Combined Tuberculosis Research Articles

Premature mortality from tuberculosis and HIV infection in Russia before and during the COVID-19 pandemic

Introduction. The introduction of restrictive measures during the COVID-19 pandemic led to a reduction in the timing of screening aimed at early detection of tuberculosis among the population. As a result, there has been increased the proportion of patients with common forms of tuberculosis, the treatment of which is of considerable complexity and creates a high risk of death.
 Objective of research: study of premature mortality from tuberculosis and HIV infection in Russia before and during the Covid-19 pandemic.
 Material and methods. Rosstat data on deaths due to tuberculosis and HIV infection over 2000–2020. The age of 70 years has been adopted as the standard age for calculating the indicator of has increased potential years of life lost (PYLL). Pearson and Spearman correlation coefficients were used for the analysis.
 Results: In Russia, before the Covid-19 pandemic in 2000–2019, the decrease in the total number of patients who died from tuberculosis and HIV infection, and the total PYLL, occurred due to a decrease in the proportion of patients who died from tuberculosis — from 99.3% to 25.4%. Pandemics in 2020 in addition, total PYLL decreased to 45.3% or by 9%, PYLL from TB to 8.9% or by 10.1%, PYLL from HIV infections to 36.4% or by 8.9% compared to 2019.
 Limitations of the study. The analysis of PYLL from tuberculosis and HIV infection was carried out for the entire population and for individual age groups in 2000–2020, which was sufficient to achieve the goal. 
 Conclusion. In Russia, during the pandemic, the main reason for the decrease in the total PYLL and PYLL from tuberculosis and HIV infection were changes in the definition of the main cause of death in the combination of tuberculosis and HIV infection with Covid-19, when Covid-19 began to be indicated as such, and tuberculosis and HIV infection moved into the category of secondary causes and ceased to take part in the formation of mortality rates from these diseases.

Clinical example of effective treatment of a patient with a combination of fibrous-cavernous tuberculosis and chronic aspergillosis of the right lung

ntroduction. The combination of destructive tuberculosis and chronic pulmonary aspergillosis remains a pressing and understudied problem. Respiratory tuberculosis is a significant risk factor for bronchopulmonary aspergillosis in 40–72% of cases. The current treatment strategy for pulmonary tuberculosis and bronchopulmonary aspergillosis is governed by clinical guidelines. However, the issues of surgical treatment tactics in complicated forms of the combination of active tuberculosis and pulmonary aspergillosis require discussion and remain relevant at present. Material and methods. A clinical case of complex treatment of a patient with a combination of fibrous-cavernous tuberculosis and chronic aspergillosis of the right lung is described. Patient S., 42 years old, became ill with infiltrative tuberculosis of the right lung in August 2008. On the background of a 9-month anti-tuberculosis chemotherapy according to the I regimen she was cured and in 2012 was removed from the dispensary registration. In February 2018, an episode of pulmonary hemorrhage (volume 200 ml) occurred, and was stopped by conservative methods. At the follow-up examination, tuberculosis recurrence was verified in the right lung with the formation of fibrous-cavernous lesion. On the background of the repeated 6-month course of treatment according to the I regimen no dynamics was obtained, pulmonary hemorrhage of the Ia stage recurred regularly. In September 2018, the patient was hospitalized to SPb NIIF. Pre-examination revealed chronic pulmonary aspergillosis. Voriconazole therapy was started, and correction of the ongoing antituberculosis therapy was carried out, taking into account drug interaction. Surgical treatment was indicated. Results. On 09.25.2018, an upper bilobectomy was performed on the right side. There were no intraoperative complications. The operation was completed by draining the pleural cavity with two drains and suturing the thoracotomy wound. Postoperative period without complications. In order to correct the volume of hemithorax, an artificial pneumoperitoneum of 1000 ml was applied. The drains were removed on the 4thand 5th days after surgery, the surgical wound healed by primary tension. At the follow-up examination after five years, there was no evidence of disease recurrence or late surgical complications. Conclusion. Providing medical care to patients with a combination of tuberculosis and pulmonary aspergillosis requires the organization of full-fledged primary diagnosis and routing of patients to a specialized hospital. A complex approach to treatment allows for successful treatment outcomes with minimal risks.

Combination of tuberculosis of the intra thoracic lymph nodes and acute lymphoblastic leukemia in a child

According to scientific research, malignant neoplasms in children are biomedical risk factors for the development of tuberculosis (TB). On the contrary, the occurrence of oncological disease in a child against the background of an existing tuberculous process is extremely rare. The combination of malignant neoplasm and tuberculosis creates difficulties in differential diagnosis, treatment of diseases, prevention of exacerbations and relapses. This article presents a clinical observation the development of acute lymphoblastic leukemia (ALL) in a 6-year-old child against the background of TB of the intrathoracic lymph nodes during treatment. TB proceeded favorably despite multiple family contact in the child and resistance of Mycobacterium tuberculosis to anti-tuberculosis drugs in adult relatives of the patient. At the onset of ALL, bilateral pulmonary infiltrates and pleural effusion were observed, which were not associated with TB. Specific polychemotherapy for ALL and continued chemotherapy for TB led to the cure of two diseases. Supportive cytostatic and immunosuppressive therapy for ALL required periodic courses of anti-relapse anti-tuberculosis therapy for 5 years. After 10 years of observation, the child is healthy. Thus, the possibility of a rare in clinical practice combination of TB and ALL in children should be taken into account in the diagnosis and treatment of these diseases. During courses of immunosuppressive therapy for ALL, there is a risk of reactivation of TB. It is necessary to recommend long-term observation of such children by a phthisiatrician and an oncologist to prevent recurrence of both diseases.

Chest X-ray features facilitate screening for pulmonary hypertension caused by fibrosing mediastinitis

Misdiagnosis and underdiagnosis of pulmonary hypertension caused by fibrosing mediastinitis (PH-FM) are considerably prevalent due to unspecific symptoms and as well as the lack of awareness of this fatal disease. The aim of this study was to evaluate the diagnostic accuracy of the chest X-ray (CXR) for screening the patients with PH-FM from those with pulmonary hypertension (PH). This was a retrospective observational cohort study. The patients with suspected PH were recruited between October 2014 and October 2020. All the clinical data and CXR findings were collected. The sensitivity, specificity, and likelihood ratio of the CXR features were calculated. Logistic regression was used to identify the factors associated with the CXR characteristics and FM and to generate a prediction model. Finally, the diagnostic efficiency of the prediction model was evaluated using nomogram and internal validation. The patients with PH-FM (n = 36) and PH caused by the diseases other than FM (PH-non-FM, n = 62) were enrolled. The CXR features, including atelectasis, pleural effusion, consolidation, nodules, calcification, interlobular septal thickening, and interstitial reticulation, were more prevalent in patients with PH-FM than in those with PH-non-FM (all p < 0.05). Atelectasis had a specificity of 97%, a sensitivity of 50%, and a greater accuracy for diagnosing of PH-FM [area under the curve (AUC) = 0.720; 95% CI: 0.634-0.806] than the other factors did. The combination of tuberculosis, natural logarithmic NT-proBNP (lnBNP), atelectasis, pleural effusion, and prominent right heart border constituted a prediction model to distinguish the PH-FM from the PH-non-FM, with a sensitivity of 91.7% and a specificity of 83.9%. The model demonstrated good prediction performance by showing an AUC of 0.922 (95% CI: 0.861-0.983) in the internal validation. In this study, atelectasis was the most specific and accurate CXR characteristic for identifying PH-FM in the PH patients. The combination of atelectasis, pleural effusion, prominent right heart border, tuberculosis, and lnBNP constituted a prediction model that distinguished the PH-FM patients from the PH-non-FM ones with good performance.

Surgical treatment of children with a combination of congenital lung malformations and tuberculosis

Congenital malformations of the bronchopulmonary system in combination with tuberculosis are extremely rare in practice, but they usually require surgical treatment. This combination often causes diagnostic difficulties.Characteristics of children and research methods. We have analyzed the experience of surgical treatment of a combination of various congenital lung defects and tuberculosis in 20 children. 9 (45%) children had lung sequestration, 4 (20%) children had lung hypoplasia, 5 (25%) children had congenital bronchiectasis, 1 (5%) child had arteriovenous malformation, and 1 (5%) child had a congenital lung cyst. There were 3 segmental resections, 15 lobeand bilobectomies, and 3 pneumonectomies. All surgeries were performed using minimally invasive approaches (VATS).Results. 11 (55%) patients had diagnostic difficulties of concomitant pathology. Only in 5 (25%) cases they found mycobacteria in sputum before surgery. Postoperative study of material from tuberculous lesions helped to establish multidrug resistance of mycobacterium tuberculosis and to change the chemotherapy regimen in 3 (15%) patients. There were no postoperative complications or deaths. All surgeries were effective. Long-term results were studied in 16 (80%) of 20 patients over a period from 1 to 10 years. No cases of reactivation of tuberculosis or disability.Conclusion. Resection surgery for combination of tuberculosis and congenital lung defects allowed to clarify the diagnosis and to achieve a direct effect in all patients by clarifying the drug resistance of mycobacterium tuberculosis and to optimize postoperative chemotherapy.

Обоснование лечебно-профилактических мероприятий для улучшения перинатальных исходов у женщин с туберкулезом

Features of pregnancy and childbirth course, as well as perinatal outcomes in women with tuberculosis and viral hepatitis B and / or C were studied. The research showed a high level of other concomitant somatic, gynecological diseases in such women, as well as high level of sexually transmitted infections compared to women without tuberculosis and viral hepatitis. Fetal growth retardation in pregnant women with tuberculosis was noted in 49.2 %, and if tuberculosis is combined with viral hepatitis it is noted in 53.3 %, while fetal growth retardation of III degree was observed only in combination of tuberculosis and viral hepatitis

Tuberculosis and COVID-19, the new cursed duet: what differs between Brazil and Europe?

ABSTRACTOn April 1st, 2020, COVID-19 surpassed tuberculosis regarding the number of deaths per day worldwide. The combination of tuberculosis and COVID-19 has great potential for morbidity and mortality. In addition, the COVID-19 pandemic has had a significant impact on the diagnosis and treatment of tuberculosis. In this review article, we address concurrent tuberculosis and COVID-19, with particular regard to the differences between Brazil and Europe. In addition, we discuss priorities in clinical care, public health, and research.

Features of diagnostics of the peripheral lymph nodes tuberculosis

The analysis of the features of diagnostics of peripheral lymph nodes tuberculosis in modern conditions is carried out. For this 28 case histories of patients suffering from tuberculosis of peripheral lymph nodes were studied and 85,7% of them had a combination of tuberculosis and infection caused by the human immunodeficiency virus. All patients were undergoing biopsies or surgery of lymph nodes, and the material was examined using microbiological molecular, genetic and histological methods. 85,7% of patients had relapses with different periods of time, on average, 34 years, and repeated periods of tuberculosis activation. At all patients the lymph nodes were enlarged, mainly cervical (71,4%) and axillary (67,9%), the sizes of nodes varied from 1 to 5 cm, on average, 2,21,6 cm. In 78,6% cases tuberculosis of peripheral lymph nodes was characterized by fluctuation of nodes and the discharge of 30 to 80 ml of odorless creamy pus. It was found that tuberculosis of peripheral lymph nodes is part of a widespread tuberculous lesions especially at patients with tuberculosis associated with an infection caused by the human immunodeficiency virus. Tuberculosis of peripheral lymph nodes develops simultaneously with a specific lesion of other groups of lymph nodes intrathoracic (75%), intra-abdominal (57,1%), which allows to generalized tuberculosis of the lymphatic system. Fibrobronchoscopy showed in 35,7% patients residual bronchial tuberculosis changes, at 14,3% an active fistulous form of bronchial tuberculosis. Microscopy of biopsy material was negative at 78,6% of cases, while cultural examination revealed Mycobacterium tuberculosis in 100% and molecular genetic studies deoxyribonucleic acid of Mycobacterium tuberculosis in 64,3% patients.

Tuberculosis in combination with HIV infection

In Ukraine, epidemics of two socially dangerous diseases tuberculosis (TB) and human immunodeficiency virus (HIV infection) are developing at an accelerated pace. According to the literature, more than 30 % of HIV-infected people get TB and about 40—80 % of those who get sick die.Objective — to assess the epidemic situation of tuberculosis, HIV infection, tuberculosis in combination with HIV infection in Ukraine. To study the features of the clinic, diagnostics, course and treatment of tuberculosis in HIV-infected people.Materials and methods. Analysis of literature sources on HIV-associated tuberculosis over the past 10 years.Results and discussion. The main epidemiological indicators of tuberculosis, HIV infection and the combination of tuberculosis with HIV infection in Ukraine are described. The peculiarities of the clinical, radiological picture and course of tuberculosis in HIV-infected persons depending on the stage of HIV infection are analyzed. TB still remains the leading cause of death for HIV patients.Conclusions. Against the background of HIV infection, the risk of TB infection and reactivation of tuberculous endogenous infection increases significantly. TB/HIV/AIDS co-infection is characterized by the development of multiorgan tuberculosis. Diagnosis of tuberculosis on the background of HIV infection, especially with CD4+ T-lymphocytes < 200 in 1 mm3 of blood, is much more difficult. TB treatment for TB/HIV co-infection can only be successful with antiretroviral therapy. Antiretroviral therapy and co-trimoxazole are prescribed regardless of the number of CD4+ T-lymphocytes.

Psychological and psychiatric disorders in tuberculosis patients

Objective — to investigate the prevalence of psychological and mental disorders among patients with tuberculosis according to the literature data.Materials and methods. 132 articles from PubMed database were included in the work. 43 of them were chosen for detailed review. Medical records of 340 patients from Kharkiv Regional Psychiatric Hospital N 3 for 2015—2019 were included to the study to present results of our investigations. 100 patients from Kharkiv Regional Tuberculosis Dispensary N 1 were included to the study to perform prospective research using interview with sf-36 scale. 20 healthy people as control group were also included to the study.Results and discussion. From literature it was found that patients with tuberculosis often have mental disorders of varying severity, more pronounced on the background of multidrug-resistant tuberculosis. With a combination of tuberculosis and mental disorders, the same patterns are observed as in the development of mental disorders in healthy individuals: women are more likely to suffer from depression; men are more likely to abuse alcohol; poor socio-economic status and low level of education are associated with a high risk of developing mental disorders. The mutual orientation of the relationship between the development of tuberculosis and mental disorders was found.A retrospective study of the structure of psychiatric pathology among 340 tuberculosis patients who were treated in Kharkiv Regional Psychiatric Hospital N 3 in 2015—2019 showed the prevalence of schizophrenia, schizotypic and schizoaffective disorders (80 %), mental backwardness (12 %) and other mental disorders, in particular due to brain damage or somatic disease (8 %). A prospective assessment of the quality of life of patients treated for tuberculosis in the Kharkiv Regional Tuberculosis Dispensary N 1 and healthy individuals showed the highest results in group of healthy control (vitality (VT) — 68.75 ± 0.95, social functioning (SF) — 100.0, role-emotional functioning (RE) — 100.0, mental health — 68.00 ± 0.65), lower ones in patient with drug-susceptible tuberculosis (vitality (VT) — 34.4 ± 3.3, social functioning (SF) — 62.4 ± 4.1, role-emotional functioning (RE) — 40.6 ± 5.8, mental health — 52.5 ± 2.2), and the lowest ones in patients with multidrug-resistant tuberculosis (vitality (VT) — 6.7 ± 1.6, social functioning (SF) — 33.4 ± 3.5, role-emotional functioning (RE) — 22.5 ± 4.4, mental health — 29.3 ± 1.6).Conclusions. This review revealed the main mental disorders in patients with tuberculosis, namely alcoholism, depression and anxiety disorders. These violations may worsen due to the socio-economic state of the patients, low level of education, stigmatization, etc. In addition, it was found that providing personality oriented care can increase the effectiveness of tuberculosis treatment and quality of life.

ВИЧ-ассоциированный туберкулез: особенности течения и эффективность лечения (обзор литературы)

Currently, despite the decline in the incidence and mortality of tuberculosis, the epidemic situation around the world, including in Russia, remains tense for tuberculosis. One of the reasons for this is an increase in the number of patients with HIV infection, which is a risk factor for tuberculosis. The combination of tuberculosis and HIV infection in recent years has turned into one of the most significant and urgent health problems. The review provides data on the prevalence of tuberculosis associated with HIV infection both in the world and in the Russian Federation, and the most comprehensive survey of scientific studies devoted to the study of the clinical and radiological and laboratory manifestations of tuberculosis in patients with HIV infection is presented. In addition, literature data on the efficacy of treatment of tuberculosis in this category of patients are given.

The use of plasmapheresis and intravenous laser blood irradiation in treatment of patients with newly diagnosed tuberculosis at the late stages of hiv infection (references review)

This article presents an overview of the current domestic and foreign literature on the problems of treatment of newly diagnosed tuberculosis in patients with late stages of HIV infection. The urgency of the problem, peculiarities of the clinical course and treatment of tuberculosis, the principles of antiretroviral therapy in the combination of tuberculosis and HIV infection are considered. It has been established that long-term chronic (или “long term” или “chronic”) tuberculosis intoxication, as well as aggressive antituberculosis therapy, lead to disruption of metabolic processes, hypercatabolism, intoxication, and development of hypercoagulable syndrome. At the same time, data is provided on the toxic effects of antiretroviral therapy. Treatment of adverse reactions begins with detoxification and antihistamine therapy followed by the addition of vitamin therapy, antioxidants, antihypoxants, hepatoprotectors, anabolic agents, and enterosorbents. Various methods of pathogenetic therapy are of great interest, including extracorporal hemocorrection (plasmapheresis) and intravenous laser irradiation of blood (ILIB). Plasmapheresis (PA) allows the effective and short time normalization of homeostasis indices as well as reduction or elimination of intoxication effects, toxic and allergic reactions, hence increasing the effectiveness of basic therapy. Course of PA in patients with common forms of tuberculosis (3-5 procedures, with an interval of 2-3 days, removal of 20-25% of the volume of circulating plasma and replacement with crystalloid solutions in combination with hydroxyethyl starches) allows the elimination of symptoms of intoxication, increases tolerance of the organism to chemotherapy, and suppresses undesirable side effects. The method of quantum therapy (ILIB) is based on the effect of quantum energy on blood directly in the vascular bed. As the result photo biological influence of ILIB, all body systems are activated to correct the existing disorders. This is manifested to a great extent in tissues suffering from oxygen deficiency, since it is in these areas the metabolism increases and the processes of tissue reparation are activated. ILID helps for activation of white blood cell function, phagocytosis, synthesis of antibodies, interferon, and in general, improves the immune status.

Detection, diagnosis and clinical tuberculosis in children with hiv infection

The problem of combination of tuberculosis (TB) and HIV remains relevant. Majority of HIV patients are young adults, 90% of which are women of childbearing age, thereby increasing the perinatal HIV transmission rate. In 2014 in Saint Petersburg, &gt;5,000 children with perinatal contact HIV were reported and &gt;300 children were confirmed with HIV infection. We present a comparative analysis of the case histories of 20 children with TB-HIV and 30 with tuberculosis without HIV infection. The analysis identified several cases of delayed diagnosis. In &gt;50% of the cases, the diagnosis of HIV infection was confirmed after 1 year. Four children with HIV infection were diagnosed at school age and connected to suspected cases of tuberculosis. The clinical detection of TB occurs more commonly in children with HIV infection than in those without HIV infection (25% and 5%, respectively). In both groups, tuberculosis of the intrathoracic lymph nodes was predominantly observed; however, generalized forms of TB were also diagnosed in the group with co-infection (25% of the cases). HIV patients often have decreased body mass, low-grade fever, lymphadenopathy, and anemia. Hepatosplenomegaly was equally observed in both groups. More than one third (35%) of patients with co-infection had negative sensitivity to tuberculin, and Diaskintest was positive in 50% of the cases. The prevalence and severity of TB in children with HIV infection correlates with the severity of immunosuppression.

Association of tuberculosis with multimorbidity and social networks.

ABSTRACTThe combination of tuberculosis with other diseases can affect tuberculosis treatment within populations. In the present study, social network analysis of data retrieved from the Mexican National Epidemiological Surveillance System was used in order to explore associations between the number of contacts and multimorbidity. The node degree was calculated for each individual with tuberculosis and included information from 242 contacts without tuberculosis. Multimorbidity was identified in 49.89% of individuals. The node degrees were highest for individuals with tuberculosis + HIV infection (p < 0.04) and lowest for those with tuberculosis + pulmonary edema (p < 0.07). Social network analysis should be used as a standard method for monitoring tuberculosis and tuberculosis-related syndemics.

HIV INFECTION STAGE, ANTIRETROVIRAL THERAPY SCHEME AND PATIENT IMMUNE STATUS INFLUENCE ON HIV/TB CO-INFECTION OUTCOME

Retrospective research of 381 clinical records is conducted to study HIV infection influence on stationary stage of tuberculosis treatment outcome in HIV-TB co-infected patients. All cases were divided depending on a hospitalization outcome on favorable and adverse. At most of patients tuberculosis of respiratory organs met. Immunological researches were conducted, the stage of HIV infection was registered and the issue of purpose of anti-retroviral therapy was resolved. Besides, as indirect signs of an immunodeficiency at the patients with a combination of tuberculosis and HIV infection who were on hospitalization the indicators received when carrying out clinical laboratory trials were analyzed: absolute and relative quantity of lymphocytes according to the general blood test, the contents the globulin fractions and circulating immune complexes concentration according to the clinical chemistry blood test. At an assessment of results in both groups of research more than at a half of patients existence of HIV infection at late stages that speaks about late identification and neglect of an immunodeficiency was revealed. At patients with tuberculosis of lungs in combination with HIV infection at a failure statistically significant decrease in an immunoregulatory index is revealed. It is interesting that the level of CD4 lymphocytes and a stage of HIV infection had no impact on the co-infection’s outcome. However, existence of virus loa ding more than 100 000 copies/ml reduced probability favorable an outcome of treatment of tuberculosis at the patient with HIV infection. Timely purpose of anti-retroviral therapy at patients with co-infection increased chances of treatment of tuberculosis at patients with an immunodeficiency. Frequency of adverse side effect of antiviral therapy met equally often at patients in both groups. Thus, patients at any stages of HIV infection with any forms of tuberculosis, including generalized, had a chance to have a favorable outcome of a disease. We consider the reasonable recommendation about carrying out anti-retroviral therapy of patients by all with a combination of tuberculosis and HIV infection, irrespective of the HIV infection stage.

Оценка влияния характера туберкулезного процесса на исход стационарного этапа лечения у пациентов с сочетанием туберкулеза и ВИЧ-инфекции

Оценка влияния характера туберкулезного процесса на исход стационарного этапа лечения у пациентов с сочетанием туберкулеза и ВИЧ-инфекции

Оценка влияния характера туберкулезного процесса на исход стационарного этапа лечения у пациентов с сочетанием туберкулеза и ВИЧ-инфекции

Оценка влияния характера туберкулезного процесса на исход стационарного этапа лечения у пациентов с сочетанием туберкулеза и ВИЧ-инфекции

P2.078 Drug Resistance of Mycobacterium Tuberculosis at Patients with Combination of Tuberculosis and the HIV Infection

PurposeTo estimate of drug resistances of (MBT) at patients with combination of tuberculosis and the HIV (TB+HIV).Materials and MethodsPatients with confection treated in tubercular hospital N02 for the period of...

AIDS, tuberculosis, and the health care worker.

The combination of tuberculosis and infection with the human immunodeficiency virus type-1 (HIV-1) poses an increased hazard to health care workers. In this AIDS Commentary, Dr. Kent Sepkowitz of Memorial Sloan-Kettering Cancer Center and New York Hospital-Cornell Medical Center reviews the current state of our knowledge with regard to the risk to health care workers of infection and active disease due to Mycobacterium tuberculosis, in the setting of HIV-1 infection and in the absence of infection with this virus. The goal of achieving complete protection from tuberculosis for persons working in hospitals and clinic will remain elusive until the rapid diagnosis of pulmonary tuberculosis is possible. Standard infection control measures have been documented to decrease the hazard to nurses, physicians, and other health care personnel. As physicians, it is our responsibility to insure that these measures are used effectively. Evaluation of unproven interventions is badly needed, as premature implementation of these often-expensive measures can result in poorer patient care, a false sense of security among health care personnel, and further strain on the resources to be devoted to inpatient care in the future. Dr. Sepkowitz has raised a number of provocative issues that deserve wide and rigorous discussion.

Further observations on tuberculosis of the right middle lobe in simple pneumoconiosis

Summary The results of treatment of fresh tuberculosis of the right middle lobe in eight elderly coalminers and a foundry worker with simple low category pneumoconiosis are described. Rapid sputum conversion and symptomatic response were not associated with comparable radiological improvement in the majority, who were left with a contracted middle lobe and a stenosed bronchus, as in Brock's (1950) syndrome in a younger age group. The combination of tuberculosis and simple pneumoconiosis in this unusual way suggests late “second primary” infection with the dust a predisposing factor. Right middle lobe disease in simple pneumoconiosis should be treated as tuberculous unless proved otherwise.