Time to initiation of anti-tuberculosis treatment

SETTING

Fairfield Hospital, Victoria, Australia.

OBJECTIVE

To examine delay in initiation of treatment for tuberculosis (TB).

DESIGN

Delay in the initiation of treatment for 142 notified TB patients was examined by a retrospective record review. Particular attention was given to the periods between (1) onset of symptoms and initiation of treatment, and (2) determination of sputum positivity and initiation of treatment. An expert panel nominated 30 days and 3 days as 'acceptable' periods for (1) and (2), respectively.

RESULTS

Only 31% of patients commenced treatment within 30 days of onset of symptoms. This was so for both sputum smear-positive and negative cases, and was not significantly related to the site of infection, referral source, age, gender or ethnicity of the patient. Of patients with smear-positive pulmonary TB, 86% received treatment within 3 days of this result being demonstrated. Those with a delay of greater than 3 days were all investigated by private doctors through private laboratories.

CONCLUSION

There are appreciable delays in initiation of treatment for TB. Measures to combat these unacceptable delays are discussed.

Chronic meningitis due to herpes simplex virus in an immunocompetent host

Herpes simplex virus (HSV) typically causes mucocutaneous disease, encephalitis, and acute men ingitis. There have been no previous reports of chronic meningitis due to this virus. A case of chronic meningitis due to herpes simplex virus type 2 (HSV-2) in a previously healthy 35-year-old woman whose predominant symptoms were headache and meningism without fever is described. Analysis of cerebrospinal fluid (CSF) revealed a lymphocytic pleocytosis, elevated protein, and hypoglycorrhachia. The diagnosis of herpes simplex meningitis was supported by the detection of HSV-2 DNA in CSF by polymerase chain reaction and by intrathecal production of HSV-specific antibody. The patient recovered after treatment with intravenous acyclovir and glucocorticoids.

Travel medicine. 2. Upon return

The volume of international travel and diversity of destinations have increased dramatically in recent decades and continue to grow. The scope and variety of travel related health problems increase accordingly, with 15% to more than 50% of travellers to developing countries reporting some illness. Infections acquired abroad may be acute and life-threatening, requiring urgent, sometimes empirical, intervention. They may also be chronic and associated with late complications, particularly in immigrants, refugees and long term travellers. We present a perspective on and practical approach to the management of illness in returned travellers.

Spotted fever in East Gippsland, Victoria: a previously unrecognised focus of rickettsial infection

A new focus of spotted fever group rickettsial infection has been recognised in East Gippsland, Victoria. Seven cases have been identified among Melbourne residents after they holidayed in the area. The infections were confirmed serologically. The precise identity of the Rickettsia has not been determined.

Postoperative primary adrenal failure in a patient with anticardiolipin antibodies

A 50-year-old woman with no history of thrombosis or recurrent abortions developed pulmonary thromboembolism and bilateral hemorrhagic adrenal infarction with adrenal failure after hysterectomy for uterine fibroids. Anticardiolipin antibodies (aCL) were detected in high titer and have persisted. She remains well, without further thromboses, taking steroid replacement and warfarin anticoagulation. The initial presentation of aCL related disease can be as thrombotic postoperative complications in middle-age.

Chronic meningococcal disease

Chronic meningococcal septicaemia is an unusual and infrequently recognised presentation of disease caused by Neisseria meningitidis. Clinical features are immunologically mediated and include fever, rash and arthritis, which may mimic cutaneous vasculitis or reactive gonococcal arthritis. Diagnosis is difficult to confirm as blood cultures commonly do not grow the organism despite weeks of symptoms. Culture of the organism from the nasopharynx may provide supportive evidence for diagnosis. Chronic meningococcaemia should be considered in the differential diagnosis of a cutaneous vasculitis. In the clinical setting of an undiagnosed fever with vasculitic rash and joint symptoms an empirical trial of intravenously administered penicillin should be considered before steroid therapy as a rapid response may simplify the diagnostic dilemma.

Psittacosis--a review of 135 cases

We reviewed retrospectively 135 cases of serologically-confirmed psittacosis that were admitted to Fairfield Hospital between January 1, 1972 and March 31, 1986. The average age of the patients was 46 years. The majority (85%) of patients described a history of recent exposure to birds. The clinical features, investigations, treatment and subsequent response were analysed in 129 patients. Psittacosis was a well-defined illness that was characterized by an abrupt onset of fever, rigors, sweats, and prominent headache, and a mild dry cough which appeared late frequently. However, respiratory symptoms were absent in 18% of patients. Diarrhoea and sore throat were occasional complaints. Over 90% of cases had an abnormal chest x-ray film, or abnormal chest signs, or a combination of both. Most patients had a normal leukocyte count. Tetracycline drugs were used for treatment in 87% of the patients. Defervescence occurred in 92% of patients after 48 h of tetracycline treatment. There were no recrudescences of psittacosis and no fatalities. The clinical diagnosis of psittacosis can be made early usually, particularly in the presence of pneumonitis on a chest x-ray film and a positive history of bird contact. Treatment with doxycycline (100 mg twice a day for 14 days) is recommended.

Atypical pneumonia: recognition and treatment

While the term "atypical pneumonia" has been in use for many years, it cannot in fact be defined. However, there is a persuasive reason to retain the clinical use of the term, and that is to provide a guide for the clinician in the choice of empirical antibiotic therapy for patients with acute pneumonia. Atypical pneumonia, then, is a descriptive term for a common clinical syndrome. Provided certain clinicoepidemiological groups are excluded, the most common infectious causes of this syndrome are Mycoplasma pneumoniae, Chlamydia psittaci, Coxiella burneti, and Legionella species, but it should be stressed that the syndrome may occasionally be produced by other infectious and non-infectious diseases. Conversely, the atypical pneumonia syndrome occupies only one part of the clinical spectrum of disease that is caused by these organisms. This becomes important when one is selecting antibiotic therapy for patients with other respiratory syndromes, especially those with life-threatening disease. The antimicrobial therapy of the three common causes of atypical pneumonia is discussed in detail.

Enterovirus type 71 infection in Melbourne

Between November 1972 and May 1973, 60 strains of a new enterovirus were isolated from 49 patients investigated at Fairfield Hospital for Communicable Diseases, Melbourne. Of these patients 39 were admitted to hospital with aseptic meningitis (which was accompanied by a rash in 6), 5 others had rash alone, 4 had acute respiratory tract infections, and 1 had infective polyneuritis. A representative strain from this outbreak had the physicochemical properties of an enterovirus but could not be identified with antisera prepared against the prototype polio, coxsackie, and echo viruses. Studies, performed in association with the WHO Collaborating Centre for Virus Reference and Research, Houston, TX, USA, showed the outbreak to be due to enterovirus 71. Most of the epidemic strains required sodium deoxycholate treatment before neutralization could be demonstrated.