Evaluation of clinical parameters to predict Mycobacterium tuberculosis in inpatients

BACKGROUND: Respiratory isolation has been recommended for all patients with suspected tuberculosis (TB) to avoid transmission to other patients and health care personnel. In implementing these guidelines, patients with and without TB are frequently isolated, significantly increasing hospital costs. The objective of this study was to derive a clinical rule to predict the need for respiratory isolation of patients with suspected TB. METHODS: To identify potential predictors of the need for isolation, 56 inpatients with sputum cultures positive for TB were retrospectively compared with 56 controls who were isolated on admission to the hospital based on clinically suspected TB but whose sputum cultures tested negative for TB. Variables analyzed included TB risk factors, clinical symptoms, and findings from physical examination and chest radiography. RESULTS: Multivariate analysis revealed that the following factors were significantly associated with a culture positive for TB: presence of TB risk factors or symptoms (odds ratio [OR], 7.9 [95% confidence interval (CI), 4.4-24.2]), a positive purified protein derivative tuberculin test result (OR, 13.2 [95% CI, 4.4-40.7]), high temperature (OR, 2.8 [95% CI, 1.1-8.3]), and upper-lobe disease on chest radiograph (OR, 14.6 [95% CI, 3.7-57.5]). Shortness of breath (OR, 0.2 [95% CI, 0.12-0.53]) and crackles noted during the physical examination (OR, 0.29 [95% CI, 0.15-0.57]) were negative predictors of TB. A scoring system was developed using these variables. A patient's total score of 1 or higher indicated the need for respiratory isolation, accurately predicting a culture positive for TB (98% sensitivity [95% CI, 95%-100%]; 46% specificity [95% CI, 33%-59%]). CONCLUSION: Among inpatients with suspected active pulmonary TB, a prediction rule based on clinical and chest radiographic findings accurately identified patients requiring respiratory isolation.     

Characteristics of patients with delayed diagnosis of infectious pulmonary tuberculosis

OBJECTIVE: The aim of this study was to identify patient and disease characteristics associated with delayed diagnosis of infectious pulmonary tuberculosis (TB). METHODOLOGY: A retrospective analysis of 375 adult patients with culture-positive pulmonary TB and cough, treated at the Singapore Tuberculosis Control Unit (TBCU) in 2000, was carried out using data extracted from the TB notification registry and clinical records of the TBCU. Demographic, social, clinical and disease characteristics of patients with reported cough of duration less than, and exceeding, the median duration for the study population were compared. RESULTS: The median duration of cough reported at TB notification was 4 weeks (range, 1-156 weeks). By multivariate analysis, patients with cough > 4 weeks were more likely to be < 65 years old (adjusted odds ratio (OR), 1.8; 95% CI, 1.1-2.9; P = 0.02), of Chinese ethnicity (adjusted OR, 2.0; 95% CI, 1.2-3; P = 0.004), more likely to be sputum acid-fast bacilli smear-positive (adjusted OR, 1.7; 95% CI, 1.1-2.7; P = 0.016), and to have weight loss (adjusted OR, 2.6; 95% CI, 1.7-4; P < 0.01). CONCLUSION: Further studies are needed to identify the possible reasons for delayed diagnosis of TB among those < 65 years old, in the Chinese population in Singapore.     

Determination of risk factors for isoniazid monoresistance and multidrug-resistant tuberculosis in treatment failure patients

India has a high number of drug-resistant tuberculosis cases. Patient records were screened to determine risk factors possibly associated with monoresistance and multidrug-resistant tuberculosis (MDR-TB) in comparison with patients with susceptible TB. We retrospectively screened and selected 250 patient records from a tertiary care centre, in which detailed clinical histories were provided. Of the 250 patients, 10 had isoniazid monoresistant TB, 184 patients had MDR-TB, and 56 patients had TB susceptible to first-line drugs. Binary regression analysis revealed that previous treatment with a fluoroquinolone and an injectable other than streptomycin (odds ratio (OR) 3.889, 95% confidence interval (CI) 1.828-8.272) was associated with MDR-TB. Previous history of TB (OR 0.697, 95% CI 0.363-1.338) and the presence of cavities on radiographs (OR 0.371, 95% CI 0.160-0.862) did not show any association. None of these reported risk factors were associated with isoniazid monoresistance. In conclusion, a history of previous treatment with a fluoroquinolone and an injectable other than streptomycin was found to be a risk factor for MDR-TB.     

Latent tuberculosis infection in a military setting diagnosed by whole-blood interferon-gamma assay

BACKGROUND AND OBJECTIVES: Rapid and accurate diagnosis of latent tuberculosis infection (LTBI) is crucial in military settings. This study aimed to detect the prevalence of LTBI using a whole-blood interferon-gamma assay based on Mycobacterium tuberculosis-specific antigens, and to identify risk factors for LTBI among military personnel in contact with patients with active pulmonary TB. METHODS: This prospective study investigated contacts in military camps in South Korea of soldiers with active pulmonary TB. The whole-blood interferon-gamma assay was performed using QuantiFERON TB-Gold. RESULTS: Among the 175 contacts, 25 (14.3%) showed positive results to the assay. Long duration of exposure (OR 2.83; 95% CI: 1.63-4.91), laryngeal TB (OR 6.04; 95% CI: 1.54-23.67) and intensive exposure (OR 5.13; 95% CI: 1.63-16.12) were associated with a positive result. CONCLUSIONS: A relatively small number of TB contacts in a military setting had LTBI.     

Identifying pulmonary tuberculosis in patients with negative sputum smear results

BACKGROUND: Clinicians need to decide whether to begin empiric therapy for patients who are suspected of having tuberculosis (TB) but have negative sputum smear results. Culture results may take weeks, and delaying treatment may allow further transmission of disease. Study objective: To identify the clinical, demographic, and radiographic characteristics that identify smear-negative patients who have TB, and to create a TB prediction rule. DESIGN: Retrospective chart review. SETTING: University-affiliated public hospital in San Francisco, CA, between 1993 and 1998. PATIENTS: Forty-seven patients with TB and 141 control patients who were hospitalized with a suspicion of pulmonary TB; all had negative sputum smear results. Measurements and results: Demographic, clinical, and radiographic variables were determined by chart review. In multivariate analysis, a positive tuberculin skin test result (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.0 to 11.9) was independently associated with an increased risk of a positive TB culture finding. A radiographic pattern not typical of pulmonary tuberculosis (OR, 0.3; 95% CI, 0.1 to 0.7) and expectoration with cough (OR, 0.3; 95% CI, 0.1 to 0.6) were predictive of a decreased risk. An interaction between HIV seropositivity and mediastinal lymphadenopathy on the chest radiograph was also associated with a positive TB culture result (OR, 7.2; 95% CI, 1.4 to 36.0). The TB prediction score (TPS) was created with widely ranging likelihood ratios that could affect the posterior probability of TB by 30-fold. CONCLUSION: The TPS put into context with the overall prevalence of TB in a given area may help clinicians decide if a patient with negative sputum smear results should start empiric antituberculous therapy or wait for culture results. These results need prospective validation.     

Impact of extensive drug resistance on treatment outcomes in non-HIV-infected patients with multidrug-resistant tuberculosis.

BACKGROUND: Recently, serious concerns about extensively drug-resistant tuberculosis (XDR-TB), which shows resistance to second-line anti-TB drugs in addition to isoniazid and rifampicin, have been raised. The aim of this study was to elucidate the impact of extensive drug resistance on treatment outcomes in non-human immunodeficiency virus (HIV)-infected patients with multidrug-resistant tuberculosis (MDR-TB). METHODS: Patients who received the diagnosis of and treatment as having MDR-TB at Seoul National University Hospital (Seoul, Republic of Korea) between January 1996 and December 2005 were included. The definition of XDR-TB was TB caused by bacilli showing resistance to both isoniazid and rifampicin and also showing resistance to any fluoroquinolone and to at least 1 of the following 3 injectable anti-TB drugs: capreomycin, kanamycin, and amikacin. To identify the impact of extensive drug resistance on treatment outcomes, univariate comparison and multiple logistic regression were performed. RESULTS: A total of 211 non-HIV-infected patients with MDR-TB were included in the final analysis. Among them, 43 patients (20.4%) had XDR-TB. Treatment failure was observed in 19 patients (44.2%) with XDR-TB, whereas treatment of 46 patients (27.4%) with non-XDR-TB failed (P=.057). The presence of extensive drug resistance (adjusted odds ratio [OR], 4.46; 95% confidence interval [CI], 1.35-14.74) and underlying comorbidity (adjusted OR, 2.62; 95% CI, 1.00-6.87) were independent risk factors for treatment failure. However, a higher level of albumin was inversely associated with treatment failure (adjusted OR, 0.87; 95% CI, 0.77-0.97). CONCLUSION: The presence of extensive drug resistance, the presence of comorbidity, and hypoalbuminemia were independent poor prognostic factors in non-HIV-infected patients with MDR-TB.     

Type 2 diabetes and multidrug-resistant tuberculosis

The association between tuberculosis (TB) and diabetes is re-emerging with the epidemic of type 2 diabetes (T2DM). We analyzed retrospective data from 2878 TB patients across the Texas/Mexico border. Overall, 161/2878 (5.6%) patients had MDR TB (resistance to rifampin and isoniazid): Texas 49/1442 (3.4%) and Mexico 112/1436 (7.8%). In Texas, MDR TB was significantly associated with T2DM (OR 2.1, 95% CI 1.1-4.2) when adjusted for age, gender, drug and alcohol abuse, HIV infection and history of previous episode of TB; and in Mexico (OR 1.80, 95% CI 1.1-2.9) when adjusted for age and gender. Patients with T2DM in both countries were more likely to be compliant with DOTS therapy (Texas: OR 2.4, 95% CI 1.1-5.4) than patients without T2DM. In Texas, all but 3 of the T2DM patients with MDR TB were resistant at their first culture at the time of diagnosis. It is possible that impaired immunity in T2DM increases susceptibility to infection with resistant strains.     

Clinical characteristics and outcomes among older nursing home residents hospitalized with pneumonia

Background: Due to population aging, the number of cases of pneumonia in nursing homes in South Korea has been increasing. This study investigated the characteristics and clinical outcomes in nursing home residents with pneumonia admitted to a tertiary hospital.Methods: A retrospective cohort study was conducted of patients transferred to the tertiary hospital from nursing homes between August 2009 and October 2016. The in-hospital mortality, Pneumonia Severity Index, bacterial pathogens in sputum cultures, and antibiotic sensitivity profile were assessed.Results: The analysis included a total of 174 patients hospitalized with pneumonia. Their median age was 78 years, and 109 patients (62.6%) were male. 108 patients (62.1%) were admitted to the intensive care unit. The in-hospital mortality rate was 12.6% (22/174). Culture of a multidrug-resistant (MDR) pathogen was an independent risk factor for mortality (odds ratio [OR]: 3.72, 95% confidence interval [CI]: 1.16–11.89). Male sex and a history of antibiotic use within the previous 3 months were independent risk factors for MDR pathogen isolation (OR: 3.32, 95% CI, 1.38–7.98 and OR: 3.93, 95% CI: 1.82–8.49, respectively).Conclusions: Detection of an MDR pathogen, rather than host factors such as old age, bedridden status, and comorbidities, was the most important risk factor for in-hospital mortality in patients with nursing home pneumonia. Patients with a history of antibiotic use within the previous 3 months had a higher probability of MDR pathogen identification. Identifying MDR pathogens is important in treating older nursing home residents with pneumonia.     

Impact of sputum gross appearance and volume on smear positivity of pulmonary tuberculosis: a prospective cohort study

ABSTRACT: BACKGROUND: Although checking specimen quality upon sputum collection for acid-fast smear of suspected tuberculosis (TB) cases is recommended, this procedure is based on expert opinion. The purpose of this study was to elucidate the impact of sputum gross appearance and volume on smear positivity among patients with suspected pulmonary TB, according to sex. METHODS: From November 2010 through June 2011, we enrolled consecutive patients suspected to have active pulmonary TB. The association of sputum gross appearance and volume with smear positivity, along with other variables possibly affecting smear positivity such as symptoms, disease extent, and cavity on chest radiograph, were investigated. RESULTS: Among 2,439 patients undergoing TB examination, 170 (113 men, 57 women) with active pulmonary TB were enrolled in the final analysis. They submitted 492 sputa. There were 73 smear-positive patients (42.9%) and 164 smear-positive sputa (33.3%). While gross appearance was associated with smear positivity in both sexes (purulent or blood-tinged sputum (rather than mucoid sputum or saliva); odds ratio (OR), 2.05, 95% confidence interval (CI), 1.21-3.47 in men; OR, 2.78, 95% CI, 1.23-6.26 in women), the amount of sputum specimens was associated with smear positivity in only female patients (4 ml or more versus less than 4 ml; OR, 4.96, 95% CI, 1.98-12.37). CONCLUSIONS: Sputum gross appearance and volume were associated with smear positivity. A volume of 4 ml seems to be the the minimum sputum volume acceptable for smear microscopy in females suspected of TB. Those suspected of TB should be encouraged to expectorate grossly qualified sputum specimens.     

Treatment and outcome of Staphylococcus aureus bacteremia: a prospective study of 278 cases.

BACKGROUND: Staphylococcus aureus bacteremia is still a serious problem, and the optimal treatment is under debate. Only a few studies concerning treatment are available. METHODS: The study population was all patients with a positive blood culture result for S aureus in Copenhagen County, Denmark, from May 1994 through April 1996. Of 278 patients with S aureus bacteremia, 186 were evaluated according to outcome in a prospective, observational follow-up study. The time above the minimum inhibitory concentration was estimated for dicloxacillin sodium for each treatment regimen and evaluated by logistic regression along with other potential risk factors. RESULTS: The following variables were statistically associated with death: the presence of an uneradicated focus (odds ratio [OR], 6.7; 95% confidence interval [CI], 2.1-21.0); the presence of septic shock (OR, 3.7; 95% CI, 1.5-9.1); the total daily dose of penicillinase-stable penicillin less than 4 g (OR, 3.7; 95% CI, 1.3-11.1); and age 60 years or older (OR, 2.4; 95% CI, 1.1-5.3). The following variables were significantly associated with recurrence: the total daily dose of penicillinase-stable penicillin less than 3 g (OR, 3.9; 95% CI, 1.6-10.0) and the presence of a secondary focus (OR, 3.2; 95% CI, 1.3-7.7). Among 155 patients with observation time longer than duration of treatment, this factor (duration of treatment, <14 days) was significantly related to mortality (OR, 0.84; 95% CI, 0.76-0.94). CONCLUSIONS: Focus eradication and the dosing of penicillinase-stable penicillin are important to the outcome of S aureus bacteremia. We recommend treatment with at least 1 g of penicillinase-stable penicillins 4 times daily for longer than 14 days.     

Variability of Infectious Aerosols Produced during Coughing by Patients with Pulmonary Tuberculosis

Rationale: Mycobacterium tuberculosis is transmitted by infectious aerosols, but assessing infectiousness currently relies on sputum microscopy that does not accurately predict the variability in transmission. Objectives: To evaluate the feasibility of collecting cough aerosols and the risk factors for infectious aerosol production from patients with pulmonary tuberculosis (TB) in a resource-limited setting. Methods: We enrolled subjects with suspected TB in Kampala, Uganda and collected clinical, radiographic, and microbiological data in addition to cough aerosol cultures. A subset of 38 subjects was studied on 2 or 3 consecutive days to assess reproducibility. Measurements and Main Results: M. tuberculosis was cultured from cough aerosols of 28 of 101 (27.7%; 95% confidence interval [CI], 19.9-37.1%) subjects with culture-confirmed TB, with a median 16 aerosol cfu (range, 1-701) in 10 minutes of coughing. Nearly all (96.4%) cultivable particles were 0.65 to 4.7 μm in size. Positive aerosol cultures were associated with higher Karnofsky performance scores (P = 0.016), higher sputum acid-fast bacilli smear microscopy grades (P = 0.007), lower days to positive in liquid culture (P = 0.004), stronger cough (P = 0.016), and fewer days on TB treatment (P = 0.047). In multivariable analyses, cough aerosol cultures were associated with a salivary/mucosalivary (compared with purulent/mucopurulent) appearance of sputum (odds ratio, 4.42; 95% CI, 1.23-21.43) and low days to positive (per 1-d decrease; odds ratio, 1.17; 95% CI, 1.07-1.33). The within-test (kappa, 0.81; 95% CI, 0.68-0.94) and interday test (kappa, 0.62; 95% CI, 0.43-0.82) reproducibility were high. Conclusions: A minority of patients with TB (28%) produced culturable cough aerosols. Collection of cough aerosol cultures is feasible and reproducible in a resource-limited setting.     

Short-term effects of wood smoke exposure on the respiratory system among charcoal production workers

STUDY OBJECTIVES: We aimed to investigate the short-term respiratory effects of heavy, occupational wood smoke exposure among traditional charcoal production workers. PATIENTS AND SETTING: A total of 22 charcoal workers (mean age, 41 years; 9 current smokers, 5 ex-smokers, and 8 nonsmokers) were studied and compared with a control group of 35 farmers residing in Perama, Rethymnon, Crete. RESULTS: The charcoal workers were exposed to wood smoke for an average of 14 h/d during a mean of 23.7 days required for the burning of kilns. The workers under study were found to have significantly more cough (odds ratio [OR], 4.8; 95% confidence interval [CI], 1.2 to 19.7), sputum production (OR, 6; 95% CI, 1.4 to 26.5), wheezing (OR, 7.7; 95% CI, 1.4 to 41.5), dyspnea (OR, 28.7; 95% CI, 5.4 to 153), and hemoptysis (OR, 2.7; 95% CI, 0.7 to 55) than the control group. The prevalence of respiratory symptoms such as cough, sputum production, wheezing, and dyspnea in the charcoal workers was significantly elevated during the exposure period (OR, 5.4; 95% CI, 1.1 to 17.7; OR, 5.7; 95% CI, 1 to 31; OR, 9.8; 95% CI, 1 to 88; and OR, 36.7; 95% CI, 1 to 327, respectively). The mean +/- SD percent of predicted values of FVC, FEV(1), FEV(1)/FVC ratio, and forced expiratory flow at 25 to 75% of FVC during the exposure period were significantly lower than those before exposure: 106 +/- 10.8 vs 101 +/- 11.9, p < 0.01; 104 +/- 16 vs 97 +/- 15, p < 0.001; 81 +/- 9 vs 78 +/- 8, p < 0.001; and 95 +/- 27 vs 80 +/- 25, p < 0.01, respectively. The mean +/- SD value of peak expiratory flow at midday and in the evening during the exposure were significantly lower than before: 524 +/- 131 L/min vs 548 +/- 108 L/min, p = 0.03; and 521 +/- 135 L/min vs 547 +/- 131 L/min, p = 0.02, respectively. CONCLUSIONS: Our results suggest that wood smoke exposure in charcoal workers is associated with increased respiratory symptoms and decreased pulmonary function. Longitudinal studies are needed to determine potential long-term adverse respiratory effects.     

Community-acquired pneumonia due to gram-negative bacteria and pseudomonas aeruginosa: incidence,risk, and prognosis

BACKGROUND: Initial empirical antimicrobial treatment of patients with community-acquired pneumonia (CAP) is based on expected microbial patterns. We determined the incidence of, prognosis of, and risk factors for CAP due to gram-negative bacteria (GNB), including Pseudomonas aeruginosa. METHODS: Consecutive patients with CAP hospitalized in our 1000-bed tertiary care university teaching hospital were studied prospectively. Independent risk factors for CAP due to GNB and for death were identified by means of stepwise logistic regression analysis. RESULTS: From January 1, 1997, until December 31, 1998, 559 hospitalized patients with CAP were included. Sixty patients (11%) had CAP due to GNB, including P aeruginosa in 39 (65%). Probable aspiration (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.02-5.2; P =.04), previous hospital admission (OR, 3.5; 95% CI, 1.7-7.1; P<.001), previous antimicrobial treatment (OR, 1.9; 95% CI, 1.01-3.7; P =.049), and the presence of pulmonary comorbidity (OR, 2.8; 95% CI, 1.5-5.5; P =.02) were independent predictors of GNB. In a subgroup analysis of P aeruginosa pneumonia, pulmonary comorbidity (OR, 5.8; 95% CI, 2.2-15.3; P<.001) and previous hospital admission (OR, 3.8; 95% CI, 1.8-8.3; P =.02) were predictive. Infection with GNB was independently associated with death (relative risk, 3.4; 95% CI, 1.6-7.4; P =.002). CONCLUSIONS: In our setting, in every tenth patient with CAP, an etiology due to GNB has to be considered. Patients with probable aspiration, previous hospitalization or antimicrobial treatment, and pulmonary comorbidity are especially prone to GNB. These pathogens are also an independent risk factor for death in patients with CAP.     

Trend of anti-tuberculosis drug resistance in Korea, 1994-2004.

SETTING: The 245 health centres through which the National Tuberculosis Programme (NTP) is implemented in Korea and the TB Laboratory Network of the Korean National Tuberculosis Association. OBJECTIVE: To observe the trend of anti-tuberculosis drug resistance in Korea from 1994 to 2004 and possible related factors. DESIGN: All tuberculosis (TB) patients registered for treatment at the health centres for a given period were assessed. RESULTS: Of 2636 new smear-positive patients from the 2004 survey, 338 cases (12.8%, 95% confidence interval [CI] 11.5-14.1) showed resistance to any of the first-line drugs: 261 with isoniazid (INH) resistance (9.9%, 95%CI 8.8-11.0) and 71 with multidrug resistance (MDR) (2.7%, 95%CI 2.1-3.3). Compared with previous surveys, a statistically significant increase in MDR (P=0.00675), any drug resistance (P=0.03779), any INH resistance (P=0.00313) and any rifampicin resistance (P = 0.00176) has been observed among new cases since 1994. Any resistance to second-line drugs ranged from 0.1% (capreomycin) to 1.1% (para-aminosalicylic acid) among new cases and from 1.1% to 3.6% among retreatment cases. Resistance to kanamycin and ofloxacin was found in 1.4% and 2.6%, respectively, of new and previously treated MDR-TB cases. CONCLUSION: A statistically significant increase in drug resistance was noticed among new cases.     

TB surveillance in correctional institutions in Hong Kong, 1999-2005.

OBJECTIVE: To understand the epidemiology of tuberculosis (TB) inside the prison system of Hong Kong. METHOD: Prospective territory-wide TB surveillance was conducted among prisoners in 24 correctional institutions. RESULTS: From 1999 to 2005, 622 prevalent TB cases diagnosed before or within 3 months of incarceration and 214 incident cases diagnosed after 3 months were reported by prison staff to a paper-based central prison TB registry. Both crude prevalence and incidence were falling (chi(2) for trend, both P < 0.001), despite a higher sex- and age-adjusted prison TB incidence as compared to the general population (indirectly standardised rate [ISR] 280.6 vs. 108.0/100000, P < 0.001). Illegal immigrants (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.8-7.4) and drug addicts (OR 2.04, 95%CI 1.13-3.7) were two major risk groups. The TB incident risk disappeared after their exclusion (ISR 117.1 vs. 108.0/100000, P = 0.52). No significant difference in the multidrug-resistant rate was found when comparing the group with the general population (3.5% vs. 1.0%, OR 3.6, 95%CI 0.5-28.4). No extensively drug-resistant (XDR) cases were identified. CONCLUSION: TB remains a significant disease in local prisons. Further strengthening of TB control programmes in prisons, especially targeting the higher risk groups, is recommended.     

Usefulness of whole-blood interferon-gamma assay and interferon-gamma enzyme-linked immunospot assay in the diagnosis of active pulmonary tuberculosis

PURPOSES: The aim of this study was to evaluate the usefulness of the whole-blood interferon-gamma assay (enzyme-linked immunosorbent assay [ELISA]) and interferon-gamma enzyme-linked immunospot assay (ELISPOT) based on early secretory antigenic target 6 and culture filtrate protein 10 in the diagnosis of active pulmonary tuberculosis (TB) in routine clinical practice. METHOD: We conducted a prospective study enrolling 144 participants with suspected pulmonary TB in a tertiary referral hospital in Seoul, South Korea, to investigate the diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these tests. Clinical assessment, tuberculin skin test (TST), whole-blood interferon-gamma ELISA (QuantiFERON-TB Gold [QFT-G]; Cellestis Ltd; Victoria, Australia), and an ELISPOT assay (T SPOT.TB; Oxford Immunotec; Oxford, UK) were performed. Test results were compared with the final confirmed diagnoses. RESULTS: Active pulmonary TB was diagnosed in 67 of 144 participants (47%). Sensitivities of QFT-G and T SPOT.TB for active pulmonary TB were 89% (95% confidence interval [CI], 79 to 96%) and 92% (95% CI, 83 to 97%), respectively; and specificities were 49% (95% CI, 37 to 61%) and 47% (95% CI, 36 to 59%). NPVs of QFT-G (84%; 95% CI, 69 to 93%) and T SPOT.TB (87%; 95% CI, 73 to 96%) were higher than that of TST (64%; 95% CI, 51 to 76%) [p = 0.001 and p < 0.001, respectively]. CONCLUSION: High NPVs of QFT-G and T SPOT.TB for the diagnosis of active TB suggest the supplementary role of these tests for the diagnostic exclusion of active TB, although the low PPV limits their usefulness in routine clinical practice in South Korea, where the prevalence of latent TB infection is considerable.     

Lack of association of HLA-B*51 with a severe disease course in Beh?et's disease.

OBJECTIVE: To investigate the previously reported association of HLA-B51 with the manifestations and severity of Beh?et's disease (BD). METHODS: The study group consisted of 148 consecutive BD patients (89 male, 59 female) with a minimum disease duration of 5 yr followed up at an out-patient BD clinic in a tertiary referral centre. The patients were classified into three severity groups (mild, moderate, severe) using a modified form of the BD total activity index. HLA-B alleles were determined by DNA amplification using the polymerase chain reaction and sequential hybridization with sequence-specific oligonucleotide probes. RESULTS: The frequencies of genital ulceration [odds ratio (OR)=3.1, 95% confidence interval (CI) 1.3-7.5], skin findings (erythema nodosum, folliculitis or acne-like lesions) (OR=4.4, 95% CI 1.1-17.7), a positive skin pathergy test (OR=3.4, 95% CI 1.1-10.9) and eye disease (OR=1.8, 95% CI 0.9-3.7) were all higher in B*51-positive patients. By contrast, no significant association was observed between B*51 positivity and a severe disease course, and B*51 homozygosity did not exhibit a prominent association with the severity of BD. Male sex was found to be the strongest determinant of the severity of BD by logistic regression analysis (OR=4.7, 95% CI 1.9-11.2). CONCLUSION: HLA-B*51 does not exhibit a strong association with a more severe disease course in BD. The involvement of other genetic and/or environmental factors seems to be required and to be more important than B*51 for the progression of BD.     

Work-related asthma-like symptoms among florists

OBJECTIVES: In this study, we evaluated the prevalence of work-related asthma-like symptoms and possible risk factors among florists in Turkey. METHODS: We collected questionnaire data from 128 florists, and investigated occupational history and respiratory, ocular, dermal, and nasal symptoms. We evaluated pulmonary function tests with spirometry and atopy by using the skin-prick test. Possible risk factors were analyzed by age-adjusted, smoking-adjusted, and gender-adjusted logistic regression models comparing symptomatic and asymptomatic individuals. RESULTS: The prevalence of work-related asthma-like symptoms was 14.1% (18 patients). We observed excess risk with a high work intensity (odds ratio [OR], 7.3; 95% confidence interval [CI], 1.1 to 51.8) and long work duration (OR, 5.1; 95% CI, 1.2 to 21.6). Florists with work-related asthma-like symptoms were 5.9 times more likely (95% CI, 1.4 to 24.3) to have a positive skin test response to a flower mix allergen. We also observed an excess risk for work-related asthma-like symptoms among those with allergic rhinitis (OR, 13.2; 95% CI, 3.1 to 56.4) and conjunctivitis (OR, 8.4; 95% CI, 2.4 to 29.2). CONCLUSION: The most prominent risk factors in florists were work intensity, work duration, and specific atopy.     

Response to empirical anti-tuberculosis treatment in patients with sputum smear-negative presumptive pulmonary tuberculosis

BACKGROUND: In many cases, physicians initiate anti-tuberculosis (TB) treatment based only on symptoms or radiographic findings without confirmation of pulmonary TB by acid-fast bacilli (AFB) smear. It has not been well known which clinical characteristics could be used as predictors for positive culture or real TB in patients with sputum smear-negative presumptive pulmonary TB. OBJECTIVE: We tried to elucidate treatment outcomes in patients with sputum smear-negative presumptive pulmonary TB and to find predictors of positive culture results. METHODS: We reviewed data of the patients who had been treated as presumptive TB with negative AFB smear on the basis of clinical and radiographic features from December 1998 to December 2000 at a university hospital in Korea. We reviewed medical records and radiographs of patients and analyzed possible predictors for positive culture. RESULTS: One hundred and one patients were enrolled. Among them, pulmonary TB was confirmed by culture in 32 patients (31%). Thirty-one (96.9%) out of 32 culture-positive patients showed clinical or radiographic improvement as did 50 (72.5%) out of 69 culture-negative patients. The predictor for a positive culture result is the presence of patchy consolidation in an initial radiograph (p = 0.025; OR 2.89; 95% CI 1.14-7.28). CONCLUSIONS: The empirical anti-TB treatment in patients with sputum smear-negative presumptive pulmonary TB was effective and adequate, especially presented with patchy consolidation in initial chest radiographs in Korea.     

Drug-resistant tuberculosis in Yangon, Myanmar

The extent of drug resistant tuberculosis (TB) in the capital city of Myanmar, Yangon has not yet been reported. This study aimed to determine the proportion and pattern of drug resistance to first-line anti-TB drugs, among Mycobacterium tuberculosis complex isolates from sputum smear positive TB patients who attended National TB Programme Yangon centres in April-August and October-December 2002. Drug susceptibility was determined by the Mycobacteria Growth Indicator Tube manual system (Becton Dickinson, MD, USA). Of the 567 patients, sputum specimens from 447 (79%) had a positive culture. Of these, 357 isolates (80%) had a susceptibility test result. Isolates from 76 of 259 (29.3%) new patients and from 45 of 98 (45.9%) previously treated patients were resistant to at least 1 of the anti-TB drugs. Resistance to isoniazid (INH) (22.0% vs 40.8%: new vs previously treated patients) and to > or =2 drugs (17.8% vs 29.6%: new vs previously treated patients) was common. Multidrug- resistant TB (MDR-TB) among new and previously treated patients was 4.2% and 18.4%, respectively. INH-resistant (adjusted OR: 2.0, 95% CI 1.1-3.6) and MDR-TB (adjusted OR: 3.4, 95% CI 1.4-8.3) cases were more likely to have taken anti-TB drugs > or =1 month previously. Collectively, prevalence of MDR-TB and TB resistance to > or =2 drugs are not rare in Yangon.