Clinical pulmonary tuberculosis in an asthmatic patient using a steroid aerosol

A patient who was receiving a steroid aerosol for treatment of asthma developed clinical pulmonary tuberculosis. Continued administration of the steroid aerosol along with antituberculosis chemotherapy did not adversely influence healing of the pulmonary lesion.     

Clinical efficacy of the amplified Mycobacterium tuberculosis direct test for the diagnosis of pulmonary tuberculosis

The amplified Mycobacterium tuberculosis direct test (MTD) is a rapid diagnostic test based on a nucleic acid amplification technique, which can be used directly on processed clinical specimens. We evaluated the clinical utility of the MTD for diagnosing pulmonary tuberculosis by comparing the sensitivity and specificity of the test with acid-fast smear, mycobacterial culture, and clinical evaluation. The study included 844 respiratory tract specimens from 421 patients, which were submitted to the microbiology laboratory of our urban teaching hospital over a 6-mo period. Compared with culture, MTD had a sensitivity of 93.6% and specificity of 97.8%. MTD was more sensitive in detecting pulmonary tuberculosis in patients with previously undiagnosed disease (74.7%) than in those with established disease receiving chemotherapy (29.2%), and in smear-positive (95.5%) than in smear-negative (70.0%) disease. There were two false positive MTD results in patients with nontuberculous mycobacteria, for a specificity in this population of 97.3%. We conclude that MTD, when used in conjunction with routine smear and culture, is a useful rapid diagnostic test for suspected pulmonary tuberculosis.     

Clinical utility of an amplification test based on ligase chain reaction in pulmonary tuberculosis

We evaluated the sensitivity and specificity of a new semiautomated direct amplification test (DAT), the LCx-MTB, for the diagnosis of pulmonary tuberculosis (TB) and assessed its positive predictive value by focusing on patients with high clinical and radiologic suspicion of pulmonary TB. Respiratory tract specimens from 32 consecutive patients with high suspicion of active pulmonary TB (case patients) and from 204 control patients were cultured for Mycobacterium tuberculosis and tested by LCx-MTB. Sensitivity and specificity of LCx-MTB when compared with culture was, respectively, 80 and 98%. Pulmonary TB was confirmed in the 32 case patients without knowledge of the LCx results: 18 patients were smear- and culture-positive for M. tuberculosis, and all gave at least one specimen that was LCx-positive. Eight patients were smear-negative culture-positive, and seven gave at least one LCx-positive specimen. LCx-MTB was negative in all the specimens obtained from six patients with smear- and culture-negative TB. A positive LCx-MTB result in a smear negative specimen was 100% predictive that at least one of the case patients' specimens would yield M. tuberculosis. As a consequence, knowledge of the LCx-MTB results at the time of specimen collection could have hastened the start of the antituberculosis therapy in three (21%) smear-negative case patients and could have avoided unnecessary invasive diagnostic procedures in four (29%). We conclude that the sensitivity of LCx-MTB in detecting M. tuberculosis DNA in respiratory tract specimens is similar to other DATs, that LCx-MTB is a reliable test for confirmation of TB in smear-positive patients and that LCx-MTB could be beneficial as a diagnostic step in smear-negative patients with a high suspicion of pulmonary TB.     

Predictive factors of Mycobacterium tuberculosis infection and pulmonary tuberculosis in prisoners

BACKGROUND: Tuberculosis currently represents a serious problem in prison populations. METHODS: With the aim of studying the predictive factors for, and the prevalence of, Mycobacterium tuberculosis infection and pulmonary tuberculosis in a Spanish prison, all those admitted during 1991 and 1992 were included (N = 1314). The tuberculin skin test, HIV serology, chest X-ray and bacteriological examination of sputum were carried out. Statistical analysis was done by univariant tests, stratified analysis and logistic regression. RESULTS: The prevalence of M. tuberculosis infection was 55.5% (95% confidence interval [CI] 52.5-58.5). An association was found with sex, imprisonment more than once, HIV infection and age. The co-infection rate (tuberculosis plus HIV) was 9.2%. Logistic regression showed a greater risk with age (4.4% per year), time spent in prison and for males. The prevalence of pulmonary tuberculosis was 1.26% and an association was found with M. tuberculosis infection, HIV infection (odds ratio [OR] = 13.7), intravenous drug users (OR = 17.2) and imprisonment more than once (OR = 7.3). Logistic regression showed an association with HIV co-infection (OR = 20.2). CONCLUSIONS: The prevalence of M. tuberculosis infection and pulmonary tuberculosis is high when compared with similar studies. The influence of age, time spent in prison and co-infection with HIV is relevant to recommendations for specific tuberculosis prevention programmes in correctional facilities.     

Differential diagnosis of pulmonary tuberculosis

Differential diagnosis of pulmonary tuberculosis is discussed. Chest X-ray findings of pulmonary tuberculosis may be greatly varied, because tuberculosis may cause three different lesions: an exudative lesion, a proliferative lesion, and a fibrotic lesion, and because it may invade all the structure. Thus, the differential diagnosis of pulmonary tuberculosis includes very many diseases. The most important differential diagnosis of nodule is tuberculoma and lung cancer. The clue of the diagnosis is the feature of the nodule and surrounding structure, such as pleural indentation, or knotching. There is, however, the limitation of the diagnosis by imaging: some tuberculoma may show the identical feature with the pulmonary adenocarcinoma. It is important to gather the pathological or bacteriological evidences by means of suitable procedures.     

The use of sputum induction for establishing a diagnosis in patients with suspected pulmonary tuberculosis in Malawi

SETTING: There has been a marked increase in notified cases of smear-negative pulmonary tuberculosis in Malawi since 1986. One reason for this may be related to the difficulties of getting adequate samples of expectorated sputum from patients. Sputum induction with nebulized hypertonic saline may be a simple way of obtaining a better specimen. OBJECTIVE: To examine the value of sputum induction for detecting cases of smear-positive tuberculosis. DESIGN: Sputum induction was performed on 82 adults presenting to the Queen Elizabeth Central Hospital, Blantyre, Malawi with clinically suspected pulmonary tuberculosis who were expectorated sputum smear-negative or unproductive of sputum. The induced sputum smear was examined for acid-fast bacilli and cultured for mycobacteria. RESULTS: Sputum was successfully induced from 73 of the 82 patients (26 previously smear-negative and 47 previously unproductive). The induced sputum was smear-positive in 18 patients (5 previously smear-negative and 13 unproductive). Cultures were positive for Mycobacterium tuberculosis in the 18 smear-positive patients and a further 12 that had been smear-negative. 94 cases of smear-positive pulmonary tuberculosis were notified during the study period. 18 (19%) were as a result of sputum induction. CONCLUSION: Sputum induction is a useful technique for improving the case detection rate of smear-positive tuberculosis in Malawi.     

The course of pulmonary tuberculosis in adolescents

The authors summarize data obtained at the examinations of 178 tuberculous adolescents aged 15-17. Primary forms of the disease were diagnosed in 52% of new-onset cases, while infiltrative tuberculosis prevailed among secondary forms (48%). The tuberculosis was detected at prophylactic fluorography in 63.5% of the examinees. Late disease diagnosis was mostly consequent to poor symptoms of tuberculosis.     

Technetium-99m-MIBI scintigraphy in pulmonary tuberculosis

The acute phase plasma protein ceruloplasmin (Cp) appears to play some role in host defense. The possibility that production of Cp in extrahepatic sites may also be essential for the activation, effector functions and cytoprotection of immune cells in localized environments has received minimal attention. Here, we have surveyed various types of human and rat immune cells for the presence of Cp mRNA using RT-PCR with primers that span exons 17-19 as an initial step in addressing this possibility. Validated Cp RT-PCR bands were obtained from RNA samples isolated from resting and activated human lymphocytes, CD4 and CD8 T-cells and B-cells. Semiquantitative RT-PCR indicated that Cp mRNA in immune cells is present at about 0.2% the level of Cp mRNA in HepG-2 human liver cell line. Various human cell lines derived from the immune system, rat splenic MNC and purified rat T-lymphocytes also constitutively express Cp gene.     

Hyperendemic pulmonary tuberculosis in a Peruvian shantytown

Even excellent clinical function after ileo-anal pouch construction is associated with a variety of physiological abnormalities. Small bowel intestinal motility is essentially normal but the ileal reservoir serves to markedly suppress the ileal motor response both to progressive distension by intestinal contents and to transmitted myoelectrical complexes. As a result, the healthy pouch can accommodate a large volume of intestinal content before the rising baseline pressure and the appearance of large isolated contraction waves produce an urge to defecate. Evacuation in the normal pouch patient is rapid and highly efficient and is achieved by means of the Valsalva maneuver without any evidence of significant intestinal propulsion. External anal sphincter function is fully preserved but internal anal sphincter function is significantly impaired in the immediate postoperative period. Recovery occurs over the next 6 to 12 months but is often incomplete. Bacterial overgrowth in the pouch and prepouch ileum is almost universal and results in the premature deconjugation of primary bile salts and accumulation of secondary bile salts within the pouch. These produce morphologic changes in the ileal mucosa, and their excretion in pouch effluent gradually depletes the bile salt pool. Anerobic organisms also bind with vitamin B12 and the vitamin B12-intrinsic factor complex, resulting in subtle but measurable reductions in vitamin B12 levels in pouch patients. Finally, anerobic fermentation of mucus and undigested carbohydrate results in excessive quantities of short chain fatty acids within the pouch lumen. The clinical significance of these substances is unclear, but they may have an adverse action on both ileal mucosal and smooth muscle function. In essence, however, the pouch surgeon can maximize the likelihood of good clinical function by constructing a large capacity pouch, by avoiding surgery in patients with clearly deficient anal sphincter mechanisms, and by careful attention to pouch-anal anastomotic technique.