Tuberculosis and diabetes: increased hospitalisations and mortality associated with renal impairment.

BACKGROUND: Diabetes mellitus (DM) triples a person's risk of active tuberculosis (TB) and is associated with increased mortality. It is unclear whether diabetes status and/or the associated renal dysfunction is associated with poor TB outcomes in New Zealand, which has high diabetes screening. AIM: To characterise the population of TB-DM and TB-alone to assess the effect of diabetes status and renal function on hospitalisation and mortality. METHODS: Clinical records from all adult patients diagnosed with TB in Auckland over a 6-year period (2010-2015) were reviewed. Baseline demographics, clinical presentation and microbiological data were assessed to compare the rates of hospitalisation and mortality between those with TB-DM and TB-alone. Statistical significance was defined as P < 0.05. RESULTS: A total of 701 patients was identified with TB; 120 (17%) had an unknown diabetes status and were excluded, and 135 had co-existing diabetes. The TB-DM and TB-alone groups had similar distribution of TB site and proportions of Mycobacterium tuberculosis culture positivity. Univariate analysis showed TB-DM patients had statistically significantly higher proportions of acute hospitalisation and mortality. Multivariate logistic regression showed only a reduced estimated glomerular filtration rate (eGFR) accounted for the higher rates of hospitalisation, with the odds of hospitalisation increasing by 2% for every unit decrease in eGFR. The odds of mortality increased by 6% for every year increase in age, and the odds of mortality increased by 3% for every unit reduction in eGFR. CONCLUSIONS: Diabetes is associated with higher TB hospitalisation and mortality; however, this is likely mediated by increased age and chronic kidney disease.

Treatment and outcomes of multidrug-resistant tuberculosis in Auckland, 1995-2018.

BACKGROUND: New Zealand has a low burden of tuberculosis; however, multidrug-resistant tuberculosis (MDR-TB) still represents a challenge for clinicians. This is the first description of clinical aspects of MDR-TB in New Zealand. AIMS: To evaluate the treatment and outcomes of patients with MDR-TB disease in Auckland. Secondary aims were to review the incidence and clinical characteristics of MDR-TB disease. METHODS: Clinical data were obtained for patients treated for MDR-TB at Auckland District Health Board (ADHB). RESULTS: There were 60 patients nationally with MDR-TB between 1989 and 2018; 41 (69%) of 60 patients received care at ADHB. Pulmonary infection was present in 36 (88%) of 41 patients, with 19 (46%) of 41 patients with smear-positive sputum (smear 1-2+ in 6/41, 15%; smear 3-4+ in 13/41, 32%). The median duration of treatment was 22 months (range 7.5-26) for 18 (44%) of 41 patients who completed MDR-TB treatment by August 2018. The median duration of amikacin treatment was 6 months (range 2-12) for the 23 (61%) of 38 patients in whom these data were available. All 38 patients who received treatment for MDR-TB experienced adverse effects, most commonly gastrointestinal (66%), neurological (50%), ototoxicity (47%) and psychiatric (37%). Complications of intravenous access were experienced by 10 (27%) of 37 patients. Of the 19 (46%) of 41 patients who completed treatment, 18 (95%) achieved cure. There was one case who had recurrence because of inadequate treatment, and one case who had spontaneous resolution without treatment. Seventeen (41%) patients left Auckland prior to completion of treatment, mostly to return to their country of origin (15/17, 88%). CONCLUSION: MDR-TB is uncommon in New Zealand. Treatment is frequently associated with adverse events; however, rates of cure for people completing treatment in New Zealand are high.

Ocular syphilis in Pacific peoples-are we making misdiagnoses secondary to yaws?

AIMS: To determine the demographic and clinical features of patients with ocular disease consistent with syphilis and positive treponemal serology in Auckland, and to compare patients who lived in a Pacific nation before 1960 with all other patients with regard to these features, considering a possible history of yaws infection. METHODS: Retrospective review of subjects seen in uveitis and neuroophthalmology clinics at Auckland District Health Board between January 2006 and June 2019. RESULTS: Two thousand four hundred and ninety-three subjects were reviewed in uveitis clinics during the timeframe, of whom 45 were diagnosed with syphilitic uveitis (1.8%). Mean age was 56.2±14.8 years and 34 (75.5%) were male. Ethnicity was Caucasian in 16 (35.5%), Pacific peoples in 16 (35.5%), Maori in two (4.4%), Asian in six (13.3%) and other in five (11.1%). Pacific peoples were older at presentation (p=0.001) and 75.0% were aged >60 compared to 24.1% of non-Pacific peoples (p=0.002). Comparing Pacific people born prior to 1960 (aged >60) to the rest of the cohort, older Pacific subjects had lower RPR titres (median 3 vs 32 p=0.004), less optic nerve swelling (0% vs 28.0% eyes p=0.014) and less posterior uveitis (6.25% vs 32.0% eyes p = 0.033). No difference was observed in anterior and intermediate uveitis between the groups. No difference was observed in the resolution or recurrence of inflammation between the groups. CONCLUSION: Syphilitic uveitis is common in New Zealand, occurring in 1 in 55 patients seen in consultant uveitis clinics. Clinicians should consider a history of yaws in Pacific peoples presenting with ocular inflammation and positive treponemal serology. In these cases alternative causes of ocular pathology should be included as differentials. In cases of diagnostic uncertainty, the risk of treatment versus the potentially severe sequelae of untreated syphilis need to be considered.

Towards elimination of tuberculosis in New Zealand.

New Zealand could be the first country in the world to eliminate tuberculosis (TB). We propose a TB elimination strategy based on the eight-point World Health Organization (WHO) action framework for low incidence countries. Priority actions recommended by the WHO include 1) ensure political commitment, funding and stewardship for planning and essential services; 2) address the most vulnerable and hard-to-reach groups; 3) address special needs of migrants and cross-border issues; 4) identify active TB and undertake screening for latent tuberculosis infection (LTBI) in recent TB contacts and selected high-risk groups, and provide appropriate treatment; 5) optimise the prevention and care of drug-resistant TB; 6) ensure continued surveillance, programme monitoring and evaluation and case-based data management; 7) invest in research and new tools; and 8) support global TB prevention, care and control. In New Zealand, central government needs to take greater responsibility for TB policy and programme governance. Urgent action is required to prevent TB in higher risk groups including Maori communities, and to enable immigration screening to detect and treat LTBI. Clinical services need to be supported to implement new guidelines for LTBI that enable better targeting of screening and shorter, safer treatment regimens. Access to WHO recommended treatment regimens needs to be guaranteed for drug-resistant TB. Better use of existing data could better define priority areas for action and assist in the evaluation of current control activities. Access to GeneXpert® MTB-RIF near the point of care and whole genome sequencing nationally would greatly improve clinical and public health management through early identification of drug resistance and outbreaks. New Zealand already has a world-class TB research community that could be better deployed to assist high-incidence countries through research and training.

Bronchiectasis in yellow nail syndrome.

BACKGROUND AND OBJECTIVE: Yellow nail syndrome (YNS) is a rare and poorly described disease process. In this case-control study, clinical features and findings on HRCT were compared with idiopathic bronchiectasis (IBx). METHODS: A review of all patients attending an adult bronchiectasis clinic between 2007 and 2013 identified 25 YNS patients. IBx patients were matched in a 2:1 ratio for age, duration of symptoms and gender. RESULTS: Median age of onset was 53 years. There were 12 male and 23 Caucasian YNS patients. Respiratory manifestations included chronic productive cough (100%), chronic rhinosinusitis (88%), pleural effusions (20%) and lymphoedema (12%). Chest symptoms preceded yellow nails in the majority (68%). Abnormal nails persisted at follow-up in 23 of 25 patients but improved in 14. In both disorders, there was symmetrical, predominantly lower lobe bronchiectasis on HRCT. Extent (P = 0.04), severity (P = 0.03) and bronchial wall thickness (P = 0.05) scores were lower in YNS, with less upper and middle lobe disease. Multivariate analysis showed an independent association with increased mucus plugging in YNS. There was a similar prevalence of Pseudomonas aeruginosa infection and mild lung function abnormalities. CONCLUSION: Bronchiectasis in YNS is less severe than IBx but is associated with increased mucus plugging, onset is in middle age and there is no female predominance. Treatment targeted at improved secretion clearance may improve both chest and nail symptoms, with consideration of long-term macrolide antibiotics.

Presumed tuberculous uveitis in non-endemic country for tuberculosis: case series from a New Zealand tertiary uveitis clinic.

BACKGROUND: To describe the clinical spectrum of presumed tuberculous (TB) uveitis in a developed, non-endemic country of high immigrant population. DESIGN: Retrospective review of a consecutive case series. PARTICIPANTS: All 39 patients diagnosed with presumed TB uveitis at the tertiary uveitis service in Auckland from 2007 to 2014. METHODS: Clinical chart review. MAIN OUTCOME MEASURES: Patient demographics, risk factors, ophthalmic manifestations, management and outcome. RESULTS: The median age was 37 years (interquartile range [IQR] 31-52) and 56% were female. The majority (97%) were born outside of New Zealand, and 77% had no TB-related history. Radiological abnormalities consistent with TB were evident in seven patients, including three who had culture positive pulmonary disease. Anterior uveitis was diagnosed in ten patients (26%), anterior and intermediate uveitis in eight (21%), posterior uveitis in 13 (33%) and panuveitis in eight (21%). Sixteen (41%) had retinal vasculitis, and five (13%) had multifocal serpiginoid choroiditis. Common complications included cataract (51%), ocular hypertension (36%), broad posterior synechiae (33%) and cystoid macular oedema (28%). Anti-TB treatment was initiated in 30 patients (76%). All but three patients completed the intended course of six to 12 months. Following anti-TB treatment, 67% remained in remission for at least 12 months, and all but two patients successfully stopped systemic steroids. The median initial and final visual acuity was 6/9 (IQR 6/6-6/18) and 6/6 (IQR 6/6-6/9), respectively. CONCLUSIONS: Despite a wide range of ocular presentations and complications, our cohort demonstrated good remission rate and visual prognosis following anti-TB treatment in carefully selected patients.

Increased uptake of cervical screening by women with HIV infection in Auckland regardless of ethnicity, requirement for an interpreter or level of education.

BACKGROUND: Current guidelines recommend that women with HIV infection receive annual cervical smears. METHODS: We evaluated the uptake of annual cervical smears by women with HIV infection under the care of the Infectious Disease Service at Auckland City Hospital. In an attempt to identify potential barriers to regularly receiving an annual cervical smear, we invited the women to complete a questionnaire. The responses from women who had regularly received an annual cervical smear were compared with those who had not. RESULTS: The proportion of women who had received a cervical smear increased from 44% in 2001, to 73% in 2010 (p=0.001). Ninety-three women (76%) completed the study questionnaire. No statistically significant differences were found in the questionnaire responses between the women who had regularly received an annual cervical smear and those who had not. CONCLUSION: The proportion of women in this cohort who received a cervical smear in 2010 is comparable with other studies of women with HIV infection in New Zealand and overseas. We have not been able to identify barriers that prevent women with HIV infection in Auckland regularly receiving an annual cervical smear. We plan to encourage women who have not received a cervical smear in the previous 2-year period to have a cervical smear performed when they attend the Infectious Disease Clinic, and will continue to notify the National Cervical Screening Programme that all women who are newly diagnosed with HIV infection should have an annual recall code attached to future cervical smear reports. We expect that these interventions will further increase the proportion of women with HIV infection in Auckland who receive an annual cervical smear.

HIV-associated tuberculosis in Auckland.

AIM: New Zealand has low rates of disease caused by to Mycobacterium tuberculosis (TB) and Human Immunodeficiency Virus (HIV). This study is the first to describe a New Zealand cohort of patients with HIV-associated TB. METHOD: We retrospectively reviewed the clinical records, laboratory data and chest radiographs of all patients who were diagnosed with HIV-associated TB and who commenced treatment for TB disease at Auckland City Hospital between January 1997 and July 2009. RESULTS: During the 12-and-a-half year study period, 40 patients were diagnosed with HIV-associated TB. The median age was 37 years and the median CD4 count was 130 cells/mm3. Only 2 patients were New Zealand born. Twenty-four (60%) patients had known HIV infection prior to their diagnosis of TB disease. Two patients with known HIV infection and positive tuberculin skin tests had not received treatment for latent tuberculosis infection (LTBI). Twenty-three (58%) patients received antiretroviral treatment during their TB treatment. There were 21 episodes of treatment interruption or immune reconstitution inflammatory syndrome. Three (8%) patients died. CONCLUSIONS: New Zealand continues to have a low incidence of HIV-associated TB. Early HIV diagnosis with universal screening and the treatment of LTBI in persons living with HIV infection is key to minimising the disease burden.

Uptake, yield and resource requirements of screening for asymptomatic sexually transmissible infections among HIV-positive people attending a hospital outpatient clinic.

UNLABELLED: Background We performed a prospective audit of screening for asymptomatic sexually transmissible infections (STIs), during an intensive effort to screen all patients at our hospital-based HIV clinic. We aimed to measure the effectiveness and resource implications of our screening program. METHODS: All outpatients who attended during an 8-month period were invited to take part in opt-out screening for chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis. Participants completed a brief questionnaire, were asked about current symptoms of STIs and self-collected specimens for laboratory testing. RESULTS: The majority (535 out of 673, 80%) of the patients who were asked to participate provided specimens for screening. No chlamydia, gonorrhoea or syphilis infections were identified in women (n=91) or in heterosexual men (n=76). In contrast, 34 out of 368 (10%) of men who have sex with men tested positive (chlamydia, 25; gonorrhoea, 2; chlamydia and gonorrhoea, 2; syphilis, 5). The laboratory cost of diagnosing each case of rectal chlamydia or gonorrhoea (NZ$664) was substantially lower than the cost of diagnosing each case of urethral infection (NZ$5309). CONCLUSIONS: There was high uptake of screening among our clinic population, who preferred screening to be performed at the hospital clinic. The yield of screening men who have sex with men warrants continued annual screening for rectal gonorrhoea and chlamydia and for syphilis.

Increasing awareness of Rhodococcus equi pulmonary infection in the immunocompetent adult: a rare infection with poor prognosis.

The aim of this case report and review is to increase awareness of this uncommon infection with Rhodococcus equi (R. equi), in immunocompetent adults. R. equi is a soil-dwelling Gram-positive bacillus that frequently causes infection in grazing livestock. Human infection is rare and mostly limited to the immunocompromised hosts. We present a case of pneumonia caused by R. equi infection in a 55-year-old male builder who presented with cough, dyspnoea and night sweats, initially suspected to have pulmonary tuberculosis. Following biopsy of the mediastinal lymph nodes, R. equi was cultured, which is usually not a contaminant. Despite extensive investigations a host immune defect was not identified. The patient recovered after three months of combination antibiotic treatment, initially with intravenous vancomycin and meropenem followed by oral clarithromycin and rifampicin. To further clarify this rare disease we did a literature review that identified 26 adult patients with R. equi infection, without an identified host immunosuppressive condition. In this cohort, the median age at presentation was 53 years and infection holds a strong male predominance 19 (73%). An environmental exposure (e.g. farming, horse breeder) was found in 13 (50%). Ten (38%) of these patients had pulmonary infection. All deaths 3 (12%) occurred in the patients had pulmonary infection. R.equi is an infection that is difficult to diagnose and carries a high mortality if prompt treatment is not established. It is important to realise the potential for this disease to be misdiagnosed as pulmonary tuberculosis or community acquired pneumonia. Clinical suspicion is important especially if an environmental exposure is suspected.

Bloodstream infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae at a tertiary care hospital in New Zealand: risk factors and outcomes.

OBJECTIVES: To define local risk factors and outcomes for bacteremia with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) at a tertiary hospital in New Zealand. METHODS: Patients with ESBL-E bacteremia were compared to matched control patients with non-ESBL-producing Enterobacteriaceae bacteremia. Patients were matched by onset of bacteremia (community vs. hospital), site of blood culture collection (peripheral vs. via central line), and infecting organism species. RESULTS: Forty-four cases with matched controls were included. Eight- and 30-day mortality was higher in cases than controls (27% vs. 7%; p=0.011 and 34% vs. 11%, p=0.011). Twenty-one cases (48%) were community-onset. Community-onset cases were associated with urinary tract infection, whereas hospital-onset cases were associated with central line infection, intensive care admission, and Enterobacter cloacae. Independent risk factors for ESBL-E bacteremia were fluoroquinolone exposure (odds ratio (OR) 6.56, 95% confidence interval (CI) 1.79-24), first-generation cephalosporin exposure (OR 12.3, 95% CI 1.01-148), and previously-known colonization with ESBL-E (OR 46.2, 95% CI 3.45-619). CONCLUSIONS: The association with fluoroquinolone exposure suggests that measures to reduce unnecessary use may be an effective preventative strategy. Known colonization with ESBL-E is a strong risk factor for ESBL-E bacteremia, and colonization status should be taken into consideration when choosing empirical therapy.

Aspiration pneumonia and challenges following the Samoa Tsunami in 2009.

On 29 September 2009, a large tsunami struck the Samoan Islands in the South Pacific Ocean, causing 142 deaths and large numbers of casualties. 199 patients presented to the emergency department within the first 72 hours. Twenty-nine patients were admitted with respiratory symptoms and histories of aspirating contaminated seawater and were diagnosed with tsunami-associated aspiration pneumonia. These patients were initially treated with empiric antibiotics based on drug availability and published experience after the Asian Boxing Day Tsunami of 2006. Antibiotic treatment was subsequently modified with sputum culture information. The good outcomes of the Samoa Tsunami patients may be attributed to early initiation of appropriate antibiotics and timely coordinated management.

Topical imiquimod treatment of aciclovir-resistant herpes simplex disease: case series and literature review.

Infection with herpes simplex virus (HSV) is extremely common worldwide. In immunocompromised patients anogenital HSV disease may have atypical features and may be very severe. Treatment of aciclovir-resistant anogenital HSV disease is challenging, as resistance to alternative treatments may occur, and effective treatment generally involves intravenous therapy with relatively toxic agents such as foscarnet. This case report presents three immunocompromised patients with presumed aciclovir-resistant anogenital HSV disease who were successfully treated with topical imiquimod. Imiquimod promotes local immune activation, which results in resolution of viral lesions such as anogenital warts and HSV disease. It is convenient to use and avoids the necessity for intravenous treatment with substantial systemic toxicity. In addition, as the mode of action of imiquimod is related to immune stimulation rather than direct antiviral activity, it may be used repeatedly without resistance developing.