What factors may influence epidemiological situation of tuberculosis in Poland and in the world?

The authors present the review of factors influencing epidemiological situation of tuberculosis in Poland and in the world. The groups of increased risk of tuberculosis, and clinical conditions predisposing to activation of latent tuberculosis infection (LTBI) such as HIV, uremia, diabetes mellitus, transplantation of organs, treatment with glucocorticosteroids and with antibodies to TNF and to its receptors, were presented. The higher prevalence and worse prognosis of tuberculosis in elderly people was emphasised. The methods of LTBI recognition, according to recent recommendations, with special consideration to patients in immunosupression, were shown. Methods of treatment to prevent LTBI activation, according to WHO experts, were also presented. All data were discussed in relation to the actual epidemiological situation of tuberculosis in Poland.

Epidemiological situation of tuberculosis in Poland: part II. What are the causes of the different epidemiological situation in various regions of Poland?

INTRODUCTION: The different epidemiological situation of tuberculosis in various regions of Poland (higher and lower notification rates) was described previously by our group. The patients diagnosed with tuberculosis in the higher notification rate areas were younger and there were more cases of primary tuberculosis (tuberculous pleurisy and tuberculosis of chest lymph nodes) than in the patients diagnosed in the lower notification areas. The aim of the present study was to assess the possible causes of the different epidemiological situation of tuberculosis in various regions of Poland. MATERIAL AND METHODS: Analysis was done at the same regions as in the previous paper. A comparison was made between two groups: Group I, which included three voivodeships with higher rates of notification, from 23.7 to 32.3/100,000 (mean rates in the analysed period of time); and Group II, which included five voivodeships with lower notification rates (mean rates from 12.2 to 18.6/100,000). The wealth of the regions (GDP, gross domestic product per capita), the level of unemployment, and social status of the patients were analysed. We compared the population density in both regions. The results of treatment in both regions were also analysed. RESULTS: We did not find any differences in GDP and unemployment rates between the compared regions. The results of treatment were different in particular regions, but there was no clear tendency for worse results in voivodeships in Group I compared to voivodeships in Group II. However, the number of patients lost from observation was significantly higher in the regions from Group I than in those from Group II. There was also a significantly higher death rate from tuberculosis in younger patients (£ 59 years) from Group I than from Group II. This is additional proof that the epidemiological situation in the two regions was different. Finally, we found that the mean density of population in the regions from Group I was higher than that from Group II. The density of population may influence transmission of tuberculosis. There is also the possibility that the differences in the epidemiological situation in various regions of Poland are caused by historical events. In the past the epidemiological situation of tuberculosis was much worse in the east of Europe than in the west. Just after the Second World War, according to the changes of the Polish territory, many Polish citizens (mainly ancestors of those from Group I) were displaced from the east to the west. CONCLUSIONS: In conclusion, the greater number of patients lost from observation, together with the higher density of population in the regions from Group I in comparison with those from Group II, seems to be partly responsible for the difference in the epidemiological situation in the two regions. It is also possible that some patients from Group I are more susceptible to infection and disease caused by Mycobacterium tuberculosis due to their ancestors, who lived in the east of Europe.

The epidemiological situation of tuberculosis in Poland: Part I. According to notification rates, the incidence of tuberculosis varies in different regions of Poland: is this true?

INTRODUCTION: In 2012 the incidence rate of tuberculosis in Poland was 19.6/100,000 but these was great variability between regions concerning notification rates (from 10.9/100,000 to 30.2/100,000). The aim of the study was to assess whether there are elements that might confirm that these differences are true. To answer this question, we compared the population of TB patients from regions with higher notification rates to the population of patients from regions with lower notifications rates. The data collected during three consecutive years were analysed. We selected for comparison the regions with the lowest and highest notification rates and those in which the notification rates for 3 years (2010-2012) were relatively stable. MATERIAL AND METHODS: Eight regions were chosen: three regions (Group I) with high notification rates (from 23.7 to 32.3/100,000 - mean rates in the analysed period of time) and five (Group II) with low notification rates (mean rates from 12.2 to 18.6/100,000). RESULTS: It was found that the proportion of sputum culture-positive patients was significantly higher in Group II. Thus, the difference in the notification rate of cases with culture-confirmed tuberculosis was smaller than the difference in the whole notification rate. Nevertheless, it was still significant. Tubercle bacilli in patients from Group I were significantly more often resistant to one drug. The incidence of chronic fibro-cavernous disease and of tuberculous pneumonia was significantly higher in Group I. The proportion of patients with symptoms was higher in Group I than in Group II. In addition, patients in Group I had the so-called primary tuberculosis (tuberculous pleuritis and tuberculous lymphadenopathy in the chest) significantly more often. It was also found that among patients from Group I there were significantly more children, more (though not significantly) youngsters and significantly fewer elderly patients. CONCLUSIONS: Based on these observations, it was concluded that there is a real difference in the epidemiological situation of tuberculosis in the selected regions of Poland with high and low rates of notification. Possible causes of this situation will be presented in a following publication.

[Extrapulmonary tuberculosis in Poland in the years 1974-2010]. / Gruzlica pozaplucna w Polsce w latach 1974­2010.

INTRODUCTION: The incidence of tuberculosis in Poland decreased from 128.5 in 100 000 in 1970 to 19.1 in 100 000 in 2010. In many countries, but not in Poland, according to the improvement of the epidemiological situation of tuberculosis (TB), the proportion of the extrapulmonary form of this disease is increasing. The aim of this study was to describe changes in extrapulmonary TB epidemiology in Poland from 1974 to 2010. MATERIAL AND METHODS: Retrospective analysis of data from National TB Register on tuberculosis in Poland in the years 1974-2010. The percentage of extrapulmonary tuberculosis among all cases of tuberculosis, the differences in the proportion of extrapulmonary tuberculosis, and differences in various locations of lesions in this form of disease in relation to sex and age groups were assessed. Information was collected from about 626,093 cases of tuberculosis reported to the Register during the period 1972-2010. In 62,251 cases extrapulmonary tuberculosis was the only form of the disease (9.9% of all tuberculosis cases). The study material consisted of 396,344 male and 196,184 female cases; 30,885 subjects were 0-19 years of age, 191,542 were 20-39 years old, 237,256 were 40-59 years old, and 166,410 subjects were ≥ 60 years old. We compared data from the years 1974-1982 with more recent data (2002-2010). The test of proportions for two independent samples was used to assess the significance of differences in proportions. RESULTS: The proportion of extrapulmonary tuberculosis (EPTB) among all TB cases was 11.2% in the years 1974-1982 and only 8.2% in the years 2002-2010. This difference was significant. The proportion of EPTB among all TB cases was higher in women than in men and was higher in people aged 0-19 years than in other age groups. The location of extrapulmonary tuberculosis was different in women and in men. Pleural TB was the most common form of extrapulmonary tuberculosis in both sexes with a predominance of males. Peripheral lymph nodes, bones and joints, urinary, genital, and skin TB were more common in women (these differences were significant). In the youngest age group intrathoracic lymph node TB dominated, and in the older age groups it was pleural TB. In accordance with the increase in age, the proportion of urinary tract, peripheral node, and pericardium TB increased. Central nervous system TB showed no predilection for a particular age group. CONCLUSIONS: The proportion of EPTB to all cases of TB is lower in Poland than in other countries. In addition, the proportion of EPTB had significantly decreased from 1974-1982 to 2002-2010. It may be due to difficulties in diagnosis of those forms of TB in Poland. Alternatively it is possible that those cases diagnosed in non-respiratory centres are not reported to the National TB Register.

Primary Sjögren's Syndrome with two extraglandular sites involvement - case report.

Primary Sjögren's Syndrome (pSS) is a chronic, slowly progressive inflammatory autoimmune disorder, characterised by lymphocytic infiltration of the exocrine glands, leading to decrease of glandular secretion. In 40-60% of pSS patients, extraglandular disease develops. We present the case of a patient with two extraglandular sites involvement in the course of pSS manifesting with progressive respiratory and gastrointestinal symptoms.

[Familial predisposition to chronic obstructive pulmonary disease]. / Rodzinne uwarunkowanie zapadalnosci na przewlekla obturacyjna chorobe pluc.

The role of cigarette smoking in development of chronic obstructive pulmonary disease (COPD) is well known, however only in about 20% of smokers clinical disease was diagnosed. It points to additional factors which influence the sensitivity to tobacco products. Familial clustering of COPD has been observed and genetic deficiency of alpha 1 antitrypsine with ZZ phenotype was proved to be a factor responsible for the early onset of this disease. However only 3% of COPD patients have this deficiency. The role of MZ phenotype of alpha 1 antitrypsine in the development of COPD and in the rate of decline of lung function were discussed. Association studies concerning the polymorphisms of "candidate genes" connected with pathophysiology of COPD were presented. Although some of those studies have shown the role of polymorphism of those genes in COPD, the results are not always reproducible. This may be due to small available population samples with poorly defined COPD phenotype. It is concluded that COPD is a complex disease influenced by multiple genes and environmental factors.

[Comparison of Th1 and Th2 response in the blood of tuberculous patients and healthy contacts]. / Odpowiedz Th1-Th2 u chorych na gruzlice oraz osób zdrowych pozostajacych z nimi w stycznosci.

INTRODUCTION: Th1 response is known to play a dominant role in the resistance to tuberculosis. Nevertheless, IFN gamma levels are frequently increased in tuberculous patients, especially at the site of the disease. It is also possible that the shift toward Th2 response is responsible for the loss of resistance. The aim of this study was to compare the Th1 function of peripheral blood cells and the levels of antimycobacterial antibodies in the serum of culture positive tuberculosis patients and healthy tuberculosis (Tb) contacts. The correlation between the levels of antimycobacterial antibodies and Th1 function of blood cells was also evaluated. MATERIAL AND METHODS: The material consisted of 51 tuberculous patients and 20 healthy persons, close contacts of tuberculosis patients. The ability of peripheral blood cells to secrete IFN gamma and IL-2 was estimated in whole blood cultures with PHA, PWM and tuberculin. The levels of IFN gamma and IL-2 in the supernatants of cultures was estimated via a commercial ELISA test. The levels of antimycobacterial antibodies was measured with commercial immunoenzymatic kits detecting IgG antibodies against 38 kDa + 16 kDa and IgG, IgA and IgM antibodies to 38 kDa + lipoarabinomannan (LAM). RESULTS: No difference was found in the secretion of IFN gamma and IL-2 after stimulation with PHA and PWM between the patients and contacts. The secretion of IFN gamma after stimulation with tuberculin was even greater in tuberculous patients than in contacts. The levels of IgG and IgA (38 kDa + LAM) were higher in tuberculous patients than in contacts. There was a negative correlation between the level of IgG anti 38 kDa + LAM and the ability of peripheral blood cells to secrete IFN gamma after non-specific stimulation in patients with tuberculosis. CONCLUSIONS: Our study confirms the hypothesis that it is not the diminished production of Th1 cytokines, but rather the parallel overproduction of Th2 cytokines, which are essential in the development of tuberculosis.

[Invasive aspergillosis (IA) in patients treated in the Institute of Tuberculosis and Chest Diseases in the years 1993-2005--diagnostic problems]. / Inwazyjna aspergiloza u chorych leczonych w Instytucie Gruzlicy i Chorób Pluc w latach 1993-2005--trudnosci diagnostyczne.

The aim of this study was to present the diagnostic problems in pts treated for invasive aspergillosis (IA) in the IIIrd Clinic of the Institute of Tuberculosis in the years 1993-2005. The material consisted of clinical documentation of 18 pts. 15 out of 18 pts (83,4%) died. In all those cases autopsy examination was done. In 13 pts IA was the main and in another 2 only the accessory cause of death. All pts were treated with corticosteroids and/or cytostatic drugs because of lung cancer (13 pts), haematologic disorders (1 pts), Wegener's granulomatosis (3 pts) and idiopathic pulmonary fibrosis (1 pts). In 13 out of 18 pts granulocytopenia was revealed (on an average from 0,008 x 10(9)/L to 0,95 x 10(9)/L) one month before death. In 13 pts IA was limited to the lungs, in 5 others there were also fungal lesions in brain, kidneys, liver, spleen, pleura, pericardium and heart. Pts with disseminated form of IA had significantly lower granulocyte count and were treated with higher doses of corticosteroids than others. Immunosupressive drugs and granulocytopenia can be regarded as predisposing factors. IA was diagnosed before death only in 5 out of 18 pts. This was mainly caused by the lack of the symptoms of infection (4 pts) and negative results of mycological (6 pts) and serological examination (8 pts). We should underline that mycological examination was only done in 11 pts and serological examination of blood for fungal antigen only in 6 pts. We conclude that mycological infection ought to be searched in all pts treated with high doses of corticosteroids and those with prolonged granulocytopenia, especially if they have the symptoms of infection which does not respond to antibiotic therapy.

[Humoral immune response against mycobacterial antigens in patients with tuberculosis and mycobacterial infections other than tuberculosis]. / Odpowiedz humoralna na antygeny pratka u chorych na gruzlice i mikobakteriozy.

The aim of the study was to compare humoral immune response against various mycobacterial antigens in TB and MOTT vs healthy control group. 350 serum samples from TB patients, 20 samples from MOTT patients and 58 samples from healthy donors were examined. ELISA detecting IgG, IgA and IgM against antigens: 38 kDa and 16 kDa, 38kDa and lipoarabinomannan, and A-60 were used. Mean IgG level was higher in TB compared to healthy controls (p<0,001). Mean IgG level against 38kDa and 38 + 16 kDa mycobacterial antigens was higher in TB than in MOTT group. Mean level of the IgG, IgA and IgM antibodies against LAM was higher in MOTT compared to TB patients. In all subgroups person-to-person heterogeneity of antigen recognition was observed. Humoral immune response to recombinant mycobacterial antigens significantly differs in TB and MOTT patients.

[Mycobacterium kansasii infection in chronic thromboembolic pulmonary hypertension (CTEPH), report of two cases]. / Dwa przypadki mykobakteriozy (M. kansasii) u chorych na przewlekle nadcisnienie plucne zakrzepowo - zatorowym.

Mycobacterium kansasii infection leads to significant morbidity both in immunocompetent and immunocompromised patients. 7 subtypes of M. Kansasii were identified so far. Subtypes 1 and 2 are known to be pathogenic to humans, subtypes 3-7 are commonly isolated from the environment and rarely cause disease. In the present study we report on two cases of chronic thromboembolic pulmonary hypertension (CTEPH) complicated by M. kansasii infection. Disease was recognized according to ATS criteria. Resolution of lesions was observed in both patients in the course of antituberculous treatment. These are to our knowledge the first recognized cases of M. Kansasii infection in CTEPH. Chronic hypoxemia with impaired lung metabolism could be responsible for susceptibility to infection with nonpathogenic subtype 4 of M. Kansasii.

[Neuron-specific enolase (NSE) serum level as a prognostic factor in non-small cell lung cancer]. / Wartosc stezenia neuronoswoistej enolazy (NSE) w surowicy chorych na niedrobnokomórkowego raka pluca w prognozowaniu wyników leczenie cytostatycznego.

The aim of the study was to assess the significance of elevated NSE serum level in NSCLC patients for tumor response to chemotherapy and for survival. The NSE serum level above 12.5 mg/l was regarded as elevated. We found elevated serum level of NSE in 71 of 146 patients (48.6%) at the time of diagnosis of inoperable non-small cell lung cancer, independently to age, sex, performance status and histological type of cancer. All patients were treated using cisplatin based combination chemotherapy. 44 patients were treated with cisplatin/etoposide (group PE), 37 with cisplatin/vinblastine (group PV), 20 with cisplatin/vinorelbine (group PN) and 58 with cisplatin/etoposide/vinblastine (group PEV) combination. In 26.7% partial response and in another 21.2% minimal regression were found after chemotherapy. Partial response was observed in 38% patients with elevated NSE serum level but only in 16% patients with normal NSE serum level and difference was significant (p = 0.0153). Median survival time was 8.5 months for the whole group with no difference according to serum level of NSE. One-year survival rate was 29% and 9 patients survived 24 month or more. We conclude that although the tumor in patients with elevated NSE serum levels regress more frequently than in others it does not influence their survival.

[Prognosis in limited disease (LD) small cell lung cancer (SCLC) patients according to status performance, local extension of lesions, type of treatment and the completeness of staging]. / Rokowanie chorych na ograniczona postac drobnokomórkowego raka pluca w zaleznosci od stanu sprawnosci, lokalnej rozleglosci zmian, sposobu leczenia oraz stopnia precyzji w ustaleniu zaawansowania.

The aim of this study was to assess the prognosis in LD SCLC pts according to their performance status, local extension of lesions, type of treatment and the completeness of staging. In the period 01.01.1986-31.12.1996 in the Institute of Tuberculosis and Chest Diseases 579 consecutive SCLC pts were treated. LD was diagnosed in 345 pts. In 193 out of them the staging was complete that is in addition to chest x-ray, abdomen USG/CT, brain CT/MRI and bilateral bone marrow trepanobiopsy was done. 152 pts were also regarded as limited but the staging was not complete. LD pts proved by complete staging survived significantly longer (median survival 15.7 months) than others (median survival 10.2 months). The pts in whom complete staging was done were however in better performance status and had smaller local extension of lesions and had more often radiotherapy than others. Status performance, local extension of lesions and radiotherapy but also completeness of staging were independent prognostic factors in multivariate analysis.

[Pulmonary mycobacterioses--frequency of occurrence, clinical spectrum and predisposing factors]. / Postaci plucne mykobakterioz--czestosc wystepowania, obrazy kliniczne i czynniki predysponujace.

Various types of non-tuberculous mycobacteria can be the aetiologic factors of chronic lung infections especially in patients with underlying chronic lung diseases. The aim of this study is to present the cases of pulmonary mycobacterioses observed in Institute of Tuberculosis and Lung Diseases in the years 1995-2001. There were 23 patients, 12 men and 11 women in the age between 35-77 years, mean 56 years. 16 out of 23 patients had underlying respiratory problems, mainly healed tuberculosis (7) and COPD (6). Two additional patients suffered from other diseases with potential immunosuppression (leukopenia). In 5 patients no disease other than mycobacteriosis was found, but they were chronic smokers. In 19 cases cough and expectoration of purulent sputum lasting from several months to several years was observed. In 5 patients onset of disease was acute or subacute with high fever. Eight patients had haemoptysis. In chest X-ray pathological lesions including (18 cases) lung cirrhosis (10) and cavities (15) were found. In 4 cases disseminated bronchiectases with small nodules were the main radiologic feature. Mycobacteriosis was caused by M. kansasii in 11 cases, by M. intracellularae in 6, by M. xenopi in 5 and by M. scrofulaceum in 1 case.