Suspected pulmonary tuberculosis in rural South Africa--sputum induction as a simple diagnostic tool?

OBJECTIVES: To assess the value of sputum induction (SI) as a diagnostic tool for patients with suspected pulmonary tuberculosis (PTB) who are unable to expectorate or who have a negative sputum smear. DESIGN: Study of an inpatient cohort undergoing SI. SETTING: Mseleni Hospital, a rural district hospital in northern KwaZulu-Natal. SUBJECTS: All adult patients with suspected TB seen at the hospital over a 4-month period. OUTCOME MEASURES: (i) Successful SI; (ii) sputum acid-fast smear result; (iii) change of admission diagnosis as a result of the induction procedure; and (iv) number of patients discharged with a diagnosis other than TB who represented within 4 months with TB. RESULTS: A total of 51 patients (31 female) underwent SI; of these 36 (71%) were able to produce a sputum sample. Fifteen (42%) of those were acid-fast smear-positive (29% of all patients included). The admission diagnosis was changed in 16 (44%) of the patients who were able to give an induced sputum sample as opposed to 4 (27%) who had been unable to expectorate despite an induction attempt (P = 0.38). Three (12.5%) of the 24 patients with a discharge diagnosis other than TB (17 pneumonia, 3 old TB, 2 carcinoma of the lung, 1 bronchiectasis) turned out to have TB within the follow-up period; 2 of those had extrapulmonary TB. CONCLUSION: SI produced a positive smear result in 29% of patients with suspected TB who had previously been smear-negative or unable to expectorate. The method proved an aid to clinical decision making.     

Delay in commencing treatment for MDR TB at a specialised TB treatment centre in KwaZulu-Natal

Background. According to the National Department of Health (NDoH) guidelines, patients diagnosed with MDR TB must be referred to a specialised treatment centre for initiation of effective therapy. MDR TB is difficult to diagnose and the centralised referral model is beset with challenges that contribute to treatment delays, increased patient morbidity and mortality, and MDR TB nosocomial transmission. Culture and DST takes 8 weeks or longer to obtain results while line probe assays (LPAs) can give a result in hours. LPAs and the GeneXpert MTB/Rif (GX) are ground-breaking discoveries for TB diagnosis. However, they are not easily accessible or available to those needing it, so culture and sensitivity testing remains the gold standard for diagnosis. Aim. This study aimed to assess the delay in the initiation of MDR TB treatment and profiled the patients being referred to a specialised drug-resistant treatment centre in KwaZulu-Natal. Results. Of all the patients, 75% referred showed a mean delay of 12.4 weeks from the date of sputum collection for culture and drug sensitivity testing to the start of treatment. Most of the patients were symptomatic for TB and HIV-positive. Discussion. Our findings suggest that current policy on the initiation of effective treatment needs urgent revision. Staff should be appropriately trained in LPA and GX technology to reduce delays in initiating treatment for MDR TB. The NDoH's plans for rapid diagnosis and reducing the treatment burden on centralised MDR TB management facilities are in the early phases of implementation and will take years to achieve favourable and significant outcomes. Conclusion. There is a significant delay in initiating definitive management for MDR TB.     

Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'

STUDY DESIGN: Case reports and survey of literature. OBJECTIVE: Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse. SETTING: Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted. RESULTS: After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated. CONCLUSIONS: Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.     

结核感染T细胞斑点试验在骨与关节结核诊断中的价值

目的探讨结核感染T细胞斑点试验(T-SPOT TB)在临床诊断骨与关节结核的应用价值。方法收集154例疑似骨与关节结核患者外周抗凝血标本,依据细菌学检验、病理学结果及临床表现判定有无结核分枝杆菌感染;其中确诊骨与关节结核73例,非结核感染81例,分别进行T-SPOT TB和结核抗体(TB-Ab)检测,并分析T-SPOT TB在骨与关节结核诊断中的敏感度和特异度。结果 73例确诊骨与关节结核中,64例T-SPOT TB阳性;81例非结核中,72例T-SPOT TB阴性;T-SPOT TB检测敏感度为87.67%(64/73),TB-Ab为41.10%(30/73),T-SPOT TB诊断骨与关节结核的敏感度显著高于TB-Ab(P0.001);T-SPOT TB检测特异度为88.89%(72/81),TB-Ab为71.60%(58/81),T-SPOT TB特异度也高于TB-Ab(P=0.006)。在结核组中,涂阳与涂阴两组T-SPOT TB阳性检出率分别为95.45%(21/22)及86.49%(32/37),差异无统计学意义(P0.05)。在结核组中,病理诊断阳性率92.16%(47/51)与T-SPOT TB总阳性率87.67%(64/73)比较差异无统计学意义(P0.05)。结论 T-SPOT TB在诊断骨与关节结核中具有良好的敏感度和特异度,具有重要临床应用价值。     

Transmission of tuberculosis from smear negative patients: a molecular epidemiology study

BACKGROUND: While smear positive patients with tuberculosis (TB) are considered more infectious than smear negative patients, the latter can also transmit TB. METHODS: In a molecular epidemiology study of 791 patients in the Greater Vancouver regional district, the number of episodes of TB transmission from two groups of smear negative clustered patients by RFLP (assumed to be involved in recent transmission) was estimated after assessing for potential bias. Group 1 (n = 79) included patients with pulmonary TB or pulmonary + extrapulmonary disease (PTB or PTB+EPTB); group 2 (n = 129) included all patients in group 1 + extrapulmonary cases alone. RESULTS: In the total sample the mean (SD) age was 51 (21) years, 54.3% were male, and 17.0% of patients were clustered. Compared with smear negative patients, smear positive patients were more likely to be in a cluster (OR = 2.0, 95% CI 1.1 to 3.6) and to have had a history of ethanol abuse (OR = 2.7, 95% CI 1.0 to 6.7), diabetes mellitus (OR = 2.8, 95% CI 1.1 to 7.0), injection drug use (OR = 3.1, 95% CI 1.1 to 8.3), and to have had a previous hospital admission (OR = 8.5, 95% CI 5.1 to 14.0). The proportion of episodes of transmission from smear negative clustered patients ranged from 17.3% to 22.2% in group 1 and from 25% to 41% in group 2. CONCLUSION: In Greater Vancouver, smear negative cases appear responsible for at least one sixth of culture positive episodes of TB transmission.     

Current evidence on diagnostic accuracy of commercially based nucleic acid amplification tests for the diagnosis of pulmonary tuberculosis

BACKGROUND: Even though commercial nucleic acid amplification tests (NAATs) have become the most frequently used molecular tests for laboratory diagnosis of pulmonary tuberculosis (TB), published studies report variable estimates of their diagnostic accuracy. We analysed the accuracy of commercial NAATs for the diagnosis of pulmonary TB in smear positive and smear negative respiratory samples using culture as a reference standard. METHODS: English language studies reporting data sufficient for calculating sensitivity and specificity of commercial NAATs on smear positive and/or smear negative respiratory samples were included. Meta-regression was used to analyse associations with reference test quality, the prevalence of TB, sample and test type. Predictive values for different levels of pre-test probability were quantified using Bayes' approach. RESULTS: Sixty three journal articles published between 1995 and 2004 met the inclusion criteria. Pooled sensitivity and specificity were 0.96 and 0.85 among smear positive samples and 0.66 and 0.98 among smear negative samples. The number of culture media used as reference test, the inclusion of bronchial samples, and the TB prevalence were found to influence the reported accuracy. The test type had no effect on the diagnostic odds ratio but seemed to be correlated with sensitivity or specificity, probably via a threshold effect. CONCLUSIONS: Commercial NAATs can be confidently used to exclude TB in patients with smear positive samples in which environmental mycobacteria infection is suspected and to confirm TB in a proportion of smear negative cases. The methodological characteristics of primary studies have a considerable effect on the reported diagnostic accuracy.     

Clinical value of the measurement of Mycobacterium tuberculosis specific antibody in pulmonary tuberculosis.

BACKGROUND: A serological test that could help to diagnose tuberculosis, especially smear negative disease, would contribute to patient management. METHODS: Levels of antibody to distinct antigens of Mycobacterium tuberculosis were assessed for their value in the diagnosis and management of pulmonary tuberculosis. Serum was taken from 52 patients who were smear positive, from 27 patients who were smear negative but with evidence of active tuberculosis (sputum culture positive in 16, response to antituberculosis chemotherapy in 11), from 11 patients with old healed tuberculosis (pre-antibiotic era), and from 39 healthy subjects vaccinated with BCG. RESULTS: In smear positive tuberculosis an enzyme linked immunosorbent assay using a single 38 kDa antigen gave a diagnostic sensitivity of 80% with a 100% specificity. In smear negative pulmonary tuberculosis, however, combination of the 19 kDa antigen, lipoarabinomannan (ML 34 epitope), and hsp 65 (TB 78 epitope) was needed to achieve a sensitivity of 64% with a specificity of 95%. Recurrent and extensive radiographic disease with a poor prognosis was associated with high anti-38 kDa and low anti-14 kDa antibody levels in patients with active disease. Patients with less pulmonary cavitation had high anti-19 kDa titres. Bacteriological relapse during treatment was indicated by a rise in anti-14 kDa (TB68 epitope) antibodies. Four patients with non-tuberculous mycobacterial infection showed no anti-38 kDa antibody. CONCLUSION: Antigen or epitope specific serology may help in the diagnosis, assessment of prognosis, and monitoring of chemotherapy in patients with pulmonary tuberculosis.     

Plasma cross linked fibrin degradation products in pulmonary embolism.

Plasma concentrations of cross linked fibrin degradation products, a marker of intravascular thrombosis and fibrinolysis, were measured in 495 patients with suspected pulmonary embolism referred for ventilation-perfusion lung scanning to determine whether concentrations are increased in pulmonary embolism and their potential use in diagnosis. Lung scans were described as normal (n = 66) or as showing a low (n = 292), indeterminate (n = 58), or high probability (n = 79) of pulmonary embolism. There was a difference between the mean levels of cross linked fibrin degradation products in each scan category: normal scans, 142 ng/ml; low probability scans, 295 ng/ml; indeterminate probability scans, 510 ng/ml; high probability scans, 952 ng/ml (p less than 0.001). Of the patients with high probability scans, 96% had raised concentrations. Explanations for discrepant low results include incorrect scan diagnosis, delay in blood sampling, and anticoagulation. Of the patients with a low or indeterminate probability of pulmonary embolism, 43% had increased concentrations of cross linked fibrin degradation products that could be attributed in most cases to another illness. Owing to the wide range of values in each lung scan diagnostic category, raised concentrations of these fibrin degradation products cannot be used without reference to the patient's clinical state as a discriminatory test for pulmonary embolism. Further evaluation of the significance of normal concentrations in excluding a diagnosis of pulmonary embolism appears to be warranted.     

Intracranial multiple tuberculomas: 2 unusual cases

BACKGROUND: Tuberculosis (TB) is still a major public health problem that continues to be an important cause of morbidity and mortality at worldwide level. Only 1% of patients with TB develop an intracranial tuberculoma (Tbm), usually as part of miliary TB. The radiological findings are often nonspecific, and they are difficult to diagnose without an increased index of suspicion. CASES DESCRIPTIONS: In this report, we presented 2 unusual patients with intracranial multiple Tbms, one of whom is a 32-year-old woman who did not have pulmonary TB or other primary origin of TB. Her diagnosis was established histopathologically, and she was treated with antituberculous chemotherapy. The other patient is a 12-year-old girl who has pulmonary TB with portal hypertension together with liver cirrhosis. Her diagnosis was established with clinical, radiological, and laboratory findings, and she was treated with antituberculous chemotherapy for 18 months. CONCLUSIONS: Intracranial Tbms have become rare in developed countries, but TB is still a very common infectious disease at worldwide level. Therefore, diagnosis should be kept in mind when confronted with brain space-occupying lesions, especially in the immunocompromised or malnutritional hosts such as liver cirrhosis. When no other active extracranial tuberculous process is found, the diagnosis should be confirmed by a biopsy before beginning antituberculous treatment, which is rapidly effective. We have not encountered in the literature such a case of multiple intracranial Tbms associated with liver cirrhosis in an adult patient.     

Presentation of abdominal tuberculosis to general surgeons.

Abdominal tuberculosis (TB) continues to give rise to diagnostic and therapeutic challenges. A total of 24 patients with abdominal TB who presented to general surgeons over a 9-year period have been reviewed. Most (92 per cent) of these patients were Asian; only one had a past history of pulmonary TB. The most common presenting complaint was abdominal pain in 21 patients (88 per cent) with the associated symptoms of weight loss in 18 (75 per cent), anorexia in 15 (62 per cent) and night sweats in 13 (54 per cent). A tissue diagnosis was obtained in 18 patients (75 per cent) and 17 patients (71 per cent) underwent laparotomy. These results show that the diagnosis of abdominal TB is still difficult to establish, and that many patients undergo laparotomy despite the existence of less invasive diagnostic procedures.     

Tuberculosis in liver transplant recipients: prophylaxis in an endemic area

Background

Tuberculosis (TB) has a high prevalence in Brazil. The scenario of liver transplantation (LT) creates challenges: atypical presentation, treatment hepatotoxicity, and increased mortality. The majority of TB cases after transplantation represent reactivation of latent infections; therefore, prophylaxis (PX) plays a major role. The aim of this study was to evaluate the benefits of PX after LT based on a pretransplantation tuberculin test (TT) in an endemic area.

Methods

Retrospective analysis of medical data from 376 adult cirrhotic patients undergoing OLT from 2001 to 2009.

Results

Among 191 selected patients, 137 (71%) showed a pretransplant TT including 41 (30%) with a TT ≥5 mm. The 17 (40%) of these patients who were prescribed PX did not experience TB. Prophylaxis was discontinued in 5 patients (20%) owing to suspicion of hepatotoxicity (medium serum alanine transaminase 175 U/L). In the group without PX, we diagnosed 1 case of pulmonary TB. The overall prevalence of anergic patients in the cirrhotic phase was 65% and prevalence of TB 1%.

Conclusions

The prevalence of TB was similar to that reported in the literature, but positivity to TT was higher (34% vs 25%), possibly because of the endemicity of the area. There was a lower prevalence of extrapulmonary disease and no mortality. No patient undergoing PX with isoniazid, although incomplete due to suspicion of hepatotoxicity displayed TB. One patient without PX was affected by TB. The drug was effective but not always safe.     

Tuberculosis affecting the oral cavity in Brazilian HIV-infected patients.

OBJECTIVE: Tuberculosis (TB) affecting the oral cavity is a very rare disease. We reviewed the medical data of 18 HIV(1)-infected patients referred to the Stomatology Group, Ear, Nose, and Throat Department, S?o Paulo University Medical School, who had a diagnosis of oral tuberculosis, between 1991 and 2002. This retrospective study aimed to analyze the relationship between oral tuberculosis and HIV infection. STUDY DESIGN: The clinical records of the patients were reviewed to note age and gender, symptoms, and site and type of the lesions in the oral mucosa. Results of CD4+ T-lymphocyte count, sputum analysis, tuberculin skin test, histopathologic characteristics, cultures of the specimens (that were taken during the biopsy), chest x-ray findings, and the type of treatment they received were also reviewed. RESULTS: The most affected sites were palate and tongue. All patients had culture confirming tuberculosis. CONCLUSION: Patients with HIV and nonhealing oral lesions or papillomatous masses in the oral mucosa should be screened for the presence of pulmonary tuberculosis.     

Various clinical presentations of tuberculosis in heart transplant recipients

The purpose of this study was to clarify the various clinical presentations, incidence, and complications associated with tuberculosis (TB), as well as patient survival in heart transplantation (HTx) recipients. A retrospective review of 177 case records of HTx recipients from May 1989 to April 2003 were evaluated for their clinical course, diagnostic procedures, treatment, and survival. TB was diagnosed by culture. TB was proven in five (2.8%) patients. There were three pulmonary lesions and two extrapulmonary lesions. TB was diagnosed at 3.5 to 85 months after HTx. Pulmonary lesions were detected by cultures of sputum, bronchoalveolar lavage, or pleural effusion. For extrapulmonay lesions, one subject had neck lymphadenopathy shown by biopsy and culture to be TB; another suffered from swelling of the finger joints which upon culture of the aspirate proved to be TB. Treatment consisted of isoniazid (INH), rifampin (RIF), ethambutol, pyrazinamide, streptomycin (STR), ciprofloxacin (Ciproxin), and levofloxacin (Cravit). During the use of RIF, the daily dosage of cyclosporine (CsA) or tacrolimus was increased to maintain appropriate levels. Because of severe hepatotoxicity and interference with CsA, RIF was withdrawn and STR given in the last three patients. In addition, ciprofloxacin was given in the patient with miliary TB. Levofloxacin was given to the other two patients. All patients survived the TB infection under treatment with at least three drugs. There were five clinical presentations of TB in our HTx recipients. Because of the high incidence of hepatitis and severe drug interaction with CsA or tacrolimus on RIF treatment, avoiding the use of RIF but treatment with at least three drugs is recommended.     

男性生殖系结核的诊断与治疗

目的 :探讨男性生殖系结核的诊断与治疗。　方法 :对 15例经病原学或病理学证实的男性生殖系结核患者的诊断、鉴别诊断及治疗进行回顾性分析。　结果 :结合病史、体格检查、精液抗酸杆菌镜检或抗酸杆菌培养和手术标本病理检查可确诊。其中 ,1例为肾结核并发附睾、睾丸结核 ,1例为肾结核并发结核性精囊炎 ,8例为原发性单纯附睾结核 ,5例为原发性附睾、睾丸结核。 4例单纯抗结核药物治疗 ,11例手术治疗。　结论 :男性生殖系结核呈现非典型化趋势 ,精液TB PCR可能为男性生殖系结核的诊断提供了新的途径 ,必要时组织活检可确诊。手术治疗应慎重 ,尤其是对年轻患者。     

A Case Report of Lumbar Abscess in a Transplant Recipient: Is It Always What It Seems?

The percentage of solid organ transplant recipients who develop extrapulmonary or disseminated tuberculosis (TB) is higher than the general population. In countries where the disease is endemic, TB should always be considered a diagnostic possibility, and extrapulmonary disease should also be considered. We present the case of a kidney transplant patient who initially presented for an abscess in the left dorsolateral region and was ultimately diagnosed with pulmonary and extrapulmonary TB. With the initiation of antibacillary treatment, a drug interaction with immunosuppressants was verified, and rifampicin was maintained at a minimum dose with other antibacillary drugs at full dose, subsequently showing an improvement in the clinical picture. The adverse effects of TB treatment present great difficulty owing to the interactions of antibacillary drugs with immunosuppressants. Most patients with conventional treatment can be cured, so prompt diagnosis and treatment are important.     

Gender differentials of pulmonary tuberculosis transmission and reactivation in an endemic area

BACKGROUND: In most low income countries there are twice as many cases of tuberculosis (TB) reported among men than among women, a difference commonly attributed to biological and epidemiological characteristics as well as socioeconomic and cultural barriers in access to health care. The World Health Organization has encouraged gender specific comparisons in TB rates to determine whether women with TB are less likely than men with TB to be diagnosed, reported, and treated. A study was undertaken to identify gender based differences in patients with pulmonary TB and to use this information to improve TB control efforts. METHODS: Individuals with a cough for more than 2 weeks in southern Mexico were screened from March 1995 to April 2003. Clinical and mycobacteriological information (isolation, identification, drug susceptibility testing and IS6110 based genotyping, and spoligotyping) was collected from those with bacteriologically confirmed pulmonary TB. Patients were treated in accordance with official norms and followed to ascertain treatment outcome, retreatment, and vital status. RESULTS: 623 patients with pulmonary TB were enrolled. The male:female incidence rate ratio for overall, reactivated, and recently transmitted disease was 1.58 (95% CI 1.34 to 1.86), 1.64 (95% CI 1.36 to 1.98), and 1.41 (95% CI 1.01 to 1.96), respectively. Men were more likely than women to default from treatment (adjusted OR 3.30, 95% CI 1.46 to 7.43), to be retreated (hazard ratio (HR) 3.15, 95% CI 1.38 to 7.22), and to die from TB (HR 2.23, 95% CI 1.25 to 3.99). CONCLUSIONS: Higher rates of transmitted and reactivated disease and poorer treatment outcomes among men are indicators of gender differentials in the diagnosis and treatment of pulmonary TB, and suggest specific strategies in endemic settings.     

The Spectrum of Abdominal Tuberculosis in a Developed Country: A Single Institution’s Experience Over 7 Years

Background  The incidence of human immunodeficiency virus (HIV) infection is rising, and as a result, tuberculosis (TB) has become a resurgent problem in many developed countries. Objectives  The aim of this study was to review the spectrum of abdominal TB and its surgical management in our institution. Methods  A retrospective review of all abdominal TB cases notified to the health authorities by our institution from Jan 01 to Oct 07 was performed. Results  There were 57 patients (37 men) with abdominal TB, with a median age of 47 (range 14–74) years. Active pulmonary TB was present in 27 patients (47%). Positive HIV status was present in 30% and untested in 58%. The majority of patients underwent computed tomography scans (n = 50, 88%). The main radiological findings included bowel thickening, lymphadenopathy, ascites, free gas suggestive of perforation, and abscesses. The diagnosis of TB was confirmed on microbiological and/or histological examination in 72%, while the remaining 28% were diagnosed based on the clinical presentation and radiological imaging. All patients were commenced on anti-tuberculous therapy. TB involved the small or large bowel in 33 patients, mesenteric lymphadenopathy in 24, peritoneum in 13, spleen in seven, pancreas in two, anus in two, and the liver in two. Disseminated (including pulmonary) TB occurred in 27 patients (47%), while isolated intra-abdominal TB occurred in the remaining 30 patients (53%). Twenty-five patients (44%) underwent surgery—16 laparotomies (six perforated viscus, five intestinal obstruction, three suspected malignancies, and two for suspected acute abdomen), five laparoscopic procedures (four diagnostic, one gastrojejunostomy bypass for gastric outlet obstruction), two appendicectomies, one drainage of abscess, and one anal fistulotomy. Conclusions  Although TB is eminently treatable medically, surgery is still often required for suspected or confirmed abdominal TB presenting with acute complications or as atypical diagnostic problems. The role of laparoscopy is likely to be more significant in future in the management of abdominal TB.     

Tuberculosis in Solid Organ Transplant Recipients at a Tertiary Hospital in the Last 20 Years in Barcelona, Spain

Objective

Mycobacterium tuberculosis (TB) is a serious opportunistic infection in solid organ transplant recipients. The TB incidence is 20 to 74 times greater than that among the general population. Our aim was to determine the incidence as well as the clinical, radiological, and microbiological features and outcomes of TB in these patients.

Materials and Methods

We reviewed the clinical records of subjects with posttransplant TB from January 1988 to December 2007. A definite TB case was defined by a positive culture; probable TB by a positive smear or histological finding; and disseminated TB when 2 organs were involved. We noted an early diagnosis as ones in the first year posttransplantation. Outcomes were classified following the WHO recommendation and mortality related defined by death during treatment.

Results

Among 4634 recipients (2757 kidney, 1334 liver, 361 double kidney-pancreas, and 182 heart), 21 (0.45%) developed posttransplant TB: namely, 0.47%, 0.22%, 1.1%, and 0.54%, respectively. In 2 cases M. tuberculosis did not grow upon culture; the diagnosis was established by positive acid-fast bacilli on a sputum smear or by histological findings on biopsy. The mean posttransplantation time to TB diagnosis was 21 months (48% early TB). Two patients had a previous history of TB. Fever was the most common symptom (71%). Pulmonary tuberculosis represented 47.6% of cases; extrapulmonary, 28.6%; and disseminated, 23.8%. Among the cases of pulmonary TB, 60% had unilateral infiltrates and 10% cavitations on X ray. Eighteen patients completed treatment. Five patients displayed adverse events, 3 of which were liver toxicity. Four patients died, with 3 deaths related to TB.

Conclusions

The incidence of TB in this cohort was higher than that among the general population (450 cases/100,000 recipients). TB was associated with adverse effects of treatment and significant mortality.     

Surgical management of pulmonary aspergilloma—12 years’ experience from a tertiary care centre in India

Introduction and purposePulmonary aspergilloma is the formation of saprophytic colonies of fungus in pre-existing pulmonary cavities. They may cause life-threatening haemoptysis. As medical treatment often fails, surgery is the mainstay of treatment in symptomatic patients. Earlier studies had reported high levels of mortality and morbidity with surgery while more recent studies have shown better results. Hence, being in a large tertiary care centre in India, we decided to analyse the details of our own experience in the surgical management of pulmonary aspergilloma.MethodsDetails of all adult patients treated surgically for pulmonary aspergilloma, between the years 2009 and 2020, maintained in a live database in our institute, were retrieved and analysed.ResultsThere were 102 patients in the study. The average age was 40 years. There was a male (M: F, 3:1) and right side preponderance. Pulmonary tuberculosis (TB) was the commonest cause for cavities in which aspergilloma developed as identified in 84 (82%) patients and diabetes mellitus, the commonest comorbidity present in 28 (27.5%) patients. Parenchyma-preserving lung resections (PPLRs) were feasible in 8 (44%) of the non-tubercular patients, but only in 14 (17%) of the TB patients. Post-operative complications (11.7%) were higher among the patients with TB. There were 2 (1.9%) post-operative mortalities.ConclusionThough surgery is technically complex in the presence of pulmonary aspergilloma, it is yielding better results with improvements in treatment strategies. Surgery for aspergilloma in patients with prior or current pulmonary TB has more morbidity and mortality when compared to the non-TB patients.     

Pulmonary tuberculosis in an HIV- and hepatitis C virus-coinfected kidney-pancreas transplant recipient: a case report

Tuberculosis (TB) is a serious infection in immunocompromised patients, such as solid organ transplant recipients and HIV-infected patients. The diagnosis and treatment in this population present several challenges because of the aspecific clinical manifestations, the difficulty in diagnosis, and the choice of the most appropriate therapeutic regimen. Therapeutic challenges arise from drug-related toxicities, interactions between immunosuppressive, antiretroviral, and antituberculous drugs. We present a case of primary TB infection that occurred 3 years after transplantation in a HIV-and hepatitis C virus-coinfected kidney-pancreas recipient. The infection was successfully treated with no hepatotoxicity or rejection with a non-rifampin-containing regimen.