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We describe a 19-year-old African-American man with a 14-year history of migratory poliosis. We suggest that this phenomenon may represent a forme fruste of alopecia areata.

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SETTING: Tuberculosis Control Program, Western Australia. OBJECTIVE: To assess the effectiveness and efficiency of tuberculosis (TB) surveillance in immigrants. DESIGN: Retrospective descriptive analysis of records of immigrants who first registered with the Tuberculosis Program from January 1994 to December 1995, having entered Western Australia on health undertakings (nonlegal contracts signed by those determined during premigration screening to require post-arrival evaluation). RESULTS: Of 1,344 immigrants on health undertakings for TB in the period, 587 (44%) had findings directly related to TB through pre-migration screening, 69 of whom required treatment for active disease. Another 443 (33%) had chest X-ray changes for which TB could not be excluded. Of the remaining 314 (23%), 172 had poor quality X-rays. Post-arrival assessment and follow-up of the whole group detected four of seven additional cases of active TB, 373 persons (28%) requiring on-going surveillance, 667 (50%) with non-TB conditions and 280 (21%) with normal chest X-rays. CONCLUSIONS: Migrant surveillance for TB in Australia is effective in detecting active disease and identifying a high-risk subgroup requiring further evaluation. Efficiency can be improved and high compliance achieved with simple administrative changes. Routine pre-migration Mantoux testing is inappropriate, and its inclusion in post-arrival assessments should be a national policy decision.

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SETTING: State Tuberculosis Control Programme, Western Australia. OBJECTIVE: To ascertain baseline information, applicability and efficacy of preventive therapy for tuberculosis (TB) under indirectly supervised treatment in Western Australia. DESIGN: Retrospective analyses of records of persons with TB infection who were prescribed preventive therapy for the period 1993-1996 inclusive, using simple descriptive statistics. RESULTS: Preventive therapy was given to 411 persons after screening for TB due to on-arrival migrant surveillance (269), contact tracing (59), tuberculin surveys (59) and other reasons (24). Six-month isoniazid monotherapy (HMT) was prescribed for 403 and multidrug regimens for the remaining eight. Excepting 34 whose compliance was unknown, varying degrees of treatment non-adherence were found in 90 (24%) of the remaining 369 persons given HMT, including 36 (10%) with under five months of total medication. Minor adverse drug effects occurred in 32 (9%) subjects and contributed to the non-adherence in 23 of these. One person has since developed active TB. CONCLUSIONS: Preventive therapy in Western Australia conformed to generally accepted guidelines. Varying degrees of non-adherence to HMT occurred in 24% of persons, but 90% completed adequate therapy under indirect supervision. Non-adherence is significantly related to adverse drug effects.

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A 63-year-old woman presented with a single plaque on her left earlobe that was shown to be a B-cell lymphoma on histopathologic examination. Immunohistochemical studies on the paraffin-embedded tissue and flow cytometry of fresh tissue helped characterize the neoplasm. She had no other systemic involvement and a diagnosis of primary cutaneous B-cell lymphoma was made. This neoplasm has, in general, a good prognosis with excellent response to radiation therapy, polychemotherapy, or both.

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A 58-year-old woman who had previously undergone radiation therapy for breast cancer sustained bullous pemphigoid confined mainly to the radiation site. Radiation-induced bullous pemphigoid is an infrequently reported occurrence. This patient's lesions resolved within several weeks with combined oral therapy using tetracycline and niacinamide.

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The records of a total of 497 patients notified to have active tuberculosis (TB) in Western Australia from 1986 to 1990 inclusive have been reviewed in relation to case-finding. Of these, 276 (55.5%) were Asian migrants, 92 (18.5%) Europeans and 110 (22.1%) Australians. The disease was confirmed bacteriologically in 247 (49.7%). The most common mode of diagnosis was symptomatic presentation (39.8%), followed by migrant health surveillance (36.8%), incidental finding (7.5%), regular follow-up (3.8%) and pre-employment chest radiography (1.8%). Contact examination in the non-Asians accounted for only 0.4% while diagnosis after death 2.6%. There was no statistical difference in the detection of TB disease and infection among contacts of index patients with diseases at different sites or of different bacteriological status. The results of the study justify the present strict surveillance over the Asian migrants but do not support the overcautious policy of the contact examination procedures in the non-Asians, for which changes are proposed. Twelve patients whose confirmed TB was diagnosed only at autopsy had a mean age of 75.4 (range 41-86) years. Six of them had miliary or disseminated TB, three co-existing serious medical conditions and none a past history of the disease. The pattern has been well described and clinicians should keep a high index of suspicion for TB in this group of patients.

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Notifications of 485 patients with culture-positive tuberculosis (TB) in Western Australia from 1980 to 1989 inclusive have been analysed. In 478 (98.6%) the disease was caused by Mycobacterium tuberculosis hominis and in seven (1.4%) M. bovis. Most (78.5%) of the disease was pulmonary with 4.3% pleural and 17.2% extrapulmonary. The annual incidence decreased from 4.6 per 100,000 in 1980 to 2.5 in 1985 steadying thereafter around 3.3. The Aborigines had over four times the average incidence of the non-Aboriginal Australians but less than a quarter that of the Asians. In a total 297 migrants, 51% of 253 with data available had been in Australia for over five years. Initial drug resistance was found in 48 patients giving an overall rate of 9.9%. In 32 (66.7%), resistance was against a single drug, mainly isoniazid and in 11 (22.9%) against two drugs, predominantly isoniazid and streptomycin. The most disturbing finding was the occurrence of multiple-drug resistance including both isoniazid and rifampicin in five immigrants (10.4%). This study has provided useful baseline TB data, raised important issues such as chemoprophylaxis and drug resistance, and clearly indicates that the campaign against TB is far from over. Continual surveillance, monitoring and regular evaluation of existing policies should be maintained.

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