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PubMed2005

Hepatic tuberculomas. A case report.

BACKGROUND: The liver is often involved secondarily by sytemic/extrahepatic vascular, metabolic, infectious, granulomatous, and malignant processes. CASE REPORT: A 57-year old woman was admitted because of fatigue, malaise, night sweating and right upper abdominal quadrant pain. Physical findings revealed pale skin and mucosae, and hepatomegaly. Laboratory data showed normocytic, normochromic anemia and marked inflammatory syndrome. Real-time ultrasonography revealed one hypo-echogenic nodule, 25 mm in size, in the segment II of the liver, and three hypoechogenic nodules, 11-25 mm in diameter, in segments III and IV. Enlarged lymph nodes, 20-50 mm, were observed in the region of the pancreatic head. Histo-pathological examination of the liver and peritoneum biopsies evidenced granulomas with caseous necrosis and multinuclear Langhans' giant cells, indicating hepatic and peritoneal tuberculosis. The tuberculostatic chemotherapy (isoniazid 300 mg/24h; rifampycin 600 mg/24h and pyrazinamid 2000 mg/24h) was applied for 12 months. The patient responded well to the treatment, followed-up for 6-12 months. CONCLUSION: In the differential diagnosis of focal liver lesions, pseudotumoral hepatic tuberculomas must be considered.

Antitubercular Agents↗

PubMedDate not supplied

Abdominal tuberculosis--a study of 25 cases.

Abdominal tuberculosis is one of the common extra pulmonary tubercular infections. Its clinical presentation is protean and it has diagnostic dilemma, as most of the investigations are non-specific and less sensitive. Therefore this study was undertaken to define the most suggestive clinical features of abdominal tuberculosis, to find out the efficacy of most commonly available investigations and also to evaluate the response of abdominal tuberculosis to conventional antitubercular therapy. Twenty five cases of either sex were studied in department of gastroenterology in BSMMU (earlier IPGMR), Dhaka from January 2001 to June 2003. All patients were clinically evaluated and were investigated by available tests. Eighteen patients were diagnosed by investigations (One by detecting AFB, 9 with caseating granuloma in biopsy specimen and 8 with suggestive radiological findings). Diagnosis of 7 patients were made from the common clinical features (fever, weight loss, altered bowel habit, abdominal pain and distension, positive non-specific findings and from response by antitubercular therapy. All patients received conventional 9 month anti-tubercular treatment with Rifampicin, Isoniazide and Pyrazinamide and were followed up clinically during and one year after completion of treatment. All patients were improved with minimum side effects of drug. Therefore, it is observed that a representative tissue biopsy (when approachable) and radiological findings are good method of diagnosis of abdominal tuberculosis. Strongly suggestive clinical features with positive non specific investigation findings are also an indication for anti tubercular treatment in all endemic countries like Nepal, Bangladesh and India. Treatment of abdominal tuberculosis is in no way different from that of other conventional anti-TB therapy.

Adult↗

PubMed2005

Deteriorated tuberculosis drugs and management system problems in lower southern Thailand.

SETTINGS: Three institutes, 11 hospitals and 38 community hospitals in southern Thailand. OBJECTIVES: To assess the quality of tuberculosis (TB) drugs used in TB treatment facilities in southern Thailand and their TB drug management systems. DESIGN: Cross-sectional study utilising interviews, document review, inspection of drug storage, visual examination of TB drugs, and laboratory analysis of samples of isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA) and ethambutol (EMB). RESULTS: No stock-out of TB drugs was found at any level. Thirteen (25%) hospitals/institutes removed coated EMB tablets from their foil packages for daily dose packing. Eleven (21%) hospitals/institutes bisected 400 mg coated EMB tablets before dispensing as a non-available 200 mg tablet. On the day of inspection grossly deteriorated EMB was observed in 44% of hospitals/institutes. All samples, except 14% of EMB, passed content assay tests. All INH and EMB samples passed the dissolution tests, but 62% of RMP samples and 26% of PZA samples failed. CONCLUSIONS: Sub-standard deteriorated TB drugs are a serious problem for TB control. TB drugs examined in the study area were not managed properly. Education on TB drug packaging and storage, and non-destructive systems in TB drug distribution, storage, inventory control, quality assurance and supervision are essential interventions.

Antitubercular Agents↗

PubMed2005

[Tuberculosis due to multidrug resistant Mycobacterium tuberculosis Beijing genotype identified by DNA fingerprinting: the first case identified in Hungary].

In a 28 years old Mongolian woman in whom pulmonary tuberculosis was diagnosed a poly- and multidrug (isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin) resistant Mycobacterium tuberculosis was isolated from sputum in 2002. Since the patient was from a country with high tuberculosis incidence it was conceivable that she had been infected by a strain with primary resistance in Mongolia. In order to confirm the origin of the strain an IS6110-based DNA fingerprint test was performed on the isolate. The assay revealed that the isolated M. tuberculosis strain belonged to the so-called Beijing family which was never detected in Hungary before.

Adult↗

PubMedDate not supplied

[Fungal and tuberculous peritonitis in patients on peritoneal dialysis: characteristics, therapy and outcome].

Peritonitis is a serious clinical complication in patients with terminal chronic renal failure (CRF) on peritoneal dialysis (PD). The incidence of peritonitis varies from center to center, and during the last decade it occurs approximately in one patient during 24-60 therapeutical months, which is the result of good education of patients, but also of employing the new systems for PD. Fungi as well as Mycobacterium tuberculosis are rare causes of peritonitis in patients on PD therapy. The incidence of peritonitis with these two causes varies: 1-15% and 0.7-3%, respectively. The most frequent causes of fungal peritonitis are yeasts (Candida species 70-100%, with most frequent C. parapsilosis), but rarely filamentous fungi such as: Aspergillus, Paecilomyces, Penicillium, Zygomycetes, etc. Gram stains are helpful for diagnosis, as well as the culture of peritoneal effluent. There are various kinds of treatment protocols: withdrawal of peritoneal catheters and application of antimicotic drugs such as amphotericin B (which has recently been abandoned), oral flucytosine, oral or intraperitoneal fluconazole (imidazol) or itraconazol in the case of resistance. Although clinical signs disappear, most of these patients cannot continue with peritoneal dialysis therapy because of peritoneal adhesions, abscesses, fibrosis or progressive sclerosing peritonitis. Percentage of death is 12-44%. The incidence of tuberculosis is higher in patients with CRF in comparison with the entire population, and tuberculous peritonitis can develop in patients who had infection with Mycobacterium tuberculosis which was not treated adequately. Diagnosis can be made by detecting mycobacterium in peritoneal effluent (cultivation for 6 weeks) and/or acidophilic bacillus or typical granuloma in peritoneal biopsy. Therapy consists of removing the peritoneal catheter and long lasting antituberculotic therapy: izoniazid, rifampicin, pyrazinamide, pyridoxin (6-12 months). Streptomycin and ethambutol are to be avoided because of side effects in these patients. In spite of therapy, possible consequences are: ultrafiltration loss, obstruction of intestines because of adhesions, abdominal abscesses, fistulae, ending PD therapy, and even death.

Humans↗

PubMedDate not supplied

[Pellagra].

Pellagra is a systemic disturbance caused by a cellular deficiency of niacin, resulting from inadequate dietary nicotinic acid and/or its precursors, the essential amino-acid tryptophan. In Europe and North America cases of pellagra are rarely encountered, but in some developing countries this disease is frequent, and is the most frequent clinical feature of nutritional deficiency of adult. The principal causes of pellagra are: nutritional niacin deficiency; chronic alcoholism; gastro-intestinal malabsorption; some medications (5-fluoro-uracil, isoniazid, pyrazinamide ehtionamide, 6-mercaptopurine, hydantoins, phenobarbital and chloramphenicol). The diagnosis of pellagra is based on the patient's history and the presence of "3 D syndrome": dermatitis, diarrhea, and dementia. The dermatitis caused by pellagra is a bilaterally symmetrical erythema at the sites of solar exposure. The dermatitis begins in the form of an erythema with acute or intermittent onset gradually changing to an exsudative eruption on the dorsa of the hand, face, neck, and chest with pruritus and burning. Acute dermatitis of pellagra resembles sunburn in the first stages, sometimes with vesicles and bullae. The gastro-intestinal disturbances are: anorexia, nausea, epigastric discomfort and chronic or recurrent diarrhea. Anorexia and malabsorbative diarrhea lead to a state of malnutrition and cachexia. Stools are typically watery, but occasionally can be bloody and mucoid. Neuropsychologic manifestation included photophobia, asthenia, depression, hallucinations, confusions, memory loss and psychosis. As pellagra advances, patient become disoriented, confused and delirious; then stuporous and finally die. Pathological changes in the skin is non-specific, there are no chemical tests available to definitively diagnose pellagra. However low levels of urinary excretion of N-methylnicotinamide and pyridone indicates niacin deficiency. The treatment of pellagra consisted to exogenous administration of niacin or nicotinamide cures. Topical management of skin lesions with emollients may reduce discomfort. The therapy should also include other B vitamins, zinc and magnesium as well as a diet rich in calories. The prevention is based in the nutritional education (food sources of niacin: eggs, bran, peanuts, meat, poultry, fish, red meat, legumes and seeds), and the eviction of alcohol.

Dementia↗

PubMed2005

Miliary tuberculosis involving the central nervous system.

A woman with chronic systemic lupus erythematosus (SLE) was treated with prednisone, and developed an acute febrile neuroinfection. The magnetic resonance images (MRI) showed miliary micronodular lesions distributed diffusely within the central nervous system and lungs. Lumbar puncture showed pleocytosis with predominance of polymorphonuclear leukocytes, hypoglycorrhachia, elevated proteins and smears positive for acid-fast bacilli. The diagnosis was confirmed by culture of Mycobacterium tuberculosis in the cerebrospinal fluid and bronchial biopsy tissue. She was treated with ethambutol, rifampin, isoniazid and pyrazinamide. MRI taken one month later showed significant improvement, but leg weakness persisted. Epidemiologic research showed her uncle with cavitary tuberculosis as the source of infection. He was also treated with combined antituberculous chemotherapy.

Adult↗

PubMed2005

[Frontier of mycobacterium research--host vs. mycobacterium].

During the past decade, we have observed advance in tuberculosis research including novel vaccines, innate immunity (TLR), SNIP analysis and molecular mechanism of drug resistance. Worldwide genome project enabled the whole genome sequence of host resistant against tuberculosis as well as the whole genome sequence of M. tuberculosis H37Rv. DNA technology has also provided a great impact on the development of novel vaccine against TB. In this symposium, we have invited leading researchers in the field of the frontier study of Mycobacterium research in order to provide general overview of the cutting edge of frontier research. Molecular mechanism of drug resistance of M. tuberculosis has been clarified. On the other hand, molecular mechanism of host-defence (insusceptibility of host) against M. tuberculosis has not yet elucidated. Dr. Taro Shirakawa (Kyoto University) reviewed the susceptibility genes of host in TB infection and presented candidate genes associated with multi-drug resistant tuberculosis. Dr. Naoto Keicho (International Medical Center of Japan) tried to identify host genetic factors involved in susceptibility to pulmonary Mycobacterium avium complex (MAC) infection by candidate gene approach and genome-wide approach. In Japan, Dr. Masaji Okada (National Hospital Organization Kinki-Chuo Chest Medical Center) has been engaged actively in the development of new tuberculosis vaccines (HVJ-liposome/Hsp65 DNA + IL-12 DNA vaccine and recombinant 72f BCG vaccine). He showed basic strategy for construction of new candidate vaccines and also showed significant efficacy on the protection of tuberculosis infection using cynomolgus monkeys, which are very similar to human tuberculosis. Dr. Hatsumi Taniguchi (University of Occupational and Environmental Health) presented that M. tuberculosis mIHF and the neighbor genes went into a dormacy-like state of M. smegmatis in J774 macrophage cells. This study might provide a weapon for elucidating the mechanism of dormacy of M. tuberculosis and the development of novel therapy. Dr. Chiyoji Abe (Nippon Becton Dickinson Co.) reviewed the molecular basis of the resistance to anti-tuberculosis drugs. Most cases of resistance are related to simple nucleotide substitutions rather than to acquisition of new elements. Dr. Kiyoshi Takeda (Kyushu University) showed interesting finding. He analyzed whether Toll-like receptor (TLR)-mediated activation of innate immunity in host defense against mycobacterial infection. MyD88/TRIF double defi-indicating that innate immunity is involved in anti-mycobacterial infection. (1) SNP (single nucleotide polymorphism) analysis in association with Mycobacterium tuberculosis: Taro SHIRAKAWA (Department of Health Promotion & Human Behavior, Kyoto University Medical School, and RIKEN SRC Center) Candidate gene approach was made on 18 SNPs in 11 genes in association with M. tuberculosis. Patients with multi-drug resistance against M. tuberculosis are also subjected. SNPs in NRAMP1 gene were associated with the disease, and drug resistance, its mechanisms remain unknown. (2) Search for genes susceptible to pulmonary Mycobacterium avium complex infection: Naoto KEICHO (Department of Respiratory Diseases, Research Institute, International Medical Center of Japan) Interaction among pathogens and host factors is important for development of infectious diseases. We are trying to identify host genetic factors involved in susceptibility to nonimmunocompromized pulmonary Mycobacterium avium complex (MAC) infection by candidate gene approach and genome-wide approach. Elucidation of functional significance of susceptibility gene polymorphisms will lead to a new strategy for control and prevention of the disease. (3) T cell immunity against Tuberculosis in host and the establishment of novel vaccine: Masaji OKADA (Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center) T cell (CTL, Th1) immunity including granulysin play an important role in host defense against tuberculosis (TB) in human. Patients with TB or Multi-drug resistant TB showed suppression of all these immunities. HVJ-liposome/Hsp65 DNA + IL-12 DNA vaccination was 100 fold more efficient than BCG on the elimination of Mycobacterium tuberculosis (M.TB) in the BALB/c mice. Cytotoxic T cells activity against M. TB was augmented. By using these new vaccines (Hsp 65 DNA + IL-12 DNA, recombinant 72f BCG) and the cynomolgus monkey models which are very similar to human tuberculosis, the prophylactic effect of vaccines was observed. Thus, these novel vaccines should provide a useful tool for the prevention of human TB infection. (4) Mycobacterium tuberculosis mIHF and the neighbor genes go into a dormancy-like state of M. smegmatis J15CS in J774 cells: Hatsumi TANIGUCHI (Department of Microbiology, School of Medicine, University of Occupational and Environmental Health) Mycobacterium smegmatis J15CS transformants harboring the mIHF gene or the mIHF-gmk-Rv1390 genes showed no difference in in vitro growth and acid-fastness. However, transformants harboring mIHF-gmk-Rv1390 formed short-rod cell morphology and decreased acid-fastness in the mouse macrophage-like cell line J774 compared to those of the other transformants, and the nuclei of the infected J774 cells also changed. Nevertheless, the colony forming units were similar. These indicate that mIHF and the neighbor genes of M. tuberculosis might regulate a growth of mycobacteria in macrophages. (5) Molecular basis of the resistance to anti-tuberculosis drugs: Chiyoji ABE (Nippon Becton Dickinson Company, Ltd.) Considerable progress has been made toward understanding the molecular basis of the resistance to anti-tuberculosis drugs. Most cases of resistance are related usually to simple nucleotide substitutions rather than to acquisition of new elements. Multi-drug resistant isolates of Mycobacterium tuberculosis arise a consequence of sequential accumulation of mutation conferring resistance to single therapeutic agents. The basis of resistance is not able to be explained yet in a substantial percentage of strains for other anti-tuberculosis drugs than rifampin and pyrazinamide. Further studies are required to fully understand the molecular mechanisms of resistance. (6) Toll-like receptors in anti-mycobacterial immune responses: Kiyoshi TAKEDA (Department of Molecular Genetics, Medical Institute of Bioregulation, Kyushu University) Toll-like receptors (TLRs) play an essential role in the recognition of specific patterns of microbial components. TLRs mediate activation of innate immunity and further development of antigen-specific adaptive immunity. In TLR signaling pathways, Toll/IL-1 receptor (TIR) domain-containing adaptors, such as MyD88, TIRAP, TRIF, and TRAM, have been shown to play pivotal roles. Thus, the molecular mechanisms for TLR-mediated activation of innate immunity have been largely understood. We analyzed whether TLR-mediated activation of innate immunity is involved in host defense against mycobacterial infection. MyD88/TRIF double deficient mice, in which TLR-dependent activation of innate immunity is abolished, showed high sensitivity to mycobacterial infection, indicating that innate immunity is critically involved in anti-mycobacterial responses.

Antitubercular Agents↗

PubMed2005

Pulmonary disease empirically treated as tuberculosis-a retrospective study of 107 cases.

Pulmonary disease is sometimes treated empirically as tuberculosis (TB) in the absence of microbial confirmation if the clinical suspicion of active TB is high. In a country of relatively high TB and low HIV burden, we retrospectively studied 107 patients (69.2% male; mean age (SD): 45 (17) years) who received empirical anti-TB treatment for intrapulmonary opacities or pleural effusions suspected of active TB in our hospitals between 1998 and 2002. The diagnosis of definite or probable 'smear-negative' pulmonary TB was made based on treatment outcome at two months with rifampicin, isoniazid, pyrazinamide and ethambutol (or streptomycin). At this end-point, 81 patients (84.4%) had both clinical and radiological improvement (definite cases), 12 (12.5%) had clinical improvement alone and 3 (3.1%) had radiological improvement alone (probable cases). Confirmation of acid-fast bacilli was subsequently obtained in 12 patients (all definite cases) from culture of initial pulmonary specimens. Eleven patients (10.5%) were diagnosed as 'non-TB' based on absence of both clinical and radiological improvement or discovery of another cause for the pulmonary condition at or before this two-month study end-point. In the 'non-TB' group, 2 had carcinoma, 2 had HIV-related pulmonary diseases, 1 had bronchiectasis, while in 6 causes were indeterminate. Six (6.3%) and 3 (27.3%) patients reported adverse effects from anti-TB drugs from the 'TB' and 'non-TB' groups respectively. Our findings suggest that empirical anti-TB treatment is an acceptable practice if clinical suspicion is high in patients coming in our region.

Adult↗

PubMed2005

[Current situation of contacts examination and chemoprophylaxis for persons exposed to multi-drug resistant tuberculosis in ordinance-designated cities in Japan].

PURPOSE: To evaluate the current situation of contacts examination and chemoprophylaxis for those who were exposed to multi-drug resistant tuberculosis (MDR-TB) in Japan. OBJECT AND METHOD: The questionnaire survey was conducted about the MDR-TB patients and their contacts examination enforced in the ordinance-designated cities in Japan from 1998 to 2002. RESULT: Nine cities out of total 13 ordinance-designated cities replied to the questionnaire (69.2%). The cases newly diagnosed as MDR-pulmonary tuberculosis were 189 cases from 1998 to 2002. Out of 189 cases, 34 MDR pulmonary tuberculosis patients were the source of MDR-TB infection. Among 659 individuals who were exposed to 34 MDR-TB, 58 persons (8.8%) were diagnosed as the contacts who were infected with MDR-TB. Out of 58 persons, 41 had chemoprophylaxis; 18 with isoniazid (INH), 3 with Ethionamide (TH), 2 with INH + Rifampin (RFP) + Ethambutol (EB), and each one with EB + Pyrazinamide (PZA) + TH, PZA + TH, PZA + Levofloxacin, PZA + EB. In 6 persons, INH was changed to other medicines, and 8 persons were treated with unknown prescription. Thirteen contacts developed MDR-TB, and out of them, 9 cases had several problems when they developed MDR-TB. Those problems were the delay in detection, infection from hospitalization refused cases, infection at the time of bacteriological relapse, and no use of chemoprophylaxis. CONCLUSION: MDR-TB bacilli produce the tuberculosis infection similarly as the sensitive tubercle bacilli, and it is necessary to re-examine the action plan of contacts examination including chemoprophylaxis.

Adolescent↗

PubMed2005

Role of isoniazid prophylaxis for prevention of tuberculosis in haemopoietic stem cell transplant recipients.

OBJECTIVE: To evaluate the role of isoniazid prophylaxis in prevention of tuberculosis among allogeneic stem cell transplant recipients. METHODS: This study was conducted at Armed Forces Bone Marrow Transplant Center Rawalpindi, Pakistan from July 2001 to October 2003. Patients suffering from various haematological disorders undergoing allogeneic stem cell transplantation were included in the study. The demographic information, primary diagnoses and relevant investigations were recorded. Patients had negative tuberculin skin tests and chest X-Ray at pre-transplant assessment. First 25 patients (group I) did not receive isoniazid prophylaxis while the next 25 (group II) were given isoniazid in a dose of 5-10 mg/kg (maximum 300 mg/day). Isoniazid prophylaxis was started on day-1 and continued for 6 months post transplant. The patients developing tuberculosis were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide during first 3 months followed by 2 drugs for a total duration of 12 months. Minimum follow up in group I and II was 783 and 403 days respectively. RESULTS: There was significant difference (p < 0.001) in frequency of tuberculosis between two groups. In group I, four patients developed Tuberculosis (frequency 16%) whereas none of the patients in group II had the disease. Out of these four cases 3 had extrapulmonary disease. One patient died two weeks after the start of anti tuberculosis treatment while others successfully completed the treatment. CONCLUSION: Tuberculosis in stem cell transplant recipients is an important opportunistic infection especially in areas of high disease prevalence like Pakistan. Isoniazid prophylaxis for 6 months is effective in preventing tuberculosis among this class of patients.

Adolescent↗

PubMed1992

Prevention and control of tuberculosis in migrant farm workers. Recommendations of the Advisory Council for the Elimination of Tuberculosis.

Farm workers are approximately six times more likely to develop tuberculosis (TB) than the general population of employed adults. These recommendations are presented to assist health-care providers serving migrant and seasonal farm workers. The following services, listed by priority, that should be available for migrant and seasonal farm workers and their family members are: a) detection and diagnosis of those with current symptoms of active TB; b) appropriate treatment and monitoring for those who have current disease; c) contact investigation and appropriate preventive therapy for those exposed to infectious persons; d) screening and appropriate preventive therapy for asymptomatically infected workers who may be immunosuppressed, such as those with human immunodeficiency virus (HIV) infection; e) screening and appropriate preventive therapy for children of migrant and seasonal farm workers; and f) widespread tuberculin test screening for workers and families with preventive therapy prescribed, as appropriate. Health-care providers should immediately perform appropriate diagnostic studies for persons with a productive, prolonged cough, or other symptoms suggestive of tuberculosis. Health departments should be immediately notified when TB is suspected or diagnosed to enable examination of contacts and initiation of other health department diagnostic, preventive, or patient management services. Workers and family members with uncomplicated pulmonary TB should be treated with a regimen that includes isoniazid, rifampin, pyrazinamide, and ethambutol (or streptomycin). Drug-resistant TB is an important consideration since it requires altered treatment regimes and because higher rates of resistance have been found in ethnic and social groups comprising much of the migrant farm worker-force. Patients should be monitored carefully for compliance, treatment response, and toxicity. Ideally, patients should be placed on directly observed therapy given by a well-trained, outreach worker from the same cultural/language background as the patients.

Adult↗

PubMed2005

Management of active tuberculosis.

Although the overall incidence of tuberculosis has been declining in the United States, it remains an important public health concern, particularly among immigrants, homeless persons, and persons infected with human immunodeficiency virus. Patients who present with symptoms of active tuberculosis (e.g., cough, weight loss, or malaise with known exposure to the disease) should be evaluated. Three induced sputum samples for acid-fast bacillus smear and culture should be obtained from patients with findings of tuberculosis or suspicion for active disease. If the patient has manifestations of extrapulmonary tuberculosis, smears and cultures should be obtained from these sites. Most patients with active tuberculosis should be treated initially with isoniazid, rifampin, pyrazinamide, and ethambutol for eight weeks, followed by 18 weeks of treatment with isoniazid and rifampin if needed. Repeat cultures should be performed after the initial eight-week treatment.

Algorithms↗

PubMed1992

Influence of prior information of drug toxicity on patient compliance.

Sixty patients with pulmonary tuberculosis, who had not received any chemotherapy in the past, were divided into two groups. All the patients were put on isoniazid, rifampicin and pyrazinamide for 8 weeks followed by isoniazid and rifampicin for another 18 weeks. Group A patients were informed of the likely occurrence of anorexia and/or vomiting but Group B patients were not. Routine and default retrieval home visits were given to ensure maximal drug compliance. Drug toxicity related early defaults were significantly less common in Group A patients (1 of 30) as compared to Group B (6 of 30).

Adult↗

PubMed2005

[A case of tuberculous peritonitis].

We report a case of a 73-year-old man with tuberculous peritonitis. He had sought treatment at a clinic near his house for his fever and abdominal distension. Massive ascites were found and he was referred to our hospital. The endoscopy and abdominal CT scan performed on admission revealed no abnormal findings except the massive ascites. Mycobacterium tuberculosis (MT) DNA was detected in the ascitic fluid by polymerase chain reaction (PCR) and ascitic adenosine deaminase (ADA) activity was 127.6 U/l. He was diagnosed as tuberculous peritonitis and transferred to the Department of Respiratory Medicine. A chest CT scan showed predominant right pleural effusion with no other abnormal findings in bilateral lung fields. His sputum were all positive by smear acid-fast staining, MT DNA and culture on MT. His final diagnosis was tuberculous peritonitis, pulmonary tuberculosis, and tuberculous pleuritis. Treatment was started by anti-tuberculosis drugs with combined use of isoniazid, rifampicin, ethambutol, and pyrazinamide. The therapy was continued for 6 months. The culture for MT (Mycobacteria Growth Indicator Tube) converted to negative after 2 weeks of treatment and the C-reactive protein level became normal after a month. The pleural effusion and ascites disappeared after 2 and 3 months, respectively. Tuberculous peritonitis is a relatively rare disease, however when we encounter unexplained ascites, MT PCR and the measurement of ADA should be done considering a rapid diagnosis of tuberculous peritonitis, before invasive diagnostic laparoscopy.

Aged↗

PubMed2005

Rapidly growing mycobacteria in King Chulalongkorn Memorial Hospital and review of the literature in Thailand.

Rapidly growing mycobacteria (RGM) have emerged as important human pathogens that can cause a variety of diseases. Thirty isolates of the pathogenic RGM were recovered from patients who attended King Chulalongkorn Memorial Hospital during 1997 and 2003. There were 16 isolates of Mycobacterium chelonae, ten isolates of M. fortuitum and four isolates of M. abscessus. Clinical data was available in only nine patients (five males and four females) including six M. chelonae, two M. abscessus, and one M. fortuitum. The mean age was 37 years (range: 13-62 years). The associated conditions were present in five patients including two diabetes, one HIV infection, one pregnancy, one SLE and one chronic renal failure. A wide spectrum of clinical features was observed. These included two chronic pulmonary infections, two post-traumatic wound infections, two disseminated infections, one lymphadenitis, one keratitis and respiratory colonization. AFB staining was positive in six patients (66.67%). The MIC of one M. chelonae and one M. abscessus were determined by Epsilon test. For M. chelonae, the MIC of clarithromycin, amikacin, ciprofloxacin, sulfamethoxazole and imipenem were 0.25, 2.0, 1.00, > 64, and 0.54 microg/ml, respectively. For M. abscessus, the MIC of clarithromycin, amikacin, ciprofloxacin, tetracycline and sulfamethoxazole were 0.016, 0.016, 0.038, > 16 and 0.002 microg/ml, respectively. Six of eight patients (75%) were initially treated with four first-line antituberculous drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) before obtaining the culture result. Of these, three patients with pulmonary and disseminated infections improved after a prolonged course of these combinations. The patients improved after switching to specific anti-RGM antibiotics. One patient died after 10 months of therapy of four anti-tuberculous drugs. One patient with post-traumatic wound infection was cured with surgical debridement and dicloxacillin. One patient improved after treatment as acute bronchitis with oral amoxicillin. An extensive review of the literature of RGM infections in Thailand is also presented.

Adolescent↗

PubMed2005

[Pulmonary tuberculosis and adenovirus-hemorrhagic cystitis after autologous peripheral blood stem cell transplantation for follicular lymphoma].

A 58-year-old man had a relapsed follicular lymphoma (Grade 2) and was treated with mitoxantrone, fludarabine and dexamethasone followed by rituximab, and achieved partial remission. The patient then underwent high-dose chemotherapy followed by autologous peripheral blood stem cell transplantation (auto-PBSCT). Three days after starting high-dose therapy, he developed a fever, and a chest X-ray revealed pneumonia in the right lower lung. Despite of the administration of antibiotics and the recovery of neutrophils to normal levels, the pneumonia got worse. Bronchoalveolar lavage (BAL) was performed on day 32, the Ziehl-Neelsen staining of the BAL fluid showed acid-fast bacilli, and the culture grew Mycobacterium tuberculosis. The patient was diagnosed as having pulmonary tuberculosis and placed on an antituberculosis regimen (isoniazid, rifampicin, ethambutol, pyrazinamide). On day 43 he also developed hemorrhagic cystitis due to adenovirus type 11, and on day 49 positive CMV antigenemia was detected, which were treated supportively. On day 75 he developed pneumonia probably due to Pneumocystis jirovecii, which was treated with sulfamethoxazole/trimethoprim. The pulmonary tuberculosis resolved completely 4 months after starting the treatment, and the hemorrhagic cystitis and pneumocystis pneumonia resolved 1 month after the diagnosis. He remains in complete remission 2 years after transplantation.

Adenoviridae Infections↗

PubMed2006

Comparison of intermittent ethambutol with rifampicin-based regimens in HIV-infected adults with PTB, Kampala.

BACKGROUND: The human immunodeficiency virus (HIV) is a key factor responsible for the high rates of tuberculosis (TB) in sub-Saharan Africa. Treatment of TB with rifampicin (R, RMP) containing short-course regimens is highly effective in HIV-infected adults. We conducted a study to compare the efficacy and safety of intermittent ethambutol (E, EMB) with two RMP-containing regimens to treat pulmonary TB in HIV-infected patients. SETTING: National Tuberculosis Treatment Centre, Mulago Hospital, Kampala, Uganda. DESIGN: This was a prospective cohort compared to two non-randomised control groups. The study group and the two control arms were treated with 2 months of isoniazid (H), RMP, pyrazinamide (Z) and EMB followed by 6 E3H3 for the study group and 4HR or 6HR for controls. RESULTS: Between April 1993 and March 2000, 136 patients were enrolled in the 2EHRZ/E3H3 arm, 147 in the 2EHRZ/4HR arm and 266 in the 2EHRZ/6HR arm. The relapse rate was 18.2 per 100 person-years observation (PYO) for the study regimen compared to 9.7/100 PYO (P = 0.0063) and 4.8/100 PYO (P = 0.0001) in patients treated with 2 EHRZ/4HR or 2EHRZ/6HR, respectively. CONCLUSION: The 2EHRZ/6E3H3 regimen is safe and effective but has a significant risk of relapse.

AIDS-Related Opportunistic Infections↗