Extrapulmonary tuberculosis in immunocompetent adults

Tuberculosis continues to be a significant cause of morbidity and mortality. Although tuberculosis usually attacks the lungs, other organs can also be affected, leading to extrapulmonary tuberculosis (EPT) or disseminated tuberculosis. This study retrospectively analysed the incidence, clinical sites and risk factors for EPT in 252 patients with EPT between 1 January 1991 and 30 June 2003. EPT was defined as clinical, laboratory, imaging, and/or histopathological evidence of mycobacterial infection in a site other than hilar lymph nodes or lung parenchyma. In our study group, tuberculous lymphadenitis (36.5%) was found to be the most common clinical presentation of EPT. 119 (47.2%) patients developed the severe form of EPT, according to the WHO report, and 133 (52.8%) patients developed the less severe form. A case history of pulmonary tuberculosis was found to be a risk factor for the development of EPT (p <0.05). The study showed that EPT is still a public health problem. These findings suggested that pulmonary tuberculosis may play a critical role in the development of EPT. 12-month therapy may be chosen in patients with EPT considering acceptable adverse effects without relapses.     

Extrapulmonary tuberculosis in children]

Extrapulmonary tuberculosis morbidity in children of the Novosibirsk region for the period of 10 years was analysed on the basis of the materials presented by the regional antituberculosis center. It was found that 44 children has extrapulmonary tuberculosis which accounted for 17.9% of the total number of sick children and 5.7% of all extrapulmonary tuberculosis patients. Tuberculous lymphadenitis was diagnosed in 50% and bone-and-joint tuberculosis in 27.3% of cases; nephrotuberculosis occupied the third and ocular tuberculosis the fourth place; 20% of sick children were detected after their examination and 80% after surgery for other general diseases. Complications of the main process at the moment of application for help had 18.2% of children. The basic causes of later extrapulmonary tuberculosis diagnosis in children is the absence of awareness for tuberculosis in the general practitioners and inadequate work carried out in tuberculosis infection foci.     

Extrapulmonary tuberculosis in the United States

From 1963 to 1986, the number of reported cases of pulmonary tuberculosis in the United States declined an average of 5.0% annually, and the number of cases of extrapulmonary tuberculosis declined an average of 0.9% annually over the same period. In 1986, 17.5% of all cases of tuberculosis were extrapulmonary. Of pulmonary cases, 63.0% occurred among racial ethnic minorities and the foreign-born, whereas of extrapulmonary cases, the respective proportion was 71.2%. After adjustment for other variables, the proportion of extrapulmonary tuberculosis among all patients with tuberculosis by age was found to be largest in children and generally to decrease with increasing age, larger among black, Asian, and American Indian than among non-Hispanic white patients, larger among female than among male patients, and larger among the foreign-born than among patients born in the United States. The smaller decline in extrapulmonary tuberculosis over the years may be partially due to changes in the demographic characteristics of patients with tuberculosis. Considerable differences in susceptibility to different sites of extrapulmonary tuberculosis by age, race/ethnicity, sex, and country of origin were found. The reasons for these differences remain largely unexplained.     

Juvenile dermatomyositis: a tertiary center experience

Juvenile dermatomyositis (JDM) is a rare chronic inflammatory disease of unknown etiology and primarily involves muscle and skin. It is the most common idiopathic inflammatory myopathy of childhood. This study aimed to evaluate demographic and clinical features, laboratory data, treatment modalities, and outcome of patients with JDM at a referral pediatric rheumatology center in Turkey. We retrospectively reviewed medical records of patients diagnosed with JDM between the years 2003–2016 at the Pediatric Rheumatology Department Cerrahpasa Medical Faculty. A total of 50 patients (35 females), median age at the onset 6.1 ± 4.1 years, were identified. Mean follow-up period was 74.5 ± 49.7 months. Presenting clinical symptoms included heliotrope rash (100%), Gottron papule (96%), muscle weakness (90%), erythroderma (88%), and calcinosis (38%). All patients had elevated muscle enzymes at the disease onset. Sixty-eight percent of the patients had anti-nuclear antibody positivity. Electromyography on 27 patients and muscle biopsy on 14 patients were performed, and all of them showed signs of juvenile dermatomyositis. Early aggressive treatment with corticosteroids mostly in combination with methotrexate was used. Cyclosporine was added to 48% of the patients’ treatment regimen in case of severe or refractory disease. All patients except two cases, who were referred to our clinic after long disease duration with widespread calcinosis, achieved remission. Early diagnosis and early initiation of intensive therapy are important in reducing JDM complications. International collaboration is needed in order to better understanding and management of the disease.     

Mycobacterium tuberculosis complex bacteremia among HIV and non-HIV patients in a Mexican tertiary care center

Objectives

To determine the factors associated with Mycobacterium tuberculosis complex-positive blood culture.

Extrapulmonary tuberculosis in the northeastern suburbs of Paris: 141 cases

Background: Big cities were particularly affected by tuberculosis in the 1990s. Methods: We studied 141 cases of extrapulmonary tuberculosis in patients not infected by HIV in the northeastern suburbs of Paris. Results: A total of 84 men and 57 women were included in the study. Their average age at diagnosis was 42.2 years. Some 73.6% of the patients were foreign-born. A total of 182 sites were identified in 141 patients. There was an association with pulmonary tuberculosis in 38 cases. The sites were: lymph node (48.9%), pleural (25.5%), skeletal (22.7%), genitourinary (5.7%), and meninges (5%). Unfavorable social conditions were frequently observed. The average duration of treatment was 10 months. Twenty-four adverse drug effects were noted. Sixty-eight strains of Mycobacterium tuberculosis were isolated. Five cases of primary resistance to at least one antituberculous drug and only one case of multidrug resistance were observed. Some 95.7% of the 93 patients who were not lost to follow up were cured. Conclusion: Independently of HIV infection, extrapulmonary tuberculosis is still present, particularly in the suburbs of big cities, where social conditions are poor. The significant number of patients lost to follow-up demands that measures be adapted for the therapeutic management of these patients.     

Extrapulmonary tuberculosis in Peninsular Malaysia: retrospective study of 195 cases

During a 2-year retrospective study, 195 non-HIV-infected patients with extrapulmonary tuberculosis (EPT) were diagnosed at the National Tuberculosis Center, Kuala Lumpur, representing 10% of all patients with tuberculosis. Their mean age was 39 (+/- SD) 14 years old (range 14-81). The largest age group was 25-34 years, while 78.5% were less than 50 years of age. The subjects were mainly female (50.3%), Malay (49.2%), married (61.5%), resided in Kuala Lumpur (51.0%), and were unemployed (50.3%). Regarding risk factors, they were smokers and/or alcohol users (21.0%), and injecting drug users (IDUs) (5.1%); they also had history of tuberculosis (3.6%) and contact with TB patients (9.2%). Lymphadenopathy was the most common sign (45.6%) shown in the medical records. 42% of x-ray findings (chest, spine, and hip) showed signs consistent with tuberculosis, while histopathology was the most useful diagnostic tool (52.3%) and lymph node was the most frequent specimen used (35.0%) in this study. The three main sites of involvement were lymph nodes (42.6%), miliary and disseminated (19.5%), and pleura (12.8%). The outcome of this study showed 72.8% of these patients had completed treatment for at least 6 months, whilst, only 4.6% of patients were still undergoing treatment, and unfortunately, 22.6% of them showed non-adherence to anti-tubercular therapy at a duration of less than 6 months. However, no MDR-TB or death cases were reported or registered in this study.     

Extrapulmonary tuberculosis in high prevalence of tuberculosis and low prevalence of HIV

The authors' data show a higher rate of pleural and meningeal involvement among extrapulmonary TB cases than expected by previous works. Special attention should be given to tuberculous meningitis cases among all extrapulmonary TB cases because of its high mortality rate. The most common extrapulmonary involvement is pleural. Pleural involvement is most common among the young male military service personnel. These data underscore the importance of determining pleural involvement among extrapulmonary TB cases and emphasize the need to consider clinic and epidemiologic differences in the diagnosis and evaluation of extrapulmonary TB. Finally, it seems unlikely that HIV infection currently has a role in the cause of extrapulmonary TB in the authors' region.     

Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience

Background

Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo).

Methods

Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort.

Results

In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease.

Conclusion

RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.     

Tuberculin skin test screening in a military school in Istanbul city center

To investigate the reason of high incidence of annual patients with tuberculosis (TB) in a military school previously known by screening tuberculin skin test (TST) and finding out the proportion of annual infection risk (PAIR), the prevalance of TB infection and the distribution for each grades. Our study is a cross-sectional epidemiologic study made about TB infection. TST were screened for all students in the school. 5 TU PPD was injected to every student and after 72 hours, the results were evaluated by measuring the diameter of enduration. Test was repeated after 10 days for negative reactions. Age, sex, the number of BCG wound, smoking and dwelling for last 5 years were asked from the students and their answers were recorded. More than 10 mm enduration for cases who had no BCG and 15 mm enduration for cases who had BCG were accepted positive. Chest roentgenogram was taken for each student enrolled into the study. Infection prevalance and PAIR were calculated after tests and measurements. The total number of students was 948. Of 917 (96.7%) were male and 31 (3.3%) were female. The mean age was 19.72 +/- 1.25. The mean of TST was 12.79 +/- 5.96 mm for all students. According to the number of BCG scar, the numbers of students, percentage and the mean of TST were like that 70 (7.3%) cases no BCG scar 8.41 +/- 7.87 mm, 393 (41.4%) students one BCG scar, 11.94 +/- 6.26 mm, 343 (36.1%) cases two BCG scars, 13.74 +/- 5.12 mm, 142 (14.9%) students three or more then three scars, 14.97 +/- 4.11 mm. In the students who had no BCG, TST positivity was 50%. TB infection prevalance of entire school and PAIR were 46% and 3.44% (respectively). In this study, we found that increased number of BCG wound associated with the increased diameter of TST enduration. The proportion of unvaccinated students was similar to the same age population in our country but it showed differences in the distribution of regions. The students who started first grade had serious TB infection risk in their first school year. We think that PAIR values derived from TST conversions done in high risky community by screening annual TST could show all aspects of TB infection risk in those community.     

Drug susceptibility patterns of Mycobacterium tuberculosis and clinical outcomes of drug-resistant tuberculosis at Srinagarind Hospital, a tertiary care center in northeastern Thailand

Drug-resistant tuberculosis is a major public health problem. The aim of this study was to assess the local susceptibility patterns of Mycobacterium tuberculosis and clinical outcomes of drug resistant tuberculosis (DR-TB) at Srinagarind Hospital, a tertiary care center in northeastern Thailand. Between January 2004 and December 2008, 1,052 patients had culture-proven M. tuberculosis infections at Srinagarind Hospital. M. tuberculosis was resistant to isoniazid (2.3%), rifampicin (2.8%), ethambutol (3.8%), streptomycin (2.1%), kanamycin (0.7%) and ofloxacin (1.9%). The occurrences of multi-drug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) were 1.2% and 0.38%, respectively. Of the 65 DR-TB patients, complete medical records were found for 55. The male to female ratio was 2.2:1. The mean age was 50 years. Thirteen patients had MDR-TB. The duration of symptoms in the MDR-TB group was longer than the non-MDR-TB group, 11.6 months vs 2.6 months, respectively. Half of MDR-TB and one-third of non-MDR-TB patients had a previous history of being treated for tuberculosis. Nearly 20% of cases were HIV positive. Mono-drug resistance was initially treated with standard first-line drugs (CAT 1). The clinical course was more likely to be worse during the maintenance phase if there was resistance to rifampicin. Whenever there was resistance to two, three or four drugs, the antituberculosis drugs were prescribed based on susceptibility patterns. Only 30% of patients with MDR-TB and XDR-TB responded to treatment. Culture and sensitivity testing for M. tuberculosis cases is recommended in patients at high risk for DR-TB, such as patients previously treated for tuberculosis and those HIV positive.     

Alagille syndrome: Experience of a tertiary care center in North India

Alagille syndrome (AGS) is an autosomal dominant disorder of chronic cholestasis characterized by paucity of interlobular bile ducts. The condition has been described only as isolated case reports in India. We describe clinical profile and outcome of nine subjects (six infants and three older children) with AGS. Cholestasis and characteristic facies were present in all, followed by congenital heart disease, vertebral anomalies, and posterior embryotoxon in seven, five, and four cases, respectively. Pruritus was the commonest symptom which was refractory to medical treatment in one third of cases. Two cases developed decompensated liver disease on follow up. High index of suspicion for this multisystemic condition is essential for correct diagnosis and management.