Primary tuberculous tracheitis

We report a case of primary tuberculous tracheitis in an otherwise healthy woman who presented with cough and stridor due to diffuse tracheal narrowing by tuberculous pseudomembranous lesion, which resolved completely with antituberculosis chemotherapy.

Evaluation of an intensive intermittent-induction regimen and duration of short-course treatment for human immunodeficiency virus-related pulmonary tuberculosis. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) and the AIDS Clinical Trials Group (ACTG)

This study examined whether adding levofloxacin to a standard four-drug regimen improved the 8-week culture response and compared effectiveness of 9 versus 6 months of intermittent therapy for human immunodeficiency virus-related pansusceptible pulmonary tuberculosis. Patients were randomized to receive either four or five drugs, the fifth being levofloxacin. Patients who completed induction therapy were randomized to complete 9 versus 6 months of intermittent therapy with isoniazid and rifampin. In the randomized induction phase, 97.3% of patients in the four-drug group and 95.8% in the five-drug group had sputum culture conversion at 8 weeks (P = 1.00). In the continuation phase, one patient (2%) assigned to 9 months and two patients (3.9%) assigned to 6 months of therapy had treatment failure/relapse (P = 1.00). In conclusion, this study showed that levofloxacin added no benefit to a highly effective, largely intermittent, four-drug induction regimen. Both 9 and 6 months of intermittent therapy were associated with low treatment failure/relapse rates.

Short-course chemotherapy for isoniazid-resistant pulmonary tuberculosis

Standard short-course chemotherapy including isoniazid, rifampicin, pyrazinamide, and ethambutol has been the recommended treatment for tuberculosis in Taiwan since November 1990. The effectiveness of this treatment was evaluated retrospectively in 108 patients with isolates resistant to isoniazid alone and 115 patients with drug-susceptible pulmonary tuberculosis diagnosed and treated at the Taiwan Provincial Chronic Disease Control Bureau from November 1990 through December 1995. The success rate of treatment was 94.4% in patients with isoniazid-resistant Mycobacterium tuberculosis strains, which was not significantly different from the 97.4% rate in patients with susceptible strains. Of the patients treated successfully, no bacteriologic relapse was found in 97 patients with isoniazid-resistant strains or 103 patients with drug-susceptible strains 12 months after the end of chemotherapy. No significant advantage in treatment outcome was found in patients infected with isoniazid-resistant strains who received chemotherapy for more than 6 months (successful treatment rate, 95.0% vs 92.8%), but the failure rate was higher in patients with a previous history of antituberculosis therapy (17.6% vs 3.3%). We conclude that short-course chemotherapy is effective for isoniazid-resistant pulmonary tuberculosis and that there is no significant difference in treatment outcome between patients with or without isoniazid-resistant disease.

[Uveitis, arthralgia and pseudo-jaundice in a HIV seronegative patient due to rifabutin]

Rifabutin is an effective drug in the treatment of Mycobacterium avium complex (MAC). Rare adverse effects have been described in non immunocompromised patients. We report the case of a 35 year-old woman, negative for the human immunodeficiency virus (HIV), who had an isolated pulmonary infection caused by MAC. Under Rifabutin (600 mg/day), Clarithromycin and Ethambutol, an uveitis, associated with a pseudojaundice and polyarthralgia, appeared, while pulmonary infection improved. Improvement of adverse effects was obtained with non-steroid anti-inflammatory drugs, local steroid treatment for uveitis and lower doses of Rifabutin (300 mg/day). Those adverse effects have not been previously described with this dose of Rifabutin in a non HIV patient. The mechanism remained unknown. The decrease of Rifabutin doses associated with symptomatic treatments allow the preservation of an effective treatment for MAC infection.

[Reasons for chronic expectoration--case reports]

To illustrate reasons for chronic culture positive pulmonary tuberculosis 4 patients are presented. In two cases the reasons for treatment failure were on the doctors' side. In one case a doctor used an insufficient number of drugs, in the second case the treatment was too short. In the third case there were more than one reason for treatment failure: the patients' poor compliance, and the doctors' fault: an inadequate choice of drugs. In the last case adverse reactions to drugs caused the treatment failure.

[Surgical treatment of patients with multi-resistant pulmonary tuberculosis--case reports]

Two patients with multidrug-resistant pulmonary tuberculosis were surgically treated after 3 and 7 years of unsuccessful chemotherapy. There was pneumonectomy in one case and lobectomy with segmentectomy in the second. Pneumonectomy was complicated by bronchopleural fistula. Both patients become sputum culture negative after surgical treatment but first patient died 5 months after surgery because of acute hepatitis.

-Skin eruption after the first dose of antitubercular quadri-therapy: consideration of pyrazinamide-

We report a rash after the first dose of antituberculosis polytherapy which raises questions concerning procedures to be followed.

CASE REPORT

An 8-year-old child presented with a pruritic rash 1.5 hours after the first dose of isoniazide, rifampicine, pyrazinamide and ethambutol was simultaneously administered, which did not recur after successive re-administration of isoniazide and rifampicine. Pyrazinamide, which was re-administered last, induced a recurrence. Slower pyrazinamide re-administration allowed continuation of treatment.

CONCLUSION

A protocol for re-administration of the four drugs is suggested.

Physician compliance with national tuberculosis treatment guidelines: a university hospital study

SETTING

The Aga Khan University Hospital, in Karachi, Pakistan, is a 650-bed university teaching hospital.

OBJECTIVES

There is little data from Pakistan on the awareness and application of the World Health Organization (WHO)'s tuberculosis treatment guidelines among physicians. This study evaluates physician compliance with these guidelines.

DESIGN

A questionnaire to measure physician compliance was developed, pilot tested and standardised. Case records of all patients hospitalized with tuberculosis were reviewed (January-December 1995, n = 229), and were classified into WHO Category 1 (n = 191), Category 2 (n = 9) and Category 3 (n = 29).

RESULTS

A total of 53 (23%) patients had a diagnostic bacteriological sputum smear examination, of which 38% were smear positive and 47% culture positive. Of 25 cerebrospinal fluid cultures 12% were positive. No sputum smear tests were conducted during treatment. Of 58 patients in Category 1 who completed therapy 74% received a 2-month intensive phase consisting of HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol) (n = 43), while 41% received a 6 month continuation phase with HE (n = 24). Over 70% patients were lost to follow up, more than half of these during the intensive phase.

CONCLUSION

Our study reflects poor awareness of the WHO guidelines and low compliance among physicians, and a high loss to follow-up. Efforts are needed to create physician awareness about the WHO guidelines and their use. This study can be used to assess the effectiveness of any future physician education and to identify areas of weakness in health care.

A resected case of Mycobacterium szulgai pulmonary disease

We present the first reported case of Mycobacterium szulgai pulmonary disease that needed surgical resection due to unsuccessful antimycobacterial chemotherapy. The patient was a non-immunocompromised 48-year-old male who presented with hemoptysis and whose sputum cultures repeatedly yielded M. szulgai. Antimycobacterial chemotherapy with isoniazid (INH) and rifampin (RMP)/ethambutol (EMB) for three years had been unsuccessful, and subsequent chemotherapy with RMP, EMB, ethionamide and kanamycin had to be discontinued due to liver dysfunction. Surgical resection was finally performed, and resulted in a favorable outcome. Although M. szulgai pulmonary disease is usually well controlled by antimycobacterial chemotherapy alone, surgical treatment may be necessary in some cases.

The role of copper on ethambutol's antimicrobial action and implications for ethambutol-induced optic neuropathy

The principal side effect of the antimycobacterial agent ethambutol (EMB) is an optic neuropathy with clinical features very similar to a mitochondrial hereditary optic neuropathy (Leber's). The mechanism of EMB-induced optic neuropathy may be EMB's chelation of copper, thereby precluding normal cytochrome c oxidase activity and mitochondrial metabolism in the optic nerve. Before attempting to use therapeutic copper to replenish endogenous stores in an attempt to preclude EMB-induced optic neuropathy, we wished to determine whether EMB is still effective against mycobacteria in the presence of copper. EMB and copper, alone and in combination, were tested against six strains of Mycobacterium tuberculosis and five strains of Mycobacterium avium using a radiometric broth macrodilution assay. Copper did not effect EMB's antimicrobial actions against either species of mycobacteria. This in vitro study suggests that if copper were given to patients to prevent EMB-induced optic neuropathy, it would not compromise EMB's bacteriostatic properties.

[Lomefloxacin in complex treatment of acute progressive form of pulmonary tuberculosis]

The effect of lomefloxacin in combination with isoniazid, pyrazinamide, streptomycin or ethambutol on the process of tuberculosis and concomitant nonspecific pathological processes in the lungs was investigated in the treatment of 69 patients with newly diagnosticated acute progressive destructive tuberculosis of the lungs and isolation of Mycobacterium tuberculosis. It was shown that lomefloxacin provided rapid disappearance of the disease clinical signs and bacillus isolation in the patients with tuberculosis due to the tubercle bacilli susceptible or resistant to the main antituberculosis drugs, acceleration of the resolution of the infiltrates and caseous lesions in the lungs and elimination of the pathological processes in the bronchi. The tolerance of lomefloxacin was satisfactory and it did not affect the tolerance of the other antituberculosis drugs.

Determinants of rifabutin-associated uveitis in patients treated with rifabutin, clarithromycin, and ethambutol for Mycobacterium avium complex bacteremia: a multivariate analysis. Canadian HIV Trials Network Protocol 010 Study Group

Uveitis occurred in a substantial proportion of AIDS patients receiving rifabutin, 600 mg daily, together with clarithromycin and ethambutol for treatment of Mycobacterium avium complex bacteremia. A case-control study was undertaken to examine potential risk factors for developing uveitis. Of eight parameters examined, only baseline body weight predicted the development of uveitis by both univariate and multivariate analyses (P = .001). The incidence of uveitis was 14% in patients weighing >65 kg, 45% in patients between 55 and 65 kg, and 64% in patients <55 kg. Concomitant therapy with fluconazole, a drug known to raise serum rifabutin concentrations, was not associated with an increased incidence of uveitis. The risk of uveitis was markedly reduced when rifabutin was given at 300 mg daily in combination with clarithromycin and ethambutol.

How drug resistance emerges as a result of poor compliance during short course chemotherapy for tuberculosis

OBJECTIVE

To explore mechanisms by which drug resistance might arise as a result of poor compliance during short course chemotherapy.

DESIGN

Four theoretical mechanisms are first described.

RESULTS

Examples of the way the mechanisms probably operate are taken from: 1) a study of once-weekly chemotherapy with streptomycin and isoniazid, and 2) the pattern of drug susceptibility in cultures from patients who relapsed after the end of treatment.

CONCLUSION

Good compliance is vitally important. The value of a fourth drug in the initial phase of chemotherapy in preventing resistance is questioned. An explanation for mono-resistance to rifampicin in patients with the acquired immune deficiency syndrome (AIDS) is suggested.

A controlled clinical trial of oral short-course regimens in the treatment of sputum-positive pulmonary tuberculosis. Tuberculosis Research Centre

SETTING

The Tuberculosis Research Centre, Chennai, and its unit at Madurai, South India.

OBJECTIVE

To design oral short-course regimens for the treatment of sputum-positive pulmonary tuberculosis that could be more easily implemented under field conditions.

DESIGN

A total of 1203 patients was randomly allocated to one of three regimens. I (2EHRZ7/6EH7): 8-month daily regimen of ethambutol (E), isoniazid (H), rifampicin (R) and pyrazinamide (Z) for 2 months, followed by E and H for 6 months. II (2EHRZ2/4EHR2): 6-month twice-weekly regimen with the same four drugs for 2 months, followed by EHR for 4 months. III (2HRZ2/4HR2): similar to Reg. II, but without ethambutol. In Reg. I, drugs were given completely unsupervised. Regs. II and III were either completely or partially supervised.

RESULTS

Drug-susceptible group: At the end of treatment, 3.6% of 305 patients in Reg. I, 0.4% of 263 in Reg. II and 9.3% of 257 in Reg. III had an unfavourable bacteriological response. By 24 months after start of treatment, 5% of 290 in Reg. I, 11% of 258 in Reg. II and 10% of 229 in Reg. III had a bacteriological relapse requiring treatment. Giving the twice-weekly regimens partly unsupervised did not influence the response to treatment, emergence of drug resistance or relapse rates. Isoniazid resistant group: Unfavourable response and relapse with Reg. I (94 patients) was 17% and 8%, with Reg. II (59 patients) 20% and 25%, and with Reg. III (74 patients) 62% and 15%, respectively.

CONCLUSION

A fully unsupervised ethambutol-containing regimen given daily for 8 months (Reg. I) was found to be very effective even in the presence of isoniazid-resistant bacilli. With the ethambutol-containing twice-weekly regimen, the response at the end of treatment was near 100%, but the relapse rate was high (11%). The non-ethambutol twice-weekly regimen was not satisfactory. All three regimens failed in the presence of bacilli resistant to rifampicin and isoniazid.

Outbreak of drug-resistant tuberculosis with second-generation transmission in a high school in California

BACKGROUND

In spring 1993, four students in a high school were diagnosed with tuberculosis resistant to isoniazid, streptomycin, and ethionamide.

METHODS

To investigate potential transmission of drug-resistant tuberculosis, a retrospective cohort study with case investigation and screening by tuberculin skin tests and symptom checks was conducted in a high school of approximately 1400 students. Current and graduated high-school students were included in the investigation. DNA fingerprinting of available isolates was performed.

RESULTS

Eighteen students with active tuberculosis were identified. Through epidemiologic and laboratory investigation, 13 cases were linked; 8 entered 12th grade in fall 1993; 9 of 13 had positive cultures for Mycobacterium tuberculosis with isoniazid, streptomycin, and ethionamide resistance, and all 8 available isolates had identical DNA fingerprints. No staff member had tuberculosis. One student remained infectious for 29 months, from January 1991 to June 1993, and was the source case for the outbreak. Another student was infectious for 5 months before diagnosis in May 1993 and was a treatment failure in February 1994 with development of rifampin and ethambutol resistance in addition to isoniazid, streptomycin, and ethionamide. In the fall 1993 screening, 292 of 1263 (23%) students tested had a positive tuberculin skin test. Risk of infection was highest among 12th graders and classroom contacts of the two students with prolonged infectiousness. An additional 94 of 928 (10%) students tested in spring 1994 had a positive tuberculin skin test; 22 were classroom contacts of the student with treatment failure and 21 of these had documented tuberculin skin test conversions.

CONCLUSION

Extensive transmission of drug-resistant tuberculosis was documented in this high school, along with missed opportunities for prevention and control of this outbreak. Prompt identification of tuberculosis cases and timely interventions should help reduce this public health problem.

[Manifestations, diagnosis and treatment of non-tuberculous mycobacterial infections in patients with HIV infection]

The most frequent bacterial infections in patients infected with HIV and suffering from AIDS are non-tuberculous mycobacterial infections. Their incidence is increasing all the more as the survival of profoundly immunocompromised patients is prolonged. There are unknown factors as regards the precise origin of these infections and as to the exact epidemiology of atypical mycobacteria. It is known that 95 per cent of atypical mycobacterial infections are due to M. avium. If the pathophysiology of the infection (involving the intervention of cytokines and also factors in relation to the virulence of the germ) is imperfectly understood, the atypical mycobacteria are an independent cause of mortality in advanced stages of the disease. The clinical picture is that of a low grade fever with weight loss and a deterioration in the general physical state. There are subtle physical signs such as a fall in the functional capacity accompanied by weight loss and an unexplained anaemia these should also suggest a diagnosis. More rarely the infection will be localised. The clinical diagnosis will be confirmed by bacteriology which has been aided by recent progress in molecular biology. With the arrival of the newer macrolides it has been shown that treatment prolongs survival in a significant manner. Current recommendations consist of a treatment with a combined regime including a minimum of Clarithyromycin and Ethambutol. The place for polychemotherapy remains to be determined in particular the role for Rifabutine and Amikacine. Immunomodulation by interferon-gamma or GCSF are also under review. The duration of treatment and the necessity of long term suppressive treatment is the object of randomised studies. Prophylaxis is currently recommended for patients with CD4 < 75/mm3. The role of Rifabutine and the new macrolides remains to be determined. Finally, in a large European study the objective is to compare prophylaxis to systematic bacteriological surveillance both as regards efficacy, tolerance, and in terms of pharmaco-economics.

[Antitubercular chemotherapy]

Treatment of tuberculosis has three major goals: healing the patient, preventing selection of resistant strains and control transmission of tuberculosis. A 6 month regimen consisting of isoniazid, rifampin with addition of pyrazinamide for 2 months is the preferred treatment for pulmonary and extra-pulmonary tuberculosis. If resistance to isoniazid is suspected, ethambutol should be added until drug susceptibility studies become available. This treatment is effective in both HIV infected and uniinfected persons. Treatment failure is mostly related to lack of patient adherence to the drug regimen and to multidrug-resistant tuberculosis. The treatment of multidrug-resistant tuberculosis requires second line drugs which are less effective and poorly tolerated. Prevention of resistant tuberculosis needs adequate treatment of each case of tuberculosis and improving of the patient compliance.

A randomized evaluation of ethambutol for prevention of relapse and drug resistance during treatment of Mycobacterium avium complex bacteremia with clarithromycin-based combination therapy. California Collaborative Treatment Group

Patients with AIDS and Mycobacterium avium complex (MAC) bacteremia are at high risk for relapse and emergence of resistant isolates during monotherapy with clarithromycin. Ninety-five AIDS patients with MAC bacteremia received clarithromycin plus clofazimine, with or without ethambutol, in a prospective, multicenter, randomized open-label trial. Of 80 patients with positive baseline cultures, sterilization or a 2 log10 reduction in colony-forming units of MAC in two consecutive blood cultures occurred in 69% of both groups. There were nine relapses in the two-drug arm and three in the three-drug arm. Kaplan-Meier estimates of risk of relapse at 36 weeks were 68% and 12%, respectively (P = .004). All relapse isolates were resistant to clarithromycin. Median time to clarithromycin resistance was 16 weeks with two drugs and 40 weeks with three drugs (P = .004). Ethambutol reduced relapses and emergence of clarithromycin resistance and should be considered an essential component of clarithromycin-based therapies for MAC bacteremia.

Susceptibility to levofloxacin of Myocobacterium tuberculosis isolates from patients with HIV-related tuberculosis and characterization of a strain with levofloxacin monoresistance. Community Programs for Clinical Research on AIDS 019 and the AIDS Clinical Trials Group 222 Protocol Team

OBJECTIVE

To characterize the susceptibility to levofloxacin of clinical isolates of Mycobacterium tuberculosis (MTB) obtained from patients with HIV-related tuberculosis and to characterize the molecular genetics of levofloxacin resistance.

DESIGN AND METHODS

Isolates from culture-positive patients in a United States multicenter trial of HIV-related TB were tested for susceptibility to levofloxacin by minimum inhibitory concentration (MIC) determinations in Bactec 7H12 broth. Automated sequencing of the resistance determining region of gyrA was performed.

RESULTS

Of the 135 baseline MTB isolates tested, 134 (99%; 95% exact binomial confidence interval, 95.9-99.9%) were susceptible to levofloxacin with an MIC < or = 1.0 microg/ml. We identified a previously unrecognized mis-sense mutation occurring at codon 88 of gyrA in a levofloxacin mono-resistant MTB isolate obtained from a patient with AIDS who had received ofloxacin for 8 months prior to the diagnosis of tuberculosis.

CONCLUSIONS

Clinical MTB isolates from HIV-infected patients were generally susceptible to levofloxacin. However, the identification of a clinical isolate with mono-resistance to levofloxacin highlights the need for circumspection in the use of fluoroquinolones in the setting of potential HIV-related tuberculosis and for monitoring of rates of resistance of MTB isolates to fluoroquinolones.

[A case of multiple intracranial tuberculoma diagnosed by open brain biopsy]

To provide histological diagnoses of brain diseases, CT-guided stereotactic brain biopsy (CT-SBB) has been widely used because of its less invasive technique compared with open brain biopsy (OBB). However, CT-SBB is not always diagnostic. We report a case of multiple intracranial tuberculoma whose diagnosis was not made by CT-SBB but by OBB. The patient is a 46-year-old man with insulin-dependent diabetes mellitus who had been receiving immunosuppressive agents (azathioprine, cyclosporin, and prednisolone) after renal transplantation for diabetic renal failure for 9 years. He gradually developed febrile, headache and unsteady gait. Brain MRI demonstrated multiple intracranial lesions involving left fronto-temporal and right parietal lobes, left cerebellar hemisphere, and the fourth ventricle. Although the MRI findings were consistent with those of previously reported cases of intracranial tuberculoma, other conditions, such as malignant lymphoma and toxoplasmosis, were not ruled out. Therefore, CT-SBB targeting the left temporal lobe lesion was done for definitive diagnosis, but it revealed only mild perivascular infiltration of mononuclear cells and hemorrhage. He was transferred to our clinic for further evaluation. On examination, mild truncal and limb ataxia on the left were noted in addition to the neurological findings corresponding to diabetic retinopathy and neuropathy. Despite vigorous laboratory examinations, including repeated bacterial cultures and PCR of cerebrospinal fluid, no evidence of tuberculous infection was obtained. A tentative diagnosis of multiple intracranial tuberculoma was made, and anti-tuberculous drugs (isoniazid 400 mg, ethambutol 750 mg, and pyrazinamide 1.5 g) were administered. Since his symptoms deteriorated because of ventricular dilatation resulting from the enlarged lesion in the fourth ventricle after a temporary clinical improvement, VP-shunting and OBB from the left temporal lobe lesion were done. The excised lesion was firmly encapsulated and the histological examination revealed typical pathology of tuberculoma. Ziehl-Neelsen staining and PCR for Mycobacterium tuberculosis of the biopsied specimen were also positive. Further administration of increased doses of anti-tuberculous drugs (isoniazid 600 mg, ethambutol 500 mg, pyrazinamide 2.0 g and intramuscular injection of streptomycin 0.3 g twice a week) eventually ameliorated the symptoms and shrank the lesions. In case of intracranial tuberculoma, the needle of CT-SBB may not penetrate the firm capsule of tuberculoma and only the surrounding brain tissue may be obtained as in the present case. Therefore, it is recommended to consider OBB from the beginning for definitive diagnosis of intracranial tuberculoma. Paradoxical worsening of the clinical and laboratory findings of tuberculosis in spite of appropriate anti-tuberculous therapy as seen in the present case has been described in both pulmonary and extra-pulmonary tuberculosis. The phenomenon, called transient worsening, could happen and we have to keep it in mind during the treatment of intracerebral tuberculoma.

Unusual miliary tuberculosis presenting with generalized lymphadenopathy and abdominal involvement

Although tuberculosis is common and well recognised in many countries, unusual presentations of the disease sometimes raise difficulties in differential diagnosis. We report a young patient who presented with weight loss, shortness of breath and easy fatiguability. Extensive lymphadenopathy involving the cervical, axillary and inguinal regions were found on physical examination. Chest X-ray and computed tomography revealed generalized lymphadenopathy of cervical, mediastinal and para-aortic chains, bilateral pulmonary miliary reticulonodular infiltrates, pleural effusion, hepatomegaly with low density, macronodular hypodense areas in spleen, ascites, peritoneal irregularity and thickening of bowel walls. Mantoux test was negative. Peritoneal fluid was exudative, but pleural fluid was transudative, probably due to mediastinal lymphatic obstruction. The initial clinical diagnosis was malignant lymphoma; however, positive sputum smears for mycobacteria and excisional cervical lymph node biopsy revealing caseating granulomatous lymphadenitis were consistent with tuberculosis. The patient responded well to appropriate therapy with regression of radiological abnormalities.

Comparison of combination therapy regimens for treatment of human immunodeficiency virus-infected patients with disseminated bacteremia due to Mycobacterium avium. ANRS Trial 033 Curavium Group. Agence Nationale de Recherche sur le Sida

We conducted a randomized, open-label trial in 42 French hospitals to compare the clinical and bacteriologic efficacy of combination therapy with clarithromycin/clofazimine (Clm/Clof) with that of combination therapy with clarithromycin/rifabutin/ethambutol (Clm/Rib/Eth) as treatment for Mycobacterium avium bacteremia. One hundred forty-four human immunodeficiency virus-seropositive patients older than 18 years of age who had CD4 lymphocyte counts of <100/mm3 and a blood culture positive for M. avium were enrolled in the study. The main measures of outcome were blood cultures, abatement of clinical symptoms (fever), and survival. Treatment success (defined as patient living, either no fever or a reduction of > or = 1 degrees C in initial body temperature, and a blood culture negative for M. avium) was similar in both treatment groups at months 2 and 6. However, following initial resolution of infection, relapse of M. avium bacteremia occurred in more patients in the Clm/Clof group than in the Clm/Rib/Eth group (22 vs. six, respectively; P < .001); these relapses were accompanied by emergence of strains resistant to clarithromycin in 21 and two patients, respectively. In conclusion, combination therapy with Clm/Rib/Eth prevented relapse of mycobacterial disease and, compared with combination therapy with Clm/Clof, was associated with a significant decrease in the emergence of resistant M. avium strains in HIV-infected patients treated for at least 28 weeks.

Antitubercular treatment does not prevent constriction in chronic pericardial effusion of undetermined etiology: a randomized trial

Patients of chronic exudative pericardial effusion are frequently treated with antitubercular treatment on presumptive grounds in developing countries, in a hope to prevent constrictive pericarditis. To assess the impact of antitubercular treatment on development of constrictive pericarditis in chronic large exudative pericarditis effusion of undetermined etiology, 25 patients above 12 years of age, with large pericarditis effusion beyond 12 weeks duration, were randomized in a prospective 2:1 fashion, to receive either 3-drug antitubercular treatment (group A) or placebo (group B) for six months. End points studied were, development of pericardial thickness as diagnosed by CT scan and constrictive pericarditis as diagnosed by cardiac catheterization. Twenty-one patients (14 in group A and 7 in group B) completed the study protocol. In all, five (23.8%) patients developed constrictive pericarditis/pericardial thickening. Histopathological examination of pericardiectomy specimens in over five patients were negative for tubercular pathology. Pericardial effusion resolved completely in another 10 (47.8%) patients. There was no significant difference in both the groups in development of constrictive pericarditis/pericardial thickening (group A: n = 3, 21.4% and group B: n = 2, 29.6%, p = NS). On multivariate analysis, development of constrictive pericarditis/pericardial thickening was associated with recurrent tamponade (p = 0.01), presence of tamponade at admission (p = 0.07) and haemorrhagic pericardial effusion (p = 0.08). Thus, antitubercular treatment does not prevent the development of constrictive pericarditis in patients of large chronic pericardial effusion of undetermined etiology.

Pancreatic insufficiency due to antituberculous therapy

OBJECTIVE

To describe a case of chronic pancreatic insufficiency related to antituberculous therapy.

CASE SUMMARY

A 57-year-old man developed rash, fever, and hepatitis (aspartate aminotransferase 369 IU/L, alanine aminotransferase 506 IU/L), 6 weeks after starting isoniazid, rifampin, ethambutol, and pyrazinamide. He also developed severe metabolic acidosis secondary to diabetic ketoacidosis and lactic acidosis (serum bicarbonate 7 mEq/L, glucose 1778 mg/dL, and lactate 4.0 mEq/L). Acute pancreatitis was diagnosed on the basis of a mildly elevated amylase concentration (392 U/L) and radiologic evidence of pancreatic inflammation. He developed pancreatic insufficiency with steatorrhea and an abnormal secretin test. He continues to require pancreatic enzyme replacement and insulin therapy. Rechallenge was not performed.

DISCUSSION

Hypersensitivity syndromes have been reported for various drug therapies, including antituberculous agents. Hypersensitivity syndrome reactions are characterized by fever, rash, and internal organ involvement. Rifampin has been reported to cause acute pancreatitis in up to 2.7% of patients. Drug-induced chronic pancreatitis, however, is reported to be extremely rare. This is the first reported case of chronic pancreatic insufficiency occurring in the setting of a hypersensitivity syndrome reaction to antituberculous drugs.

CONCLUSIONS

Chronic pancreatic insufficiency should be considered as a possible long-term sequelae of a hypersensitivity syndrome reaction to antituberculous therapy.

[Long-term efficacy of full course intermittent short-course chemotherapy on new smear positive tuberculosis patients]

OBJECTIVE

To evaluate the long-term efficacy of full course intermittent short-course chemotherapy [2H3R3Z3S3(E3)/4H3R3], which has first been used in the National Tuberculosis Control Programme with the loan from the World Bank and its satisfactory short-term efficacy has been achieved, on new smear positive tuberculosis patients.

METHOD

All new smear positive tuberculosis patients, registered by 56 counties of 12 project provinces and autonomous regions in 1992, were investigated to find out the bacteriological relapse rate 2 years after treatment.

RESULT

One hundred thirty five out of 4400 patients followed up were found smear positive, with a relapse rate of 3.1%.

CONCLUSION

The result suggests that the chemotherapy should be given a priority in the National Tuberculosis Control Programme because of its high cure rate.

Clarithromycin and ethambutol with or without clofazimine for the treatment of bacteremic Mycobacterium avium complex disease in patients with HIV infection

OBJECTIVE

To compare the efficacy of two- and three-drug regimens for treating Mycobacterium avium complex (MAC) bacteremia in patients with AIDS.

DESIGN

Randomized open-label clinical trial.

SETTING

Outpatient HIV specialty centers' clinics.

PATIENTS

A total of 106 adults with AIDS and MAC bacteremia.

INTERVENTIONS

Patients were treated with clarithromycin 500 mg twice daily and ethambutol 800-1,000 mg daily and were randomized to receive clofazimine 100 mg daily or no clofazimine.

MAIN OUTCOME MEASURES

Quantitative blood MAC cultures, symptoms, adverse reactions and survival.

RESULTS

Patients randomly assigned to three drugs had significantly higher baseline colony counts of MAC in blood than patients receiving two drugs. The proportion of patients becoming culture-negative was 65% in the two-drug group and 54% in the three-drug group. The median time to negative culture was 58 days for patients in the two-drug and 63 days for the three-drug group. At the last visit during treatment, the mean reduction in colony forming units/ml of MAC in blood was 1.8 log10 for the two-drug group and 2.3 log10 for the three-drug group. Improvement in fever and night sweats was reported by 87 and 89% of the two-drug patients and 84 and 86% of the three-drug patients. During the study, 38% of two-drug patients and 61% of three-drug patients died (P = 0.032), and time to death was shorter in patients treated with three drugs (P = 0.012). In a multivariate analysis, both assignment to clofazimine and high baseline colony counts of MAC bacteremia were significantly associated with death (P < 0.05).

CONCLUSION

The addition of clofazimine to a regimen of clarithromycin and ethambutol for MAC bacteremia in AIDS patients does not contribute to clinical response and is associated with higher mortality.

Randomised controlled clinical trial of short course chemotherapy in abdominal tuberculosis: a five-year report

OBJECTIVES

To assess and compare the efficacy of a 6-month short-course chemotherapy regimen (SCC) with that of a 12-month standard regimen in the treatment of abdominal tuberculosis.

DESIGN AND SUBJECTS

A total of 193 adult patients with evidence of abdominal tuberculosis were randomly allocated to one of two daily regimens: 1) a 6-month SCC regimen with rifampicin, isoniazid and pyrazinamide for 2 months followed by rifampicin with isoniazid for another 4 months (6R series) and 2) and 12-month standard regimen of ethambutol and isoniazid with streptomycin supplemented for 2 weeks (12E series). Surgery was undertaken only for patients suspected to have obstruction or perforation of the intestine.

RESULTS

A total of 163 (85 6R, 78 12E) patients were available for efficacy analysis after exclusion of 30 patients for various reasons. At the end of treatment clinical status was normal in 84 (99%) in 6R patients and in 73 (94%) in 12E patients. Of these, 147 patients completed follow-up for 5 years; none had relapsed requiring treatment for abdominal tuberculosis.

CONCLUSION

A 6-month SCC regimen has been found to be as effective as the standard 12-month regimen in the treatment of all forms of abdominal tuberculosis.

Efficacy of twice weekly treatment for tuberculosis given under direct observation in Africa

The efficacy of a 6 months course of twice weekly therapy with 4 drugs for tuberculosis, preceded by a 2-3 weeks intensive daily phase, is unknown. Implementation of this regime as community-based directly observed therapy in Africa is highly effective (85% completion rate); it is important to estimate the efficacy of the regime before advocating its widespread use and before conducting prospective trials. We retrospectively evaluated 109 consecutive adults with culture-positive pulmonary tuberculosis who had documented completion of treatment; 84 (77%) were traced and in 15 (14%) a history was obtained from a close relative; 10 (9%) had left the area. Nineteen patients were producing sputum and 4 of these were culture-positive for Mycobacterium tuberculosis, giving an estimated cure rate of 95% (95% confidence interval, 89-98%). Follow-up specimens revealed no acquired drug resistance and restriction fragment length polymorphism analysis of patient-paired specimens showed them to be nearly identical, indicating that treatment had failed or there had been early relapse. This preliminary study suggested that generally twice weekly 4-drug treatment for tuberculosis, given under direct observation, is curative in an acceptable proportion of patients. Prospective trials are indicated.

Esophagomediastinal fistula as a complication of tuberculous mediastinal lymphadenitis

In a 44-year-old female esophagomediastinal fistula was found secondary to tuberculous mediastinal lymphadenitis. Chest computed tomography revealed amorphous air collection in the subcarinal region of the mediastinum with mediastinal lymphadenopathy. Esophagography with gastrografin confirmed esophagomediastinal fistula. The patient was treated with antituberculous therapy with rifampicin, isoniazid, pyrazinamide and ethambutol, resulting in resolution of the esophagomediastinal fistula and mediastinal lymphadenopathy.

Successful treatment of atypical mycobacterial meningitis by fluoroquinolone

We report a case of restricted meningeal infection by atypical mycobacteria, identified by the polymerase chain reaction, in a non-immunocompromised adult successfully treated by multiple antibiotics including fluoroquinolone. New quinolones should be considered as a therapeutic option for such mycobacterial meningitis.

Randomized controlled trial of a drug regimen that includes ciprofloxacin for the treatment of pulmonary tuberculosis

The fluoroquinolones are promising new antituberculous agents. A randomized controlled trial of 200 adult patients with sputum smear-positive pulmonary tuberculosis was conducted in Tanzania. Patients received either a trial regimen (HRC) consisting of isoniazid (300 mg), rifampin (600 mg), and ciprofloxacin (750 mg) or a control regimen (HRZE) consisting of isoniazid (300 mg), rifampin (600 mg), pyrazinamide (25 mg/kg), and ethambutol (15 mg/kg). The 168 evaluable patients all had negative smears and cultures by month 6, but the time to conversion to negativity was longer for the HRC group than for the HRZE group because of the poor response of patients infected with human immunodeficiency virus (HIV) to the HRC regimen. Relapse was more frequent in the HRC group. The sterilizing activity of ciprofloxacin does not appear to be equal to that of the combination of pyrazinamide and ethambutol, but the difference in outcome was significant only among HIV-infected patients.

[Effects of intermittent short-course chemotherapy under full-course supervision on the treatment of smear positive pulmonary tuberculosis]

OBJECTIVE

To evaluate the effects of intermittent short-course chemotherapy under full-course supervision on the treatment of smear positive pulmonary tuberculosis.

METHOD

The regimens of 2H3R3Z3S3(E3)/4H3R3 and 2H3R3Z3S3E3/6H3R3E3 were respectively used in 125 initial and 249 relapse smear positive pulmonary tuberculosis cases under full-course supervision and management.

RESULTS

The total rate of treatment completion was 99.7%, and the rates of sputum negative conversion in initial and relapse cases were 96.7% and 84.8% respectively. During three-year follow-up, the bacteriological relapse rates were found to be 1.8% in initial cases and 10.2% in relapse cases.

CONCLUSIONS

The regimen was proved to be convenient, economical and effective in tuberculosis control programme.

[CT scanning and treatment of intracranial tuberculoma]

OBJECTIVE

To evaluate the value of CT scanning and the efficacy of anti-tuberculosis short-course chemotherapy in intracranial tuberculoma patients.

METHOD

The CT manifestations and the clinical characteristics of 55 intracranial tuberculoma patients were analysed.

RESULTS

44 out of 55 patients were cured. Among them, 40 patients' lesions were entirely resolved, while other 11 cases, clinical symptoms were subsided and still under treatment. In the contrast enhancing CT scanning, plate shaped or ring-form shadows were shown surrounding the lesions of tuberculoma. The characteristical features were more special for diagnosis and the positive rate was higher than that of other laboratory findings. The incidence of intracranial tuberculoma was found to be higher in children and juvenile patients who lived in rural areas.

CONCLUSIONS

Enhancing CT scanning is valuable for diagnosis of intracranial tuberculoma. The anti-tuberculosis short-course chemotherapy used nowadays with which almost all the intracranial tuberculoma patients can be cured and only few of them need surgical operation.

[Efficacy and tolerance of the treatment of tuberculosis in the aged]

We analyzed 55 confirmed cases of tuberculosis in patients over 65, a sample that amounted to 9% of all patients seen in our practice over a period of 5 years. Mean age was 72.4 and the male/female ratio was 4/1. The most frequently associated diseases were tobacco addiction (49%), chronic obstructive pulmonary disease (33%), alcoholism (25%) and prior diagnosis of tuberculosis (20%). Lung involvement was the most common clinical presentation (76%), followed by pleural (9%) and skeletal (7%) involvement. The clinical picture was non specific, with 13% remaining asymptomatic. Cough was the most frequent symptom (45%) and unilateral apical fibrosis with ulceration was the most frequent radiological finding. Pleural discharge and cavitation were demonstrated in 14 and 22%, respectively. Scarring was visible on X-rays in 44%. The tuberculin test was positive in 88% of the cases in which it was performed. Mean delay in diagnosis was 3.4 months; 62% were diagnosed by sputum test, 11% by culture, and 27% histology. In 4% death was directly caused by tuberculosis. Three patients withdrew from treatment, in one case treatment failed, and there was one relapse detected at follow-up. We observed adverse side effects in 33%, and found no statistically significant differences between the 2 therapeutic protocols used (2 months RHS/7 months RH and 2 months RHZS/4 months RH). The incidence of tuberculosis among the elderly is low in our practice and the entity behaves much as it does in the rest of the adult population. Both the efficacy and tolerance of treatment can be considered optimal.

In vitro bactericidal and in vivo therapeutic activities of a new rifamycin derivative, KRM-1648, against Mycobacterium tuberculosis

The in vitro and in vivo activities of a new rifamycin derivative, KRM-1648, against Mycobacterium tuberculosis H37Rv were compared with those of rifampin. Bactericidal activity was evaluated by using a silicone-coated slide culture method. The MBC of KRM-1648 was 0.15 to 0.3 microgram/ml for 24 h of exposure, while that of rifampin was > 160 microgram/ml under the same conditions. Against experimental murine tuberculosis, KRM-1648 exhibited significant therapeutic effects, in terms of prolonged survival times for mice compared with those with rifampin treatment, even at lower doses, such as 1 and 3 mg/kg. At a dose of 3 mg/kg, KRM-1648 was at least as effective as rifampin at 10 mg/kg. The combination of KRM-1648 (3 mg/kg) plus isoniazid (3 mg/kg) plus ethambutol (10 mg/kg) exhibited much more activity than did rifampin (10 mg/kg) plus isoniazid (3 mg/kg) plus ethambutol (10 mg/kg). These findings suggest that KRM-1648 is a promising candidate for the treatment of tuberculosis.

Relative bioavailability of rifampicin, isoniazid and ethambutol from a combination tablet vs. concomitant administration of a capsule containing rifampicin and a tablet containing isoniazid and ethambutol

Twenty male volunteers who were slow metabolisers of isoniazid, completed this single-blind, single-dose, randomised, cross-over study to compare the bioavailability of rifampicin (CAS 13292-46-1), isoniazid (CAS 54-85-3) and ethambutol (CAS 1070-11-7) from Myrin tablets (test preparation) with the bioavailability of these drugs from a combination of capsules containing rifampicin and tablets containing isoniazid and ethambutol (reference). There were 2 treatment periods and on clinic days volunteers were given either the reference (300 mig rifampicin plus 200 mg isoniazid and 600 mg ethambutol HCl), or the test preparation (300 mg rifampicin, 150 mg isoniazid and 600 mg ethambutol HCl). Serial blood samples were drawn from the volunteers and rifampicin, isoniazid and ethambutol assays were performed. The results of this study indicate that the test preparation is equivalent to the reference with respect to both the rate and the extent of absorption of rifampicin, isoniazid (after adjustment for the different doses of isoniazid and ethambutol).

Long-term treatment of pulmonary tuberculosis with ofloxacin in a subject with liver cirrhosis

We report on the clinical case of a patient suffering from active pulmonary tuberculosis associated with liver cirrhosis, which limited the use of the major antituberculosis drugs. The patient was treated with a 12 month ofloxacin and ethambutol therapy. At completion of the therapy, the lung cavity disappeared with a considerable reduction of the lung infiltration, as seen in the chest radiograph. At the same time, a positive to negative conversion of the sputum was noted. The only significant side-effect was hyperuricaemia.