Tuberculosis associated with Triplet therapy for lung cancer.

We report the first case of TB associated with triplet therapy (chemotherapy and immunotherapy concurrently) for lung cancer, developing just 44 days after treatment initiation. We feel that several important learning points arise from the discussion that are likely to be very relevant to the broad readership of Thorax, and have important clinical and scientific implications. In the three discussion paragraphs, we highlight that: 1) Triplet therapy is now standard first-line treatment for inoperable lung cancer. 2) TB reactivation is increasingly recognised as an adverse effect of immune checkpoint inhibition, but sending diagnostic samples is critical to avoid a missed diagnosis. 3) These insights from novel cancer immunotherapies are challenging the traditional views of the host-pathogen interaction in TB, with wide implications for future control strategies. We propose that the cases reported in the literature are likely to be the tip of the iceberg as most people with lung cancer managed with antiprogrammed death-1 agents who develop new lung lesions will be treated with standard antibiotics and then palliated when they do not respond.

Lung infections in the HIV-infected adult.

PURPOSE OF REVIEW: This review describes current epidemiology, diagnosis, treatment and prevention of adult HIV-related lung infections using evidence published within the past 2 years. RECENT FINDINGS: Recent evidence has helped better determine the importance of early initiation of antiretroviral therapy in co-infected individuals with advanced immune suppression. Although this has led to a greatly reduced incidence of opportunistic infections in people with HIV, Pneumocystis pneumonia remains common. Pneumonia due to bacterial pathogens, such as Streptococcus pneumoniae, also causes considerable disease burden, but emerging evidence of the clinical efficacy of pneumococcal vaccination, especially conjugated vaccines, offers considerable promise. As HIV-infected populations become older, more emphasis should be given to the potential benefit of influenza prevention, particularly with vaccination, and encouraging smoking cessation. Co-infection with tuberculosis is still a huge problem worldwide, but the recent development and use of simple clinical algorithms based on symptoms and point-of-care testing for recognizing active disease offers great potential. SUMMARY: The lung remains an important site of disease in HIV-infected individuals. Increasing emphasis should be placed upon prevention of infection and modification of risk factors.

Utility of endobronchial ultrasound-guided transbronchial needle aspiration in patients with tuberculous intrathoracic lymphadenopathy: a multicentre study.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as an important tool for the diagnosis and staging of lung cancer but its role in the diagnosis of tuberculous intrathoracic lymphadenopathy has not been established. The aim of this study was to describe the diagnostic utility of EBUS-TBNA in patients with intrathoracic lymphadenopathy due to tuberculosis (TB). METHODS: 156 consecutive patients with isolated intrathoracic TB lymphadenitis were studied across four centres over a 2-year period. Only patients with a confirmed diagnosis or unequivocal clinical and radiological response to antituberculous treatment during follow-up for a minimum of 6 months were included. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, HIV status, pathological findings and microbiological results were recorded. RESULTS: EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). Pathological findings were consistent with TB in 134 patients (86%). Microbiological investigations yielded a positive culture of TB in 74 patients (47%) with a median time to positive culture of 16 days (range 3-84) and identified eight drug-resistant cases (5%). Ten patients (6%) did not have a specific diagnosis following EBUS; four underwent mediastinoscopy which confirmed the diagnosis of TB while six responded to empirical antituberculous therapy. There was one complication requiring an inpatient admission. CONCLUSIONS: EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.