Various Forms Of Tuberculosis Research Articles

Revised definition of ‘fever of unknown origin’: limitations and opportunities

Aim The limitations and opportunities of revised definition of fevers of unknown origin (FUO) in comparison to conventional definition were investigated, and prehospital characteristics of the patients were detailed. Method The patients were grouped according to both revised and classic definitions of FUO. Results Fifty-nine of the 80 patients (74%) met the conventional definition of FUO. Before their admissions, all patients had at least one course of antibiotic therapy. The aetiology was infectious in 52%, autoimmune in 19%, and neoplastic in 17%. In 12% of the cases, the reason for high fever could not be explained. The most common infectious aetiologies were various forms of tuberculosis (12%), brucellosis (12%), salmonella (7%) and malaria (5%). The revised definition inflated the rate of infectious aetiology. Conclusion A standardized set of diagnostic tools used in this study was suggested. The subjects of FUO series have to be screened for endemic infections.

Molecular epidemiology of tuberculosis in Prague: Analysis by restriction fragment length polymorphism

Objectives: To characterize by restriction fragment length polymorphism (RFLP) patterns, the distribution of different Mycobacterium tuberculosisstrains isolated consecutively from 75 tuberculosis patients who resided in Prague and had culture-confirmed cases during a 4-month period in 1995. Methods: The insertion sequence IS 6110-based RFLP analysis of M. tuberculosis isolates was carried out. Results: There were a total of 75 patients with various forms of tuberculosis (54 males; 21 females). The sources of M. tuberculosis isolates were sputum (n = 64), pleura or lymph node drainage (n = 8), and urine (n = 3). Fifty-three of the patients (70.7%) had isolates with unique RFLP patterns, while 22 (29.3%) had isolates that belonged to seven clusters of related RFLP patterns. The seven clusters consisted of four groups of two patients, two groups of four patients, and one group of six patients. Most of the patients whose isolates fell within a clustered RFLP pattern lived in different quarters of the city and had no identifiable contacts with other patients whose isolates had the same pattern. Conclusions: The finding that isolates from most patients (70.7%) had unique rather than clustered RFLP patterns suggests that endogenous reactivation rather than exogenous transmission is the major determinant of most of the tuberculosis cases in Prague. The occurrence of seven distinct clusters comprising 29.3% of the isolates suggests that approximately one third of cases developed active tuberculosis from recent exogenous transmission.

The diagnosis of pulmonary tuberculosis by gaschromatographic detection of tuberculostearic acid using flame ionisation detectors

It has been shown that the detection of tuberculostearic acid (TBSA) with gas chromatography-mass-spectrometry provides a highly specific, sensitive and rapid method for the diagnosis of various forms of tuberculosis. However, the need for complex and expensive equipment prevented the more widespread use of this method. We report on the application of conventional gas chromatography with flame ionization detectors in the detection of TBSA in sputum samples. TBSA was detected in all patients with proven pulmonary tuberculosis before treatment or under treatment for less than 4 weeks (n = 18). Six of these patients (33%) had a negative microscopy result at the time of the study. Sputum samples from patients under therapy for longer than 4 weeks (n = 20) were TBSA-positive in 15 cases (75%). Only in two cases was the diagnosis by microscopy and/or culture not met by TBSA-detection. All sputa of 20 control patients with lung diseases other than tuberculosis were TBSA negative. Additional analysis of patients' data showed a significant relationship (P < 0.005) between the relative amounts of TBSA detectable in the sputum samples and the duration of therapy. It is concluded that conventional capillary gaschromatography may be sensitive and specific enough to be used for the detection of TBSA in sputum of patients with pulmonary tuberculosis.

Simultaneous quantification of cycloserine and its prodrug acetylacetonylcycloserine in plasma and urine by high-performance liquid chromatography using ultraviolet absorbance and fluorescence after post-column derivatization

d-Cycloserine is a broad-spectrum antibiotic used with other antibiotics to treat various forms of tuberculosis. Its prodrug sodium ( R)-4-[(1-methyl-3-oxo-1-butenyl)amino]-3-isoxazolidinone hemihydrate, developed for better aqueous stability and solubility, is combined with another broadspectrum antibiotic, fludalanine. An ion-pair, reversed-phase high-performance liquid chromatographic assay has been developed to simultaneously detect cycloserine and its prodrug in plasma and urine. The prodrug is detected directly by ultraviolet absorbance and cycloserine by fluorescence following post-column derivatization.

Diagnostic value of bacilliform discharge in focal tuberculosis

The intensity of bacilliform excretion and the characteristics of the pathogen in patients with various forms of tuberculosis are not only of diagnostic value but also contribute to the selection of a rational combination of antituberculosis drugs and to the determination of the required duration of therapy. In addition, the occasional bacilliform discharge in nonspecific lung diseases complicates the differential diagnosis.

Blood groups in patients with respiratory tuberculosis

The distribution of blood groups of the ABO system was studied in 455 patients with various forms of tuberculosis and 3321 healthy donors. It was found that blood type B (III) was more common in patients (27.9%) than in healthy (21.3%). The severe course of the tuberculosis process in the lungs was observed mainly in patients with blood group B (III), while in those with blood group AB (IV), the disease was productive.

Über die Beziehungen zwischen der serumbakteriostatischen Aktivität und Blutgruppen bei Patienten mit Lungentuberkulose

The bacterial activity of sera from 116 patients suffering from various forms of tuberculosis of the lung, pleuritis exsudativa, neoplasm of the lung and histologically verified sarcoidosis of the lung were tested against 12 different strains of mycobacteria. The results obtained were then related to the blood-group of the respective patients. As can be seen from the results, there was a statistically significant difference (p = 0.001) between the values of bacterial activity for patients with (1) positive and negative Tb excretion and (2) patients suffering from an indurative and destructive form of tuberculosis of the lung. In contrast, it was not possible to establish statistically significant differences in the level of bacterial activity in patients with different levels of the i.d. tuberculin reaction (3). In patients with positive Tb excretion (4) and patients with destructive tuberculosis of the lung (5) there were increased levels of bacterial activity for all blood-groups if compared with values for patients with negative Tb excretion or patients suffering from indurative forms of lung tuberculosis. A statistical analysis of all results did not confirm the authors' hypothesis that the elevated incidence of destructive forms of tuberculosis and of bacterial excretion among patients having blood-group “O” could be ascribed to an insufficiency of bacteriostatic activity in the sera of these patients. Bei 116 Kranken mit verschiedenen Formen der Lungen-Tbc, Pleuritis exsudativa, neoplastischer Lungenerkrankungen und mit histologisch verifizierten Lungensarkoidose wurde die bakt. Aktivität der Seren mit 12 verschiedenen mykobakteriellen Stämmen getestet. Die erzielten Ergebnisse wurden dann mit den Blutgruppen derselben Patienten in Beziehung gebracht. Wie aus den erzielten Ergebnissen zu entnehmen ist, wurde ein statistisch signifikanter Unterschied (p = 0,001) zwischen den Werten der bakt. Aktivität bei Kranken 1. mit positiver und negativer Tb-Ausscheidung und 2. bei Patienten mit einer indurativen und destruktiven Form der Lungen-Tbc verzeichnet. 3. Dagegen konnten wir bei den Tuberkulosekranken mit verschiedener Größe der i.d. Tuberkulinreaktion keine statistisch signifikante Unterschiede in dem Umfange der bakt. Aktivität feststellen. 4. Bei den Patienten mit einer positiven Tb-Ausscheidung und 5. Patienten mit destruktiven Lungen-Tbc konnten wir in allen Blutgruppen eine Erhöhung der Werte von bakt. Aktivität registrieren im Vergleich mit den Werten bei den Patienten mit negativer Tb-Ausscheidung oder Patienten mit indurativen Formen der Lungen-Tbc. Die Ergebnisse einer statistischen Analyse aller unserer Resultate bestätigen unsere Arbeitshypothese nicht, wonach das häufigere Vorkommen von Tuberkulosekranken mit einer destruktiven Form der Tuberkulose und mit Tb-Bakterienausscheidung in der Blutgruppe 0, der Insuffizienz der bakteriostatischen Aktivität in den Seren dieser Patienten zugeschrieben werden könnte.

Transmission of tubercle bacilli: The effects of chemotherapy.

The important differences in the infectivity of the various forms of tuberculosis can be explained by quantitative data concerning the behaviour of the tubercle bacillus in man and the number of bacilli in the lesions and sputum. Patients in whom tubercle bacilli can be detected by direct examination of the sputum smear are the main sources of transmission. Moreover the individuals infected by them break down more often with the disease. In the individual patient, the use of antibacterial drugs completely changes the natural history of the disease: not only do patients no longer die but they are cured; their period of infectivity is considerably reduced, relapses are avoided, chronicity disappears. The drugs used prophylactically in individuals of high risk groups prevent development of the disease. The impact of chemotherapy is reflected by a two-to-three-fold increase in the speed of decline of the risk of infection, a decline which had started before the introduction of the drugs. While patients given the right combination of drugs lose their infectivity in a few weeks (probably most often in less than two weeks), treatment must of course be continued much longer and regularly in order to ensure the maintenance of conversion and the absence of relapse. This stresses the importance of providing means to ensure the taking of the drugs by all patients. The future reduction of transmission will essentially depend on the maintenance of an adequate system ensuring the early diagnosis and correct treatment of cases, which will inevitably continue to appear among the already infected portion of the population. Epidemiological surveillance is mandatory as well as the surveillance of the delivery of services, particularly of the quality of diagnosis and therapeutic services. The roles of public health authorities and perhaps still more that of the practising physician, specialized and not specialized, remain considerable both from an epidemiological point of view and from the point of view of the relief of all the suffering still created by the disease.

Incidence of tuberculosis in enlarged neck nodes, our experience

To determine the incidence of tuberculous lymphadenitis in enlarged neck nodes. Continuous prospective study is carried out in the department of otorhinolaryngology head & neck surgery, Kathmandu Medical College, Kathmandu, during two years, from January 2006 to January 2008. The study included a group of 155 patients with cervical lymphadenopathy. Each patient underwent a detail clinical Ear, Nose and Throat (ENT) examination and a battery of investigations which included Fine Needle Aspiration Cytology (FNAC) of the nodes, Montoux's test, blood Erythrocyte Sedimentation Rate (ESR) and chest X-ray. Those patients with tubercular lymphadenitis were referred to Directly Observed Therapy System (DOTS) clinic for anti-tubercular therapy. Others with reactive lymphadenitis were treated with antibiotic and those with metastatic neck nodes were treated accordingly. Of the 155 cases with enlarged neck nodes, 83 (54%) had tubercular lymphadenitis. Fifty two (33%) cases had reactive lymphadenitis and 17 (11%) cases were diagnosed with metastatic neck nodes. Fine needle aspiration cytology was found to be highly effective in the diagnosis of tubercular lymphadenitis with 94% accuracy. Majority of patients were otherwise healthy adults, aged between 8 - 71 years. No difference was observed between male and female in this study. Posterior triangle (PT) nodes were most commonly affected group of nodes accounting for 35 (42%) cases and preauricular region 1 (1%) case being the least commonly affected site. Fifteen (18%) cases presented with abscess formation. Only 42 (50%) cases had family history of tuberculosis but 8 (9%) patients had previous history of various forms of tuberculosis. Twelve (14%) patients had positive chest X-ray findings suggesting of concurrent pulmonary tuberculosis. All the patients were referred to DOTS clinic and were treated with category (CAT) - III anti tubercular therapy (ATT). Others with concurrent pulmonary tuberculosis were treated with CAT I regime. None of the patients required surgical treatment. There is high incidence of tubercular cervical lymphadenitis in patients with enlarged neck nodes in developing countries like Nepal. Involvement of cervical lymphnodes are the most commonly affected group of nodes. Therefore, it is important that otolaryngologists are aware of tuberculosis in the head and neck region.

Needle biopsy of the liver in various forms of childhood tuberculosis

Needle biopsy of the liver from 120 children with various forms of tuberculosis revealed pathologic evidence of dissemination of tubercle bacilli to the liver in 17 per cent. Seventy-one of the children had only primary pulmonary tuberculosis; the presence of positive hepatic lesions in this group is further evidence that there is some dissemination of organisms even in this form of tuberculosis.

Osseous tuberculosis with concurrent pulmonary lesions.

With the discovery of streptomycin by Waksman in 1943, a new era in treatment of tuberculosis made its entrance. Glowing reports of its effectiveness in pulmonary and other types of the disease led us first to conclude that it would wipe out tuberculosis. But the effectiveness in bone and joint tuberculosis was minimal. True, it appeared to slow down the rate of destruction, but it did not reverse the destructive process, nor bring cure to the many involvements of spinal, sacroiliac and peripheral joint tuberculosis. Disappointment was the lot of the orthopedic surgeon, and reliance upon the old rules of treatment was the usual course of procedure. To briefly paint the background of this previously accepted and undisputed therapeutic regimen, we should recall that arrest of the disease was based upon the evidence that skeletal tuberculosis was almost always a joint region involvement and practically never a destruction of the shafts of long bones. Principles were based on the fact that if motion could be stopped, the disease would become quiescent, and if fusion with complete obliteration of the joint secured, by whatever means, then cure of the disease was possible. Only with the absolutely fused joint was this to be attained. Only the ingenuity of the physician limited the various methods of using splinting, frames, casts, traction, and braces. Improvement required years of patient care. The subsequent surgical procedures of bone grafting, osteotomy etc., to secure solid bony arthrodesis and good functional positions, then became the final problem. The existence of cold abscesses was looked upon with alarm, and aspiration, to relieve the internal tension, and prevent its breaking through the skin, was resorted to, because the formation of a draining sinus with subsequent secondary pyogenic infection was felt to be the cause of the almost invariably fatal “amyloid disease.” The statement that “draining the tuberculous abscess frequently signs the patient’s death warrant” was quoted in many texts of bone and joint tuberculosis. This generally was the status of the treatment of osseous forms of tuberculosis in 1946, 10 years ago, when this reported study was begun. The decision to depart radically from these accepted tenets of treatment was based upon tha following theoretical thinking: 1. An analysis of reported success and failures of streptomycin of various forms of tuberculosis revealed the success to be largely related to location of lesions as to adequacy of physiologic drainage. For example, laryngotracheo bronchial lesions-with surface drainage easily attained, responded rapidly in comparison with interstitial fibrotic lesions in the pulmonary tis-

Changes in blood serum protein fractions as indicators of the course of inflammatory processes

Paper electrophoresis was used in the determination of serum proteins in patients with various forms of tuberculosis. The dynamics of the exudative inflammation of the lungs, pleura and extrapleural cavity was characterized by a rise on α-globulins, mostly α2-globulins of the blood serum and a decrease of the albumin level.

ISONIAZID IN TREATMENT OF TUBERCULOSIS IN CHILDHOOD

THE ADVENT of streptomycin as a therapeutic agent in tuberculosis has caused considerable modification of the previously hopeless prognosis which attended the diagnosis of tuberculous meningitis in children. As pointed out in a recent study,¹however, the results of treatment with this drug in conjunction with either thiazolsulfone (Promizole) or paraaminosalicylic acid have been far short of the desired goal. Further, there has remained this ever-present question: When should one use streptomycin in the treatment of the lesser forms of tuberculosis in childhood? Since there are many questions not completely answered and since isoniazid has been demonstrated to be a promising tuberculostatic compound, it has seemed advisable to continue the clinical use of this agent in the treatment of the various forms of tuberculosis as the disease appears in children. The Committee on Chemotherapy and Antibiotics of the American College of Chest Physicians²feels that "isoniazid has not

Studies in experimental ocular tuberculosis. Failure of aureomycin to affect the course of ocular tuberculosis.

AUREOMYCIN has been shown to be successful in the treatment of a wide variety of infectious diseases. 1 It has also been shown that resistance to aureomycin by many organisms is developed much more slowly and to a less degree than is resistance to streptomycin. 2 Braley and Sanders 3 reported 2 cases of tuberculous uveitis in which decided improvement followed treatment with aureomycin. Schoenbach 4 treated 6 patients with various forms of tuberculosis. Two of these 6 showed improvement, 1 with a renal infection, the other with scrofulous draining sinuses of the neck. Steenken and Wolinsky 5 found the in vitro sensitivity of the H37 RV strain of Mycobacterium tuberculosis to vary from 5 to 40 micrograms per cubic centimeter, depending on the medium used for the assay. These authors treated the disease in guinea pigs with aureomycin and concluded that the course of the clinical disease was not

Tuberculosis in Pediatric Practice

Complete eradication of tuberculosis as a major cause of illness and death in the United States within the next generation or two is an attainable possibility by application of methods already known. If streptomycin or a similar drug proves efficacious this time would be considerably shortened. In the over-all fight against the disease the physician whose practice deals with children can contribute much in this final drive. Diagnostic tuberculin is one of the most specific of all the specific tests available for the detection of disease. The physician should use it routinely in his child patients at two to three year intervals. False negative tests occur only rarely. A positive test means only that a primary tuberculous infection has occurred at some previous time. However, the finding of a positive reaction in a child, especially a young child in the first years of life, may be the means of uncovering an hitherto unsuspected source of contagion. Furthermore, a positive test in a child identifies the individual who must be kept under observation for the possible development of chronic pulmonary tuberculosis at some future date. Mass x-raying the chests of children fails to make this distinction. Knowledge of the pathogenetic development of the various forms of tuberculosis aids the physician in recognizing the stage in the evolutionary course of the disease at which his patient may have arrived. There are fundamental differences between primary tuberculosis and reinfection tuberculosis. The development of tuberculoallergy several weeks after the initial infection is responsible for these differences. In the majority of children primary tuberculosis is limited to the pneumonic lesion and to the lymph node lesion. In a few, extension may occur by contiguity about the pulmonary focus, or by hematogenous or bronchogenic spread from the lymphnode focus. Thus accounted for are the acute reinfection forms of tuberculosis such as tuberculous broncho-pneumonia, miliary tuberculosis, and tuberculous meningitis. The latter, however, is not the direct result of hematogenous seeding, but rather, results from rupture of an older focus into the sub-arachnoid space. Chronic pulmonary tuberculosis is rarely encountered before puberty. No certain explanation exists for the remarkable freedom children between the ages of five and puberty enjoy from tuberculous morbidity and mortality. Possible factors having a bearing upon the high infection rate of chronic reinfection tuberculosis, especially in girls, during the teen age are the increased need for minerals and protein and other metabolic changes which occur in adolescence in association with the establishment of menses. The reaction of every child to tuberculin should be known at or before the onset of puberty. Positive reactors should have, at least annual x-ray films of the lungs made in order to recognize at the earliest possible time, the characteristic soft mottled apical shadows of the early infilliate. Diagnostic tuberculin and the x-ray constitute the bulwarks upon which chief dependence is placed for the diagnosis of the various forms of tuberculous disease occuring in childhood. History of exposure, symptoms of illness and physical findings are relatively poor guide posts. Demonstration of tubercle bacilli by gastric lavage is frequently helpful in clinching a previously suspected diagnosis. Studies of the blood, including the hemogram, sedimentation rate and Schilling differential count are of less value in diagnosis than in estimating prognosis and the favorable or unfavorable course of the disease. The immediate prognosis of all primary tuberculous infections is good, with the exception of the comparatively few children in the first five years of life whose primary complexes extend to the development of such acute reinfection forms as meningitis, miliary disease and tuberculous pneumonia. The remote prognosis however, is more uncertain, both from the point of view of the number who will ultimately develop chronic pulmonary tuberculosis and the number who will die from this form of the disease. An environment safe from the risks of tuberculosis infection should be provided every child. In this preventive phase the pediatrician and the physician can accomplish much. Experiments now being carried on with streptomycin may provide a specific form of therapy, but until its efficacy has been proven, rest, diet, healthful living conditions and time are the general measures to be relied upon for bringing about healing in most of the tuberculous lesions of children. Collapse therapy may occasionally be indicated.

PITYRIASIS-ROSEA-LIKE DERMATITIS FOLLOWING GOLD THERAPY

Chrysotherapy has been employed with encouraging results in the constitutional treatment of arthritis, lupus erythematosus and various forms of tuberculosis for the past twenty-five or more years. However, the use of gold has been attended in many instances by accidents of varying degrees of severity. Dermatitis has been a frequent manifestation of toxicity. Recent observation of 2 unusual cases in which there were eruptions similar to pityriasis rosea accompanied by lesions on the mucous membranes appearing during gold therapy has stimulated our interest in this subject. Gold was first used therapeutically in 1810 by Chrestien for the treatment of pulmonary tuberculosis. 1 Koch showed that the presence of gold was lethal to the tubercle bacillus in vitro in 1890. This apparently stimulated others to further investigation for suitable therapeutic forms of gold and their effect on various diseases. Bruck and Gluck 2 were the first in recent years to attempt

Diättherapie der Lungentuberkulose

This book, with a foreword by Felix Fleischner, contains an elaborate discussion of diet in the treatment of tuberculosis. Many pages are devoted to a theoretical discussion of acute and chronic infection, anaphylaxis, allergy, vitamins and minerals in the diet. Considerable attention is given to the importance of recognizing allergic conditions, which may result in migraine, asthma and gastro-intestinal disturbance, with the thought of discovering the exciting cause and removing it when the diet is responsible. Gerson's diet in the treatment of pulmonary tuberculosis, which has become well known in various parts of the world, is outlined and discussed in considerable detail. Cases are reported representing various forms of tuberculosis that have been treated by the Gerson diet. This section of the book contains a large number of illustrations made from x-ray films of the chests of patients who have been treated by the dietetic method. It is interesting

Tuberculosis bacilli in the blood of cadavers

The authors, using conventional methods of culture of tubercle bacilli (bac), found them in blood clots taken from the hearts of subjects who had died of various forms of tuberculosis.

ULTRAVIOLET RAY THERAPY IN PERITONEAL AND GLANDULAR TUBERCULOSIS OF CHILDREN

In the United States, the literature is barren as to the value of the ultraviolet rays in the treatment of peritoneal and glandular tuberculosis of children, even though various authors, such as Selma Meyer, 1 in 1918, and R. Hamburger, 2 in 1920, from Czerny's clinic, have reported very favorably on its use in tuberculosis of the peritoneum and of the glands. Recently Finkelstein, 3 and Rohr, 4 Birk 5 and Kleinschmidt 6 have made similar reports, although Birk is inclined to prefer the roentgen ray in many instances. Since the fall of 1921, we have been interested in carrying out this treatment in the various forms of tuberculosis that have come to our limited service. Ten cases have been observed since then, and the observations made on them form the basis of this report. All our patients were exposed to one of the same sources of light, namely, a

SYMPTOMS FOLLOWING THE CUTANEOUS TUBERCULIN TEST, SUGGESTIVE OF A SPECIFIC GENERAL REACTION

A few months ago when Dr. C. von Pirquet made known to the medical world his tuberculin skin test much was hoped from it in a diagnostic way, and, indeed, much was promised. Simplicity of detail, practical reliability, and freedom from specific general and focal symptoms were claimed for it. There can be no argument as to the first claim made for this test, but much has been said against its reliability as a diagnostic means in tuberculosis. Regardless of what we had expected of it, or of what had been claimed for it in a diagnostic way by Dr. von Pirquet, it has never been determined definitely as yet just what its true diagnostic reliability is, or will prove to be, in the various forms of tuberculosis. However, opinions on its diagnostic value may have been at variance, it seems to have been generally conceded by those who