Tuberculosis recurrence in a high incidence setting for HIV and tuberculosis in Brazil.

BACKGROUND: To compare epidemiological data between recurrent cases after cure (RC), distinguishing relapse from reinfection, after dropout (RD) and new cases (NC) in an ambulatory setting in a TB-endemic country. METHODS: Records of patients who started treatment for pulmonary TB between 2004 and 2010 in a TB clinic were reviewed. Epidemiological data were analyzed. Spoligotyping and MIRU patterns were used to determine relapse or reinfection in 13 RC available. RESULTS: Of the eligible group (1449), 1060 were NC (73.2%), among the recurrent cases, 203 (14%) were RC and 186 (12.8%) were RD. Of RC, 171 (84.2%) occurred later than 6 months after a previous episode, 13 had available DNA, in 4 (30.7%) the disease was attributed to reinfection and in 9 (69.3%), to relapse. Comparing RC to NC, HIV (p < 0.0001) was independent risk factor for RC. When RC and RD were compared, alcohol abuse (p = 0.001) and treatment noncompliance (p = 0.006) were more frequent in RD. CONCLUSIONS: HIV is the sole more important associated factor for RC. This finding points the need to improve the approach to manage TB in order to decrease the chance for exposure especially in vulnerable people with increased risk of developing disease and to improve DOTS strategy to deal with factors associated to treatment noncompliance.

HIV behind bars: human immunodeficiency virus cluster analysis and drug resistance in a reference correctional unit from southern Brazil.

People deprived of liberty in prisons are at higher risk of infection by the human immunodeficiency virus (HIV) due to their increased exposure through intravenous drug use, unprotected sexual activity, tattooing in prison and blood exposure in fights and rebellions. Yet, the contribution of intramural HIV transmission to the epidemic is scarcely known, especially in low- and middle-income settings. In this study, we surveyed 1,667 inmates incarcerated at Presídio Central de Porto Alegre, located in southern Brazil, for HIV infection and molecular characterization. The HIV seroprevalence was 6.6% (110/1,667). Further analyses were carried out on 40 HIV-seropositive inmates to assess HIV transmission clusters and drug resistance within the facility with the use of molecular and phylogenetic techniques. The molecular epidemiology of HIV-1 subtypes observed was similar to the one reported for the general population in southern Brazil, with the predominance of HIV-1 subtypes C, B, CRF31_BC and unique BC recombinants. In particular, the high rate (24%) of URF_BC found here may reflect multiple exposures of the population investigated to HIV infection. We failed to find HIV-infected inmates sharing transmission clusters with each other. Importantly, the analysis of HIV-1 pol genomic fragments evidenced high rates of HIV primary and secondary (acquired) drug resistance and an alarming proportion of virologic failure among patients under treatment, unveiling suboptimal access to antiretroviral therapy (ARV), low ARV adherence and dissemination of drug resistant HIV strains in primary infections. Our results call for immediate actions of public authority to implement preventive measures, serological screening and, for HIV-seropositive subjects, clinical and treatment follow-up in order to control HIV infection and limit the spread of drug resistance strains in Brazilian prisons.

Retreatment of tuberculosis patients in the city of Porto Alegre, Brazil: outcomes.

OBJECTIVE: To describe the outcomes of retreatment in tuberculosis patients receiving the regimen known, in Brazil, as regimen 3 (streptomycin, ethambutol, ethionamide, and pyrazinamide for 3 months + ethambutol and ethionamide for 9 months) after treatment failure with the basic regimen (rifampin, isoniazid, and pyrazinamide for 2 months + rifampin and isoniazid for 4 months). METHODS: A descriptive, uncontrolled, historical cohort study involving adult tuberculosis patients treated with regimen 3. We evaluated adverse drug effects, recurrence, treatment outcomes, and associated factors. RESULTS: The study included 229 patients. The overall cure rate was 62%. For the patients who used the medications regularly and those who did not, the cure rate was 88% and 31%, respectively. Adverse events occurred in 95 patients (41.5%), and most of those events were related to the gastrointestinal tract. In the five-year follow-up period, relapse occurred in 17 cases (12.0%). CONCLUSIONS: Overall, the outcomes of treatment with regimen 3 were unsatisfactory, in part because this regimen was administered to a selected population of patients at high risk for noncompliance with treatment, as well as because it presents high rates of adverse effects, especially those related to the gastrointestinal tract, which might be caused by ethionamide. However, for those who took the medications regularly, the cure rate was satisfactory. The recurrence rate was higher than that recommended in international consensus guidelines, which might be attributable to the short (12-month) treatment period. We believe that regimen 3, extended to 18 months, represents an option for patients with proven treatment compliance.

Desfechos do retratamento de pacientes com tuberculose com o uso do esquema 3 em Porto Alegre, Brasil / Retreatment of tuberculosis patients in the city of Porto Alegre, Brazil: outcomes

OBJETIVO: Descrever os desfechos do retratamento de pacientes com tuberculose com o uso do esquema 3 (estreptomicina, etambutol, etionamida e pirazinamida por 3 meses + etambutol e etionamida por 9 meses) devido à falência do tratamento com o esquema básico (rifampicina, isoniazida e pirazinamida por 2 meses + rifampicina e isoniazida por 4 meses). MÉTODOS: Estudo descritivo de coorte histórica, não controlada, com adultos que foram tratados com o esquema 3. Foram avaliados os desfechos desse tratamento, as reações adversas aos fármacos, as recidivas e os fatores associados. RESULTADOS: Foram incluídos no estudo 229 pacientes. A taxa de cura geral foi de 62 por cento. Entre os pacientes que usaram a medicação regularmente e aqueles que a usaram irregularmente, a taxa de cura foi de 88 por cento e 31 por cento, respectivamente. Observaram-se reações adversas em 95 pacientes (41,5 por cento), principalmente digestivas. Ocorreram 17 recidivas (12,0 por cento) nos cinco anos de seguimento. CONCLUSIONS: Os desfechos com o uso do esquema 3, em geral, não foram satisfatórios, pois esse esquema foi aplicado em uma população selecionada com alto risco de não adesão ao tratamento e apresenta altas taxas de reações adversas, especialmente as de tipo digestivo, possivelmente causadas pela etionamida. No entanto, para aqueles que conseguiram tomar a medicação regularmente, a taxa de cura foi satisfatória. A taxa de recidiva foi superior àquela preconizada por consensos internacionais, possivelmente devido ao tempo de tratamento curto (apenas 12 meses). Acreditamos que o esquema 3 estendido para 18 meses poderia ser uma alternativa para pacientes com comprovada adesão ao tratamento.

OBJECTIVE: To describe the outcomes of retreatment in tuberculosis patients receiving the regimen known, in Brazil, as regimen 3 (streptomycin, ethambutol, ethionamide, and pyrazinamide for 3 months + ethambutol and ethionamide for 9 months) after treatment failure with the basic regimen (rifampin, isoniazid, and pyrazinamide for 2 months + rifampin and isoniazid for 4 months). METHODS: A descriptive, uncontrolled, historical cohort study involving adult tuberculosis patients treated with regimen 3. We evaluated adverse drug effects, recurrence, treatment outcomes, and associated factors. RESULTS: The study included 229 patients. The overall cure rate was 62 percent. For the patients who used the medications regularly and those who did not, the cure rate was 88 percent and 31 percent, respectively. Adverse events occurred in 95 patients (41.5 percent), and most of those events were related to the gastrointestinal tract. In the five-year follow-up period, relapse occurred in 17 cases (12.0 percent). CONCLUSIONS: Overall, the outcomes of treatment with regimen 3 were unsatisfactory, in part because this regimen was administered to a selected population of patients at high risk for noncompliance with treatment, as well as because it presents high rates of adverse effects, especially those related to the gastrointestinal tract, which might be caused by ethionamide. However, for those who took the medications regularly, the cure rate was satisfactory. The recurrence rate was higher than that recommended in international consensus guidelines, which might be attributable to the short (12-month) treatment period. We believe that regimen 3, extended to 18 months, represents an option for patients with proven treatment compliance.

Hepatotoxicity due to rifampicin, isoniazid and pyrazinamide in patients with tuberculosis: is anti-HCV a risk factor?

BACKGROUND AND RATIONALE: Among the adverse events related to tuberculosis treatment, hepatotoxicity is the most serious, and recognition of risk factors for it is essential to achieve successful therapy. The aim of the study is to evaluate the role of anti-HCV as a risk factor for hepatotoxicity in hospitalized patients under tuberculosis treatment with rifampicin, isoniazid and pyrazinamide (RHZ). METHODS: Historical cohort study carried out at Hospital Sanatório Partenon, from 1998 to 2006. Patients aged 18 years or older, tested for anti-HCV, who presented normal pre-treatment aminotransferases (AST, ALT) and bilirrubin and who used RHZ during hospitalization were included in the study. Individuals who used anti-tuberculosis drugs six months prior to hospitalization, had clinical evidence of chronic liver disease or showed previous history of hepatotoxicity to RHZ were excluded. RESULTS: A sample of 534 patients was studied. The incidence of hepatotoxicity was 8.8% (n = 47). After univariate analysis, the following variables were associated to hepatotoxicity: anti-HIV positive, anti-HCV positive, use of antiretroviral therapy and high doses of rifampicin and isoniazid per kg of body weight (p < 0.05). When Cox regression was performed, anti-HIV positive [RR = 2.3 (IC(95% )1.2-4.1); p = 0.008] and high doses of isoniazid per kg of body weight [RR = 1.3 (IC(95%) 1.1-1.7); p = 0.016] remained independently associated to development of hepatotoxicity. CONCLUSIONS: In conclusion, the anti-HIV positive and high doses of isoniazid were considered independent risk factors for hepatotoxicity due to RHZ esqueme in the present study. Though univariate analysis showed that anti-HCV was associated to the outcome, it was not identified as an independent risk factor for hepatotoxicity related to the use of RHZ when the analysis was controlled to HIV.

Fungus ball in HIV-infected patients / Bola fúngica em pacientes HIV-infectados

Aspergillus is a phagocyte opportunistic fungus that causes aspergillosis, an unusual disease in patients with AIDS. Six cases of fungal ball in patients with AIDS are reported here. In this group, all patients had hemoptysis and tuberculosis as the underlying lung disease. The diagnosis of pulmonary fungus ball was based on the clinical and radiographic feature, combined with serological and mycological evidence of Aspergillus fumigatus.

Os fungos filamentosos são oportunistas de fagócitos, motivo pelo qual aspergilose é incomum em pacientes com Aids. A apresentação clínica depende do estado imune, tamanho do inóculo fúngico e doença de base. São relatados neste trabalho seis casos de bola fúngica em pacientes com Aids. Neste grupo, todos tiveram tuberculose como doença de base e hemoptise foi o principal sintoma. O diagnóstico da bola fúngica foi através da apresentação clínica, achados radiológicos combinados com imunodifusão radial dupla, exame micológico direto e cultivo do material do trato respiratório, sendo A. fumigatus o agente isolado

Fungus ball in HIV-infected patients.

Aspergillus is a phagocyte opportunistic fungus that causes aspergillosis, an unusual disease in patients with AIDS. Six cases of fungal ball in patients with AIDS are reported here. In this group, all patients had hemoptysis and tuberculosis as the underlying lung disease. The diagnosis of pulmonary fungus ball was based on the clinical and radiographic feature, combined with serological and mycological evidence of Aspergillus fumigatus.

[Multiresistant tuberculosis in Brazil: history and control]. / Tuberculose multirresistente no Brasil: histórico e medidas de controle.

The article aimed at assessing multidrug-resistant tuberculosis control in Brazil, based on the experiences of reference institutions, and the most relevant studies carried out to determine local and national resistance rates. Control measures and the current situation of treatment and diagnoses after the implementation of the national guidelines, which were revised in 2004, are considered. The first national survey on resistance to anti-tuberculosis drugs was performed in the middle of last decade. From its outcomes, a regimen to treat all cases of multidrug-resistant tuberculosis was validated and adopted. Government measures enabled the implementation of a surveillance system, whose outcomes are also commented.

Risk factors for recurrence of tuberculosis.

OBJECTIVE: To identify risk factors for recurrence of tuberculosis. METHODS: We studied a cohort of 610 patients with active pulmonary tuberculosis who were enrolled for treatment between 1989 and 1994 and cured using a three-drug treatment regimen of rifampin, isoniazid and pyrazinamide (RHZ). The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of disease, diabetes mellitus, alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and medication doses. In order to detect recurrence, the patients were monitored through the Rio Grande do Sul State Healt Department Information System for 7.7 +/- 2.0 years after cure. Data were analyzed using the Student's t-test, the chi-square test or Fisher's exact test, and Cox regression models. RESULTS: There were 26 cases of recurrence (4.3%), which corresponds to 0.55/100 patients-year. The recurrence rate was 5.95 and 0.48/100 patients-year in HIV-positive and HIV-negative patients, respectively (p < 0.0001). In the multivariate analysis, HIV infection [RR = 8.04 (95% CI: 2.35-27.50); p = 0.001] and noncompliance [RR = 6.43 (95% CI: 2.02-20.44); p = 0.002] proved to be independently associated with recurrence of tuberculosis. CONCLUSIONS: Recurrence of tuberculosis was more common in HIV-positive patients and in patients who did not comply with the self-administered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation of a post-treatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with tuberculosis treatment would be the use of supervised treatment.

Differences in the clinical and radiological presentation of intrathoracic tuberculosis in the presence or absence of HIV infection.

OBJECTIVE: To describe the differences in the clinical and radiological presentation of tuberculosis in the presence or absence of HIV infection. METHODS: A sample of 231 consecutive adults with active pulmonary tuberculosis admitted to a tuberculosis hospital were studied, assessing HIV infection, AIDS, and associated factors, as well as re-evaluating chest X-rays. RESULTS: There were 113 HIV-positive patients (49%) Comparing the 113 HIV-positive patients (49%) to the 118 HIV-negative patients (51%), the former presented a higher frequency of atypical pulmonary tuberculosis (pulmonary lesions accompanied by intrathoracic lymph node enlargement), hematogenous tuberculosis, and pulmonary tuberculosis accompanied by superficial lymph node enlargement, as well as presenting less pulmonary cavitation. The same was found when HIV-positive patients with AIDS were compared to those without AIDS. There were no differences between the HIV-positive patients without AIDS and the HIV-negative patients. Median CD4 counts were lower in HIV-positive patients with intrathoracic lymph node enlargement and pulmonary lesions than in the HIV-positive patients with pulmonary lesions only (47 vs. 266 cells/mm3; p < 0.0001), in HIV-positive patients with AIDS than in those without AIDS (136 vs. 398 cells/mm3; p < 0.0001) and in patients with atypical pulmonary tuberculosis than in those with other forms of tuberculosis (31 vs. 258 cells/mm3; p < 0.01). CONCLUSION: Atypical forms and disseminated disease predominate among patients with advanced immunosuppression. In regions where TB prevalence is high, the presence of atypical pulmonary tuberculosis or pulmonary tuberculosis accompanied by superficial lymph node enlargement should be considered an AIDS-defining condition.

Fatores de risco para a recidiva da tuberculose / Risk factors for recurrence of tuberculosis

OBJETIVO: Identificar fatores de risco para a recidiva da tuberculose. MÉTODOS: Estudou-se uma coorte de 610 pacientes com tuberculose pulmonar bacilífera inscritos para tratamento entre 1989 e 1994 e curados com o esquema contendo rifampicina, isoniazida e pirazinamida (RHZ). Avaliaram-se os seguintes fatores de risco: idade, sexo, cor, duração dos sintomas, cavitação das lesões, extensão da doença, diabetes melito, alcoolismo, infecção pelo HIV, negativação tardia do escarro, adesão ao tratamento e doses dos fármacos. Para detecção das recidivas, os pacientes foram seguidos por 7,7 ± 2,0 anos, após a cura, pelo sistema de informação da Secretaria Estadual da Saúde do Rio Grande do Sul. Nas análises utilizaram-se os testes t de Student, qui-quadrado ou exato de Fisher e a regressão de Cox. RESULTADOS: Ocorreram 26 recidivas (4,3 por cento), correspondendo a 0,55/100 pessoas-ano. A taxa de recidiva foi de 5,95 e 0,48/100 pessoas-ano, respectivamente, nos pacientes HIV-positivos e nos HIV-negativos (p < 0,0001). Na análise multivariada, a infecção pelo HIV [RR = 8,04 (IC95 por cento: 2,35-27,50); p = 0,001] e o uso irregular da medicação [RR = 6,43 (IC95 por cento: 2,02-20,44); p = 0,002] mostraram-se independentemente associados às recidivas. CONCLUSÕES: A recidiva da tuberculose foi mais freqüente nos pacientes HIV-positivos e naqueles que não aderiram ao tratamento auto-administrado (esquema-RHZ). Pacientes com pelo menos um destes fatores de risco poderão se beneficiar com a implantação de um sistema de vigilância pós-tratamento para detecção precoce de recidivas. Para prevenir a não-adesão ao tratamento da tuberculose, a alternativa seria a utilização de tratamento supervisionado.

OBJECTIVE: To identify risk factors for recurrence of tuberculosis. METHODS: We studied a cohort of 610 patients with active pulmonary tuberculosis who were enrolled for treatment between 1989 and 1994 and cured using a three-drug treatment regimen of rifampin, isoniazid and pyrazinamide (RHZ). The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of disease, diabetes mellitus, alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and medication doses. In order to detect recurrence, the patients were monitored through the Rio Grande do Sul State Healt Department Information System for 7.7 ± 2.0 years after cure. Data were analyzed using the Student's t-test, the chi-square test or Fisher's exact test, and Cox regression models. RESULTS: There were 26 cases of recurrence (4.3 percent), which corresponds to 0.55/100 patients-year. The recurrence rate was 5.95 and 0.48/100 patients-year in HIV-positive and HIV-negative patients, respectively (p < 0.0001). In the multivariate analysis, HIV infection [RR = 8.04 (95 percent CI: 2.35-27.50); p = 0.001] and noncompliance [RR = 6.43 (95 percent CI: 2.02-20.44); p = 0.002] proved to be independently associated with recurrence of tuberculosis. CONCLUSIONS: Recurrence of tuberculosis was more common in HIV-positive patients and in patients who did not comply with the self-administered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation of a post-treatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with tuberculosis treatment would be the use of supervised treatment.

Tuberculose multirresistente no Brasil: histórico e medidas de controle / Multiresistant tuberculosis in Brazil: history and control

O objetivo do artigo foi analisar o controle da tuberculose multirresistente no Brasil, com base nas experiências de instituições de referência e dos principais estudos de determinação das taxas locais e nacionais de resistência. Foram consideradas as medidas de controle e a situação atual de diagnóstico e tratamento, a partir da implementação das diretrizes nacionais, revisadas em 2004. O primeiro inquérito nacional de resistência aos medicamentos anti-tuberculose foi realizado em meados da década de 1990. A partir de seus resultados, foi validado e adotado um regime terapêutico nacional para todos os casos de tuberculose multirresistente. Medidas governamentais possibilitaram a implementação de um sistema de vigilância epidemiológica, cujos resultados também são comentados.

The article aimed at assessing multidrug-resistant tuberculosis control in Brazil, based on the experiences of reference institutions, and the most relevant studies carried out to determine local and national resistance rates. Control measures and the current situation of treatment and diagnoses after the implementation of the national guidelines, which were revised in 2004, are considered. The first national survey on resistance to anti-tuberculosis drugs was performed in the middle of last decade. From its outcomes, a regimen to treat all cases of multidrug-resistant tuberculosis was validated and adopted. Government measures enabled the implementation of a surveillance system, whose outcomes are also commented.

Diferenças na apresentação clínico-radiológica da tuberculose intratorácica segundo a presença ou não de infecção por HIV / Differences in the clinical and radiological presentation of intrathoracic tuberculosis in the presence or absence of HIV infection

OBJETIVO: Descrever as diferenças na apresentação clínico-radiológica da tuberculose segundo a presença ou não de infecção por HIV. MÉTODOS: Examinou-se uma amostra consecutiva de 231 adultos com tuberculose pulmonar bacilífera internados em hospital de tisiologia. A presença de infecção por HIV, AIDS e fatores associados foi avaliada e as radiografias de tórax foram reinterpretadas. RESULTADOS: Havia 113 pacientes HIV-positivos (49 por cento). Estes pacientes apresentavam maior freqüência de tuberculose pulmonar atípica (lesões pulmonares associadas a linfonodomegalias intratorácicas), tuberculose de disseminação hemática e tuberculose pulmonar associada a linfonodomegalias superficiais e menor freqüência de lesões pulmonares escavadas do que os pacientes HIV-negativos. Isto também ocorreu entre os pacientes HIV-positivos com AIDS e os HIV-positivos sem AIDS. Não se observaram diferenças entre os pacientes HIV-positivos sem AIDS e os HIV-negativos. Os valores medianos de CD4 foram menores nos pacientes HIV-positivos com linfonodomegalias intratorácicas e lesões pulmonares em comparação aos com lesões pulmonares exclusivas (47 vs. 266 células/mm³; p < 0,0001), nos pacientes HIV-positivos com AIDS em comparação aos HIV-positivos sem AIDS (136 vs. 398 células/mm³; p < 0,0001) e nos pacientes com tuberculose pulmonar atípica em comparação aos com outros tipos de tuberculose (31 vs. 258 células/mm³; p < 0,01). CONCLUSÃO: Há um predomínio de formas atípicas e doença disseminada entre pacientes com imunossupressão avançada. Em locais com alta prevalência de tuberculose, a presença de tuberculose pulmonar atípica ou de tuberculose pulmonar associada a linfonodomegalias superficiais é definidora de AIDS.

OBJECTIVE: To describe the differences in the clinical and radiological presentation of tuberculosis in the presence or absence of HIV infection. METHODS: A sample of 231 consecutive adults with active pulmonary tuberculosis admitted to a tuberculosis hospital were studied, assessing HIV infection, AIDS, and associated factors, as well as re-evaluating chest X-rays. RESULTS: There were 113 HIV-positive patients (49 percent) Comparing the 113 HIV-positive patients (49 percent) to the 118 HIV-negative patients (51 percent), the former presented a higher frequency of atypical pulmonary tuberculosis (pulmonary lesions accompanied by intrathoracic lymph node enlargement), hematogenous tuberculosis, and pulmonary tuberculosis accompanied by superficial lymph node enlargement, as well as presenting less pulmonary cavitation. The same was found when HIV-positive patients with AIDS were compared to those without AIDS. There were no differences between the HIV-positive patients without AIDS and the HIV-negative patients. Median CD4 counts were lower in HIV-positive patients with intrathoracic lymph node enlargement and pulmonary lesions than in the HIV-positive patients with pulmonary lesions only (47 vs. 266 cells/mm³; p < 0.0001), in HIV-positive patients with AIDS than in those without AIDS (136 vs. 398 cells/mm³; p < 0.0001) and in patients with atypical pulmonary tuberculosis than in those with other forms of tuberculosis (31 vs. 258 cells/mm³; p < 0.01). CONCLUSION: Atypical forms and disseminated disease predominate among patients with advanced immunosuppression. In regions where TB prevalence is high, the presence of atypical pulmonary tuberculosis or pulmonary tuberculosis accompanied by superficial lymph node enlargement should be considered an AIDS-defining condition.

Coexistência de colonização fúngica intracavitária (bola fúngica) e tuberculose ativa / Coexistence of intracavitary fungal colonization (fungus ball) and active tuberculosis

INTRODUÇAO: Embora a tuberculose pulmonar seja o principal fator predisponente para o surgimento de colonização fúngica em cavidade saneada, a coexistência das duas doenças é rara. A simultaneidade de colonização fúngica e micobacteriose ativa na mesma cavidade (bacilos álcool-ácido resistentes entre as massas de hifas) é excepcional. OBJETIVO: Descrever achados clínicos, diagnósticos, radiológicos, condições associadas e evolução em pacientes com tuberculose e colonização fúngica intracavitária pulmonar. MÉTODO: Foram avaliadas, retrospectivamente, fichas clínicas de 625 pacientes, entre os anos de 1974 e 2002, com bola fúngica diagnosticada por imunodifusão e/ou estudo micológico. O critério de inclusão foi baciloscopia positiva no escarro ou em histopatologia. RESULTADOS: Foram selecionados catorze pacientes. Todos apresentaram hemoptise, seguida de tosse com expectoração, dispnéia, emagrecimento, febre, astenia e dor torácica. Em dois casos, um colonizado por Aspergillus niger e outro por Scedosporium apiospermum (Teleomorfo, Pseudallescheria boydii), houve concomitância lesional da tuberculose ativa e bola fúngica. Nos demais, a micobactéria foi encontrada em parênquima circunjacente ou em pulmão contralateral. CONCLUSAO: Este estudo corrobora o antagonismo entre A. fumigatus e Mycobacterium tuberculosis. A possibilidade de concomitância de colonização fúngica e micobacteriose é demonstrada em outros agentes fúngicos, particularmente S. apiospermum (P. boydii) e A. niger.

Resultado do tratamento da tuberculose com estreptomicina, isoniazida e etambutol (esquema SHM) / Results of tuberculosis treatment with streptomycin, isoniazid, and ethambutol (scheme SHM)

Objetivo: Avaliar o desempenho do esquema SHM (estreptomicina, isoniazida e etambutol), na rotina de trabalho de uma unidade ambulatorial de tratamento da tuberculose. Método: Setenta e oito pacientes tuberculosos, cujo tratamento prévio com o esquema RHZ (seis meses de rifampicina, isoniazida e pirazinamida) teve de ser interrompido devido a efeitos adversos, ou que não puderam receber o esquema RHZ por serem de alto risco para hepatotoxicidade a esse esquema, foram tratados ambulatorialmente com o esquema de 12 meses de SHM, de 1986 a 1994, em Porto Alegre, Rio Grande do Sul, Brasil. Resultados: Em três pacientes houve necessidade de troca de esquema por toxicidade (3,8 por cento). Nos 75 restantes observaram-se 58 curas (77,3 por cento), oito abandonos (10,7 por cento), cinco falências (6,7 por cento) e quatro óbitos (5,3 por cento). A taxa teórica de cura, que é o percentual de cura entre os bacilíferos que fizeram tratamento regular, foi de 95,3 por cento. Reações adversas ocorreram em 32 pacientes (41 por cento), sendo as mais freqüentes as manifestações de dano vestibular, em 18 (23,1 por cento). Esses resultados foram comparados com os obtidos no mesmo ambulatório com o esquema de 12 meses de RHM (rifampicina, isoniazida e etambutol) e de seis meses de RHZ. Conclusão: O esquema SHM pode ser recomendado como alternativa para o tratamento da tuberculose quando o esquema RHZ não pode ser indicado

Do isolamento ao sanatório: diferentes práticas e serviços em um espaço de saúde pública de Porto Alegre - de 1909 a 2001 / From the isolation to the sanatorium: different practices and services in a space of public health of Porto Alegre - from 1909 to 2001

Pretende trazer alguma contribuiçäo para a pesquisa e a reflexäo acerca da temática do resgate da memória da saúde pública no Estado do Rio Grande do Sul, a partir do microcosmos do Hospital Sanatório Partenon e dos diferentes serviços implementados numa mesma área física do bairro Partenon, em Porto Alegre, do início do século XX a este início de século XXI. A trajetória de ocupaçäo deste espaço - de Hospital de Isolamento a partir de 1909 a um complexo de serviços públicos de saúde nos dias atuais - pode auxiliar a compreensäo de como diferentes políticas, demandas e práticas sanitárias determinam a estruturaçäo dos serviços de saúde, em particular no campo do tratamento das doenças infecto-contagiosas. (AU)

Tuberculose: epidemiologia, diagnóstico e tratamento em clínica e saúde pública / Tuberculosis: epidemiology, diagnostic and treatment

Dividido em duas partes - a primeira retrata as dificuldades e o trabalho relativos à organizaçäo e à administraçäo de medidas de controle eficazes em âmbito institucional e ambulatorial, e a segunda dedicada à clínica, a qual evidencia a possibilidade e as vantagens de associar o trabalho de rotina à pesquisa científica.

Tuberculose miliar e meningea em gestante: relato de um caso. / Miliary and meningeal tuberculosis in a pregnant woman: report of a case

E relato um caso de gestante com tuberculose sistemica, no qual ocorreu parto prematuro de feto natimorto, no dia anterior a morte da paciente por meningite