Mycobacterium tuberculosis infection in cancer patients at a tertiary care cancer center in Japan

The characteristics of active tuberculosis in cancer patients in Japan and the effects of this infection on cancer treatment have not yet been clarified. The records of all consecutive patients with microbiologically documented Mycobacterium tuberculosis infection diagnosed between September 2002 and March 2008 at Shizuoka cancer center (a 557-bed tertiary care cancer center in Japan) were reviewed. There were 24 cancer patients with active tuberculosis during the study period. Of these, 23 had solid-organ tumors, and the most common site of the underlying malignancy was the lung. Most of the patients had pulmonary tuberculosis. Among 15 patients followed up for more than 2 months prior to the diagnosis of pulmonary tuberculosis, 12 had healed scars suggestive of old tuberculosis lesions, as shown by chest imaging obtained at the time of the initial evaluation. Discontinuation of cancer therapy or more than a month's delay in surgery occurred in 10 patients with pulmonary tuberculosis. Development of active tuberculosis can delay cancer treatment in Japanese centers. Cancer patients with scars suggestive of old tuberculosis disease lesions as shown by chest imaging should be screened for active tuberculosis and carefully followed up. In some cases, prophylactic treatment should be considered.     

Tuberculosis Infection in Children

Globally, tuberculosis (TB) is the leading cause of infectious disease mortality; however, clinicians in the United States are increasingly unfamiliar with TB and the recommended tests and treatment for latent TB infection. Compared with adults, children who develop TB more often develop severe disease, and children < 2 years are particularly susceptible to developing TB disease after initial infection. Nurse practitioners who work in primary care are on the front lines of identifying children at high risk and obtaining testing and treatment. This article reviews the clinical course for identifying children at risk for TB and provides updated guidelines for testing and treatment.     

Return of tuberculosis: screening and preventive therapy

Approximately 25 percent of individuals exposed to Mycobacterium tuberculosis become infected. Of those, about 10 percent will develop clinically active tuberculosis at some time in their lives. The tuberculin skin test should be used to screen all patients, especially those at greatest risk of contracting the disease, such as the young and the old, and those with weakened immune systems from poor nutrition, alcohol and drug abuse, chronic illness and human immunodeficiency virus infection. Depending on the characteristics of the local population and individual medical risk factors, a reaction (induration) between 5 and 15 mm (or more) generally represents infection. Isoniazid therapy in persons with positive skin tests will decrease the risk of disease by 60 to 80 percent. Family physicians will play a critical role in efforts to eliminate tuberculosis from the United States by the year 2010.     

Tuberculosis: a focused review for the emergency medicine clinician

IntroductionTuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat.ObjectiveThis narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician.DiscussionTB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations.ConclusionsTB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.     

Prevention of tuberculosis for the immunocompromised host with biological agents and corticosteroid

Immunosuppressive drugs, such as corticosteroid and biological agents, inhibit the cell-mediated immunity and the granuloma formation against Mycobacterium tuberculosis. The rate of infection increases in patients given a daily dose of > or = 10 mg or a cumulative dose of > or = 700 mg of prednisone, and those patients need for the prevention of tuberculosis. Active tuberculosis may also develop after the initiation of TNFalpha inhibitors among biological agents. Before prescribing these immunosuppressive drugs, physicians should screen patients for latent tuberculosis infection or active disease with examining chest X-ray and CT, skin tuberculin test, and Quantiferon. The isoniazid daily regimen for 6-9 month is recommended for prevention, and rifampicin daily regimen for 4-6 month should be prescribed for the suspicious cases of isoniazid resistant.     

Evaluation and management of patients with pulmonary nontuberculous mycobacterial infections

Tuberculosis is responsible for more then 2 million deaths worldwide each year and vies with HIV as the world’s most fatal infectious disease. In many developing countries, attempts to control the spread of infection rely solely on identification and treatment of those with active disease, ignoring subclinical infection. However, in developed countries, large efforts are also expended to identify and give prophylactic drugs to people with latent tuberculosis infection. Until recently, the 100-year-old tuberculin skin test (Mantoux) has been the only available diagnostic test for latent tuberculosis infection, despite its many well-known limitations. Advances in scientific knowledge have led to the development of tests for tuberculosis that measure the production of interferon-γ by T-cells stimulated in vitro with Mycobacterium tuberculosis-specific antigens. These interferon-γ tests are highly specific and unaffected by prior Bacille Calmette–Guérin vaccination or immune reactivity to most atypical mycobacteria. They are more sensitive than the tuberculin skin test in detecting people with active tuberculosis, and their results correlate more closely with M. tuberculosis exposure risk factors than the tuberculin skin test in people likely to have latent tuberculosis infection. Science has caught up with one of the oldest diagnostic tests still in use worldwide, and the adoption of new, tuberculosis-specific interferon-γ-based tests should move us one step closer to better control of this insidious pathogen.     

结核菌素皮肤试验阳性人群是否应该接受化学预防治疗

结核病是我国常见的呼吸道传染病之一,发病率和死亡率仍居传染病之首。WHO估计全球有1/3的人口感染结核分枝杆菌(MTB),即潜伏结核感染者(LTBI),而我国是结核病高负担国家之一,大约有40%⁴5%的人口感染MTB。LTBI者在2年内发展成为有临床表现的活动性结核病的风险为5%45%的人口感染MTB。LTBI者在2年内发展成为有临床表现的活动性结核病的风险为5%¹0%,如果采取化学预防,可以降低LTBI者2年内的发病率。LTBI的检测最常用的方法是结核菌素皮肤试验(TST),但并非所用TST阳性人群均适宜化学预防。在我国对于TST强阳性人群,尤其是结核病的高危人群,适合采取化学预防治疗。预防方案可以是单药异烟肼,也可以是异烟肼联合利福平或利福喷汀预防治疗,疗程及给药方式没有统一标准。     

Disseminated tuberculosis complicating anti-TNF-alpha treatment

An unusually large number of cases of tuberculosis, often of miliary or disseminated form, have been reported in patients receiving infliximab therapy for rheumatoid arthritis or Crohn's disease. We describe a patient with rheumatoid arthritis who was treated with infliximab and became systemically ill with Mycobacterium tuberculosis-disseminated infection. Patients who are candidates for treatment with tumour necrosis factor-alfa inhibitors should be evaluated for the presence of latent or active     

Diagnosis of latent Mycobacterium tuberculosis infection: is the demise of the Mantoux test imminent?

Tuberculosis is responsible for more then 2 million deaths worldwide each year and vies with HIV as the world's most fatal infectious disease. In many developing countries, attempts to control the spread of infection rely solely on identification and treatment of those with active disease, ignoring subclinical infection. However, in developed countries, large efforts are also expended to identify and give prophylactic drugs to people with latent tuberculosis infection. Until recently, the 100-year-old tuberculin skin test (Mantoux) has been the only available diagnostic test for latent tuberculosis infection, despite its many well-known limitations. Advances in scientific knowledge have led to the development of tests for tuberculosis that measure the production of interferon-gamma by T-cells stimulated in vitro with Mycobacterium tuberculosis-specific antigens. These interferon-gamma tests are highly specific and unaffected by prior Bacille Calmette-Guérin vaccination or immune reactivity to most atypical mycobacteria. They are more sensitive than the tuberculin skin test in detecting people with active tuberculosis, and their results correlate more closely with M. tuberculosis exposure risk factors than the tuberculin skin test in people likely to have latent tuberculosis infection. Science has caught up with one of the oldest diagnostic tests still in use worldwide, and the adoption of new, tuberculosis-specific interferon-gamma-based tests should move us one step closer to better control of this insidious pathogen.     

Management of advanced HIV disease in patients with tuberculosis or hepatitis co-infection

Advanced human immunodeficiency virus (HIV) disease can be defined as a cluster of differentiation 4 (CD4) count <50 cells/mm³ or the presence of an acquired immunodeficiency syndrome (AIDS)‐defining illness. In the UK and Ireland, the number of patients who present with advanced HIV disease is increasing, with 301/977 (31%) of patients presenting late (<200 CD4 cells/mm³). Many patients who present with advanced HIV disease will have comorbid conditions, such as hepatitis B or C or tuberculosis (TB), which complicates the choice of therapy. This article reviews the evidence and some clinical scenarios for specific patient groups who may present with advanced HIV disease: those with comorbid TB, hepatitis B or hepatitis C. The aim is to offer practical advice on therapeutic options for treatment‐naïve patients who present with advanced HIV disease on the basis of available clinical evidence.     

类风湿关节炎合并活动性肺结核病的临床特征及相关因素分析

目的 分析类风湿关节炎(RA)合并活动性肺结核病的临床特征以及相关危险因素.方法 回顾分析41例RA合并活动性肺结核住院患者临床资料,按照年龄、性别1:1匹配选择同期无RA及其他风湿疾病的活动性肺结核住院患者进行临床特征分析,随机选取101例无活动性肺结核及其他病原体感染的RA同期住院患者进行相关因素分析,所有患者均有...     

Tuberculin skin test conversion from exposure to contaminated pulmonary function testing apparatus.

Tuberculosis is a prevalent infectious disease that is transmitted primarily from man to man by droplet nuclei. This report describes an outbreak of tuberculosis infection in a hospital in which 8 persons--7 hospital employees and 1 patient--had documented conversion of intermediate strength tuberculin tests from negative to positive in a period of about 10 weeks. The 7 employees constituted 18% of those selected for skin testing because of close contact with a patient who had newly discovered smear-positive pulmonary tuberculosis. The one patient converter had been tested on pulmonary function testing apparatus previously used by the person with active disease; 21 other patients who had also used the contaminated apparatus in the same time period did not convert. Infection of the patient who did convert is attributed to the pulmonary function testing apparatus. Epidemiological investigation revealed the importance of considering factors of inoculum, reservoir, and host in the transmission of infection.     

Chronic hepatitis B virus infection: issues in treatment

As research continues to define the optimal management of chronic hepatitis B virus (HBV) infection, clinicians must deal with a number of yet unresolved issues: Should we treat all patients with HBV infection to prevent liver cancer, even if they have no evidence of active disease? Which is the best treatment strategy? What do we do with patients who develop resistance to our current drugs? Should we treat patients with HBV infection who have already developed cirrhosis?     

Management of cardiac implantable electronic device infections: the challenges of understanding the scope of the problem and its associated mortality

The indications for cardiac implantable electronic devices (CIEDs) have increased significantly over the last two decades. This has led to a surge in device implants in an expanding cohort of recipients who are in general older and who have more comorbidities. Implantation of CIED is carried out under sterile techniques and with the use of perioperative antibiotics; however, despite all these preventive measures, CIED infection remains a significant complication. Many recent reports and data from national registries have suggested an increased rate of CIED infection. However, our understanding of its true incidence remains limited due to the lack of a clear denominator as the number of patients living with CIEDs continues to expand and the pool of patients who are at risk for developing infection is growing. The importance of CIED infection has been emphasized in many recent studies that have also suggested significant morbidity and mortality risk associated with this complication that spans beyond the extraction procedure of the infected device.     

Is cytomegalovirus reactivation increasing the mortality of patients with severe sepsis?

Cytomegalovirus (CMV) is a ubiquitous virus present in approximately two-thirds of the healthy population. This virus rarely causes an active disease in healthy individuals, but it is among the most common opportunistic infections in immunocompromised patients such as solid organ transplant recipients, patients receiving chemotherapy for cancer or patients with human immunodeficiency virus. Critically ill patients who are immunocompetent before intensive care unit admission may also become more prone to develop active CMV infection if they have prolonged hospitalizations, high disease severity, and severe sepsis. The development of active CMV infection in these critically ill patients has been associated with a significantly higher risk of death in several previous studies. The present issue of Critical Care brings a new study by Heininger and colleagues in which the authors found that patients with severe sepsis who developed active CMV infection had significantly longer intensive care unit and hospital stays, prolonged mechanical ventilation, but no changes in mortality compared to patients without CMV infection. We discuss the possible reasons for their findings (for example, selection bias and low (20%) statistical power to detect mortality endpoints), and also perform an update of our previous meta-analysis with the addition of Heininger and colleagues' study to verify whether the higher mortality rate with CMV holds. Our updated meta-analysis with approximately 1,000 patients shows that active CMV infection continues to be associated with a significant 81% higher mortality rate than that in critically ill patients without active CMV infection.     

Human immunodeficiency virus infection, Part II

The acceptance of highly active antiretroviral therapy (HAART) among patients and health care providers has had a dramatic impact on the epidemiology and clinical characteristics of many opportunistic infections associated with human immunodeficiency virus (HIV). Previously intractable opportunistic infections and syndromes are now far less common. In addition, effective antibiotic prophylactic therapies have had a profound impact on the risk of patients developing particular infections and on the incidence of these infections overall. Most notable among these are Pneumocystis carinii, disseminated Mycobacterium avium complex, tuberculosis, and toxoplasmosis. Nevertheless, infections continue to cause significant morbidity and mortality among patients who are infected with HIVThe role of HAART in many clinical situations is unquestioned. Compelling data from clinical trials support the use of these therapies during pregnancy to prevent perinatal transmission of HIV HAART is also recommended for health care workers who have had a ‘significant’ exposure to the blood of an HIV infected patient. Both of these situations are discussed in detail in this article. In addition, although more controversial, increasing evidence supports the use of HAART during the acute HIV seroconversion syndrome. An “umnune reconstitution syndrome” has been newly described for patients in the early phases of treatment with HAART who develop tuberculosis, M avium complex, and cytomegalovirus disease.Accumulating data support the use of hydroxyurea, an agent with a long history in the field of myeloproliferative disorders, for the treatment of HIV Newer agents, particularly abacavir and adefovir dipivoxil, are available through expanded access protocols, and their roles are being defined and clarified.     

Tuberculosis Health Education Needs in Homeless Shelters

Abstract Tuberculosis has reemerged as an important public health concern, particularly with the rise in multi-drug-resistant strains. The homeless are at increased risk for infection, for active disease, and for incomplete treatment. Public health authorities have recommended that tuberculosis health education materials be developed specifically for residents and staff of homeless shelters. In this study, a diverse sample of 20 adult homelessshelter residents responded to open-ended questions regarding 1) their knowledge of tuberculosis and tuberculosis screening and treatment, 2) their perceptions of access to health care services related to tuberculosis, and 3) their views of health education regarding tuberculosis. The majority of the subjects had limited knowledge of tuberculosis and of screening and treatment for the disease. Many had misconceptions about the disease, particularly regarding its transmission. An analysis of the subjects' responses within the framework of the Health Belief Model indicated that basic tuberculosis health education programs for residents of homeless shelters are needed. The study findings indicated that a small-group educational format utilizing written materials and video aids might be most effective.     

Latent tuberculosis: concordance and duration of treatment regimens

Over the past century, the UK has made significant progress in combating tuberculosis (TB) through improved health care and better preventative measures. However, it has now been identified as a new threat that needs concerted action. An important component in dealing with this threat is identifying and treating people with latent infection. This will prevent active disease and thwart the spread of tuberculosis infection. The aim of the study was to determine whether treatment concordance was affected by length of treatment regimen in the UK and to identify factors that may impact upon treatment completion. The audit was spread over a two-year period and looked at all patients on treatment for latent infection using the UK recommended regimens of either three months of dual therapy or six months using monotherapy. The results indicated that the 3-month regime had not improved concordance, as expected, with a slightly better completion rate in the 6-month group. However, the study did highlight a 'lost-to-follow-up' group of patients, who failed to present themselves following presumed completion.     

Tuberculous meningitis in adults--experience from Turkey

Background: The annual incidence of tuberculous meningitis (TM) is unknown. TM is a disease that still often results in residual sequelae, and has a mortality rate ranging between 15 and 51%. Experience of countries such as Turkey where drug‐resistant tuberculosis and TM are prevalent is important. Methods: Clinical and laboratory findings of 42 patients with TM, followed between 1991 and 2002, were evaluated retrospectively. Results: Twenty‐eight female and 14 male patients were included in this study. The mean age of the patients was 33.9 ± 13.2 years (range, 16–60 years). Fourteen had a history of pulmonary tuberculosis; 12 reported close contact with a person with active pulmonary tuberculosis; three were diagnosed with active pulmonary tuberculosis; two, with HIV infection; two, with Pott's disease; and one, with systemic lupus erythematosus. On admission, 17 patients were diagnosed with stage I; 15, with stage II; and 10, with stage III disease. Hemiparesis (35.7%), cranial nerve palsy (30.9%), and altered consciousness (26.9%) were the most common neurological deficits. Prolonged duration of pre‐existing symptoms and female gender were found as significant risk factors in those who develop neurological sequelae (p < 0.01 and p < 0.05, respectively). Cranial computerised tomography revealed various pathological findings in all but five patients. Sulcus effacement was the most common radiological finding. Enlargement of ventricles, focal cerebral oedema/shunt, calcification of meninges, tubercle, and infarction were other common abnormal radiological findings. Conclusions: Prolonged duration of pre‐existing symptoms and female gender are predictors of neurological sequelae of TM. Early identification of such patients and prompt initiation of anti‐tuberculosis therapy may improve their outcome.     

Non-pharmacological modification of cardiac risk factors: part 1

Many factors influence whether a person will develop coronary heart disease. Genetic predisposition, gender and advanced age are recognized risk factors for the development of coronary heart disease over which we have little control. On the other hand, high serum cholesterol, cigarette smoking, high blood pressure, excessive body weight and long-term physical inactivity are key risk factors over which we have considerable control. In many cases cardiac risk factors can be modified without resorting to pharmacological intervention. Current evidence suggests that individuals who follow a diet which is low in saturated fats and cholesterol, lose weight, stop cigarette smoking and take regular aerobic exercise will significantly reduce their risk of developing coronary heart disease. In addition, patients who already have evidence of coronary heart disease may improve their symptoms and prognosis by similar life-style changes. In the first of two parts, we review the role of exercise in modifying cardiac risk factors.