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PubMed1990

Mycobacterial infections in the transplant patient.

Mycobacterial infections in the transplant recipient differ considerably from those occurring in the normal host. The incidences of active disease, atypical disease, and extrapulmonary disease, especially dissemination, are all increased. These differences are reflected clinically in an increased mortality (30%) and a high rate (37%) of infection associated with rejection. The clinician must rely on sparse data to draw conclusions regarding prophylaxis and therapy. In general, cyclosporine-related drug interactions must be constantly monitored. Pyrazinamide should replace rifampin whenever cyclosporine is in use. Prompt recognition of the diverse presentations of mycobacterial disease and definitive diagnosis and treatment will improve outcome.

Humans↗

PubMed1990

Tuberculous meningitis.

Tuberculous meningitis is an uncommon but potentially devastating form of tuberculosis. Current antituberculous drugs are highly effective when treatment is initiated early, before the onset of altered mentation or focal neurologic deficits. Because the clinical outcome depends greatly on the stage at which therapy is initiated, early recognition is of paramount importance. Patients with the meningoencephalitis syndrome and CSF findings of low glucose levels, elevated protein levels, and pleocytosis should be treated immediately if there is evidence of TB elsewhere in the body, or if prompt evaluation fails to establish an alternative diagnosis. Examination of CSF is the best diagnostic approach; with sufficient diligence, serial AFB smears and cultures will usually yield positive results, even days after therapy has been started. The CT scan is an important and highly effective tool for the diagnosis and management of patients with TBM. In a patient with compatible clinical features, the combination of basilar meningeal enhancement and any degree of hydrocephalus is strongly suggestive of the diagnosis of TBM. Serial evaluation by CT scanning is useful for following the course of hydrocephalus and tuberculoma, particularly in reference to the need for, or response to, adjunctive therapy with corticosteroids and surgery. The decision to administer corticosteroids should be based on careful correlation of the clinical and radiographic features of the case. Surgical shunting should be considered early in the patient with hydrocephalus and symptoms of raised intracranial pressure. Tuberculomas are best treated medically, often in conjunction with corticosteroids where cerebral edema is believed to contribute to neurologic decline. The recommended chemotherapy regimen is isoniazid and rifampin in all patients, together with pyrazinamide for the first 2 months.

Arachnoiditis↗

PubMed1990

[Therapeutic modalities in pulmonary tuberculosis].

In 1990, specific antituberculous chemotherapy can cure almost 100 p. cent of patients with pulmonary tuberculosis in France, provided practitioners follow strict therapeutic rules and patients' compliance with treatment is perfect. A single standard treatment is proposed for those patients whose tuberculosis has never previously been treated; it consists of a six months' course of isoniazid (5 mg/kg/day) and rifampicin (10 mg/kg/day); combined with ethambutol (20 mg/kg/day) and pyrazinamide (30 mg/kg/day) during the first two months. This treatment must be administered under regular medical supervision, and it must be prolonged for some time after cure has been obtained. In case of relapse or in some special situations (e.g. pregnant women, HIV positive patients, serofibrinous pleurisy, complex anatomico-clinical forms of the disease) treatment is more difficult, but it should always give favourable results.

Adult↗

PubMed1975

Diuretics, urate excretion and sodium reabsorption: effect of acetazolamide and urinary alkalinization.

The uricosuric properties of acetazolamide were investigated in order to elucidate the relationship between changes in proximal tubular sodium reabsorption and urate excretion in man. Acetazolamide produced a modest uricosuric response which was not suppressible by pyrazinamide. Alkalinization of the urine with sodium bicarbonate elicited an even smaller increment in the urate clearance. If urinary alkalinization does play a role in the uricosuric response to acetazolamide, it probably decreases urate reabsorption within the distal nephron. The present studies, when taken together with previous work, suggest that alterations in proximal tubular sodium and water reabsorption probably do not play an important role in the normal control of urate excretion or in the pathogenesis of hyperuricemic states. Diuretic-induced hyperuricemia occurring during extracellular fluid volume depletion probably results from either diminished tubular secretion of urate, accelerated postsecretory urate reabsorption, or both.

Acetazolamide↗

PubMed1990

[Six-month treatment of pulmonary tuberculosis in children. Review of 11 cases].

Between April 1987 and April 1988, 11 children with the diagnosis of pulmonary tuberculosis, have been treated with a short-course chemotherapy consisting in the administration of isoniacid (10-20 mg/kg, maximum 300 mg), rifampicin (10-20 mg/kg, maximum 600 mg), ethambutol (15-25 mg/kg, maximum 2.5 g) and pyraxinamide (15-30 mg/kg, maximum 2g) daily for two months, followed by the administration of isoniacid and rifampicin at the same dosage, daily, for the next four months. The results were excellent, symptoms cleared in few days and laboratory values and radiographic alterations cleared in few weeks. Only one of the children had to discontinue the therapy for a pyrazinamide intoleration. The advantages of this treatment are evident, short-course suppose greater comfort for the patient, a better observance of the therapy and less cost with a similar efficacy and without a larger incidence of adverse effects. We conclude that this therapy could be in children so useful than in adults, although more studies with larger series are needed.

Antitubercular Agents↗

PubMed1989

[A supplement study on the in vitro activity of sulfadimethoxine on Mycobacterium avium complex--combined effect with other antituberculosis drugs].

Previously the author observed that sulfadimethoxine is most effective among sulfa drugs against Mycobacterium avium complex strains (Tsukamura, M.: Kekkaku 58: 247-250, 1983) and used this drug in the treatment of pulmonary infection caused by M. avium complex (Tsukamura, M.: Kekkaku 59: 33-37, 1983). In the present study, some supplemental observations were carried out on the in vitro activity of this drug. In vitro susceptibility testing of sulfadimethoxine by the use of Ogawa egg medium was influenced by the number of viable bacteria (colony-forming units) used in the susceptibility testing. By the use of small inocula (50 to 100 colony-forming units), minimal inhibitory concentration (MIC) was determined as 0.8 to 3.13 micrograms/ml, whereas, by the use of large inocula, the MIC was determined as 6.25 to 25 micrograms/ml. Furthermore, the prolongation of incubation time resulted in the elevation of the MIC. The finding shows that the activity of this drug is only to delay the growth. Comparing various combinations with low concentrations of other drugs, combinations with p-aminosalicylate, isoniazid and pyrazinamide seemed to be antagonistic, and combinations with the other drugs seemed to be additive. The influence of the inoculation size on the reading of MICs were compared in Mycobacterium tuberculosis and M. avium complex strains. The susceptibility testings to most drugs were influenced by the inoculation size. However, the testings to ethionamide, ethambutol and isoniazid in M. tuberculosis strains were less influenced by the inoculation size. In contrast, the susceptibility testings to ethionamide and isoniazid in M. avium complex strains seemed to be more influenced.(ABSTRACT TRUNCATED AT 250 WORDS)

Antitubercular Agents↗

PubMed1989

Present chemotherapy of tuberculosis.

Significant advances in the treatment of tuberculosis have occurred with the introduction of short-course therapy using isoniazid and rifampin throughout therapy. The addition of pyrazinamide to the initial phase of therapy permits shortening of the total duration of treatment to 6 months for most patients. This regimen is well tolerated, results in rapid disappearance of bacilli from the sputum, and has a low rate of relapse. Ethambutol should be added to this regimen for any patient with an increased chance of having isoniazid resistant disease. Periodic culturing of the sputum from patients with pulmonary tuberculosis is essential for monitoring response to therapy. Patient noncompliance with therapy is the most common cause of treatment failure, and any patient suspected of being noncompliant should receive directly observed therapy. For this purpose, most treatment regimens may be adapted to twice weekly administration.

Adult↗

PubMed1989

New uses for old drugs.

Existing therapies are often tried when new diseases are discovered or new manifestations of known organisms are recognized. This article reviews the successful application of older commonly used antibiotics to several representative "new" or "newly recognized" illnesses. Examples include new uses for the antistaphylococcal agents, penicillin, the tetracyclines, erythromycin, vancomycin, trimethoprim-sulfamethoxazole, pyrazinamide, metronidazole, clindamycin, and others.

Acne Vulgaris↗

PubMed1989

Encephalopathy as a presentation of pediatric AIDS: case report.

Fifty to ninety percent of pediatric AIDS cases are complicated by neurologic dysfunction. We present a case of a 5-year-old black female with AIDS encephalopathy and Mycobacterium avium intracellulare. Her initial presentation was that of neuroencephalopathy with loss of developmental milestones, pyramidal tract signs, and subsequent evidence of cortical atrophy. Her initial CT scan at the time of frank encephalopathy was normal, whereas 18 months into the clinical course of her encephalopathy, her CT scan of the head demonstrated typical ventricular dilatation and severe cortical atrophy consonant with her clinical picture. She subsequently developed Mycobacterium avium intracellulare documented by gastric aspirate culture and other opportunistic infections including Candida esophagitis. Her neuroencephalopathy plateaued with continued evidence of immune dysfunction and mycobacterium by gastric aspirate, despite triple antibiotic therapy with INH, streptomycin, Pyrazinamide with later addition of Rifampin and final substitution of the investigational congener Rifabutin. AIDS encephalopathy and Mycobacterium intracellulare are discussed in terms of their prognosis and therapy, particularly in view of new reports of the application of AZT and immunoglobulin therapy.

AIDS Dementia Complex↗

PubMed1989

[Respiratory tuberculosis in Seine-Saint-Denis. Results of treatment].

A study was carried out in 1984-1986 in Seine-Saint-Denis on the clinical management of tuberculous cases. It was possible to observe in routine practice the nature, duration and results of treatment in 336 adult cases suffering for the first time from respiratory tuberculosis. The recommendations of the French Society of Pneumology were taken as a reference. A minority of patients (22%) were treated entirely at home. The others were admitted to hospital then treated at home (33%) or had a stay in a sanatorium (45%). The mean duration of stay in institutions was five months for those patients staying in a sanatorium. The most common therapeutic regime in the initial phase consisted of rifampicin and isoniazid, with additional ethambutol alone (60%) or ethambutol in combination with pyrazinamide (15%). The mean duration of treatment was 10.5 months, without any difference between those regimes consisting of three or four drugs. At the end of the period of treatment 85% of patients were considered to be cured; 16 patients (or 5%) had died and 18 patients (6%) were lost to follow up before the end of treatment. There were 15 patients (or 4%) who showed no significant change between the beginning and the end of the study.

Adolescent↗

PubMed1989

[Survey of the initial treatment of pulmonary tuberculosis in West Germany. A study by the German Central Committee for the Prevention of Tuberculosis].

1405 adult patients were selected for assessment who had been newly notified in the years 1986/87 with confirmed diagnosis of active progressive pulmonary tuberculosis who required treatment. Of these, 83.5% excreted tubercle bacilli in the sputum; radiographic lung cavities were confirmed in 53.6%, and 859 (61.1%) had a concomitant disease. 1173 patients (94.2%) were hospitalized for initial treatment and only 232 (5.8%) received outpatient treatment. The median duration of the hospital stay was 12 weeks. Isoniazid and rifampicin were prescribed in 96% and 93% patients, respectively, mostly all the time, ethambutol in 75% initially and in 50% throughout, streptomycin in 50% initially. Three or four drug regimens including pyrazinamide in the initial phase were employed in 76% of the patients. Premature discontinuation of therapy for different reasons was noted in 135 patients (9.5%). Of these, treatment was discontinued in 59 (4.2%) due to death; 37 (2.6%) patients died due to tuberculosis. Adverse reactions were observed in 193 patients (13.7%); 0.3% of the patients discontinued chemotherapy because of toxicity. The duration of chemotherapy was between 9 and 12 months in the majority of patients; 30%, however, were treated for more than 12 months. The chemotherapy of 6-months duration was performed only in about 10% of treated patients. Among the patients who completed the treatment, this proved effective in 98%. Although the majority received initially the rational chemotherapy with a three or four drugs regimen, it is concluded that the inpatient stay and the outpatient duration of chemotherapy in the routine clinical practice is too long, therapy control is insufficient.

Adolescent↗

PubMed1989

[A case report of multiple intracranial tuberculoma associated with miliary tuberculosis and review of the literature].

We reported a case of multiple intracranial tuberculoma associated with miliary tuberculosis and reviewed the cases reported as intracranial tuberculoma in the past 11 years. A 41-year-old diabetic man was admitted to our hospital for the treatment of miliary tuberculosis and respiratory insufficiency. On admissIon, he had no neurological deficits except mild consciousness disturbance due to respiratory failure. He developed headache and mental confusion three weeks after the beginning of antituberculous therapy with isoniazid, streptomycin, rifampicin, and ethambutol. Neurological examination revealed that he had progressive right hemiparesis and was in a confusional state. Enhanced CT showed multiple intracranial nodular lesions. During 6 weeks, he had progressive neurological manifestations in spite of his initial antituberculous treatment. He responded well, however, to the chemotherapy with combination of isoniazid, kanamycin, pyrazinamide and ethionamide that were sensitive to tuberculous bacilli separated from his sputum. He became minimally right-hemiparetic by 6 weeks after the change of antituberculous medication. Serial enhanced CT scan proved to be of great value in the diagnosis and follow-up study of intracranial tuberculoma. From 1978 to 1988, there were 72 reported cases of intracranial tuberculoma in Japan; 37 were male, 32 were female and 3 were uncertain because of no detailed document. The age of onset was distributed from 6 month to 81 years in age and 2 peaks were seen in the second decade and fifth to seventh decade. Thirty-three (48%) out of 69 cases had multiple intracranial lesions. A few reports commented that neurological complications tended to appear even if they were under antituberculous therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1989

Tuberculosis and human immunodeficiency virus infection.

Because of the abnormalities of host defenses caused by the human immunodeficiency virus (HIV), persons with HIV infection are vulnerable to tuberculosis. Inferential data from several parts of the country indicate increases in tuberculosis case rates, probably occurring in patients with HIV infection. In a person infected with both HIV and Mycobacterium tuberculosis, attack rates of tuberculosis seem to be very high. In general, the disease tends to occur earlier in the course of HIV infection than other opportunistic processes that serve to define the acquired immunodeficiency syndrome (AIDS), presumably because M tuberculosis is more pathogenic than Pneumocystis carinii or Mycobacterium avium complex, for example. The clinical features of tuberculosis in this patient population seem to vary depending on the stage of the HIV infection. Late in the process, tuberculosis usually has atypical features with chest films showing diffuse infiltration, no cavities, and intrathoracic adenopathy. Tuberculin skin tests commonly are negative. At earlier stages of HIV infection, the clinical findings are similar to those in HIV-seronegative persons. Response to treatment is generally good; however, it is recommended that the standard duration be at least 9 months, using isoniazid and rifampin usually supplemented by pyrazinamide in the first 2 months. The use of isoniazid for preventive therapy is recommended for all HIV-seropositive persons who have tuberculin skin test reactions greater than or equal to 5 minutes. Those implementing infection-control measures for HIV-infected patients who have pulmonary findings should take tuberculosis into account until the disease is excluded. Medical personnel providing care for patients with tuberculosis should use universal blood and body substance precautions because of the possibility of undetected HIV infection in patients with tuberculosis.

Acquired Immunodeficiency Syndrome↗

PubMed1989

Current tuberculosis treatment regimens. Choosing the right one for your patient.

This article has reviewed the use and adverse effects of available first-line and second-line antituberculosis drugs. Treatment regimens consisting of combinations of isoniazid, rifampin, pyrazinamide, streptomycin, and ethambutol will be sufficient in the majority of patients with tuberculosis. The rationale for use of short-course chemotherapy for tuberculosis is based on extensive worldwide experience. The clinical trials that provide the evidence to support the use of ATS/CDC-recommended 6- and 9-month chemotherapeutic regimens have been summarized with attention to the reported relapse rates. Alternative regimens are acceptable in patients who have adverse reactions or resistance to isoniazid and rifampin. Management of patients after starting chemotherapy for tuberculosis requires monitoring for adverse effects, ensuring adherence to therapy and evaluation of response to chemotherapy by documenting bacteriologic conversion. Extrapulmonary tuberculosis responds to the same chemotherapy regimens recommended for pulmonary disease, and corticosteroids are indicated in some forms.

Antibiotics, Antitubercular↗

PubMed1989

Overview and epidemiological assessment of the current global tuberculosis situation: with an emphasis on tuberculosis control in developing countries.

This paper reviews the global epidemiological situation to tuberculosis, with an emphasis on the disappointing tuberculosis control achievements in developing countries over the last three decades. It is concluded tht in low prevalence developed countries it will take at least 35-40 years to eliminate tuberculosis because of endogenous exacerbation in subjects remotely infected. In developing countries most of the estimated 4 million new smear-positive and 4 million new smear-negative and extra-pulmonary cases with some 2-3 million deaths from tuberculosis occur each year. It is evident that a low cure rate is the most important reason for failure of tuberculosis control programmes in poor developing countries. Canetti stressed the urgent need to develop chemotherapeutic methods adapted to the conditions prevailing in developing countries. Based on a 9-year experience in IUATLD-assisted national tuberculosis programmes in 10 developing countries, it became apparent that the basic chemotherapeutic regimen consisting of Thiazina (combined tablet of isoniazid and thiacetazone) for 12 months supplemented by streptomycin for the first 2 months is not suitable for achieving a high cure rate in those countries. A high cure rate (90%) under routine conditions can be achieved with an inexpensive 8-month short-course regimen with a 2-month strictly supervised initial intensive phase with daily isoniazid, rifampicin, pyrazinamide and streptomycin, followed by 6 months of self-administered Thiazina daily. A substantial decrease in the risk of tuberculous infection in developing countries is essential, since we are facing their serious problems concerning tuberculosis with the increasing number of AIDS patients. BCG vaccination alone at least with the present type of vaccine, cannot substantially influence the epidemiological situation. It goes without saying that it should be applies to children to prevent tuberculosis whenever its use is justified for its purpose.

Acquired Immunodeficiency Syndrome↗

PubMed1989

Treatment of extrapulmonary tuberculosis.

The duration of therapy for pulmonary tuberculosis (TB) is now shortened to 6 or 9 months with the use of bactericidal drugs. There are few reports on the results of short course chemotherapy (SCC) in extrapulmonary tuberculosis (EP). It is unlikely that many controlled studies shall be forthcoming in the future because of involvement of many sites with the disease, each of which has special problems. However, available controlled studies and clinical experiences in EP indicate early success. The site of the disease appears to be less important since the bacterial population is much smaller in EP than in TB and is easily amenable to the bactericidal drugs. Present bactericidal drugs (isoniazid [INH], rifampin [RIF], pyrazinamide [PZA]) penetrate well into tissues and attain bactericidal levels to kill the organisms. Our experience with 9-month SCC consisting of INH 300 mg and RIF 600 mg daily for one month, followed by INH 900 mg and RIF 600 mg twice weekly for another 8 months in 478 cases of EP showed overall success in over 95% of those patients who completed therapy over a median follow-up of 42 months. The drugs may be given daily throughout with the same success. Thus, 9-month therapy with INH and RIF is highly effective in EP due to drug sensitive organisms. In TB, the duration may be shortened to 6-months with initial intensive four-drug therapy consisting of INH, RIF, PZA and streptomycin (SM) or ethambutol (EMB) daily for 2 months, followed by INH and RIF daily or twice weekly for another 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1989

Tuberculosis in children and its management.

Children with tuberculosis (TB) in the United States are generally asymptomatic, 60% are under 5 years, 80% belong to racial/ethnic minorities or are foreign born, and most are diagnosed during the investigation of contacts of known cases of pulmonary TB. A presumptive diagnosis of primary TB is made on the basis of a positive tuberculin reaction and a characteristic chest roentgenogram, usually showing hilar adenopathy. Treatment may be with isoniazid (INH) and rifampin (RIF), largely twice weekly for 9 months, or INH, RIF, and pyrazinamide for 2 months followed for 4 months by INH and RIF. Four drugs are needed in cases of infection with drug-resistant organisms or in tuberculous meningitis. All therapy must be closely monitored for toxicity and compliance. In noncompliant families, all medication should be directly administered. This is now possible with short-course therapy, largely twice weekly. Preventive therapy for the tuberculin positive, but disease-free child, is provided more cost-efficiently with 6 months than with 12 months of treatment with INH; less than 6 months is not adequate. All tuberculin reactive children should receive INH for 6 months. More diligence in providing INH prophylaxis to adult reactors will decrease future infectious TB cases, and thus prevent transmission to other children.

Antitubercular Agents↗

PubMed1989

[Short term treatment of infantile pulmonary tuberculosis].

Due to the scarcity of published articles on short-course chemotherapeutic regimens for pediatric pulmonary tuberculosis, the following study has been carried out: Twenty-five children diagnosed of pulmonary tuberculosis were administered a short course therapeutic regimen consisting of three tuberculostatics for the first two month (isoniazid, rifampicin and pyrazinamide) and only two (isoniazid and rifampicin) for the following four months. The results were compared with those obtained from a control group of twenty-five children receiving the "classical" therapy: two drugs (isoniazid and rifampicin) for a nine month period. The statistical analysis did not demonstrate any significant difference related to evolution, duration and complications of the disease, between both groups. Therefore, this short course therapeutic regimen could be accepted for pediatric pulmonary tuberculosis.

Antitubercular Agents↗

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