RESUMEN
UK guidelines no longer recommend routine screening of household contacts of adult patients with extrapulmonary TB (EPTB). From 27 March 2012 to 28 June 2016, we investigated the prevalence of active TB disease in household contacts of 1023 EPTB index cases in North West England, and compared estimates with: published new entrant migrant screening programme prevalence (~147/100 000 person-years); London-based contact screening data (700/100 000 contacts screened); and National Institute for Health and Care Excellence (NICE) new entrant TB screening thresholds (TB prevalence >40/100 000 people). Active TB disease prevalence in EPTB contacts was 440/100 000 contacts screened, similar to UK new entrant screening programmes, London EPTB contact prevalence and >10 times NICE's threshold for new entrant screening. The decision to no longer recommend routine screening of EPTB contacts should be re-evaluated and cost-effectiveness analyses of screening strategies for EPTB contacts should be performed.
Asunto(s)
Tuberculosis Pulmonar/epidemiología , Adulto , Trazado de Contacto , Femenino , Humanos , Londres/epidemiología , Masculino , Vigilancia de la Población , Prevalencia , Estudios Retrospectivos , MigrantesRESUMEN
Approximately 72% of tuberculosis (TB) cases in England occur among non-UK born individuals, mostly as a result of reactivation of latent TB infection (LTBI). Programmatic LTBI screening is a key intervention of the TB strategy for England. This article reviews the results of a long-standing LTBI screening initiative in England.A retrospective cohort was created through probabilistic linkage between LTBI screening data and national TB case notifications. Screened persons were followed until they died, became a case, emigrated or until cohort-end. TB incidence rates and rate ratios (IRR) were calculated.97 out of 1820 individuals screened for LTBI were reported to have active TB. Crude incidence rates among LTBI-positive, treatment-naïve individuals were 4.1 and 2.3 per 100â person-years in the QuantiFERON and tuberculin skin test cohorts, respectively. Among the QuantiFERON cohort, Poisson regression showed that LTBI positivity (IRR 22.6, 95% CI 6.8-74.6) and no chemoprophylaxis increased the probability of becoming a TB case (IRR 0.17, 95% CI 0.05-0.6).We found high TB rates in LTBI-positive, treatment-naïve individuals and a strong association between no treatment and becoming a TB case, demonstrating feasibility and effectiveness of LTBI screening and providing important policy lessons for LTBI screening in England and beyond.
Asunto(s)
Tuberculosis Latente/diagnóstico , Tuberculosis Latente/epidemiología , Tamizaje Masivo , Adulto , Bases de Datos Factuales , Inglaterra/epidemiología , Femenino , Humanos , Interferón gamma/sangre , Tuberculosis Latente/sangre , Masculino , Análisis Multivariante , Análisis de Regresión , Estudios Retrospectivos , Prueba de Tuberculina , Adulto JovenRESUMEN
SETTING: Drug-induced hepatitis is known to occur in a proportion of patients on treatment for active tuberculosis (TB). DESIGN: We prospectively examined the incidence of drug-induced hepatitis in 2070 patients treated for TB with the standard regimen based on 6 months of rifampicin (R, RMP) and isoniazid (H, INH), with 2 months of initial pyrazinamide (Z, PZA) and ethambutol (E, EMB), over a 30-year period from 1981 to 2010, in Blackburn, UK. RESULTS: Of the 1031 (49.8%) males and 1039 (50.2%) females studied, 451 (21.8%) were White and 1585 (76.6%) were of South Asian origin. Only 34 (1.6%) were of African or other origins. Of the total number of patients treated, 63 (3.0%) had drug-related hepatitis, 26 (5.8%) of whom were White, 37 (2.33%) Asians and 0 other. Incidence was significantly higher in Whites than Asians (OR 2.13, P = 0.008). Incidence increased with increasing age (OR 1.16, P = 0.02). The presumed causative drug was PZA 57%, RMP 32%, INH 11%, EMB 0%. There was no trend of increased hepatitis rates over time. CONCLUSION: Rates of drug-induced hepatitis where change of treatment is required are low in patients treated with standard RHZE-based therapy (3%). Caucasians and older patients were more likely to develop hepatitis than their counterparts.
Asunto(s)
Antituberculosos/efectos adversos , Enfermedad Hepática Inducida por Sustancias y Drogas/epidemiología , Hepatitis/epidemiología , Tuberculosis/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antituberculosos/administración & dosificación , Enfermedad Hepática Inducida por Sustancias y Drogas/diagnóstico , Niño , Preescolar , Etambutol/uso terapéutico , Femenino , Estudios de Seguimiento , Hepatitis/diagnóstico , Humanos , Incidencia , Lactante , Recién Nacido , Isoniazida/uso terapéutico , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Pirazinamida/uso terapéutico , Rifampin/uso terapéutico , Adulto JovenRESUMEN
SETTING: Blackburn, Hyndburn and Ribble Valley Local Government areas of England and Wales, the former a high tuberculosis (TB) prevalence district. BACKGROUND: The incidence of tuberculosis in new entrants aged 16-34 with positive tuberculin skin tests but normal chest X-rays after initial entry is not definitely known, and was previously estimated from cross-sectional national surveys and derived data for the 2006 and 2011 NICE economic appraisals of new entrant TB screening. METHODS: New entrants aged 16-34 years predominantly from South Asia (India, Pakistan and Bangladesh), with tuberculin tests inappropriately positive for their BCG history were identified for the years 1989-2001 inclusive from a new entrant database. These entrants were compared with the current GP registration database to see if local residence could be confirmed and the local TB notification database to October 2008. Survival analysis was carried out using Kaplan-Meier survival curves and a Cox Regression model. RESULTS: Four hundred and seventy-nine such new entrants with normal initial chest X-rays were identified. Of these 402 (84%) registered with a General Practitioner in East Lancashire for a period of time and could be followed up by this study. The crude incidence density of active TB amongst these individuals with latent disease was 1297 per 100 000 person-years (95% CI; 991-1698 per 100 000 person-years). After 10 and 15 years of follow-up 13.5 and 16.3% of individuals, respectively, had progressed on to active disease. CONCLUSION: This patient-derived, rather than estimated, data shows a minimum risk of TB disease of 16.3% at 15 years. The 2006 NICE economic appraisal, suggested that treatment for latent TB infection (LTBI) was cost-effective when the incidence of clinical TB over 15 years surpassed 18% in these populations. The 2011 NICE economic appraisal reduced this to 12% active TB over 15 years, and showed that at 16% active TB over 15 years a single interferon gamma release assay was the most cost-effective strategy. Further cohort studies are urgently needed to confirm or revise the assumptions behind the 2011 NICE economic appraisal.
Asunto(s)
Emigrantes e Inmigrantes/estadística & datos numéricos , Tuberculosis Pulmonar/diagnóstico , Adolescente , Adulto , Bangladesh/etnología , Análisis Costo-Beneficio , Femenino , Estudios de Seguimiento , Humanos , Incidencia , India/etnología , Ensayos de Liberación de Interferón gamma/economía , Masculino , Pakistán/etnología , Estudios Retrospectivos , Resultado del Tratamiento , Prueba de Tuberculina/economía , Prueba de Tuberculina/estadística & datos numéricos , Tuberculosis Pulmonar/tratamiento farmacológico , Tuberculosis Pulmonar/economía , Tuberculosis Pulmonar/prevención & control , Reino Unido/epidemiología , Adulto JovenRESUMEN
The scientific basis of drug treatment for both active tuberculosis (TB) disease and TB infection, has been established, with treatment in children being largely extrapolated from adult active disease trials. It is essential that active TB disease is excluded before asymptomatic TB infection is diagnosed and treated. Nearly half of all children with active TB disease are found as asymptomatic tuberculin, or interferon gamma release assay (IGRA), positive contacts on screening by local TB services, usually of sputum TB microscopy positive adult relatives or other index cases, but with evidence of lung infiltrate or mediastinal lymphadenopathy on the child's chest x-ray. New drug regimens for both active disease and latent infection are in development, and also some novel drugs. However, none of these have yet been tested in children, and so again data will need to be extrapolated from adult results. In addition, there are issues regarding pharmacokinetics and dosing for current drugs, particularly isoniazid.
Asunto(s)
Antituberculosos/uso terapéutico , Tuberculosis Latente/tratamiento farmacológico , Tuberculosis/tratamiento farmacológico , Antituberculosos/inmunología , Niño , Humanos , Tuberculosis Latente/inmunología , Esputo/microbiología , Prueba de Tuberculina , Tuberculosis/inmunologíaAsunto(s)
Infecciones Oportunistas Relacionadas con el SIDA/tratamiento farmacológico , Fármacos Anti-VIH/uso terapéutico , Antituberculosos/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Tuberculosis Pulmonar/tratamiento farmacológico , Infecciones Oportunistas Relacionadas con el SIDA/epidemiología , Adulto , Coinfección , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Humanos , Tuberculosis Pulmonar/epidemiología , Reino Unido/epidemiologíaRESUMEN
BACKGROUND: East Lancashire has had high rates of tuberculosis for 40 years. The ethnically diverse population is predominantly of South Asian and white origin. Drug resistance data from 1960 to 1999 indirectly suggest that no significant inter-ethnic transmission has occurred. This study used mycobacterial interspersed repetitive unit variable number tandem repeat (MIRU-VNTR) fingerprinting to assess clustering within and between ethnic groups. METHODS: All isolates of Mycobacterium tuberculosis from January 2001 to July 2009 from East Lancashire postcode areas were MIRU-VNTR fingerprinted. Clusters of strains with indistinguishable profiles were also assessed epidemiologically, and their MIRU-VNTR profiles compared with the UK M tuberculosis Strain Typing Database. RESULTS: 332 strains were typed (63 white patients, and 269 non-white patients). 198 MIRU-VNTR profiles were identified, with 144 profiles occurring only once. The typing clustered 187 strains into 53 clusters indistinguishable at all 12 loci and these were further characterised using the exact tandem repeat loci A, B, and C. The 15 loci clustered 32/63 (50.8%) of white and 110/269 (40.9%) of non-white cases and all but nine clusters were of the same ethnicity. The nine inter-racial clusters were further assessed from an epidemiological and clinical perspective and fingerprinting using nine additional loci. Isolates within two of the clusters were further discriminated using the additional nine loci. However, the additional loci did not further discriminate the isolates in the other seven inter-racial clusters. CONCLUSIONS: MIRU-VNTR fingerprinting indicates that although there is evidence of a high rate of transmission within the South Asian sub-population, the data suggest that there is little inter-ethnic transmission.
Asunto(s)
Mycobacterium tuberculosis/genética , Tuberculosis/etnología , Adolescente , Adulto , Anciano , Asia/etnología , Técnicas de Tipificación Bacteriana/métodos , Análisis por Conglomerados , Dermatoglifia del ADN/métodos , ADN Bacteriano/genética , Inglaterra/epidemiología , Femenino , Humanos , Secuencias Repetitivas Esparcidas/genética , Masculino , Persona de Mediana Edad , Mycobacterium tuberculosis/clasificación , Mycobacterium tuberculosis/aislamiento & purificación , Secuencias Repetidas en Tándem/genética , Tuberculosis/microbiología , Tuberculosis/transmisión , Población Blanca/estadística & datos numéricos , Adulto JovenRESUMEN
BACKGROUND: Continuing rises in tuberculosis notifications in the UK are attributable to cases in foreign-born immigrants. National guidance for immigrant screening is hampered by a lack of data about the prevalence of, and risk factors for, latent tuberculosis infection in immigrants. We aimed to determine the prevalence of latent infection in immigrants to the UK to define which groups should be screened and to quantify cost-effectiveness. METHODS: In our multicentre cohort study and cost-effectiveness analysis we analysed demographic and test results from three centres in the UK (from 2008 to 2010) that used interferon-γ release-assay (IGRA) to screen immigrants aged 35 years or younger for latent tuberculosis infection. We assessed factors associated with latent infection by use of logistic regression and calculated the yields and cost-effectiveness of screening at different levels of tuberculosis incidence in immigrants' countries of origin with a decision analysis model. FINDINGS: Results for IGRA-based screening were positive in 245 of 1229 immigrants (20%), negative in 982 (80%), and indeterminate in two (0·2%). Positive results were independently associated with increases in tuberculosis incidence in immigrants' countries of origin (p=0·0006), male sex (p = 0·046), and age (p < 0·0001). National policy thus far would fail to detect 71% of individuals with latent infection. The two most cost-effective strategies were to screen individuals from countries with a tuberculosis incidence of more than 250 cases per 100,000 (incremental cost-effectiveness ratio [ICER] was £17,956 [£1=US$1·60] per prevented case of tuberculosis) and at more than 150 cases per 100,000 (including immigrants from the Indian subcontinent), which identified 92% of infected immigrants and prevented an additional 29 cases at an ICER of £20,819 per additional case averted. INTERPRETATION: Screening for latent infection can be implemented cost-effectively at a level of incidence that identifies most immigrants with latent tuberculosis, thereby preventing substantial numbers of future cases of active tuberculosis. FUNDING: Medical Research Council and Wellcome Trust.
Asunto(s)
Emigrantes e Inmigrantes , Interferón gamma/sangre , Tuberculosis Latente/diagnóstico , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Análisis Costo-Beneficio , Árboles de Decisión , Femenino , Humanos , Incidencia , Tuberculosis Latente/economía , Tuberculosis Latente/epidemiología , Masculino , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Prevalencia , Estudios Prospectivos , Análisis de Regresión , Reino Unido/epidemiología , Adulto JovenRESUMEN
BACKGROUND: The varied behaviour of tuberculous lymph nodes during TB chemotherapy can cause clinical uncertainty, resulting in prolonged courses of treatment. OBJECTIVES: To investigate whether results in routine practice in Blackburn, a high-incidence tuberculosis (TB) area in England and Wales, replicated the results of the 6-month chemotherapy trial for lymph node TB conducted by the British Thoracic Society. DESIGN: All TB cases managed at the Blackburn Chest Clinic are recorded prospectively. Patients with lymph node TB were identified over a 10-year period. RESULTS: A total of 100 patients with lymph node TB were listed in the database. Fine-needle aspiration was performed in 49 patients, while 66 underwent incisional lymph node biopsy. Culture confirmation was achieved in 60 cases. Sinus and new lymph node development was comparable between our study and the BTS trial. After cessation of treatment, 10 patients developed new/enlarged lymph nodes, but further investigations revealed that only three patients had relapsed TB. CONCLUSION: The varied behaviour of lymph node TB during and after treatment causes clinical uncertainty. Six months of chemotherapy is effective for fully susceptible TB in routine clinical practice in England. Investigation of new signs is important in differentiating patients with relapsed TB from normal varied behaviour.
Asunto(s)
Antituberculosos/uso terapéutico , Ganglios Linfáticos/microbiología , Tuberculosis Ganglionar/tratamiento farmacológico , Adulto , Biopsia , Biopsia con Aguja Fina , Bases de Datos Factuales , Inglaterra , Femenino , Humanos , Ganglios Linfáticos/patología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Factores de Tiempo , Resultado del Tratamiento , Tuberculosis Ganglionar/diagnóstico , GalesRESUMEN
BACKGROUND: Non-tuberculous mycobacteria have long been identified as capable of causing human disease and the number at risk, due to immune-suppression, is rising. Several reports have suggested incidence to be increasing, yet routine surveillance-based evidence is lacking. We investigated recent trends in, and the epidemiology of, non-tuberculous mycobacterial infections in England, Wales and Northern Ireland, 1995-2006. METHODS: Hospital laboratories voluntarily report non-tuberculous mycobacterial infections to the Health Protection Agency Centre for Infections. Details reported include age and sex of the patient, species, specimen type and source laboratory. All reports were analysed. RESULTS: The rate of non-tuberculous mycobacteria reports rose from 0.9 per 100,000 population in 1995 to 2.9 per 100,000 in 2006 (1608 reports). Increases were mainly in pulmonary specimens and people aged 60+ years. The most commonly reported species was Mycobacterium avium-intracellulare (43%); M. malmoense and M. kansasii were also commonly reported. M. gordonae showed the biggest increase over the study period rising from one report in 1995 to 153 in 2006. Clinical information was rarely reported. CONCLUSIONS: The number and rate of reports increased considerably between 1995 and 2006, primarily in older age groups and pulmonary specimens. Increases in some species are likely to be artefacts but real changes in more pathogenic species, some of which will require clinical care, should not be excluded. Enhanced surveillance is needed to understand the true epidemiology of these infections and their impact on human health.
Asunto(s)
Notificación Obligatoria , Infecciones por Mycobacterium/epidemiología , Mycobacterium/aislamiento & purificación , Adulto , Femenino , Humanos , Laboratorios de Hospital , Masculino , Persona de Mediana Edad , Mycobacterium/clasificación , Mycobacterium/patogenicidad , Vigilancia de la Población , Reino Unido/epidemiologíaRESUMEN
UNLABELLED: BACKGROUND/SETTING: Treatment for 3 months with rifampicin (R) and isoniazid (H) (3RH) for latent tuberculosis infection (LTBI), defined as an inappropriately positive tuberculin skin test with no clinical or x-ray evidence of disease, has been used locally since 1989. The efficacy of this regimen in children in the UK has only been studied indirectly. The long-term outcome of those children treated with 3RH, in the Chest Clinic of this high tuberculosis (TB) incidence district, has been studied to derive a more direct assessment of effectiveness. METHODS: All children treated with 3RH for LTBI from 1989 to 2004 inclusive were matched with the local patient administration system (PAS), GP registration and local TB notification databases. Only those persons still registered locally on PAS, or locally GP registered were then checked for subsequent TB notification. RESULTS: A total of 334 patients were identified, of whom 252 remained locally, with 82 lost to follow-up; 3 cases of clinical TB developed in the 252 (1.19%), with 3113 years observation (mean 12.35 years) giving 0.964/1000 person years (95% CI 0.199 to 2.816). Sensitivity analyses showed a 'best case' scenario of 0.727/1000 person years (95% CI 0.15 to 2.12), and if 10% of those lost to follow-up developed clinical TB of 2.66/1000 person years (95% CI 1.33 to 4.77). CONCLUSIONS: Follow-up of those cases treated with 3RH, for a mean of 12.35 years, and over 3100 patient years observation, shows a rate of active TB of under 1/1000 patient years. This suggests that 3RH has very high efficacy when used to treat LTBI in children in the UK and compares favourably with the expected untreated TB rate.
Asunto(s)
Antituberculosos/uso terapéutico , Isoniazida/uso terapéutico , Tuberculosis Latente/tratamiento farmacológico , Rifampin/uso terapéutico , Adolescente , Niño , Esquema de Medicación , Quimioterapia Combinada , Inglaterra/epidemiología , Estudios de Seguimiento , Humanos , Lactante , Tuberculosis Latente/epidemiología , Resultado del Tratamiento , Tuberculosis/epidemiología , Tuberculosis/prevención & controlRESUMEN
BACKGROUND: Abdominal tuberculosis (ATB) is a great mimic and an important cause of morbidity. Its incidence is more common in certain groups. AIM: To review the cases of ATB in Blackburn from 1985 to 2004, with emphasis on presentation, investigation, diagnosis, treatment and follow-up. METHODS: A retrospective cases note analysis from a prospectively compiled database. RESULTS: Eighty-six cases of ATB were on a prospective database of all tuberculosis (TB) cases in Blackburn for 1985-2004 inclusive. Full case papers were available for 82 and partial data for the remaining four cases. Median age was 34.8 years, with an equal sex distribution. South Asians accounted for 91% of cases. The highest proportion of patients had peritoneal TB, and a considerable number (27%) had TB at multiple sites. CONCLUSION: The diagnosis can be difficult to make because of the varied presentation, the low percentage with positive microscopy for acid-fast bacilli and the time delay of up to several weeks for a positive TB culture. The thresholds for laparoscopy and/or laparotomy for the diagnosis were therefore very low. The diagnosis could be made rapidly by these methods, and early treatment instituted. Six months short-course chemotherapy is very effective in ATB. This should be changed, if appropriate, on the basis of drug susceptibility data.
Asunto(s)
Tuberculosis/diagnóstico , Adulto , Antituberculosos/uso terapéutico , Asia Sudoriental/etnología , Emigrantes e Inmigrantes , Inglaterra , Femenino , Hospitales de Distrito , Hospitales Generales , Humanos , Laparoscopía , Laparotomía , Masculino , Peritonitis Tuberculosa/diagnóstico , Peritonitis Tuberculosa/tratamiento farmacológico , Estudios Retrospectivos , Resultado del Tratamiento , Tuberculosis/tratamiento farmacológico , Tuberculosis Gastrointestinal/diagnóstico , Tuberculosis Gastrointestinal/tratamiento farmacológico , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/tratamiento farmacológicoRESUMEN
We report 79 cases of bone and joint tuberculosis between 1988 and 2005, eight of which were in the Caucasian population and 71 in the non-white population. The diagnosis was made in the majority (73.4%) by positive bacteriology and/or histology. The mean age at the time of diagnosis was higher in the Caucasian group at 51.5 years (28 to 66) than in the South Asian group at 36.85 years (12 to 93). Only one patient had previous BCG immunisation. The spine was the site most commonly affected (44.3%). Surgical stabilisation and/or decompression was performed in 23% of these cases because of cord compression on imaging or the presence of neurological signs. A six-month course of chemotherapy comprising of an initial two months of rifampicin, isoniazide, pyrazinamide and sometimes ethambutol followed by four months treatment with rifampicin and isoniazide, was successful in all cases without proven drug resistance.
Asunto(s)
Tuberculosis Osteoarticular/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Pueblo Asiatico/etnología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Tuberculosis Osteoarticular/diagnóstico , Tuberculosis Osteoarticular/cirugía , Reino Unido , Población Blanca/etnologíaRESUMEN
SETTING: A local government area in North West England with a significant population of Indian subcontinent (ISC) ethnic origin and a high incidence of tuberculosis. OBJECTIVE: To assess whether return visits to the ISC are associated with an increased risk of developing clinical tuberculosis. METHODS: Analysis of data prospectively obtained from ISC patients diagnosed with TB in 1998-2002 (cases) and age and sex matched ISC patients in two local GP practices (controls). RESULTS: There is at best weak evidence of association between case status and whether individuals have had a repeat visit to the subcontinent within 3 years of notification in this cohort; odds ratio 1.26 (95% CI (0.95, 1.76)); Fishers exact test P=0.09.
Asunto(s)
Viaje , Tuberculosis/epidemiología , Adulto , Factores de Edad , Anciano , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Humanos , India/etnología , Oportunidad Relativa , Estudios Prospectivos , Factores de Riesgo , Encuestas y Cuestionarios , Factores de Tiempo , Tuberculosis/etnología , Reino Unido/epidemiologíaAsunto(s)
Terapia Antirretroviral Altamente Activa , Antituberculosos/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Tuberculosis/tratamiento farmacológico , Terapia Antirretroviral Altamente Activa/efectos adversos , Antituberculosos/efectos adversos , Lactancia Materna , Terapia por Observación Directa , Interacciones Farmacológicas , Farmacorresistencia Viral , Femenino , Infecciones por VIH/complicaciones , Humanos , Embarazo , Complicaciones del Embarazo/prevención & control , Prevención Secundaria , Insuficiencia del Tratamiento , Prueba de Tuberculina , Tuberculosis/complicaciones , Tuberculosis/prevención & control , Tuberculosis Resistente a Múltiples Medicamentos/complicaciones , Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológicoRESUMEN
Multidrug-resistant tuberculosis (MDR-TB) is an increasing global problem, with most cases arising from a mixture of physician error and patient non-compliance during treatment of susceptible TB. The extent and burden of MDR-TB varies significantly from country to country and region to region. As with TB itself, the overwhelming burden of MDR-TB is in high-burden resource-poor countries. The diagnosis depends on confirming the drug susceptibility pattern of isolated organisms, which is often only possible in resource-rich settings. There should be a strong suspicion of drug resistance, including MDR-TB, in persons with a history of prior treatment or in treatment failure cases. Treatment in developed countries is expensive and involves an individualized regimen based on drug susceptibility data and use of reserve drugs. In resource-poor settings a WHO retreatment regimen may be used, but increasingly the move is to a directly observed treatment based 'DOTS-plus' regimen in a supported national TB programme. However, even where such treatment is given, the outcome for patients is significantly worse than that for fully susceptible TB and has a much higher cost.
Asunto(s)
Tuberculosis Resistente a Múltiples Medicamentos/tratamiento farmacológico , Tuberculosis Pulmonar/tratamiento farmacológico , Antibióticos Antituberculosos/uso terapéutico , Antituberculosos/uso terapéutico , Países Desarrollados , Países en Desarrollo , Humanos , Isoniazida/uso terapéutico , Cooperación del Paciente , Rifampin/uso terapéutico , Factores de Riesgo , Insuficiencia del Tratamiento , Tuberculosis Resistente a Múltiples Medicamentos/epidemiología , Tuberculosis Resistente a Múltiples Medicamentos/prevención & control , Tuberculosis Pulmonar/epidemiología , Tuberculosis Pulmonar/prevención & controlRESUMEN
This report describes two cases of segmental pulmonary vein occlusion secondary to lung malignancy in which lung biopsies showed histological features of veno-occlusive disease. These are the first cases to be reported in the literature in which such lung parenchymal histological changes are described in association with lung malignancy.
Asunto(s)
Carcinoma de Células Escamosas/complicaciones , Leiomiosarcoma/complicaciones , Neoplasias Pulmonares/complicaciones , Enfermedad Veno-Oclusiva Pulmonar/etiología , Adulto , Carcinoma de Células Escamosas/patología , Resultado Fatal , Femenino , Humanos , Leiomiosarcoma/patología , Neoplasias Pulmonares/patología , Persona de Mediana Edad , Venas Pulmonares/patología , Enfermedad Veno-Oclusiva Pulmonar/patología , Tomografía Computarizada por Rayos X/métodosRESUMEN
OBJECTIVE: Controlled trials have failed to show an effect of Mycobacterium vaccae immunotherapy on treatment outcome and mortality in patients with tuberculosis (TB); however, several studies have suggested improvement in radiographic clearing and resolution of cavitary disease. METHODS: To assess the effect of M. vaccae immunotherapy on radiographic healing in pulmonary TB, chest X-rays from three randomized placebo-controlled trials of M. vaccae given as a single injection during the first 2 weeks of treatment were interpreted by a single, masked assessor using a standard scheme. Endpoints were the overall degree of radiographic improvement or deterioration and changes in cavitary disease at the end of antituberculosis treatment and follow-up. RESULTS: Of 1018 patients (478 HIV-infected; 540 HIV-uninfected) with an end of treatment or end of follow-up X-ray analyzed, 496 received M. vaccae and 522 received placebo. There was no difference in radiographic improvement or deterioration or cavitary disease at the end of treatment or follow-up comparing the M. vaccae and placebo groups. Results were similar comparing HIV-infected and HIV-uninfected patients. CONCLUSION: Adjunctive immunotherapy of drug-susceptible pulmonary TB with M. vaccae during the first 2 weeks of treatment did not improve radiographic responses to treatment or resolution of cavitary disease.