Malignant pleural mesothelioma in a 17-year old boy: A case report and literature review.

BACKGROUND: Malignant pleural mesothelioma is a rare, invasive and often fatal neoplasm that develops in the thin layer of tissue surrounding the lungs known as the pleura. Although rare, mesotheliomas do occur in the young; their characteristics are distinct from those of older patients. CASE PRESENTATION: This is a case report of a 17-year-old boy who had moderate dyspnea, cough, right-sided pleuritic chest pain, fever, headache and no weight loss. Physical examination showed a right pleural effusion and chest roentgenograms revealed a homogenous opacity on lower right hemithorax. Biochemical analysis of pleural fluid showed hemorrhagic/turbid effusion compatible with exudate. It was initially treated as an empyema. The pleural fluid culture was negative. Adenosine deaminase level was 34.3 U/L (admission) and 19.02 U/L (two weeks after). Pleural fluid smear and culture for Mtb were negative. During the open pleural biopsy, thickened pleura and multiple pale yellow nodules in the lung were observed. The histopathological report was compatible with malignant pleural mesothelioma. With this diagnosis, a chemotherapy regimen with cisplatin was initiated. After two cycles, the patient had no clinical and radiological improvement. The patient is currently under regular follow up. CONCLUSION: MPM is rare in young adults and its clinical presentation makes it different from mesothelioma in elderly patients, so it will be necessary to identify the new risk factors that can identify these patients.

Drug resistance beyond extensively drug-resistant tuberculosis: individual patient data meta-analysis.

The broadest pattern of tuberculosis (TB) drug resistance for which a consensus definition exists is extensively drug-resistant (XDR)-TB. It is not known if additional drug resistance portends worsened patient outcomes. This study compares treatment outcomes of XDR-TB patients with and without additional resistance in order to explore the need for a new definition. Individual patient data on XDR-TB outcomes were included in a meta-analysis comparing outcomes between XDR alone and three nonmutually exclusive XDR-TB patient groups: XDR plus resistance to all the second-line injectables (sli) and capreomycin and kanamycin/amikacin (XDR+2sli) XDR plus resistance to second-line injectables and to more than one group 4 drug, i.e. ethionamide/protionamide, cycloserine/terizidone or para-aminosalicylic acid (XDR+sliG4) and XDR+sliG4 plus resistance to ethambutol and/or pyrazinamide (XDR+sliG4EZ). Of 405 XDR-TB cases, 301 were XDR alone, 68 XDR+2sli, 48 XDR+sliG4 and 42 XDR+sliG4EZ. In multivariate analysis, the odds of cure were significantly lower in XDR+2sli (adjusted OR 0.4, 95% CI 0.2-0.8) compared to XDR alone, while odds of failure and death were higher in all XDR patients with additional resistance (adjusted OR 2.6-2.8). Patients with additional resistance beyond XDR-TB showed poorer outcomes. Limitations in availability, accuracy and reproducibility of current drug susceptibility testing methods preclude the adoption of a useful definition beyond the one currently used for XDR-TB.

Effect of altitude on the frequency of pulmonary tuberculosis.

SETTING: Pulmonary tuberculosis (PTB) incidence greatly varies around the world, a phenomenon usually attributed to socio-economic factors or health service availability. A recent study, however, indicated that PTB was inversely related to altitude. OBJECTIVE: To evaluate factors associated with PTB notification rates in Mexico. METHODS: Annual notification rates (1998-2002) of PTB in each of the 32 Mexican states were analysed, and likely factors were assessed through correlation and multiple regression analyses. RESULTS: Most variables lacked association with PTB rates, including percentage of population aged > or = 65 years, population density, percentage of population with < or = 2 minimum salaries, percentage of population with social security, level of education, diabetes incidence, percentage of immigration, percentage of rural population and a global marginalisation index. Only altitude above sea level correlated with tuberculosis incidence (r = -0.74, P < 0.0001). Likewise, in the multiple regression analysis only altitude reached a statistically significant association. CONCLUSION: Our results showed that altitude had a strong inverse relationship to PTB notification rates in Mexico, which might be related to the well known changes in alveolar oxygen pressure at different altitudes. Interestingly, several factors traditionally considered as predisposing conditions for the development of PTB did not correlate with the disease.

Diabetes modifies the male:female ratio in pulmonary tuberculosis.

SETTING: Socio-cultural factors have been invoked to explain the male predominance among patients with pulmonary tuberculosis, but there is no conclusive evidence of their role. OBJECTIVE: To assess male predominance in a group of diabetics with pulmonary tuberculosis compared with patients with pulmonary tuberculosis alone. DESIGN: Clinical records of in-patients with pulmonary tuberculosis and with (TBDM group, n = 202) or without (TB group, n = 226) diabetes mellitus were reviewed, and the male percentages in each of six age groups (15-29, 30-39, 40-49, 50-59, 60-69, > or = 70 years) calculated. RESULTS: In the TB group, no gender difference (51% males) was found in the first age period, followed by a male predominance thereafter (71%, 68%, 75%, 63% and 58%). The TBDM group showed a similar pattern in the first two age groups (56% and 74%), followed by a steadily decline (r(S) = -0.90, P = 0.04) in male percentage (60%, 44%, 45%, 27%), leading to a female predominance after age 50. The association of age and gender was also corroborated by logistic regression in TBDM (P = 0.02), but not in TB (P = 0.19) patients. CONCLUSIONS: Diabetes was associated with a progressive shift of male predominance in pulmonary tuberculosis. Because diabetes is a disease that affects social activities similarly in men and women, our results suggest that factors other than socio-cultural ones are also important for determining the male predominance in pulmonary tuberculosis.

Results of a 12-month regimen for drug-resistant pulmonary tuberculosis.

SETTING: Several therapeutic regimens for drug-resistant tuberculosis have been suggested, most of them with a total duration of 18-24 months. OBJECTIVE: To report our experience using a shorter regimen. DESIGN: Fifty patients with drug-resistant pulmonary tuberculosis were managed by withdrawing all anti-tuberculosis drugs until the results of a drug sensitivity test were obtained (approximately 3 months), and then a 12-month self-administered regimen with four to six anti-tuberculosis drugs at full daily doses was initiated, based primarily on the sensitivity test and secondarily on the history of previous treatment. RESULTS: In 31 patients treatment was completed as planned, in six it was irregular and 13 definitively abandoned it. In the best scenario, 90.3% (28/31) of patients with full treatment were cured; this outcome was similar for both multidrug-resistant (MDR, n = 18, 88.9%) and non-MDR (n = 13, 92.3%) patients. Six months later, the relapse rate was 4.8%, and after a 5-year follow-up 14 out of 18 cured patients who were located remained asymptomatic (77.8%). If the worst scenario was applied, a 62.0% cure rate (31/50) was obtained. CONCLUSIONS: A 12-month regimen with a minimum of four anti-tuberculosis agents at full dose, essentially selected on drug sensitivity testing, could be an alternative option for the treatment of drug-resistant pulmonary tuberculosis.

Cooking with biomass stoves and tuberculosis: a case control study.

OBJECTIVE: To search for an association between tuberculosis and use of biomass stoves found recently in a cross sectional study. DESIGN: In a case-control study based in a chest referral hospital, the cases were 288 patients with active smear-positive or culture-positive tuberculosis, and the controls were 545 patients with ear nose and throat ailments with no evidence of chest disease studied at the same time as the cases. Exposure to present or previous biomass smoke by history of cooking with traditional wood stoves was assessed by positive or negative response. RESULTS: Exposure to biomass smoke was significantly higher in cases than in controls. Crude odds ratios for tuberculosis and biomass smoke exposure were 5.2 (95%CI 3.1-8.9) for current exposure, 3.4 (95%CI 2.4-5.0) for past or present exposure and 1.8 (95%CI 1.1-3.0) for past exposure. The association was observed only for patients living in Metropolitan Mexico City and urban or suburban areas in the center of Mexico providing most cases and controls. For rural areas, the power of the study was low and the origin of the patients heterogeneous. Odds ratio for Mexico City Metropolitan area and the center of Mexico was 2.4 (95%CI 1.04-5.6), adjusted for age, sex, level of education, crowding, smoking, socio-economic level, zone of residence and state of birth. In the same model smoking had an OR of 1.5 (95%CI 1.0-2.3) for tuberculosis. CONCLUSION: Our results support a causal role of current domestic biomass smoke exposure in tuberculosis.

Atypical radiological images of pulmonary tuberculosis in 192 diabetic patients: a comparative study.

SETTING: Comparative studies of pulmonary tuberculosis images in diabetics have yielded conflicting results. OBJECTIVE: To assess radiological images of pulmonary tuberculosis in a large population of diabetic patients. DESIGN: Radiographs from in-patients admitted with pulmonary tuberculosis and diabetes (TBDM group, n = 192) were reviewed and compared with a control group of patients with pulmonary tuberculosis alone (TB group, n = 130). RESULTS: Both groups had a similar evolution time of tuberculosis (approximately 2 years). Statistical differences were observed as follows: TBDM patients were older (51.3+/-0.9 vs. TB group 44.9+/-1.8 years, mean +/- SEM), and had a decreased frequency of upper (17% vs. 56%), and an increased frequency of lower (19% vs. 7%) and upper + lower (64% vs. 36%) lung field lesions. More TBDM patients developed cavitations (82% vs. 59%) more often in the lower lung fields (29% vs. 3%). More multiple cavities were seen in TBDM patients (25% vs. 2%). TBDM group had a lower total leukocyte count (8836.7+/-219.5 vs. 10013.1+/-345.2 cells/mm3), mainly due to a lower number of non-lymphocyte cells (6815.8+/-221.8 vs. 8095.7+/-321.9 cells/mm3). Multiple logistic regression showed that being a diabetic patient was the most important factor determining lower lung field lesions and cavities. CONCLUSIONS: This study in a large number of diabetics with pulmonary tuberculosis confirmed that their chest X-ray images significantly depart from the typical presentation. Clinicians must keep this in mind to avoid misdiagnosis.

Progressive age-related changes in pulmonary tuberculosis images and the effect of diabetes.

Atypical radiologic images of pulmonary tuberculosis are common in elderly and in diabetic patients. To investigate the relationship of chest radiographic findings of tuberculosis to age in diabetic and nondiabetic patients, we compared the chest radiographic findings of 192 inpatients with pulmonary tuberculosis and diabetes with those of 130 patients with pulmonary tuberculosis alone. The proportion of patients with lower lung field lesions progressively increased with age (r(S) = 0.89, p < 0.01), whereas the frequency of cavitation steadily decreased with age (r(S) = -0.79, p < 0.05). In diabetic patients, a high frequency of lower lung lesions and cavitation was observed in all age groups. We speculated that, in older patients and in diabetics, the increased alveolar oxygen pressure in the lower lobes favors development of lower lobe disease in these groups.

Does aging modify pulmonary tuberculosis?: A meta-analytical review.

STUDY OBJECTIVES: To evaluate the differences in the clinical, radiologic, and laboratory features of pulmonary tuberculosis (TB) in older patients, as compared to younger patients. DESIGN: A meta-analysis (the Schmidt-Hunter method) of published works found in MEDLINE and other sources was performed. A total of 12 studies were collected, and each variable was submitted to meta-analysis. RESULTS: No differences were found between older (>/= 60 years old) and younger TB patients with respect to male predominance, evolution time before diagnosis, prevalence of cough, sputum production, weight loss, fatigue/malaise, radiographic upper lobes lesions, positive acid-fast bacilli in sputum, anemia or hemoglobin level, and serum aminotransferases. A lower prevalence of fever, sweating, hemoptysis, cavitary disease, and positive purified protein derivative, as well as lower levels of serum albumin and blood leukocytes were noticed among older patients. In addition, the older population had a greater prevalence of dyspnea and some concomitant conditions, such as cardiovascular disorders, COPD, diabetes, gastrectomy history, and malignancies. CONCLUSIONS: This meta-analytical review identified the main differences of older TB patients, as compared to younger TB patients, that should be considered during the diagnostic evaluation. Most of these differences are explained by the already known physiologic changes that occur during aging.