Epidemiology of childhood tuberculosis after ceasing universal Bacillus Calmette-Guérin vaccination.

Universal Bacillus Calmette-Guérin (BCG) vaccination is recommended in countries with high tuberculosis (TB) burden. Nevertheless, several countries have ceased universal BCG vaccination over the past 40 years, with scarce comparative epidemiological analyses regarding childhood TB after the policy change. We analysed data on childhood TB in countries that ceased universal BCG vaccination. Data sources included national/international databases, published papers, annual TB reports, and public health authority websites. Childhood TB notification rate increased in one of seven countries with available data. Pulmonary TB and TB lymphadenitis were the main causes of increasing childhood cases, while changes in severe forms of TB cases were minor. Maintaining high vaccine coverage for the target group was a common challenge after shifting selective vaccination. In some countries showing no increase in childhood TB after a BCG policy change, the majority of childhood TB cases were patients from abroad or those with overseas parents; these countries had changed immigration policies during the same period. Heterogeneity in childhood TB epidemiology was observed after ceasing universal BCG vaccination; several factors might obscure the influence of vaccination policy change. Lessons learned from these countries may aid in the development of better BCG vaccination strategies.

Tuberculosis lymphadenitis in Ethiopia.

Tuberculosis (TB) is one of the most serious public health challenges in Ethiopia. Indeed, Ethiopia ranks 7th among 22 countries with a high burden of TB worldwide. Both pulmonary TB and extrapulmonary TB (EPTB) are issues of concern. Ethiopia ranks 3rd in terms of the number of EPTB patients worldwide, with TB lymphadenitis (TBL) being the most common. According to the World Health Organization's Global TB Report 2009, the estimated number of TB patients in Ethiopia was 314,267 in 2007, with an estimated incidence rate of 378 patients per 100,000 population. Furthermore, 36% patients suffered from EPTB, with TBL accounting for 80% of these patients. In Ethiopia, pathological services, culture, and drug susceptibility testing for mycobacterium species are not available as routine tests, not even for cases with suspected infection by drug-resistant strains. Therefore, the management of multidrug-resistant (MDR) TB in Ethiopia is currently unsatisfactory. Against this background, a high index of clinical doubt and timely use of diagnostic methods, prompt confirmation of diagnosis, and early initiation of specific anti-TB treatment are the key factors for the successful management of MDR-TB and TBL in Ethiopia.

[Development of cervical tuberculous lymphadenitis in a patient with Crohn's disease receiving infliximab despite of chemoprophylaxis with isoniazid].

We herein report a case of a 41-year-old female with a 14-year history of Crohn's disease who had been treated with diet and mesalazine. Because of inadequate control, therapy with infliximab was planned. She had a positive result on the interferon-gamma release assay (QuantiFERON TB). After active tuberculosis was ruled out by chest x-ray and computed tomography, she was started on a six-month course of isoniazid 7 weeks prior to starting infliximab. After 10 doses of infliximab (15 months of therapy), she presented with pain of cervical lymphadenopathy. A biopsy of the lymph nodes revealed Langhans giant cells from granulomas and a positive result of polylmerase chain reaction for Mycobacterium tuberculosis. The treatment with infliximab was discontinued and anti-tuberculosis therapy was started. Although treatment for latent tuberculosis infection lowers the risk of reactivation of tuberculosis due to tumor necrosis factor alpha-blockers, it cannot completely inactivate tuberculosis. Despite the completion of chemoprophylaxis, patients receiving such agents should be instructed to watch out for any symptoms associated with pulmonary and extrapulmonary tuberculosis such as fever, cough, malaise, body weight loss, night sweating and lymphadenopathy, and they should also be closely followed up.

[Clinical and morphological features of peripheral lymph node tuberculosis].

Under social, ecological and medical-preventive factors there are changes in the clinical and morphological behavior of peripheral lymph nodes tuberculosis observed. The analysis based on the result of the general clinical inspection, objective examination and cytomorphological investigations. Also, it is significant non-disseminated disease course without evident sings of tuberculous intoxication. The morphological substrate of the peripheral lymph nodes tuberculosis is caseation with or without Koch's bacillus.

Cervical tuberculosis: a decision tree for protecting healthcare workers.

OBJECTIVES/HYPOTHESIS: The clinical presentation of cervical tuberculosis (TB) is a unique challenge to the otolaryngologist. To minimize the risk of nosocomial transmission, otolaryngologists must suspect the diagnosis and be familiar with recommendations for TB prevention. STUDY DESIGN: Scientific review. METHODS: We review current literature and recent changes in TB prevention strategies including the Centers for Disease Control and Prevention "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." RESULTS: Nosocomial transmission may occur from either unrecognized pulmonary disease or from aerosolization of tubercle bacilli during diagnostic procedures. History of prior TB infection, residence in a country where TB is endemic, close contact with a TB patient, or positive tuberculin skin test should raise suspicion of cervical TB. Physical examination findings may include painless, unilateral cervical lymphadenopathy. Children and human immunodeficiency virus infected patients present unique challenges, as these groups may have atypical presentations. When cervical TB is suspected, the provider should always screen for pulmonary and laryngeal disease. Fine needle aspiration with polymerase chain reaction or culture may accurately identify cervical TB. In rare cases, excisional biopsy may be required. CONCLUSIONS: To facilitate interpretation and rapid diagnosis while minimizing risk to health care providers, we provide a decision tree based on new federal guidelines and the clinical experience of a team of infectious disease specialists and otolaryngologists.

Vaccination of white-tailed deer (Odocoileus virginianus) with Mycobacterium bovis bacillus Calmette Guerín.

Wildlife reservoirs of Mycobacterium bovis represent serious obstacles to the eradication of tuberculosis in domestic livestock. In Michigan, USA tuberculous white-tailed deer transmit M. bovis to cattle. One approach in dealing with this wildlife reservoir is to vaccinate deer in order to interrupt the cycle of deer to deer and deer to cattle transmission. Thirty-one white-tailed deer were assigned to one of three groups; 2 SC doses of 10(7)CFU of M. bovis BCG (n=11); 1 SC dose of 10(7)CFU of M. bovis BCG (n=10); or unvaccinated deer (n=10). After vaccination, deer were inoculated intratonsilarly with 300 CFU of virulent M. bovis. Gross lesion severity scores of the medial retropharyngeal lymph node were significantly reduced in deer receiving 2 doses of BCG compared to unvaccinated deer. Vaccinated deer had fewer lymph node granulomas than unvaccinated deer, and most notably, fewer late stage granulomas characterized by coalescent caseonecrotic granulomas containing numerous acid-fast bacilli. BCG was isolated from 7/21 vaccinated deer as long as 249 days after vaccination. In one case BCG was transmitted from a vaccinated deer to an unvaccinated deer. In white-tailed deer BCG provides measurable protection against challenge with virulent M. bovis. However, persistence of vaccine within tissues as well as shedding of BCG from vaccinates remain areas for further investigation.

Tuberculosis treatment default among Brazilian children.

OBJECTIVES: To study the prevalence and time of tuberculosis (TB) treatment default among children and to compare defaulters with those who completed treatment. METHODS: Retrospective cohort study at the Hospital Municipal Jesus, Rio de Janeiro, Brazil, among TB patients aged <15 years followed from 1998 to 2002. The group that completed treatment was compared with those that defaulted. RESULTS: The records of 248 patients were studied. The default rate was 24.2% and was more frequent in the first 2 months of treatment (43.3%) and among those aged <1 year (42.4%). The following variables were associated with default: previous default (relative risk [RR] 1.99, 95%CI 1.12-3.54, P = 0.035), father not living with the child (RR 1.85, 95%CI 1.06-3.21, P = 0.030) and father using illicit drugs (RR 2.93, 95%CI 1.44-5.97, P = 0.002). CONCLUSIONS: Health professionals responsible for treating children with TB should pay special attention to children aged <1 year, those with a history of previous default, and those whose father is absent or an illicit drug user.

[Procedure in case of suspected mycobacterial infection of lymph nodes of the neck. 2. Therapy]. / Vorgehen bei mykobakteriellen Halslymphknoteninfektionen - Teil 2: Therapie.

In the treatment of tuberculosis the patients normally receive a two month daily treatment with Isoniazid, Rifampicin, Pyrazinamid and Ethambutol, followed by a daily treatment with Isoniazid and Rifampicin for four month. The atypical mycobacterial infections can be addressed as a local infection and are amendable to surgical therapy, eventually followed by a daily treatment with antibiotics for four to twelve weeks. In Germany it is obligatory to inform the local public health department about typical mycobacterial infections. Hygiene procedures following German law are discussed in this review.

Tuberculosis in children--what has changed in last 20 years?

Several changes have been observed in the epidemiology, clinical manifestations, diagnostic modalities and treatment of tuberculosis. Emergence of HIV epidemic and drug resistance have posed significant challenges. With increase in number of diseased adults and spread of HIV infection, the infection rates in children are likely to increase. It is estimated that in developing countries the annual risk of tuberculosis infection in children is 2.5%. Nearly 8-20% of the deaths caused by tuberculosis occur in children. Lymph node tuberculosis has increased over last two decades. HIV infected children are at an increased risk of tuberculosis, particularly disseminated disease. In last two decades drug resistant tuberculosis has increased gradually. The rates of drug resistance to any drug varied from 20% to 80% in different geographic regions. Various diagnostic techniques such as improved culture techniques, serodiagnosis, and nucleic acid amplification have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests have desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising advance. Relatively less experience in children, need for technical expertise and high cost are limiting factors for their use in children with tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Treatment with intermittent regimens is comparable to daily regimens. Directly observed treatment strategy have shown encouraging result.

Is fine needle aspiration cytology a useful tool for the diagnosis of tuberculous lymphadenitis?

OBJECTIVE: To study the role of fine needle aspiration cytology (FNAC) in the diagnosis of tuberculous lymphadenitis and find a place for FNAC as laboratory diagnostic method in tuberculosis (TB) control programmes. DESIGN: Prospective laboratory study. METHOD: Duplicate smears from 127 lymph node aspiration were prepared. Both slides were air-dried. Giemsa stain for cytological examination and Ziehl-Neelsen stain for demonstration of acid fast bacillus(AFB) were used and examined by a pathologist and laboratory technologist respectively. SETTING: Tigrai Regional Health Research and Laboratory Centre which is the only unit with microbiological and cytopathological service in the region. SUBJECTS: Patients with one or more enlarged lymph nodes who were sent for FNAC were included. RESULTS: The AFB positivity among the cytologically diagnosed cases of TB lymphadenitis was 56.77%. If we had used culture media for Mycobacterium spp, the positivity would have probably been higher. The positivity rate varied depending on the type of the aspirate. Caseous aspirate showed a higher positivity rate of 60.47% whereas no AFBs were detected in haemorrhagic aspirates. CONCLUSION: This study has demonstrated the usefulness of FNAC in the diagnosis of TB lymphadenitis and the national TB and leprosy control programmes should encompass FNAC as a diagnostic means instead of biopsy which is more invasive and costly.

Human immunodeficiency virus-positive tuberculous lymphadenitis in Central Africa: clinical presentation of 157 cases.

SETTING: University Teaching Hospital, Lusaka, Zambia. OBJECTIVE: To compare the clinical presentation of human immunodeficiency virus (HIV)-positive tuberculous lymphadenitis with primary HIV lymphadenopathy and HIV-negative tuberculous lymphadenitis. DESIGN: Prospective study of patients undergoing diagnostic lymph node biopsy, with details of lymph node distribution, character and size assessed immediately before biopsy. RESULTS: In total, 157 patients with HIV-positive tuberculous lymphadenitis, 71 with primary HIV lymphadenopathy and 28 with HIV-negative tuberculous lymphadenitis were examined. Amongst patients with HIV-positive tuberculous lymphadenitis, lymph node enlargement was symmetrical in 29% (45/157); cervical nodes were enlarged in 99% (155/157), axillary nodes in 82% (128/ 157), epitrochlear nodes in 36% (57/157) and ilioinguinal nodes in 54% (84/157). The size of the largest nodes was 3 cm in 36% (57/157), 2 cm in 24% (37/157) and 1 cm in 6% (10/157). This presentation overlapped with that of primary HIV lymphadenopathy, which was usually a symmetrical polylymphadenopathy with nodes < or = 3 cm in size, and contrasted with that of HIV-negative tuberculous lymphadenitis, which mostly presented with focal, asymmetrical cervical lymphadenopathy. CONCLUSION: Tuberculous lymphadenitis may be more common in HIV-positive African patients with superficial lymphadenopathy than is generally believed. Greater use of lymph node aspiration or biopsy may improve the diagnosis of suspected tuberculosis in Africa.

Cytomorphologic patterns in Calmette Guerin bacillus lymphadenitis.

OBJECTIVE: To study the cytomorphologic patterns of Calmette Guerin bacillus (BCG) lymphadenitis and compare it to those of tuberculous lymphadenitis. STUDY DESIGN: A retrospective cytomorphologic study of 136 cases of clinically diagnosed BCG adenitis. All fine needle aspiration smears of lymphadenitis in the age group 2 months to 2 years during a three-and-half-year period were analyzed. RESULTS: Three distinct cytomorphologic patterns were seen in 112 cases. They were acid-fast bacilli in a necrotic background (62), granulomas with necrosis (47) and granulomas in a reactive lymphoid background (3). CONCLUSION: The cytomorphologic patterns in BCG lymphadenitis were similar to those seen in tuberculous lymphadenitis; however, an exudative response and high acid-fast bacillus positivity was seen more frequently in BCG lymphadenitis. Moreover, Ziehl-Neelsen staining helped to distinguish these cases from pyogenic abscesses.

Immune response profile in patients with active tuberculosis in a BCG vaccinated area.

Tuberculosis patients with pulmonary (N = 95) or lymph node disease (N = 23) were assessed for Th1 responses (PPD skin test and lymphocyte blastogenic and interferon gamma) and Th2 responses (polyclonal and antigen specific IgE). Skin test responses to PPD and lymphocyte proliferative responses to crude mycobacterial antigens (PPD, culture filtrate and sonicate) and recall antigens (tetanus toxoid and streptolysin O) were significantly suppressed (p < 0.001) in patients with pulmonary disease compared to endemic controls. However, mitogen (phytohemagglutinin)-stimulated responses were comparable in patients and controls. Polyclonal and antigen specific (M. tuberculosis culture filtrate) IgE responses which are considered to be surrogate markers for Th2 responses were significantly higher in patients with pulmonary disease compared to healthy endemic controls (Mann Whitney analysis p < 0.01). Patients with lymph node disease showed strong Th1 responses but did not show significant responses for either polyclonal or antigen specific IgE. Thus overall suppression of T cell memory response was observed only in patients with pulmonary disease but not in patients with lymph node disease suggesting that sequestration of antigen in different compartments leads to differential activation of Th1 and Th2 responses. PPD skin test responses were highly positive in endemic controls (47% positive) and household contacts (86% positive). Furthermore, PPD positivity decreased with disease severity. Therefore PPD positivity in a BCG vaccinated TB endemic area cannot be used as a diagnostic marker for active tuberculosis particularly in advanced disease.

Tuberculosis: a re-emerging problem for health care workers.

The current upward trend in the incidence of tuberculosis, particularly in the USA, and the problems of treating multiply drug resistant strains of Mycobacterium tuberculosis have caused a resurgence of interest in this infection. This review describes the microbiology, routes of transmission and epidemiology of Mycobacterium tuberculosis infections. The emergence and problems of treating multiply drug resistant strains are outlined. The significant potential for occupationally acquired infection among health care workers is discussed, together with a summary of the available infection control measures currently being examined. The true level of occupational risk to dental personnel remains uncertain.

[Morbidity and the organization of antiepidemic and prophylactic measures in illness in children in an environment with tuberculosis patients]. / Zabolevamost' i organizatsiia protivoépidemicheskikh i profilakticheskikh meropriiatii pri zabolevanii detei v okruzhenii bol'nykh tuberkulezom.

Data on tuberculosis morbidity rates in children and on main preventive measures (vaccination, revaccination, etc.) in Udmurtia. Over 5 years, the morbidity rates of children contacting with Mycobacterium tuberculosis-isolated and Mycobacterium-nonisolated individuals were 1215.4 and 1432.1, respectively. An analysis of the types of tuberculosis of sick children established that tuberculosis of the intrathoracic lymph nodes was prevalent (63.1%). The children having familial contacts for 6-12 months fell ill more frequently. Timely isolation of children and adolescents at the sanatorium-type institution is of beneficial value among measures for familial focal sanitation, in addition to specific prophylaxis.

[Tuberculosis in young children not vaccinated with BCG]. / Tuberkulez u nevaktsinirovannykh BTsZh detei rannego vozrasta.

Manifestations of tuberculosis infection were studied in 168 infants aged 3 months to 3 years of whom 32.7% had not been given BCG vaccine at birth and 67.3% received improper vaccination (the postvaccinal skin signs were absent in all patients). In 58.9% of the infants, local tuberculosis ran along with complications: dissemination into the lungs and other organs were detected in 44.4%, bronchopulmonary lesions in 42.4%, destruction of lung tissue in 18.2% and tuberculous extrapulmonary lesions in 28.3% of the infants. Specific changes were located in several organs in 9.1%. Tuberculosis of the intrathoracic lymph nodes and primary tuberculosis complex had a complicated course 2.2 times and 3.2 times more frequently, respectively, in BCG unvaccinated than in vaccinated infants. Acute tuberculosis (tuberculous meningitis, miliary and progressive tuberculosis with fatal outcome) in infancy is common in 75-100% of the unvaccinated children. Hence immunoprophylaxis of tuberculosis in newborns must be developed and improved.