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PubMed2005

[A case of arteria cerebri aneurysm, sepsis, and miliary lung infiltrates in a 32-year-old woman].

BACKGROUND: Miliary tuberculosis is a rare manifestation of tuberculosis with a high mortality rate. Diagnosis may easily be missed when severe neurologic symptoms are the first clinical manifestation. A typical case of miliary tuberculosis is reported, with special regard to the problems of diagnostic work-up. The need for an early empirical therapy for suspected military tuberculosis is emphasized in particular. CASE REPORT: A 32-year-old Moroccan woman was admitted to the hospital with aphasia and a hemiparesis due to an intracerebral hemorrhage caused by a ruptured septic A. cerebri media aneurysm. Despite intensive work-up no septic focus could be found. Chest radiograph and computerized tomography (CT) showed miliary consolidations in the lungs. Skin testing (Tuberkulin Behring GT5) and smears for acid-fast bacilli and polymerase chain reaction (PCR) for tuberculosis of bronchoalveolar lavage (BAL) were negative. A four-drug antituberculous regimen (rifampicin [RMP], isoniazid [INH], pyrazinamide [PZA], ethambutol [EMB]) was initiated, and resulted in normalization of temperature, blood pressure, and C-reactive protein. Subsequently, cultures of BAL yielded Mycobacterium tuberculosis. The patient was discharged, a two-drug regimen was conducted (RMP, INH) after 2 months. Follow-up of the patient showed a significant improvement of the miliary lung consolidations after 5 months in CT of the lung. Only minor neurologic symptoms persisted after cessation of the therapy. CONCLUSION: In developed countries, miliary tuberculosis is a very rare cause of septic infiltrative lung disease. However, due to the nonspecific nature of the presentation and despite improved diagnostic techniques, a high clinical suspicion is essential for successful treatment.

Adult↗
PubMed2003

[Tuberculosis-current therapeutic principles].

Chemotherapy for tuberculosis is indicated in case of disease as well as in latent tuberculosis infection. Standard medication for drug-susceptible tuberculosis consists of isoniazid and rifampicin for six months with additional pyrazinamide and ethambutol for the first two months. Prolonged treatment is necessary in cases of cavernous pulmonary tuberculosis with lack of negative cultures by two months of therapy, in tuberculosis of the central nervous system and in some cases of superficial lymph node disease. Especially in multiple-drug resistant tuberculosis prolonged treatment with three or more drugs, that have been proven to be effective by susceptability testing, is mandatory. Attention must be payed to reliable delivery of chemotherapy as well as to side effects of antituberculosis medications. The classical treatment for latent tuberculosis infection is isoniazid. Multidrug short-course therapy, which has been shown to be equally effective, enhances patients' compliance, but toxicity is increased.

Animals↗
PubMed2003

Disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection in a patient with infliximab and methotrexate.

CASE PRESENTATION: Despite chemoprophylaxis with isoniazid a 58-year-old Creole patient with mild rheumatoid arthritis developed disseminated tuberculosis, pulmonary aspergillosis and cutaneous herpes simplex infection during treatment with infliximab and methotrexate. TREATMENT: The patient received antituberculous drugs (ethambutol, isoniazid, pyrazinamide, rifampicin), amphotericin B, flucytosine, and valaciclovir, along with prolonged intensive care treatment and mechanical ventilation. CONCLUSIONS: The present case confirms that isoniazid prophylaxis (300 mg once daily, during 6 months) does not protect against the reactivation and dissemination of latent tuberculosis. It also shows that combined treatment with infliximab and methotrexate may induce severe immunosuppression with prolonged leukocytopenia and depressed cellular immunity, leading to multiple opportunistic infections. Extensive diagnostic testing, early start of antimicrobial therapy and enteral immunonutrition, and further infection prevention with selective decontamination of the digestive tract may have been the key to a good clinical outcome.

Antibodies, Monoclonal↗
PubMed2003

Diagnosing tuberculous spondylitis: patients with back pain referred to a rheumatology outpatient department.

The onset of tuberculous spondylitis is insidious in nature, with various clinical presentations, slow development of radiographic abnormalities, and nonspecific constitutional symptoms. This lack of specific symptoms causes delays in diagnosis. Magnetic resonance imaging demonstrates osteitis, intraosseous abscesses, paravertebral and epidural soft tissue extensions and abscesses, discitis, multilevel involvement of spinal cord or nerve root compression, and scoliosis. We present six patients with tuberculous spondylitis referred to our outpatient department with back pain resistant to medical therapy. All of them were women aged from 25 to 58 years (mean 44.6). The diagnosis of tuberculous spondylitis was based on clinical presentation, radiographic and/or MRI evidence of focal destructive vertebral lesions (with paravertebral mass), and positive bacteriological findings of Mycobacterium tuberculosis. The combined antituberculous chemotherapy consisted of 1.0 g/day streptomycin for 1 month, 25 mg/kg ethambutol or 25 mg/kg pyrazinamide, 600 mg/day rifampicin, and 300 mg/day isoniazid. The duration of therapy was 12 months. All the patients recovered without any sequelae. The mean follow-up period was 28 months (range 12-48). Magnetic resonance imaging is considered the main imaging modality for patients with suspected tuberculous spondylitis; it must be included in differential diagnosis of back pain and, if it is diagnosed in early stages, antituberculous chemotherapy enables satisfactory outcome.

Adult↗
PubMed2004

Connatal tuberculosis in a very premature infant.

UNLABELLED: Connatal tuberculosis is increasing in incidence and the mortality and morbidity of this disease remains high. We report a 27-week-old, 896 g female premature infant who had mild respiratory distress syndrome after birth. She developed signs of infection, progressive pneumonia and atelectasis which did not respond to mechanical ventilation and antibiotics. At 41 days of age, Mycobacterium tuberculosis was isolated from the non-bronchoscopic bronchoalveolar lavage. The isolate was sensitive to isoniazid, rifampin, streptomycin, and pyrazinamide. Miliary tuberculosis was subsequently diagnosed in her mother on a chest X-ray film and sputum cultures. The infant was treated successfully with anti-tuberculosis drugs. She had normal growth and development at the chronological age of 20 months old. CONCLUSION: Connatal tuberculosis should be considered in premature infants with symptoms of sepsis refractory to antibiotics. Most premature infants with connatal tuberculosis have lung involvement, and non-bronchoscopic bronchoalveolar lavage can be a useful procedure to establish the diagnosis.

Antitubercular Agents↗
PubMed2005

Multidrug-resistant tuberculosis in Russia: clinical characteristics, analysis of second-line drug resistance and development of standardized therapy.

The aim of the study presented here was to identify patients with multidrug resistant tuberculosis (MDRTB) in the Samara region of Russia and to analyze the susceptibility of their isolates to second-line drugs in order to develop an empirical, standard, second-line treatment regimen. Treatment of MDRTB can be individualized based on in vitro laboratory analysis or standardized. In the latter case there is still a need to ascertain local second-line drug-resistance patterns. Described here are the clinical characteristics of 251 MDRTB patients identified in the study and the second-line drug susceptibility of 69 MDRTB isolates obtained from them. Antimicrobial resistance to the following agents was detected in the isolates: rifabutin (88.2%), streptomycin (42.8%), amikacin (7.2%), doxycycline (7.4%), ciprofloxacin (4.3%), clofazimine (2.9%), cycloserine (7.4%), and prothionamide (1.5%). The results of the study indicate it is possible to develop a standard, effective, clinical treatment regimen using ethambutol, pyrazinamide, prothionamide, a fluoroquinolone and amikacin.

Anti-Bacterial Agents↗
PubMed1999

Rapid improvement of intracranial tuberculomas after addition of ofloxacin to first-line antituberculosis treatment.

Reported here is the case of a 9-year-old girl presenting with disseminated tuberculosis, the manifestations of which included mediastinal adenopathy, an osteolytic parietal lesion with a large associated scalp abscess, cerebral empyema, meningoencephalitis, and tuberculomas. No clear improvement was observed after 4 weeks of first-line antituberculosis treatment (10 mg/kg rifampin, 15 mg/kg isoniazid, 30 mg/kg ethambutol, 30 mg/kg pyrazinamide). The isolation of an isoniazid-resistant organism prompted institution of ofloxacin. Introduction of this drug was associated with dramatic improvement. Its good penetration into the central nervous system and its distribution into macrophages suggest that this drug may be of interest for the treatment of intracranial tuberculomas, particularly those due to isoniazid-resistant strains.

Anti-Infective Agents↗
PubMedDate not supplied

Leber's hereditary optic neuropathy precipitated by ethambutol.

BACKGROUND: Leber's hereditary optic neuropathy (LHON) predominantly affects young men between 10 and 30 years of age. However, two cases of LHON during ethambutol administration have been reported in older men and one case in an older woman. We now report a second case of an older woman in whom administration of ethambutol triggered the development of LHON. CASE: A 70-year-old woman received ethambutol, rifampicin, isoniazid, and pyrazinamide for the treatment of tuberculosis. OBSERVATIONS: Three months after the beginning of this treatment, a marked decrease in visual acuity occurred in both eyes and ethambutol was discontinued. Her corrected visual acuity was 0.03 in both eyes. There was no hyperemia, swelling of the optic disc, or capillary dilatation in either eye. Centrocecal scotomas were found bilaterally. After 1 month, her visual acuity had further decreased to 0.01, and the scotomas had enlarged. At this time, genetic analysis revealed a point mutation in mitochondrial DNA 11778. CONCLUSIONS: Ethambutol can be a risk factor for LHON because the number of reported ethambutol-related LHON cases has increased to four, including the present one. Ethambutol administration to patients with a family history of LHON should be avoided.

Aged↗
PubMed2001

Tuberculosis Meningitis.

Treatment of tuberculous meningitis should begin with an anti-tuberculous regimen of at least three drugs: isoniazid, pyrazinamide, and rifampin. Early in the course of therapy, ethambutol or streptomycin may be of some added benefit. If the local incidence of drug resistance to Mycobacterium tuberculosis is greater than 4%, or is unknown, then a fourth drug (ethambutol or streptomycin) should be added. If the patient is from an area with organisms resistant to multiple drugs, or is likely to be infected with a multiply resistant organism for any reason, then the patient should be on enough drugs to insure that at least two active anti-tubercular drugs are included in the therapy. An expert should be consulted Length of therapy is not standardized. For sensitive organisms, a regimen of three drugs daily for 2 months, followed by two-drug therapy (isoniazid and rifampin) has been recommended. The American Thoracic Society (ATS) and the Centers for Disease Control (CDC) have recommended a minimum of 12 months of therapy for tuberculous meningitis. If cultures remain positive for extended periods, or signs or symptoms respond slowly, therapy should be extended to 18 months. Patients with HIV also may need longer courses of therapy. The severity of tuberculous meningitis can be classified based on a system devised by the British Medical Research Council. Stage I patients are fully conscious, rational, and do not have neurologic signs. Stage II patients are confused or have neurologic signs such as cranial nerve palsy or hemiparesis. Stage III patients are comatose or stuporous with more severe neurologic signs. Corticosteroids are recommended if the patient is mentally confused, has neurologic signs, or is comatose (Stages II and III). In patients with moderate disease (Stage II), corticosteroids appear to improve neurologic sequelae and survival. Dexamethasone 6 to 12 mg per day and prednisone 60 to 80 mg per day tapered over 4 to 8 weeks has been used. Symptoms of central nervous system (CNS) inflammation may recur if the corticosteroid taper is implemented too soon or too fast. Steroids and diuretics such as furosemide and acetazolamide are sometimes used to treat hydrocephalus. Ventriculoperitoneal or ventriculoatrial shunting may be required to relieve signs and symptoms of hydrocephalus.

Journal Article↗
PubMed2006

Treatment of neuro-ophthalmologic manifestations of tuberculosis.

In the absence of obvious pulmonary or disseminated tuberculosis, ocular and central nervous system (CNS) tuberculosis may represent a significant diagnostic challenge. Refinements in polymerase chain reaction techniques and neuroimaging have strengthened the battery of tests used to diagnose CNS and ocular tuberculosis, yet in many cases, the diagnosis remains one of exclusion; it may ultimately be determined through exacerbation by anti-inflammatory therapy with subsequent improvement by antitubercular medication treatment. Because of emerging drug resistance, at least a two-drug regimen is required for therapeutic testing and treatment of isolated ocular tuberculosis. If pulmonary or miliary disease coexists, a 6-month, four-drug regimen with isoniazid, rifampin, pyrazinamide, and ethambutol is required for treatment. Tubercular meningitis is treated with the same four-drug regimen for at least 9 to 12 months. Burden of therapeutic compliance rests on the treating physician and public health sector. Best compliance is realized with directly observed therapy.

Journal Article↗
PubMed2002

Change in demographic picture and increase of drug resistance in pulmonarytuberculosis in a 10-year interval in Taiwan.

BACKGROUND: This study was designed to compare the change in demographics, medical characteristics and drug resistance of patients with active pulmonary tuberculosis (TB) between two time periods within a 10-year interval. PATIENTS AND METHODS: We retrospectively reviewed the clinical records and chest radiographs of 1,826 patients with active pulmonary TB for two time periods from 1992-1996 (n = 884) and 1982-1986 (n = 942). RESULTS: The mean age was significantly higher and there were significantly more female patients in the 1992-1996 period than in the 1982-1986 period. In the 1992-1996 period, there were significantly fewer patients with the main complaints of cough, fever and body weight loss at the time of diagnosis but significantly more patients who had diabetes mellitus, obstructive airway disease, cancer other than lung cancer or who were on corticosteroid therapy. During the 1992-1996 period, single drug resistance against isoniazid (INH), rifampin (RIF) and streptomycin increased by 0.5%, 3% and 0.7%, respectively. Multiple drug resistance against both INH and RIF increased by 2% in the 1992-1996 period. A history of pulmonary TB and extensive pulmonary involvement were two significant factors for drug resistance against INH, RIF or ethambutol (EMB). CONCLUSION: In the 1992-1996 period, the mean age of patients and number of female patients significantly increased. There were more patients with diabetes mellitus, obstructive airway diseases, cancer other than lung cancer and prior steroid therapy but fewer patients presenting with classic clinical symptoms of TB. In consideration of the high prevalence and increasing rate of single and multiple drug resistance, we recommend an initial four-drug regimen (INH, RIF, EMB, pyrazinamide) for the treatment of pulmonary TB in Taiwan.

Adolescent↗
PubMed1995

Surgical treatment of childhood mediastinal tuberculous lymphadenitis.

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.

Bronchoscopy↗
PubMed1988

Effect of kynurenine loading on quinolinic acid production in the rat: studies in vitro and in vivo.

In vitro and in vivo techniques were used to examine the production and subsequent fate of the endogenous excitotoxin quinolinic acid (QUIN) following administration of its bioprecursor L-kynurenine (KYN). Incubation of liver slices in the presence of 10-1000 microM KYN resulted in a dose- and time-dependent release of QUIN into the incubation medium. Less than 15% of total QUIN produced was recovered from the tissue. In vivo experiments, performed with a microdialysis probe inserted in the jugular vein of anesthetized rats, showed that injection of KYN (20-600 mg/kg, i.v.) causes rapid and dose-dependent increases in the serum level of QUIN. Peak QUIN concentrations in serum dialysates were reached 75 minutes following KYN administration. Longer lasting increases were detected following the administration of pyrazinamide (20 mg/kg, i.p.), an indirectly acting stimulator of QUIN biosynthesis in the periphery. The data demonstrate the feasibility of assessing the mechanisms of QUIN production and disposition in experimental paradigms which can be expected to allow insights into the function and possible dysfunction of QUIN in the brain.

Analysis of Variance↗
PubMedDate not supplied

Aspects of tuberculosis in Africa. 1. Tuberculosis in Africa in the AIDS era--the role of chemoprophylaxis.

An estimated 2.8 million people in Africa have dual infections with tuberculosis and human immunodeficiency virus (HIV). Because of the increasing numbers of cases of tuberculosis as a consequence of the HIV epidemic, chemoprophylaxis may become a cost effective tuberculosis control measure in high prevalence countries. Although isoniazid (INH) is the only drug evaluated in controlled trials of preventive tuberculosis therapy, studies are now under way to determine the efficacy of INH and other drugs, including rifampicin and pyrazinamide, in preventing tuberculosis reactivation in persons with HIV infection. If chemoprophylaxis is effective in persons with dual infection, further studies will be required to determine whether chemoprophylaxis is cost effective for tuberculosis prevention and control and whether it is feasible to introduce it as a community control measure.

Africa↗
PubMed1976

Biochemical background of some enzymatic tests used for the differentiation of mycobacteria.

The break-down of benzamide, acetamide, malonamide and allantoin in M. smegmatis was investigated. It has been stated that the uptake of liberated NH3 into the cells, favoured by the presence of an organic acid, occasionally results in a negative NH3 determination. This difficulty can be overcome by an increase of the substrate concentration from 0.8 up to 4 mM. All antoinase activity in mycobacteria can be demonstrated only by an NH3 determination, when all the enzymes necessary for the complete break-down of allantoin are present. Bacteria containing allantoinase but not urease will be negative in this test. Using high amide concentrations (4 mM) some doubtful results concerning the degradation of acetamide, benzamide, nicotinamide and pyrazinamide can be eliminated as could be demonstrated for different strains of mycobacteria.

Acetamides↗
PubMed1981

A study of bovine strains of Mycobacterium tuberculosis isolated from humans in South-East England, 1977-1979.

Bovine strains of Mycobacterium tuberculosis were isolated from 137 of 5021 cases of tuberculosis (2.7%) occurring in South East England during the years 1977 to 1979. These were divisible into 'classical' and 'Afro-Asian' bovine strains according to their susceptibility to pyrazinamide. Classical strains were the predominant type among the Europeans and Afro-Asian types were commoner in immigrants. Bovine strains caused a high incidence of extrapulmonary disease in both ethnic groups and there was a significant relationship between renal disease and 'classical' strains. The age and sex distributions of bovine strains were similar to those of human strains in both ethnic groups. It was considered that these bovine strains were transmitted from human to human by the pulmonary route.

Adolescent↗
PubMed1984

Study of a fully supervised programme of chemotherapy for pulmonary tuberculosis given once weekly in the continuation phase in the rural areas of Hong Kong.

In the rural areas of Hong Kong outpatient treatment is organised from general primary health-care clinics which are visited only once a week by chest clinic staff. A daily 18-month, self-administered regimen of isoniazid and sodium PAS supplemented by daily streptomycin injections for the first 3 months has been the standard regimen, the patients attending a clinic once a month to collect their oral drugs, even during the first 3 months. In 1979 a new rural service programme of fully supervised chemotherapy was introduced for a trial period of 1 year. Patients were to be admitted to hospital initially for up to 2 months for daily treatment with streptomycin, isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by once-weekly streptomycin, isoniazid, rifampicin, and ethambutol up to 12 months, fully supervised in the primary health-care clinics. The therapeutic results achieved with this new regimen were excellent. Among 101 patients with ne or more positive sputum smears or cultures and 24 with all their smears and cultures negative pretreatment, who were assessable up to 30 months, there were no bacteriological failures during chemotherapy and only one bacteriological relapse after stopping. However, the regimen had a major operational defect in that 41% of the 263 patients treated during the year had to be prescribed standard chemotherapy, which was not fully supervised, instead of the study regimen, 37% because they refused an initial period of hospital admission. The therapeutic results were far less satisfactory with the standard regimen.

Adolescent↗
PubMed1987

The course of fever during treatment of pulmonary tuberculosis.

We studied 161 patients with pulmonary tuberculosis: 55 (34%) were afebrile and 106 (66%) were febrile at presentation. Febrile patients were younger and more symptomatic than afebrile individuals. Fever was also associated with a higher incidence of lymphopenia, hyponatraemia, hypoalbuminaemia and many acid-fast bacilli on sputum smear. Most patients were treated with isoniazid, rifampicin and pyrazinamide. Of 83 individuals who became afebrile while in hospital, 74 (89%) did so within a week and 77 (93%) in 2 weeks. Prolonged fever was associated with alcoholism, anaemia, hyponatraemia and hypoalbuminaemia. A therapeutic trial of antituberculosis drugs may be more useful than has been previously thought, since in most patients the temperature falls to normal within 2 weeks.

Adult↗