Seizures with single therapeutic dose of isoniazid

Isoniazid (INH) is an integral component of treatment of tuberculosis. An acute overdose is potentially fatal and is characterised by the clinical triad of repetitive seizures unresponsive to the usual anticonvulsants, metabolic acidosis with a high anion gap and coma. A case of isoniazid induced seizures after therapeutic dose of 600 mg. as a part of CAT I thrice weekly intermittent anti-tuberculosis regimen for pulmonary tuberculosis is reported. The frequency of the usage of Isoniazid as antituberculosis therapy requires that physicians be aware of such toxicity.

A pilot study of same day sputum smear examination, its feasibility and usefulness in diagnosis of pulmonary TB

INTRODUCTION

A large number of tuberculosis cases are continuously being reported from India and other developing countries leading to high morbidity and mortality. In spite of many newer tests available for diagnosing a case of tuberculosis, smear microscopy of sputum is still the preferred test under programmatic conditions. The current national and international guidelines recommend two sputum smear examinations in two days for diagnosing cases of tuberculosis, which is time-consuming, tedious, needs multiple visits, leading to high dropout of infectious cases. In the background of existing limitations of smear microscopy, we attempted to complete the diagnosis of tuberculosis on same day by serial collection of the spot sputum specimen and analyze its advantages, feasibility and viability.

MATERIAL & METHODS

The study was undertaken by the Department of Microbiology, Lala Ram Sarup Institute of Tuberculosis and Respiratory Diseases during May 2010 to April 2011. Sputum specimens were collected from 330 randomly selected tuberculosis suspects who attended OPD of hospital, patients submitted spot and home collected morning sputum sample in a standard method and spot and additional spot sputum (X- spot) collected one hour after the first spot sample as per the proposed front loading method. All the samples received were stained by acid fast Ziehl-Neelsen (ZN) stain and examined on the same day. The sputum sample was pooled and cultured in Lowenstein Jensen (LJ) media in duplicate set of bottles. The results of two different microscopic methods were compared with the gold standard culture test.

RESULTS

Out of the total 330 TB suspects, 70.60% were males and 29.39% females. The most common complaint was of cough with sputum (88.18%), chest pain (70.21%), fever (55.15%) and loss of appetite (43.03%). Upon examining the total sputum slides, 18.48 % were positive for acid fast bacilli. The smear positivity was 61/330 (18.48%) by standard methods and in proposed new method 43/330 (13.03%). Sensitivity of the standard and proposed new method smear microscopy was 58.25% and 40.07% respectively and specificity was 99.55% in both the methods.

CONCLUSION

Same day smear microscopy for diagnosing tuberculosis by a proposed new method of smear examination in the case of suspected tuberculosis seems not a promising step towards improving the quality of sputum smear examination. The results of sensitivity and specificity of the two approaches were not similar. More than eighty per cent responded in favour of same day sputum delivery system and getting result on same day. This study can be confirmed on larger scale and preference of patients can be examined in peripheral laboratory also before taking it up for consideration in the national tuberculosis programme.

Linezolid: an effective, safe and cheap drug for patients failing multidrug-resistant tuberculosis treatment in India

Linezolid is identified as an effective drug with which to treat patients failing multidrug-resistant (MDR)-tuberculosis (TB) treatment. However, cost and safety are the concerns. In India, the average price of a 600-mg pill of linezolid is less than one US dollar, much cheaper than most of the third-line drugs. A prospective study of 29 MDR-TB treatment failure patients (16 with laboratory-proven extensively drug-resistant (XDR)-TB and the remaining 13 with MDR-TB with resistance to any quinolone but sensitive to injectables) was carried out in Delhi, India. All patients received daily unsupervised therapy with linezolid, one injectable agent, one fluoroquinolone and two or more other drugs. Patients received a median of six anti-mycobacterial agents. Besides linezolid, capreomycin, moxifloxacin, levofloxacin and amoxycillin-clavulanic acid were used in 41.4%, 58.6%, 41.4%, and 79.3% of patients. Out of a total of 29 patients, 89.7% patients achieved sputum smear and culture conversion; 72.4% showed interim favourable outcome; 10.3% died, 6.8% failed and 10.3% patients defaulted. Linezolid had to be stopped in three (10.3%) patients due to adverse reactions. The outcome of treatment of 16 XDR-TB patients was comparable to the other 13 MDR-TB patients. Linezolid is an effective, cheap and relatively safe drug for patients failing MDR-TB treatment, including those with confirmed XDR-TB.

Preparation and characterization of rodent intestinal microsomes: comparative assessment of two methods

Small intestine plays an important role in the first-pass metabolism of orally ingested xenobiotics as a result of expression of both Phase I and Phase II metabolic enzymes, together with associated transporters. Intestinal microsomes thus can be used to study susceptibility of compounds to metabolism in vitro. The present study was undertaken to have a comparative assessment between different methods of preparation of rodent intestinal microsomes. Mouse and rat intestinal microsomes were prepared by two methods, in method A intestines were homogenized, while in method B mucosal cells were scrapped followed by homogenization. Further, microsomes were prepared by centrifugation (10000xg) followed by ultra centrifugation (100000×g) of the homogenates. The prepared microsomes were characterized for protein concentration using Bradford's method and CYP450 content using carbon monoxide bubbling method. The protein concentration and CYP450 content in microsomes prepared by method B was significantly higher than method A. In conclusion, superior quality intestinal microsomes can be obtained from rodents by using scrapped intestinal mucosal cells as compared to the intestinal homogenates.

Pyrazinamide-induced maculopapular rash

Pyrazinamide is a commonly used first-line antitubercular drug. Gastric-related adverse drug reactions are common with pyrazinamide. Dermatological manifestations due to pyrazinamide are rare. This study aimed find out the dermatological manifestations/adverse drug reaction (ADR) due to pyrazinamide. We reported a case of maculopapular rash caused by pyrazinamide in a patient on antituberculosis treatment using structured questionnaires. The patient developed maculopapular rashes on receiving combination antituberculosis treatment. The rashes disappeared after stopping the suspected drug. The patient was rechallenged with pyrazinamide, which led to reappearance of a similar type of rash. The causality, preventability, and severity were assessed using the Naranjo algorithm and Hartwig scale. Since pyrazinamide is a commonly used drug in tuberculosis and which is a common infectious disease in developing countries, with the similar reports, we can predict early case detection and can prevent the occurrence of similar reactions in future.

A retrospective study of seasonal variation in the number of cases diagnosed at a tertiary care tuberculosis hospital

OBJECTIVE

To study the seasonality of tuberculosis (TB) in a tertiary care tuberculosis and respiratory hospital in Delhi.

METHODS

Data from a tertiary care respiratory hospital in south Delhi over a six years period from April 2002 to March 2008 were analysed.

RESULTS

Symptomatics: A total of 192,863 patients were registered newly in the hospital during this period. Maximum number of symptomatic patients reported to the out-patient department during April-June and the minimum during October-December. An increase of about 25% in symptomatics was observed (p < 0.05) in the period from April to June in comparison to October to December. The amplitude of seasonal variation was estimated as 11% of the annual mean symptomatics. Tuberculosis cases: The maximum sputum-positive TB cases were diagnosed during the period from April to June and the number was least during October to December. There was an increase of about 34% in sputum-positive cases (p < 0.001) during the period from April to June against October to December. The amplitude of seasonal variation was estimated as 14.4% of the annual mean smear-positives per quarter. The extra-pulmonary TB (EPTB) cases were the maximum during April-June. Chest symptomatics of all types of TB cases were the lowest in January.

CONCLUSIONS

A seasonal pattern of TB was observed for pulmonary TB and EPTB cases. This information would be useful for administration and managers to take extra care to arrange and provide extra facilities during the peak seasons.

Prevalence of XDR TB cases--a retrospective study from a tertiary care TB hospital

BACKGROUND

The emergence of XDR -TB strains is a major roadblock in the successful implementation of TB control programmes. This further leads to high morbidity and mortality, especially in immuno-compromised patients. Identification and observation of resistance patterns of XDR-TB strains may help clinicians manage MDR-TB cases, the treatment line of which is expensive, time-taking and involves intake of toxic drugs with many side-effects. Our study is aimed to find out the prevalence of XDR-TB among the MDR-TB strains isolated in a tertiary care hospital.

MATERIAL & METHODS

The study population consisted of 223 patients of tuberculosis who were culture positive and Mycobacterium tuberculosis was resistant to Rifampicin and Isoniazid during January 2007 to December 2009. Each patient had submitted two sputum samples i.e. spot and morning. The identified Mycobacterium tuberculosis complex was subjected to drug sensitivity testing by first and second line drugs by proportion and absolute concentration methods as per standard procedure.

RESULTS

The results showed that 20.17% strains (45/223) were XDR-TB strains. Most of these strains showed resistance to four drug combination viz. KM, ETH, OFX & PAS (5.82%), KM & OFX (3.13%), OFX, KM and ETH (1.79%), 1.34% strains showed resistance to all the drugs i.e. pan resistance and other combinations in the remaining strains. Nearly 80% of the XDR-TB strains showed resistance to three or more drugs combination pattern.

CONCLUSION

The multidrug resistant TB cases need urgent and timely sensitivity report for second line ATT drugs to help clinicians start proper drug combinations to treat MDR-TB patients.

Smear microscopy as surrogate for culture during follow up of pulmonary MDR-TB patients on DOTS Plus treatment

BACKGROUND

DOTS Plus site at LRS Institute, New Delhi, covering 1.8 million population.

AIMS

To ascertain if sputum smear could be used as a surrogate for culture during intensive phase of treatment of MDR-TB patients thereby enabling early shift from intensive phase to continuation phase, reducing the need for frequent cultures and saving time and cost in their management.

METHODS

The study is a retrospective analysis of 138 MDR-TB patients on DOTS Plus treatment whose sputum samples were simultaneously subjected to smear microscopy and culture, monthly during Intensive Phase and once in two months during Continuation Phase. Sputum results in the treatment card were supplemented from laboratory register, if required, and analyzed. Predictive values, sensitivity and specificity of smear were compared with culture results.

RESULTS

The Negative Predictive Value (NPV) of smear was high from the 3rd month onwards (above 91%), at four months 98% or more and approached 100% from eight months onwards. The specificity of smear test gradually increased during treatment and from five months onwards, it was above 90%.

CONCLUSIONS

Considerable correlation was observed between sputum smear and culture during follow up of DOTS Plus treatment in the Intensive Phase. Accordingly, sputum smears can be recommended instead of culture.

Tuberculosis pneumonia as a primary cause of respiratory failure--report of two cases

Tuberculosis (TB) is one of the treatable diseases rarely causing Acute Respiratory Failure (ARF). Hypoxic respiratory failure is often fatal in miliary tuberculosis and acute tuberculous bronchopneumonia. We describe two patients of tuberculous pneumonia with ARF who were successfully treated with early appropriate anti-tuberculosis therapy.

Clinical profile and treatment outcome of tuberculous lymphadenitis in children using DOTS strategy

BACKGROUND

Extra pulmonary TB (EPTB) including tuberculous lymphadenitis is becoming more common probably due to human immuno deficiency virus (HIV) co-infection. While children do experience a high TB related morbidity and mortality, management of TB in children is challenging. The present study was designed to study the treatment outcome of DOTS strategy for pediatric tuberculous lymphadenitis.

OBJECTIVE

To study the efficacy of DOTS strategy for pediatric lymphhnode tuberculosis.

METHODS

Retrospective analysis of 669 children of lymphnode tuberculosis treated with DOTS strategy over 9 1/2 years.

RESULTS

Mean age was 9.8 years with significantly more girls (61.3%) than boys (38.7%) {chi2=34.08, P<0.001 (S)}. Most of the patients were in the age group of 11-14 years (48.0%) followed by 6-10 years (34.5%) and 0-5 years (17.5%) respectively. Cervical tuberculous lymphadenitis (88.2%) was the commonest form for all ages followed by axillary lymphadenitis in 3.3%. TB of other sites was seen in only 57 (8.5%) cases. Out of total 622 (93%) cases of lymphnode TB where fine needle aspiration and/or excisional biopsy was done, it was positive (84.2%) and negative (15.6%) respectively for AFB/cytology, while it could not be done in 47 patients due to inaccessible sites. Category I, II and III was started on 15.4%, 7.5% and 77.1% patients respectively. Overall, treatment completion rate was 94.9% and the default rate was 2.2% with a failure rate of 2.5%. Death rate was 0.3%.

CONCLUSION

The study confirms the efficacy of DOTS strategy for pediatric TB lymphadenitis.

Clinical profile and treatment outcome of tubercular pleurisy in pediatric age group using DOTS strategy

BACKGROUND

A significant proportion of global tuberculosis (TB) caseload is contributed by children. Management of pediatric TB especially EPTB is challenging. The present study was designed to study demographic, clinical profile and treatment outcome of DOTS strategy for pediatric tubercular pleurisy.

AIM

To study the efficacy of DOTS strategy.

METHODS

Retrospective analysis of 106 TB pleurisy children treated with DOTS.

RESULTS

Mean age was 10.8 years (median age 12.2 years) with more females (51.9%) than males (48.1%) chi1(2) = 0.15; P = 0.698 (NS). In the age group of 0-5, 6-10 and 11-14 years, there were 15.1%, 30.2% and 54.7% patients respectively. Fever was the commonest symptom (98.1%) followed by cough (77.4%) and chest pain (55.7%). History of contact could be elicited only in 2/3rd of cases unilateral effusion (61.3%) was commonest, followed by empyema (22.6%), massive effusion and broncho-pleural fistula each in 13.2% cases respectively. Bilateral effusion was seen in 3.8% cases only. Conventional methods (mantoux, radiograph, ultrasound, pleural aspiration) and minimal invasive surgical techniques, percutaneous pleural biopsy were done to arrive at the diagnosis. Diagnosis was made by X-ray Chest in 92.5%, exudative pleural fluid (100%) predominantly lymphocytic in 85.8%, positive AFB smear and culture in 4.7 and 5.7% cases respectively. Category I, II and III was started on 35.9%, 2.8% and 61.3% patients respectively. Overall treatment completion rate was 94.3%, 4.7% default rate, 0.9% failure rate and no deaths.

CONCLUSION

The study confirms early detection by simple tests and ensuring complete treatment using DOTS strategy.

Seven-year DOTS-Plus pilot experience in India: results, constraints and issues

BACKGROUND

India is initiating the DOTS-Plus strategy at the national level.

OBJECTIVES

To highlight the results, constraints and issues of a pilot DOTS-Plus experience in an urban setting in India.

METHODS

Records of 126 patients with multidrug-resistant tuberculosis (MDR-TB) enrolled from January 2002 to December 2006, who received a daily fully supervised standardised treatment regimen under a pilot DOTS-Plus study in India, were analysed retrospectively.

RESULTS

Of the 126 patients enrolled, 61% were cured, 19% died, 18% defaulted and 3% failed treatment. There was an average delay of 5 months in the diagnosis of MDR-TB and a subsequent delay of approximately 3.3 months in initiating treatment. Of the 24 patients who died, 29% did so within a month of starting treatment. Migration was the most common reason for default. Cycloserine (CYC) had to be stopped in 15 patients and kanamycin (KM) in five due to major adverse effects.

CONCLUSIONS

The DOTS-Plus programme in resource-poor settings may provide reasonable results; however, it may confront significant operational difficulties in the timely diagnosis and early initiation of treatment. Early diagnosis and start of treatment may prevent some deaths. Default is commonly due to migration. CYC proved to be the most toxic drug, followed by KM.

Risk factors for new pulmonary tuberculosis patients failing treatment under the Revised National Tuberculosis Control Programme, India

SETTING

Tertiary level tuberculosis (TB) institute in Delhi, India.

OBJECTIVE

To study the risk factors for new pulmonary TB (PTB) patients failing treatment.

DESIGN

Prospective case-control study. The profile of new PTB patients failing treatment (i.e., sputum smear-positive at 5 months of treatment) and responders under the Revised National Tuberculosis Control Programme (RNTCP) were compared and risk factors associated with treatment failure were analysed.

RESULTS

A total of 42 treatment failure cases and 76 controls were enrolled in the study. The presence of cavity on chest X-ray (CXR), sputum acid-fast bacilli (AFB) smear positivity at 2 months of treatment and the number of interruptions in treatment were independently associated with failures. Among failure patients at 5 months, 17 (40.5%) had negative sputum culture for Mycobacterium tuberculosis, and only six (14.3%) had multidrug-resistant TB (MDR-TB). When put on retreatment, patients with smear-positive, culture-negative sputum had cure rates of 88.2% compared to 28.6% among culture-positive patients.

CONCLUSIONS

The presence of cavity on CXR, sputum smear positivity at 2 months of treatment and the number of interruptions of treatment are risk factors for failure. Among failures based on smear examination, the prevalence of MDR-TB is low and many patients have negative cultures for M. tuberculosis. Smear positivity at the end of treatment may not be a reliable indicator of treatment failure.

Avoidance of allergens by the patients with bronchial asthma

OBJECTIVES

Association between environmental allergens and bronchial asthma is well established. A great number of substances found in the environment can precipitate or aggravate respiratory symptoms in asthmatics. Avoiding allergens is recognized as an integral part of management. Through various educational interventions the patients can be taught various measures to avoid these allergens. The present study was undertaken to evaluate the impact of 'self care manual' an educational intervention on the avoidance of various environmental allergens.

METHODS

The total enrolled patients were 523 of which 260 were included in the study group to whom 'self care manual' was given and 263 in the control group with no access to self care manual. A fourteen items interview schedule consisting of three parts was administered. The first two subparts were in the form of checklist to know the various allergens which were inducing symptoms in the patients and weather they could avoid these triggers. The third part which was open ended was administered to know their ways of avoiding these triggers. All the patients were followed up at 2 weeks, 6 months and at 1 year.

RESULT

Mean age of the subjects in both the groups was 36.72 +/- 11.52 years and 34.33 +/- 12.86 years respectively. Both the groups were comparable on majority of the socio-demographic variables. The number of patients whose symptoms were aggravated by a particular triggering factor reduced significantly on each successive visit in the study group. Almost all the patients started avoiding their triggers in follow-ups in the study group. In control group this change was only for few triggers. More and more patients started using inhalers on exposure to dust or triggering weather conditions. They started slowing down for exercises and diverted their attentions against triggering emotional situations.

CONCLUSION

Patient education should be an essential component in the overall management of bronchial asthma. Control of asthma symptoms is better achieved with avoidance of allergens. This can be accomplished by emphasizing these facts particularly with the use of self care manuals.