Approach to a Child with Monoarthritis.

Indian J Pediatr. 2010 Sep 7;

Authors: Prabhu AS, Balan S

Arthritis in childhood is common. The pattern, presentation and duration of arthritis help differentiate between the various possible diagnoses. When only one joint is involved, i.e., monoarthritis, it may be difficult to make a diagnosis as there are many possibilities both acute and chronic in nature. A detailed history and clinical examination is important to reach a correct diagnosis and the single most important investigation when a child presents acutely is a joint aspiration to rule out septic arthritis that may destroy the joint in hours. Inflammatory markers, antinuclear antibody testing, test for tuberculosis and imaging (in specific cases) play an important role in the diagnosis of a child that presents with a chronic monoarthritis. In this article we provide a clinical approach to the diagnosis of monoarthritis in a child.

PMID: 20821284 [PubMed - as supplied by publisher]

[Prevalence of HIV-TB co-infection and impact of HIV infection on pulmonary tuberculosis outcome in Togo.]

Bull Soc Pathol Exot. 2010 Sep 4;

Authors: Dagnra AY, Adjoh K, Tchaptchet Heunda S, Patassi AA, Sadzo Hetsu D, Awokou F, Tidjani O

The aim of this study was to determine the prevalence of HIV infection in tuberculosis patients and its impact on the TB treatment. We enrolled 569 pulmonary TB patients in four diagnosis and treatment centres in Togo. All patients were new TB cases and received the first-line TB drugs: two months of rifampicinpyrazinamide- isoniazid-ethambutol and six months of isoniazid-ethambutol. HIV testing was done according to the national guidelines, using rapid diagnosis tests. The CD4 lymphocyte counting was performed by Facscalibur (BD, Sciences) for all HIV-positive patients. Of the 569 TB patients enrolled, 135 (23.7%) were HIV positive (TB/HIV+). HIV prevalence was 22.4% (76 of 339) among men and 25.6% (59 of 230) among women without statistical difference. The global rate of treatment success was 82.2%. The rate of treatment success was lower (64.3%) in TB/HIV+ patients than in TB/HIV- patients (87.5%) (p <0.01). The mortality rates were 25.6% and 11.8% in TB/HIV+ patients and TB/HIV- patients, respectively, with a statistically significant difference (p <0.01). We did not found any statistical difference between the rates of treatment success among TB/HIV- (87.5%) patients and TB/HIV+ patients who had TCD4 lymphocyte counts above 200/mul (84.4%). TB program in Togo must take into account HIV infection to improve its performance.

PMID: 20821178 [PubMed - as supplied by publisher]

Time to detection of the growth of Mycobacterium tuberculosis in MGIT 960 for determining the early bactericidal activity of antituberculosis agents.

Eur J Clin Microbiol Infect Dis. 2010 Sep 4;

Authors: Diacon AH, Maritz JS, Venter A, van Helden PD, Andries K, McNeeley DF, Donald PR

Evaluation of early bactericidal activity (EBA) by the determination of a fall in viable colony-forming units (CFU) of Mycobacterium tuberculosis in sputum is a first step in the clinical study of new antituberculosis agents. The time to detection (TTD) of growth in liquid media is more sensitive and could substitute for CFU counting on solid media. Overnight sputum samples collected during the evaluation of the novel agent TMC207 in comparison to isoniazid and rifampicin were studied. For the determination of CFU, we incubated 10-fold dilutions of homogenized sputum on selective 7H10 agar. The TTD was measured by incubating decontaminated sputum in the BACTEC MGIT 960 system. The fall in bacillary load over 7 days determined by CFU counting closely matched the prolongation of the TTD in the BACTEC MGIT 960 system. The CFU counts correlated significantly with the TTD. While the ranking of agents and different dosages of TMC207 was similar, the highest dose of TMC207 showed markedly better activity when measured by the TTD than CFU counting when compared to the activity of isoniazid. Automated TTD could augment, or, in future, replace, CFU counting to determine sputum bacillary load in EBA clinical trials pending a more formal evaluation of the correlation of the measurements.

PMID: 20820832 [PubMed - as supplied by publisher]

Isoniazid resistance and death in patients with tuberculous meningitis: retrospective cohort study.

BMJ. 2010;341:c4451

Authors: Vinnard C, Winston CA, Wileyto EP, Macgregor RR, Bisson GP

Objective To determine whether initial isoniazid resistance is associated with death during the treatment of tuberculous meningitis. Design Retrospective cohort study. SETTING: National Tuberculosis Surveillance System at the Centers for Disease Control in the United States. Participants Patients with a clinical diagnosis of tuberculous meningitis, reported to the National Tuberculosis Surveillance System between 1 January 1993 and 31 December 2005. MAIN OUTCOME MEASURE: All cause mortality during antituberculous treatment. Results Between 1993 and 2005, 1896 patients had a clinical diagnosis of tuberculous meningitis and positive cultures from any site. In 123 (6%) of these patients, isoniazid resistance was present on initial susceptibility testing. The unadjusted association between initial isoniazid resistance and subsequent death among these 1896 patients did not reach statistical significance (odds ratio 1.38, 95% confidence interval 0.94 to 2.02). However, among 1614 patients with positive cerebrospinal fluid cultures, a significant unadjusted association was found between initial isoniazid resistance and subsequent death (odds ratio 1.61, 1.08 to 2.40). This association increased after adjustment for age, race, sex, and HIV status (odds ratio 2.07, 1.30 to 3.29). Conclusions Isoniazid resistance on initial susceptibility testing was associated with subsequent death among cases of tuberculous meningitis with positive cerebrospinal fluid cultures. Randomised controlled trials are needed to evaluate the optimal empirical regimen for treating patients with tuberculous meningitis who are at high risk for both initial isoniazid resistance and poor clinical outcomes.

PMID: 20819874 [PubMed - as supplied by publisher]

Factors Associated with Multidrug-resistant Tuberculosis: Comparison of Patients Born Inside and Outside of the Czech Republic.

J Int Med Res. 2010;38(3):1156-1163

Authors: Bartu V, Kopecka E, Havelkova M

Multidrug-resistant tuberculosis (MDR-TB) is defined as resistance of Mycobacterium tuberculosis complex (MTB) to at least isoniazid and rifampicin. The aim of this study was to evaluate and compare a cohort of 50 patients with MDR-TB according to birthplace, resistance type, clinical outcome, length of bacteriological positivity of sputum and length of hospitalization. Thirty-three of the patients were born in the Czech Republic (group A) and 17 were immigrants to the Czech Republic (group B). Patients in group B were significantly younger (mean [range] age 33 [19 - 56] years) than those in group A (mean [range] age 48 [33 - 80] years). Primary resistance was present in 16 (48%) cases in group A and in 13 (76%) cases in group B. There were 36 (72%) cured patients, five (10%) remained on treatment and nine (18%) died; no patients failed or transferred out of the study. The mean length of bacteriological positivity of sputum samples was 5.9 months and the mean length of hospitalization was 8.2 months. Resistance to capreomycin was an important predictor of poor outcome.

PMID: 20819455 [PubMed - as supplied by publisher]

Genetic Polymorphisms of Cytochrome P450 and Glutathione S-transferase Associated with Antituberculosis Drug-induced Hepatotoxicity in Chinese Tuberculosis Patients.

J Int Med Res. 2010;38(3):977-986

Authors: Wang T, Yu HT, Wang W, Pan YY, He LX, Wang ZY

This study was designed to investigate the association of genetic polymorphisms of cytochrome P450 subtype 2E1 (CYP2E1) and glutathione S-transferase mu 1 (GSTM1) with susceptibility to antituberculosis drug-induced hepatotoxicity (ADIH) in Chinese tuberculosis patients. All patients were treated with a combination of isoniazid, rifampicin, pyrazinamide and ethambutol. Genomic DNA from 104 patients with ADIH and 111 without ADIH was analysed for the frequency of CYP2E1 RsaI and GSTM1 RsaI genotypes by polymerase chain reaction and restriction fragment length polymorphism. The association of polymorphisms with susceptibility to ADIH was calculated using the chi(2)-test and logistic regression analysis. The CYP2E1 RsaI polymorphisms were significantly associated with ADIH and the c1/c1 genotype was an independent risk factor for ADIH. Compared with the GSTM1 RsaI present genotype, the GSTM1 RsaI null genotype tended to increase susceptibility to ADIH, but the association with ADIH was not significant. The results indicate that CYP2E1 RsaI genotype c1/c1 is a potential risk factor for ADIH in the Chinese population. The tendency of the GSTM1 RsaI null genotype to increase susceptibility to ADIH needs further study.

PMID: 20819434 [PubMed - as supplied by publisher]

Anti-tuberculosis drug resistance in Dohuk, Iraq.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1213-1214

Authors: Merza MA, Farnia P, Masjedi MR, Ridell M

PMID: 20819274 [PubMed - as supplied by publisher]

Predictive values of QuantiFERON(R)-TB Gold testing in screening for tuberculosis disease in asylum seekers.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1209-1211

Authors: Harstad I, Winje BA, Heldal E, Oftung F, Jacobsen GW

Screening with chest X-ray and the Mantoux test (the tuberculin skin test [TST]) is compulsory for adult asylum seekers who arrive in Norway. In 2005-2006, we included 823 asylum seekers in a study of the QuantiFERON(R)-TB Gold test (QFT-G), and followed them for 23-32 months. Eight subjects with a positive and one with a negative QFT-G test were diagnosed with tuberculosis (TB). The positive (PPV) and negative predictive values (NPV) for TB were respectively 3.3% and 99.8%. The PPV was 2.3% and the NPV 99.1% for TST >/= 15 mm, and the NPV was 99.5% for TST >/= 6 mm in combination with a negative QFT-G.

PMID: 20819271 [PubMed - as supplied by publisher]

Feasibility of the T-SPOT(R).TB assay for the immunodiagnosis of smear-positive pulmonary tuberculosis using induced sputum.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1205-1208

Authors: Dilektasli AG, Erdem E, Durukan E, Eyüboğlu FO

Diagnosis of active tuberculosis (TB) remains a challenge. In this a preliminary proof-of-concept study seeking to determine the feasibility of using cells from induced sputum for the immunodiagnosis of pulmonary TB (PTB) in smear-positive cases, a total of 75 subjects with PTB (n = 31) and healthy controls (n = 44) underwent the blood T-SPOT(R).TB test. T-SPOT.TB in induced sputum samples was performed in 29 of 31 TB and 14/44 healthy subjects. Induced sputum T-SPOT.TB results were indeterminate in 72.6% of TB and 100% of healthy subjects. The T-SPOT.TB test in induced sputum samples does not seem a feasible method for diagnosing PTB and needs improvement.

PMID: 20819270 [PubMed - as supplied by publisher]

Beijing family Mycobacterium tuberculosis isolated from throughout Japan: phylogeny and genetic features.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1201-1204

Authors: Maeda S, Wada T, Iwamoto T, Murase Y, Mitarai S, Sugawara I, Kato S

To estimate the current population genetic structure of Mycobacterium tuberculosis in Japan, phylogenetic traits were analysed for 237 Beijing family strains isolated from tuberculosis patients throughout the country. Unlike previous reports from other countries, the ancient Beijing sublineage was predominant throughout Japan. Clustering analysis based on JATA-VNTR (Japan Anti-Tuberculosis Association variable numbers of tandem repeats), a specialised set of VNTR for the discrimination of Japanese M. tuberculosis strains, revealed high similarity of the modern Beijing sublineage strains, irrespective of their geographic origin. JATA-VNTR might be useful for the phylogenetic classification in populations where ancient Beijing strains are frequently isolated.

PMID: 20819269 [PubMed - as supplied by publisher]

The challenge of osteo-articular tuberculosis in the twenty-first century: a 15-year population-based study.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1181-1186

Authors: Lešić AR, Pešut DP, Marković-Denić L, Maksimović J, Cobeljić G, Milošević I, Atkinson HD, Bumbaširević M

SETTING: Serbia, an intermediate tuberculosis (TB) incidence country in socio-economic transition. OBJECTIVE: To examine the epidemiological and clinical pattern of osteo-articular TB (OATB) in Serbia over 15 years. DESIGN: This retrospective observational study included OATB cases diagnosed between 1 January 1993 and 31 December 2007, according to the National Referral Institute of Lung Diseases and TB in Belgrade and the Central TB Register. Population estimates with extrapolations were based on 1991 and 2002 census data. RESULTS: The 295 OATB cases represented 10.9% (range 5.3-20.2) of all extra-pulmonary TB cases notified in Serbia over the period. One tenth of these were relapses. The incidence rate showed a significant increasing trend (y = 0.1167 + 0.0175x, R(2) = 0.3196), with an average age-specific incidence rate of 0.26 per 100 000 population. The peak number of cases was in the 45-64 year age group for both men and women. The average male:female ratio was 0.85. The outcome was favourable for 279 of the 295 patients (94.6%). In addition to a standardised chemotherapy regimen, 25.4% patients underwent surgery. CONCLUSION: The increasing time trend of OATB is caused by increased morbidity, a higher TB detection rate and better notification. Although rare in children, OATB remains a challenge in clinical practice.

PMID: 20819266 [PubMed - as supplied by publisher]

Evaluation of MGIT 960 and the colorimetric-based method for tuberculosis drug susceptibility testing.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1169-1175

Authors: Morcillo N, Imperiale B, Di Giulio B

SETTING: Dr Cetrángolo Hospital, Buenos Aires Province, Argentina. OBJECTIVE: Evaluation of the BACTEC Mycobacteria Growth Indicator Tube (MGIT) 960 system and the colorimetric-based method (CMM) for first- and second-line drug susceptibility testing (FL-DST, SL-DST) against Mycobacterium tuberculosis. DESIGN: FL-DST was studied using SIRE MGIT 960. Minimal inhibitory concentrations (MICs) for isoniazid (INH), streptomycin, rifampicin (RMP), ethambutol (EMB) and levofloxacin (LVX) were also determined by CMM using 3-(4,5-dimethylthiazolyl-2)-2,5-diphenyltetrazolium bromide (MTT). MICs for amikacin (AMK), kanamycin (KM), capreomycin (CPM), ethionamide (ETH), cycloserine, ofloxacin (OFX), linezolide (LZ) and moxifloxacin (MFX) were determined on 94 multidrug-resistant M. tuberculosis isolates by MGIT 960 and CMM. Statistical methods were applied to define drug-susceptible and drug-resistant isolates on the basis of the comparison between results obtained by gold standards. RESULTS: A total of 1626 clinical isolates were studied. Critical drug concentrations could be defined in less than 10 days for both CMM and MGIT 960. CMM was cheaper but more laborious than MGIT 960. The highest performances of both methods were achieved for AMK, RMP, OFX, LZ and MFX, followed by INH, ETH, KM, CPM and LVX (tested only by CMM). CONCLUSIONS: Both methods could be implemented as rapid diagnostic tools to detect drug-resistant isolates in clinical practice.

PMID: 20819264 [PubMed - as supplied by publisher]

Concentration of Mycobacterium tuberculosis from sputum using ligand-coated magnetic beads.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1164-1168

Authors: Wilson S, Lane A, Rosedale R, Stanley C

SETTING: Direct sputum smear microscopy is usually less sensitive than the indirect approach using concentration by centrifugation, but laboratories often do not have access to appropriate equipment. An alternative method of sample concentration has been developed based on magnetic beads coated with a polymeric ligand that binds mycobacteria species. The 'TB-Beads' technology allows manual sample preparation using simple magnetic separation equipment prior to microscopy. OBJECTIVE: 1) To evaluate TB-Beads, in combination with fluorescent auramine staining, on a blind panel of 129 frozen samples from the Special Programme for Research & Training in Tropical Diseases (TDR), the World Health Organization sputum bank; and 2) to compare the microscopy results to indirect microscopy, culture and the clinical data already available on these samples. RESULTS: The correlation between the TB-Beads protocol and indirect microscopy was 96.1% (124/129). The TB-Beads protocol was 89.4% (76/85) sensitive compared to culture and 77.8% (77/99) sensitive compared to clinical diagnosis. CONCLUSION: Capture by magnetic particles yields a concentrated sample that is immobilised over a defined area of the slide, thereby aiding microscopic analysis. TB-Beads allow laboratories that currently perform comparatively insensitive direct microscopy to implement a concentration method that has the potential to improve TB detection rates.

PMID: 20819263 [PubMed - as supplied by publisher]

Association of P2X(7) receptor +1513 (A-->C) polymorphism with tuberculosis in a Punjabi population.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1159-1163

Authors: Sharma S, Kumar V, Khosla R, Kajal N, Sarin B, Sehajpal P

BACKGROUND: Development of tuberculosis (TB) disease is an outcome of complex host-pathogen interactions. The purinergic P2X(7) receptors are adenosine triphosphate gated molecules shown to induce killing of intracellular Mycobacterium tuberculosis, followed by apoptosis of the infected macrophage. A single nucleotide polymorphism in exon 13 of the P2X(7) receptors gene at +1513 position has been shown to abolish the function of this receptor and to be associated with increased susceptibility to TB in some ethnic groups. OBJECTIVE: To explore the association of +1513 (A-->C) polymorphism in TB patients in Punjab, North India. DESIGN: A case-control study was conducted by studying peripheral blood samples from 204 TB patients (181 pulmonary, 23 extra-pulmonary) and 177 controls with no history of TB. P2X(7) +1513 (A-->C) polymorphism was studied using amplification refractory mutation system analysis. RESULT: The distribution of +1513 A/C genotypes in the TB patient and the control groups revealed a statistically significant association with TB (P = 0.002). CONCLUSION: The +1513C allele is a risk factor for the development of TB in the North Indian Punjabi population.

PMID: 20819262 [PubMed - as supplied by publisher]

Pleural fluid cytokines correlate with tissue inflammatory expression in tuberculosis.

Int J Tuberc Lung Dis. 2010 Sep;14(9):1153-1158

Authors: Seiscento M, Vargas FS, Acencio MM, Teixeira LR, Capelozzi VL, Sales RK, Antonangelo L

SETTING: A tertiary care research centre in São Paolo, Brazil. OBJECTIVE: To quantify interleukin (IL) 8, tumour necrosis factor alpha (TNF-alpha), vascular endothelial growth factor (VEGF) and transforming growth factor beta(1) (TGF-beta(1)) in pleural fluid from tuberculous patients, correlating its values with the histopathological patterns in pleural biopsies. DESIGN: Cytokines were quantified in patients with transudates secondary to congestive heart failure (n = 8) and exudates secondary to tuberculosis (TB; n = 39). In parietal pleural biopsies from TB patients, the histological patterns of the inflammatory response were quantified by morphometric analysis (stereological point-counting method). RESULTS: IL-8, TNF-alpha, VEGF and TGF-beta(1) levels were higher in TB than in transudates. A positive correlation existed between components of the fibrinoid exudative phase with pleural fluid IL-8 (R = 0.52, P = 0.004) and VEGF (R = 0.42, P = 0.0021) levels. A negative correlation existed between pleural fluid IL-8 (R = -0.37, P = 0.048) and VEGF (R = -0.44, P = 0.0015) levels with tissue components of fibroproliferation. CONCLUSION: The high pleural levels of TNF-alpha, IL-8, VEGF and TGF-beta(1) suggest the involvement of these cytokines in the TB immunological response. The positive correlation between pleural fluid IL-8 and VEGF with the components of the acute exudative phase and the negative correlation between these cytokines with the fibroproliferative components suggest a temporary inflammatory response in the pleural space.

PMID: 20819261 [PubMed - as supplied by publisher]