耐多药结核病:流行病学,危险因素及病人发现

尽管耐多药结核病(MDR-TB)的流行是最近出现的问题,但是已经有许多研究试图了解它。我们现在已经很好的估计了当前的负担(全世界约500000例MDR-TB),并且正在预测MDR-TB控制策略对这些数字的影响。估算的结核(TB)与MDR-TB的发病率趋势是不一样的。耐药的危险因素分为2类:(1)社区中促使耐药选择的因素;(2)可以增加某些病人对耐药易感性的特定条件。每个国家之间流行病学形势有很大差别,但主要的原因都是治疗不合理、结核病防治规划在过去(甚至目前,只是程度较轻)执行差。最近的报道显示,国家结核病防治规划有效地使用现有的药物,可以推迟甚至逆转MDR-TB的流行。本文还分析了其他流行病学相关的因素。认识到MDR-TB流行的因素、鉴别出MDR-TB高危人群有助于明确病人发现的重点。从个体角度,接受过含利福平的一线治疗方案治疗失败的病例以及MDR-TB接触者有最高的耐药风险。接受过治疗的结核病人,以及本文中分析的其他危险因素在病人发现时应优先考虑。     

Multidrug-resistant tuberculosis in pregnancy: case report and review of the literature

A woman at 23 weeks' gestation was treated with rifampin, isoniazid, and ethambutol for cavitary tuberculosis (TB). She did not respond within 3 weeks, and multidrug-resistant (MDR) TB was suspected. Direct plating on susceptibility media was performed immediately. Treatment was initiated with IV capreomycin, levofloxacin, para-aminosalicylic acid, pyrazinamide, cycloserine, and high-dose vitamin B(6) at 26 weeks' gestation. The patient delivered vaginally at week 35. The newborn was not infected. Following delivery, ethionamide was added as a sixth drug, and levofloxacin was replaced with moxifloxacin. The patient's sputum became smear-negative and culture-negative for TB. All reported cases of MDR-TB during pregnancy are reviewed.     

Multidrug-resistant tuberculosis: a menace that threatens to destabilize tuberculosis control

Multidrug-resistant tuberculosis (MDR-TB), caused by Mycobacterium tuberculosis that is resistant to both isoniazid and rifampicin with or without resistance to other drugs, is a phenomenon that is threatening to destabilize global tuberculosis (TB) control. MDR-TB is a worldwide problem, being present virtually in all countries that were surveyed. According to current World Health Organization and the International Union Against Tuberculosis and Lung Disease estimates, the median prevalence of MDR-TB has been 1.1% in newly diagnosed patients. The proportion, however, is considerably higher (median prevalence, 7%) in patients who have previously received anti-TB treatment. While host genetic factors may contribute to the development of MDR-TB, incomplete and inadequate treatment is the most important factor leading to its development, suggesting that it is often a man made tragedy. Efficiently run TB control programs based on a policy of directly observed treatment, short course (DOTS), are essential for preventing the emergence of MDR-TB. The management of MDR-TB is a challenge that should be undertaken by experienced clinicians at centers equipped with reliable laboratory services for mycobacterial cultures and in vitro sensitivity testing as it the requires prolonged use of costly second-line drugs with a significant potential for toxicity. The judicious use of drugs; supervised standardized treatment; focused clinical, radiologic, and bacteriologic follow-up; and surgery at the appropriate juncture are key factors in the successful management of these patients. With newer effective anti-TB drugs still a distant dream, innovative approaches such as DOTS-Plus are showing promise for the management of patients with MDR-TB under program conditions and appear to be a hope for future.     

Orbital tuberculosis diagnosed by immunohistochemistry: case reports

PURPOSE: To describe three cases of orbital tuberculosis, with their clinical characteristics and respective diagnostic procedures, showing the importance of histopathology for the correct diagnosis. PATIENTS AND METHODS: Three patients diagnosed and treated for orbital tuberculosis, in the "Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo" during the years of 1999 and 2001. RESULTS: All of the patients were female and referred a chronic evolution of swelling of one eyelid associated or not with other symptoms. They had not HIV infection. Two of them had positive epidemiology for tuberculosis. However, the search for systemic evidence of the disease and staining for bacilli (Ziehl-Neelsen method) were negative in all three patients. In all the cases, only the biopsy with immunohistochemical analysis could confirm the diagnosis. COMMENTS: Orbital involvement is a rare ocular manifestation of tuberculosis. Even in a tertiary hospital, few cases, if any, are diagnosed per year. However, the global incidence and prevalence of M. tuberculosis infections is not under control yet, and it has been a serious public health problem. Thus, one must be aware of the possibility of tuberculosis among the orbital diseases.     

Central nervous tuberculosis in patients non-VIH: seven case reports

PURPOSE: Tuberculosis involving the central nervous system (CNS) is rarely observed in non immuno-compromised hosts. We report herin the various clinical, biological and radiological manifestations observed in 7 patients with CNS tuberculosis. METHODS: Clinical and biological records of 7 patients with CNS tuberculosis were retrospectively studied. All patients had encephalic CT-scan and MRI in the course of the disease. RESULTS: 5 women and 2 men with a mean age of 38.4 years initially initially presented with headache (n = 6), fever (n = 5), meningeal irritation (n = 3), localizing neurological signs (n = 1). Lumbar punction revealed lymphocytic meningitis (n = 6/7). Mycobacterium tuberculosis or bovis was isolated in 3 patients only. Cerebral tomodensitography or magnetic resonance imaging were initially normal in most of cases (n = 4/7), but discovered in the course of disease basilar meningitis (n = 6), hydrocephalus (n = 6), abcess or tuberculoma (n = 4). In all the patients, initiation of the treatment was complicated by clinical and/or biological deterioration, called paradoxal reaction, leading in all cases to glucocorticoid adjunction, with various final results. Indeed, 4 patients developed neurological sequelae. No patient died. CONCLUSION: CNS tuberculosis is a rare disease in non immunocompromised patients whose diagnostic may be difficult due to the absence of specific clinical symptoms, negative initial radiological examination, as well as delayed and often negative bacterial isolation. Paradoxal reaction appeared to be frequent despite specific antibiotherapy and underlines the beneficial effects of addictive corticosteroids.     

Social participation in health: a case study in Brazil

OBJECTIVE: To study the complex relationships between government power and health care utilization in Brazil, through the analysis of local initiatives of social participation fostered by decentralization of health services. MATERIAL AND METHODS: A qualitative study was carried out among the local executive groups (LEG), particularly the one located in the peripheral area of Rio de Janeiro, known as AP.3.1. Group activities were followed during 1986. Data were collected by means of open interviews to community leaders, health service managers and university faculty. One of the main information sources was the LEG proceedings book. RESULTS: Data analysis disclosed the dynamics of the relationship between social mobilization and healthcare responses, underscoring the limits and potential of governmental initiatives regarding the inclusion of social groups as active interlocutors and actors in the definition of demands, as well as the limits of institutionalization of popular participation in settings socially and politically deprived. CONCLUSIONS: Contraposition between health policymakers and healthcare users is evidenced by the implementation of social participation strategies that do not take into account the organizational figures of social groups.     

Male genital tuberculosis: a review of the literature with instructive case reports

The prevalence of extrapulmonary tuberculosis, including cases at male genital sites, has remained relatively constant during the past two decades in the United States. The most common genital sites of tuberculous infection are the epididymis and prostate; the testicle is infected in a lower proportion of cases. The usual modes of genital involvement include descending infection from the kidneys, intracanalicular or direct extension from neighboring foci in the genital tract, and hematogenous seeding. Local symptoms are usually insidious and progressive. Systemic manifestations such as fever, chills, and sweats are infrequently present in isolated genital tuberculosis. Tuberculous genital infection can be confused with other bacterial (including nontuberculous mycobacterial) infections, fungal disease, tumors, and cysts as well as with a number of less common illnesses. Although some diagnostic and therapeutic indications for surgical excision still exist, the preferred approach to treatment is primarily multiple-drug antituberculous chemotherapy.     

Multidrug-resistant tuberculosis: eight years of surveillance in France.

The aim of this study was to evaluate the annual prevalence of multidrug-resistant tuberculosis (MDRTB) and to describe the characteristics of the patients with MDRTB in France. Annual questionnaire surveys from 1992-1999 were mailed to all French microbiological laboratories performing mycobacterial cultures. A total of 264 distinct patients were reported to the National Reference Centre for Resistance of Mycobacteria to Antituberculosis Drugs during the 8-yr surveillance period resulting in a mean annual prevalence of MDRTB of 0.6%. A mean of 16% of the MDRTB patients were reported over several subsequent years. The majority of patients were male (69.7%), foreign-born (55.7%), with a previous history of treatment (65.9%), and pulmonary involvement (92.8%) with smear-positive results (59.1%). Human immunodeficiency virus (HIV) coinfection was present in 20.8% of the patients. Strains were resistant only to isoniazid and rifampin in 37.9% of the cases, and additional resistance to both streptomycin and ethambutol was present in 25.8%. HIV coinfection and female status were statistically associated with primary resistance, whereas smear-positive results were associated with secondary resistance. Foreign-birth and smear-positive results were associated with a chronic status. The prevalence of multidrug-resistant tuberculosis is low in France (<1%). However, a substantial proportion of patients remain positive for several years, suggesting nonoptimal management. Therefore, as recommended by the World Health Organization, a few reference teams, working in collaboration with national associations of physicians and microbiologists, should be established to improve the outcome of multidrug-resistant tuberculosis.     

Multidrug-resistant tuberculosis in bone marrow transplant recipient

Multidrug-resistant tuberculosis (TB) is an increasing problem worldwide, however only three cases have been previously described in transplant recipients, especially involving lung and heart transplant. We describe a case of multidrug-resistant TB in an allogenic bone marrow transplant recipient with good response to second-line therapy.     

Multidrug-resistant tuberculosis: Treatment and outcomes of 93 patients

BACKGROUND:Tuberculosis (TB) remains a leading cause of death worldwide and the emergence of multidrug-resistant TB (MDR TB) poses a threat to its control. There is scanty evidence regarding optimal management of MDR TB. The majority of Canadian cases of MDR TB are diagnosed in Ontario; most are managed by the Tuberculosis Service at West Park Healthcare Centre in Toronto. The authors reviewed 93 cases of MDR TB admitted from January 1, 2000 to December 31, 2011.RESULTS:Eighty-nine patients were foreign born. Fifty-six percent had a previous diagnosis of TB and most (70%) had only pulmonary involvement. Symptoms included productive cough, weight loss, fever and malaise. The average length of inpatient stay was 126 days. All patients had a peripherally inserted central catheter for the intensive treatment phase because medications were given intravenously. Treatment lasted for 24 months after bacteriologic conversion, and included a mean (± SD) of 5±1 drugs. A successful outcome at the end of treatment was observed in 84% of patients. Bacteriological conversion was achieved in 98% of patients with initial positive sputum cultures; conversion occurred by four months in 91%.CONCLUSIONS:MDR TB can be controlled with the available anti-TB drugs.