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Hesseling AC, Schaaf HS, Hanekom WA, Beyers N, Cotton MF, Gie RP, Marais BJ, van Helden P, Warren RM. Danish Bacille Calmette-Guerin Vaccine-Induced Disease in Human Immunodeficiency Virus-Infected Children. Clin Infect Dis 2003; 37:1226-33. [PMID: 14557968 DOI: 10.1086/378298] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2003] [Accepted: 06/11/2003] [Indexed: 11/03/2022] Open
Abstract
An analysis of isolates of Mycobacterium tuberculosis complex was performed to determine the prevalence of bacille Calmette-Guérin (BCG) disease among human immunodeficiency virus (HIV)-infected children. Speciation was done with polymerase chain reaction; 183 isolates from mycobacterial cultures for 49 HIV-infected patients were analyzed. The Danish Mycobacterium bovis BCG strain was isolated from 5 patients. No cases of Tokyo M. bovis BCG strain disease were detected. All patients were asymptomatic at birth, <12 months of age, and severely immunodeficient at presentation. Four patients had regional axillary adenitis ipsilateral to the vaccination site, and 2 had pulmonary BCG disease. Two patients with regional BCG disease had simultaneous pulmonary M. tuberculosis infection. Although chest radiographic features were similar to those seen in patients with tuberculosis, BCG disease should be considered in HIV-infected infants with right axillary adenitis ipsilateral to the vaccination site. Young, symptomatic, HIV-infected infants are at risk for BCG-related complications. Controlled, population-based studies are needed to assess the risk of BCG in HIV-infected children.
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Schaaf HS, Michaelis IA, Richardson M, Booysen CN, Gie RP, Warren R, van Helden PD, Beyers N. Adult-to-child transmission of tuberculosis: household or community contact? Int J Tuberc Lung Dis 2003; 7:426-31. [PMID: 12757042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
SETTING If a child develops tuberculosis, it is assumed that the source was an adult infectious case, usually living in the same house. Restriction fragment length polymorphism (RFLP) was used in this study to establish transmission from source cases to children. DESIGN Adult and child tuberculosis cases were prospectively identified from 1993 to 1998 and cultures of Mycobacterium tuberculosis collected. Interviews and RFLP analysis of M. tuberculosis strains were performed to establish epidemiological links and to confirm household transmission. RESULTS Tuberculosis was confirmed by culture in 1139 (91%) of 1291 adults and 65 (16%) of 417 children. Due to problems in recovering specimens or extracting DNA, RFLP analysis was done in 832 adults and 35 children: 19 (54%) children had household members identified with tuberculosis, 12 with the same strain as the child. Twenty-nine (83%) strains from children formed part of community clusters, but definite contact with source cases was established in only 15. CONCLUSION The presence of an adult with infectious tuberculosis in the same house as a child with tuberculosis does not necessarily imply adult-to-child transmission. Young children may be infected in the community or in the household. These findings have implications for contact tracing and treatment strategies in high incidence areas.
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Hesseling AC, Schaaf HS, Gie RP, Starke JR, Beyers N. A critical review of diagnostic approaches used in the diagnosis of childhood tuberculosis. Int J Tuberc Lung Dis 2002; 6:1038-45. [PMID: 12546110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
SETTING The diagnosis of tuberculosis (TB) in children is seldom confirmed, and is based mainly on clinical signs, symptoms and special investigations. Various attempts in the form of diagnostic approaches have been made to rationalise this diagnostic process. AIMS To review and describe published diagnostic approaches aimed at diagnosing mainly intrathoracic tuberculosis in children in developing countries; to compare diagnostic approaches with each other and with bacteriologically confirmed TB; and to describe modifications to the diagnosis of TB in HIV-infected or malnourished children. METHODS Literature review classified into 1) diagnostic approaches, 2) characteristics used in diagnostic approaches, and 3) studies done to validate diagnostic approaches. RESULTS Sixteen systems were analysed. Comparison of systems is difficult because characteristic definitions and the ranking of characteristics are not standardised, few studies have been performed to validate these diagnostic approaches, and the gold standard of diagnosis is not practicable in most settings. The minority of systems are adapted for HIV-infected and malnourished patients. RECOMMENDATIONS Characteristic definitions and ranking of characteristics should be standardised. Any new diagnostic approaches developed should be relevant to developing countries with limited resources, a high burden of tuberculosis, malnutrition and HIV/AIDS and a young population. Studies done to validate diagnostic approaches should be conducted scientifically.
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Van Rie A, Warren R, Mshanga I, Jordaan AM, van der Spuy GD, Richardson M, Simpson J, Gie RP, Enarson DA, Beyers N, van Helden PD, Victor TC. Analysis for a limited number of gene codons can predict drug resistance of Mycobacterium tuberculosis in a high-incidence community. J Clin Microbiol 2001; 39:636-41. [PMID: 11158121 PMCID: PMC87790 DOI: 10.1128/jcm.39.2.636-641.2001] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2000] [Accepted: 11/04/2000] [Indexed: 11/20/2022] Open
Abstract
Correct and rapid diagnosis is essential in the management of multidrug-resistant tuberculosis (MDR-TB). In this population-based study of 61 patients with drug-resistant tuberculosis, we evaluated the frequency of mutations and compared the performance of genotypic (mutation analysis by dot blot hybridization) and phenotypic (indirect proportion method) drug resistance tests. Three selected codons (rpoB531, rpoB526, and katG315) allowed identification of 90% of MDR-TB cases. Ninety percent of rifampin, streptomycin, and ethambutol resistance and 75% of isoniazid resistance were detected by screening for six codons: rpoB531, rpoB526, rrs-513, rpsL43, embB306, and katG315. The performance (reproducibility, sensitivity, and specificity) of the genotypic method was superior to that of the routine phenotypic method, with the exception of sensitivity for isoniazid resistance. A commercialized molecular genetic test for a limited number of target loci might be a good alternative for a drug resistance screening test in the context of an MDR "DOTS-plus" strategy.
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Schaaf HS, Gie RP, Beyers N, Sirgel FA, de Klerk PJ, Donald PR. Primary drug-resistant tuberculosis in children. Int J Tuberc Lung Dis 2000; 4:1149-55. [PMID: 11144457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
SETTING The Western Cape Province of South Africa, an area with a high tuberculosis (TB) incidence where initial isoniazid (INH) resistance and multidrug resistance (MDR) among adults was 3.9% and 1.1%, respectively, during 1992-1993. OBJECTIVE To determine the drug resistance incidence among children as compared to adults, to compare the clinical features of drug-resistant and drug-susceptible TB, and the degree of INH resistance in isoniazid-resistant isolates. METHODS All Mycobacterium tuberculosis cultures obtained from children (0-13 years) at a regional hospital were prospectively collected from August 1994 to April 1998 and susceptibility testing done on each child's specimens. Degree of INH resistance was determined in available resistant isolates. The children's clinical records were reviewed. RESULTS Susceptibility results were available in 306/338 children with cultures of M. tuberculosis; 21 isolates (6.9%) were INH-resistant, and seven were MDR. Taking into account study limitations, the incidence of INH resistance was 5.6% and MDR 1% in children aged <5 years. Clinical features were similar in children with drug-susceptible and drug-resistant TB. CONCLUSION The incidence of drug resistance in childhood tuberculosis in Western Cape is low, and probably reflects the level of primary drug resistance amongst organisms currently circulating in the community.
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Kling S, Gie RP. Pneumonia in ventilated babies in an emerging country: clinical features, aetiology and short-term outcome. J Trop Pediatr 2000; 46:307-9. [PMID: 11077943 DOI: 10.1093/tropej/46.5.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Forty-four babies (< 6 months) with pneumonia admitted for ventilation to a paediatric ICU serving a low-income community, were studied. Twenty-three per cent had been ventilated during the neonatal period and three had bronchopulmonary dysplasia. The median duration of symptoms was 1.5 days; 45 per cent presented with apnoea. Five babies (11 per cent) died. Blood cultures were positive in six children (14 per cent). Viruses were cultured in 13 children (30 per cent).
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Schaaf HS, Van Rie A, Gie RP, Beyers N, Victor TC, Van Helden PD, Donald PR. Transmission of multidrug-resistant tuberculosis. Pediatr Infect Dis J 2000; 19:695-9. [PMID: 10959735 DOI: 10.1097/00006454-200008000-00005] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To compare the Mycobacterium tuberculosis isolates of adult index cases with multidrug-resistant (MDR) tuberculosis to the isolates obtained from their child contacts. PATIENTS AND METHODS A 4-year prospective study in the Western Cape Province of South Africa. We evaluated 149 child contacts of 80 adult MDR pulmonary tuberculosis cases. This report includes those cases where a culture for M. tuberculosis was obtained from both the adult source case and the child contact. Isolates were compared by drug susceptibility pattern and restriction fragment length polymorphism analysis. RESULTS Six adult-child pairs with cultures for M. tuberculosis were identified. Two children had contact with more than one adult tuberculosis case. One child received previous isoniazid prophylaxis. Drug susceptibility pattern and restriction fragment length polymorphism analysis were identical for five adult-child pairs. One child, with no other known source case, had a strain different from that of the identified source case, but the MDR M. tuberculosis strain with which he was infected was prevalent in the community in which he resided. All children responded well to treatment. CONCLUSION This study confirms that most of the childhood contacts of adults with MDR tuberculosis are likely to be infected by these MDR source cases despite their exposure to other drug-susceptible adults with tuberculosis in some instances. Child contacts of adults with MDR tuberculosis should be treated according to the drug susceptibility patterns of the likely source cases' M. tuberculosis strains unless their own strain's susceptibility testing indicates otherwise. Contact tracing remains of fundamental importance in identifying children at risk.
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Van Rie A, Warren R, Richardson M, Gie RP, Enarson DA, Beyers N, Van Helden PD. Classification of drug-resistant tuberculosis in an epidemic area. Lancet 2000; 356:22-5. [PMID: 10892760 DOI: 10.1016/s0140-6736(00)02429-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Traditionally, patients with drug-resistant tuberculosis are classified as having acquired drug-resistant or primary drug-resistant disease on the basis of a history of previous tuberculosis treatment. Only cases of primary drug resistance are assumed to be due to transmission of drug-resistant strains. METHODS This descriptive study of 63 patients with drug-resistant tuberculosis assessed the relative contribution of transmission of drug-resistant strains in a high-incidence community of Cape Town, South Africa, by restriction-fragment length polymorphism (RFLP). The RFLP results were compared with the results obtained by traditional classification methods. FINDINGS According to RFLP definitions, 52% (33 cases) of drug-resistant tuberculosis was caused by transmission of a drug-resistant strain. The proportion of cases due to transmission was higher for multidrug-resistant (64%; 29 cases) than for single-drug-resistant (no cases) tuberculosis. By the clinical classification, only 18 (29%) patients were classified as having primary drug-resistant tuberculosis (implying transmission). The clinical classification was thus misleading in 25 patients. INTERPRETATION The term acquired drug resistance includes patients infected with strains that truly acquired drug resistance during treatment and patients who were initially infected with or reinfected with a drug-resistant strain. This definition could lead to misinterpretation of surveillance studies, incorrect evaluation of tuberculosis programmes, and delayed diagnosis and treatment of patients with multidrug-resistant disease. The clinical term acquired drug resistance should be replaced with the term "drug resistance in previously treated cases", which includes cases with drug resistance due to true acquisition as well as that due to transmitted drug-resistant strains.
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Schaaf HS, Gie RP, van Rie A, Seifart HI, van Helden PD, Cotton MF. Second episode of tuberculosis in an HIV-infected child: relapse or reinfection? J Infect 2000; 41:100-3. [PMID: 11041705 DOI: 10.1053/jinf.2000.0671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report a case of an HIV-infected child with a second episode of tuberculosis 22 months after completing antituberculosis treatment. DNA fingerprinting of organisms from both episodes showed an identical strain of Mycobacterium tuberculosis. We believe this to be the first case of confirmed relapsed tuberculosis in an HIV-infected child, and suggest that a longer course of antituberculosis treatment be given to such children. ¿ 2000 The British Infection Society.
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van Der Merwe PL, Kalis NN, Gie RP. An explanation of the unusual electrocardiographic findings in a patient with pulmonary agenesis and dextrocardia. CARDIOVASCULAR JOURNAL OF SOUTH AFRICA : OFFICIAL JOURNAL FOR SOUTHERN AFRICA CARDIAC SOCIETY [AND] SOUTH AFRICAN SOCIETY OF CARDIAC PRACTITIONERS 2000; 11:146-148. [PMID: 11447476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Interpretation of the electrocardiagram (ECG) is extremely helpful in distinguishing between the different forms of dextrocardia. The patient in this report had agenesis of the right lung and dextroposition; the ECG mimicked mirror-image dextrocardia, with elements of dextroversion also present.
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Weber HC, Beyers N, Gie RP, Schaaf HS, Fish T, Donald PR. The clinical and radiological features of tuberculosis in adolescents. ANNALS OF TROPICAL PAEDIATRICS 2000; 20:5-10. [PMID: 10824206 DOI: 10.1080/02724930091995] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
This retrospective review of clinical records and chest radiographs (CR) of adolescents aged 10-18 years was designed to determine age and sex differences in the clinical and radiological features of adolescent tuberculosis (TB). Records of adolescents who were admitted to Brooklyn Hospital for Chest Diseases (BCH) or who were treated at local authority health clinics were screened. Data from 324 adolescents (male:female ratio 1:1.2) were studied. Intra-thoracic lesions were present on CR in 306 (94%). Primary TB with mediastinal adenopathy was present in 32 (10%). Cavitation was present in 180 (56%), 16% at 10 and 73% at 18 years of age. Cavitation occurred in 55% of males and in 56% of females with increasing frequency from 15 years of age in the former and from age 14 in the latter. Microbiological confirmation of diagnosis was obtained in 254 (78%) cases, 52% in those aged 10-13 years and 86% in those > or = 14 years. Pleural effusion was present in 42 (13%), 26 males and 16 females (p < 0.05). Thirteen (7%) of the 182 hospitalized adolescents and 27 (19%) of the ambulant group did not complete therapy. The nature of tuberculous disease in adolescents changed dramatically with increasing age.
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van Rie A, Warren RM, Beyers N, Gie RP, Classen CN, Richardson M, Sampson SL, Victor TC, van Helden PD. Transmission of a multidrug-resistant Mycobacterium tuberculosis strain resembling "strain W" among noninstitutionalized, human immunodeficiency virus-seronegative patients. J Infect Dis 1999; 180:1608-15. [PMID: 10515823 DOI: 10.1086/315054] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Since 1990, several outbreaks of multidrug-resistant tuberculosis (MDR-TB) have been described among institutionalized patients infected with human immunodeficiency virus (HIV). We describe a community MDR-TB outbreak among HIV-seronegative patients in Cape Town, South Africa. Isolates were characterized by restriction fragment length polymorphism (RFLP) analysis and dot-blot hybridization analysis of mutations conferring resistance for isoniazid, rifampin, streptomycin, and ethambutol. All isolates were identical on RFLP analysis. In 2 patients, RFLP analysis showed exogenous reinfection during or after treatment for drug-susceptible TB. Mutation analysis confirmed the genotypic identity of the isolates. The infecting strain was genotypically related to strain W, which is responsible for the majority of MDR-TB outbreaks in New York City. Transmission of MDR-TB is thus not limited to HIV-seropositive patients in an institutional setting but occurs within a community.
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van Rie A, Warren R, Richardson M, Victor TC, Gie RP, Enarson DA, Beyers N, van Helden PD. Exogenous reinfection as a cause of recurrent tuberculosis after curative treatment. N Engl J Med 1999; 341:1174-9. [PMID: 10519895 DOI: 10.1056/nejm199910143411602] [Citation(s) in RCA: 384] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND For decades it has been assumed that postprimary tuberculosis is usually caused by reactivation of endogenous infection rather than by a new, exogenous infection. METHODS We performed DNA fingerprinting with restriction-fragment-length polymorphism analysis on pairs of isolates of Mycobacterium tuberculosis from 16 compliant patients who had a relapse of pulmonary tuberculosis after curative treatment of postprimary tuberculosis. The patients lived in areas of South Africa where tuberculosis is endemic. Medical records were reviewed for clinical data. RESULTS For 12 of the 16 patients, the restriction-fragment-length polymorphism banding patterns for the isolates obtained after the relapse were different from those for the isolates from the initial tuberculous disease. This finding indicates that reinfection was the cause of the recurrence of tuberculosis after curative treatment. Two patients had reinfections with a multidrug-resistant strain. All 15 patients who were tested for the human immunodeficiency virus were seronegative. CONCLUSIONS Exogenous reinfection appears to be a major cause of postprimary tuberculosis after a previous cure in an area with a high incidence of this disease. This finding emphasizes the importance of achieving cures and of preventing anyone with infectious tuberculosis from exposing others to the disease.
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Wessels G, Schaaf HS, Beyers N, Gie RP, Nel E, Donald PR. Haematological abnormalities in children with tuberculosis. J Trop Pediatr 1999; 45:307-10. [PMID: 10584477 DOI: 10.1093/tropej/45.5.307] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Over a 16 month period 307 children with suspected tuberculosis (TB) and an available full blood count (FBC) seen at Tygerberg Hospital in South Africa were evaluated and categorized as confirmed (A), probable (B), and no TB (C) according to WHO criteria. There was no difference in the mean age of the 168 group A (33.6 months), 83 group B (34.4 months), and the 56 group C (31.6 months) children. A lower mean haemoglobin (Hb 10.2 vs. 10.8 g/dl) was the only significantly different haematological parameter in children with TB compared with the comparison group (Group C). There were no differences in median total white cell count, neutrophils, lymphocytes, monocytes, platelets, or the proportion of children in each group with anaemia, microcytosis, neutrophilia, neutropenia, lymphocytosis, lymphopenia, monocytosis, thrombocytosis or thrombocytopenia. The most common haematological abnormalities in children with TB were the presence of anaemia, neutrophilia, and monocytosis but these changes were found with equal frequency in control patients. Although haematological abnormalities are fairly common in children with TB, in a developing country these abnormalities also occur frequently in children with other non-tuberculosis respiratory infections. An FBC has no diagnostic predictive value when investigating a child for TB.
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Smith J, Pieper CH, Maree D, Gie RP. Compliance of the respiratory system as a predictor for successful extubation in very-low-birth-weight infants recovering from respiratory distress syndrome. S Afr Med J 1999; 89:1097-102. [PMID: 10582068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
OBJECTIVE To develop additional criteria to predict for successful extubation of very-low-birth-weight infants recovering from respiratory distress syndrome. DESIGN Prospective study. SETTING Neonatal intensive care unit at a university teaching hospital. INTERVENTIONS Infants ready for extubation according to clinical, ventilatory and blood gas criteria were studied. Before extubation, tidal volume (Vt), minute ventilation, respiratory rate/Vt and mean inspiratory flow were measured during two different ventilatory settings: (i) during intermittent mandatory ventilation (IMV); and (ii) while breathing spontaneously with endotracheal continuous positive airway pressure (CPAP). Tidal volume was obtained through electronically integrated flow measured by a hot-wire anemometer. Total respiratory compliance (Crs) was determined during IMV and was derived from the formula Vt/PIP-PEEP, where the difference between peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP) represented the ventilator inflation pressure. MEASUREMENTS AND MAIN RESULTS Each of 49 infants was studied once before extubation. 33 infants (67%) were successfully extubated and 16 (32.6%) required reintubation. Infants in the success and failure groups were matched for gestation, post-conceptional age, study weight and methylxanthine therapy at the time of study. Successful extubation was associated with a higher mean absolute Crs value (ml/cm H2O) specific Crs value (standardised for body length; ml/cm H2O/cm) compared with infants in whom extubation failed (0.67 v. 0.46; P = 0.01 and 0.018 v. 0.014; P = 0.03, respectively). Analysis of ROC curves detected thresholds for Crs (0.5 ml/cm H2O) and Vt (7 ml) for predicting successful extubation. An absolute Crs value 0.5 ml/cm H2O or more improved the likelihood of successful extubation when compared with clinical/ventilator and blood gas criteria. The likelihood of successful extubation was 81% if the Crs value was > or = 0.5 ml/cm H2O. A tidal volume of 7 ml or more was less sensitive in contributing to successful extubation (sensitivity 69%). The major causes for extubation failure included atelectasis (diffuse and/or localised) and the presence of a patent ductus arteriosus. CONCLUSIONS In addition to following very precise ventilatory criteria for extubation, we found that bedside measurement of total respiratory system compliance added to the likelihood of extubation success in infants recovering from respiratory distress syndrome. Prospective studies are needed to validate the findings of this study.
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Adams JF, Schölvinck EH, Gie RP, Potter PC, Beyers N, Beyers AD. Decline in total serum IgE after treatment for tuberculosis. Lancet 1999; 353:2030-3. [PMID: 10376618 DOI: 10.1016/s0140-6736(98)08510-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infection with Mycobacterium tuberculosis induces a type-1 immune response, whereas intestinal parasites elicit a type-2 response. Given that type-1 and type-2 responses inhibit each other, we investigated if M tuberculosis downregulates serum IgE, a marker of a type-2 response. METHODS A prospective study was done in the Western Cape Province of South Africa, where tuberculosis and intestinal-parasite infection are common. Total serum IgE was determined for 37 controls and for 33 adolescent patients at presentation with tuberculosis and after successful completion of treatment. IgE specific for ascaris and allergens were measured in a subset of these individuals. Mantoux skin tests were done on 35 controls and on 31 patients at diagnosis. FINDINGS Total IgE concentrations were high in controls (mean 313 kU/L) and in patients before treatment (mean 457 kU/L, p=0.085) and declined in all patients following successful treatment (mean 175 kU/L, p<0.0001). Posttreatment IgE concentrations did not differ from concentrations in controls. Ascaris-specific IgE was lower in controls (mean 1.73 kU/L) than in patients before treatment (4.62 kU/L, p=0.023) and was 2.39 kU/L in patients after treatment (p=0.0625). Tuberculin induration correlated inversely with IgE in patients but not in controls. INTERPRETATION Infection with M tuberculosis as such is not incompatible with a prominent IgE response. IgE concentrations decreased after successful treatment of tuberculosis, showing that IgE concentrations in human beings can be downregulated under these circumstances, presumably due to enhancement of a type-1 response.
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Schaaf HS, Vermeulen HA, Gie RP, Beyers N, Donald PR. Evaluation of young children in household contact with adult multidrug-resistant pulmonary tuberculosis cases. Pediatr Infect Dis J 1999; 18:494-500. [PMID: 10391177 DOI: 10.1097/00006454-199906000-00004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevention and management of multidrug-resistant (MDR) tuberculosis has received much attention, but little attention has been given to children with MDR tuberculosis or children in contact with adults with MDR tuberculosis. The aim of this study was to determine the prevalence of tuberculous infection and disease in childhood contacts of adults with MDR pulmonary tuberculosis. METHOD All children <5 years of age in household contact with 75 recently diagnosed adults with MDR pulmonary tuberculosis were evaluated. Evaluation included clinical examination, tuberculin skin test, chest radiography and culture for Mycobacterium tuberculosis from gastric aspirates. RESULTS One hundred twenty-eight children, median age 27 months, were evaluated. Fifty children had recent contact with other adult tuberculosis cases. Sixty-six children previously had chemoprophylaxis or treatment of whom 36 defaulted treatment or received insufficient chemoprophylaxis. One child had HIV infection. Forty-seven children were classified as noninfected, 66 were considered infected only (Mantoux test, > or = 15 mm) and 15 had disease. Three children, who had not previously received antituberculosis drugs, had positive cultures for M. tuberculosis; all were multidrug-resistant. CONCLUSION This study documents the transmission of multidrug-resistant M. tuberculosis to childhood contacts, the development of disease in these contacts and the importance of knowing the index case's M. tuberculosis susceptibility pattern in choosing a proper treatment regimen for the childhood contact.
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van Rie A, Beyers N, Gie RP, Kunneke M, Zietsman L, Donald PR. Childhood tuberculosis in an urban population in South Africa: burden and risk factor. Arch Dis Child 1999; 80:433-7. [PMID: 10208948 PMCID: PMC1717911 DOI: 10.1136/adc.80.5.433] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To study the epidemiology of childhood tuberculosis (TB) in a developing country. SETTING Two urban communities of Cape Town, South Africa with a TB case notification rate of 1149/100 000. DESIGN Retrospective descriptive study using the national population census (1991), 10 year official TB notification records, and a geographical information system. RESULTS The case notification rate of TB in children 0-5 years old was 3588 cases/100 000 children aged 0-5 years, 3.5 times the case notification rate in adults. Children (0-14 years) accounted for 39% of the total case load. Childhood TB case notification rate correlated with parental education (r = -0.64), annual household income (r = -0.6), and crowding (r = 0.32). CONCLUSION Children, especially those living in poor socioeconomic conditions, form an important epidemiological group and account for a notable proportion of the morbidity caused by TB. Efforts to improve TB control must therefore not only target adults (case detection and cure of infectious cases) but also children (screening of child contacts of adult cases) and the socioeconomic living conditions.
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Beyers N, Cotton MF, Donald PR, Gie RP, Henning PA, Hesseling PB, Kirsten GF, Kling S, Nel ED, Pieper CH, Ravenscroft A, Schaaf HS, Schoeman JF, Smith J, van Buuren AJ, van der Merwe PL, van Schalkwyk HJ, Wessels G. The mother-to-child HIV transmission debate. S Afr Med J 1999; 89:104, 106. [PMID: 10357681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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Classen CN, Warren R, Richardson M, Hauman JH, Gie RP, Ellis JH, van Helden PD, Beyers N. Impact of social interactions in the community on the transmission of tuberculosis in a high incidence area. Thorax 1999; 54:136-40. [PMID: 10325918 PMCID: PMC1745413 DOI: 10.1136/thx.54.2.136] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Tuberculosis (TB) is transmitted by close contact with an infectious person. It is assumed that close contact occurs amongst household members and that contact outside the house is "causal" and does not play a major role in the transmission of TB. METHODS This study was conducted in an impoverished area with a high incidence of TB and a low HIV seropositive prevalence. Thirty three households with 84 TB patients were identified between February 1993 and April 1996 and the transmission of TB was studied by combining Mycobacterium tuberculosis fingerprinting with in depth sociological interviews. RESULTS Forty two strain genotypes were identified in the 84 patients. In 15 households all the patients had identical strains, in nine households all the patients had different strains, and in nine households some patients had identical strains and one had a different strain. In 26 houses at least one patient had a strain which formed part of a larger community cluster and in 12 of these households the patient(s) had contact with a community member who had the identical strain. In 58% of the cases the contact took place while drinking in social groups. CONCLUSION In high incidence areas contact outside the household may be important for the transmission of TB. This contact often takes place during recreation which, in the case of this study of impoverished people, consisted of drinking in social groups. Social interaction patterns should be studied and understood for effective implementation of control strategies.
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Schaaf HS, Geldenduys A, Gie RP, Cotton MF. Culture-positive tuberculosis in human immunodeficiency virus type 1-infected children. Pediatr Infect Dis J 1998; 17:599-604. [PMID: 9686725 DOI: 10.1097/00006454-199807000-00005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adults infected by HIV have increased susceptibility to Mycobacterium tuberculosis and progress more rapidly to disease. HIV and tuberculosis (TB) coinfection in children has been reported but often lacks bacterial confirmation. We report on the clinical picture, special investigations, clinical course and outcome of 14 children with HIV infection and culture-confirmed TB from a developing country. METHODS The clinical records of all children, from 1992 to 1997, with HIV infection and culture-proved TB were reviewed. RESULTS Fourteen (10.4%) of 135 children with vertically transmitted HIV infection, 93% <2 years of age, fit the criteria. Nonresolving pneumonia (4) and otorrhoea (6) were common complaints. A Mantoux test was positive (> or =15 mm) in 6 of 11 children. Extrapulmonary TB was present in 5 cases. Ear swabs were the source of M. tuberculosis culture in 3. Chest radiographs were abnormal in all with hilar and paratracheal lymphadenopathy present in 7. A source case with pulmonary TB was identified for 10. Susceptibility tests were done on 9 strains of which 1 was drug-resistant. Four children were culture-positive 4 to 10 months after initiation of TB treatment. Mortality was 21% and 3 were lost to follow-up. CONCLUSIONS In HIV-infected children the Mantoux skin test remains useful and culture specimens should be obtained from all sources. Response to treatment is unpredictable, and for this reason repeated cultures should be taken during treatment and a 9-month course of treatment considered.
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Heyns L, Gie RP, Kling S, Samaai P, Schaaf HS, Beyers N. Management of children with tuberculosis admitted to a pediatric intensive care unit. Pediatr Infect Dis J 1998; 17:403-7. [PMID: 9613654 DOI: 10.1097/00006454-199805000-00011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To review the incidence, clinical features, ventilatory support and outcome of children with tuberculosis (TB) admitted to a Pediatric Intensive Care Unit (PICU) in a region with an high incidence of TB. MATERIALS AND METHODS The study was performed in a PICU situated in a province with a extremely high incidence of TB (> 700 new cases/ 100000/year). This is a retrospective descriptive study of TB admissions to the PICU in a 4-year period. Data regarding indications for admission, clinical picture, duration of ventilation, PICU and hospital stay were collected from patient files. Outcome measures included mortality and long term morbidity. RESULTS Of the 1862 children admitted to the hospital for TB during the 4 years, 57 (3.1%) required PICU admission (1 to 6% of annual admissions). Of these 57 children 41 (72%) were admitted for respiratory failure. In 12 cases TB was the cause of the respiratory failure, 17 cases suffered from other respiratory diseases and in 12 cases the cause was nonrespiratory disease of which TB meningitis (n=8) was the most common. Mechanical ventilation was indicated in 43 (75%) patients who were ventilated for 7.3+/-11.5 days. The duration of PICU admission was 10.2+/-2.4 days whereas the duration of hospitalization was 70.3+/-148.9 days. The PICU mortality was 23% with TB meningitis having the highest mortality of 75%. CONCLUSIONS In a region with a high incidence of TB, tuberculous patients constitute up to 6% of PICU admissions. A high degree of suspicion for the diagnosis is needed because in 30% of our cases the diagnosis was not initially considered.
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Ellis JH, Beyers N, Bester D, Gie RP, Donald PR. Sociological and anthropological factors related to the community management of tuberculosis in the Western Cape communities of Ravensmead and Uitsig. S Afr Med J 1997; 87:1047-51. [PMID: 9323429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To determine the sociocultural understanding of tuberculosis among patients and their household members. DESIGN Qualitative descriptive study. SETTING Two adjacent Western Cape suburbs with a population of approximately 35,000, a tuberculosis incidence of > 1,000/100,000 and a surface area of 2.42 km2. SUBJECTS Twenty-three adult patients on treatment for tuberculosis and their adult household members. INTERVENTIONS None. METHODOLOGY Consecutive selected adult tuberculosis patients and their household members were interviewed with an open-ended interview schedule. General household and community conditions and non-verbal responses were recorded. RESULTS There were relatively affluent but also severely deprived households with severe overcrowding. Substance abuse was common. Patients had limited understanding and knowledge about health, hygiene and the cause of tuberculosis. There was a perception of both physical and social distance between patients and health care providers. All patients relied exclusively on the conventional biomedical curative approach of the medical system to deal with tuberculosis.
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Kling S, Gie RP, Riphagen S. Dornase alpha in the management of a mechanically ventilated infant with cystic fibrosis. Pediatr Pulmonol 1997; 24:124-5. [PMID: 9292906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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