Purified Protein Derivative Skin Research Articles

Preventive therapy for iatrogenic active tuberculosis in systemic lupus erythematosus patients

To explore the efficacy and safety of preventive therapy for iatrogenic active tuberculosis (TB) induced by glucocorticoid. During 2007-2011, a total of 203 systemic lupus erythematosus (SLE) patients with high-risk active TB, such as a history of TB infection, TB family member and strong positive purified protein derivative (PPD) skin test or hypoalbuminemia and hyperglycemia were enrolled. They were randomly divided into three groups based on whether or not anti-TB treatment was offered at the beginning of glucocorticoid treatment for SLE: simple glucocorticoid group (n = 70); glucocorticoid plus rimifon group (n = 67); glucocorticoid plus rimifon plus ethambutol group (n = 66). Anti-TB treatment was offered at least 12 months for the preventive anti-TB group. And follow-ups were conducted every 2-3 months for 2 year to observe the efficacy and side effects of anti-TB drugs. During this period, anyone with fever and/or cough consulted a physician immediately. No active TB occurred in anti-TB treatment group. And 8 patients (11.43%) had active TB in simple glucocorticoid group, including hematogenous disseminated TB (n = 1), pulmonary TB (n = 3), bone TB (n = 1), tuberculous meningitis (n = 1) and undefined focus TB infection (n = 2). And 6/8 cases had active TB within 6 months after using glucocorticoids. According to the study protocol, any case of active TB shall receive 3-4 combined anti-TB drugs for 1 year. The TB conditions of 7/8 patients were better controlled by anti-TB treatment.One patient died of tuberculous meningitis after lost follow-up. Two patients had mild temporary numbness in finger tap of both hands. And 3 patients on double anti-TB drugs showed a mild elevation of liver enzymes. For high-risk population of active TB, glucocorticoid therapy plus 1 or 2 preventive anti-TB treatment drugs may prevent its occurrence. And there is no serious adverse reaction during preventive anti-TB treatment.

Return of the usual suspect

In October, 2010, a 76-year-old woman born in the USA presented to our emergency department complaining of a severe sore throat and painful swallowing. She reported having had a non-productive cough without haemoptysis 1 month previously. The cough resolved, but a sore throat then developed. At the time she was assessed by her general practitioner and specialists in the emergency and otolaryngology departments, who diagnosed pharyngitis and recommended conservative management. Her odynophagia progressed until she was unable to eat solid foods, prompting her to present to our hospital. She denied fevers, chills, night sweats, myalgias, dysphonia, dyspnoea, or dysphagia but did report a 7 kg weight loss. She also reported occasional tobacco and alcohol use. On examination she was afebrile and thin but appeared well. She had dry mucous membranes and mild erythema of the posterior pharynx without tonsilar enlargement or exudate. No oral thrush, cervical lymphadenopathy, rales, splenomegaly, or rash were noted. Leucocyte concentration was 7·9 × 109/L with a predominance of neutrophils. She was admitted for further assessment. Rapid streptococcal antigen test, monospot test, human immunodefi ciency virus (HIV) antibody test, and rapid antigen test for infl uenza A and B were negative. A temperature of 38·7°C prompted a chest radiograph, which showed bilateral airspace disease and an area of dense consolidation in the right upper lung with a rounded lucency likely to be cavitation (fi gure A), subsequently confi rmed on chest CT (fi gure B). CT of her neck showed non-specifi c epiglottis oedema. Purifi ed protein derivative skin test was negative. A few acid fast bacilli were present in the sputum, and she was started on empiric therapy for presumed pulmonary tuberculosis. DNA probe performed on sputum confi rmed Mycobacterium tuberculosis which was sensitive to all antituberculous drugs tested. Subsequently, her fever and odynophagia resolved. Laryngeal tuberculosis was the most likely cause of our patient’s sore throat as evidenced by her clinical symptoms and presumed active pulmonary tuberculosis, the non-specifi c oedema of the epiglottis noted on CT, and the resolution of her sore throat and odynophagia with antituberculous therapy. However, a defi nitive diagnosis cannot be made without laryngoscopy and histopathological confi rmation; laryngoscopy was deferred because of the substantial infectious risk associated with the procedure in the setting of active tuberculosis. She was discharged with instructions for tuberculosis testing of close contacts and plans for direct observed therapy. At last contact in February, 2011, she was well, with no recurrence of symptoms. Laryngeal tuberculosis, which accounted for 25% of all cases of tuberculosis in the early 20th century, now accounts for less than 1% of cases and is typically associated with pulmonary infection. Whereas extrapulmonary tuberculosis occurs frequently in persons with HIV, cases of laryngeal tuberculosis have been reported in immunocompetent persons. Our patient presented with odynophagia, a common presenting complaint in patients with laryngeal tuberculosis, but she denied hoarseness, the most common presenting symptom. She denied any history of tuberculosis or known contact with persons with tuberculosis, but she did report having worked as a home health aide during the 1970s. Laryngeal tuberculosis results from either direct bronchogenic spread from infected sputum or, less commonly, haematogenous spread. Laryngeal tuberculosis is highly infectious, and a delay in diagnosis can lead to disease progression and longer exposure to contacts. Therefore, physicians should consider laryngeal tuberculosis in the diff erential diagnosis of patients presenting with a persistent sore throat and odynophagia, especially in patients such as ours who also report weight loss. A chest radiograph should be considered before laryngoscopy to minimise unnecessary risk to healthcare providers.

A 67-Year-Old Woman With Cough and Shortness of Breath

67-year-old woman was admitted to the hospital with complaints of cough and shortness of breath. She had immigrated to the United States from Pakistan 4 months earlier and subsequently developed the cough, which had worsened over the past months. Two weeks prior to admission she developed worsening dyspnea on exertion. The patient did not speak English, and her daughter did the translation. Her cough was mostly dry with occasional production of minimal whitish-brown sputum. She had received amoxicillinclavulanate and ciprofl oxacin for her symptoms by her primary care physician without any benefi t. She denied any complaints of persistent fever, night sweats, chest pain, skin rash, joint pains, hemoptysis, or weight loss. Her remaining medical history was signifi cant for hypertension, diabetes mellitus, and asthma. Her medications included amlodipine, metformin, glyburide, and albuterol metered-dose inhaler. She denied any history of tobacco or alcohol abuse; however, she had been exposed to biomass fuels as a child. There was no history of prior pulmonary infection or positive purifi ed protein derivative skin test.

Intermediate-strength purified protein derivative. Its diagnostic significance in active tuberculosis.

It has been conceded for a long time that tuberculin skin testing is one of the most powerful aids in the diagnosis of tuberculosis. It attains greater significance with each passing year, with an ever-increasing tuberculin-negative population. Since the excellent work of Palmer (1) has convincingly shown that the second-strength purified protein derivative (PPD) skin test has limited value because fully 33 per cent of the population will give nonspecific reactions, it has been apparent that the true significance of tuberculin skin testing hinges on the validity of the reaction to intermediate-strength PPD. Reports have lately appeared stating that the intermediate-strength PPD skip reaction will be negative in a significant number of active cases of tuberculosis, enough to limit seriously the diagnostic value of the test. As early as 1942, Furcolow, Hewell, and Nelson (2) reported a positive skin reaction to an intermediate dose of a standard PPD preparation in 99.6 per cent of 468 tuberculous patients. Other workers (3-7), however, have not attained this percentage. Lester and Atwell (3) recently stated that the reaction to intermediate PPD was negative in 8 per cent of their patients with tuberculosis. In an effort to bring into clearer focus the true significance of this test, the present writers undertook a critical reappraisal of its specificity in active tuberculosis, in a two-part, prospective study ..