Management of Pulmonary Hydatidosis and Lung Abscess in Low-Resource Settings.

In the modern era, infections of the lung are typically managed medically. However, all pulmonary hydatid cysts require surgery with rare exceptions, and bacterial abscesses require surgery if they are complicated, resistant to treatment, and/or large. Surgical treatment of these pulmonary conditions requires clinical knowledge of tests for causative organisms, perioperative antimicrobial therapies, options for surgical management, and postoperative care.

Referral Process for Surgical Management of Tuberculosis in Lima: A Qualitative Study.

BACKGROUND: Lung resection surgery can be a complementary therapy for managing tuberculosis (TB) complications, but access is lacking in high-burden areas. The referral process for surgical evaluation is not well described. This study aimed to elucidate the TB surgery referral process in Peru. METHODS: A qualitative study was conducted using focus groups and interviews of health care providers from the Peruvian National TB Program. A semi-structured interview guide was developed with local partners. Focus groups and individual interviews were recorded and transcribed. Thematic analysis was used to reconstruct the referral process and identify barriers as well as areas for improvement. RESULTS: A total of 12 sessions were recorded (7 interviews and 5 focus groups; 36 participants total). The main themes identified were: (1) Surgical referral workflow, (2) Unstandardized selection criteria for surgery, (3) Limited inter-institutional communication, and (4) Material barriers to surgical management. CONCLUSION: Health care providers involved in the referral process of surgical management of tuberculosis in Lima reported a hierarchical referral workflow. Interinstitutional communication may be a critical interventional point to improve a patient's quality of care during the referral process.

Evaluation of a New Immunochromatographic Test Using Recombinant Antigen B8/1 for Diagnosis of Cystic Echinococcosis.

Diagnosis of cystic echinococcosis (CE) is based on the identification of the cyst(s) by imaging, using immunodiagnostic tests mainly as complementary tools in clinical settings. Among the antigens used for immunodiagnosis, previous studies described a good performance of the recombinant antigen B8/1 (rAgB) in an enzyme-linked immunosorbent assay (ELISA) format; however, in remote parts of areas where the disease is endemic, the implementation of an ELISA is difficult, so a more simple, rapid, and reliable method such as the immunochromatographic test (ICT) is required. In this study, using a set of 50 serum samples from patients with surgically confirmed CE, we compared the performance of an ICT and that of an ELISA using the rAgB. The overall sensitivities of ICT and ELISA were not statistically different (78% versus 72%; P = 0.36). The overall agreement between both tests was moderate (κ = 0.41; P < 0.01). Concordance between ICT and ELISA was substantial or almost perfect for patients with liver involvement (κ = 0.65; P < 0.001) and patients with more than one hydatid cyst (κ = 0.82; P < 0.001), respectively. Moreover, specificity analysis using a total of 88 serum samples from healthy individuals (n = 20) and patients (n = 68) with other parasitic infections revealed that ICT had a specificity of 89.8%. ICT and ELISA had similar performance for the detection of specific antibodies to E. granulosus, and ICT had a high specificity, opening the possibility of using ICT as a screening tool in rural settings.

Tratamiento quirúrgico de la tuberculosis pulmonar multidrogo resistente en el Perú: serie de 304 casos / Surgical therapy of multidrug-resistant pulmonary tuberculosis in Peru: report of 304 cases

El tratamiento de la tuberculosis pulmonar (TB) es esencialmente farmacológico, pero debido a la aparición de resistenciaa drogas, el tratamiento se ha dificultado. En ese contexto la cirugía pulmonar es una importante estrategia coadyuvantepara el tratamiento de la tuberculosis multidrogo resistente (TB MDR). Objetivo. Describir las características clínicas,resultados y complicaciones en una serie de 304 pacientes con TB MDR sometidos a terapia quirúrgica. Materiales y métodos. Entre mayo de 1999 y enero del 2007 un total de 336 intervenciones quirúrgicas fueron realizadas en 304 pacientes, pertenecientes al Programa Nacional de Control de la Tuberculosis, los cuales fueron operados por un equipoquirúrgico del Ministerio de salud, en el Hospital Nacional Hipólito Unanue y en un Centro Privado de Lima. Resultados. Lamayoría de casos fueron de sexo masculino (60 por ciento) y el promedio de edad fue 28 años. Los pacientes tuvieron resistencia a una mediana de 5 drogas. Las lesiones cavitarias fueron las más frecuentes (91.8 por ciento) y la lobectomía fue el procedimiento quirúrgico más utilizado (68.4 por ciento). La morbilidad postoperatoria ocurrió en 12,8 por ciento de los casos y la mortalidad post-operatoria fue de 2 por ciento. Los pacientes fueron seguidos hasta 79,3 meses y la curación fue alcanzada en el 77,2 por ciento de los casos. Conclusiones. La cirugía pulmonar coadyuvante es una alternativa efectiva para la curación en pacientes con TB MDR. Esta estrategia debe ser incluida como parte de los programas de tratamiento de la TB MDR.

Treatment for pulmonary tuberculosis (TB) is drug-based but the emergence of drug-resistance has decreased itstherapeutic efficacy. Pulmonary surgery is an important beneficial adjuvant strategy for MDR TB treatment in this context.Objectives. To describe the clinical characteristics results and complications in a series of 304 patients with MDR TBsubmitted to surgical therapy. Material and methods. Between May of 1999 and January of 2007 a total of 336 surgicalinterventions were performed on 304 patients from the National Program of TB Control who, were operated by a surgicalteam of the Ministry of Health in the Hipolito Unanue National Hospital and in a Private Center in Lima. Results. Mostcases were male (60 per cent) and the mean age was 28 years. Patients were resistant to a median of 5 drugs. Cavitarylesions were the most common (91.8 per cent) and lobectomy was the most commonly performed surgical procedure (68.4 per cent). Postoperative morbidity and mortality occurred in 12.8 per cent and 2 per cent respectively. Patients were followed post-operatively for a maximum time of 79.3 months and healing was reached in the 77.2 per cent of cases. Conclusions. Pulmonary adjuvantsurgery on MDR TB patients is an effective alternative for cure. This strategy should be included as part of treatmentprograms for MDR TB.

Micetoma pulmonar por scedosporium sp, reporte de dos casos / Pulmonary mycetoma by scedosporium sp, report of two cases

Se reporta los dos primeros casos de micetoma pulmonar por Scedosporium sp, en el Perú, tratados quirúrgicamenteen el Hospital Nacional Hipólito Unanue. Se practicó resección pulmonar debido a micetoma pulmonar de donde se tomó muestras que fueron enviadas a microbiología y anatomía patológica para cultivo y estudio histopatológico. Seidentificó el moho Scedosporium sp en dos pacientes con secuelas cavitarias por tuberculosis, quienes presentarontos y hemoptisis de dos meses y tres años de evolución, respectivamente. Radiológicamente las cavidades estabanocupadas por una bola fúngica. La histopatología indicó presencia de abundantes hifas, indistinguibles de las de Aspergillus sp, mientras que la inmunodifusión para Aspergillus fue negativa.

We report the two first cases of pulmonary mycetoma by Scedosporium sp. in Peru who underwent surgery in the Hipolito Unanue National Hospital. Pulmonary resection was made as therapy of pulmonary mycetoma, and samples were sent for microbiological cultures and pathologic examination. Scedosporium fungus was identified in two patients with post-TB cavitary sequelae who presented cough and hemoptysis, with two months and three years of evolution respectively. chest X ray showed cavitaries occupied by fungus ball. Pathologic examination showed hifae not distinguishable fromAspergillus sp and the test for aspergillum inmunodiffusion was negative.

Absence of brain involvement and factors related to positive serology in a prospective series of 61 cases with pulmonary hydatid disease.

A prospective series of 65 patients with surgically confirmed lung cystic hydatid disease was evaluated in terms of their radiologic characteristics, serologic response, and presence of cysts in other organs. Cysts were mostly single and located in lower lung lobes. Liver compromise was found in 34% of the patients. Despite a systematic search, no patient showed brain cysts in this series. Twelve patients had previous hydatid disease: six in the liver and eight in the lung (two had involvement of both organs in the past). Serology using bovine cyst fluid in an immunoblot assay was 85% sensitive. Serologic response was not associated with number or cyst or compromise of other organs but was clearly associated to the presence of at least one complicated cyst. Cyst status in terms of complications should be described to allow appropriate assessment of serologic evaluations.

Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru.

BACKGROUND: While most patients with tuberculosis (TB) can be successfully treated using short-course medical chemotherapy, thoracic surgery is an important adjunctive strategy for many patients with drug-resistant disease. The need for physical, technical and financial resources presents a potential challenge to implementing surgery as a component of treatment for multidrug-resistant TB (MDR-TB) in resource-poor settings. However, a cohort of patients with severe MDR-TB in Lima, Peru underwent surgery as part of their treatment. METHODS: 121 patients underwent pulmonary surgery for drug-resistant tuberculosis between May 1999 and January 2004. Surgery was performed by a team of thoracic surgeons under the Ministry of Health. Patient demographic data, clinical characteristics, surgical procedures and surgical outcomes were studied. RESULTS: Most of the patients had failed multiple TB regimens and were resistant to a median of seven drugs. The median time of follow-up after surgery was 33 months. 79.3% of patients were culture-positive before surgery, and sustained culture-negative status among survivors was achieved in 74.8% of patients. 63% of those followed up for at least 6 months after surgery were either cured or probably cured. Postoperative complications, observed in 22.6% of patients, were associated with preoperative haemoptysis, vital capacity <50% and low forced expiratory volume in 1 s. CONCLUSIONS: This is one of the largest cohorts with MDR-TB to be treated with surgery, and the first from a resource-poor country. Although surgery is not often considered an option for patients in resource-poor settings, the findings of this study support the argument that adjunctive surgery should be considered an integral component of MDR-TB treatment programmes, even in poor countries such as Peru.