[Computed tomography with normal chest radiography in childhood tuberculosis]

CT and 18F-FDG PET abnormalities in contacts with recent tuberculosis infections but negative chest X-ray

Close contacts of individuals with pulmonary tuberculosis are at risk for tuberculosis infection and the development of active tuberculosis. In current contact investigations, immunologic tests (the tuberculin skin test and interferon-gamma release assay) and chest X-ray examinations are used to dichotomize contacts with Mycobacterium tuberculosis infections into those with active (X-ray abnormalities) versus latent tuberculosis (normal radiographs). This article is a critical review of computed tomographic (CT) and 18-fluorodeoxyglucose positron emission tomographic (PET) findings of incipient tuberculosis without X-ray abnormalities based on a systematic literature review of twenty-five publications. The CT and 18-fluorodeoxyglucose PET studies revealed minimal pauci-nodular infiltrations in the lung parenchyma and mediastinal lymph nodes abnormalities with metabolic uptake in approximately one-third of asymptomatic close contacts with negative chest radiographic and bacteriological/molecular results for active tuberculosis. Tuberculosis with minimal changes challenge the validity of simply dichotomizing cases of recent M. tuberculosis infections in contacts depending on the presence of X-ray abnormalities as the recent infections may spontaneously regress, remain stagnant, or progress to active tuberculosis in human and nonhuman primate studies. Whether contacts with tuberculosis with minimal changes are interpreted as having active tuberculosis or latent tuberculosis has clinical implications in terms of specific benefits and harms under the current contact management. Advanced imaging tools may help further stratify contacts intensely exposed to M. tuberculosis on a continuous spectrum from latent tuberculosis to incipient, subclinical and active tuberculosis. Identifying incipient tuberculosis would provide an opportunity for earlier and tailored treatment before active tuberculosis is established.

Infliximab plus plasma exchange rescue therapy in Kawasaki disease

OBJECTIVE

To evaluate infliximab (IFX) in patients with Kawasaki disease (KD) that was unresponsive to additional intravenous immunoglobulin (IVIG) therapy and subsequent rescue with supplementary plasma exchange (PE) in patients unresponsive to treatment.

STUDY DESIGN

We studied 76 patients with KD who received IVIG therapy twice and were unresponsive to additional IVIG.

REULTS

Seventy were treated with IFX alone (92.1%). Six patients who were unresponsive IFX (7.9%) were further treated by PE. This resulted in disappearance of fever and other clinical symptoms, and improvement of laboratory data. There was no severe life-threatening adverse events.Twelve of the 76 cases had developed coronary artery dilatation, and 3 had coronary artery aneurysm within 1 month of disease onset. At the end of follow-up, in all cases, coronary artery lesions were suppressed or reversed.

CONCLUSIONS

Treatment of intractable KD with sequential IVIG, IFX, and PE treatments in a step-wise protocol was effective.