In a retrospective survey of the management of extrapulmonary tuberculosis lymph node and genitourinary tuberculosis were found more commonly than bone and joint or gynaecological disease. Only 29% of patients received 18 moths'' chemotherapy while 31% received nine to 12 months'' treatment with rifampicin and isoniazid regimens and 34% had short-course chemotherapy with other regimens. Five patients were not offered any chemotherapy after diagnosis, and in five patients the diagnosis was overlooked because of administrative errors. One patient died from tuberculosis (renal). Poor drug compliance appeared less of a problem than in pulmonary tuberculosis. Only 14% of patients had their disease managed solely by consultants who were not specialists in chest disease. Liaison with a chest consultant did not necessarily ensure chemotherapy for 18 moths.     

Tuberculosis in HIV-infected patients in Croatia between 1986 and 2005

A retrospective medical chart review was performed on 65 HIV-infected patients with tuberculosis hospitalized between 1986 and 2006 at the University Hospital for Infectious Diseases "Dr. Fran Mihaljevi?", Zagreb. Thirty two patients presented with pulmonary involvement, 13 with extrapulmonary, and 20 patients had disseminated tuberculosis. Forty five patients had an abnormal chest X-ray. Mycobacterium tuberculosis was identified in 35 (53.9%) patients. Ten (15.3%) of 65 patients had already been receiving antiviral therapy, while another 31 (47.7%) initiated antiviral therapy after antituberculosis therapy. Tuberculosis-associated immune reconstitution inflammatory syndrome was observed in 11/27 (40.7%) patients. Forty one patient received the standard six month course of antituberculous therapy, while in 12 patients the therapy was prolonged. Twenty one patient (32%) experienced an adverse event to antituberculosis drugs. Twelve patients died (18.5%). After the introduction of highly active antiviral therapy (HAART) the mortality decreased. The incidence of tuberculosis in HIV-infected patients in Croatia is increasing, and tuberculosis is still an important opportunistic infection in our HIV-infected patients.     

局部注药联合口服康复新液辅助治疗颈淋巴结结核疗效观察

目的:探讨局部注射药物联合口服康复新液辅助治疗颈淋巴结结核的临床疗效及安全性。方法:按照随机数字表法将2010年1月-2014年1月我院收治的140例颈淋巴结结核患者分为对照组(n=70)和观察组(n=70),对照组口服异烟肼、利福平、乙胺丁醇、吡嗪酰胺及肌注链霉素进行全身抗结核治疗,观察组在对照组的基础上局部注射异烟肼、链霉素粉联合口服康复新液治疗。比较两组患者治疗后1个月、3个月及6个月症状缓解率,淋巴结吸收率,治疗后3个月复发率及不良反应发生率。结果:观察组治疗后1个月、3个月及6个月的症状缓解率、淋巴结吸收率均高于对照组(P0.05)。治疗后3个月,观察组复发率为2.86%,显著低于对照组的11.43%(P0.05)。观察组恶心、局部反应、白细胞减少及肝功能损害发生率均低于对照组(P0.05)。结论:局部注射抗结核药物联合口服康复新液辅助治疗颈淋巴结结核可提高患者的症状缓解率和淋巴结吸收率,且安全性高,有重要的临床推广价值。     

乳腺癌保乳术后局部复发的相关因素

随着保乳手术的开展及保乳病人的增多,相应出现了一些保乳术后局部复发的病例,而切缘阴性或阳性、术后全乳照射与否、年龄、病理类型、病例的选择、新辅助化疗后保乳术切除范围、SLNB(前哨淋巴结活检)等都与保乳术后局部复发有关。因此确保严格选择适应症病例、手术切缘阴性、术后全乳照射、病理类型为非EIC(广泛导管内癌成分)、新辅助化疗后手术范围的准确以及提高SLNB的准确率都可降低保乳手术的局部复发。本文在此就乳腺癌保乳术后局部复发的相关因素进行探讨。     

Immunological memory in tuberculosis. I. Influence of persisting viable organisms

Rats were immunized with 10⁸ BCG and treated with rifampicin plus isoniazid for 9 months; similarly immunized subjects received no chemotherapy. Immediately before the institution of chemotherapy and at predetermined intervals thereafter, the immunological status of these two groups of animals was evaluated with respect to tuberculin hypersensitivity, resistance to reinfection with virulent tubercle bacilli (H37Rv), and the capacity of thoracic duct lymphocytes to consider specific antimicrobial resistance on normal recipients. Treatment with antituberculosis drugs had very little influence upon these parameters of acquired immunity despite the fact that living BCG were eradicated from the animals given chemotherapy. It is concluded that immunological memory in tuberculosis does not depend upon the persistence of viable tubercle bacilli.     

Concentration of Lymph Node Aspirate Improves the Sensitivity of Acid Fast Smear Microscopy for the Diagnosis of Tuberculous Lymphadenitis in Jimma,Southwest Ethiopia

Background

Tuberculous lymphadenitis (TBLN) is the most common form of extrapulmonary tuberculosis. The cytomorphological features of lymph node smears have reduced specificity for the diagnosis of tuberculosis. The diagnosis of TBLN with direct smear microscopy lacks sensitivity due to the limited number of bacilli in lymph node aspirate. Therefore, we aimed to assess whether the concentration of lymph node aspirate improves the sensitivity of acid fast smear microscopy for the diagnosis of tuberculous lymphadenitis.

Methods

A cross-sectional comparative study was conducted on 200 patients clinically suspected for tuberculous lymphadenitis in Jimma, Ethiopia. Lymph node aspirate was collected. The first two drops were used for cytomorphological study and direct acid fast staining. The remaining aspirate was treated with N-acetyl-L-cysteine (NALC) and concentrated by centrifugation at 3000 g for 15 minutes. The sediment was used for acid fast staining and culture. Differentiation of M. tuberculosis complex (MTBC) from non-tuberculous mycobacteria (NTM) was done by para-nitrobenzoic acid susceptibility test.

Result

Complete data were available for 187 study subjects. 68% (127/187) were positive for M. tuberculosis on culture. Four isolates, 2.1% (4/187), were identified as NTM. The detection rate of direct smear microscopy was 25.1% and that of the concentration method 49.7%. Cytomorphologically, 79.7% of cases were classified as TBLN. The sensitivity of direct smear microscopy was 34.6%, for concentrated smear microscopy 66.1%, and for cytomorphology 89.8%. Two AFB positive cases on concentration method were non-tuberculosis mycobacteria (NTM). The concentration method yielded a positive result from seven cases diagnosed as suppurative abscess by cytology. Both for the direct and concentration methods the highest rate of AFB positivity was observed in smears showing caseous necrosis alone. Smear positivity rate decreased with the appearance of epithelioid cell aggregates.

Conclusion

The concentration of lymph node aspirates for acid fast smear microscopy had significantly higher sensitivity than direct microscopy.     

Spectrum of cytomorphology of tuberculous lymphadenitis and changes during anti-tubercular treatment

OBJECTIVE: To analyse the morphological changes in tuberculous lymph nodes and the clinical response during short course anti tubercular chemotherapy. METHODS: Thirty-six patients with tuberculous lymphadenitis under treatment were followed up clinically and cytologically at 0, 2, 4 and 6 months. RESULTS: Twenty-six (72.2%) patients had palpable lymph nodes at the end of chemotherapy. Of the 14 patients with residual lymph nodes exceeding 1 cm in size, 92.8% (13) still had evidence of continuation of the disease. Acid-fast bacilli could be found in 38.8% patients at the end of 6 months. Intense lymphocytic infiltration of granulomata in the early phase of chemotherapy predicted a favourable outcome. CONCLUSIONS: Following completion of anti-tubercular treatment a significant percentage of patients have persistent lymphadenopathy and harbour the disease. Morphological follow up of these patients is essential as they may be at increased risk of relapse.     

Community-acquired MRSA and pig-farming

Background

Female genital tuberculosis is an uncommon disease that is rarely diagnosed in developed countries.

Case presentation

A 61-year-old postmenopausal woman who had undergone surgery and treated with adjuvant chemotherapy for infiltrating ductal carcinoma of the breast five years ago, presented with bloody vaginal discharge, fatigue, weight loss, and low grade fevers at night for two months. Histological examination of the endometrium, done based on the suspicion of a second primary cancer due to the tamoxifen therapy, revealed a granulomatous reaction. Liquid and solid mycobacterial cultures of the tissues were performed. Although the acid fast staining was negative, the liquid culture was positive for Mycobacterium tuberculosis. Involvement of other systems was not detected. The patient was treated with a three-drug antituberculosis regimen for 9 months and recovered fully.

Conclusion

Female genital tuberculosis is a rare but curable disease that should be included in the differential diagnosis of women with menstrual problems. Early diagnosis is important and may prevent unnecessary invasive procedures for the patient.     

Efficacy of cow's kumiss in the treatment of large intestine dysbacteriosis and its impact on tolerability of antituberculosis agents in patients with respiratory tract tuberculosis]

Dysbacteriosis of the large intestine is one of severe complications of long-term use of antituberculosis agents in the treatment of respiratory tract tuberculosis that results in a significant decrease of tolerability of antituberculosis agents, persistence of tuberculosis intoxication and slower involution of the tuberculosis process in the lungs. When the complex treatment with antituberculosis agents was accompanied by the use of cow's kumiss for correction of the large intestine dysbacteriosis, the intoxication signs disappeared in 12% of the patients in the main group, while in the patients of the control group the level of the intoxication syndrome increased twice. The rate of the tuberculosis lesions regression evident from the lung roentgenograms was 2.7-fold higher in the main group vs. the control (62 and 23% respectively). The indices of the lung functional capacity recovery in the patients of the main group vs. the control were also higher (41 and 33% respectively). Hepatic toxic reactions in the patients not given cow's kumiss for correction of dysbacteriosis were 8 times more frequent vs. the control. The results of the study made it possible to develop recommendations for phthisiologists in the use of cow's kumiss as one of the methods of pathogenetic therapy in complex treatment of patients with respiratory tract tuberculosis in sanatoria.     

Hereditary melanoblastoma in miniature pigs and its successful therapy by devitalization technique.

Applying selective breeding for 10 years we established the MeLiM (Melanoblastoma-bearing Libechov Minipigs) strain. Melanoblastoma (MB) in this strain shows a hereditary occurrence. Cutaneous tumours are usually nodular, multiple and distributed on various parts of body. They appear in darkly pigmented animals already at the birth or during two months thereafter (57% of all animals). Numerous organ metastases mainly into the spleen, lymph nodes and lungs are regularly ascertained in animals with cutaneous MB. Tumour cells were surprisingly found also in the inner organs of phenotypically healthy minipigs in which no cutaneous MBs were observed visually (27% of all animals). About 34% of all affected piglets die during the first 2 months of age. These features document a malignancy of this tumour in the MeLiM strain. Original surgical technique was applied in more than 40 affected minipigs at 1-2 months of age. It consists in a devitalization (ischemization) of one of cutaneous tumours by the mattress sutures conducted around the tumour base without any excision of tumour tissue. This simple procedure causes a total destruction of MB cells in all cutaneous tumours as well as in all organ metastases during 4-6 months. Animals treated by this technique were fully healed of tumour cells and no relapses were observed. This technique could bring similar positive results also in therapy of human MB.     

Circulating immune complexes in cerebrospinal fluid of patients with tuberculous meningitis.

Circulating immune complexes (ICs) were isolated from cerebrospinal fluids (CSFs) of patients with tuberculous meningitis (TBM), non-tuberculous neurological diseases by a polyethylene glycol (PEG) precipitation method. Mycobacterium tuberculosis antigen 5 was detected in CICs of 30% patients with TBM, by sandwich ELISA. CIC level decreases during antituberculosis chemotherapy and therefore its detection can provide a method to monitor the therapeutic schedule in patients with TBM.     

病理分期在颌颈部淋巴结核治疗中的价值

目的:探讨病理分期在颌颈部淋巴结核治疗中的价值,以期寻找颌颈部淋巴结核的最佳治疗方案。方法:收集我科近5年的临床资料,对颌颈部淋巴结核患者的发病及治疗情况作一临床统计,并结合淋巴结核的病理分期对之加以分析,寻找治疗规律。结果:所有颌颈部淋巴结核患者按病理分期采取不同治疗方案,均达到较佳治疗效果,处于病理初期和中期的患者,临床治疗周期明显小于常规化疗。结论:遵从病理分期治疗颌颈部淋巴结核是一种较为科学合理的治疗思路和方法。     

难治性急性白血病研究现状与进展

难治性急性白血病治疗反应差,诱导缓解率低,复发率高,生存期短,因而是白血病治疗中的难题。本文从难治性急性白血病诊断标准与免疫学、细胞遗传学及分子生物学特征,多药耐药与难治性白血病,难治性急性白血病治疗现状以及治疗展望五大方面阐述了难治性急性白血病研究现状与进展。基础与初步临床研究显示中药配合化疗能够提高难治性急性白血病围化疗期临床缓解率。认为中药在提高难治性白血病临床疗效方面具有潜在临床应用前景和开发的商业价值,值得进行深入研究。     

Tuberculous Enteritis

Tuberculous enteritis occurs in about 2 percent of patients with pulmonary tuberculosis. Although it is uncommon in the United States, tuberculous enteritis should be considered in any patient with active pulmonary tuberculosis and abdominal complaints.Eight cases of T. enteritis have been treated at Harbor General Hospital in the last 25 years. Associated pulmonary disease was shown radiologically to be present in seven of eight patients. Findings on contrast studies of the gastrointestinal tract showed disease in six of six patients examined.In five patients, surgical operation was required for diagnosis or complications. Resection of diseased bowel with primary anastomosis was done in five patients. Although medical therapy is the mainstay in the treatment of both pulmonary and intestinal tuberculosis, one staged resection of diseased bowel with primary anastomosis is the procedure of choice for complications such as obstruction, hemorrhage or perforation.     

Nontuberculous Mycobacterial Disease in Children – Epidemiology,Diagnosis & Management at a Tertiary Center

Background

There are limited data on the epidemiology, diagnosis and optimal management of nontuberculous mycobacterial (NTM) disease in children.

Methods

Retrospective cohort study of NTM cases over a 10-year-period at a tertiary referral hospital in Australia.

Results

A total of 140 children with NTM disease, including 107 with lymphadenitis and 25 with skin and soft tissue infections (SSTIs), were identified. The estimated incidence of NTM disease was 0.6–1.6 cases / 100,000 children / year; no increasing trend was observed over the study period. Temporal analyses revealed a seasonal incidence cycle around 12 months, with peaks in late winter/spring and troughs in autumn. Mycobacterium-avium-complex accounted for most cases (77.8%), followed by Mycobacterium ulcerans (14.4%) and Mycobacterium marinum (3.3%). Polymerase chain reaction testing had higher sensitivity than culture and microscopy for acid-fast bacilli (92.0%, 67.2% and 35.7%, respectively). The majority of lymphadenitis cases underwent surgical excision (97.2%); multiple recurrences in this group were less common in cases treated with clarithromycin and rifampicin compared with clarithromycin alone or no anti-mycobacterial drugs (0% versus 7.1%; OR:0.73). SSTI recurrences were also less common in cases treated with two anti-mycobacterial drugs compared with one or none (10.5% versus 33.3%; OR:0.23).

Conclusions

There was seasonal variation in the incidence of NTM disease, analogous to recently published observations in tuberculosis, which have been linked to seasonal variation in vitamin D. Our finding that anti-mycobacterial combination therapy was associated with a reduced risk of recurrences in patients with NTM lymphadenitis or SSTI requires further confirmation in prospective trials.