Course Of Anti-tuberculosis Treatment Research Articles

Clinical and Genetic Characteristics of BCG Disease in Chinese Children: a Retrospective Study.

Summarize the characteristics of a large cohort of BCG disease and compare differences in clinical characteristics and outcomes among different genotypes and between primary immunodeficiency disease (PID) and patients without identified genetic etiology. We collected information on patients with BCG disease in our center from January 2015 to December 2020 and divided them into four groups: chronic granulomatous disease (CGD), Mendelian susceptibility to mycobacterial disease (MSMD), severe combined immunodeficiency disease (SCID), and gene negative group. A total of 134 patients were reviewed, and most of them had PID. A total of 111 (82.8%) patients had 18 different types of pathogenic gene mutations, most of whom (91.0%) were classified with CGD, MSMD, and SCID. CYBB was the most common gene mutation (52/111). BCG disease behaves differently in individuals with different PIDs. Significant differences in sex (P < 0.001), age at diagnosis (P = 0.013), frequency of recurrent fever (P = 0.007), and vaccination-homolateral axillary lymph node enlargement (P = 0.039) and infection severity (P = 0.006) were noted among the four groups. The CGD group had the highest rate of males and the oldest age at diagnosis. The MSMD group had the highest probability of disseminated infection (48.3%). The course of anti-tuberculosis treatment and the survival time between patients with PID and without identified genetic etiology were similar. Greater than 80% of BCG patients have PID; accordingly, gene sequencing should be performed in patients with BCG disease for early diagnosis. BCG disease behaves differently in patients with different types of PID. Patients without identified genetic etiology had similar outcomes to PID patients, which hints that they may have pathogenic gene mutations that need to be discovered.

Recurrent Abdominal Distension: Colonic Ulcer is a Cause or a Consequence?

Question: A 48-year-old woman presented with a 5-month history of recurrent abdominal distension and constipation. She had a history of pulmonary tuberculosis in childhood and breast cancer treated with surgery and chemotherapy (adriamycin/cyclophosphamide [AC] regimen) 1 year ago followed by long-term endocrine therapy with toremifene. Additionally, she took 3 months of Chinese herbs including high-dose aconite postoperatively. Physical examination revealed the distended abdomen with diffuse tenderness. Laboratory investigations indicated anemia and hypoalbuminemia. Indicators of inflammation were normal. Plain abdominal radiographs and computed tomography showed massive dilation of the small intestine and colon, and thickening of the wall of the transverse and descending colon (Figure A). Subsequently, colonoscopy was performed and revealed 2 large irregular ulcers in the transverse and descending colon (Figure B). Biopsies of lesions showed nonspecific inflammation. Based on the history of pulmonary tuberculosis, she was empirically started on antituberculosis therapy. Five months later, unfortunately, her abdominal distension was worsening (Figure C). Transverse colostomy was subsequently performed to alleviate the symptoms. Furthermore, a repeated colonoscopy showed no improvement of the ulcer lesions after a standard course of antituberculosis treatment (1 year). Thereafter, the patient received a 3-month therapy of prednisone and thalidomide. None of these therapies seemed to improve the patient’s intestinal symptoms and ulcer lesions, nor did they halt progression. What is the diagnosis? What shall we do? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Finally, segmental colon resection was performed and the pathology showed thickening of muscularis mucosae, muscularis propria atrophy and fibrosis, aberrant muscularization in serosa (Figure D), and reduction of ganglion cells accompanied by inflammatory cells infiltration, consistent with obstructive enteritidis. Additionally, histopathology demonstrated some bluish-purple crystallin-like substances engulfed by multinucleated giant cells (Figure E). Based on these findings, the patient was diagnosed with chronic intestinal pseudo-obstruction (CIPO), which may be secondary to drug-induced gut injury. Unfortunately, 1 month later, her abdominal distension recurred. Subsequently, radiopaque marker test for colonic transit was performed and revealed impaired motility of the entire colon (24 of 24 radiopaque markers diffusely distributed throughout the colon after 72 hours; Figure F). Pseudo-obstruction is characterized by signs and symptoms of a mechanical obstruction of the small or large bowel in the absence of an anatomic lesion.1De Giorgio R. Sarnelli G. Corinaldesi R. et al.Advances in our understanding of the pathology of chronic intestinal pseudo-obstruction.Gut. 2004; 53: 1549-1552Crossref PubMed Scopus (196) Google Scholar Because the symptoms of CIPO are nonspecific, it is a challenge to make precise diagnosis, especially for patients with colonic ulcers as in our case, and it may be misdiagnosed with intestinal tuberculosis and Crohn’s disease, which might be mistaken for the cause of the intestinal symptoms. Many patients undergo futile and potentially harmful surgical procedures2De Giorgio Roberto Cogliandro Rosanna F. Barbara Giovanni et al.Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy.Gastroenterol Clin North Am. 2011; 40: 787-807Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar as in our case. In fact, in our patient, CIPO, which may be secondary to drug-induced gut injury, is the cause of the colonic ulcers and intestinal symptoms. Unfortunately, the patient may need total colectomy to alleviate the symptoms.

Multiple Strictures of Small Intestine: Is It Crohn’s Disease?

Question: A previously healthy 43-year-old woman presented with epigastric pain and intermittent postprandial vomiting for 1 year. The patient denied any fever, night sweats, extraintestinal symptoms, and perianal disease. Physical examination was unremarkable. Initial laboratory values were within normal limits except for increased erythrocyte sedimentation rate (46 mm/h) and positive fecal calprotectin. Ileocolonoscopy revealed erosions in the terminal ileum. Biopsy specimens showed unspecific alterations with acute and chronic inflammation. Computed tomography enterography showed circumferential thickening and enhancement of the multiple segmental small intestinal walls, with luminal stricture and enlarged peripheral lymph nodes (Figure A). Subsequent interferon-γ release assay for Mycobacterium tuberculosis was negative and no tuberculous lesions were found on a computed tomography scan of the chest. What is the most likely diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to the symptoms of mechanical obstruction and diagnostic uncertainty, a decision was made to undertake a surgical approach. Laparoscopy confirmed 8 segments of thickened intestinal wall between 5 and 200 cm proximal to the ileocecal valve, accompanied by numerous white, miliary nodules on the mesenterium and intestinal wall (Video). Focally stenosis was found (Figure B) and partial intestinal resection was obtained followed by end-to-side anastomosis. Macroscopic examination showed a circumferential ulcer (Figure C, arrows). Pathology revealed numerous caseating granulomas throughout intestinal tissue, characterized by confluent granuloma, large granuloma, and granuloma with surrounding cuffing lymphocytes (Figure D). Additionally, the results of acid-fast staining (Figure E, circle) and polymerase chain reaction testing for M tuberculosis were positive. Hence, a firm diagnose of intestinal tuberculosis was made. HIV testing was negative. The patient is on a 1-year course of antituberculosis treatment with good response. Multiple diagnostic models have been developed regarding the differentiation of intestinal tuberculosis from Crohn’s disease.1He Y. Zhu Z. Chen Y. et al.Development and validation of a novel diagnostic nomogram to differentiate between intestinal tuberculosis and Crohn's disease: a 6-year prospective multicenter study.Am J Gastroenterol. 2019; 114: 490-499Crossref PubMed Scopus (33) Google Scholar An interferon-γ release assay is the most commonly used tool. Although this assay has very high specificity (>95%), the sensitivity is only approximately 80%, as in our case.2Pai M. Zwerling A. Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.Ann Intern Med. 2008; 149: 177-184Crossref PubMed Scopus (1150) Google Scholar Persons with tuberculosis in high incidence countries (like China) often have advanced disease and are likely to be malnourished or infected with HIV. Anergy owing to advanced disease (which may be applicable to our patient), malnutrition, and HIV-associated immune suppression may decrease the sensitivity of interferon-γ release assays. Hence, it is a challenge to make the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Multiple segmental involvement at small intestine, especially with a normal-appearing ileocecal valve are very unusual in intestinal tuberculosis.3Bae J.H. Park S.H. Ye B.D. et al.Development and validation of a novel prediction model for differential diagnosis between Crohn's disease and intestinal tuberculosis.Inflamm Bowel Dis. 2017; 23: 1614-1623Crossref PubMed Scopus (24) Google Scholar It is frequently misdiagnosed as Crohn’s disease preoperatively. As seen in this patient, exploratory abdominal surgery was usually required for the final diagnosis. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MmVmM2EzMDEyNjRiZGU1NmI2Y2JmZDZiZGQ5NTliOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTExMjExfQ.isWS2Gk2qOguY5qIEWij4OJBJJuDXzRct5FoY4d49ZTUqfOvNyjzd1PuZwASlAVJpvWR_qEgLYpzjYhehlCMN4gTvH8mTzg_UwEDnoLexdCTsH7vGKnT_xuoZGKwhtNfM0gn4I4Egq4qkollG2UzWKHjesnMvmGKA4ConZhyqLtNlvkqdKFhWR5lW_6KLRIGLvHJqjRC6CcZlJyw1eaIBWQIyTRIqRLoQptMipd4z30ZuvX4XeDx6KNv8KIovkFSqXtDAPflPunRAUETprl6ZY0Gsakyh79bWf9_SLhN1jIiQnIqC_4AAE-EolCxqQA-zFICCCfw8QlB48Y4ITISHA Download .mp4 (16.47 MB) Help with .mp4 files Video

S2897 Diarrhea in a Patient With Gastrointestinal Tuberculosis

INTRODUCTION: Gastrointestinal (GI) tuberculosis (TB) is a rare diagnosis in the United States. Overall, it accounts for approximately 1% to 3% of all TB cases. However, in those who have immigrated from a developing country and are immunosuppressed, extrapulmonary involvement can be more prevalent. We illustrate a case of diarrhea secondary to GI TB. CASE DESCRIPTION/METHODS: A 51-year-old Venezuelan male with end-stage renal disease secondary to autosomal dominant polycystic kidney disease status post deceased donor kidney transplant in 2012 presented with fever, chills, and a three-month history of diarrhea. An increase in bowel movement frequency that was associated with new nocturnal awakening prompted his emergency room visit. He reported no blood or mucus in his stool, no steatorrhea, and no recent travel or exposure to new foods. At his own discretion, he took fewer tablets of mycophenolate mofetil without any significant improvement. There was no recent antibiotic use and no sick contacts. Social history was unremarkable. Vitals showed a temperature of 38.1°C, pulse of 122 bpm, and normotension. A CT scan of the abdomen showed significant terminal ileal thickening. A colonoscopy revealed a patulous ileocecal valve with multiple ulcerations in the terminal ileum (Figure A). Biopsies demonstrated granulomatous ileocolitis with acid-fast bacilli identified on AFB and FITE stains (Figures B, C). Mycobacterium tuberculosis complex was identified from the tissue block by PCR. The patient was treated with a regimen of rifabutin, isoniazid, pyrazinamide, and ethambutol for two months and then with rifabutin and isoniazid for four additional months. The patient experienced substantial improvement in his symptoms once therapy was initiated. DISCUSSION: GI TB can involve the entire GI tract, with the ileocecal region being the most common location. The narrow lumen and relative stasis of the ileocecal region provides an ideal environment for absorption of TB into the lymphatic system with inflammatory response. Long-term inflammation can result in development of fibrotic strictures. Our patient had extensive ulcer development with surrounding hypertrophic reaction but no strictures. Most guidelines recommend a 6-month course of antituberculosis treatment as opposed to 9 months, as there have been similar cure rates with the added benefit of reduced cost and increased adherence. Surgical intervention may be warranted if obstruction or perforation develops.Figure 1.: Patulous ileocecal valve.Figure 2.: Suppurative granulomatous inflammation involving the terminal ileum. Hematoxylin and eosin, 100x.Figure 3.: High power photomicrograph of a granuloma containing acid-fast bacilli. AFB (Ziehl-Neelsen carbol fuschin/methylene blue), 600x.

Unusual case of vaginal stenosis in an adolescent girl

Foreign body insertion into the vagina has been described across all ages. The presenting symptoms may be persistent vaginal discharge, chronic pelvic pain, post menopausal bleeding. Foreign body as a differential diagnosis is rarely thought of with the above presentations and remains a diagnostic challenge.An unusual case of a foreign body causing vagina l stenosis, haematocolpos and inflammatory adnexal masses leading to diagnostic confusion and difficult surgery is presented.An eighteen year old unmarried woman with chronic pelvic pain of 3 years duration was diagnosed to have bilateral adnexal masses on pelvic USG. On suspicion of genital tuberculosis she received a course of anti tuberculosis treatment with no symptomatic relief or decrease in size of the adnexal mass. A second sonogram four months later suggested presence of vaginal /cervical foreign body surrounded by fluid (haematocolpos?) and she was referred to a gynaecologist. An MRI confirmed the findings. As examination showed what was presumed to be a transverse vaginal septum the patient was posted for examination under anaesthesia. There were dense vaginal adhesions and as the haematocolpos could not be accessed from below a laparotomy was performed, the vagina opened from above and after draining 300ml of chocolate colored fluid a bottle cap was retrieved. The stenosed vagina was successfully opened by vaginal dissection by abdomino-vaginal approach. This case is an unusual presentation of a foreign body causing vaginal stenosis and causing much diagnostic dilemma and difficult surgery.

Efficacy and tolerability of desensitization in the treatment of delayed drug hypersensitivities to anti-tuberculosis medications.

Delayed drug hypersensitivity to first-line anti-tuberculosis medication is a major challenge in tuberculosis treatment. This study was performed to investigate the efficacy/tolerability of desensitization therapy in treatment of first-line anti-tuberculosis medication hypersensitivity and the usefulness of immunologic evaluation therein. This study was conducted as a prospective, observational cohort study. Subjects who experienced hypersensitivity reactions, including maculopapular exanthema (MPE) and drug reaction with eosinophilia and systemic symptoms (DRESS), to first-line anti-tuberculosis medications (isoniazid [INH], ethambutol [EMB], rifampin [RFP], and pyrazinamide [PZA]) were enrolled. Patch, intradermal, lymphocyte transformation, and oral provocation tests were performed to determine culprit drugs, which were desensitized with rapid and graded challenge protocols. Breakthrough reactions (BTRs) during or after desensitization were assessed. In total, 31 desensitization treatments (INH, 8; EMB, 8; RFP, 11; PZA, 4) to 12 patients (8 with MPE and 4 with DRESS) were performed. The overall success rate of desensitization was 80.7%. All the study subjects except one completed the full course of anti-tuberculosis treatment. The overall BTR free rate was 64.5%. Sixteen (80%) treatments for MPE and four (36.4%) for DRESS were BTR free (P = 0.023). Drugs that were positive on any two of three immunologic studies showed significantly high BTR rates (P = 0.014), although this was not correlated with desensitization failure rate. Rapid desensitization therapy to multiple anti-tuberculosis medications for delayed drug hypersensitivity was safe and successful. Combination of multiple immunologic evaluations may predict BTR although it needs validation in larger studies.

A Novel Tool to Detect Treatment Failures Early in the course of Antituberculosis treatment: Old Wine in New Bottle?

A Novel Tool to Detect Treatment Failures Early in the course of Antituberculosis treatment: Old Wine in New Bottle?

Frequency of Mycobacterium tuberculosis-specific CD8+ T-cells in the course of anti-tuberculosis treatment

Anti-tuberculosis drug treatment is known to affect the number, phenotype, and effector functionality of antigen-specific T-cells. In order to objectively gauge Mycobacterium tuberculosis (MTB)-specific CD8+ T-cells at the single-cell level, we developed soluble major histocompatibility complex (MHC) class I multimers/peptide multimers, which allow analysis of antigen-specific T-cells without ex vivo manipulation or functional tests. We constructed 38 MHC class I multimers covering some of the most frequent MHC class I alleles (HLA-A*02:01, A*24:02, A*30:01, A*30:02, A*68:01, B*58:01, and C*07:01) pertinent to a South African or Zambian population, and presenting the following MTB-derived peptides: the early expressed secreted antigens TB10.4 (Rv0288), Ag85B (Rv1886c), and ESAT-6 (Rv3875), as well as intracellular enzymes, i.e., glycosyltransferase 1 (Rv2957), glycosyltransferase 2 (Rv2958c), and cyclopropane fatty acid synthase (Rv0447c). Anti-TB treatment appeared to impact on the frequency of multimer-positive CD8+ T-cells, with a general decrease after 6 months of therapy. Also, a reduction in the total central memory CD8+ T-cell frequencies, as well as the antigen-specific compartment in CD45RA-CCR7+ T-cells was observed. We discuss our findings on the basis of differential dynamics of MTB-specific T-cell frequencies, impact of MTB antigen load on T-cell phenotype, and antigen-specific T-cell responses in tuberculosis.

Unusual cause of pyopericardium with tamponade

Acute pyopericardium due to tuberculosis is uncommon even in high prevalence countries. We report an unusual case of acute pyopericardium with cardiac tamponade complicating tuberculosis pneumonia of lingula in an adult. Prompt catheter drainage of pyopericardium under echocardiographic guidance and six month course of anti-tuberculosis treatment resulted in complete recovery without any sequelae during the follow-up period of ten months.

Spina ventosa in an 18 year old

An 18 year old female presented with painless swelling and a chronic discharging sinus at the base of right thumb for last 6 months. The swelling was insidious in onset and progressively increasing in size. She was also suffering from pulmonary tuberculosis. Local examination revealed a spindle shaped swelling of 3 cm 2 cm over the right 1st metacarpal. This swelling was bony hard tender and was fixed to underlying bone with a pus discharging sinus (Fig. 1). X-ray showed a cystic expansile lesion of right 1st metacarpal (Fig. 2). There was an increase in ESR (24 mm at 1 h). Montoux test and sputum for AFB were positive. Histopathological examination revealed an epitheloid granuloma with Langhans' giant cells suggestive of tuberculosis (Fig. 3). She was given a course of antituberculosis treatment for 12 months. At 1 year follow up, the discharging sinus had healed and the ESR had returned to normal, but the bony swelling had persisted. Tubercular dactylitis (spina ventosa) is an uncommon presentation of tuberculosis. It is characterised radiologically by spindle shaped cystic swelling of the short tubular bones. About 80e85% of cases occur below the age group of 6 years

ASSESSMENT OF THE SPECIFIC LOCAL HUMORAL IMMUNITY IN PATIENTS WITH INFERTILITY INCLUDING CASES ASSOCIATED WITH GENITAL TUBERCULOSIS

Abstract. In order to optimize the detection and diagnosis of genital tuberculosis evaluation of the specific local antituberculosis immunity in 39 patients with infertility entered to the Department of Gynecology for the implementation of therapeutic and diagnostic laparoscopy has been carried out. All patients were divided into 3 groups: the 1st one included patients with tubal-peritoneal infertility, the group 2 included patients with infertility not associated with the defeat of the fallopian tubes, the third group was presented by patients with tubal-peritoneal infertility associated with genital tuberculosis who completed the basic course of anti-tuberculosis treatment. It was established that in case of the tubal-peritoneal infertility the local humoral immunity was characterised by increasing of IgM in the whole peritoneal fluid. Among women who recovered from genital tuberculosis increasing of IgA and IgG to M. tuberculosis was revealed in contrast to patients with infertility not associated with damage of fallopian tubes (p 0.05). In 25% of patients of the 1st group genital tuberculosis was diagnosed. The diagnostic criteria for early detection of genital tuberculosis were determined and the algorithm of genital tuberculosis identification have been proposed.

An Incidental Nasopharyngeal Carcinoma Coexistent with Primary Nasopharyngeal Tuberculosis

Objective: To describe a case of nasopharyngeal carcinoma coexistent with primary nasopharyngeal tuberculosis and review the literature.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Public University Hospital&#x0D; Patient: One&#x0D; Results: A 28-year-old man presented with recurrent sore throat and neck pain with clinically enlarged tonsils. He underwent a routine adenotonsilectomy. Histopathologic examination revealed non-keratinizing squamous cell carcinoma with caseating granulomatous inflammation typical for tuberculosis in the same adenoid specimen. Nasopharyngeal carcinoma was staged T2bN2M0. He was treated with concurrent chemoradiotherapy and a 9-month course of anti tuberculosis treatment. He recovered and remained symptom free 1 year after treatment.&#x0D; Conclusion: Nasopharyngeal carcinoma (NPC) and tuberculosis (TB) are both very common diseases in Sabah, East Malaysia. However, it is very rare that both diseases present at the same time and same anatomical area in a patient. Diagnosis can be very challenging and confusing. Multidisciplinary consultations are warranted for appropriate treatment. Combined anti-tuberculosis treatment and concurrent chemoradiotherapy may be appropriate and effective.&#x0D; &#x0D; Keywords: Nasopharyngeal carcinoma, Primary Nasopharyngeal Tuberculosis, adenotonsillectomy &#x0D;

CD4 Cell Levels during Treatment for Tuberculosis (TB) in Ethiopian Adults and Clinical Markers Associated with CD4 Lymphocytopenia

BackgroundThe clinical correlations and significance of subnormal CD4 levels in HIV-negative patients with TB are unclear. We have determined CD4 cell levels longitudinally during anti-tuberculosis treatment (ATT) in patients, with and without HIV co-infection, and their associations with clinical variables.MethodAdults diagnosed with TB (maximum duration of ATT for 2 weeks, and with no history of antiretroviral therapy (ART) in HIV-positive subjects) were included consecutively in eight out-patient clinics in Ethiopia. Healthy individuals were recruited for comparison at one of the study health centers. Data on patient characteristics and physical findings were collected by trained nurses following a structured questionnaire at inclusion and on follow-up visits at 2 and 6 months. In parallel, peripheral blood CD4 cell levels were determined. The evolution of CD4 cell levels during ATT was assessed, and the association between clinical characteristics and low CD4 cell levels at baseline was investigated using regression analysis.ResultsIn total, 1116 TB patients were included (307 HIV-infected). Among 809 HIV-negative patients, 200 (25%) had subnormal CD4 cell counts (<500 cells/mm3), with <350 cells/mm3 in 82 (10%) individuals. CD4 cell levels increased significantly during the course of ATT in both HIV+ and HIV- TB-patients, but did not reach the levels in healthy subjects (median 896 cells/mm3). Sputum smear status, signs of wasting (low mid upper arm circumference (MUAC)), and bedridden state were significantly associated with low CD4 cell counts.ConclusionA high proportion of Ethiopian TB patients have subnormal CD4 cell counts before starting treatment. Low CD4 cell levels are associated with smear positive disease and signs of wasting. The continuous increase of CD4 cell counts during the course of ATT suggest a reversible impact of active TB on CD4 cell homeostasis, which may be considered in interpretation of CD4 cell counts in HIV/TB co-infected subjects.

Patient Characteristics Associated with Non-Adherence to Anti Tuberculosis Treatment in Sri Lanka

Introduction: Sri Lanka had achieved a significant improvement in the tuberculosis control including a reduction of the default rate since introduction of the DOTS strategy to the National TB control Programme in 1997. Patients’ adherence to anti TB treatment may be measured using either process oriented or outcome oriented definitions. Default rate is an outcome oriented definition that may be used as an indicator of poor patient adherence to anti TB treatment. One of the main obstacles in achieving the best tuberculosis (TB) control is that patients do not complete full course of anti TB treatment. A prospective cohort study was carried out with the objective to identify patient characteristics that associate with defaulting anti tuberculosis treatment. Methodology: This was a prospective cohort study of new smear positive pulmonary tuberculosis patients registered for treatment between 1.6.2008 and 31.8.2008 in seven districts in Sri Lanka. Data on the patient characteristics and the plan of management were collected at the beginning of the treatment using a pre tested structured questionnaire. During the follow up and at the end of the treatment, results of sputum microscopy and the treatment outcome were recorded. The patients who interrupted treatment for 2 months or more (defaulters) during the course of treatment were again investigated in the field. In the statistical analysis, patient characteristics of the defaulters were compared with the characteristics of patients who were cured. Results: There were 22 defaulters giving a default rate of 4.59%. Being a male, poor educational background, having a casual job, regular smoking, and regular alcohol use were significantly associated with defaulting treatment (p &lt; 0.05). Sinhalese had lower default rate than other ethnic groups. At the field investigation, 43% of the defaulters were found not living in the addresses given to the treatment providers. Field investigators have further reported that financial reasons, substance abuse, feeling well, and lack of family support also as causes of defaulting treatment. Conclusion: Identification of risk factors by careful patient interview, early home visit, and monitoring of patient behaviour early in the course of treatment will help to predict whether adherence is likely to be a problem. So that, the treatment provider will be able to arrange a flexible and patient centered approach to ensure maximum adherence. SAARC Journal of Tuberculosis, Lung Diseases &amp; HIV/AIDS; 2012; IX(2) 19-25 DOI: http://dx.doi.org/10.3126/saarctb.v9i2.7974

結核性髄膜炎の診断に Nested PCR 法が有用であった慢性腎不全の1例

A 44 year-old woman was diagnosed as having chronic renal failure due to rapidly progressive glomerulonephritis (RPGN) from one year earlier. She has been managed with steroid therapy and hemodialysis. The patient was admitted to our hospital because of fever and sudden disturbance of consciousness with generalized convulsion on October 30, 2003. She showed mild meningeal irritation. Cerebrospinal fluid (CSF) examination demonstrated a cell count of 60/microl, protein level of 70 mg/dl, glucose level of 52 mg/dl, and chloride (Cl) level of 116 mEq/l. Both the CSF culture for Mycobacterium (M.) tuberculosis and the conventional single polymerase chain reaction (PCR) for M. tuberculosis DNA in CSF were negative results on admission. In contrast, nested PCR of preserved CSF samples obtained at admission demonstrated positive results. We diagnosed her conditions as tuberculous meningitis (TBM) and administered a total of 3 anti-tuberculosis agents over a period of about 2 months. Her clinical condition and CSF examinations improved immediately in response to anti-tuberculosis treatment. Serial CSF cultures for M. tuberculosis and the serial single PCRs for M. tuberculosis DNA in CSF were all negative during the course of anti-tuberculosis treatment. However, serial nested PCR results gradually converted from positive to negative, correlating with the improvement in clinical conditions during the course of anti-tuberculosis treatment. Therefore, nested PCRs were much more useful for the rapid and accurate diagnosis of TBM and for assessment of the clinical course and anti-tuberculosis treatment response of TBM than conventional CSF cultures and single PCRs. To the best of our knowledge, there have been few previous reports of diachronic study in which the serial nested PCR was used to test CSF samples obtained earlier in the clinical course of TBM. In conclusion, our findings suggest that nested PCR for M. tuberculosis DNA in CSF was highly useful not only for rapid and accurate diagnosis of TBM, but also for assessment of the antituberculous treatment response in cases highly suspected of TBM despite negative results on conventional cultures and single PCRs.

Tuberculosis-associated immune reconstitution disease: incidence, risk factors and impact in an antiretroviral treatment service in South Africa

To determine the burden and impact of immune reconstitution disease (IRD) associated with tuberculosis (TB) among patients initiating antiretroviral treatment (ART) in sub-Saharan Africa. Retrospective analysis of a study cohort enrolled over 3 years within a community-based ART service in South Africa. Patients receiving treatment for TB at the time ART was initiated (n = 160) were studied. Cases of TB-associated IRD during the first 4 months of ART were ascertained. The median baseline CD4 cell count was 68 cells/microl [interquartile range (IQR), 29-133 cells/microl) and ART was initiated after a median of 105 days (IQR, 61-164 days) from TB diagnosis. Although IRD was diagnosed in just 12% (n = 19) of patients overall, IRD developed in 32% (n = 12) of those who started ART within 2 months of TB diagnosis. Pulmonary involvement was observed in 84% (n = 16) and intra-abdominal manifestations were also common (37%). Overall, 4% (n = 7) of the cohort required secondary level health-care for IRD and two (1%) patients died. In multivariate analysis, risk of IRD was strongly associated with early ART initiation and low baseline CD4 cell count. Of patients with CD4 counts < 50 cells/microl, the proportions who developed IRD following initiation of ART within 0-30, 31-60, 61-90, 91-120 and > 120 days of TB diagnosis were 100%, 33%, 14%, 7% and 0%, respectively. The risk of TB-associated IRD in this setting is very high for those with low baseline CD4 cell counts initiating ART early in the course of antituberculosis treatment. However, most cases were self-limiting; overall secondary health-care utilization and mortality risk from IRD were low.

Pleural fluid interferon‐γ and adenosine deaminase levels in tuberculosis pleural effusion: a cost‐effectiveness analysis

Pleural fluid levels of interferon-gamma (IFN-gamma) and adenosine deaminase (ADA) have been found to be high in patients with tuberculosis (TB). The present study was carried out to compare the diagnostic utility of these two markers and to carry out a cost-effectiveness analysis of performing IFN-gamma estimation in comparison to ADA. A total of 52 patients with pleural effusion, 35 of which were found to have TB etiology, were prospectively included for estimation of ADA and IFN-gamma levels. The difference in the cost of performing the two diagnostic tests was compared with the cost of the treatment for a patient with TB. Pleural fluid IFN-gamma (median [range]: 2,100 [70-14,000] vs. 3 [0-160]; P<0.001) as well as ADA levels (mean [SD]: 93.1 [62.3] vs 15.4 [8.7]; P<0.001) were significantly higher in patients with TB effusion. Even though IFN-gamma estimation was more sensitive (97.1 vs. 91.4%), the extra cost of IFN-gamma estimation for detecting one patient with TB was found to be equivalent to the cost of a complete course of antituberculosis treatment for six patients. In developing countries, where TB is rampant and cost is a major concern, pleural fluid IFN-gamma estimation does not seem to be a cost-effective investigation method for differentiating TB from non-TB pleural effusion.

Clinical Comparisons of 1,498 Chronic Renal Failure Patients with and without Tuberculosis

Objective. To investigate the clinical characteristics of chronic renal failure (CRF) patients suffering from tuberculosis. Methods. Clinical materials from CRF inpatients in our department suffering from tuberculosis from 1997 to 2003 were investigated and compared with similar data from tuberculosis patients without CRF in Chongqing City (China) during the same period. Results. Of the 1,498 tested CRF inpatients, 71 suffered from tuberculosis, more than half of which suffered from atypical type V tuberculosis (lesion spot uncertain). The incidence of tuberculosis in the CRF inpatients (4740/100,000) was significantly higher than that in Chongqing City (151/100,000; P < .001). We found an inverse association between renal function and tuberculosis; the worse the renal function, the higher the tuberculosis incidence. CRF patients suffering from tuberculosis had fewer positive antituberculosis-antibody and purified protein derivative tests (12.7% and 15.5%, respectively) than did tuberculosis patients without CRF (72.1% and 58.1%, respectively; P < .05). In CRF patients with tuberculosis, the two-thirds dosage antituberculosis drug treatment was effective. Twelve cases had good outcome after a 1-year course of antituberculosis treatment and then kidney transplantation. In contrast, 4 patients who received less than half a year of antituberculosis treatment died after kidney transplantation, in association with relapsed tuberculosis. Conclusion. CRF patients are susceptible to tuberculosis, especially to atypical tuberculosis outside the lung. Thus, antituberculosis treatment might be necessary in CRF patients found to be suffering from chronic fevers of unknown origin. Furthermore, it appears to be safe for patients with CRF plus tuberculosis to receive kidney transplantation after 1 year of antituberculosis treatment.