High mortality in adults hospitalized for active tuberculosis in a low HIV prevalence setting.

BACKGROUND: This study aims to evaluate the outcomes of adults hospitalized for tuberculosis in a higher-income region with low HIV prevalence. METHODS: A retrospective cohort study was conducted on all adults hospitalized for pulmonary and/or extrapulmonary tuberculosis in an acute-care hospital in Hong Kong during a two-year period. Microscopy and solid-medium culture were routinely performed. The diagnosis of tuberculosis was made by: (1) positive culture of M. tuberculosis, (2) positive M. tuberculosis PCR result, (3) histology findings of tuberculosis infection, and/or (4) typical clinico-radiological manifestations of tuberculosis which resolved after anti-TB treatment, in the absence of alternative diagnoses. Time to treatment ('early', started during initial admission; 'late', subsequent periods), reasons for delay, and short- and long-term survival were analyzed. RESULTS: Altogether 349 patients were studied [median(IQR) age 62(48-77) years; non-HIV immunocompromised conditions 36.7%; HIV/AIDS 2.0%]. 57.9%, 16.3%, and 25.8% had pulmonary, extrapulmonary, and pulmonary-extrapulmonary tuberculosis respectively. 58.2% was smear-negative; 0.6% multidrug-resistant. 43.4% developed hypoxemia. Crude 90-day and 1-year all-cause mortality was 13.8% and 24.1% respectively. 57.6% and 35.8% received 'early' and 'late' treatment respectively, latter mostly culture-guided [median(IQR) intervals, 5(3-9) vs. 43(25-61) days]. Diagnosis was unknown before death in 6.6%. Smear-negativity, malignancy, chronic lung diseases, and prior exposure to fluoroquinolones (adjusted-OR 10.6, 95%CI 1.3-85.2) delayed diagnosis of tuberculosis. Failure to receive 'early' treatment independently predicted higher mortality (Cox-model, adjusted-HR 1.8, 95%CI 1.1-3.0). CONCLUSIONS: Mortality of hospitalized tuberculosis patients is high. Newer approaches incorporating methods for rapid diagnosis and initiation of anti-tuberculous treatment are urgently required to improve outcomes.

Clinical and microbiological characteristics of urine culture-confirmed genitourinary tuberculosis at medical centers in Taiwan from 1995 to 2007.

All patients with urine culture-confirmed genitourinary tuberculosis (GUTB) diagnosed between 1995 and 2007 at two medical centers in northern Taiwan were included in this retrospective study. Genotypes of 48 preserved Mycobacterium tuberculosis (MTB) isolates from these patients were determined by spoligotyping and double repetitive element PCR (DRE-PCR) analysis. Among the 64 patients, 38 (59.4%) were male with a mean ±SD age of 60.3 ± 16.1 years old. The overall mortality rate was 26.2%. Poor prognostic factors included age over 65 years (HR = 4.03; 95%; CI: 1.27-12.76), cardiovascular disease (HR = 5.96; 95% CI: 1.98-17.92), receiving steroids (HR = 10.16; 95% CI: 2.27-45.47), not being treated (HR 4.81; 95% CI 1.12-20.67). Spoligotyping and DRE-PCR of the 48 MTB isolates revealed that 20 (41.7%) belonged to the Beijing family and 40 (83.3%) had a clustering pattern. Identification of a Beijing family isolate was not correlated with drug resistance or mortality. Clustering strains were likely to be resistant to isoniazid (OR = 4.71; 95% CI: 1.10 to 23.53). In this study of patients with urine culture-confirmed GUTB, age and coexisting diseases were independently associated with an unfavorable outcome. The Beijing family was the dominant genotype of GUTB isolates, but did not correlate with drug resistance or outcome.

Urogenital tuberculosis in immunocompromised patients.

OBJECTIVE: Compare the clinicoradiological presentation of urogenital tuberculosis (UGT) between immunocompromised and nonimmunocompromised patients. PATIENTS AND METHODS: Eighty patients diagnosed with UGT were divided into two groups: eight immunocompromised patients (four with acquired immunodeficiency syndrome [AIDS], and four renal transplant patients on immunosuppressive therapy) and 72 nonimmunocompromised patients. The groups were compared as for age, signs and symptoms, diagnostic approach, pattern of urogenital organ involvement, and early specific mortality (within 6 months from diagnosis). RESULTS: AIDS patients were younger (median age 26 years, range 16-38 years), and renal transplant patients were older (median age 51.5 years, range 45-57 years), compared with the nonimmunocompromised subjects (median age 35 years, range 12-75 years). Immunocompromised patients had greater frequency of fever (87.5% versus 43.1%, P = 0.024), lower frequency of storage symptoms (37.5% versus 76.4%, P = 0.033), shorter length of disease (<6 months: 87.5% versus 2.8%, P < 0.001), and larger frequency of disseminated tuberculosis (62.5% versus 18.1%, P = 0.012). Predominantly parenchymatous renal involvement was more frequent in immunocompromised patients (87.5% versus 6.2%, P < 0.001), who also had lower frequency of stenosis of the collecting system (12.5% versus 93.8%, P < 0.001) and contracted bladder (12.5% versus 65.3%, P = 0.001). CONCLUSIONS: UGT has a different clinicoradiological presentation in immunocompromised patients, with predominance of systemic symptoms, disseminated tuberculosis, multiple parenchymatous renal foci, and lower frequency of lesions of the collecting system. In the context of immunosuppression, UGT behaves as a severe bacterial infection, with bacteremia and visceral metastatic foci.

[Choice of surgical correction of urodynamics in ureteral tuberculosis].

To determine an optimal choice of surgical correction of urodynamic disorders and time of its conduction in ureteral tuberculosis, we made a retrospective analysis of 271 case histories of primary patients with tuberculosis of the kidneys who had x-ray picture of ureteral lesions, hydro- or ureterohydronephrosis. We used the following methods of this correction: calycoureteroanastomosis (n = 7, 2.5%), plastic reconstruction of the pelvoureteral segment (n = 9, 3.3%), ureteroureterostomy (n = 6, 2.2%), ureterocystostomy (n = 125, 46.1%), ureteroileoplasty (n = 6, 2.2%), ureteroileocystoplasty (n = 12, 4.4%), intestinal cystoplasty with ureteral transplantation (n = 86, 31.7%). Three-four months was an optimal preoperative preparation (treatment with antituberculous drugs). Long-term administration of the drugs (up to 1 year and longer) and late surgical urodynamic correction leads to complete dysfunction of the kidney which may result in removal of this organ (35%). Palliative operations (cystostomy, nephrostomy, ureterostomy, ureterocutanestomy) often invalidate the patients and degrade quality of their life (n = 20, 7.4%). Only high qualification of the surgeon in reconstructive plastic surgery provides good results of medical rehabilitation.

[Disability in patients with urogenital tuberculosis].

The timely diagnosis of urogenital tuberculosis and the early initiation of specific therapy are an essential prerequisite to the maximum maintenance of function of an affected organ and to a good prognosis of the disease. Analysis of 205 history cases in patients with new-onset urogenital tuberculosis who were examined and treated at our hospital in 1999-2003 has revealed advanced destructive urogenital tuberculosis in 56.1% of cases. The able-bodied patients were 58.05%. Medical examination determined disability group II in 27.8%. The able-bodied patients who were recognized to be disabled were 57.89%. Since the highest disability rates (34.15%) among the patients with new-onset urogenital tuberculosis were observed in the group of the most able-bodied age (41-50 years), this condition inflicts a great economic loss. The true disability rates are higher than those observed by us since some patients undergo medical examination in their local tuberculosis dispensaries and fail to be statistically registered at our hospital.

Reconstructive surgery for treatment of urogenital tuberculosis: 30 years of observation.

Tuberculosis has continued to be a public health problem around the world. The urogenital tuberculosis clinic in the Russian Scientific Research Institute of Phthisiopulmonology was founded in 1950. The development of reconstruction operations for those with urogenital tuberculosis began in 1960. Since then 4298 patients with urogenital tuberculosis have been treated, and 2364 operations have been performed: 885 to remove an organ, 531 to preserve an organ, and 948 for reconstruction. The cases of extrapulmonary tuberculosis in recent years have increased to 6.0%. Surgery for urogenital tuberculosis is performed after specific medical therapy has been tried, but it is difficult, particularly if it is a reconstruction. The clinical features and results of various ureteral neoimplantation procedures using intestinal transplants (ileocystoplasty, sigmoidocystoplasty, cecocystoplasty) are discussed.

The frequency of unsuspected tuberculosis found post-mortem in a geriatric population.

Over a period of 14.5 years, 1911 complete autopsies were performed consecutively in two divisions of the same University Department of Geriatric Care, i.e., the Geriatric Hospital and the Center for Continuous Care. Sixty cases of active tuberculosis were observed, of which 37 cases (mean age of 84.51 years) had been clinically undiagnosed. Comparison with other published series indicate that the risk of unsuspected active (in fact, reactivated) tuberculosis mainly concerns "high age". The conditions which favor the disease are mainly in the context of immunodeficiency. Those which hinder the diagnosis are various, e.g., non-indicative tuberculin test, frequent impossibility to perform eye fundus examination or more aggressive investigations, frequency of cancer, and frequency of dementia in elderly people.

Genitourinary tuberculosis. A study of 1117 cases over a period of 34 years.

One thousand one hundred and seventeen patients with genitourinary tuberculosis who were treated over a period of 34 years have been reviewed. During this time various regimens of treatment were used and have been evaluated. Emphasis is placed on the results of the group on short-course chemotherapy which has been in use since 1970 and is now standard practice. This group has been carefully studied, as the chemotherapeutic combinations are important to developing countries. The clinical response, sterilisation of urine, urinary reversion, drug toxicity and the place of surgery in relation to modern chemotherapy have been discussed and assessed. They show that the results of short-course chemotherapy are satisfactory and confirm that there is no need to extend chemotherapy beyond 4 months, except in unusual circumstances.