Household contact investigation of multidrug-resistant and extensively drug-resistant tuberculosis in a high HIV prevalence setting

SETTING

Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) are now a nationwide epidemic in South Africa. Epidemiological data suggest nosocomial transmission as the primary route of spread; however, transmission among household contacts has not yet been investigated.

OBJECTIVE

To determine the incidence rates of MDR- and XDR-TB among household contacts of MDR- and XDR-TB index cases diagnosed between January 2005 and September 2008 in a high human immunodeficiency virus prevalence setting.

DESIGN

Prospective, observational study evaluating adult household contacts for active TB by culture and drug susceptibility testing at index case diagnosis and again 1 year later. Outcomes were incidence and time to diagnosis of MDR- and XDR-TB.

RESULTS

A total of 1766 contacts of 221 MDR-TB and 287 XDR-TB index cases were screened. Of 793 contacts of MDR-TB index cases, 14 (1.8%) were diagnosed with MDR-TB (incidence 1765/100 000); 19 (2.0%) of 973 XDR-TB contacts had XDR-TB (incidence 1952/100 000). Median time to diagnosis of household cases was 70 days (interquartile range 57-89).

CONCLUSION

Incidence rates of MDR- and XDR-TB among household contacts were extremely high, with most secondary cases occurring shortly after the diagnosis of the index case. Active case finding of drug-resistant TB is a high-yield public health activity and must be a priority, as early diagnosis may stem further disease spread and improve survival.

Extensively drug-resistant tuberculosis in children with human immunodeficiency virus in rural South Africa

SETTING

Extensively drug-resistant tuberculosis (XDR-TB) has been documented worldwide, but reports of XDR-TB in children are extremely limited.

OBJECTIVE

To report the characteristics of pediatric XDR-TB patients in rural South Africa.

DESIGN

We retrospectively reviewed children with sputum culture-confirmed XDR-TB from Tugela Ferry, South Africa, from January 2006 to December 2007. Demographic, clinical and microbiologic data were abstracted from medical records.

RESULTS

Four children aged 6-8 years with XDR-TB were reviewed. Two had previous histories of TB. All were human immunodeficiency virus (HIV) infected orphans; three received highly active antiretroviral therapy (HAART) before XDR-TB diagnosis. All had clinical and radiographic improvement and sputum culture conversion while on standardized XDR-TB treatment and HAART. Two tolerated concomitant XDR-TB and HIV treatment well. Two experienced neuropsychiatric side effects related to cycloserine. All have survived >24 months and all were cured. Prior to XDR-TB diagnosis, the children had resided in the hospital's pediatric ward for a median of 8 months (range 5-17), including a 3-month overlapping period.

CONCLUSIONS

XDR-TB is a microbiologic diagnosis that, even with HIV co-infection, can be successfully identified. Concurrent XDR-TB and HIV therapy is feasible and effective in children, although more research is needed into potential overlapping toxicities. Nosocomial transmission is suggested, calling for infection control policies in pediatric wards.

Study of bone mineral density in resident doctors working at a teaching hospital

CONTEXT

The erratic lifestyle of resident doctors may affect their serum 25-hydroxy vitamin D [25-(OH)D] levels and bone mineral density (BMD).

AIM

To study BMD and the effect of environmental factors on it in resident doctors.

SETTINGS AND DESIGN

Prospective, cross-sectional study conducted in a tertiary healthcare centre.

MATERIALS AND METHODS

BMD was obtained by dual-energy X-ray absorptiometry and was correlated with various factors including weight, height, body mass index (BMI), sun exposure, physical activity, parathyroid hormone, 25-(OH)D, dietary factors. Statistical Analysis : SPSS software Version 10 (Unpaired t test was used to compare BMD of different groups and Pearson's correlation coefficient was used to calculate correlation).

RESULTS

Two hundred and fourteen apparently healthy resident doctors were enrolled in the study. Based on Caucasian normative data, osteopenia was noted in 104 (59.7%) males and 27 (67.5%) females. Thirty-two (18.39%) males and five (12.5%) females had osteoporosis. The BMD values of males were 0.947+/-0.086, 0.911+/-0.129 and 1.016+/-0.133 at lumbar spine, femur neck and total hip while those in females were 0.981+/-0.092, 0.850+/-0.101 and 0.957+/-0.103 respectively. BMD of our cohort was lesser by 12.5-18.2% and 4.2-14.5% than the Caucasian and available Indian figures, respectively. BMD had significant positive correlation with weight, height, BMI, physical activity, and dietary calcium phosphorus ratio. 25-(OH)D levels were insufficient in 175 (87.5%) subjects but had no correlation with BMD.

CONCLUSIONS

Young healthy resident doctors had significantly lower BMD, contributors being lower BMI, lower height, reduced bioavailability of dietary calcium and inadequate physical activity. Deficiency of vitamin D did not contribute to low BMD.

The value of an acute octreotide suppression test in predicting response to long-term somatostatin analogue therapy in patients with acromegaly

CONTEXT

The usefulness of the acute octreotide test in the selection of patients with acromegaly for chronic somatostatin depot analogues treatment is controversial.

AIMS

To determine the efficacy of acute octreotide suppression test (OST) in predicting response to long-term somatostatin analogue (Octreotide-long-acting repeatable, OCT-LAR) therapy in patients with acromegaly.

SETTINGS AND DESIGN

Prospective study (2006-2007) conducted at a tertiary healthcare centre in western India.

MATERIALS AND METHODS

Sixteen drug-naive patients with active acromegaly (postoperative+/-post radiotherapy) underwent 50 microg subcutaneous OST. Ten patients were treated with OCT-LAR for one year. Remission was defined as a nadir growth hormone (GH) < 1 ng/ml during 75 g oral glucose tolerance test (OGTT) (0, 10, 30, 60, 120, 180 min) and normal age, sex-matched insulin-like growth factor 1 (IGF1) levels.

STATISTICAL ANALYSIS

SPSS Software Version 11 was used for data analysis.

RESULTS

Using GH cutoff.

CONCLUSIONS

Nadir GH < 1 ng/ml following an OST is a useful predictive marker of achieving disease remission with long-term OCT-LAR therapy.

Autoimmune hypophysitis: a single centre experience

INTRODUCTION

Autoimmune hypophysitis (AH) is a rare primary autoimmune inflammatory disorder involving the pituitary gland.

METHODS

A retrospective analysis of the clinical features and outcome of patients diagnosed with AH between 1988 and 2006, was carried out.

RESULTS

15 patients (14 females and one male) with AH were identified. Three patients presented in the peripartum period. Headache, vomiting and visual field defects, suggestive of an expanding sellar mass, were the most common presenting symptoms (67 percent). The most common deficient hormone was adrenocorticotropic hormone (ACTH) (67 percent), followed by thyroid stimulating hormone (53 percent) and gonadotropins (40 percent). Imaging revealed a definite, enhancing sellar mass in 87 percent of the patients and stalk thickening in 33 percent of the patients. Three patients underwent surgery. On serial monitoring, the sellar mass regressed or disappeared spontaneously without any immunosuppressive treatment in the other ten patients with a definite sellar mass.

CONCLUSION

We report a higher female to male ratio and a lower incidence of peripartum cases in our series. Symptoms of mass effect were the most common presentation, while ACTH was the most commonly-deficient hormone. Surgery was rarely needed, and most patients experienced a spontaneous resolution of the mass.

Prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is commonly associated with type 2 diabetes mellitus (DM) though its prevalence is not well studied. We conducted a prospective study of prevalence and risk factors of NAFLD in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

204 type 2 DM patients attending an out-patient diabetic clinic underwent abdominal sonography. Ninty of 127 patients with fatty infiltration on ultrasound consented for liver biopsy, clinical and biochemical workup.

RESULTS

Eighty seven percent had NAFLD on histology with 62.6% steatohepatitis and 37.3% fibrosis. Age, duration of diabetes mellitus, degree of glycemic control, body mass index, waist circumference, family history of diabetes mellitus, did not predict the presence or severity of NAFLD or fibrosis. Serum alanine aminostranferase (ALT) and alkaline phosphatase levels, though within normal limits, were significantly higher in patients with steatohepatitis. Prevalence of NASH increased with increase in the components of the metabolic syndrome. Serum AST/ALT ratio were also significantly higher (p-0.049) in patients with severe fibrosis. All patients with severe fibrosis had metabolic syndrome.

CONCLUSIONS

Prevalence of NAFLD and NASH in our cohort of type 2 DM patients is high and increases with multiple components of metabolic syndrome. NASH and advanced fibrosis can occur in diabetic patients without any symptoms, signs or routine laboratory test abnormalities.

Carotid body tumours: three case reports

A carotid body tumour is a rare presentation of an extra-adrenal pheochromocytoma. They commonly present with asymptomatic neck masses, and careful preoperative evaluation is required to find out the functional and vascular status of these tumours. We report three cases of carotid body paraganglioma, their evaluation, management and the final outcome.

Validation of the line-probe assay for rapid detection of rifampicin-resistant Mycobacterium tuberculosis in Vietnam

BACKGROUND

Delays in identifying multidrug-resistant tuberculosis (MDR-TB) contribute to higher TB morbidity and mortality, and ongoing transmission. The line-probe assay (LiPA) is a rapid, commercially available polymerase chain reaction based assay that detects most mutations in the rpoB gene for rifampicin (RMP) resistance. We validated and compared this assay with conventional drug susceptibility testing (DST).

METHODS

We re-cultured a random sample of stored isolates known to be either RMP-resistant or RMP-susceptible according to DST (proportion method). We performed a blinded comparison between LiPA and conventional DST. Genetic sequencing of the rpoB gene was performed on RMP-resistant isolates and discordant results.

RESULTS

We tested 79 RMP-resistant and 64 RMP-susceptible strains. Concordance of LiPA with DST was 94%. For detecting RMP resistance, LiPA sensitivity was 90% and specificity was 100%. Molecular analysis of possible false-negative isolates by LiPA revealed an absence of mutations in the rpoB gene. RMP resistance was a good proxy for MDR-TB, as 66 (93%) of 71 RMP-resistant isolates were also isoniazid-resistant.

CONCLUSION

The LiPA provided rapid results that were highly predictive of RMP resistance and MDR-TB. False-negatives occurred, but only among isolates with mutations in regions not assessed by LiPA. Performance and cost-effectiveness should be evaluated in patients during routine program conditions.

Congenital adrenal hyperplasia 11beta-hydroxylase deficiency: two cases managed with bilateral adrenalectomy

This series describes two patients with congenital adrenal hyperplasia due to 11beta-hydroxylase deficiency. The first patient, a ten-year-old with XX genotype, reared as a male, presented with resistant hypokalaemia and hypertension. The second patient, a 23-year-old with XY genotype, presented with bilateral adrenal masses and resistant hypertension. Both the patients were offered bilateral adrenalectomy. These two patients are described with a discussion on the role of bilateral adrenalectomy in the management of difficult cases of congenital adrenal hyperplasia. The association of myelolipoma and testicular rests with this condition is also discussed.

Population-based chest X-ray screening for pulmonary tuberculosis in people living with HIV/AIDS, An Giang, Vietnam

SETTING

Human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) program, An Giang Province, Vietnam.

OBJECTIVE

To evaluate the coverage and yield of a chest radiography (CXR) screening program for tuberculosis (TB) among people living with HIV/AIDS (PLHA), risk factors for a TB CXR, inter-rater reliability of CXR readings and direct costs.

DESIGN

Retrospective review of routine public health program records and CXRs.

RESULTS

An increasing proportion of PLHAs received a screening CXR each year of the program (range 21% in 2001 to 61% in 2004, P<0.001). Of 876 screening CXRs performed, 191 (22%) were classified as suspicious for active TB ('TB CXR'). Compared to PLHAs with a CXR not suspicious for active TB, PLHAs with a TB CXR were more likely to be aged between 24 and 64 years, male and previously treated for TB (P<0.01 for each comparison). Agreement between the expert and local program CXR readings was 81% (kappa 0.50). Direct costs were approximately US$40 per TB suspect identified. Among TB suspects, <10% were followed up with sputum smear examination and enrolled for treatment.

CONCLUSION

In An Giang Province, a large proportion of PLHAs are screened for TB annually, and one in five persons screened is classified as a TB suspect based on CXR. Annual CXRs may be a high-yield, inexpensive method for TB screening in PLHAs, but the follow-up of TB suspects to confirm diagnosis and initiate treatment is crucial.

Microscopic-observation drug susceptibility assay provides rapid and reliable identification of MDR-TB

BACKGROUND

Liquid culture systems are more rapid and sensitive for both the detection and drug susceptibility testing (DST) of Mycobacterium tuberculosis.

SETTING

St Peter's TB Specialised Hospital and public health laboratory, Addis Ababa.

OBJECTIVE

To compare the microscopic-observation drug susceptibility (MODS) assay with the BACTEC-MGIT 960 system for isoniazid and rifampicin DST (i.e., multidrug-resistant tuberculosis [MDR-TB] identification) of M. tuberculosis.

DESIGN

The evaluation was based on 58 smear- and culture-positive sputum samples from patients diagnosed in Addis Ababa, Ethiopia. BACTEC-MGIT was used as the reference standard.

RESULTS

For the detection of MDR-TB, MODS has a sensitivity, specificity and accuracy rate of respectively 95%, 100% and 98.3% (kappa 0.981, concordance 98.3%). Concurrent culture detection and DST results are obtained in a median of 9 days with MODS, while indirect DST results with BACTEC-MGIT are obtained in a median of 8 days (this does not include time to primary isolate).

CONCLUSION

MODS is an accurate, rapid and relatively inexpensive method for the identification of MDR-TB.

Evaluation of low dose ACTH stimulation test in suspected secondary adrenocortical insufficiency

BACKGROUND

Several studies in the last few years have shown that the standard 250 micro g dose used in ACTH stimulation test may be very high and have suggested that a dose of 1 micro g may be sufficient for evaluating hypothalamo-pituitary adrenal (HPA) axis.

AIMS

To evaluate the role of low dose ACTH stimulation test in patients with suspected Secondary Adrenal Insufficiency (SAI).

SUBJECTS AND METHODS

Thirty-one patients of suspected SAI with a documented pituitary lesion and seven normal healthy controls were included in the study. All the subjects underwent ACTH stimulation test with standard high dose (HD= 250 microg) and low dose (LD= 1 microg) ACTH. Insulin Induced Hypoglycaemia (IIH) test was done in 7 out of 9 patients in whom the results of the two tests were discordant. The cut off for normal HD stimulation test was taken as peak cortisol response > 18 microg/dl and for LD test, either a cortisol response of > 18 microg/dl or an increment of more than 7 micro g/dl over the basal value at any time during the test, on the basis of response observed in controls.

RESULTS

22/31 patients (74%) in SAI group showed concordant results with both tests, whereas nine patients had discordant results. These nine patients showed AI with LD ACTH, but HD ACTH test showed a normal response. In 7 of these 9 patients who underwent IIH, AI was confirmed in 6.

CONCLUSION

The LD ACTH stimulation test seems to be better than HD ACTH stimulation test for evaluating HPA axis in patients with suspected SAI. When basal cortisol is normal, LD ACTH stimulation test detects subtle SAI.

Utility of clinical parameters of tissue oxygenation in a quantitative model of irreversible hemorrhagic shock

The aim of this study was to assess the value of parameters of tissue oxygenation in monitoring the progression to irreversibility in a quantitative model of hemorrhagic shock. Rats were bled to a mean arterial pressure of 40 mmHg and were maintained at this level by further blood withdrawal until the compensation endpoint; this point was defined as the time at which the rat was no longer able to maintain its blood pressure at this level and shed blood was required for transfusion. The shock period was maintained until 0%, 20%, 40%, or 50% of the maximum shed blood volume (MBV) had been returned (n = 10 in each group, total n = 40). The animals were then resuscitated with remaining shed blood plus twice MBV as lactated Ringer's solution to MAP > 80 mmHg. Blood gas and serum lactate samples were measured at baseline, compensation endpoint, and at the time of resuscitation, and 24 h survival was recorded. Increasing the severity of shock progressively worsened the acidosis, with increased base deficit and lacticacidemia, and deterioration in central venous oxygen saturation (CvO2). Tissue oxygenation parameters, particularly CvO2, predicted subsequent mortality. Lactate levels only predicted irreversibility in late, severe shock. This quantitative model of hemorrhagic shock showed that tissue oxygenation parameters can be used to monitor the progression from the decompensated phase of hemorrhagic shock to irreversibility. Furthermore, this experimental study suggests that venous indices may be a valuable tool in reflecting the severity of hemorrhagic insult in a setting when arterial blood samples may not be easily available.

Role of nitric oxide in inflammation and tissue injury during endotoxemia and hemorrhagic shock

Since the discovery that nitric oxide (.NO) accounts for the biologic activity of endothelial-derived relaxing factor, a torrent of research over the last decade has focused on its role, protective or detrimental, in myriad pathophysiologic conditions. Recently, increasing attention has focused on .NO as a possible mediator of the severe hypotension and impaired vasoreactivity characteristic of circulatory failure. Given the ubiquitous and complex role of .NO in biologic systems, inhibition of .NO synthesis in experimental and clinical studies of shock has yielded mixed, sometimes contradictory, results. Although overproduction of .NO in the vasculature may result in systemic vasodilation, .NO synthesis has also clearly been shown to have a beneficial role in regulating organ perfusion and mediating cytotoxicity. In this review, the pathophysiologic importance of .NO in septic shock and hemorrhagic shock is discussed, and novel therapeutic strategies for manipulation of .NO formation are examined.

Physiologic and molecular characterization of the role of nitric oxide in hemorrhagic shock: evidence that type II nitric oxide synthase does not regulate vascular decompensation

To determine the role of nitric oxide (NO) in decompensated and irreversible hemorrhagic shock, rats were subjected to hemorrhagic shock (HS) for 3 or 5 h. Lung, liver, and plasma samples were studied for evidence of NO formation using Northern analysis and immunohistochemistry for Type II NOS, as well as measurement of plasma nitrite/nitrate, cyclic GMP, and nitrosylated hemoglobin levels. Comparisons were made with similarly instrumented time-matched sham rats. Type II NOS mRNA and protein were detectable in lung and liver only in the irreversible phase of HS (5 h). A large accumulation of nitrosylated hemoglobin and nitrite/nitrate appeared in the irreversible phase. Significant accumulation of cyclic GMP or nitrite/nitrate was not detectable in the decompensation phase. Despite the hemodynamic decompensation at 3 h of HS, Type II NOS mRNA and protein expression, as well as NO metabolites were not elevated. To assess whether NO plays a physiologically significant role in decompensation, rats in the decompensation phase and sham animals were subjected to nonspecific NOS inhibition. Both groups displayed a similar magnitude and duration of blood pressure elevation. Hemodynamic decompensation in HS is not mediated by Type II NOS induction. NO production increases only after prolonged HS; significant NO production is observed only in severe, irreversible HS.

Efficacy of inhaled nitric oxide in oleic acid-induced acute lung injury

OBJECTIVE

To assess the efficacy of inhaled nitric oxide in improving pulmonary hypertension and gas exchange following oleic acid-induced acute lung injury.

DESIGN

Prospective, pharmacologic study.

SETTING

Surgical research laboratory at the University of Pittsburgh, Pittsburgh, PA.

SUBJECTS

Instrumented, intubated pigs weighing 16 to 27 kg.

INTERVENTIONS

Intravenous oleic acid and inhaled nitric oxide.

MEASUREMENTS AND MAIN RESULTS

All pigs treated with intravenous oleic acid (0.11 mL/kg) developed a severe lung injury with pulmonary hypertension, accompanied by impaired oxygenation, intrapulmonary shunting, and increased extravascular lung water (p < .05 compared with baseline). Following nitric oxide inhalation, although pulmonary hypertension decreased in a dose-dependent fashion, no amelioration in pulmonary gas exchange was observed, as reflected by PaO2 and intrapulmonary shunt. Plasma nitrite and nitrate concentrations, the stable end products of nitric oxide metabolism, did not increase following nitric oxide exposure in this model of severe lung injury.

CONCLUSIONS

The effect of inhaled nitric oxide, restricted to relieving pulmonary vasoconstriction in this model of lung injury, may have limited benefit in improving pulmonary gas exchange when diffusion is impaired by severe lung injury and inflammatory thickening of the alveolar-capillary barrier. Nitric oxide inhalation may have better results when used at an earlier, less severe stage of acute lung injury.

A long-term review of the Shah Permavent tube

A retrospective study of 74 Shah Permavent tube insertions is presented. These were inserted into 74 ears of 55 patients during the period between 1985 and 1988. At the time of review, 35 tubes had extruded spontaneously, 11 tubes had been removed for recurrent infections, 10 tubes had been removed electively and 10 tubes were still in situ. On examination of the ears approximately 12 months after the tubes had extruded, the overall rate of tympanic membrane perforation was 18.2 per cent. In ears in which the Permavent tube extruded spontaneously the perforation rate was 22.2 per cent. In ears which the tube was removed because of infection the perforation rate was 20.0 per cent. However in ears in which the tube was removed electively the perforation rate was zero. This finding has implications in the use and management of long-term ventilation tubes.