HIV-associated tuberculosis in Africa exemplified by Zimbabwe

In Africa, a rapid increase of human immunodeficiency virus (HIV)-associated tuberculosis cases has been observed; 80% of a worldwide 6 million dually infected persons live in this part of the world. The annual risk of progression to clinically overt tuberculosis in dually infected persons approaches the lifetime risk in persons with tuberculosis but no HIV infection. Zimbabwe is an example which illustrates the rapid increase in notified tuberculosis cases since 1985, accounted for primarily by HIV-associated tuberculosis cases. In sputum-smear positive HIV-associated tuberculosis, classical symptoms are reported with the same frequency as in HIV negative cases. Thus, case-finding activities need not be altered. In sputum-smear negative patients, reliable diagnostic tests are not available. Therapeutic trials are widely used and this causes overdiagnosis of tuberculosis. Extrapulmonary manifestations are common in HIV-associated tuberculosis. A majority of lymph node enlargements, pleurisy and pericarditis in Africa are now due to tuberculosis. If compliance is ensured, response to chemotherapy is excellent, but overall case fatality and relapse rates are increased. The cost-effectiveness of tuberculosis control programmes using directly observed therapy for at least the first 2 months of treatment is well established. With the prominent global significance of tuberculosis and the possibility of cost-effective interventions, a commitment to the fight against the worldwide epidemic is more important than ever before.     

Male genitourinary tuberculosis. Report of 12 cases and review of the literature

The incidence of genitourinary tuberculosis is constant in western countries, despite dramatically falling prevalence of pulmonary tuberculosis. The kidney is especially involved in urinary tuberculosis, and genital tuberculosis mostly affects the epididymis in males and the fallopian tubes in females. Twelve cases of male genitourinary tuberculosis are presented and the literature is briefly reviewed.     

Genitourinary tuberculosis

Genitourinary tuberculosis, once the most prevailed disease, has become very rare. Urinary frequency, pain on urination and aseptic pyuria are the key symptoms of urinary tuberculosis. At least three consecutive urine cultures for Mycobacterium tuberculosis are necessary. Renal calcification in KUB film, distortion, obliteration and destruction of single or more calices in excretory urography may lead to proper diagnosis. Induration and swelling of the globus minor of epididymis adhering to the skin or with cutaneous fistula are suggestive of genital tuberculosis. It is of extreme importance to suspect the tuberculosis in such patients especially when the symptoms are not relieved by antibiotic treatment. Current short-term chemotherapy using pyrazinamide, isonizid and rifampicin with a help of surgery is successful in most of the patients with genitourinary tuberculosis.     

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Pulmonary tuberculosis: primary tuberculosis, usually asymptomatic, represents the first infection and is shown by a parenchymal mostly mid-pulmonary focus and satellite lymphadenopathy. Postprimary pulmonary tuberculosis, mostly located in the upper fields may be caused by endogenous reinfection for reactivation of a hematogenous focus formed during primary infection or from exogenous reinfection. Extrapulmonary tuberculosis: it includes numerous forms mostly from hematogenous spread. Miliary tuberculosis may involve a number of organs and apparatus besides the lung. Tuberculous meningitis predominantly involves the base of the skull, the fluid is clear with hypoglycorrhachia and lymphocyte pleocytosis. Lymph node tuberculosis is generally unilateral and cervical. Tuberculous pleuritis is exudative or dry. Other forms of tuberculous serositis are pericarditis and peritonitis. Renal tuberculosis involves the medullaris and intestinal tuberculosis the ileocecum; tuberculous spondilitis (Pott's disease) involves the last dorsal vertebrae. Other forms are osteoarthritis, genital tract tuberculosis, pancreatitis, laryngitis, otitis.     

Activity of amoxicillin/clavulanate in patients with tuberculosis

Some beta-lactam antibiotics are active in vitro against Mycobacterium tuberculosis. There are anecdotal reports of successful treatment of tuberculosis caused by multiple-drug-resistant strains of M. tuberculosis with regimens that included amoxicillin/clavulanate. Reduction of M. tuberculosis in the sputum of patients with pulmonary tuberculosis during administration of amoxicillin/clavulanate was measured by a quantitative culture method to determine the activity in vivo. Patients were randomized to receive isoniazid, ofloxacin, or amoxicillin/clavulanate for 7 days. Isoniazid was the most effective agent, reducing M. tuberculosis after 2 days at a mean rate (+/- standard deviation) of 0.60 +/- 0.30 log10 cfu/mL per day, compared with 0.32 +/- 0.05 and 0.34 +/- 0.03 for ofloxacin and amoxicillin/clavulanate, respectively. The early bactericidal activity of amoxicillin/clavulanate was comparable to that reported for antituberculous agents other than isoniazid. Further studies of beta-lactam antibiotics with in vitro activity against M. tuberculosis are warranted to define their role in treatment of tuberculosis.     

Tuberculosis of the endocrine system

Tuberculosis now rarely affects the endocrine system. Adrenal tuberculosis is responsible for Addison's disease, but now fewer cases are affected. Although the symptoms and signs of Addison's disease appear when most of the adrenal glands have been functionally destroyed, adrenal tuberculosis results in not only chronic adrenal insufficiency but also acute adrenal failure. Dissemination of M. tuberculosis is responsible for adrenal tuberculosis, other tuberculous lesions (including the past lesions) should be evaluated. Bilateral adrenal calcification and/or enlargement which are often pointed out on abdominal CT, are important signs of adrenal tuberculosis. Thyroid gland is rarely affected, but thyroid function impairment is uncommon even if it is affected. Hypopituitarism due to intracranial tuberculoma or tuberculous meningitis are also reported. Tuberculosis of the endocrine system is a part of disseminated infection, so it should not be overlooked in miliary spread tuberculosis.     

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The unfavourable tuberculosis situation in the corrective labour facilities affects the main rates of tuberculosis in the region. Presently, the total registered cases of tuberculosis among prisoners are 36.7 times as high as those in the age-matched general population of the Sverdlovsk Region. The rates of relapses, incidence, death due to tuberculosis show 72.0-, 36.1-, and 10.4-fold increases, respectively. Almost every 10 persons from the labour corrective facilities suffer from active tuberculosis. In the past decade, the growth rates of main tuberculosis parameters in the corrective labour facilities were much higher (total tuberculosis morbidity by 2.1 times, relapses by 2.1 times, general morbidity by 1.7 times, and total tuberculosis mortality by 2.8 times) than those in the region's general population. Extrapulmonary tuberculosis was not virtually detected in the labour corrective facilities) due to the lack of special diagnostic methods.     

Cytological characteristics, elemental composition of alveolar macrophages from bronchoalveolar lavage, lung pathology in liquidators of the consequences of the accident at the Chernobyl power plant

Tuberculosis is an ancient disease which has had a resurgence in the United States. Many elderly clients were exposed to tuberculosis as children and young adults and are still carrying the infection today. This article describes tuberculosis as it affects the elderly client in community and nursing home settings. The history, etiology, clinical manifestations, treatment, and prevention of tuberculosis infection and disease are presented. Because nurses can be very instrumental in controlling tuberculosis in the elderly, gerontological nursing implications are discussed.     

Interpreting outcomes

Analysis of clinical forms of tuberculosis in patients of a pulmonological showed that 65.5% of them had infiltrative tuberculosis, 13.8% fibrocavernous tuberculosis, 10.4% disseminated tuberculosis, 6.9% focal tuberculosis, and 1.7% tuberculoma. It was ascertained that in these patients destructive tuberculous changes were common and occurred in 67.2% and tuberculosis was concurrent with other lung diseases in 70.7%. This follows that special attention should be given to the patients of pulmonological hospitals and sputum tests for mycobacteria are to be performed 3 times.     

Differentiation of Mycobacterium ulcerans, M. marinum, and M. haemophilum: mapping of their relationships to M. tuberculosis by fatty acid profile analysis, DNA-DNA hybridization, and 16S rRNA gene sequence analysis

Although Mycobacterium ulcerans, M. marinum, and M. haemophilum are closely related, their exact taxonomic placements have not been determined. We performed gas chromatography of fatty acids and alcohols, as well as DNA-DNA hybridization and 16S rRNA gene sequence analysis, to clarify their relationships to each other and to M. tuberculosis. M. ulcerans and M. marinum were most closely related to one another, and each displayed very strong genetic affinities to M. tuberculosis; they are actually the two mycobacterial species outside the M. tuberculosis complex most closely related to M. tuberculosis. M. haemophilum was more distinct from M. ulcerans and M. marinum, and it appeared to be as related to these two species as to M. tuberculosis. These results are important with regard to the development of diagnostic and epidemiological tools such as species-specific DNA probes and PCR assays for M. ulcerans, M. marinum, and M. haemophilum. In addition, the finding that M. ulcerans and M. marinum are more closely related to M. tuberculosis than are other pathogenic mycobacterial species suggests that they may be evaluated as useful models for studying the pathogenesis of M. tuberculosis. M. marinum may be particularly useful in this regard since strains of this species grow much more rapidly than M. tuberculosis and yet can cause systemic disease in immunocompromised hosts.     

Homologs of Mycobacterium leprae 18-kilodalton and Mycobacterium tuberculosis 19-kilodalton antigens in other mycobacteria

Most of the antigens of Mycobacterium leprae and M. tuberculosis that have been identified are members of stress protein families, which are highly conserved throughout many diverse species. Of the M. leprae and M. tuberculosis antigens identified by monoclonal antibodies, all except the 18-kDa M. leprae antigen and the 19-kDa M. tuberculosis antigen are strongly cross-reaction between these two species and are coded within very similar genes. Studies of T cell reactivity against mycobacterial antigens have indicated that M. tuberculosis bears epitopes that are cross-reactive with the M. leprae 18-kDa antigen, but attempts to identify an 18-kDa antigen-like protein or protein coding sequence in M. tuberculosis have been unsuccessful. We have used a combination of low-stringency DNA hybridization and polymerase chain reaction techniques to identify, isolate, and sequence genes from M. avium and M. intracellulare that are very similar to the 18-kDa antigen gene of M. leprae and others that are homologs of the 19-kDa antigen gene of M. tuberculosis. Unlike M. leprae, which contains a single 18-kDa antigen gene, M. avium and M. intracellulare each have two 18-kDa antigen coding sequences. Although the M. leprae, M. avium, and M. intracellulare 18-kDa antigen genes are all very similar to one another, as are the M. tuberculosis, M. avium, and M. intracellulare 19-kDa antigen genes, we have been unable to detect any 18-kDa antigen-like coding sequences in DNA from M. tuberculosis.     

Multiple drug-resistant tuberculosis

The national and international emergence of drug-resistant M. tuberculosis has complicated both the programmatic control of the tuberculosis epidemic and the clinical management of individual cases. In the United States, the problem of MDR tuberculosis is regionalized and likely stems from multifactorial causes, including the concurrent HIV epidemic. The epidemic is propagated by two distinct entities, PDR and ADR tuberculosis, which result from different inadequacies in tuberculosis control programs. The clinical management of drug-resistant tuberculosis, MDR tuberculosis in particular, is complex, frequently results in adverse outcomes, and often necessitates consultation with a specialist in the field. Two important management principles are to always use at least two agents to which the organism is susceptible and to never add a single drug to a failing regimen. Selection of an appropriate treatment regimen and determination of the duration of therapy depend on the resistance pattern, toxicities of the drugs, and the patient's response to therapy. Measures to ensure patient adherence with therapy are of paramount importance in the setting of drug resistance. Preventive therapy should be considered in the management of close contacts to active cases of MDR tuberculosis, although there is little evidence to support this practice.     

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An audit of 690 cases of tuberculosis out of 46,276 patients seen during the last 25 years in a busy general practice is reported. Of the 690 cases, 67% were pulmonary, 33% extra-pulmonary TB. Modes of both types of tuberculosis are described and the reason for increased incidence of extra-pulmonary tuberculosis are discussed.     

Intestinal tuberculosis

Since the symptoms and clinical presentation of intestinal tuberculosis is nonspecific, the diagnosis is frequently delayed and may be achieved at autopsy only. Intestinal tuberculosis is very rare in Denmark, but may now be seen more often because of increasing numbers of immigrants from countries of the third world with a high prevalence of tuberculosis. A case of intestinal tuberculosis in a 28 year old Somalian female is reported. Methods of diagnosing intestinal tuberculosis are commented, and the frequent necessity of starting medical treatment before a bacteriological diagnosis is reached is emphasized.     

Infectiousness of laryngeal tuberculosis

Two patients with laryngeal tuberculosis in the absence of extensive pulmonary tuberculosis are presented. In both, tuberculin testing of household members failed to show infectiousness of their disease. This contradicts the commonly held view that laryngeal tuberculosis is invariably highly infectious. The extent and activity of pulmonary disease probably determines the infectiousness of patients with laryngeal tuberculosis rather than the laryngeal lesion per se.     

Ocular tuberculosis

The frequency of tuberculous uveitis has extremely decreased in Japan. Anterior granulomatous or non-granulomatous uveitis, chorioretinitis and retinal vasculitis are common ocular manifestations, while tuberculoma, scleritis, keratitis and orbital tuberculosis are rare. The diagnosis of ocular tuberculosis is extremely difficult because ocular tuberculosis tends to be negative in chest x-ray or tuberclin skin test. To diagnose ocular tuberculosis clinically some ophthalmologists recommend subconjunctival tuberculin test or therapeutic isoniazide (INH) test. Recently, for confirmed diagnosis, polymerase chain reaction (PCR) technique has been used to detect mycobacterium in intraocular samples such as aqueous or vitreous humor. The mainstay of treatment is antituberculosis agents. Active retinal vasculitis or tuberculoma are generally responsive to corticosteroid therapy. Although ocular tuberculosis is rare, it must be considered as one of the possible causes of uveitis.     

Neuropeptides of the autonomic nervous system in Sj?gren''s syndrome

Posterior spinal tuberculosis or arch tuberculosis is a form of skeletal tuberculosis that selectively involves the vertebral arch. It may mimic skeletal neoplasm clinically and radiographically. Although posterior spinal tuberculosis has been reported in developing countries it has rarely been found in the United States. As a result, there is limited information about this entity in the US literature. We are presenting our experience in a patient born in the United States.     

Tuberculosis, 1994

In 1994, a total of 2,074 people in Canada were diagnosed with tuberculosis, a rate of 7.1 cases per 100,000 population. The same year, tuberculosis and its late effects caused 150 deaths-just over one in every 1,400 deaths. Although tuberculosis is no longer a major health problem in Canada or a leading cause of death, some groups are particularly susceptible to the disease: Aboriginal people, residents of low-income households, immigrants, and the elderly. In the first two instances, the occurrence of tuberculosis is associated with poor living conditions. The risk of tuberculosis among immigrants is high because of the greater likelihood of exposure in their countries of origin. Among the elderly, the potential for developing active tuberculosis is relatively high due to exposure decades ago when the disease was far more prevalent. Since 1980, the rate of pulmonary tuberculosis has declined, while the rate of extra-pulmonary tuberculosis has remained steady. As a result, the proportion of cases attributable to extra-pulmonary tuberculosis has risen.     

Oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal neoplasm

During the last decade the number of cases of abdominal tuberculosis diagnosed in Western countries has dramatically increased. There are many reasons, including the appearance of AIDS and the increased morbidity of people across the world due to the westward migration of many people coming from areas with a high incidence of tuberculosis. Oesophageal involvement is rare in tuberculosis, occurring mainly as an extension of the disease from the adjacent tuberculous lymph nodes. Fifty-eight cases of oesophageal tuberculosis have so far been reported. We describe a patient affected by oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal malignancy.