Hyperbaric oxygen therapy increases the risk of tuberculosis disease.

BACKGROUND: As Mycobacterium tuberculosis is an aerobic microbe, hyperbaric oxygen therapy (HBOT) could trigger progression from latent tuberculous infection (LTBI) to active tuberculosis (TB) disease. OBJECTIVE: To evaluate the effect of HBOT on TB reactivation. DESIGN: Our study sample was from the National Health Insurance Research Database containing one million beneficiaries. We identified a group of patients who underwent HBOT, and matched this group with individuals without HBOT. We compared the incidence of activation of TB between these two groups. RESULTS: A total of 2258 patients were identified, with each group comprising 1129 patients. One year after exposure to hyperbaric oxygen, the number of cases of active TB was significantly higher in the HBOT group than in the non-HBOT group (11 cases vs. 1 case, P = 0.006). Multiple regression analysis showed that HBOT was the only statistically significant contributor to TB activation. CONCLUSION: HBOT is likely to trigger the reactivation of TB. High-risk patients should undergo the tuberculin skin test or interferon-gamma release assays before HBOT to identify patients with LTBI.

Linfadenitis por Mycobacterium bovis, una entidad a tener en cuenta / Mycobacterium bovis lymphadenitis, an entity to consider

Las medidas de control del ganado y la pasteurización de los productos lácteos han hecho que la enfermedad tuberculosa por Mycobacterium bovis sea infrecuente en nuestro medio. El diagnóstico de esta entidad requiere un alto índice de sospecha, fundado en una historia clínica detallada y pruebas complementarias oportunas. La presentación más frecuente es extrapulmonar, principalmente como linfadenitis, por lo que ante una adenopatía de mala evolución se recomienda remitir al paciente para estudio y valorar la realización de punción aspiración con aguja fina para examen citológico y cultivo. Presentamos un caso de linfadenitis por M. bovis en una niña de siete años que respondió adecuadamente al tratamiento médico (AU9

Cattle control measures and milk products pasteurization have made Mycobacterium bovis disease uncommon in our environment. The diagnosis of this disease requires a high index of suspicion based on a detailed medical history and appropriate laboratory tests. Extrapulmonary cases are the main presentation, especially lymphadenitis, for this reason, is recommended to refer to study all the adenopathies with poor evolution, for evaluating de need of a fine-needle aspiration for citologý examination and culture. We report the case of M. bovis lymphadenitis in a 7-year-old girl with adequate response to medical treatment (AU)

Despistaje de tuberculosis latente en el paciente con psoriasis moderada grave candidato a terapia sistémica y/o biológica / Screening for Latent Tuberculosis in the Patient With Moderate to Severe Psoriasis Who Is a Candidate for Systemic and/or Biologic Therapy

Los pacientes con psoriasis moderada-grave que van a iniciar tratamiento con agentes biológicos deben ser monitorizados para la detección de infección tuberculosa latente antes, durante y después del tratamiento. En el último informe publicado de BIOBADADERM la prevalencia de infección latente por M.tuberculosis (ILMT) alcanzaba el 20,5% de los pacientes psoriásicos tratados con agentes biológicos en nuestro país. En la actualidad no existe un método diagnóstico gold standard que permita una aplicación sistemática y consensuada, con variaciones en los diferentes países según el grado de endemicidad y vacunación con BCG. La prueba de tuberculina (PT) continúa siendo el método de elección para el diagnóstico de infección, pero presenta importantes limitaciones en su sensibilidad (principalmente en pacientes inmunodeprimidos). Esta situación, junto a su falta de especificidad conocida, errores en su administración, la subjetividad en la interpretación de los resultados, la necesidad de una segunda visita para la lectura y la ausencia de privacidad hacen de ella una prueba limitada, cuyas principales ventajas resultarían su bajo coste y fácil realización. Por eso la mayoría de los estudios de coste beneficio se inclinan por el método IGRA para el diagnóstico de la ILMT, ya que minimiza los falsos positivos (especialmente en población vacunada), eliminando costes extra y efectos secundarios de la quimioprofilaxis antituberculosa. Valoramos la aplicabilidad en pacientes psoriásicos candidatos a terapia biológica y discutimos la necesidad de su realización previamente a terapia sistémica convencional, puesto que la mayoría de las guías actuales no consideran imprescindible su realización

Screening to detect latent tuberculosis infection (LTBI) is essential before patients with moderate to severe psoriasis start treatment with biologics and vigilance will continue to be needed during and after such treatment. The most recently analyzed statistics from the BIOBADADERM registry show a 20.5% prevalence of LTBI in psoriasis patients treated with biologics in Spain. Various screening protocols are in effect in different countries according to their levels of endemic TB and bacillus Calmette-Guérin (BCG) vaccination, and there is no consensus on a gold-standard approach to the diagnosis of LTBI. Tuberculin skin testing (TST) continues to be the diagnostic method of choice in spite of its limited sensitivity, mainly in immunocompromised patients. Additional problems include the TST’s well-established lack of specificity, errors in application, subjectivity in the interpretation of results (which must be read during a second visit), and lack of privacy; the main advantages of this test are its low cost and ease of application. Most cost-benefit studies are therefore inclined to favor using interferon- release assays to detect LTBI because they minimize false positives (especially in BCG-vaccinated individuals), thereby eliminating the extra costs and side effects of unnecessary chemoprophylaxis. We review the methods used for LTBI screening in psoriasis patients who are candidates for biologic therapy. Additionally, given the fact that most guidelines do not currently consider it necessary to screen patients about to start conventional systemic therapy, we discuss the reasons underlying the need for such screening

Prueba de la tuberculina en paciente con psoriasis / Tuberculin skin test in a patient with psoriasis

No disponible

Tuberculin Skin Test, chest radiography and contact screening in children ≤5 y: relevance in Revised National Tuberculosis Control Programme (RNTCP).

OBJECTIVES: To ascertain the status of Tuberculin Skin Test (TST) in the children aged 0-5 y who are household contacts of adults having sputum smear positive pulmonary tuberculosis and also to study the relationship of TST and Chest X-Ray (CXR) and their relevance in contact screening under RNTCP setup. METHODS: This prospective hospital based clinical study was conducted at a tertiary level referral medical college in Northern India. Study subjects were 200 children ≤5 y of age who were household contacts of adults with sputum smear positive pulmonary tuberculosis. All these adult index cases were registered and taking regular treatment at RNTCP centre attached to a medical college. Demographic data collection, detailed clinical history along with clinical examination, growth assessment, TST and chest radiography (CXR) was done for every child. RESULTS: TST was positive in 39 % children and out of these 68 % of child contacts had CXR findings suggestive of tuberculosis. This correlation was found to be highly significant (p < 0.001), especially in children less than 1 y of age. A high percentage of clinically asymptomatic children also had positive TST and CXR consistent with definition of TB disease. CONCLUSIONS: Contact screening must be prioritized in RNTCP. Unlike presently, TST and CXR should be actively employed in RNTCP for contact screening.

Vitamin D, tuberculin skin test conversion, and latent tuberculosis in Mongolian school-age children: a randomized, double-blind, placebo-controlled feasibility trial.

BACKGROUND: By modulating immune function, vitamin D might increase innate immunity and inhibit the growth of initial bacterial invasion and protect against tuberculosis infection. OBJECTIVE: We examined the effect of vitamin D supplementation on tuberculin skin test (TST) conversion. DESIGN: A double-blind, placebo-controlled study was conducted in 120 Mongol schoolchildren. We estimated the prevalence of latent tuberculosis infection at baseline and examined the effect of vitamin D (800 IU/d) on serum concentrations of 25-hydroxyvitamin D [25(OH)D] and TST conversion. RESULTS: At baseline, the mean (±SD) 25(OH)D concentration was 7 ± 4 ng/mL, and all concentrations were <20 ng/mL. Vitamin D supplementation increased serum 25(OH)D by a mean of 12.7 ng/mL compared with placebo (P < 0.0001). At baseline, 16 children in the vitamin D group and 18 in the placebo group were TST positive (P = 0.7). Over 6 mo, TSTs converted to positive in 5 (11%) children receiving vitamin D compared with 11 (27%) receiving placebo (RR: 0.41; 95% CI: 0.16, 1.09; P = 0.06). Only one TST conversion occurred among those whose serum 25(OH)D concentration increased to >20 ng/mL, whereas 8 TST conversions occurred in those whose final 25(OH)D concentration remained <10 ng/mL (P = 0.05). The mean increase in stature was 2.9 ± 1.6 cm in the vitamin D group and 2.0 ± 1.7 cm in the placebo group (95% CI: 2.16, 2.81; P < 0.003). CONCLUSIONS: Vitamin D supplementation for 6 mo had significant favorable effects on serum 25(OH)D concentrations and on growth in stature. A trend was seen toward fewer TST conversions in the vitamin D group. This trial was registered at clinicaltrials.gov as NCT01244204.

Diagnostic work-up and loss of tuberculosis suspects in Jogjakarta, Indonesia.

BACKGROUND: Early and accurate diagnosis of pulmonary tuberculosis (TB) is critical for successful TB control. To assist in the diagnosis of smear-negative pulmonary TB, the World Health Organisation (WHO) recommends the use of a diagnostic algorithm. Our study evaluated the implementation of the national tuberculosis programme's diagnostic algorithm in routine health care settings in Jogjakarta, Indonesia. The diagnostic algorithm is based on the WHO TB diagnostic algorithm, which had already been implemented in the health facilities. METHODS: We prospectively documented the diagnostic work-up of all new tuberculosis suspects until a diagnosis was reached. We used clinical audit forms to record each step chronologically. Data on the patient's gender, age, symptoms, examinations (types, dates, and results), and final diagnosis were collected. RESULTS: Information was recorded for 754 TB suspects; 43.5% of whom were lost during the diagnostic work-up in health centres, 0% in lung clinics. Among the TB suspects who completed diagnostic work-ups, 51.1% and 100.0% were diagnosed without following the national TB diagnostic algorithm in health centres and lung clinics, respectively. However, the work-up in the health centres and lung clinics generally conformed to international standards for tuberculosis care (ISTC). Diagnostic delays were significantly longer in health centres compared to lung clinics. CONCLUSIONS: The high rate of patients lost in health centres needs to be addressed through the implementation of TB suspect tracing and better programme supervision. The national TB algorithm needs to be revised and differentiated according to the level of care.

Scrofuloderma--a case series from rural India.

Cutaneous tuberculosis is the rarest presentation of all the forms of tuberculosis. Scrofuloderma is a frequent manifestation of cutaneous tuberculosis in Indian scenario. Males are affected one and half times more than females. The most common affected age group showing clinical infection is within the first three decades of life. A series of cases mostly malnourished children attending a tertiary care centre in a rural area of central India is being reported. They have presented with a wide spectrum of clinical features, forcing us to establish the final diagnosis by Mantoux test, fine needle aspiration cytology and histopathological examination. The mainstay of treatment remains medical therapy but the underlying cause for severe immunosuppression needs to be ruled out and treated.

Randomized study of the effect of topical anesthesia on tuberculin skin test reaction size in children.

Tuberculin skin test (TST) application in children can be eased by topical anesthesia, but no study has determined whether lidocaine-prilocaine mixture application modifies TST skin reactions. We compared TST performed with and without topical anesthesia in 46 children (range, 0.4-15.9 years), and found that topical lidocaine-prilocaine did not affect the TST size reaction. Topical lidocaine-prilocaine can be used for TST.

[LOW-INTENSITY LASER THERAPY IN THE PROPHYLACTIC TREATMENT OF TUBERCULIN HYPERERGIC CHILDREN].

The results of sanatorium treatment were analyzed in 156 children and adolescents aged 11-17 years at high risk for tuberculosis. All the patients had been long infected with Mycobacterium tuberculosis with hyperergic tuberculin sensitivity; they had comorbidity and were susceptible to frequent respiratory diseases. A course of percutaneous low-intensity laser irradiation was incorporated as a new method into a complex of prophylactic treatment. The time course of changes in tuberculin sensitivity, serological values, and clinical data were estimated. The proposed treatment regimen was shown to have some advantage over the conventional treatment one.

Zinc cream and reliability of tuberculosis skin testing.

In 50 healthy Peruvian shantytown residents, zinc cream applied to tuberculosis skin-test sites caused a 32% increase in induration compared with placebo cream. Persons with lower plasma zinc had smaller skin-test reactions and greater augmentation with zinc cream. Zinc deficiency caused false-negative skin-test results, and topical zinc supplementation augmented antimycobacterial immune responses enough to improve diagnosis.

Abordaje de la tuberculosis en Atención Primaria. Estudio de contactos / Dealing with tuberculosis in primary care. Contact tracing procedures

Aunque el número de casos de tuberculosis en Navarra ha descendido en los últimos años, resulta necesario adaptar los programas de control a la nueva situación. Las claves para avanzar en su prevención y control son: conseguir un diagnóstico precoz y un tratamiento efectivo de los enfermos y detectar y tratar a las personas con infección latente. En ambas actividades la atención primaria juega un importante papel. La mitad de los casos de tuberculosis activa que se diagnostican han sido contactos de enfermos bacilíferos o bien tenían una elevada predisposición personal de desarrollar la enfermedad. Por ello la detección y tratamiento de la infección latente en nuestro medio se debe realizar: 1. Mediante cribado en personas con alto riesgo de infectarse y desarrollar enfermedad, y 2. Fundamentalmente en el estudio sistemático de contactos de los casos con enfermedad. En el tratamiento, tanto de la tuberculosis activa como de la infección latente, es imprescindible conseguir un buen cumplimiento del paciente

Although the number of cases of tuberculosis in Navarre has fallen in recent years, it is necessary to adapt the control programs to the new situation. The keys to advancing in its prevention and control are: obtaining an early diagnosis and an effective treatment of patients and detecting and treating people with a latent infection. Primary care plays an important role in both activities. Half of the cases of active tuberculosis that are diagnosed have been contacts by bacilliferous TB patients or else have had a high personal predisposition to developing the disease. That is why detection and treatment of the latent infection in our setting must be carried out: 1) through screening persons at high risk of becoming infected and developing the disease, and 2) trough a systematic study of contacts of persons with the disease. In the treatment of both active tuberculosis and latent infection it is essential to obtain good patient adherence

Terapia biológica y psoriasis / Biologic therapy and psoriasis

La psoriasis es una enfermedad inflamatoria, frecuente y persistente, con un importante impacto en la calidad de vida de los pacientes. Los tratamientos sistémicos convencionales para la psoriasis no son fármacos seguros y eficaces a largo plazo. El hallazgo de fenómenos inmunológicos mediados por linfocitos T en la patogenia de la psoriasis ha orientado la investigación a la búsqueda, por medio de tecnología recombinante del ADN, de nuevos fármacos que bloqueen pasos específicos de la formación de placas de psoriasis. Los tratamientos biológicos actúan inhibiendo la activación y maduración de las células presentadoras de antígeno, inhibiendo la activación y proliferación de los linfocitos T, desviando la respuesta inmune del tipo 1 al 2, reduciendo el número de linfocitos T de memoria activados y bloqueando la acción de las citocinas. En este artículo se revisan los tratamientos biológicos más empleados en la psoriasis

Psoriasis is a common, persistent, inflammatory skin disorder that can have a major effect on patient quality of life. Conventional psoriasis treatment fail to meet the clinical needs for a save and remittive therapy. The implication of an immunological lymphocyte T phenomena in the pathogenesis of psoriasis has led to research for new treatment options over the past few years. With advances in molecular research and technology, several biological therapies may be employed in the treatment of psoriasis. Biological treatments are designed to modulate key steps in the pathogenesis of psoriasis. They act by: inhibition of activation of antigen-presenting cells, inhibition of activation and proliferation of lymphocytes, immune deviation (from a T1 immune response to a T2 immune response) and reduction of pathogenic T cells and blocking the activity of inflammatory cytokines. Different biological treatments are discussed in this article

The effects of androstenediol and dehydroepiandrosterone on the immune response to BCG at puberty.

In order to assess the effects of age-related changes of serum dehydroepiandrosterone sulphate (DHEAS) and androstenediol (AED) concentrations on BCG vaccination throughout the puberty period, we matched 41 prepubertal (mean age 8.63 +/- 1.36 years, range 8-14 years) and 43 pubertal (mean age 13.8 +/- 1.31 years, range 10-16 years) schoolchildren who were PPD negative and free of disease or medication known to affect immune function. The tuberculin test was performed 8 weeks after vaccination and tuberculin response and hormone levels were compared between prepubertal and pubertal subjects. We found a higher tuberculin response in the pubertal group when compared with the prepubertal ones. The pubertal children had 79.1 per cent tuberculin positivity compared with 46.4 per cent of prepubertal children (p < 0.05). Diameters of induration of the tuberculin test among prepubertal students vs. pubertal students were 9.5 +/- 3.8 mm and 11.9 +/- 3.7 mm, respectively (p < 0.005). Pubertal stage, testis volume, and pubic stage were also found to have significant effects on tuberculin test results. No difference was observed between both sexes with regard to responses of the tuberculin test in either the prepubertal or the pubertal group (p > 0.05). DHEAS and AED levels in the tuberculin-positive subjects were found to be significantly higher than tuberculin-negative ones (p = 0.040 and p = 0.046, respectively). Among both these hormones, only AED levels were correlated with tuberculin test responses. These results suggest that AED may play a role in the immunity to BCG vaccination and further immunological investigations are warranted to provide support for this idea.