Tuberculous infections of the head and neck.
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Antitubercular Agents↗
Biomedical subjects
G Schecter
Publications and source records attributed to G Schecter.
Contemporary management of cervical tuberculosis.
Although excisional biopsy has traditionally been required to diagnose cervical tuberculosis (TB), fine needle aspiration biopsy (FNAB) has also been found to be useful. The presentation and management of 47 patients diagnosed with cervical TB between 1984 and 1988 were retrospectively reviewed. Chest x-rays were normal in 58% of the patients, and purified protein derivative (PPD) skin testing was positive in 96%. When FNAB was used, TB could be suspected in 83% of cases and definitively established in 62%. Open biopsy correctly diagnosed cervical TB in all masses excised. Medical therapy alone resulted in resolution of disease in 94% of patients diagnosed by FNAB, and subsequent excisional biopsy was necessary in only one patient. The results suggest that FNAB is a useful initial procedure in the diagnosis of cervical TB. Excisional biopsy should be reserved for cases where no diagnosis by FNAB can be made, or for persistent cervical disease despite full-course antituberculous chemotherapy.
Adult↗
Stability of positive tuberculin tests: are boosted reactions valid?
To determine the stability and presumed significance of tuberculin skin tests, we followed a cohort of 380 tuberculin-positive patients living in chronic care facilities. Each patient had a positive reaction (greater than or equal to 10 mm induration to 5 tuberculin units of purified protein derivative) to one of three sequential baseline tuberculin tests. One year after the initial series, each patient had a single repeat skin test. Reversion to a negative test occurred in 98 (26%) of the 380 patients. Decreases in induration of 6 mm or more occurred in 88 (90%) of the reverters. Initially positive tests were more likely (p less than 0.001) to remain stable than tests that were "boosted" to positive reactions on the second or third initial administration. Stable responses were found in 96% of those whose tests had greater than or equal to 15 mm induration compared with 61% of those with reactions of 10 to 14 mm induration. Increasing age also was associated with a high rate of reversion. The instability of boosted tuberculin reactions brings into question the clinical significance of these tests. We propose limiting tuberculin testing to two sequential tests.
Aged↗
Why tuberculosis is not prevented.
Because of the effectiveness of isoniazid in treating tuberculosis infection, progression to tuberculosis should be largely preventable. Thus, each case of tuberculosis that occurs may be viewed as a "failure" of the prevention system. We studied the reasons for these "failures" at three centers in different geographic areas in the United States. Two hundred seventy-nine patients with bacteriologically confirmed tuberculosis were evaluated by means of a questionnaire. Our results suggest three main reasons for these missed opportunities of tuberculosis prevention. (1) Patients are out of the health care system until they develop tuberculosis. (2) Patients are in the system but are either not screened for tuberculous infection or, if screened, are not offered preventive therapy when it is appropriate. (3) Because of false negative skin test results, screening may be ineffective at the time it is applied. Advances in tuberculosis prevention will require attention to these areas.
Adolescent↗
Presumptive diagnosis and treatment of pulmonary tuberculosis based on radiographic findings.
We analyzed the outcome of therapy for 139 patients who were treated for a presumptive diagnosis of pulmonary tuberculosis based on radiographic abnormalities. Patients who had acid-fast bacilli seen on sputum smears and patients who had received adequate therapy for tuberculosis in the past were excluded from the analysis. Accuracy of the diagnosis was determined by comparison of clinical and radiographic findings after 3 months of isoniazid, rifampin, and ethambutol, as well as the results of sputum cultures. Of 139 patients started on therapy presumptively, 66 (48%) were determined to have current tuberculosis (16 had positive cultures, 43 because of improvement in their chest films, and 7 because of clinical improvement). Adverse reactions requiring change of therapy occurred in six of 72 (8.3%) patients determined to have inactive tuberculosis. One patient had both tuberculosis and carcinoma found at bronchoscopy after 3 months of therapy. For purposes of comparison, chest radiographs of 59 patients documented by culture to have current tuberculosis were reviewed. Of these, 45 (70%) were improved at 3 months. Presumptive therapy is of benefit in that it stops progression of the disease at an early stage and decreases the potential for spread of tuberculous infection. In addition, such therapy coupled with systematic reevaluation of patients substantiates the diagnosis or indicates that further evaluation is needed. These benefits must be weighed against the adverse reactions and costs of overtreating patients with inactive disease. Determining the appropriateness of presumptive therapy must be based on local factors including prevalence of tuberculosis and available resources.
Antitubercular Agents↗
Hand deformity and sensory loss due to Hansen's disease in American Samoa.
We report the prevalence of sensory loss and hand deformity in 63 patients with Hansen's disease in American Samoa. Open ulceration, the most common deformity, was present in 41% of patients; sensory abnormalities were present in 54% and were bilateral in 65%. The presence of abnormal sensibility correlated with a high percentage of other deformities. Hand abnormalities were most prevalent in lepromatous patients and were related to a prolonged duration of disease. Nerve thickening did not appear to be a helpful clinical finding to assess the degree of sensory loss.
Adolescent↗
Evaluation of a third sequential tuberculin skin test in a chronic care population.
To evaluate factors that might influence the accuracy of tuberculin tests in identifying elderly persons recently infected with Mycobacterium tuberculosis, we performed as many as 3 sequential administrations of 5 tuberculin units of purified protein derivative in 1,726 persons residing in chronic care facilities. Significant reactions (greater than or equal to 10 mm of induration) to 1 of 3 tests were found in 702 (40.7%) persons. Of these, 68% were found with Test 1, 22.5% with Test 2, and 9.5% with Test 3. Of 1,146 persons with nonsignificant reactions to Test 1, 13.8% had significant reactions on Test 2, and of 769 persons with nonsignificant reactions to Tests 1 and 2, 8.7% had significant reactions on Test 3. Males, nonwhites, and persons between 50 and 79 yr of age had a greater proportion of significant reactions for each of the first 2 tests but not for the third test. These data indicate that continued boosting of the tuberculin reaction occurs in a substantial number of persons who receive a third sequential test. Marked increases in the size of reactions caused by boosting may explain high apparent conversion rates found in facilities where the third test is delayed for one year.
Adolescent↗
Conversion and reversion of tuberculin reactions in nursing home residents.
To assess the consistency of tuberculin reactions over time, we performed tuberculin tests in a cohort of 495 nursing home residents in both 1982 and 1985. Significant reactions (greater than or equal to 10 mm of induration to 5 TU PPD) were found in 258 (52.1%) and 209 (42.2%) residents in 1982 and 1985, respectively. Males, nonwhites, and persons younger than 80 yr of age had a greater proportion of significant reactions (all, p less than 0.01). Of the 237 persons with nonsignificant reactions in 1982, 15 (6.3%) had a significant reaction in 1985. None of the 15 converters was found to have current tuberculosis. Tuberculin reversions occurred in 64 (24.8%) of 258 persons who had significant reactions in 1982. Of the patients who had a significant reaction only after boosting in 1982, 16 of 21 (76.2%) had nonsignificant reactions with up to 3 tests in 1985. Tuberculin reactions in nursing home residents may vary over time and may not be recalled by boosting, boosted reactions may be transient, and apparent conversions may be due to an extension of the booster phenomenon.
Age Factors↗
Identification of Mycobacterium tuberculosis antigens in Seibert fractions by immunoblotting.
Seibert fractions prepared from Mycobacterium tuberculosis culture filtrates were evaluated by immunoblotting with a serum pool from patients with active pulmonary tuberculosis. Antibody activity was observed primarily with antigens in the polysaccharide II and A protein fractions; these fractions were further evaluated by immunoblotting with sera from individual patients with tuberculosis, from individuals without tuberculosis and positive for the purified protein derivative antigen skin test, and from individuals negative for the purified protein derivative antigen skin test. The antigens identified in the protein A fraction, a 32,000-molecular-weight antigen and a heterogeneous high-molecular-weight antigen, reacted with antibody found in sera from all patients with tuberculosis and with antibody from over 25% of the control individuals. A 10,000-molecular-weight antigen, a 30,000- to 44,000-molecular-weight antigen, and a heterogeneous high-molecular-weight antigen were observed in the polysaccharide II fraction; these antigens reacted with serum antibody from 70% or more of the patients with tuberculosis and with antibody from 20 to 70% of the control individuals. One of the antigens, with a molecular weight ranging from 17,000 to 28,000 in the polysaccharide II fraction, reacted with antibody in 64% of the sera from patients with tuberculosis but with only 1 of 15 control normal sera. This antigen may elicit an antibody response specifically associated with tuberculosis.
Antigens, Bacterial↗
Tropical pyomyositis of the iliacus muscle in American Samoa.
Ten cases of pyomyositis of the iliacus muscle are described in otherwise healthy young Samoans. The correct diagnosis was frequently delayed. Staphylococcus aureus was the most common pathogen isolated from drained abscesses. Preference for hip flexion was seen in six patients, and localized pain or induration at the anterior superior iliac spine were found in seven patients. These clues may help expedite a correct diagnosis.
Adolescent↗
Necrotizing fasciitis of the upper extremity.
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Adolescent↗
Bacillus cereus septicemia in a drug addict: case report.
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Adult↗
Intestinal parasites in Southeast Asian refugees.
A survey of intestinal parasitism in 6,241 Southeast Asian refugees (3,576 males and 2,665 females) indicated that 32.9 percent of the refugees had one or more intestinal parasites. A total of 1,178 (57.3 percent) males and 878 (42.7 percent) females harbored the parasites, with helminths representing the most frequent isolate. Intestinal parasitic infections may be considered minimal public health threats in the United States because of effective hygienic practices and sanitation facilities. However, it is important to emphasize that the attack rate also will be influenced by continued health education, job activities, and diagnosis and treatment of the refugees for these parasites.
Adolescent↗