Understanding the gaps in elimination of tuberculosis in India

Tuberculosis (TB) is a highly infectious disease, and it has the highest global burden on India with 21% prevalence rate and 27% of patients who do not receive pertinent medical treatment. Although India spends 23 billion dollars annually towards medical expenses for TB, India still ranks among the top 2 countries with the highest incidence and prevalence rates with more than 300,000 deaths excluding the patients with HIV and TB calling for prompt consideration. India faces a great challenge socially and economically. They lack a uniform health care system, making it burdensome to use effective surveillance techniques for prevention of TB. Currently, India is working on resolving the issue meticulously through the web-based application program ‘Nikshay’ with other strategies like Revised National Tuberculosis Control Program (RNTCP) and World Health Organization's The End TB Strategy. India's cardinal goal is to make advanced diagnostic tools made available and public-private healthcare sector collaboration. India needs to focus more on primary prevention by effective policy formation and campaign which promote proper sanitation and vaccine administration while educating the layman.     

Study of treatment outcomes of multidrug-resistant tuberculosis under programmatic conditions and factors influencing the outcomes in Hyderabad District

BackgroundTreatment outcomes for Multidrug-Resistant Tuberculosis (MDR TB) is generally poor. The study aims to know about the treatment outcomes of MDR-TB under programmatic conditions in Hyderabad District and to analyze the factors influencing the treatment outcomes.MethodsThis is a retrospective study in which 377 patients of Hyderabad district, Telangana state who were diagnosed with MDR TB and registered at Drug Resistance TB Treatment site of Government General & Chest Hospital, Hyderabad from 4th quarter 2008 to 4th quarter 2013 were included in the study. Impact of Demographic factors (age, sex; Nutritional status (BMI); Co-morbid condition (Diabetes, HIV, Hypothyroidism); Programmatic factors (time delay in the initiation of treatment); Initial Resistance pattern on the outcomes were studied and analyzed.ResultsThe treatment outcomes of Multidrug-Resistant Tuberculosis under Programmatic Conditions were: 57% cured, 21.8% died, 19.6% defaulted, 1.1% failed and 0.5% switched to XDR. Age, Sex, BMI had a statistically significant impact on treatment outcomes. Hypothyroidism and Delay in the initiation of treatment >1 a month had an impact on the outcomes though not statistically significant. NO impact on treatment outcomes was found when Rifampicin resistance & INH sensitive patients were compared with those resistant to both INH and Rifampicin.ConclusionTo reduce MDR-TB transmission in the community, improvement of treatment outcomes, via ensuring adherence, paying special attention to elderly patients is required. The Programmatic Management of Drug Resistance Tuberculosis (PMDT) should seriously think of providing Nutritional support to patients with low BMI to improve outcomes. In the programmatic conditions if we could address the problems like delay in initiation of treatment and proper management of comorbidities like HIV, Diabetes, Hypothyroidism would definitely improve the treatment outcomes.     

HIV and tuberculosis co-infection in south-western Sydney: experience from a case series

A case series of six patients with HIV and Mycobacterium tuberculosis co-infection is presented. All patients were overseas-born and in all but one there was profound immunodeficiency. We recommend HIV screening of all cases of M. tuberculosis and a high degree of suspicion of tuberculosis in immigrants with HIV infection from endemic areas. Management problems included delayed diagnosis, rapid progression, paradoxical reactions and requirement for surgical intervention in three patients. Therapeutic complications included possible drug malabsorption, adverse events and drug interactions. M. tuberculosis was fully drug sensitive in all cases.     

聚合酶链反应-增强化学发光法快速检测结核杆菌的研究

目的　建立聚合酶链反应 -增强化学发光法 (polymerase chain reaction-enhanced chemilumine cence ,PCR-ECL)快速高灵敏度和高特异性检测结核杆菌的方法。方法 以结核分支杆菌、牛分支杆菌特异性抗原Pab基因的419bp片段为靶序列,PCR体系经优化,直接酶标法标记探针 ,增强化学发光检测(ECL)进行分子杂交。结果 PCR体系对结核分支杆菌、牛分支杆菌、卡介苗的扩增为阳性,PCR体系灵敏度为5fgDNA分子。ECL体系灵敏度为0.5pgDNA分子。采用模拟痰样,可检至10个以下结核杆菌。结论 建立了结核杆菌的PCR-ECL快速检测方法,整个过程可在一天半内完成。     

Surgical treatment for pulmonary tuberculosis: is video-assisted thoracic surgery “better” than thoracotomy?

Objective

To compare video-assisted thoracoscopic surgery (VATS) lobectomy and conventional open lobectomy in patients with pulmonary tuberculosis (TB) who require surgery.

Methods

Forty patients with pulmonary TB who required lobectomy were randomized to receive either VATS or open lobectomy. Patient demographic, pulmonary function, operative, and postoperative data were compared between the groups.

Results

There were 20 patients who received VATS lobectomy (median age 31.5 years, range 19-67 years) and 20 that received open lobectomy (median age 33.5 years, range 16-60 years). The two groups were similar with respect to gender, age and pulmonary function (all, P>0.05). Lobectomy was completed by VATS in 19 of 20 patients (95%), and by thoracoscope-assisted mini-incision lobectomy in 1 patient. The median intraoperative blood loss was 345 mL (range, 100-800 mL), and the median duration of pleural cavity closed drainage was 5 days (range, 3-7 days). All open lobectomies were completed successfully, and the median intraoperative blood loss was 445 mL (range, 150-950 mL) and the median duration of pleural cavity closed drainage was 5 days (range, 3-9 days). No statistically significant differences were found between the groups with respect to operation completion rates, type of lung resection, intraoperative blood loss, closed pleural drainage duration and volume of postoperative chest drainage. The operation time, number of postoperative complications, postoperative pain index at 24 hours after surgery and postoperative hospital stay were all significantly less in the VATS group. With a median follow-up duration of 14 months (range, 8-18 months) no positive sputum examination results were found in either group.

Conclusions

VATS lobectomy is an effective and minimally invasive method for treating patients with pulmonary TB.     

The performance and limitation of T-SPOT.TB for the diagnosis of TB in a high prevalence setting

Background

Tuberculosis (TB) diagnosis remains difficulty. The previous reports have shown that the T-SPOT.TB assay may be a more promising diagnostic tool for TB, however, it needs a further study to evaluate the diagnostic value of T-SPOT.TB for the specific populations in a high prevalence setting.

Methods

In this present study, we conducted stratified and comparable analyses to explore the clinical value and the limitation of T-SPOT.TB assay in TB diagnosis in a high TB prevalence setting, Southern China. A total of 413 subjects including 163 pulmonary TB (PTB), 39 extrapulmonary TB (EPTB), 106 non-TB pulmonary diseases (NTBPDs), 20 medical staff and 85 healthy controls were included in the study.

Results

According to T-SPOT.TB, there had a high incidence of latent TB infection (LTBI) in general population in Southern China, especially in the NTBPDS and medical staff. The T-SPOT.TB had a high performance in the diagnosis of active TB (ATB) in a lower risk of TB infection population such as the general population, however, the T-SPOT.TB for the diagnosis of ATB in the high risk of TB infection populations involving close contacts such as the patients with pulmonary diseases (PD) or medical staff isn’t reliable due to the interference by LTBI. Under this condition, the value of rule-out of the assay was seemed to be better than that of rule-in. We believed that the T-SPOT.TB is suitable for screening both the EPTB and the ATB combined with diabetes mellitus (DM). However, we found that the sensitivity of T-SPOT.TB in sputum smear-negative population wasn’t as high as that in smear-positive population.

Conclusions

The T-SPOT.TB testing results should be interpreted with caution combined with subject’s characteristics in a high prevalence setting.     

老年肺结核的临床特点

通过对５９２例老年肺结核临床资料的分析，并与同期２１０例中青年肺结核相比较，总结老年肺结核的特点为：（１）临床症状复杂而不典型，除有咳嗽、咳痰、发热、咯血等常见肺结核症状外，也常有以乏力、食欲不振、消瘦、精神萎糜、呼吸困难等症状中之１－２项为主要表现或首发症状者；（２）合并症明显多于对照组；（３）Ｘ线表现多样，以双侧病变、浸润型和慢性纤维空洞型改变为多见；（４）误诊率高；（５）治疗难，初治、复治有     

Role of medical thoracoscopy in the treatment of tuberculous pleural effusion

Background

Fibrous tuberculous pleural effusion (TPE) represents common disease in tuberculous clinic. Medical thoracoscopy has been used to treat pleural empyema and shown promising outcomes, but data of its use in multiloculated and organized TPE remains limited to know.

Methods

The study was performed on 430 cases with TPE. The cases were divided into free-flowing, multiloculated effusion and organized effusion group. Each group was subdivided into two or three types of therapeutic approaches: ultrasound guided pigtail catheter, large-bore tube chest drainage and medical thoracoscopy. Patients with multiloculated or organized effusions received streptokinase, introduced into the pleural cavity via chest tubes. The successful effectiveness of the study was defined as duration of chest drainage, time from treatment to discharge days and no further managements.

Results

Patients with organized effusion were older than those with free-flowing effusion and incidence of organized effusion combined with pulmonary tuberculosis (PTB) was higher than those of multiloculated effusion and free-flowing effusion respectively. Positive tuberculosis of pleural fluid culture was higher in organized effusion than that in free-flowing effusion. Sputum positive for acid-fast bacillus (AFB) in organized effusion was higher than that in multiloculated effusion and free-flowing effusion. Medical thoracoscopy showed significant efficacy in the group of multiloculated effusion and organized effusion but free-flowing effusion. No chronic morbidity and mortality related to complications was observed.

Conclusions

Medical thoracoscopy was a safe and successful method in treating multiloculated and organized TPE.     

High resolution computed tomography findings in smear-negative pulmonary tuberculosis patients according to their culture status

Objective

The aim of this study was to assess the clinical features and high resolution computed tomography (HRCT) findings in smear-negative pulmonary tuberculosis (PTB) and to evaluate the correlation between these parameters and the culture results.

Methods

We retrospectively studied 78 active smear-negative PTB patients. They were divided into two groups according to their culture results. The HRCT findings and clinical features at the beginning of the antituberculosis treatment were reviewed.

Results

The mean age was 22.48±3.18 years. Micronodules (87%), large nodules (63%) and centrilobular nodules (62%) were the most common HRCT findings. HRCT findings were observed in the right upper (72%), left upper (56%), right lower (32%), and left lower lobes (29%). Cough (37%) and chest pain (32%) were the most frequent symptoms at presentation.

Conclusions

There were no significant differences in the HRCT findings and clinical features between the two groups. Thus, in cases of smear-negative and culture-negative PTB, the patient with compatible clinical and radiological features should be considered for tuberculosis treatment.     

复治肺结核患者血清IL-17、IFN-γ和IL-4的表达及其临床意义

目的探讨IL-17、IFN-γ及IL-4等细胞因子在复治肺结核治疗过程中的表达情况及其临床意义。方法采用ELISA法分别测定复治肺结核患者治疗前组(20例)、治疗3个月组(16例)、治疗8个月组(14例)的IL-17、IFN-γ和IL-4水平。对照组为18例健康志愿者。统计分析比较各组间细胞因子水平的差异性。结果 IL-17、IL-4水平,治疗前组高于治疗3月组、治疗8个月组及正常对照组(P均小于0.05);治疗3个月组高于治疗8个月组及正常对照组(P均小于0.05);而IFN-γ水平与IL-17、IL-4水平恰恰相反。治疗8个月组与正常对照组三者水平差异均无统计学意义(P均0.05)。结论随着抗结核疗程的进行,IL-17、IL-4水平逐渐降低,而IFN-γ水平逐渐升高。提示动态监测这些细胞因子表达情况对判断复治肺结核患者的疗效具有重要的临床意义。     

人类免疫缺陷病毒(HIV)感染合并肺结核34例临床分析

目的　分析人类免疫缺陷病毒阳性合并肺结核感染的临床表现 ,探讨诊断方法。方法 对117例人类免疫缺陷病毒阳性合并肺结核感染 34例的临床表现、胸部X线及其他实验室检查进行分析。结果 117例人类免疫缺陷病毒阳性合并肺核感染 34例 ,感染率 2 9.1%。共用注射器静脉吸毒是主要原因。中等度发热、咳嗽、盗汗、消瘦 ,部分病例伴咯血、呼吸困难等与结核中毒症状相似。胸部X线检查以继发性肺结核为主 6 1.8%。多重感染中主要为念珠菌感染。住院期间病死率 17.6 %,死因为呼吸功能衰竭和多脏器功能衰竭。抗结核治疗对改善病情有帮助。因表现复杂 ,临床误诊较高。结论 肺结核合并机会性感染尤念珠菌感染 ,流行病学资料有静脉吸毒行为 ,应作HIV抗体检查有利诊断。     

腺苷脱氨酶及结核抗体在糖尿病合并肺结核诊断中的价值

目的评价腺苷脱氨酶和结核抗体检测用于辅助诊断糖尿病合并肺结核的价值。方法对116例糖尿病合并肺结核患者、133例糖尿病合并非结核肺部感染患者以及120例健康人群的血清腺苷脱氨酶（ADA）、结核抗体（TB-Ab）进行检测并分析。结果糖尿病合并肺结核患者血清ADA水平（22.7±7.3 u/L）和阳性率（70.3%）明显高于其它两组,均有显著性差异（P〈0.01）。糖尿病合并肺结核患者TB-Ab阳性率（71.5%）较糖尿病合并非结核肺部感染患者（8.5%）和健康人群对照组（7.5%）有显著性差异（P〈0.01）。结论 ADA和TB-Ab联合检测对于辅助诊断糖尿病合并肺结核特别是结核症状不典型的病例有一定价值。     

老年肺结核患者白细胞介素6分泌水平的研究

目的探讨老年肺结核患者细胞免疫功能。方法采用ＭＴＴ（噻唑蓝）比色法,检测其外周血单个核细胞（ＰＢＭＣ）白细胞介素６（ＩＬ－６）分泌水平。结果①老年肺结核ＩＬ－６水平明显高于正常人（Ｐ＜０．０５）;②肺结核进展期ＩＬ－６水平老年组低于中青年组（Ｐ＜０．０１）,而好转期无此差异（Ｐ＞０．０５）;③老年肺结核进展期与好转期相比ＩＬ－６分泌高峰前移;④ＩＬ－６水平与结核病变范围及排菌情况均有关且差异显著（Ｐ＜０．０１）。结论检测ＩＬ－６水平有助于老年肺结核免疫状况观察及病情监测。     

PANCREATIC TUBERCULOSIS AND ITS DIAGNOSIS BY ENDOSCOPIC ULTRASONOGRAPHY: REPORT OF TWO CASES AND REVIEW OF THE LITERATURE

Mass lesions in the head of the pancreas are generally malignant and it is difficult to diagnose benign lesions preoperatively. We describe two patients with pancreatic tuberculosis, who presented with abdominal pain, jaundice and a pancreatic head mass, mimicking cancer. The correct diagnosis could be made by endoscopic ultrasonography (EUS) and EUS‐guided fine‐needle aspiration (FNA) cytology in both patients, precluding the need for surgery. Both patients responded well to anti‐tuberculosis treatment. We conclude that EUS with guided FNA is a useful modality to diagnose pancreatic tuberculosis.     

利福平注射液对初治菌阳肺结核病人的疗效观察

目的观察利福平注射液治疗初治菌阳肺结核的疗效及安全性。方法 100例初治菌阳肺结核患者随机分为治疗组（50例）与对照组（50例）,强化期分别采用HZE＋利福平注射液治疗和HZE＋口服利福平胶囊方案治疗;观察强化期1、2个月末痰菌阴转、肺部病灶吸收及毒副反应情况。结果 1、2个月末痰菌阴转率,治疗组分别为78%、96%,对照组分别为62%、82%;1、2个月末胸部X线影像学检查显效率,治疗组分别为22%、48%,对照组分别为12%、30%;治疗组与对照组2个月末空洞闭合、缩小率分别为40%、23%,肝功能异常发生率分别为24%、20%,胃肠道反应发生率分别为22%、48%。结论利福平注射液治疗具有局部药物浓度高,作用快,副作用小的特点,其治愈率高,有较好的临床应用价值。     

普通级动物实验室开展结核菌动物实验的生物安全性探讨

目的 对普通级实验动物房进行适当的改造,在进行结核菌动物实验时采取严密的防范措施,观察是否会对环境和工作人员造成危害.方法 对普通级动物房进行适当改造,加强消毒灭菌措施,检测实验废物及环境中的结核菌污染情况;实验人员进行实验前后健康检测.结果 对实验室排风口过滤槽中的消毒液、实验室废液、废物进行多次涂片镜检和培养,均未发现结核菌.实验密切接触者的跟踪调查:实验结束1年后,对参与实验的人员进行了X线胸片检验和结核菌纯蛋白衍生物(PPD)试验.密切接触实验的6人中,肺部X线胸片均无异常.PPD试验的红肿大小与实验前无差异.结论 普通级动物房经过适当改造后,并加强消毒和防护措施,能避免对周围环境和实验密切接触者的危害,具有进一步探讨的价值.     

Four cases of pulmonary Mycobacterium avium intracellulare complex presenting as a solitary pulmonary nodule and a review of other cases in Japan

OBJECTIVE: To evaluate clinical findings of patients with a solitary pulmonary nodule in Japan caused by pulmonary Mycobacterium avium complex (MAC) disease. METHODS: The authors investigated the clinical features of 12 patients diagnosed as having pulmonary MAC disease who had presented with a solitary pulmonary nodule. RESULTS: The causative microorganisms were M. avium in seven patients, Mycobacterium intracellulare in two and MAC in three. The diagnostic methods were bronchoscopic biopsy or percutaneous lung biopsy in three patients and surgical operations in the remaining nine. Eleven patients had a complete surgical resection of the nodule and antituberculous drugs were administered to eight. On X-ray, there was an absence of calcification, satellite lesions, cavities, or bronchoectasis that are often thought to be characteristic of pulmonary mycobacterial disease. Differentiation from lung cancer was thought necessary in five patients. There was no microbiological or radiological relapse in those who underwent complete surgical resection. CONCLUSIONS: Because treatment is often poorly effective for patients with pulmonary non-tuberculous mycobacterial disease, it is important to identify the causative microorganisms by performing a culture examination of resected lung tissue especially if there is a solitary pulmonary nodule.     

结核分枝杆菌总RNA提取方法的比较研究

目的探讨两种不同方法提取结核分枝杆菌总RNA,并在实验中对其进行优化。方法收集结核分枝杆菌培养物,分别用甲醇和玻璃粉裂解其细胞壁,然后加入Trizol提取结核分枝杆菌总RNA,用琼脂糖凝胶电泳检测其完整性,用Nano-drop2000检测其得率和纯度。结果玻璃粉裂解细胞壁法和甲醇裂解细胞壁法提取的结核分枝杆菌总RNA的获得率分别为6.124±1.144和13.437±1.767(P<0.01),纯度A260/A280的值分别为1.924±0.039和1.899±0.072(P>0.01)。结论玻璃粉裂解细胞壁法和甲醇裂解细胞壁法提取的结核分枝杆菌总RNA均未发生明显降解,其完整性均能满足后续实验的需要。用甲醇裂解法提取的结核分枝杆菌总RNA的获得率明显高于玻璃粉法。     

Amplisensor-聚合酶反应定量检测脑脊液中结核分支杆菌DNA的研究

目的　探讨Amplisensor-聚合酶反应 (Amplisensor-PCR)定量检测脑脊液中结核分支杆菌DNA(TB-DNA)对结核性脑膜炎的诊断价值。方法 采用Amplisensor-PCR对117例结核性脑膜炎患者及36例非结核性脑膜炎患者的脑脊液标本进行检测,并与PCR(凝胶电泳后,经溴化乙锭染色)、涂片、培养法比较。结果 Amplisensor-PCR的敏感性显著高于涂片及培养,阳性率分别为57.13%、1.7%、6.7% (P＜0.001)。结论 Amplisensor-PCR可以通过标准曲线划定检出下限,并可换算出标本中原始的靶DNA值,同时具有较高的特异性和敏感性,对结核性脑膜炎的诊断有一定的临床意义。     

An unusual cause of a large fibrinous pericardial effusion

The commonest cause of a large fibrinous pericardial effusion in sub-Saharan Africa is tuberculosis. There are, however, limited resources available for making a definitive diagnosis of tuberculous pericarditis. The diagnosis is largely based on clinical criteria. There is a risk of misdiagnosing lesscommon causes of large fibrinous pericardial effusions. We present a patient who had a pericardial angiosarcoma that was initially thought to be a tuberculous pericardial effusion, and discuss the challenges in making a definitive diagnosis of tuberculosis.