Latent tuberculosis in a newborn: diagnostic challenges.

In countries where the incidence of tuberculosis is low, perinatal tuberculosis is seldom diagnosed. With increasing numbers of human immunodeficiency virus-infected people and increasing immigrant population from high tuberculosis incidence countries, one might expect perinatal tuberculosis to become more frequent. Early recognition of newborns at risk for perinatal tuberculosis infection is of utmost importance to prevent disease by chemoprophylaxis. We describe a case of latent perinatal tuberculosis infection in a newborn infected from a mother with extrapulmonary primary tuberculosis. Tuberculin skin test was negative, and latent tuberculosis infection was eventually diagnosed by specific immunological tests. We discuss the difficulties in diagnosis of recent tuberculosis infection in neonates and infants, and the risk factors for vertical transmission of tuberculosis, which need to be taken into account in considering the need for chemoprophylaxis in the newborn. Although perinatal TB infection is a rare condition and diagnosis is difficult due to poor diagnostic testing in pregnancy and newborns, a high index of suspicion is needed to limit the diagnostic delay and to avoid progression to perinatal TB disease.

Tuberculosis transmission and use of methamphetamines in Snohomish County, WA, 1991-2006.

OBJECTIVES: We investigated a cluster of tuberculosis (TB) cases among persons using methamphetamines in Snohomish County, Washington, to determine the extent of the outbreak, examine whether methamphetamine use contributed to TB transmission, and implement strategies to prevent further infections. METHODS: We screened contacts to find and treat persons with TB disease or infection. We then formed a multidisciplinary team to engage substance abuse services partners and implement outreach strategies including novel methods for finding contacts and a system of incentives and enablers to promote finding, screening, and treating patients with TB and their infected contacts. RESULTS: We diagnosed and completed treatment with 10 persons with TB disease. Eight of 9 adult patients and 67% of their adult contacts reported using methamphetamines. Of the 372 contacts, 319 (85.8%) were screened, 80 (25.1%) were infected, 71 (88.8%) started treatment for latent infection, and 57 (80.3%) completed treatment for latent infection. CONCLUSIONS: Collaborative approaches integrating TB control, outreach, incentives, and enablers resulted in high rates of treatment adherence and completion among patients and infected contacts. TB control programs should collaborate with substance abuse programs to address addiction, overcome substance abuse-related barriers to treatment, treat TB, and prevent ongoing transmission.

Molecular epidemiology of pleural and other extrapulmonary tuberculosis: a Maryland state review.

BACKGROUND: Limited information exists about the current epidemiological characteristics of extrapulmonary tuberculosis. However, pleural tuberculosis is usually considered to be a manifestation of primary tuberculosis. Our objective was to use molecular epidemiological techniques to describe the occurrence of pleural and other extrapulmonary tuberculosis in Maryland, a state with moderate tuberculosis incidence. METHODS: We surveyed tuberculosis cases reported with a single site of disease in Maryland from 1996 through 2001. Genotyping of Mycobacterium tuberculosis isolates was performed with an IS6110-based restriction fragment-length polymorphism analysis. DNA clustering of strains with >5 IS6110 bands, with supporting epidemiologic information on patients, served as a proxy for recent transmission. RESULTS: A total of 1811 patients with tuberculosis were reported (incidence, 5.9 cases per 100,000 population). Of 1411 patients (77.9%) with cultures positive for M. tuberculosis, 1246 (88.3%) had a single site of disease, with 934 (75.0%) of these isolates having >5 IS6110 bands. Of the 934 patients included in the analyses, 729 (78.0%) had pulmonary tuberculosis, and 205 (22.0%) had extrapulmonary tuberculosis; of the latter group, 46 patients had pleural disease, and 159 patients had nonrespiratory disease. In multivariate analyses, patients with pleural tuberculosis were not significantly associated with clustered strains, compared with patients with nonrespiratory or pulmonary tuberculosis disease. Having a DNA-clustered strain was negatively associated with nonrespiratory tuberculosis, compared with pulmonary disease (adjusted odds ratio, 0.48; P = .003). CONCLUSIONS: Nonrespiratory extrapulmonary tuberculosis is less likely than pulmonary tuberculosis to be a result of recent infection. Pleural tuberculosis is not an appropriate indicator for recent transmission among our population.

[Current state and related factors in examinations of those who have had contact with tuberculosis].

OBJECTIVE: This study investigated the current conditions of identifying tuberculosis contacts and enforcing their examinations in Public Health Centers and examined related factors. METHODS: The study subjects were 431 index cases with tuberculosis who were newly registered between 1995 and 1997 at four Public Health Centers in Tokyo and Yokohama. Based on case registration card information and interviews with public health nurses in charge, the data of identification of contacts and enforcement of examination of their contacts were collected. RESULTS: The proportion of index cases with insufficient identification of contacts was 28.3%, particularly the non-family contact data being insufficient. From logistic regression analysis: index cases aged 20-39 years; contact with many people; "a moderate risk index of infection" cases; and being homeless were factors significantly related to insufficient identification of contacts. The proportion of contacts who were examined in individual contact examinations was 59.1%, that of mass contact examinations was 80.4%. From logistic regression analysis: negative index cases on sputum smear; and no history of routine health examinations for the past 3 years or a complete lack of information were factors significantly related to insufficient enforcement of individual contact examinations. As to mass contact examinations, not interviewing index cases was a factor significantly related to insufficient enforcement. Further individual and mass contact examinations differed in quality according to Public Health Center. The incidence in close contacts with active tuberculosis was 1.0%, and was especially high in members of the same household and friends of the newly diagnosed. CONCLUSIONS: This study showed that the current contact examinations for tuberculosis are insufficient. In addition it was shown that an adequate identification of contacts and a complete enforcement of contact examinations are urgent needs in Japan.

Mycobacterium tuberculosis miniepidemic in a church gospel choir.

BACKGROUND: Conventional contact investigation and molecular fingerprinting of Mycobacterium tuberculosis isolates in tuberculosis (TB) outbreaks have facilitated recognition as well as application of public health control activities. Singing in a choir as an activity that promotes TB transmission has been occasionally recognized. Such avocational transmission in a middle class community can occur with attendant difficulties encountered in contact investigation. METHODS: Five cases of TB (one index case; three secondary cases; one unassociated case) were identified among members of a famous church gospel choir in Newark, NJ. DNA fingerprinting and susceptibility testing were done on all retrieved strains. Of 306 choir members who had tuberculin tests, 19% were reactors. The presumed outbreak site was investigated. RESULTS: Four of the five patients were tenors, and one was an alto. Tenors were approximately twice as likely to be tuberculin reactors than subjects with other vocal ranges combined (relative risk, 2.04; 95% confidence interval, 1.17 to 3.56). An air ventilation outlet was directly in front of the tenor section. Some limited extra-church activity between choir members may have contributed to transmission. CONCLUSION: Conventional contact investigation must be supplemented by newer techniques, such as DNA fingerprinting, in identifying possible outbreak transmission. Singing, location of a ventilation outlet, and exposure time may have contributed to TB transmission in this outbreak. Transmission need not only be in congregate settings among well-defined socioeconomic groups but may occur unexpectedly in middle class communities.

Clinical spectrum of pulmonary and pleural tuberculosis: a report of 5,480 cases.

The aim of the present study was to investigate the epidemiological, clinical, laboratory and radiological features of patients with active pulmonary tuberculosis (TB) (with or without pleural involvement) or with pleural TB (in the absence of radiological parenchymal disease). A systematic predetermined form, including 60 items regarding the above-mentioned features, was completed for 5,480 patients. Sputum smear and culture data, radiological findings, and additional extrapulmonary involvement were evaluated in the patients with pulmonary TB (n = 5,094). Epidemiological features, and other clinical and laboratory characteristics were investigated in all patients (n = 5,480). TB was more common among persons aged 20-39 yrs, males, and those living in large urban centres in our region. There were 4,268 newly detected patients (78%), and 1,212 active ex-patients (22%) who had history of previous antituberculosis treatment. Additional extrapulmonary involvement was found in 455 patients (9%). Sputum samples were smear-positive in 3,916 (79%), and culture-positive in 3,748 cases (76%). Most common radiological patterns were parenchymal infiltrate in 5,017 (99%), and cavitation in 3,363 (66%). Unusual radiological patterns were also noted, i.e., lower lung field TB (LLFTB) in 317 cases (6.2%), pneumothorax in 78 cases (1.5%), and miliary pattern in 66 cases (1.3%). In conclusion, because of the more frequent occurrence in the younger age group, it is considered that the prevalence of disease is still high and that the transmission of tubercle bacilli is not decreasing in our region. The highest risk group consisted of male subjects and those living in urban centres. The high percentage of active ex-patients suggests that new control programmes for tuberculosis are required in Turkey.

[DNA-fingerprinting and tuberculosis]. / DNA-fingerprinting og tuberkulose.

DNA-fingerprinting or RFLP (Restriction Fragment Length Polymorphism) is a molecular biological technique which allows differentiation between tuberculosis strains. The technique is based on the occurrence of repetitive elements in the mycobacterial genome and is a powerful tool in epidemiological studies. DNA-fingerprinting is also of value in tracking the spread of infection in patients with tuberculosis. The latter is illustrated in two case stories.

Infectiousness of a university student with laryngeal and cavitary tuberculosis. Investigative team.

A search for the source of infection for four children with tuberculosis (TB) identified a university student with cavitary and laryngeal TB. An investigation was conducted at the university, including tuberculin skin test (TST) screening and the use of questionnaires, chest radiographs, and DNA fingerprint analyses of Mycobacterium tuberculosis isolates. Six students with active TB were identified. All were linked to the source case. TSTs were positive for 22.4% of 419 students who had contact with the source case vs. 3.6% of 1,306 students without contact. The odds of a positive TST increased to 9.0 with 80 hours of classroom contact. Infectiousness increased significantly in the last of three semesters during which the source case was symptomatic (RR of a positive TST in classmates, 4.8; 95% CI, 1.8-11.8). TST conversions were documented in 23 students; eight had, at most, 5 hours of classroom contact. The source case was highly infectious; transmission following only a few hours of exposure was documented. Her infectiousness increased as her clinical course progressed. This report illustrates the potential infectiousness of TB cases and demonstrates important aspects of tuberculosis control.

Tuberculosis in a contact.

A 12 year old girl developed a large tuberculous pleural effusion. She was a contact of an adult with pulmonary tuberculosis who was positive on smear testing, and she had been managed in accordance with current British Thoracic Society recommendations.

Tuberculous pleurisy--a family outbreak.

Three female members of a family presented with tuberculous pleurisy over a 4-month period. All three responded to chemotherapy but identification of the source of infection proved difficult.