Tuberculosis pulmonar asociada a Infliximab: a propósito del primer caso reportado en Cuba / Infliximab-associated pulmonary tuberculosis: regarding the first case reported in Cuba

La terapia con fármacos antagonistas del factor de necrosis tumoral alfa ha sido beneficiosa en el tratamiento de varias enfermedades como las del tejido conectivo e inflamatorias del intestino, pero no está exenta de riesgos. Las principales complicaciones de estas drogas inmunosupresoras son las infecciones, y la tuberculosis pulmonar es una de las principales afecciones, que se pueden observar en los pacientes con este tipo de tratamiento.Se presentó una mujer de 31 años, atendida en el Hospital Clínico Quirúrgico Hermanos Ameijeiras, La Habana, Cuba, con antecedentes de colitis ulcerativa, que hace 3 meses recibe terapia con Infliximab. Acude al hospital por referir 4 días previos al ingreso, fiebre de 390 C dos veces al día, acompañándose de cefalea, pérdida del apetito y dolor en la región perineal. Se le realizó radiografía de tórax, donde se describe radiopacidad heterogénea que va desde el cuerno superior del hilio derecho hasta planos axilares, en la tomografía axial de tórax reportan consolidación en segmento anterior del lóbulo superior derecho con presencia de broncograma aéreo y en el lavado bronquial microbiológico para bacilos ácido-alcohol resistentes se informó codificación 8, positivo a Mycobacterium tuberculosis. El diagnóstico preciso de tuberculosis relacionada con el uso de fármacos antagonistas del factor de necrosis tumoral alfa requiere un alto índice de sospecha y una investigación detallada. Existe un alto grado de complejidad diagnóstica, por la existencia de un amplio espectro clínico y la necesidad de excluir otras enfermedades.

Tumor necrosis factor alpha antagonist drug therapy has been beneficial in the treatment of several diseases such as connective tissue and inflammatory bowel diseases, but it is not without risks. The main complications of these immunosuppressive drugs are infections, and pulmonary tuberculosis is one of the main conditions, which can be observed in patients with this type of treatment. A 31-year-old woman, treated at the Hermanos Ameijeiras Clinical Surgical Hospital, Havana, Cuba, with a history of ulcerative colitis, who has been receiving Infliximab therapy for 3 months, presented. He went to the hospital for referring 4 days prior to admission, a fever of 390 C twice a day, accompanied by headache, loss of appetite and pain in the perineal region. A chest X-ray was performed, which described heterogeneous radiopacity that goes from the upper horn of the right hilum to axillary planes, in the chest axial tomography they report consolidation in the anterior segment of the right upper lobe with the presence of air bronchogram and in the bronchial lavage microbiological for acid-fast bacilli coding 8, positive for mycobacterium tuberculosis was reported. Accurate diagnosis of tuberculosis related to the use of tumor necrosis factor alpha antagonist drugs requires a high index of suspicion and detailed investigation. There is a high degree of diagnostic complexity, due to the existence of a wide clinical spectrum and the need to exclude other diseases.

Intra-Axial Metastatic Angiosarcoma of the Central Nervous System Associated with Anemia, Pulmonary Tuberculosis and Short Survival

Introduction Angiosarcoma (AG) is a malignant mesenchymal neoplasm that predominantly affects the soft tissues and, to variable degrees, expresses themorphological and functional characteristics of the endothelium. The incidence of sarcomas of the central nervous system(CNS) is low (0.5% to 2.7%), and AGs involving the brain are even rarer. Case Description A 45-year-old male patient presented with complaints of headache, nausea, and vomiting. An examination showed bilateral papilledema and a right lung pleurotomy. The patient's previous history included drug addiction, pulmonary tuberculosis, lung abscess, pleural empyema, and pulmonary artery embolization for severe hemoptysis. Computed tomography/magnetic resonance imaging scans revealed a large intra-axial lesion extending into the right parietal and temporal lobes, with hemorrhagic zones. The patient underwent surgical resection of the lesion. Microscopy showed a poorly-differentiated, high-grade malignant tumor composed of plump/epithelioid cells forming small vascular spaces and solid nests, compatible with AG.In the postoperative period, the patient developed recurrent hemoptysis. A biopsy of the tissues adjacent to the pleurotomy determined the diagnosis of pulmonary AG. At 30 days after the resection, the patient died from hemoptysis, hemothorax, lung atelectasis, and intracranial hypertension related to the recurrence of the brain tumor. Conclusion Angiosarcoma is a rare neoplasia related to short survival due to the high proliferative index, which must be considered in patients presenting hemorrhagic tumors. No specific genetic abnormalities have been described for this neoplasia.

Caracterización de la tuberculosis pulmonar en mayores de 15 años. Hospital de Día "Dr. Efrén Jurado López" / Characterization of pulmonary tuberculosis in over 15 years. "Dr. Efrén Jurado López Day Hospital"

La tuberculosis pulmonar constituye una enfermedad de salud pública en el territorio ecuatoriano en expansión que provoca muerte y sufrimiento para la población. El objetivo del estudio es caracterizar la tuberculosis pulmonar en individuos mayores de 15 años que asisten al Hospital de Día "Dr. Efrén Jurado López" de la ciudad de Guayaquil. Se realizó una investigación cuantitativa, descriptiva, retrospectiva. La muestra de estudio quedó conformada por 58 pacientes de ambos géneros mayores de 15 años, diagnosticados con tuberculosis en todas sus formas, atendidos en el contexto de estudio entre enero 2017 y enero de 2018. En la recolección de la información se aplicó una ficha de observación validada por expertos con previo consentimiento informado de los pacientes estudiados. Como resultados se obtuvo que el 72,4% eran del sexo masculino y el 27,6% femenino. El predominio de diagnóstico presentado fue sintomático TBP BK+ en un 100%. Por otra parte para el diagnóstico por TBP cultivo + fue 87,9% (51/58) y TBP cultivo- de 12,1% (7/58). Por otra parte la TB EP fue de 25,9% (15/58) con predominio en el sexo masculino 80%, las formas de tuberculosis y la comorbilidad asociada al al Virus de Inmunodeficiencia Humana (VIH), se observó una frecuencia de 6,9% (4/58) de personas con TB que tenían VIH, de las cuales el 5,2% correspondían a casos de VIH con tuberculosis extra pulmonar y 1,7% a casos de TBP BK+/VIH. Se debe continuar trabajando en la búsqueda de TB en pacientes sintomáticos respiratorios para un diagnóstico oportuno(AU)

Characterization of pulmonary tuberculosis in teenagers older than 15 years in thedr.Efrénjuradolópez day time hospital. Pulmonary tuberculosis is a public health disease in the expanding Ecuadorian territory that causes death and suffering for the population. The objective of the study is to characterize pulmonary tuberculosis in individuals over 15 years of age attending the "Dr. Efrén Jurado López" Day Hospital in the city of Guayaquil. A quantitative, descriptive, retrospective investigation was carried out. The study sample consisted of 58 patients of both genders over 15 years of age, diagnosed with tuberculosis in all its forms, treated in the context of the study between January 2017 and January 2018. A data sheet was applied in the collection of information observation validated by experts with prior informed consent of the patients studied. As a result, it was obtained that 72.4% were male and 27.6% female. The prevalence of diagnosis presented was symptomatic TBP BK + in 100%. On the other hand for the diagnosis by TBP culture + it was 87.9% (51/58) and TBP culture- of 12.1% (7/58). On the other hand, the TB TB was 25.9% (15/58) with a predominance in the male sex 80%, the forms of tuberculosis and the comorbidity associated with the Human Immunodeficiency Virus (HIV), a frequency of 6 was observed, 9% (4/58) of people with TB who had HIV, of which 5.2% corresponded to HIV cases with extra pulmonary tuberculosis and 1.7% to cases of BK + / HIV TBP. Work should continue in the search for TB in symptomatic respiratory patients for a timely diagnosis(AU)

Update on the approach to smoking in patients with respiratory diseases / Atualização na abordagem do tabagismo em pacientes com doenças respiratórias

ABSTRACT Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with "healthy" smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.

RESUMO O tabagismo é o maior responsável pelas doenças respiratórias (DR). Os efeitos nocivos do tabaco sobre o aparelho respiratório se iniciam ainda intraútero e influenciam as respostas imunológicas ao longo da infância e vida adulta. Os tabagistas com DR possuem peculiaridades que podem dificultar a cessação tabágica, tais como maior grau de dependência e de abstinência de nicotina; níveis mais elevados de monóxido de carbono exalado; motivação e autoeficácia baixas; maior preocupação com ganho ponderal; e elevada prevalência de ansiedade e depressão. Além disso, requerem tratamento mais intensivo e prolongado. É necessário esclarecer sempre o paciente sobre o fato de que parar de fumar será a única medida que irá reduzir a progressão das DR e melhorar sua qualidade de vida, independentemente do tempo e da gravidade da doença. Os médicos devem sempre oferecer o tratamento de cessação tabágica. O tratamento ambulatorial ou hospitalar deve ser multidisciplinar, baseado em intervenções comportamentais e farmacoterapia, sendo eficaz e custo-efetivo, dobrando as chances de sucesso.

Tuberculose entre crianças e adolescentes indígenas no Brasil: fatores associados ao óbito e ao abandono do tratamento / Tuberculosis in indigenous children and adolescents in Brazil: factors associated with death and treatment dropout / Tuberculosis entre niños y adolescentes indígenas en Brasil: factores asociados al óbito y al abandono del tratamiento

Resumo: O objetivo deste estudo foi descrever características clínicas e sociodemográficas, estimar a incidência da tuberculose (TB), além de analisar fatores associados ao abandono e ao óbito na vigência do tratamento dos casos de TB notificados entre crianças e adolescentes indígenas, no Brasil, entre 2006-2016. Realizou-se análise da série histórica de incidência, segundo faixa etária e macrorregião e utilizou-se regressão logística multinomial para elucidar fatores associados ao abandono e ao óbito. Do total de 2.096 casos notificados, 88,2% tiveram cura, 7,2% abandonaram o tratamento e 4,6% evoluíram para óbito. Houve predomínio de casos em meninos de 15-19 anos e maior proporção de óbitos (55,7%) em < 4 anos. Considerando o conjunto de crianças e adolescentes indígenas com TB no Brasil, a incidência média foi 49,1/100 mil, variando de 21,5/100 mil a 97,6/100 mil nas regiões Nordeste e Centro-oeste, respectivamente. Os casos com acompanhamento insuficiente e regular tiveram maiores chances de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) e óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Os casos em retratamento (OR = 2,4; IC95%: 2,08-8,55) e com anti-HIV positivo (OR = 8,2; IC95%: 2,2-30,9) também mostraram-se associados ao abandono. As formas clínicas extrapulmonar (OR = 1,8; IC95%: 1,1-3,3) e mista (OR = 5,6; IC95%: 2,8-11,4), os casos em < 4 anos (OR = 3,1; IC95%: 1,5-6,4) e os casos provenientes das regiões Norte (OR = 2,8; IC95%: 1,1-7,1) e Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) mostraram-se associados ao óbito. Acreditamos que o controle da TB em crianças e adolescentes indígenas não poderá ser alcançado sem investimentos em pesquisa e desenvolvimento e sem a redução das desigualdades sociais.

Abstract: The study aimed to describe clinical and sociodemographic characteristics, estimate incidence, and analyze factors associated with dropout and death during treatment of TB cases reported in indigenous children and adolescents in Brazil from 2006 to 2016. A historical case series was performed on incidence according to age bracket and major geographic region, and multinomial logistic regression was used to explain factors associated with treatment dropout and death. Of the 2,096 reported cases, 88.2% evolved to cure, 7.2% dropped out of treatment, and 4.6% evolved to death. There was a predominance of cases in boys 15-19 years of age and a higher proportion of deaths (55.7%) in children < 4 years. Considering indigenous children and adolescents with TB in Brazil as a whole, mean incidence was 49.1/100,000, ranging from 21.5/100,000 to 97.6/100,000 in the Northeast and Central, respectively. Cases with insufficient and irregular follow-up showed higher odds of dropout (OR = 11.1; 95%CI: 5.2-24.8/OR = 4.4; 95%CI: 1.9-10.3) and death (OR = 20.3; 95%CI: 4.9-84.9/OR = 5.1; 95%CI: 1.2-22.7). Cases in retreatment (OR = 2.4; 95%CI: 2.08-8.55) and with HIV coinfection (OR = 8.2; 95%CI: 2.2-30.9) were also associated with dropout. Extrapulmonary (OR = 1.8; 95%CI: 1.1-3.3) and mixed clinical forms (OR = 5.6; 95%CI: 2.8-11.4), age < 4 years (OR = 3.1; 95%CI: 1.5-6.4), and cases from the North (OR = 2.8; 95%CI: 1.1-7.1) and Central (OR = 2.8; 95%CI: 1.1-7.0) were associated with death. TB control in indigenous children and adolescents cannot be achieved without investments in research and development and without reducing social inequalities.

Resumen: El objetivo de este estudio fue describir características clínicas y sociodemográficas, estimar la incidencia de la tuberculosis (TB), además de analizar factores asociados al abandono y al óbito en la vigencia del tratamiento de los casos de TB, notificados entre niños y adolescentes indígenas, en Brasil entre 2006-2016. Se realizó un análisis de la serie histórica de incidencia, según la franja de edad y macrorregión y se utilizó la regresión logística multinomial para elucidar factores asociados al abandono y al óbito. Del total de 2.096 casos notificados, un 88,2% tuvieron cura, un 7,2% abandonaron el tratamiento y un 4,6% evolucionaron hacia óbito. Hubo un predominio de casos en chicos de 15-19 años y mayor proporción de óbitos (55,7%) en < 4 años. Considerando el conjunto de niños y adolescentes indígenas con TB en Brasil, la incidencia media fue 49,1/100.000, variando de 21,5/100.000 a 97,6/100.000 en las regiones Nordeste y Centro-oeste, respectivamente. Los casos con un seguimiento insuficiente y regular tuvieron mayores oportunidades de abandono (OR = 11,1; IC95%: 5,2-24,8/OR = 4,4; IC95%: 1,9-10,3) y óbito (OR = 20,3; IC95%: 4,9-84,9/OR = 5,1; IC95%: 1,2-22,7). Los casos de retorno al tratamiento (OR = 2,4; IC95%: 2,08-8,55) y con anti-VIH positivo (OR = 8,2; IC95%: 2,2-30,9) también se mostraron asociados al abandono. Las formas clínicas extrapulmonares (OR = 1,8; IC95%: 1,1-3,3) y mixta (OR = 5,6; IC95%: 2,8-11,4), los casos en < 4 años (OR = 3,1; IC95%: 1,5-6,4) y los casos procedentes de las regiones Norte (OR = 2,8; IC95%: 1,1-7,1) y Centro-oeste (OR = 2,8; IC95%: 1,1-7,0) se mostraron asociados al óbito. Creemos que el control de la TB en niños y adolescentes indígenas no se podrá alcanzar sin inversiones en investigación y desarrollo y sin la reducción de las desigualdades sociales.

Chest X-ray and chest CT findings in patients diagnosed with pulmonary tuberculosis following solid organ transplantation: a systematic review / Achados de radiografia e de TC de tórax em pacientes transplantados de órgãos sólidos e diagnosticados com tuberculose pulmonar: uma revisão sistemática

ABSTRACT The objective of this systematic review was to select articles including chest X-ray or chest CT findings in patients who developed pulmonary tuberculosis following solid organ transplantation (lung, kidney, or liver). The following search terms were used: "tuberculosis"; "transplants"; "transplantation"; "mycobacterium"; and "lung". The databases used in this review were PubMed and the Brazilian Biblioteca Virtual em Saúde (Virtual Health Library). We selected articles in English, Portuguese, or Spanish, regardless of the year of publication, that met the selection criteria in their title, abstract, or body of text. Articles with no data on chest CT or chest X-ray findings were excluded, as were those not related to solid organ transplantation or pulmonary tuberculosis. We selected 29 articles involving a collective total of 219 patients. The largest samples were in studies conducted in Brazil and South Korea (78 and 35 patients, respectively). The imaging findings were subdivided into five common patterns. The imaging findings varied depending on the transplanted organ in these patients. In liver and lung transplant recipients, the most common pattern was the classic one for pulmonary tuberculosis (cavitation and "tree-in-bud" nodules), which is similar to the findings for pulmonary tuberculosis in the general population. The proportion of cases showing a miliary pattern and lymph node enlargement, which is most similar to the pattern seen in patients coinfected with tuberculosis and HIV, was highest among the kidney transplant recipients. Further studies evaluating clinical data, such as immunosuppression regimens, are needed in order to improve understanding of the distribution of these imaging patterns in this population.

RESUMO O objetivo desta revisão sistemática foi selecionar artigos com achados radiográficos e/ou tomográficos de tórax em pacientes que desenvolveram tuberculose pulmonar após transplante de órgãos sólidos (pulmão, rim ou fígado). Os descritores utilizados para a pesquisa foram: "tuberculosis", "transplants", "transplantation", "mycobacterium" e "lung". As bases de dados utilizadas nesta revisão foram PubMed e Biblioteca Virtual em Saúde. Foram selecionados artigos em inglês, português e espanhol, independentemente do ano de sua publicação, que possuíam em seu título, resumo ou corpo do texto os aspectos selecionados quanto ao objetivo da pesquisa. Foram excluídos artigos sem dados sobre achados de radiografia ou de TC de tórax e aqueles não relacionados com transplantes de órgão sólido ou tuberculose pulmonar. Foram selecionados 29 artigos para o estudo, somando 219 pacientes. As maiores amostras vieram de estudos realizados no Brasil e na Coreia do Sul (78 e 35 pacientes, respectivamente). Os achados de imagem foram subdivididos em cinco padrões mais comuns. Os achados de imagem nesses pacientes variaram dependendo do órgão transplantado. O padrão mais comum foi o clássico para tuberculose pulmonar (escavação e nódulos em árvore em brotamento) nos transplantados de fígado e pulmão, que é similar ao acometimento da doença na população em geral. Transplantados de rim apresentaram um maior número de casos de acometimento miliar e de linfonodomegalia, que é mais similar aos casos de pacientes coinfectados com tuberculose e HIV. Estudos que avaliem dados clínicos, como o esquema farmacológico de imunossupressão, são necessários para um melhor entendimento da distribuição desses padrões de imagem nessa população.

Relationship between climatic factors and air quality with tuberculosis in the Federal District, Brazil, 2003-2012

Abstract Introduction: Despite the high rate of tuberculosis indicators in Brazil, the Federal District shows a low prevalence of the disease. Objective: To analyze the relationship between climatic factors and air quality with tuberculosis in the Brazilian Federal District. Methodology: This was an ecological and descriptive study comparing 3927 new cases of Tuberculosis registered at the Federal District Tuberculosis Control Program with data from the National Institute of Meteorology, Brazilian Institute of Geography and Statistics, Brazilian Agricultural Research Institute, Brasilia Environmental Institute, and the Federal District Planning Company. Results: From 2003 to 2012, there has been a higher incidence of Tuberculosis (27.0%) in male patients in the winter (27.2%). Patients under 15 years of age (28.6%) and older than 64 years (27.1%) were more affected in the fall. For youth and adults (15-64 years), the highest number of cases was reported during winter (44.3%). The disease was prevalent with ultraviolet radiation over 17 MJ/m2 (67.8%; p = <0.001); relative humidity between 31.0% and 69.0% (95.8% of cases; p = <0.00); 12 h of daily sunlight or more (40.6%; p = 0.001); and temperatures between 20 °C and 23 °C (72.4%; p = <0.001). In the city of Taguatinga and surrounding area, pollution levels dropped to 15.2% between 2003 and 2012. Smoke levels decreased to 31.9%. In the Sobradinho region, particulate matter dropped to 13.1% and smoke to 19.3%, coinciding with the reduction of Tuberculosis incidence rates during the same period. Conclusion: The results should guide surveillance actions for Tuberculosis control and elimination and indicate the need to expand observation time to new climate indicators and air quality.

High-resolution computed tomography findings of pulmonary tuberculosis in lung transplant recipients / Achados de tuberculose pulmonar na tomografia computadorizada de alta resolução em transplantados de pulmão

ABSTRACT Objective: Respiratory infections constitute a major cause of morbidity and mortality in solid organ transplant recipients. The incidence of pulmonary tuberculosis is high among such patients. On imaging, tuberculosis has various presentations. Greater understanding of those presentations could reduce the impact of the disease by facilitating early diagnosis. Therefore, we attempted to describe the HRCT patterns of pulmonary tuberculosis in lung transplant recipients. Methods: From two hospitals in southern Brazil, we collected the following data on lung transplant recipients who developed pulmonary tuberculosis: gender; age; symptoms; the lung disease that led to transplantation; HRCT pattern; distribution of findings; time from transplantation to pulmonary tuberculosis; and mortality rate. The HRCT findings were classified as miliary nodules; cavitation and centrilobular nodules with a tree-in-bud pattern; ground-glass attenuation with consolidation; mediastinal lymph node enlargement; or pleural effusion. Results: We evaluated 402 lung transplant recipients, 19 of whom developed pulmonary tuberculosis after transplantation. Among those 19 patients, the most common HRCT patterns were ground-glass attenuation with consolidation (in 42%); cavitation and centrilobular nodules with a tree-in-bud pattern (in 31.5%); and mediastinal lymph node enlargement (in 15.7%). Among the patients with cavitation and centrilobular nodules with a tree-in-bud pattern, the distribution was within the upper lobes in 66.6%. No pleural effusion was observed. Despite treatment, one-year mortality was 47.3%. Conclusions: The predominant HRCT pattern was ground-glass attenuation with consolidation, followed by cavitation and centrilobular nodules with a tree-in-bud pattern. These findings are similar to those reported for immunocompetent patients with pulmonary tuberculosis and considerably different from those reported for AIDS patients with the same disease.

RESUMO Objetivo: As infecções respiratórias constituem a principal causa de morbidade e mortalidade em transplantados de órgãos sólidos. A incidência de tuberculose pulmonar é alta entre esses pacientes. Em exames de imagem, a tuberculose tem diferentes apresentações. Uma maior compreensão dessas apresentações poderia reduzir o impacto da doença ao facilitar o diagnóstico precoce. Portanto, buscamos descrever os padrões de tuberculose pulmonar na TCAR em transplantados de pulmão. Métodos: De dois hospitais no sul do Brasil, foram coletados os seguintes dados sobre transplantados de pulmão que desenvolveram tuberculose pulmonar: sexo; idade; sintomas; doença pulmonar que levou ao transplante; padrão na TCAR; distribuição dos achados; tempo entre transplante e tuberculose pulmonar; e taxa de mortalidade. Os achados na TCAR foram classificados como nódulos miliares; cavitação e nódulos centrolobulares com padrão de árvore em brotamento; atenuação em vidro fosco com consolidação; linfonodomegalia mediastinal; ou derrame pleural. Resultados: Foram avaliados 402 transplantados de pulmão, dos quais 19 desenvolveram tuberculose pulmonar após o transplante. Entre esses 19 pacientes, os padrões mais comuns na TCAR foram atenuação em vidro fosco com consolidação (em 42%); cavitação e nódulos centrolobulares com padrão de árvore em brotamento (em 31,5%); e linfonodomegalia mediastinal (em 15,7%). Entre os pacientes com cavitação e nódulos centrolobulares com padrão de árvore em brotamento, esses achados se distribuíam nos lobos superiores em 66,6%. Não se observou derrame pleural. Apesar do tratamento, a mortalidade em um ano foi de 47,3%. Conclusões: O padrão predominante na TCAR foi atenuação em vidro fosco com consolidação, seguido por cavitação e nódulos centrolobulares com padrão de árvore em brotamento. Esses achados são semelhantes aos relatados para pacientes imunocompetentes com tuberculose pulmonar e consideravelmente diferentes dos relatados para portadores de AIDS com a mesma doença.

Protective effect of metformin against tuberculosis infections in diabetic patients: an observational study of south Indian tertiary healthcare facility

ABSTRACT Background: World Health Organization estimated that people with diabetes (DM) are at 2-3 times higher risk for tuberculosis (TB). Studies have shown that DM not only increases the risk of active TB, but also puts co-affected persons at increased risk of poor outcomes. Objectives: To determine the protective effect of metformin against TB in DM patients and also, to investigate the relationship between poor glycemic control and TB. Methods: A case-control study was conducted over 8 months, where cases and controls were selected based on the inclusion and exclusion criteria of the study. The diabetics diagnosed with TB were selected as study group (SG = 152) and without TB were as control group (CG = 299). Exposure status of metformin in both groups were analyzed. Results: The mean (SD) age of both CG and SG were 55.54 ± 11.82 and 52.80 ± 11.75, respectively. Majority of the subjects in the study were males. The mean hospital stay of SG and CG were 7 days and 6 days, respectively. Poor glycemic control (HbA1c > 8) observed in SG (51.7%) vs CG (31.4%). HbA1c value <7 is associated protective factor for TB occurrence [OR = 0.52 (95% CI 0.29-0.93)]. The protective effect of metformin against TB was 3.9-fold in diabetics (OR = 0.256, 0.16-0.40). Conclusion: Poor glycemic control among diabetics is a risk factor for TB occurrence. The result shows metformin use is a protective agent against TB infection in diabetics. Hence, incorporation of metformin into standard clinical care would offer a therapeutic option for the prevention of TB.

Cenário atual da tuberculose / Current scenario of tuberculosis

Mesmo após 133 anos desde a descoberta do Mycobacterium tuberculosis, a tuberculose continua ser uma das principais causas de morte por doenças infecciosas no mundo, principalmente em países em desenvolvimento.O objetivo deste estudo foi mostrar aspectos relevantes da doença visando uma atualização literária e a busca de um olhar mais atento à problemática da tuberculose no contexto atual. Foram utilizados 130 artigos advindos das bases LILACS, MEDLINE/PUBMED, SCielo, Paho, Biblioteca Cochrane, WHOLIS, IBECS e Scopus, com as principais palavras-chaves selecionadas em terminologia em saúde encontradas no DECS. As espécies pertencentes ao Complexo M. tuberculosis compartilham cerca de 99% de identidade do DNA,com sequências altamente conservadas, mas diferem na distribuição geográfica, patogenicidade e hospedeiros. O mecanismo de resistência clinicamente significativo para rifampicina é uma mutação do gene rpoB, que codifica o alvo desse antibiótico. Há grandes avanços no diagnóstico da TB, com novos instrumentos de biologia molecular e testes rápidos, mas ainda não substituem os métodos clássicos bacteriológicos, apesar de suas conhecidas limitações. Atualmente, a associação de métodos moleculares, principalmente aqueles baseados em reações da PCR tem proporcionado grande impulso nos estudos da epidemiologia molecular do MT. Embora haja uma diminuição do número de casos no mundo, dentre os desafios da doença estão a necessidade de pesquisas na área, envolvimento político para solucionar as questões sociais atribuídas à TB, treinamento permanente dos profissionais e monitoramento de vigilância dos casos para eliminar a doença no cenário mundial.

Even 133 years after the discovery of Mycobacterium tuberculosis, tuberculosis continues to be one of the main causes of death due to infectious diseases worldwide, especially in developing countries. The objective of this study was, after a survey of recent publications, to show issues relevant to the disease and to takea closer look at the tuberculosis problem in the current context. A total of 130 articles were found in the LILACS, MEDLINE/PubMed, SciELO, Paho, Cochrane Library, WHOLIS, IBECS and Scopus databases using the main keywords selected from health terminology of MeSH. Species belonging to the M. tuberculosis complex have highly conserved sequences and share about 99% DNA identity, but differ in their geographic distribution, pathogenicityand host. The clinically significant mechanismof rifampicin resistance is due to a mutation of the rpoB gene which encodes the target of the antibiotic. Great advances in the diagnosis of tuberculosis have occurred, with new molecular biology tools and rapid tests, but without replacing classical bacteriological methods, despite their known limitations. Recently, the association of molecular methods, especially based on PCR, has provided great impetus in molecular epidemiology studies of M. tuberculosis. Although the number of cases in the world has decreased, among the challenges are the need for further research, political involvement to solve social issues linked to tuberculosis, permanent training and the surveillance of cases in order to eliminate the disease on the world stage.

Association of pulmonary tuberculosis and dermatological conditions among patients of a rural medical college hospital.

Introduction. Pulmonary tuberculosis (PTB) affects a significant proportion of the population. There are many contributory aetiological factors common to tuberculosis (TB) and dermatological conditions. Aim. To study the spectrum of concurrent skin conditions in patients with PTB and to compare with patients having other diseases. Methods. All patients with PTB admitted to our Institute during the period of the study were included in the study. A comparable number of patients admitted in other departments constituted the control group. All patients were screened for skin diseases. Results. There were 498 patients in each group, matched for age and gender. There were 126 patients with skin conditions in the study group as against 60 patients in the control group. Pityriasis versicolor was the commonest skin condition in both the groups. Whereas acniform eruptions and pruritis were more common in the control group. Pityriasis versicolor, herpes zoster, erythema nodosum and leprosy were significantly more frequent among patients. Conclusion. There is a high frequency of concurrent skin diseases in patient with PTB that should be managed along with it.

Radiographic patterns in HIV associated pulmonary tuberculosis

To evaluate Radiographic patterns in HIV associated PULMONARY TUBERCULOSIS. Observational, retrospective, descriptive study. This study was conducted in the Department of Infectious Diseases, Civil Hospital, Karachi between July 2008 to April 2009. This study is conducted by reviewing the admission records of 54 HIV diagnosed patients. A total of 30 patients presented with pulmonary symptoms were evaluated by sputum smear for acid fast bacilli [AFB] and chest radiographs. Out of 30 HIV seropositive patients, 29 were male and 1 was female of mean age +/- SD 33.9 +/- 95 years. Sputum staining for acid-fast bacilli was positive in 10 patients [33.3%]. Frequent radiographic patterns were 12 [40%] normal, 5 [16.6%] apical infiltrate, cavitatory lesion was observed in 1 patient. Dominant symptoms were weight loss 29 [93.3%], fever 24 [80%]. Majority of HIV seropositive patients with pulmonary tuberculosis were male, common radiographic patterns were normal radiograph, apical infiltrates atypical radiographic presentation is particularly related in advance stages of immunosuppressant. Cavitatory lesions and pleural effusion were rare findings

Clinical Outcome of Treatment with Infliximab in Crohn's Disease: A Single-Center Experience / 대한소화기학회지

BACKGROUND/AIMS: Our aim was to assess the long-term data regarding efficacy and safety of infliximab (IFX) treatment for refractory Crohn's disease (CD) patients in our tertiary teaching hospital. METHODS: We have retrospectively analyzed the medical records of 89 CD patients who underwent IFX treatment between March 2003 and February 2011 at Kyung Hee University Hospital (Seoul, Korea). The primary outcome measurements were the rates of initial clinical response (CR) at 10 weeks after the 1st IFX infusion and sustained CR at the end of the follow-up. Overall adverse events related to IFX treatment were also evaluated. RESULTS: The mean (SD) follow-up period of eligible 80 patients was 33.7 (21.9) months. A total of 77 patients (96%) showed initial clinical response, but 8 patients showed loss of response to IFX during the follow-up. Finally, 59 patients (59/77, 76.6%) showed sustained CR at the end of the study. Logistic regression analyses showed that an initial CR at 10 weeks was the independent predictor associated with sustained CR (OR 22.286, 95% CI 2.742-132.717, p=0.001). Overall adverse events reported in 18 patients (18/80, 23.3%), including 3 serious infection (pulmonary tuberculosis and herpes zoster). CONCLUSIONS: Treatment with IFX was efficacious and relatively safe for refractory CD patients in Korea. An initial CR at 10 weeks was significantly associated with sustained CR.

Alterações cutâneas no Kwashiorkor: relato de caso de um homem adulto após cirurgia abdominal / Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery

Kwashiorkor é um tipo de desnutrição proteico-energética em que há deficiência dietética de proteína, embora a ingestão de calorias se mantenha adequada. As manifestações cutâneas incluem pele xerótica, com aspecto de esmalte descascado, típica coloração avermelhada a branco-acinzentada dos cabelos, o sinal da bandeira e edema mais evidente, nos membros inferiores e na face, dando aspecto de lua cheia. O presente artigo relata o caso de um paciente adulto, do sexo masculino, previamente submetido à duodenopancreatectomia para tratamento de pancreatite crônica associada ao pseudotumor em cabeça de pâncreas que evoluiu com alterações cutâneas de kwashiorkor após tuberculose pulmonar.

Kwashiorkor is a type of protein-energy malnutrition where diet protein deficit is found, in spite of appropriate caloric intake. Cutaneous manifestations include xerosis, with abnormally dry skin that has a flaking enamel paint aspect, a typical red to gray-white hair color, the "flag sign" and more evident edema in lower limbs and face, giving it a full moon appearance. This article reports a case of a male adult patient who had undergone Whipple surgery for treatment of chronic pancreatitis associated with pseudotumor of the pancreatic head that progressed to cutaneous manifestations of kwashiorkor after pulmonary tuberculosis.

Diferencias en manifestaciones clínicas y gravedad en niños con tuberculosis menores y mayores de 1 año / Differences in clinical manifestations and severity in patients with tuberculosis in children under one year and older

Introducción: Debido a la inmadurez del sistema inmune en los primeros años de vida, la edad sería uno de los factores más importantes que determinaría progreso de infección tuberculosa a enfermedad en individuos inmunocompetentes. Evaluamos si pacientes con tuberculosis menores de un año tienen mayor riesgo de presentar manifestaciones clínicas extrapulmonares y mayor gravedad que los mayores de un año. Población y métodos: Estudio de casos y controles incluyendo niños con tuberculosis menores (n=30) y mayores (n=60) de 1 año de edad. Se analizaron manifestaciones clínicas (pulmonar/extrapulmonar) y gravedad (moderada/grave). Resultados: De acuerdo a la metodología utilizada y al análisis estadístico aplicado, no se encontraron diferencias significativas entre menores y mayores de un año en relación a proporción de manifestaciones extrapulmonares (23,3% vs. 8,3% p=0,09; OR=3,35 IC95=0,81-14,65), ni a la de formas graves (23,3% vs. 8,3%; p=0,09; OR=3,35 IC95%=0,81-14,65). Al excluir pacientes con comorbilidades (n=11) el análisis de la proporción de formas extrapulmonares entre los menores y mayores de 1 año fue el siguiente: 25,9% vs. 7,7% p=0,03; OR=4,2 IC95%=0,93-21,6. Los datos comparativos analizando la gravedad fueron: 25,9% vs. 7,7%; p=0,03; OR=4,2 IC95%=0,93-21,6. Conclusión: No encontramos diferencias significativas en manifestaciones clínicas ni gravedad de tuberculosis entre menores y mayores de un año. Es posible que este hecho se halle influenciado por un tamaño muestral insuficiente, particularmente en pacientes sin comorbilidades.

Introduction: Because of immature cell-mediated immunity in young children, age could be one of the most important factors determining progression of tuberculosis from infection to disease.We evaluated whether children with tuberculosis below one year of age had a greater risk for extrapulmonary or severe tuberculosis than older children.Population and methods: Case-control study including children with tuberculosis below one year of age (n=30) and older children (n=60). We analyzed clinical manifestations (pulmonary/extrapulmonary) and severity (moderate/severe).Results: There were no significant differences in the proportions of extrapulmonary manifestations (23.3% vs. 8.3%; p=0.09; OR=3.35; IC95=0.81-14.65), and the proportions of severe cases (23.3% vs. 8.3%; p=0.09; OR=3.35; IC95=0.81-14.65), between children with tuberculosis younger and older of one year. After controlling for comorbidities (n=11), the proportions of extrapulmonary manifestations between the two age groups were: 25.9% vs. 7.7% (p=0,03; OR=4.2; IC95%=0.93-21.6), and the proportions of severe cases were: 25.9% vs. 7.7% (p=0.03; OR=4.2; IC95%=0,93-21.6). Conclusion: There were no significant differences in prevalence of extrapulmonary manifestations or severe cases between children with tuberculosis younger and older of one year. These findings could be influenced by a limited sample size, especially regarding patients without comorbidities.

Domestic cooking fuel exposure and tuberculosis in Indian women.

Background. A case-controlled study was undertaken to find out the possible relationship of biomass fuel and pulmonary tuberculosis. Methods. Ninety-five non-smoking females with sputum positive tuberculosis (TB) and 109 healthy controls were interviewed using a questionnaire to obtain detailed information on type of fuel used in homes, duration of cooking, passive smoking, location of kitchen, socio-economic status, adequacy of ventilation, number of people per room and respiratory symptoms occurring during cooking. Odds ratio (OR) was ascertained by logistic regression analysis. Results. The cases were from a low socio-economic status and the kitchens used by them were inadequately ventilated. Controls had less smoke accumulation in the rooms while cooking and cases had associated respiratory symptoms more often. Logistic regression analysis revealed that TB was significantly influenced by the location of the kitchen (OR 0.201, 95% confidence interval [CI] 0.08-0.51) and the presence of respiratory symptoms while cooking (OR 10.70, 95% CI 2.90- 39.56). The odds of having TB did not differ significantly among various fuel types either on univariate (OR 0.99, 95% CI 0.45- 2.22) or multivariate analysis (OR 0.60, 95% CI 0.22-1.63). Conclusions. No association was found between type of fuel used and TB. However, low socio-economic status, smoky rooms, location of the kitchen, ventilation and associated respiratory symptoms during cooking are likely to be important contributors.

Perfil epidemiológico de pacientes portadores de TB internados em um hospital de referência na cidade do Rio de Janeiro / Epidemiological profile of hospitalized patients with TB at a referral hospital in the city of Rio de Janeiro, Brazil

OBJETIVO: Analisar o perfil epidemiológico dos pacientes internados em um hospital especializado no tratamento da TB. MÉTODOS: Foi realizado estudo descritivo e retrospectivo dos prontuários dos pacientes internados com TB no Hospital Estadual Santa Maria (HESM), na cidade do Rio de Janeiro, entre janeiro de 2002 e dezembro de 2003, por meio de formulário previamente padronizado. RESULTADOS: Dos 451 pacientes incluídos, 313 (69,4 por cento) foram referenciados para o HESM por unidades de saúde, e 302 (67,0 por cento) eram do gênero masculino. A maioria dos pacientes tinha entre 30 e 59 anos, 443 (98,2 por cento) residiam na região metropolitana, e 298 (66,1 por cento) residiam no município do Rio de Janeiro. O motivo de internação mais frequente foi mau estado geral (em 237, 52,5 por cento). A AIDS foi a comorbidade mais frequente (em 137, 30,4 por cento). Os sinais e sintomas mais frequentes no momento da internação foram emagrecimento, febre e tosse produtiva. A baciloscopia foi positiva em 122 casos (71,0 por cento) com tosse produtiva no momento da internação. Dos 212 pacientes que estavam em retratamento, 156 (73,6 por cento) referiram abandono a tratamento anterior. Quanto ao desfecho, 297 (65,8 por cento) foram encaminhados para centros municipais de saúde, 83 (18,4 por cento) evoluíram para óbito, e 44 (9,8 por cento) curaram. As altas indesejadas ocorreram em 27 (6,0 por cento) dos casos. CONCLUSÕES: A provisão de hospitais especializados em TB é de relevância para o controle da TB, principalmente em regiões metropolitanas. Esses hospitais precisam estar adequados a medidas de biossegurança, assim como estar mais bem equipados e capacitados para prestar atendimento a pacientes com diversas comorbidades e problemas sociais associados à TB. A realização deste estudo resultou em melhorias para o HESM.

OBJECTIVE: To determine the epidemiological profile of inpatients at a TB referral hospital. METHODS: This was a descriptive, retrospective study of the medical charts of patients with TB hospitalized at the Hospital Estadual Santa Maria (HESM), in the city of Rio de Janeiro, Brazil, between January of 2002 and December of 2003. Data were collected using a standardized form. RESULTS: Of the 451 patients included in the study, 313 (69.4 percent) had been referred to the HESM from health care clinics, and 302 (67.0 percent) were male. Most of the patients were in the 30-59 year age bracket, 443 (98.2 percent) lived in the greater metropolitan region of Rio de Janeiro, and 298 (66.1 percent) lived in the city of Rio de Janeiro itself. The most common reason for hospitalization was poor health status (in 237, 52.5 percent). The most common comorbidity was AIDS (in 137, 30.4 percent). The most common signs and symptoms at admission were weight loss, fever and productive cough. Sputum smear microscopy was positive in 122 (71.0 percent) of the patients presenting with productive cough at admission. Of the 212 patients being retreated, 156 (73.6 percent) reported noncompliance with previous treatment. Regarding the outcome, 273 (65.8 percent) of the patients were referred to municipal health care centers, 83 (18.4 percent) died, 44 (9.8 percent) were cured, and 27 (6 percent) were discharged against medical advice. CONCLUSIONS: Providing hospitals specializing in TB is relevant for TB control, especially in metropolitan regions. In addition to taking biosafety measures, these hospitals must be prepared to treat patients with TB-related comorbidities and social problems. This study has resulted in improvements at the HESM.

case-control study of tobacco smoking and tuberculosis in India

To evaluate the role of smoking as a risk factor for the development of pulmonary tuberculosis. A total of 111 sputum smear-positive patients of pulmonary tuberculosis and 333 controls matched for age and sex were interviewed according to a predesigned questionnaire. The adjusted odd ratio of the association between tobacco smoking and pulmonary tuberculosis was 3.8 [95% confidence interval, 2.0 to 7.0; P value, <.0001]. A positive relationship between pack years, body mass index and socioeconomic class was also observed. There is a positive association between tobacco smoking and pulmonary tuberculosis