Prevalence of Latent Infection with Mycobacterium Tuberculosis in Mazowieckie Province Using Interferon Gamma Release Assay after Stimulation with Specific Antigens ESAT-6 and CFP-10

Introduction: Over 8000 cases of tuberculosis (TB) are diagnosed annually in Poland. People infected with Mycobacterium tuberculosis (MTB) have a risk of active disease of around 10% during their whole life, and the risk is highest in the first two years after infection. Recognizing infection before TB disease development enables prophylaxis against its activation and ceases transmission of infection. Knowledge about the proportion of infected people in the population is crucial to predict the number of new cases of active disease. Materials and methods: The prevalence of latent TB infection (LTBI) was tested in 700 healthy adult inhabitants of the Mazowieckie province in different age groups, using both tuberculin skin test (TST) and interferon gamma release assay (IGRA). Commercial test QuantiFERON®-TB-Gold In Tube (QFT) was used. All participants were mandatorily BCG vaccinated according to the Polish vaccination schedule. Results: Twenty-three per cent of participants tested positively for QFT, which was significantly less than for TST (50.3%). The prevalence of positive QFT results increased with age, as well as the incidence of TB in Poland. Positive QFT was most frequent in the oldest age group (48.8%) and rarest in the youngest (7.1%). Conversely, positive TST occurred more often in younger participants (45%), who rarely suffer from TB. Among people over 60, with the highest TB incidence rate, only 33.8% tested positively with TST. Concordance between both tests was low, with a kappa value of 0.198. The prevalence of LTBI defined as positive QFT among health care workers (HCW) was significantly higher than among other participants (32.2% v. 20.4%, p < 0.01). Conclusions: LTBI was diagnosed in 23.3% of the tested population of the Mazowieckie province. QFT is a better tool for diagnosing LTBI as it shows a positive correlation with age (as the incidence of TB disease does). Concordance between both tests is low. The prevalence of LTBI in HCW is higher than in other participants.

Bacteriologically Confirmed Pulmonary Tuberculosis in a Patient with Lymphangioleiomyomatosis Accompanying Tuberous Sclerosis Syndrome

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown origin, that may be sporadic or develop in the course of tuberous sclerosis (TS). Patients do not present immune deficiency, but structural changes in the lung parenchyma (cysts) may encourage various infections, for example tuberculosis. Radiologic findings are often difficult to interpret, because of changes related to LAM itself. We present a young women with a history of TS and LAM in whom protracted respiratory tract infection was finally diagnosed as tuberculosis. Initial diagnosis was based primarily on clinical signs and symptoms and treatment was started despite a negative result of sputum microscopy for acid-fast bacilli. In the course of treatment, the diagnosis was supported by genetic test for M. tuberculosis in bronchoalveolar lavage fluid, positive tuberculin skin test, interferon-gamma release assay and finally, positive sputum culture in liquid media.

[Diagnostic value of induced sputum in interstitial lung disease]

BACKGROUND

Induced sputum (IS) has been recently used to investigate pulmonary inflammation in patients with interstitial lung disease (ILD), but still little attention has been paid to its efficacy in diagnosing sarcoidosis and other ILD. The aim of this study was to evaluate the diagnostic value of IS differential cell count and CD4+/CD8+ ratio in sarcoidosis (SA) and nonsarcoidosis ILD (NSA ILD).

MATERIAL AND METHODS

We studied prospectively newly diagnosed 59 patients: 36 SA and 23 NSA ILD [16 hypersensitivity pneumonitis (HP) and 7 idiopathic pulmonary fibrosis (IPF)]. IS was performed by inhaling a 5% NaCl solution for 4 periods of 5 minutes. Giemsa stained cytopreps were differentially counted and T-lymphocyte subsets were analyzed by flow cytometry method. The k-nearest neighbour rule (k-NN) or predictive value of CD4+/CD8+ ratio were used to discriminate between SA and NSA ILD. The variables of IS used in k-NN rule were: cells viability, total cell count, percentages of alveolar macrophages, lymphocytes, neutrophils, eosinophils, CD4+ and CD8+ subsets, and CD4+/CD8+ ratio.

RESULTS

33 patients were able to produce an adequate sputum sample (SA-15, HP-11, IPF-7). A CD4+/CD8+ ratio>2.6 had a sensitivity of 100% and a specificity of 72% with 84% of correctly classified cases in distinguishing SA from NSA ILD. However, using k-NN rule the probability of correct classification was 79% (classification error rate-21%).

CONCLUSION

To distinguish SA from NSA ILD cut off CD4+/CD8+ ratio>2.6 alone was superior to k-NN rule using all the parameters of IS.

[Bacteriologically confirmed pulmonary tuberculosis in a patient with lymphangioleiomyomatosis accompanying tuberous sclerosis syndrome]

Lymphangioleiomyomatosis (LAM) is a rare disease of unknown origin, that may be sporadic or develop in the course of tuberous sclerosis (TS). Patients do not present immune deficiency, but structural changes in the lung parenchyma (cysts) may encourage various infections, for example tuberculosis. Radiologic findings are often difficult to interpret, because of changes related to LAM itself. We present a young women with a history of TS and LAM, in whom protracting respiratory tract infection was finally diagnosed as tuberculosis. Initial diagnosis was based primarily on clinical signs and symptoms and treatment was started despite the negative result of the sputum microscopy for acid fast bacilli. In the course of treatment the diagnosis was supported by positive tuberculin skin test, interferon-gamma release assay and genetic test for M. tuberculosis in bronchoalveolar lavage fluid, and finally, positive sputum culture in liquid medium.

[Prevalence of latent infection with Mycobacterium tuberculosis in Mazovia Region using interferon gamma release assay after stimulation with specific antigens ESAT-6 and CFP-10]

INTRODUCTION

Over 8000 cases of tuberculosis (TB) are diagnosed annually in Poland. People infected with Mycobacterium tuberculosis (MTB) have a risk of active disease around 10% during whole life, the risk is biggest in the first two years after infection. Recognizing infection before TB disease occurred enables prophylaxis against its activation and ceases transmission of infection. Knowledge about proportion of infected people in the population is crucial to predict the number of new cases of active disease.

MATERIAL AND METHODS

Prevalence of latent TB infection (LTBI) was tested in 700 healthy adult inhabitants of Mazovia Region in different age groups, using both tuberculin skin test (TST) and interferon gamma release assay (IGRA). Commercial test QuantiFERON(®)-TB-Gold In Tube (QFT) was used. All participants were mandatory BCG vaccinated according to Polish vaccination schedule.

RESULTS

Twenty three per cent of participants tested positively for QFT, which was significantly less than positive results of TST (50.3%). Prevalence of positive QFT result increased with age, as does the incidence of TB in Poland. Positive QFT was most frequent in the oldest age group (48.8%) and rare in the youngest (7.1%). On the contrary, positive TST occurred more often in younger participants (45%), who rarely suffer from TB. Among people over 60, who have the highest TB incidence rate, only 33.8% tested positively with TST. Concordance between both tests was low, with kappa value 0.198. Prevalence of LTBI defined as positive QFT among health care workers (HCW) was significantly higher than in other participants (32.2% v. 20.4%, p 〈 0.01).

CONCLUSIONS

LTBI was diagnosed in 23.3% of tested population of Mazovia Region. QFT is a better tool for diagnosing LTBI as it shows positive correlation with age, the same as incidence of TB disease does. Concordance between both tests is low. Prevalence of LTBI in HCW is higher than in other participants.

Diagnostic Value of Induced Sputum in Interstitial Lung Disease

Introduction: Although induced sputum (IS) has recently been used in studies of interstitial lung disease (ILD), there havebeen few reports on studies investigating the usefulness of this method in the differential diagnosis of ILD. The aim of ourstudy was to determine the diagnostic value of differential cell counts and CD4+/CD8+ ratio in induced sputum frompatients with sarcoidosis and other ILDs. Material and methods: We enrolled 59 patients in the study (36 with sarcoidosis, 16 with hypersensitivity pneumonitis[HP] and seven with idiopathic pulmonary fibrosis [IPF]). Sputum was induced a minimum of seven days following BAL byinhalation of 5% NaCl solution for five minutes and repeated four times. Differential cell count was determined in Giemsastained cytospins by counting 400 mononuclear cells for specific cell types per slide. The analysis of T-cell subtypes wascarried out by flow cytometry. The potential for differentiating sarcoidosis from the other ILDs was checked by determiningthe predictive value for CD4+/CD8+ ratio or by using the object classification method based on the k-nearest neighbour(k-NN) rule. The variables used in the k-NN rule were the following parameters of IS: cell viability, total cell count,percentages of macrophages, lymphocytes, neutrophils, eosinophils, CD4+ lymphocytes and CD8+ lymphocytes, and theCD4+/CD8+ ratio. Results: Evaluation of IS was possible in 33 patients (15 with sarcoidosis, 11 with HP and seven with IPF). A CD4+/CD8+ratio in IS exceeding 2.6 had a sensitivity of 100%, and a specificity of 72% with the likelihood of establishing the correctdiagnosis while differentiating sarcoidosis from HP and IPF. On the other hand, when we used the k-NN rule, the likelihood ofestablishing the correct diagnosis was 79% (with an estimated classification error of 21%). Conclusion: Using the object classification method based on the k-NN rule in the differential diagnosis of sarcoidosis, HPand IPF on the basis of all the IS parameters is not associated with a higher likelihood of establishing the correct diagnosisthan the analysis of CD4+/CD8+ ratio alone.

Report from an Annual Congress of the European Respiratory Society, Berlin, 4–8 October 2008

Problematyka zaburzeń oddychania w czasie snu była reprezentowana na kongresie dość szeroko, obejmując: jedno sympozjum, trzy sesje doniesień ustnych, dwie sesje doniesień elektronicznych (e-communication), siedem sesji plakatowych, a ponadto dwie sesje „Gorący Temat” (Hot Topic) i praktyczny warsztat dotyczący stosowania nCPAP (nasal continuous positive airway pressure treatment). Najszerzej dyskutowano problematykę obturacyjnego bezdechu sennego (OBS) [...]

Współistnienie samoistnego włóknienia płuc i rozedmy

Samoistne (idiopatyczne) włóknienie płuc(SWP) jest bardzo dobrze scharakteryzowane podwzględem zaburzeń czynnościowych, zmianw obrazie radiologicznym płuc, w badaniu mikrosko-powym wycinków miąższu płuca, objawów, prze-biegu i rokowania [...]

[Treatment outcomes in culture positive pulmonary tuberculosis]

INTRODUCTION

The aim of the study was to evaluate treatment outcomes in sputum culture positive patients with tuberculosis in three Polish provinces (Warsaw, Gdansk and Siedlce Provinces) in 1995 and again in 2000. We also assessed whether the implementation of the Directly Observed Therapy Short Course (DOTS) strategy in the former Gdansk Province led to improved outcomes compared to the outcomes observed in 1995, when this strategy was not being followed.

MATERIAL AND METHODS

We started the study by reviewing microbiology registers covering the years 1995 and 2000 from all the tuberculosis laboratories in three provinces (Warsaw, Gdansk and Siedlce Provinces) and identified sputum culture positive patients. We then reviewed inpatient and outpatient medical records of patients who had been with pulmonary tuberculosis diagnosed and confirmed by bacteriology in 1995 and 2000. Treatment outcomes were evaluated in accordance with the World Health Organisation (WHO) recommendations and classified as: cure, treatment completed, default, treatment failure, death or other.

RESULTS

A total of 708 patients were included in the study: 373 diagnosed in 1995 and 335 diagnosed in 2000. According to the WHO criteria, the treatment success rate (the sum of cures and treatment completions) in 1995 and 2000 was 58.8% and 54.0%, the default rate was 15.5% and 17.9%, the failure rate was 2.4% and 2.7% and the death rate was 5.6% and 6.3%, respectively. The rate of outcomes classified as "other" was 18.2% and 22.1%, respectively. Following the implementation of the DOTS strategy in Gdansk Province, treatment outcomes in significantly improved in 2000 compared to the year 1995. The treatment success rate was 89.6% vs 69.3% (p = 0.0037), the default rate was 0.0% vs. 14.7% (p = 0.0005) and the death rate was 0.0% vs. 9.3% (p = 0.0184).

CONCLUSIONS

The treatment success rate (the rate of cures and treatment completers) in 1995 and 2000 was 58.8% and 54.0% and was lower than that recommended by WHO (at least 85%). The results demonstrated that the treatment outcomes in the former Gdansk Province in 2000, following the implementation of the DOTS strategy, were significantly better than those in 1995, when the strategy was not being followed. Treatment success was observed in 89.6% and 69.3% of the patients, respectively (p = 0.0037).

Treatment Outcomes in Culture-Positive Pulmonary Tuberculosis

Introduction: The aim of the study was to evaluate treatment outcomes in sputum culture positive patients with tuberculosis in three Polish provinces (Warsaw, Gdansk and Siedlce Provinces) in 1995 and again in 2000. We also assessed whether the implementation of the Directly Observed Therapy Short Course (DOTS) strategy in the former Gdansk Province led to improved outcomes compared to the outcomes observed in 1995, when this strategy was not being followed. Material and methods: We started the study by reviewing microbiology registers covering the years 1995 and 2000 from all the tuberculosis laboratories in three provinces (Warsaw, Gdansk and Siedlce Provinces) and identified sputum culture positive patients. We then reviewed inpatient and outpatient medical records of patients who had been with pulmonary tuberculosis diagnosed and confirmed by bacteriology in 1995 and 2000. Treatment outcomes were evaluated in accordance with the World Health Organisation (WHO) recommendations and classified as: cure, treatment completed, default, treatment failure, death or other. Results: A total of 708 patients were included in the study: 373 diagnosed in 1995 and 335 diagnosed in 2000. According to the WHO criteria, the treatment success rate (the sum of cures and treatment completions) in 1995 and 2000 was 58.8% and 54.0%, the default rate was 15.5% and 17.9%, the failure rate was 2.4% and 2.7% and the death rate was 5.6% and 6.3%, respectively. The rate of outcomes classified as “other” was 18.2% and 22.1%, respectively. Following the implementation of the DOTS strategy in Gdansk Province, treatment outcomes in significantly improved in 2000 compared to the year 1995. The treatment success rate was 89.6% vs. 69.3% (p = 0.0037), the default rate was 0.0% vs. 14.7% (p = 0.0005) and the death rate was 0.0% vs. 9.3% (p = 0.0184). Conclusions: The treatment success rate (the rate of cures and treatment completers) in 1995 and 2000 was 58.8% and 54.0% and was lower than that recommended by WHO (at least 85%). The results demonstrated that the treatment outcomes in the former Gdansk Province in 2000, following the implementation of the DOTS strategy, were significantly better than those in 1995, when the strategy was not being followed. Treatment success was observed in 89.6% and 69.3% of the patients, respectively (p = 0.0037).

Sprawozdanie z Kongresu Europejskiego Towarzystwa Oddechowego w Sztokholmie, 15–19 Września 2007 Roku (Część II)

Żylna choroba zakrzepowo-zatorowa i nadciśnienie płucne nie stanowiły wiodących tematów kongresu [...]

Mycobacterial Infection Caused by Mycobacterium avium in Allogenic Bone Marrow Transplant Recipient with Concomittant Bronchiolitis Obliterans as a Manifestation of Graft Versus Host Disease—Case Report and Review of the Literature

Patients after organ transplantations are at risk for mycobacteriosis development. Frequency of the mycobacterial infection after bone marrow transplantation (BMT) is not as high as one could expect. It ranges from 0.4 to 4.9%. We present a case of a female patient after allogenic BMT as a treatment of chronic myelogenous leucaemia, with bronchiolitis obliterans as a symptom of graft versus host disease (GvHD), treated with corticosteroids and infected with Mycobacterium avium. She was admitted to the hospital with dyspnoea, cough with large amount of sputum production and subfebrile status. She had partial respiratory insufficiency and obturative disturbances of respiration (FEV1 0.67 l i.e., 22% of normal) with decline of VC (2.23 l i.e., 64% of normal). The high-resolution computed tomography (HRCT) revealed multifocal infiltrations and bronchiectases in the upper and middle pulmonary fields, which were absent in the previous HRCT taken 3 years earlier. In the bronchial secretion acid-fast bacilli were found by smear and culture. The isolate was classified as Mycobacterium avium complex (MAC) by high performance liquid chromatography (HPLC). The patient was treated with clarithromycin, ciprofloxacin, isoniazide (INH), ethambutol (EMB), amikacin, but M. avium was still present in the sputum after 3 months. Treatment was continued in her parent hospital, where after a few months her sputum became negative for M. avium. But she died over a year later from progressive respiratory insufficiency in the course of bronchiolitis obliterans. The patient was in the group of high risk for mycobacterial infection development and the course of her illness was typical. We decided however to present the case as the topic seems to be quite neglected in the literature.

[Mycobacterial infection caused by Mycobacterium avium in allogenic bone marrow transplant recipient with concomittant bronchiolitis obliterans as a manifestation of graft versus host disease - case report and review of the literature]

Patients after organ transplantations are at risk for mycobacteriosis development. Frequency of the mycobacterial infection after bone marrow transplantation (BMT) is not as high as one could expect. It ranges from 0.4 to 4.9%. We present a case of a female patient after allogenic BMT as a treatment of chronic myelogenous leucaemia, with bronchiolitis obliterans as a symptom of graft versus host disease (GvHD), treated with corticosteroids and infected with Mycobacterium avium. She was admitted to the hospital with dyspnoea, cough with large amount of sputum production and subfebrile status. She had partial respiratory insufficiency and obturative disturbances of respiration (FEV(1) 0.67 l i.e. 22% of normal) with decline of VC (2.23 l i.e. 64% of normal). The high-resolution computed tomography (HRCT) revealed multifocal infiltrations and bronchiectases in the upper and middle pulmonary fields, which were absent in the previous HRCT taken 3 years earlier. In the bronchial secretion acid-fast bacilli were found by smear and culture. The isolate was classified as Mycobacterium avium complex (MAC) by high performance liquid chromatography (HPLC). The patient was treated with clarithromycin, ciprofloxacin, isoniazide (INH), ethambutol (EMB), amikacin, but M. avium was still present in the sputum after 3 months. Treatment was continued in her parent hospital, where after a few months her sputum became negative for M. avium. But she died over a year later from progressive respiratory insufficiency in the course of bronchiolitis obliterans. The patient was in the group of high risk for mycobacterial infection development and the course of her illness was typical. We decided however to present the case as the topic seems to be quite neglected in the literature.