Reactivation Of Tuberculosis Research Articles

Clinical manifestations and diagnosis of acute myeloid leukemia in a patient with a medical history of pulmonary tuberculosis (a case report)

The aim is to familiarize practitioners with the initial clinical manifestations of acute myeloid leukemia and its diagnosis in a patient with a past medical history of pulmonary tuberculosis.Materials and methods. The article presents a clinical case of acute myeloid leukemia clinical manifestations based on our own clinical experience and its diagnosis in the patient with previous pulmonary tuberculosis. The patient was followed-up and diagnosed with acute myeloid leukemia in the Municipal Institution “Zaporizhzhia Regional Tuberculosis Clinical Dispensary”.Results. The patient presented in this study was diagnosed with pulmonary tuberculosis and received antimycobacterial treatment including isoniazid and rifampicin, which may have initially contributed to the hematopoietic mechanisms impairment. Perhaps the stressful situation triggered the development of acute myeloid leukemia due to underlying impaired mechanisms of hematopoiesis that had occurred. In this case, the initial clinical manifestations were weakness, loss of appetite and weight loss. A clinical blood analysis with leukogram and the bone marrow biopsy with aspirate examination became priority methods in diagnosing acute myeloid leukemia. The clinical case presented primarily demonstrates patient’s irresponsibility for their own health, who having symptoms such as weakness, loss of appetite, and weight loss for 5 months as well as past medical history of tuberculosis, did not seek medical advice timely.Conclusions. In a patient with a past medical history of pulmonary tuberculosis, priority task is to confirm or rule out reactivation tuberculosis. The initial clinical manifestations of acute myeloid leukemia are: unprovoked weakness for several months; increasing exertional dyspnea; anemia, leukopenia, neutropenia, ESR acceleration. The primary methods to diagnose acute myeloid leukemia are: clinical blood test with leukogram, biochemical blood tests to determine the levels of erythropoietin, ferritin and vitamin B12; bone marrow biopsy with aspirate examination (myelogram); cytochemical examination of bone marrow (myeloperoxidase); bone marrow immunophenotyping (expression of myeloid-associated antigens).

Tuberculosis following programmed cell death receptor-1 (PD-1) inhibitor in a patient with non-small cell lung cancer. Case report and literature review

Immune checkpoint inhibitors (ICIs)—anti-programmed death-1 (PD-1) and their ligands (PD-L1 and PD-L2) have become widely used in the treatment of several malignancies. Many immune-related adverse events (irAEs) have been linked to these agents. Nonetheless, tuberculosis (TB) reactivation during their use is increasingly recognized and reported. Herein, we present a 58-year-old lady with advanced non-small cell lung cancer (NSCLC) ALK-negative, EGFR wild, and PD-L1 immune histochemistry (IHC) strongly positive in 95% of tumor cells, on ongoing treatment with Pembrolizumab as a first-line monotherapy. Our patient presented with 1-week history of productive cough and high-grade fever. Further workup yielded the diagnosis of pulmonary tuberculosis after her Pembrolizumab sixth cycle with positive AFB smear and TB PCR from BAL (rifampin resistance not detected), with negative HIV status. Hence, immunotherapy was held, and patient was commenced on anti-TB regimen. History revealed contact with active TB patient over the past decade, without previous documentation of latent TB or previous TB infection. Her sputum AFB smear remained persistently positive 4 weeks through anti-TB regimen course. Later, the patient was discharged after her sputum was cleared from AFB (two negative sets). In light of pembrolizumab mechanism of action as an immune checkpoint inhibitor, we suspected its implication on reactivating latent TB which was observed in our patient demonstrating features of pulmonary tuberculosis. She was not re-challenged with Pembrolizumab following TB diagnosis.

Total Hip Arthroplasty in 52 Active Advanced Tubercular Arthritic Hips

BackgroundThe role of total hip arthroplasty (THA) in healed tuberculosis (TB) of the hip has been reported with success in the past. However, the role and success of THA in active TB of the hip has remained controversial. MethodsWe retrospectively evaluated a prospective study of 52 THAs done for active TB of the hip in 51 patients. The protocol includes 3-6 months of effective preoperative and 9-18 months postoperative anti-TB therapy. All THAs were performed by the same surgeon (author 1). The selection criteria excluded patients with poor immunity, HIV +ve patient, and presence of discharging sinus. The type of THA implant includes 12 cemented, 38 uncemented, and 2 hybrid fixations. ResultsThe mean follow-up was 10.5 years (2-29). Six patients were (6 THAs) lost to follow up after 4 years, including 2 deaths unrelated to TB or THA. There was no reactivation of TB. Mean Harris Hip Score improved from preop 31.77 (20-51) to postop 88 (72-100) in the last follow-up. Two patients had delayed wound healing up to 21 days postop with no evidence of subsequent episode till last follow-up. There was no case of dislocation, neurological complication in any patient. Seven THAs underwent revision for aseptic loosening unrelated to TB. ConclusionSingle-stage THA is safe in active advanced tubercular arthritic hips with good immunity status under cover of effective anti-TB therapy using strict preop selection protocol.

S2238 Crohn's Flare While Treating Tuberculosis Reactivation

INTRODUCTION: Crohn’s disease (CD) is an idiopathic inflammatory condition of the gut with relapsing-remitting nature. There is increasing evidence for the use of anti-TNF therapy early in the course of disease, but this comes with an increased risk of tuberculosis (TB) reactivation. We present a case of maintaining remission of CD while treating extrapulmonary TB. CASE DESCRIPTION/METHODS: A 25-year-old male with ileocolonic CD presented with shortness of breath, fever and productive cough. CD was diagnosed 2 years prior and complicated by anorectal fistula Previous treatment included prednisone and methotrexate (MTX) before escalating to infliximab. Upon presentation, CT scan of the chest revealed a large left pleural effusion with sputum AFB and pleural biopsy positive for mycobacterium tuberculosis (MTB). Of note the TB Quantiferon gold test prior to starting Infliximab was negative and infliximab was stopped upon TB diagnosis. During this admission there was increased drainage from the perianal fistula, requiring placement of a seton stitch. A colonoscopy and biopsy of the fistula excluded tuberculosis and was consistent with a Crohn’s flare. Prednisone 60 mg daily was started to achieve Crohn’s remission and he was discharged on RIPE therapy. While tapering steroids he developed increased drainage and was restarted on MTX. He responded well, with decreasing draining from the fistula and remained in remission while tapering off steroids and completing the initiation phase of TB treatment. He remains on continuation phase. DISCUSSION: Anti-TNF therapy brings hope for treating CD early in the disease course, but also increases the risk of TB. It is believed that TNF mediated signaling is impaired by these agents leading to an exacerbation of chronic infection associated with granuloma formation. Once reactivation occurs it is necessary to discontinue biologic agents and establish a new regimen for maintenance of CD. Glucocorticoids are rarely used in fistulizing CD and MTX can be considered with little data for perianal disease. There is no clear data to suggest the optimal agent to maintain remission during tuberculosis treatment. In a small population anti-tuberculous therapy may provide a benefit over placebo for the prevention of relapse in participants with CD. Our patient’s presentation is very rare and disease induction and remission was achieved with MTX. We believe MTX is a useful option in this special situation to navigate tuberculosis treatment safely.

IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME: THE RISK OF ADALIMUMAB CESSATION IN TB TREATMENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pharmacologic inhibition of tumor necrosis factor-alpha (TNF-a) is a mainstay in the treatment of autoimmune disease. Guidelines recommend starting TNF-a antagonists after a negative screening test result for tuberculosis (TB) infection is confirmed, due to the increased risk of reactivation TB in an immunosuppressed host. We present the case of a patient on adalimumab who developed extrapulmonary TB and immune reconstitution inflammatory syndrome (IRIS) after starting TB treatment. CASE PRESENTATION: A 67-year-old woman with a history of psoriasis, on adalimumab therapy for one year, presented to our hospital with chills, fevers, and a non-productive cough for one month. She denied hemoptysis and night sweats but acknowledged a 30-pound weight loss over the prior two months. On presentation, she was afebrile, normotensive, saturating 95% on room air. Chest X-ray was notable for bilateral miliary nodules and CT scan showed extensive miliary lesions in her lungs and spleen. She was admitted to the medicine service and put on airborne isolation. Interferon-gamma release assay (IGRA) and testing for HIV were negative. Induced sputum was collected, acid-fast bacilli (AFBs) were noted on smear microscopy, and PCR-based assay confirmed presence of Mycobacterium tuberculosis (MTb). Mycobacterial blood cultures were sent. Anti-TB therapy was started, and she was discharged to home isolation. One month later, she re-presented with dyspnea on exertion. Repeat CT scan showed a large left pleural effusion and a small pericardial effusion. AFB stain and culture of pleural fluid was negative. Repeat sputum AFB stain and culture was also negative, and MTb was not detected by PCR. Prior blood cultures resulted as positive for MTb. She was discharged home after clinical improvement with resolution of her dyspnea. DISCUSSION: TB is one of the top 10 causes of death worldwide. 20% of patients with active TB can have false negative IGRAs, especially if immunosuppressed. IRIS, most often seen in HIV+ patients, can develop with TB treatment initiation. Paradoxical worsening of clinical status occurs as the depressed immune system begins to recover. Patients on TNF-a antagonists are also at risk for IRIS, more commonly in lung and extrapulmonary TB. Thus, the combination of TNF-a antagonist discontinuation and TB treatment placed our patient at heightened risk for IRIS. CONCLUSIONS: This case demonstrates TB dissemination in an immunocompromised patient on a TNF-a antagonist who developed IRIS with adalimumab cessation and TB treatment initiation. Among commonly used biologic agents, adalimumab has been associated with a greater risk for both TB infection and IRIS development after starting TB treatment. Clinicians should be aware of this risk and monitor patients accordingly once treatment is initiated. Reference #1: World Health Organization. Global tuberculosis report 2019. Geneva, Switzerland: World Health Organization; 2019. Reference #2: Dobler, C. C. (2016). Biologic agents and tuberculosis. Microbiology Spectrum, Dec; 4(6). Reference #3: Cheng, V. C. et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur. J. Clin. Microbiol. Infect. Dis. 21, 803–809 (2002). DISCLOSURES: No relevant relationships by Mark Adelman, source=Web Response No relevant relationships by Vickie Kassapidis, source=Web Response

Association of Secukinumab Treatment With Tuberculosis Reactivation in Patients With Psoriasis, Psoriatic Arthritis, or Ankylosing Spondylitis

Approximately one-quarter of the global population have latent tuberculosis infection (LTBI), and tuberculosis (TB) is accountable for more than 1.5 million deaths annually. Methotrexate, cyclosporine, and tumor necrosis factor inhibitors may be associated with increased risk of TB and LTBI reactivation, although data are limited on the risks of TB with use of newer biologics. To assess the association of secukinumab with reporting of active TB development, TB reactivation, and LTBI activation as an adverse event (AE) in patients with psoriasis, psoriatic arthritis, or ankylosing spondylitis. This pooled cohort study pooled data from 28 clinical trials of secukinumab used in psoriasis (17 phase 3 or 3b and 2 phase 4 trials), psoriatic arthritis (5 phase 3 trials), and ankylosing spondylitis (4 phase 3 trials). A search of the Novartis Secukinumab Compound Pool Database was conducted for the 28 trials. All trial participants who had received at least 1 approved subcutaneous dose of secukinumab (150 mg or 300 mg) were included. Before randomization in these trials, patients underwent screening for TB. Patients with active TB were excluded, and patients with LTBI were treated according to local guidelines. Data were analyzed from the start of treatment in the individual studies through December 25, 2018. Reporting of active TB or LTBI as an AE over a 5-year period using exposure-adjusted incidence rates (EAIR; incidence rates per 100 patient-years). A total of 12 319 patients were included, of whom 8819 patients had psoriasis (71.6%; 5930 men [67.2%]; mean [SD] age, of 44.9 [13.5] years), 2523 had psoriatic arthritis (20.5%; 1323 women [52.4%]; mean [SD] age, 48.8 [12.1] years), and 977 had ankylosing spondylitis (7.3%; 658 men [67.3%]; mean [SD] age, 42.3 [11.9] years). In the total population, 684 patients (5.6%) had tested positive for LTBI at screening. Over 5 years, LTBI as an AE during secukinumab treatment was reported in 13 patients (0.1% of 12 319). Of these 13 patients, 6 had a prior positive LTBI test result, and 7 were newly diagnosed as having LTBI. Four of the 7 patients had psoriasis (EAIR, 0.03; 95% CI, 0.01-0.07), 1 had psoriatic arthritis (EAIR, 0.02; 95% CI, 0.00-0.11), and 2 had ankylosing spondylitis (EAIR, 0.08; 95% CI, 0.01-0.28). No cases of active TB were reported. This study found that LTBI reported as an AE after secukinumab treatment was uncommon and appeared to support the use of secukinumab in chronic systemic inflammatory conditions.

Prolonged infection triggered by dormant Mycobacterium tuberculosis: Immune and inflammatory responses in lungs of genetically susceptible and resistant mice.

We developed an approach for substantial attenuation of Mycobacterium tuberculosis by prolonged culturing under gradually acidifying conditions. Bacteria subjected to acidification lost the capacity to form colonies on solid media, but readily resuscitated their growth in the murine host, providing a useful model to study in vivo development of infection mimicking latent and reactivation tuberculosis (TB) in humans. Here we characterize biomarkers of lung pathology and immune responses triggered by such attenuated bacteria in genetically TB-susceptible and resistant mice. In susceptible I/St mice, CFU counts in lungs and spleens were ~1.5-log higher than in resistant B6 mice, accompanied by diffuse pneumonia and excessive lung infiltration with highly activated CD44+CD62L- T-lymphocytes resulting in death between months 7–9 post challenge. B6 mice were characterized by development of local inflammatory foci, higher production of pro-inflammatory IL-6 and IL-11 cytokines and a more balanced T-cell activation in their lungs. CFU counts remained stable in B6 mice during the whole 18-mo observation period, and all mice survived. Thus, we established a mouse model of fatal reactivation TB vs. indefinite mycobacterial possession after identical challenge and characterized the features of immune responses in the lung tissue underlining these polar phenotypes.

Blood M2a monocyte polarization and increased formyl peptide receptor 1 expression are associated with progression from latent tuberculosis infection to active pulmonary tuberculosis disease

ObjectivesThis study aims to explore the role of M2a polarization and formyl peptide receptor (FPR) regulation in the reactivation of Mycobacterium tuberculosis (Mtb) infection. MethodsM1/M2a monocyte percentage and FPR1/2/3 protein expression of blood immune cells were measured in 38 patients with sputum culture (+) active pulmonary TB disease, 18 subjects with latent TB infection (LTBI), and 28 noninfected healthy subjects (NIHS) using flow cytometry method. ResultsM1 percentage was decreased in active TB versus either NIHS or LTBI group, while M2a percentage and M2a/M1 percentage ratio were increased. FPR1 expression on M1/M2a, FPR2 expression on M1, and FPR3 expression of M1 were all decreased in active TB versus LTBI group, while FPR1 over FPR2 expression ratio on NK T cell was increased in active TB versus either NIHS or LTBI group. In 11 patients with active TB disease, M1 percentage became normal again after anti-TB treatment. In vitro Mtb-specific antigen stimulation of monocytic THP-1 cells resulted in M2a polarization in association with increased FPR2 expression on M2a. ConclusionsIncreased M2a and decreased M1 phenotypes of blood monocyte may serve as a marker for active TB disease, while decreased FPR1 on blood monocyte may indicate LTBI status.

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.

Vitamin D deficiency predicts latent TB reactivation independent of preventive therapy: a longitudinal study.

BACKGROUND: Vitamin D deficiency is associated with progression of latent tuberculosis (TB) infection to active disease. The impact of preventive therapy on this association is unknown.METHOD: Serum 25-hydroxyvitamin D (25(OH)D) levels were retrospectively linked to adults diagnosed with latent TB between April 2010 and January 2019 in a hospital in London, UK. Individuals in the cohort who progressed to active TB were identified by matching to a national notification register. A logistic regression model was used to examine baseline vitamin D deficiency and use of preventive therapy with subsequent incidence of TB disease.RESULTS: Of 1509 latently infected individuals with 3902 patient-years of follow-up, 687 (45.5%) were identified as vitamin D deficient and 691 (45.8%) individuals had a LTBI regimen prescribed. There were 29 (1.9%) instances of TB reactivation. On multivariate analysis, profound (<25 nmol/L) vitamin D deficiency (aHR 5.68, 95%CI 2.18-14.82; P = 0.0003) and the absence of preventive therapy (aHR 3.84, 95%CI 1.46-10.08; P = 0.006) were associated with progression to active TB disease. There was no evidence that preventive therapy modified the association between vitamin D status and TB reactivation.CONCLUSION: Our results show an independent association between vitamin D deficiency and progression from latent TB infection to active disease.

Risk of tuberculosis reactivation with interleukin (IL)-17 and IL-23 inhibitors in psoriasis - time for a paradigm change.

Tuberculosis is an infectious disease with a major global impact, ranked in the top 10 mortality causes worldwide. In an immunocompetent individual, the host defence mechanisms control Mycobacterium tuberculosis infection and induce the latent form of the disease. However, in the presence of diseases or therapies, which exert an immunosuppressive effect, latent tuberculosis can be re-activated. Psoriasis is an immune-mediated, inflammatory disease, and its treatment has rapidly evolved over the last few years. It has long been recognized that the tumour necrosis factor (TNF)-α inhibitors are associated with increased risk of reactivation of latent tuberculosis infection. Thus, international guidelines have been suggesting tuberculosis screening before starting the treatment with all biological agents since then. In addition, the institution of chemoprophylaxis in the presence of latent tuberculosis and the annual screening for tuberculosis thereafter have also been indicated. However, anti-tuberculosis treatments can have significant side-effects and there are currently several contraindications to their use. The risk benefit of starting anti-tuberculous treatment should be carefully weighed up. The emergence of new biological drugs for the treatment of psoriasis, such as interleukin (IL)-17 and IL-23 inhibitors, has reignited the subject of tuberculosis reactivation as it is possible that IL-17 and 23 blockade do not carry the same risk of TB reactivation as TNF-α inhibitors. Although preclinical studies have shown that cytokines IL-17 and IL-23 have a possible role against infection with M.tuberculosis, data from clinical trials and post-marketing surveillance with drugs that inhibit these cytokines appear to suggest that they are not crucial to this response. In this article, we review the available data on tuberculosis reactivation after the treatment of psoriasis with IL-17 and IL-23 inhibitors, and its possible impact on the way we currently manage latent tuberculosis infection before or after starting treatment with these new drugs.

Treatment of latent M. tuberculosis infection and use of antiretroviral therapy to prevent tuberculosis.

Even with treatment of HIV with antiretroviral therapy (ART), the risk of tuberculosis (TB) reactivation remains higher in HIV-infected than HIV-uninfected persons. In this issue of the JCI, Ganatra et al. explored TB reactivation in the context of ART using TB and simian immunodeficiency virus-coinfected (TB/SIV-coinfected) nonhuman primates. The authors found that treating rhesus macaques with ART restored CD4+ T cells in whole blood, spleen, and bronchoalveolar lavage (BAL) fluid, but not in the lung interstitium. TB risk was not decreased in the coinfected macaques treated with ART for 14-63 days, suggesting that ART does not decrease the short-term risk of reactivation. Reactivation occurred as CD4+ T cells were increasing, which is consistent with observations made in humans. This study provides a potential model for systematic evaluation of TB/SIV coinfection and different treatment regimens and strategies to prevent TB reactivation.

Antiretroviral therapy does not reduce tuberculosis reactivation in a tuberculosis-HIV coinfection model.

While the advent of combination antiretroviral therapy (ART) has significantly improved survival, tuberculosis (TB) remains the leading cause of death in the HIV-infected population. We used Mycobacterium tuberculosis/simian immunodeficiency virus-coinfected (M. tuberculosis/SIV-coinfected) macaques to model M. tuberculosis/HIV coinfection and study the impact of ART on TB reactivation due to HIV infection. Although ART significantly reduced viral loads and increased CD4+ T cell counts in blood and bronchoalveolar lavage (BAL) samples, it did not reduce the relative risk of SIV-induced TB reactivation in ART-treated macaques in the early phase of treatment. CD4+ T cells were poorly restored specifically in the lung interstitium, despite their significant restoration in the alveolar compartment of the lung as well as in the periphery. IDO1 induction in myeloid cells in the inducible bronchus-associated lymphoid tissue (iBALT) likely contributed to dysregulated T cell homing and impaired lung immunity. Thus, although ART was indispensable for controlling viral replication, restoring CD4+ T cells, and preventing opportunistic infection, it appeared inadequate in reversing the clinical signs of TB reactivation during the relatively short duration of ART administered in this study. This finding warrants the modeling of concurrent treatment of TB and HIV to potentially reduce the risk of reactivation of TB due to HIV to inform treatment strategies in patients with M. tuberculosis/HIV coinfection.

Lymph nodes-The neglected battlefield in tuberculosis.

Lymph nodes, particularly thoracic lymph nodes, are among the most common sites of extrapulmonary tuberculosis (TB). However, Mycobacterium tuberculosis (Mtb) infection in these organs is understudied. Aside from being sites of initiation of the adaptive immune system, lymph nodes also serve as niches of Mtb growth and persistence. Mtb infection results in granuloma formation that disrupts and—if it becomes large enough—replaces the normal architecture of the lymph node that is vital to its function. In preclinical models, successful TB vaccines appear to prevent spread of Mtb from the lungs to the lymph nodes. Reactivation of latent TB can start in the lymph nodes resulting in dissemination of the bacteria to the lungs and other organs. Involvement of the lymph nodes may improve Bacille Calmette-Guerin (BCG) vaccine efficacy. Lastly, drug penetration to the lymph nodes is poor compared to blood, lung tissue, and lung granulomas. Future studies on evaluating the efficacy of vaccines and anti-TB drug treatments should include consideration of the effects on thoracic lymph nodes and not just the lungs.

Estimated Latent Tuberculosis Infection Prevalence and Tuberculosis Reactivation Rates Among Non-U.S.-Born Residents in the United States, from the 2011–2012 National Health and Nutrition Examination Survey

Increased testing and treatment of latent tuberculosis infection (LTBI) among US-residents who were born (or lived) in countries with high rates of TB can hasten progress toward TB elimination. We calculated LTBI prevalence using QuantiFERON®-TB Gold In-Tube results from the 2011 to 2012 National Health and Nutrition Examination Survey (NHANES). LTBI prevalence was highest for persons born in India (31.7%, 95% confidence interval [21.2, 44.5]). Non-Hispanic white persons had the lowest LTBI prevalence (6.3% [1.9, 18.9]). TB reactivation rate, defined as the number of TB cases not associated with recent transmission per 100 person-years of life with LTBI, was highest for persons born in Vietnam [0.183 (0.117, 0.303)]. Reactivation rates were lower among persons who had resided in the United States for ≥ 10years than among those who had resided for < 10years. Results among high risk populations can guide LTBI targeted testing and treatment among non-U.S.-born residents.

Profil and Evaluation of Resistant Tuberculosis Drug’s Side Effect in Diabetes and Non Diabetes Mellitus Patient at RSUD Arifin Achmad

Backgrounds: Diabetes mellitus (DM) increases the risk of reactivation of tuberculosis included multi-resistant drug tuberculosis (MDR-TB). This situation is threatening Riau province due to the high prevalence of DM. Since 2014 Arifin Achmad Hospital as a referral hospital of MDR-TB management. It’s treatment especially in DM patients, requires an evaluation of both outcome and side effects. This evaluation needs to be compared with non-DM MDR TB patients. The aim of this study was to evaluate and analyse patient’s characteristic, conversion of smear or culture, drugs side effect and treatment outcome. &#x0D; Methods: This is a cross sectional retrospective study in RSUD Arifin Achmad Pekanbaru on April-October 2018. Sample of this study were all patients from 2014 – 2017. This study was divided into 2 groups, namely the DM and non-DM groups, then analysed the differences between the two groups &#x0D; Results: There were 113 MDR TB patients had its treatment, which 61% of the patients were male. Baseline data show 26.5% of MDR TB patients have comorbid DM. The most common side effects were nausea and vomiting (100%) in all subjects. In the MDR TB DM group, we found included: well controlled plasma glucose level was 33.3%, severe side effects was16.7%, conversion in the second month 40% and cured or complete treatment was 30%.&#x0D; Conclusions: As many as 26,5% of MDR TB patients had DM comorbidity. There were no differences in the percentage of drugs side effects, smear conversion in the second month and treatment outcome between MDR TB DM and MDR TB non-DM group. (J Respir Indo. 2020; 40(3): 156-62)

Extensive tracheal resection in lung cancer and tuberculosis: a case report

BackgroundTracheal bifurcation resection remains the greatest challenge in airway reconstruction, especially with extensive lesions. Additionally, lung cancer and pulmonary tuberculosis comorbidity complicate the chemoradiotherapy treatment due to the TB reactivation. This case describes tracheal resection in a patient with both tuberculosis (TB) and lung cancer.Case presentationThe patient was diagnosed with right lung tuberculosis and upper lobe cancer with trachea invasion complicated by hemoptysis. A right pneumonectomy with circular trachea bifurcation resection was performed. Radiotherapy and chemotherapy were not administered to avoid TB reactivation. At 5.5 years post-surgery, there was cancer recurrence that was treated with radiation therapy. At 10 years post-surgery, an invasive squamous-cell carcinoma of a three-segment bronchus on the left was revealed. Radiation therapy and a course of chemotherapy were carried out with almost complete tumor regression.ConclusionsTB presence should not serve as a basis for the refusal of cancer treatment. Combined treatment may be recommended when the main infection focus in the pulmonary parenchyma is removed during surgery.

Tuberculose pulmonaire sous traitement par immunothérapie type anti-PD1

Immunotherapy is now a standard of care in oncology. There is a need to improve our knowledge about immune-related adverse events, especially infectious diseases. We describe the case of a 49-year old male who received anti-PD1 therapy, to treat metastatic melanoma with pulmonary metastasis. After 3 cycles of nivolumab, computed tomography scanning showed a decrease of the pulmonary metastasis in the upper left lobe, but revealed new pulmonary lesions such as tree-in-bud and a lung cavity in the same lobe. This was diagnosed as pulmonary tuberculosis with no antibiotic resistance identified. The patient continued the immunotherapy and was initiated onto a standard anti-tuberculosis therapy. In the absence of an initial positive IFN-γ release assay (Quantiferon) test, but as there might have been a history of primary infection during childhood, a reactivation of tuberculosis was considered to be likely. This is the ninth case of tuberculosis infection under immunotherapy and it underlines the need to consider infection risks in patients undergoing immunotherapy. An INF-γ release assay screening test should be considered an essential part of the pre-treatment work-up.

Tuberculin skin test conversion in patients under treatment with anti-tumor necrotizing factor alpha agents

BackgroundDespite successful clinical outcomes of biologic medications in patients with chronic rheumatic diseases, some considerable adverse effects such as infections remain a major concern. Possibility of tuberculosis (TB) reactivation over treatment with anti-tumor necrotizing factor (TNF) alpha agents has necessitated a screening test before initiation of treatment. However, screening over the course of treatment is not recommended in those patients with negative baseline screening tests. This study aimed to evaluate the efficacy of tuberculin skin test (TST) before treatment in patients with chronic rheumatologic diseases who were indicated to receive anti-TNF-alpha therapy and the necessity of repeating this test over the course of treatment.MethodsIn this prospective study, patients with chronic rheumatologic diseases receiving anti-TNF-alpha agents were studied in a two-year period. TST was performed before treatment and those with positive results were excluded from the study. Thereafter, treatment with anti-TNF-alpha agents was initiated with the indicated dose. TST was repeated before administration of biologic treatment until TST became positive or 16 weeks after the initiation of treatment with anti-TNF-alpha.ResultsA total of 51 cases were studied, of whom one patient (1.9%) was excluded due to positive TST before treatment. All participants received infliximab and the TST test became positive in one patient (2%) 2 weeks after receiving the first dose. Also, the results of further tests at weeks 6, 10, and 14 were all negative for the remaining patients.ConclusionDue to the possibility of TST conversion after administration of anti-TNF-alpha therapy, it is important to consider TB monitoring in patients under treatment with these agents using available methods such as TST.

No reactivation of tuberculosis in patients with latent tuberculosis infection receiving ixekizumab: A report from 16 clinical studies of patients with psoriasis or psoriatic arthritis

No reactivation of tuberculosis in patients with latent tuberculosis infection receiving ixekizumab: A report from 16 clinical studies of patients with psoriasis or psoriatic arthritis