Treatment of leukemic relapse after allogeneic stem cell transplantation with cytotoreductive chemotherapy and/or immunotherapy or second transplants

We analyzed toxicity and efficacy of chemotherapy (CT) or second stem cell transplantation (SCT) and/or immunotherapy defined as stop of immunosuppression (IS) or donor leukocyte infusion (DLI) in 47 patients relapsing with acute leukemia. Ten patients received no treatment and 14 patients were treated with CT only. In 12 patients IS was stopped and three of them received additional CT. Five patients received DLI after CT as consolidation and one patient as frontline therapy. Five patients received a second SCT. Median overall survival after relapse was 2 months for the untreated patients, 2 months for patients receiving CT only, 2 months in patients after cessation of IS, 17 months in DLI treated patients and three months in patients receiving a second SCT. Fourteen patients achieved remission after relapse. Two with CT (2, 2 months), three with SI (3, 19, 19+ months), six with DLI (3, 8, 9, 14, 20, 36 months) and three with second SCT (2, 4, 6 months). Conventional CT was able do re-establish donor hematopoiesis and patients achieving remission showed a significantly better survival than patients with refractory disease. Patients who were brought into remission by DLI or cessation of IS had a significantly better survival than patients who achieved remission with CT alone or a second SCT. We conclude that a selected group of patients achieving remission with regeneration of donor hematopoiesis following CT might benefit from immunotherapy as consolidation.

PBPC mobilization with chemotherapy and G-CSF in patients with chronic myeloid leukemia: quantification of bcr/abl-positive cells by interphase fluorescence in situ hybridization and competitive PCR

BACKGROUND

Autografting of normal stem cells mobilized after chemotherapy is increasingly used in chronic myeloid leukemia (CML). Thus, quantification of possible contamination of progenitor cell apheresis with breakpoint cluster region (bcr)/Abelson murine leukemia (abl)-positive cells is of great clinical interest.

STUDY DESIGN AND METHODS

Two molecular methods were compared to quantify bcr/abl positivity in leukapheresis components obtained after mobilizing chemotherapy in six patients with CML. To document the efficacy of in vivo purging, the leukapheresis procedures were monitored with interphase fluorescence in situ hybridization (FISH) and quantitative competitive PCR (QC-PCR) as a ratio of bcr/abl:abl.

RESULTS

From the first to the last leukapheresis, bcr/abl positivity in FISH increased from a median of 11 percent to 33 percent. For bcr/abl transcripts, a simultaneous increase in consecutive leukapheresis procedures was seen. The median percentage of bcr cells in a bcr/abl:abl ratio was 3.1 percent in the first apheresis. In the last apheresis after the mobilization with mRNA, the QC-PCR showed a median of 19.5 percent. FISH and QC-PCR showed a statistical significant increase of bcr/abl positivity from the first to the last apheresis.

CONCLUSIONS

Both FISH and QC-PCR were reliable methods of quantifying bcr/abl positivity, and they allowed selection of the optimal apheresis component for autologous transplantation. In both methods, a significant increase in bcr/abl positivity was seen from the first to the last leukapheresis. With FISH, results can be obtained within 24 hours. This method may prevent additional contaminated leukapheresis in case of increasing percentages of bcr/abl-positive cells.

Age, sex and practice variations in the use of statins in general practice in England and Wales

BACKGROUND

Statins are highly effective in reducing the risk of sudden cardiac death and other acute coronary events in patients with pre-existing ischaemic heart disease or with raised blood cholesterol levels. However, relatively little is known about how statins are used in primary care. The objectives of this study were to investigate age, sex and inter-practice variations in the prescribing of statins.

METHODS

This was an observational study of statin prescribing rates in 288 general practices in England and Wales that contributed data to the General Practice Research Database in 1996.

RESULTS

In 1996, 0.7 per cent of men and 0.5 per cent of women received a prescription for a statin. In the subgroup of patients with a general practitioner (GP) diagnosis of ischaemic heart disease, 13.3 per cent of men and 8.2 per cent of women received a prescription for a statin in 1996. Below the age of 65 years, men with ischaemic heart disease were more likely to be prescribed a statin than were women. Patients aged 75 years and over with ischaemic heart disease were unlikely to be prescribed a statin irrespective of their sex. The percentage of patients prescribed statins in individual practices varied from 0.1 to 2.3 per cent in men and from 0 to 2.3 per cent in women. The recorded prevalence of ischaemic heart disease explained only 12 per cent of this variation in men and 7 per cent in women.

CONCLUSIONS

There are large age, sex and inter-practice variations in the use of statins in primary care, which are poorly explained by measures of health need. Developing and implementing clinical guidelines to accompany the introduction of new drugs for the management of common chronic disorders should be seen as a priority for GPs, primary care groups and the National Institute of Clinical Excellence.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken

BACKGROUND

Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London.

AIM

To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices.

METHOD

Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997.

RESULTS

Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status.

CONCLUSION

Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Positioning of vagal nerve stimulators: technical note

BACKGROUND

Vagal nerve stimulation has become an important treatment for patients with intractable seizure disorders. Many of these patients will require magnetic resonance imaging (MRIs) of the brain after the stimulator has been implanted to monitor underlying neurologic conditions. Functional MRI (fMRI) is also being used in the evaluation of epilepsy. With the current recommended implant techniques the magnetic field of the MRI will deactivate the pulse generator while the patient is in the supine position for the scan. A simple change in positioning of the pulse generator will help to avoid deactivating the device during an MRI. This will avoid exposing the patient to lengthy time periods with a deactivated stimulator and also allow for the performance of fMRIs and any other MRI scans needed to monitor underlying neurologic conditions.

METHODS

A working model of the NeuroCybernetic Prosthesis (NCP) pulse generator was assessed with an oscilloscope and LED light connected to it that related activation of the generator while in the MRI. This simulation was performed with the device alone, in multiple positions. Then patients with implanted devices who could personally confirm the activation of their stimulators were also studied.

RESULTS

A pulse generator placed with the electrode inputs parallel to the long axis of the body was not deactivated by the magnetic field of the MRI when the patient was in the supine position.

CONCLUSION

Changing the implant position of a vagal nerve stimulator pulse generator will help to prevent deactivation of the device while in the MRI, allowing for the performance of fMRIs while not exposing the patient to lengthy time periods with a deactivated vagal nerve stimulator.

Age- and sex-specific antibiotic prescribing patterns in general practice in England and Wales in 1996

Using data from 288 general practices in England and Wales contributing data to the General Practice Research Database in 1996, we derived age-sex specific antibiotic prescribing and exposure rates. The overall antibiotic prescribing rate was 607 per 1000 in males and 852 per 1000 in females. In both males and females, prescribing rates were highest in children aged 0-4 years and in the elderly. Prescribing rates in young and middle-aged women were substantially higher than in men of the same age. Overall, 29% of males and 39% of females were prescribed antibiotics in 1996. Children under five years of age were most likely to receive a prescription for an antibiotic. Antibiotic prescribing rates for the 288 practices in the study varied nearly five-fold, from 333 to 1616 per 1000. Reducing this variation and overall antibiotic prescribing rates will be major challenges for general practitioners.

Hematopoietic donor chimerism and graft-versus-myeloma effect in relapse of multiple myeloma after allogeneic bone marrow transplantation

A large group of patients relapsing after allogeneic bone marrow transplantation (BMT) have obtained remission after infusion of leukocytes from their original donor, suggesting a graft-versus-myeloma effect. However, side effects such as graft-versus-host disease and myelosuppression are severe, and sometimes fatal, complications of this therapeutic approach. Previously we demonstrated that patients with leukemia who lack donor hematopoiesis in relapse after BMT experience severe and lasting aplasia after infusion of donor leukocytes. In two patients - one with extramedullary and one with marrow relapse after a sex-mismatched transplantation - we analyzed hematopoietic chimerism by cell sorting and bone marrow cultures. CD34-positive cells, CD4-CD8-positive cells, committed progenitors, and LTC-IC were of donor origin, as demonstrated by two-color fluorescence in situ hybridization (FISH). Additionally, in relapse complete donor T-cell chimerism was seen. In contrast, plasma cells were of recipient origin in the patient who had a relapse in the bone marrow. Both patients were treated with infusions of donor leukocytes from their original donor. Neither patient suffered myelosuppression, and one achieved a stable complete remission.

Frequent genetic alterations in simple urothelial hyperplasias of the bladder in patients with papillary urothelial carcinoma

In order to understand the origin of bladder cancer, very early urothelial lesions must be investigated in addition to more advanced tumors. Tissue from 31 biopsies of 12 patients with urothelial hyperplasias and simultaneous or consecutive superficial papillary tumors were used to microdissect urothelium from 15- microm sections of biopsies. The biopsies were obtained with the recently developed highly sensitive diagnostic method of 5-aminolevulinic acid-induced fluorescence endoscopy (AFE). Besides flat and papillary urothelial neoplasms, the method of photodynamic diagnostics also detects simple urothelial hyperplasias as fluorescent positive lesions. In addition, 12 fluorescence-positive biopsies showing histologically normal urothelium were investigated. Fluorescence in situ hybridization was done using a dual color staining technique of biotinylated centromeric probes of chromosomes 9 and 17 and digoxigenin-labeled gene-specific P1 probes for chromosomes 9q22 (FACC), 9p21(p16/CDKI2), and 17p13(p53). Ten of 14 hyperplasias (70%) showed deletions of chromosome 9. In 7 out of 8 patients with genetic alterations in the hyperplasias the genetic change was also present in the papillary tumor. Six out of 12 samples of microdissected normal urothelium also showed genetic alterations on chromosome 9. Microdissection of urothelial lesions, obtained during AFE, has led to the first unequivocal documentation of genetic changes in urothelial lesions diagnosed as normal in histopathology. Thus, this technical approach is important to provide insight into the earliest molecular alterations in bladder carcinogenesis.

A study of tuberculosis among foreign-born Hispanic persons in the U.S. States bordering Mexico

In 1996, 10% of the 20,973 U.S. tuberculosis (TB) cases were among foreign-born (FB) Hispanic persons, with the four states bordering Mexico accounting for 83% of FBH cases. Limited information is available on this population's health care seeking and migration practices and on differences between FB Hispanic patients in border and nonborder areas. Therefore, we conducted interviews and record reviews for all consenting FB Hispanic TB patients from eight counties bordering Mexico (BC; n = 167) and seven urban nonborder counties (NBC; n = 158) in these States during 1995-1997. BC patients had resided in the U.S. longer than NBC patients (17.4 versus 10.8 yr; p < 0.01), had immigrated more often from Mexican border communities (62.4% versus 25.4%; p < 0.01), and had returned to Mexico more often in the past 12 mo (71.5% versus 47.3%; p < 0. 01). TB symptoms were present for >/= 6 mo in 37% of BC and 34% of NBC patients. Binational collaboration is essential for improving TB control in both countries and should extend beyond border areas of Mexico.

Australia's notifiable diseases status, 1997. Annual report of the National Notifiable Diseases Surveillance System

In 1997 there were 89,579 notifications to the National Notifiable Diseases Surveillance System. A notable feature of 1997 was the pertussis outbreak which peaked towards the end of the year and resulted in 10,668 cases being notified. The highest number of notifications received was for hepatitis C (unspecified) with 19,692 notifications; this is the first year for which data have been reported for New South Wales and South Australia for this disease category. The number of measles cases rose after the low number reported in 1996 but is still well below the number reported in the outbreak years of 1993 and 1994. Rubella notifications continued to decline in 1997. Notifications of Haemophilus influenzae type b appeared to have stabilised at a low rate, having declined markedly after introduction of the conjugated vaccine in 1992. The number of cases of campylobacteriosis remained steady after having risen for several years. Notifications of hepatitis A cases rose considerably, much of this being due to one outbreak in New South Wales. The number of cases of salmonellosis rose while shigellosis numbers dropped slightly. Notifications for chlamydial infection and gonococcal infection continued to rise, whilst those for syphilis continued to fall.

Development of housing programs to aid in the treatment of tuberculosis in homeless individuals: a pilot study

STUDY OBJECTIVES

To describe our experience with novel supervised housing programs developed to aid in the treatment of tuberculosis (TB) in homeless individuals, including a preliminary analysis of their effectiveness and estimate of potential cost savings.

DESIGN

Retrospective chart review.

SETTING

A county TB control program.

METHODS

The San Diego County TB Control Program's computer database was used to identify homeless individuals placed in one of two supervised housing programs for treatment of TB [Young Men's Christian Association (YMCA), for noninfectious patients, or Bissell House, for infectious patients]. Charts for all these patients were reviewed and information regarding their demographics, underlying medical conditions, therapy, microbiologic markers of response to therapy, hospitalizations, and participation in supervised housing programs was recorded.

MEASUREMENTS AND RESULTS

The sputum culture conversion and treatment completion rates for those housed in the YMCA were 100 and 84.6%, respectively. Of the patients in the Bissell House program, 100% had converted their smear and culture. In addition, all patients in this program completed an adequate course of supervised therapy. These rates of microbiologic conversion and treatment completion compare favorably with historical data from San Diego County and other locations. Estimated cost savings for placing medically stable infectious patients in the Bissell House for respiratory isolation and supervised treatment were estimated to be $27,034 per patient.

CONCLUSIONS

Use of supervised housing to aid in treatment of TB in the homeless appears to be effective and results in substantial cost savings. A larger multicenter study should be considered to confirm these findings and better quantify the cost-effectiveness of such programs.

Drug-resistant pulmonary tuberculosis in the Baja California-San Diego County border population

A study was conducted to determine the frequency of, and risk factors for, drug-resistant pulmonary tuberculosis (TB) among Baja California (BC) and San Diego County (SDC) residents. Another purpose was to document the amount of contact between pulmonary TB patients and residents of the opposite side of the the border. During the period from February 1995 to May 1996, pulmonary TB patients from BC (n = 427) and SDC (n = 331) were evaluated with cultures, drug susceptibility tests, and questionnaires. Drug resistance was found in 41% of the BC Mycobacterium tuberculosis complex (MTB) isolates and 20% of the SDC isolates. Resistance to both isoniazid (INH) and rifampin (RIF) varied from 1% of isolates from SDC patients to 17% of isolates from BC patients. Patients with a history of previous treatment had increased odds of drug-resistant disease. Older BC patients were more likely to have INH- or RIF-resistant TB. Although 42% of Tijuana TB patients reported recent contact with residents from SDC, travel to Mexico and contact with residents from Mexico were not significant risk factors for drug-resistant TB among SDC residents. However, the demonstrated contact between TB patients and residents on opposite sides of the border indicates the importance of coordinating efforts internationally to control TB.

The use and overlap of AED and general practice services by patients registered at two inner London general practices

BACKGROUND

The improvement of general practitioner (GP) availability has been suggested as a factor influencing the rise in attendance rates at accident and emergency departments (AEDs) in the United Kingdom, particularly in innercity areas. However, previous studies suggest that only 3-6% of patients attempt to contact their GP before attending the AED, and measures of the availability of appointments in the surgery are not associated with AED self-referral rates.

AIM

To examine the overlap of services between general practice and AEDs, and the characteristics of patients who attend at both sites.

METHOD

A prospective observational study, set in east London, of all AED attendances from two group practices located within two kilometers of the Royal London Hospital, over a seven month period in 1994.

RESULTS

Of 1785 attendances analysed, 80% were self referrals. Rates of hospital admission (18.1%) and outpatient referral (9.5%) reflect national figures. There was a significantly higher proportion of attendance from those of white ethnicity among children under 16. Using the Sheffield process-based classification, 43% of adult attendances were categorized as primary care attendances. Within this category the rate of attendance declined with age. Twenty-five point eight per cent of primary care attendances occurred between 10.00 pm and 8.00 am. Among self-referrals to the AED, 16% were seen by their GP in the previous two weeks for a similar problem. Frequent attendance at the AED was associated with a significantly higher consultation rate at the GP surgery (F = 19.6, df = 5, P < 0.0001). Less than 2% of attendances were recalled to the AED for follow-up. A minority (14%) of attendances resulted in a communication with the GP. The seven-month AED attendance rates for the two practices were significantly different (72 per 1000 (95% CI 67-78) and 111 per 1000 (95% CI 105-116), despite similar practice organization and markers of social deprivation.

CONCLUSIONS

AED attendance rates were below the national average. GP referral and admission rates to AEDs from inner urban practices mirror national rates. High rates of primary care attendance occurred in younger age groups, with more than expected occurring out of hours. The reduction in case follow-up within the AED must be supported by improvements in communication with GPs, and an expansion of practice-based nursing. Practices that are geographically close, and with similar sociodemographic features, may have different AED attendance rates. This has important implications for resource allocation in primary care.

Analysis of chronic obstructive pulmonary disease referrals for lung volume reduction surgery. The University of California San Diego Emphysema Treatment Group

BACKGROUND

Preliminary results of lung volume reduction surgery (LVRS) for patients with severe emphysema are promising, although many issues regarding the selection process for LVRS are still unaddressed. For example, it is unclear which patients should be referred for pulmonary rehabilitation, lung transplantation, or LVRS, and whether health-care providers are optimizing conservative treatment options before referral for surgical intervention. The purpose of this analysis is to describe preliminary results of the evaluation process for LVRS implemented as part of an integrated, programmatic approach to the evaluation, treatment, and rehabilitation of patients with advanced emphysema.

METHODS

The records of 105 consecutive patients with chronic obstructive pulmonary disease (COPD) referred for consideration for LVRS at the University of California San Diego Medical Center were reviewed. Results of prospective data collection pertaining to patient demographic, baseline dyspnea scores, and history of prior treatment, including pulmonary rehabilitation, were extracted. Patient disposition after the evaluation was noted.

RESULTS

One hundred five patients (mean age 65 years, range 40 to 84 years) completed evaluation. Fifty-eight had never before participated in pulmonary rehabilitation, and 47 of these patients were eventually referred to a rehabilitation program. Fourteen patients were referred for consideration of lung transplantation, 25 were considered eligible for LVRS, 13 were still undergoing rehabilitation and surgical eligibility had not yet been determined, and 53 were ineligible for LVRS because patients had other illnesses (n = 34), did not meet radiological or physiologic criteria (n = 5), were considered too ill (n = 5), or were too healthy (n = 9) after rehabilitation to warrant surgical intervention.

CONCLUSIONS

Lung volume reduction surgery is a surgical option to be considered within the framework of an integrated medical evaluation program that includes pulmonary rehabilitation. Pulmonary rehabilitation remains an often underused therapeutic alternative in patients with severe COPD. It has become the central component of our comprehensive management program for patients with severe dyspnea and deteriorating quality of life.

National Influenza Surveillance 1996

In 1996 data from laboratories, general practitioners and a national employer were combined to detect trends in influenza activity in Australia. An epidemic of influenza A (H3N2) was recorded. Little influenza B activity was noted throughout the winter months, however the number of laboratory reports of influenza B rose in the last quarter of the year. Influenza activity was reflected in the consultation rates recorder by sentinel general practitioner reporting schemes. Of particular note was the Tropical Influenza Surveillance in the Northern Territory which demonstrated a bimodal epidemic pattern. There was no apparent trend in national absenteeism rates recorded by a national employer.

Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organization, population characteristics and distance

OBJECTIVES

To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments.

DESIGN

Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census.

SETTING

East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London.

MAIN OUTCOME MEASURE

Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994.

RESULTS

Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8-18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = -0.31, P = 0.002) and residents lacking amenities (R = -0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = -0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value.

CONCLUSIONS

Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.

Rapid assessment of human immunodeficiency virus seroprevalence in a community-based hospital

BACKGROUND

To aid in development of patient testing policy, in-service education, and resource planning, it is necessary to have a useful and meaningful tool for determining the population-specific HIV seroprevalence rate for our hospital patients. We were offered by the Centers for Disease Control a newly developed survey tool: "Rapid Assessment of HIV Seroprevalence in Hospital Patients." We subsequently served as one pilot site for this tool.

METHODS

A population-based sample of 1000 patients (500 inpatients, 500 outpatients) was stratified into age and sex groups on the basis of admission statistics from the previous year in a general community hospital system in southeastern Pennsylvania that consists of two clinical campuses: an urban site with 343 beds and a suburban site with 506 beds. The study was conducted as an anonymous, unlinked screening for HIV antibody in 1000 serum samples.

RESULTS

We found our overall seroprevalence rate to be 2.60% (Poisson 95% confidence interval, 1.77% to 3.81%), or 1 in 38 patient specimens. The highest rates for both sexes were found in the age range 25 to 44 years.

CONCLUSIONS

This protocol is a useful survey tool for community hospitals to determine the HIV seroprevalence rate in patient populations, a practical necessity for planning and education. Survey results would aid in implementation of current Centers for Disease Control guidelines for HIV testing of inpatients and outpatients in the acute care hospital setting.

Mycobacterium bovis infections in San Diego: a clinicoepidemiologic study of 73 patients and a historical review of a forgotten pathogen

We have presented 73 patients (48 adults and 25 children) with microbiologically documented M. bovis infections identified over the 12-year period from 1980 through 1991. Epidemiologic investigation of these patients revealed that the majority (80%) were of Hispanic origin. The non-Hispanic patients either had traveled extensively outside the United States, were born in the United States during its endemic period or in other countries with endemic bovine tuberculosis, or were exposed to a close relative with a positive PPD and known exposure to M. bovis. For Hispanic patients, the presence of reactivation disease in adults and primary disease in children indicate that this mycobacterium remains endemic in Mexican beef and dairy herds, a position supported by United States monitoring of Mexican cattle transferred across the border. Our review of the historical and contemporary efforts to eradicate this animal and human pathogen from the livestock industry in the United States and abroad shows that the implementation of similar methods could be effective in Mexico. The detailed presentations of selected patients and summaries of the clinical manifestations in the remainder of our 73 patients reveal striking similarities to historical accounts and to more contemporary studies of reactivated disease in England. Although M. bovis infections are still expressed predominantly in extrapulmonary sites (cervical and mesenteric nodes, the peritoneum, and the GU tract), as many as 50% of adult patients will present only with pulmonary disease. Underlying immunosuppressive disorders were particularly prominent in adults with extrapulmonary disease. For example, HIV positive patients accounted for 12 of 48 adults and 1 adolescent patient in our series. Overall, M. bovis infections accounted for almost 3% of all tuberculous disease reported in San Diego County during the study period. The intrinsic resistance of M. bovis to PZA could threaten the response of patients with bovine tuberculosis to the short-course chemotherapeutic regimens now recommended by the CDC and the American Thoracic Society. We strongly recommend continued surveillance for this forgotten pathogen because the importation of Mexican cattle, the migration of Hispanic immigrants from border areas to the United States interior, and the persistence of extrapulmonary disease in immunocompetent and HIV-infected United States citizens assure its persistence in this country.