Genotipificación de aislamientos del complejo Mycobacterium tuberculosis mediante MIRU-VNTR, Cali, Colombia, 2013-2015 / MIRU-VNTR genotyping of Mycobacterium tuberculosis in a population of patients in Cali, Colombia, 2013-2015

Resumen Introducción. La tuberculosis continúa siendo uno de los problemas de salud más importantes a nivel mundial y, con la infección por el virus de la inmunodeficiencia humana (HIV), constituye la principal causa de muerte por infecciones. En el 2016, se notificaron 6,3 millones de casos nuevos de la enfermedad. Objetivo. Describir los patrones genéticos determinados mediante la genotipificación del número variable de repeticiones en tándem de unidades repetitivas interespaciadas de micobacterias (Mycobacterial Interspersed Repetitive Units - Variable Number of Tandem Repeats, MIRU-VNTR) en la población de estudio y compararlos con los hallados en otros estudios locales e internacionales. Materiales y métodos. Mediante MIRU-VNTR, entre el 2013 y el 2015 se hizo la genotipificación de 105 muestras de ADN extraídas del esputo o de aislamientos en cultivo de M. tuberculosis provenientes de pacientes residentes en Cali con diagnóstico de tuberculosis pulmonar. La amplificación de 24 loci MIRU-VNTR se hizo por medio de la reacción en cadena de la polimerasa (PCR). Los amplicones resultantes se visualizaron por electroforesis en geles de agarosa (2 %) teñidos con SYBR Safe™. La asignación de los alelos se hizo con un análisis gráfico con el programa GelAnalyzer 2010. Los resultados obtenidos se analizaron con el algoritmo UPGMA y se compararon con las bases de datos internacionales MIRU-VNTRplus y SITVITWEB. Resultados. Se genotipificaron por completo 62 de las muestras y se obtuvieron 58 perfiles diferentes de MIRU-VNTR. Al comparar con las bases de datos internacionales, su distribución por linajes fue la siguiente: 54,8 % para el LAM, 25,8 % para el Haarlem, 14,5 % para el S, 3,2 % para el Beijing y 1,6 % para el Cameroon. Los patrones MIRU-VNTR correspondieron a 20 tipos internacionales de MIRU (MIRU International Types, MIT) diferentes, y los más frecuentes fueron el MIT 190 y el MIT 110, con 22,6 y 6,5 %, respectivamente. Conclusión. Estos resultados confirmaron hallazgos previos sobre el predominio de los linajes LAM y Haarlem en la ciudad y la presencia de los MIT encontrados en otra ciudad de Colombia.

Abstract Introduction: Tuberculosis continues to be one of the main public health problems in the world. Together with the HIV infection, it is one of the main causes of death due to infections worldwide. In 2016, 6.3 million new cases of the disease were reported. Objective: To describe the genetic patterns determined by genotyping using variable-number tandem repeats of mycobacterial interspersed repetitive units (MIRU-VNTR) in the study population and compare them with other studies carried out in Cali, Colombia, and the world. Materials and methods: We genotyped a total of 105 DNA samples extracted from sputum or culture isolates of the Mycobacterium tuberculosis complex, which were obtained from pulmonary tuberculosis diagnosed patients over the period 2013-2015, in Cali. We performed PCR amplification of 24 loci by MIRU-VNTR on the DNA extracted from the samples. The amplicons were visualized in agarose gel electrophoresis (2%) with SYBR Safe™ staining. Then, the alleles were designated by graphical analysis using the GelAnalyzer 2010 software. These results were analyzed using the UPGMA logarithm and compared with the registers from the MIRU-VNTR plus and SITVITWEB databases. Results: We genotyped 62 of the samples completely and we obtained 58 different MIRU-VNTR profiles. By comparing with the international databases, we determined the following distributions per lineage: LAM, 54.8%; Haarlem,25.8%; S, 14.5%; Beijing, 3.2%, and Cameroon, 1.6%. The MIRU-VNTR patterns corresponded to 17 different MITs; the most frequent were MIT 190 and MIT 110, with 22.6% and 6.5%, respectively. Conclusions: These results demonstrated previous observations about the predominance of the LAM and Haarlem lineages in the city, and the presence of the MITs found in another city of Colombia.

La importancia de investigar Mycobacterium bovis en muestras clínicas de procedencia humana / Importance of investigating Mycobacterium bovis in clinical samples of human origin

Resumen Introducción. La tuberculosis es una enfermedad infectocontagiosa que continúa siendo un problema mundial de salud pública. Es la principal causa de mortalidad en personas con HIV. Objetivo. Identificar la presencia de Mycobacterium bovis como agente etiológico de tuberculosis humana en muestras de esputo con baciloscopia positiva, mediante la prueba Genotype MTBC™. Materiales y métodos. Se llevó a cabo un estudio descriptivo de 88 muestras de esputo remitidas al Grupo de Micobacterias del Instituto Nacional de Salud entre enero y noviembre de 2015. Se hizo el análisis microbiológico convencional y se empleó la prueba molecular de Genotype MTBC™ para diferenciar las especies del complejo M. tuberculosis. Resultados. Sesenta y dos casos (70,5 %) correspondían a pacientes de sexo masculino; los grupos más afectados fueron el de 24 a 34 años, el de residentes en las cabeceras municipales, y el de afiliados al régimen subsidiado. En el 50 % (44) de las muestras con resultados en la prueba de identificación de la especie, se detectó el complejo M. tuberculosis. Conclusiones. La mayor carga de la enfermedad se registró en la población masculina y en edad productiva. La prueba de identificación para especies del complejo, solo demostró la presencia de M. tuberculosis. Sin embargo, con estos datos no es posible descartar M. bovis en humanos con tuberculosis en Colombia. La identificación diferencial de la especie debería implementarse de forma rutinaria en los casos de tuberculosis en los grupos de riesgo y en las zonas donde se conoce la circulación de esta micobacteria en bovinos.

Abstract Introduction: Tuberculosis is an infectious disease that still represents a major public health problem worldwide. It is one of the main causes of mortality in people with HIV. Objective: To identify the presence of M. bovis as an etiological agent of human tuberculosis in sputum smear positive samples using the test Genotype MTBC™. Materials and methods: We conducted a descriptive study, 88 sputum samples were submitted to the Grupo de Micobacterias of the Instituto Nacional de Salud between January and November, 2015. We used the conventional microbiological analysis and the molecular test Genotype MTBC™ to identify the M. tuberculosis complex species. Results: Sixty two (70.5%) were males; the most affected groups were those between 24 and 34 years old, those residing in the municipal seats and those affiliated to the subsidized health plans. In 50.0% (44) of the samples with a result in the species identification test, we detected M. tuberculosis. Conclusion: The highest burden of the disease was recorded among the male population in productive ages. The identification test for species of the complex showed all were M. tuberculosis. However, it is not possible to discard the presence of M. bovis in humans in Colombia. The differential identification of species should be done in risk groups and in areas where the circulation of this mycobacterium in cattle is known.

Therapeutic itinerary of people with tuberculosis in face with their health needs / Itinerario terapéutico de personas con tuberculosis ante sus necesidades de salud / Itinerário terapêutico de pessoas com tuberculose diante de suas necessidades de saúde

Abstract Objective: To describe the therapeutic itinerary of people with tuberculosis in face of their health needs. Method: Descriptive, qualitative study. Semi-structured interviews were carried out with ten patients. Hermeneutic-dialectic method of analysis and concept of therapeutic itinerary as driver of the analysis. Results: Most had classic symptoms at the beginning, however there was a case with coughing for more than one year. Entrance door, access to diagnosis and treatment were predominant in Primary Care, through smear microscopy and X-ray; patients had to pay for exams. Decentralization of treatment for other services when necessary or by link with the professional. The patient followed the decisions of the professionals and the support of relatives; prejudice regarding the disease was noted. Conclusions and implications for practice: Fragility in disease management, importance of bonding and family. It should be considered the impact of the disease and the need to support patients to ensure continuity of care.

Resumen Objetivo: Describir el itinerario terapéutico de personas con tuberculosis ante sus necesidades de salud. Método: Estudio descriptivo, cualitativo. Se realizaron entrevistas semiestructuradas con diez pacientes. Método de análisis hermenéutico-dialéctico y concepto de itinerario terapéutico como conductor del análisis. Resultados: La mayoría presentó síntomas clásicos al inicio, pero hubo un caso con tos durante más de un año. Puerta de entrada, acceso al diagnóstico y tratamiento fueron predominantes en la Atención Primaria, a través de baciloscopía y radiografía; se realizó un seguimiento de los exámenes por los pacientes. Descentralización del tratamiento para otros servicios cuando necesario o por vínculo con el profesional. Paciente siguió las decisiones de los profesionales y del apoyo de familiares; prejuicio con la enfermedad. Conclusiones e implicaciones para la práctica: Fragilidad en el manejo de la enfermedad, importancia del vínculo y de la familia. Se debe considerar el impacto de la enfermedad y la necesidad de apoyo a los pacientes para garantizar la continuidad de la atención.

Resumo Objetivo: Descrever o itinerário terapêutico de pessoas com tuberculose diante de suas necessidades de saúde. Método: Estudo descritivo, qualitativo. Realizadas entrevistas semiestruturadas com dez pacientes. Método de análise hermenêutica-dialética e conceito de itinerário terapêutico como condutor da análise. Resultados: A maioria apresentou sintomas clássicos no início da doença, mas houve caso com tosse por mais de um ano. Porta de entrada, acesso ao diagnóstico e tratamento foram predominantes na Atenção Primária, através de baciloscopia e raio-X; houve custeio de exames pelos pacientes. Descentralização do tratamento para outros serviços quando necessário ou por vínculo com o profissional. O paciente seguiu as decisões dos profissionais e do apoio de familiares; constatou-se preconceito relativo à doença. Conclusões e implicações para a prática: Fragilidade no manejo da doença, importância do vínculo e da família. Deve-se considerar o impacto da doença e a necessidade de apoio aos pacientes para garantir a continuidade da atenção.

Neumonía por Corynebacterium pseudodiphtheriticum / Pneumonia caused by Corynebacterium pseudodiphtheriticum

Corynebacterium pseudodiphtheriticum forma parte de la microbiota normal de orofaringe y de piel. Sin embargo, en las últimas décadas está emergiendo como oportunista causante de infecciones clínicamente significativas en pacientes con algún compromiso previo. Se refiere el caso clínico de una paciente de 76 años con antecedentes de hipertensión arterial, hipotiroidismo, diabetes tipo 2 e insuficiencia renal crónica, que presentó neumonía durante su estadía en terapia intensiva. El examen directo del esputo inducido (coloración de Gram) reveló una muestra representativa con abundante microbiota monomicrobiana constituida por bacilos gram positivos pleomórficos corineformes y el cultivo presencia de C. pseudodiphtheriticum. La paciente recibió medicación empírica con cefalosporina de tercera generación con evolución favorable.

Microorganisms of the genera Corynebacterium, specie pseudodiphtheriticum are a part of the indigenous microbiota of human skin and oropharinx. Nevertheless in recent decades these bacilli are emerging as opportunistic pathogens causing clinically significant infections in patients with previous compromise. We report the case of a 76 years old female patient, with a history of hypertension, hypothyroidism, type 2 diabetes and chronic renal failure, who presented pneumonia during their stay at the intensive care unit. The induced sputum revealed a representative sample with monomicrobial gram positive pleomorphic coryneform rods (Gram stain) and cultures demonstrated the presence of C. pseudodiphtheriticum as the only bacteria recovered. The pacient received an empirical third generation cephalosporin medication with a succesfull recovery.

Comparison of the safety and efficacy of a fixed-dose combination regimen and separate formulations for pulmonary tuberculosis treatment

OBJECTIVES: Fixed-dose combination formulations, which simplify the administration of drugs and prevent the development of drug resistance, have been recommended as a standard anti-tuberculosis treatment regimen. However, the composition and dosage recommendations for fixed-dose combination formulations differ from those for separate formulations. Thus, questions about the effectiveness and side effects of combination formulations remain. The aim of this study was to compare the safety and efficacy of these two types of anti-tuberculosis regimens for pulmonary tuberculosis treatment. METHOD: A prospective, randomized controlled study was conducted using the directly observed treatment short-course strategy. Patients were randomly allocated to one of two short-course regimens. One year after completing the treatment, these patients’ outcomes were analyzed. ClinicalTrials.gov: NCT00979290. RESULTS: A total of 161 patients were enrolled, 142 of whom were evaluable for safety assessment. The two regimens had a similar incidence of adverse effects. In the per-protocol population, serum bilirubin concentrations at the peak level, at week 4, and at week 8 were significantly higher for the fixed-dose combination formulation than for the separate formulations. All patients had negative sputum cultures at the end of the treatment, and no relapse occurred after one year of follow-up. CONCLUSIONS: In this randomized study, transient higher serum bilirubin levels were noted for the fixed-dose combination regimen compared with the separate formulations during treatment. However, no significant difference in safety or efficacy was found between the groups when the directly observed treatment short-course strategy was used. .

O programa de controle da tuberculose em Pelotas/RS, Brasil: investigação de contatos intradomiciliares / The tuberculosis control program in Pelotas/RS, Brazil: home contact investigations / El programa de control de la tuberculosis de Pelotas/RS, Brasil: investigación de contactos intradomiciliarios

Objetivou-se avaliar as ações de investigação dos contatos intradomiciliares dos casos índices de tuberculose (TB) no Programa de Controle da Tuberculose (PCT), de Pelotas/RS - Brasil. Trata-se de um estudo descritivo de corte transversal, com dados do prontuário dos casos índices. A amostra foi constituída por 163 contatos de 68 indivíduos com TB pulmonar em tratamento no PCT, entre junho e agosto de 2009. Os contatos eram, predominantemente, do sexo feminino, com idade acima dos 10 anos e filhos dos casos índices. Os exames solicitados foram a radiografia de tórax e a baciloscopia. Verificou-se a presença da doença ativa em 1,8% dos contatos. Os resultados evidenciam que a atenção à TB, em Pelotas/RS - Brasil, centralizada em um único serviço especializado, dificulta a investigação dos contatos intradomiciliares, necessitando envolver a atenção primária, para aproximar os profissionais da família e facilitar o diagnóstico precoce e a interrupção da cadeia de transmissão da TB em tempo oportuno.

The aim of this study is to evaluate the investigation actions of home contacts of tuberculosis (TB) index cases in the Tuberculosis Control Program (TCP) of Pelotas/RS - Brazil. This cross-sectional descriptive study was based on data from the records of index cases. The sample consisted of 163 contacts of 68 subjects with pulmonary TB in treatment in the TCP between June and August, 2009. These contacts were predominantly female, over 10 years of age and the daughters of index cases. The requested examination was a chest radiography and bacilloscopy. Active TB was found in 1.8 % of contacts. Results show that assistance for TB patients in Pelotas-Brazil, which is centralized in a single specialized service, hinders the investigation of home contacts. Primary care is required to narrow the gap between professionals and the family, and facilitate early diagnosis and interruption of the TB transmission chain in a timely manner.

El objetivo fue evaluar las acciones de investigación de los contactos intradomiciliaros de casos índices de tuberculosis (TB), en el Programa de Control de Tuberculosis (PCT) de Pelotas/RS - Brasil. Se trata de un estudio descriptivo de corte transversal, con datos del prontuario de los casos índices. La muestra fue constituida por 163 contactos de 68 sujetos con TB pulmonar en tratamiento en el PCT, entre julio y agosto de 2009. Los contactos eran predominantemente del sexo femenino, con edad superior a los 10 años e hijos del caso índice. Los exámenes solicitados fueron Rayos X del tórax y baciloscopia. Se verificó la presencia de la enfermedad activa en un 1,8% de los contactos. Los resultados evidencian que la atención a TB en Pelotas-Brasil, centralizada en un único servicio especializado, dificulta la investigación de los contactos intradomiciliarios, necesitando abarcar la atención primaria, para aproximar a los profesionales de la familia y facilitar el diagnóstico precoz y la interrupción de la cadena de transmisión de la TB en tiempo oportuno.

Consenso Intersociedades para el manejo de infecciones respiratorias: bronquitis aguda y enfermedad pulmonar obstructiva crónica / [Inter-society consensus for the management of respiratory infections: acute bronchitis and chronic obstructive pulmonary disease].

The Argentine Society for Infectious Diseases and other national societies issued updated practical guidelines for the management of acute bronchitis (AB) and reactivations of chronic obstructive pulmonary disease (COPD) with the aim of promoting rational use of diagnostic and therapeutic resources. AB is a condition characterized by inflammation of the bronchial airways which affects adults and children without underlying pulmonary disease. It is usually caused by a virus. The diagnosis is based on clinical findings after community acquired pneumonia has been ruled out. Treatment of AB is mainly symptomatic. Antibiotics should be used in immune-compromised hosts, patients with chronic respiratory or cardiac diseases and in the elderly with co-morbidities. Reactivation of COPD is defined as an acute change in the patient's baseline clinical situation beyond normal day to day variations, with an increase in dyspnea, sputum production and/or sputum purulence, warranting a change in medication. An increase in one symptom is considered a mild exacerbation, two as moderate, and the presence of three symptoms is considered a severe exacerbation. An infectious agent can be isolated in sputum in 50 to 75

of COPD reactivations. Moderate and severe episodes must be treated with antibiotics, amoxicillin/ beta-lactamase inhibitor, macrolides and fluoroquinolones are first choice drugs.

Tuberculosis and latent tuberculosis in prison inmates / Tuberculose e tuberculose latente na população prisional / Tuberculosis y tuberculosis latente en la población carcelaria

OBJECTIVE: To estimate the prevalences of tuberculosis and latent tuberculosis in inmates. METHODS: Observational study was carried out with inmates of a prison and a jail in the State of São Paulo, Southeastern Brazil, between March and December of 2008. Questionnaires were used to collect sociodemographic and epidemiological data. Tuberculin skin testing was administered (PPD-RT23-2TU/0.1 mL), and the following laboratory tests were also performed: sputum smear examination, sputum culture, identification of strains isolated and drug susceptibility testing. The variables were compared using Pearson's chi-square (Χ2) association test, Fisher's exact test and the proportion test. RESULTS: Of the 2,435 inmates interviewed, 2,237 (91.9 percent) agreed to submit to tuberculin skin testing and of these, 73.0 percent had positive reactions. The prevalence of tuberculosis was 830.6 per 100,000 inmates. The coefficients of prevalence were 1,029.5/100,000 for inmates of the prison and 525.7/100,000 for inmates of the jail. The sociodemographic characteristics of the inmates in the two groups studied were similar; most of the inmates were young and single with little schooling. The epidemiological characteristics differed between the prison units, with the number of cases of previous tuberculosis and of previous contact with the disease greater in the prison and coughing, expectoration and smoking more common in the jail. Among the 20 Mycobacterium tuberculosis strains identified, 95.0 percent were sensitive to anti-tuberculosis drugs, and 5.0 percent were resistant to streptomycin. CONCLUSIONS: The prevalences of tuberculosis and latent tuberculosis were higher in the incarcerated population than in the general population, and they were also higher in the prison than in the jail.

OBJETIVO: Estimar a prevalência da tuberculose e tuberculose latente em detentos. MÉTODOS: Estudo observacional foi realizado com detentos de uma penitenciária e de um centro de detenção provisória do Estado de São Paulo, SP, entre março e dezembro de 2008. Questionários foram utilizados para a coleta de dados sociodemográficos e epidemiológicos. O teste tuberculínico foi aplicado (PPD-RT23-2UT/0,1ml) e os seguintes exames laboratoriais foram realizados: baciloscopia de escarro, cultura de escarro, identificação das cepas isoladas e teste de sensibilidade às drogas antituberculose. As variáveis foram comparadas utilizando-se o teste de associação qui-quadrado de Person (Χ2), teste exato de Fisher e teste das proporções. RESULTADOS: Dos 2.435 detentos entrevistados, 2.237 (91,9 por cento) concordaram em submeter-se ao teste tuberculínico e destes, 73,0 por cento foram reatores. O coeficiente de prevalência da tuberculose foi de 830,6 por 100.000 detentos. Os coeficientes de prevalência foram de 1.029,5/100.000 detentos na penitenciária e de 525,7/100.000 detentos no centro de detenção provisória. As características sociodemográficas dos detentos nos dois grupos estudados foram semelhantes; a maioria dos detentos era jovem e solteiro com baixa escolaridade. As características epidemiológicas diferiram entre as unidades prisionais com o número de casos de tuberculose no passado e de contato prévio com doente maior na penitenciária e tosse, expectoração e hábito de fumar mais comum no centro de detenção. Entre as 20 cepas de Mycobacterium tuberculosis identificadas, 95,0 por cento foram sensíveis às drogas antituberculose e 5,0 por cento foram resistentes à estreptomicina. CONCLUSÕES: As prevalências da tuberculose e da tuberculose latente foram maiores na população carcerária do que na população geral; e também maiores na penitenciária do que no centro de detenção provisória.

OBJETIVO: Estimar la prevalencia de la tuberculosis y tuberculosis latente en detenidos. MÉTODOS: Estudio observacional realizado de marzo a diciembre de 200 con 4.435 detenidos de una penitenciaria y de un centro de detención provisional del Estado de Sao Paulo, sureste de Brasil, entre marzo y diciembre 2008. Cuestionarios fueron utilizados para colecta de datos sociodemográficos y epidemiológicos. Prueba tuberculina fue aplicada (PPD-RT23-2UT/0,1ml), así como los exámenes de laboratorio: baciloscopia de esputo, cultivo de esputo, identificación y prueba de sensibilidad a las drogas antituberculosis. Las variables fueron comparadas utilizándose la prueba de chi-cuadrado de Pearson, prueba exacta de Fisher y la prueba de las proporciones. RESULTADOS: De los 2.435 detenidos entrevistados, 2.237 (91,9 por ciento) concordaron a se someter a la prueba tuberculina y de estos, 73,0 por ciento reaccionaron. El coeficiente de incidencia de la tuberculosis fue de 830,6 por 100.000 detenidos. Los coeficientes de incidencia fueron de 1.029,5/100.000 detenidos en la penitenciaria y de 525,7/100.000 detenidos en el centro de detención provisional. Las características sociodemográficas de los detenidos de los dos grupos estudiados fueron semejantes; la mayoría de los detenidos era joven y soltero con baja escolaridad. Las características epidemiológicas se diferenciaron entre las unidades prisonales, con mayor número de casos de tuberculosis en el pasado y de contacto previo con enfermo en la penitenciaria; y mayor número de tos, expectoración y hábito de fumar en el centro de detención. Entre las 20 cepas de Mycobacterium tuberculosis identificadas, 95,0 por ciento fueron sensibles a las drogas antituberculosis y 5,0 por ciento fueron resistentes a la estreptomicina. CONCLUSIONES: Las prevalencias de la tuberculosis y de tuberculosis latente fueron mayores en la población carcelaria que en la población general; y mayores en la penitenciaria que en el centro de detención provisional.

Etiología y biomarcadores de inflamación sistémica en las exacerbaciones leves a moderadas de la enfermedad pulmonar obstructiva crónica / Etiology and biomarkers of systemic inflammation in mild to moderate COPD exacerbations

Background: The etiology of acute exacerbations of chronic obstructive pulmonary disease (COPD) is heterogeneous and still under discussion. Inflammation increases during exacerbation of COPD. The identification of inflammatory changes will increase our knowledge and potentially guide therapy. Aim: To identify which inflammatory parameters increase during COPD exacerbations compared to stable disease, and to compare bacterial and viral exacerbations. Material and Methods: In 85 COPD patients (45 males, mean age 68 ± 8 years, FEV1 46 ± 17% of predicted) sputum, nasopharyngeal swabs and blood samples were collected to identify the causative organism, during a mild to moderate exacerbation. Serum ultrasensitive C reactive protein (CRP), fibrinogen and interleukin 6 (IL 6), neutrophil and leukocyte counts were measured in stable conditions, during a COPD exacerbation, 15 and 30 days post exacerbation. Results: A total of 120 mild to moderate COPD exacerbations were included. In 74 (61.7%), a microbial etiology could be identified, most commonly Mycoplasma pneumoniae (15.8%), Rhinovirus (15%), Haemophilus influenzae (14.2%), Chlamydia pneumoniae (11.7%), Streptococcus pneumoniae (5.8%) and Gram negative bacilli (5.8%). Serum CRP, fibrinogen and IL 6, and neutrophil and leukocyte counts significantly increased during exacerbation and recovered at 30 days post exacerbation. Compared to viral exacerbations, bacterial aggravations were associated with a systemic inflammation of higher magnitude. Conclusions: Biomarkers of systemic inflammation increase during mild to moderate COPD exacerbations. The increase in systemic inflammation seems to be limited to exacerbations caused by bacterial infections.

Evolução clínica de um grupo de pacientes com TB multirresistente atendidos em um centro de referência na cidade do Rio de Janeiro / Clinical evolution of a group of patients with multidrug-resistant TB treated at a referral center in the city of Rio de Janeiro, Brazil

OBJETIVO: Analisar as características clínicas e a evolução de um grupo de pacientes com culturas de escarro positivas para Mycobacterium tuberculosis multirresistente (MR) e tratados em um centro de referência no município do Rio de Janeiro. MÉTODOS: A partir dos resultados de M. tuberculosis MR em culturas de escarro, foram selecionados 50 pacientes cujos dados clínicos foram obtidos através do Banco de Dados TBMR do Ministério da Saúde. Foram considerados a frequência de abandono, as recidivas, as falências e os tratamentos prévios para TB até o diagnóstico de TBMR. O padrão radiológico foi classificado em uni- ou bilateral, e cavitário ou não. Dois anos após o término do tratamento padronizado para TBMR, o desfecho (cura, falência, abandono ou óbito) de cada paciente foi avaliado e repetido a cada dois anos. O período de seguimento foi de oito anos após o tratamento. RESULTADOS: A média do número de tratamentos prévios foi de 2,3 ± 0,9. O tempo médio entre o diagnóstico inicial e o desenvolvimento de TBMR foi de 2 ± 1,7 anos. Após dois anos do tratamento inicial para TBMR houve 2 abandonos, 8 óbitos, 18 curas e 22 falências. A análise bivariada mostrou que o comprometimento pulmonar bilateral e o padrão cavitário reduziram acentuadamente a chance de cura, com risco relativo de 1-0,6 (40 por cento) e 1-0,7 (30 por cento), respectivamente. Ao final do seguimento, houve 2 abandonos, 9 falências, 17 curas e 22 óbitos. CONCLUSÕES: O comprometimento pulmonar bilateral e lesões cavitárias reduziram a possibilidade de cura dos pacientes com TBMR. A maioria dos pacientes com falha de tratamento evoluiu para óbito no período de 8 anos.

OBJECTIVE: To analyze the clinical characteristics and evolution of a group of patients with positive sputum cultures for multidrug-resistant (MDR) Mycobacterium tuberculosis and treated at a referral center in the city of Rio de Janeiro, Brazil. METHODS: Based on the positive results in sputum cultures for MDR M. tuberculosis, 50 patients were selected, and their clinical data were obtained from the Brazilian Ministry of Health MDR-TB Database. The frequencies of noncompliance, relapses, failures and previous treatments for TB up to diagnosis of MDR-TB were compiled. The radiological patterns were classified as unilateral or bilateral, and with or without cavitation. Two years after the end of the standard treatment for MDR-TB, the outcome (cure, failure, noncompliance or death) for each patient was evaluated and reassessed every two years. The post-treatment follow-up period was eight years. RESULTS: The mean number of previous treatments was 2.3 ± 0.9. The mean interval between the initial diagnosis and the development of MDR-TB was 2.0 ± 1.7 years. Two years after the initial treatment for MDR-TB, 2 patients had abandoned treatment, 8 had died, 18 had been cured, and 22 had presented treatment failure. The bivariate analysis showed that bilateral pulmonary involvement and cavitary pattern markedly reduced the chances for cure, with a relative risk of 1-0.6 (40 percent) and 1-0.7 (30 percent), respectively. At the end of the follow-up period, 2 patients had abandoned treatment, 9 had presented treatment failure, 17 had been cured, and 22 had died. CONCLUSIONS: Bilateral pulmonary involvement and cavity pattern greatly reduced the chances for cure of the patients with MDR-TB. Most patients who presented treatment failure died within the 8-year follow-up period.

Perfil de patógenos nas exacerbações agudas da doença pulmonar obstrutiva crônica: resultados preliminares / Pathogenic profile in acute exacerbations of chronic obstructuve pulmonary disease: preliminary results

Objetivo: Descrever os patógenos isolados em cultura quantitativa de escarro, nas exacerbações agudas de doença pulmonar obstrutiva crônica, em pacientes internados no Hospital Nossa Senhora da Conceição – Tubarão/SC e no Hospital Nereu Ramos – Florianópolis/SC. Metodologia: Foi realizado um estudo de delineamento transversal, utilizando escarro coletado em pacientes internados, o qual foi submetido à cultura quantitativa. Foi utilizada como ponto de corte a presença de 106 ufc/mL. O uso da antibioticoterapia foi confrontado com o isolamento em cultivo de agente etiológico bacteriano, através do índice de concordância Kappa. Resultados: Foram avaliados consecutivamente 13 pacientes, sendo 69,2% pertencentes ao gênero masculino, com média de idade de 67,15. A cultura de escarro evidenciou o crescimento de 53,8% de Streptococcus viridans e 7,7% de Haemophilus influenzae. Em 38,5% das culturas, não houve crescimento bacteriano. Quantificou-se 38,5%(n = 5) das culturas com mais de 106 UFC e 23,1% (n = 3) com menos de 106 UFC. O índice de concordância Kappa entre o uso de antibioticoterapia e a presença de infecção foi de -0,519. Conclusão: Houve um predomínio de pacientes do gênero masculino, e o agente mais comumente isolado nas culturas foi o Streptococcus viridans. Ocorreu discordância entre o uso de antimicronianos e a presença ou ausência de infecção.

Objective: To describe the pathogens isolated through quantitative sputum culture, in acute exacerbations of chronic obstructive pulmonary disease in patients admitted to the Hospital Nossa Senhora da Conceição, Tubarão/SC and Hospital Nereu Ramos, Florianópolis/SC. Methodology: A cross-sectional study was conducted using sputum collected from hospitalized patients, which was subjected to quantitative culture. The presence of 106 cfu/mL was used as a cutoff point. The use of antibiotics was compared with isolation of bacterial culture from the etiologic agent by Kappa index of agreement. Results:Thirteen patients were consecutive evaluated, 69.2% out of them were male, mean age 67.15. Sputum culture showed 53.8% growth of Streptococcus viridans and 7.7% of Haemophilus influenzae. There was no bacterial growth in 38.5% of the cultures. Of the total, 38.5% (n = 5) contained more than 106 CFU and 23.1% (n = 3) contained less than 106 CFU. The Kappaindex of concordance between antibiotic use and the presence of infection was -0.519. Conclusion: There was a predominance of male patients, and the agent most commonly isolated in cultures was Streptococcus viridans. There was disagreement between antimicrobial use and the presence or absence of infection.

Nocardiose pulmonar em portador de doença pulmonar obstrutiva crônica e bronquiectasias / Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease and bronchiectasis

Relatamos o caso de um paciente com doença pulmonar obstrutiva crônica e bronquiectasias, em uso crônico de corticosteróides, que desenvolveu nocardiose pulmonar, sob a forma de múltiplos nódulos pulmonares escavados. Os sintomas principais foram a tosse produtiva com escarro purulento, febre e dispnéia A radiografia simples e a tomografia computadorizada do tórax mostravam nódulos em ambos os pulmões, alguns escavados. O exame direto de escarro e a cultura mostraram a presença de Nocardia spp. A paciente foi tratada com imipenem e cilastatina, com excelente resposta clínica.

We report the case of a patient with chronic obstructive pulmonary disease and bronchiectasis, chronically using corticosteroids, who acquired pulmonary nocardiosis, which presented as multiple cavitated nodules. The principal symptoms were fever, dyspnea and productive cough with purulent sputum. Chest X-ray and computed tomography of the chest revealed nodules, some of which were cavitated, in both lungs. Sputum smear microscopy and culture revealed the presence of Nocardia spp. The patient was treated with imipenem and cilastatin, which produced an excellent clinical response.

Perfil epidemiológico dos casos notificados de tuberculose entre os profissionais de saúde no Hospital Universitário em Vitória (ES) Brasil / Epidemiological profile of tuberculosis cases reported among health care workers at the University Hospital in Vitoria, Brazil

OBJETIVO: Traçar o perfil epidemiológico dos casos notificados de tuberculose entre os profissionais de saúde no Programa de Controle da Tuberculose do Hospital Universitário Cassiano Antônio de Moraes, em Vitória (ES) Brasil. MÉTODOS: Realizou-se um estudo descritivo e retrospectivo de dados secundários no período de 2002 a 2006. RESULTADOS: Foram notificados 25 casos de profissionais de saúde com tuberculose: 8 técnicos de enfermagem (32 por cento); 4 médicos (16 por cento); 3 enfermeiros (12 por cento); 2 técnicos em radiologia (8 por cento) e 8 profissionais pertencentes a outras categorias (32 por cento); 14 do sexo masculino (56 por cento) e 11 do sexo feminino (44 por cento). A faixa etária com maior incidência foi a de 35-39 anos. A forma clínica predominante foi a extrapulmonar com 12 casos (48 por cento), seguido da pulmonar com 11 casos (44 por cento), e 2 casos (8 por cento) apresentaram ambas as manifestações. Entre os agravos associados, AIDS, etilismo e tabagismo apresentaram a mesma proporção entre a população do estudo: 33,3 por cento. Quanto ao desfecho, houve 22 casos de cura (88 por cento), 2 transferências (8 por cento) e 1 óbito (4 por cento). A proporção de profissionais de saúde com diagnóstico de tuberculose no período estudado foi de 2,53 por cento. CONCLUSÕES: Os resultados deste estudo apontam a necessidade de os profissionais de saúde que trabalham nos programas de controle da tuberculose preencherem o campo "ocupação profissional" nas fichas de notificação do Sistema de Informação de Agravos de Notificação. Além disso, apontam para a necessidade da implementação de um programa de controle de tuberculose ocupacional.

OBJECTIVE: To describe the epidemiological profile of tuberculosis cases reported among health care workers in the Tuberculosis Control Program of the Cassiano Antonio of Moraes University Hospital in Vitoria, Brazil. METHODS: A retrospective descriptive study of secondary data was conducted between 2002 and 2006. RESULTS: Twenty-five cases of health care workers with tuberculosis were reported: 8 in nursing technicians (32 percent); 4 in doctors (16 percent); 3 in nurses (12 percent); 2 in radiology technicians (8 percent) and 8 in professionals from other categories (32 percent). Of those 25 health care workers, 14 (56 percent) were male and 11 (44 percent) were female. The incidence of the disease was highest among those from 35 to 39 years of age. The predominant clinical presentation was extrapulmonary (12 cases, 48 percent), followed by pulmonary (11 cases, 44 percent) and a combination of the two (2 cases, 8 percent). Regarding comorbidities, AIDS, alcoholism and smoking, respectively, were present in 33.3 percent of the study population. Outcomes were as follows: 22 cases of cure (88 percent); 2 transfers (8 percent); and 1 death (4 percent). The proportion of health care workers diagnosed with tuberculosis in the period studied was 2.53 percent. CONCLUSIONS: The results show the need for heath care workers who work in the tuberculosis control program to fill out the field "professional occupation" on the tuberculosis case registry database reporting forms. In addition, this situation draws attention to the need to implement an occupational tuberculosis control program.

Exame do escarro no manejo clínico dos pacientes com pneumonia adquirida na comunidade / Sputum examination in the clinical management of community-acquired pneumonia

OBJETIVO: Este estudo retrospectivo avaliou a freqüência do uso da bacteriologia do escarro no manejo clínico de pacientes com pneumonia adquirida na comunidade (PAC) em um hospital geral, e se a utilização deste método modificou a mortalidade. MÉTODOS: Os prontuários de pacientes internados no Hospital Nossa Senhora da Conceição, em Porto Alegre (RS) Brasil, para tratamento de PAC entre maio e novembro de 2004 foram revisados quanto aos seguintes aspectos: idade; sexo; gravidade da pneumonia (escore de Fine); presença de expectoração; bacteriologia do escarro; história de tratamento; resposta clínica; troca de tratamento; e mortalidade. RESULTADOS: Foram avaliados 274 pacientes com PAC, sendo 134 do sexo masculino. Dentre os 274 pacientes, 79 (28,8 por cento) apresentavam, de acordo com o escore de Fine, classe II; 45 (16,4 por cento), classe III; 97 (35,4 por cento), classe IV; e 53 (19,3 por cento), classe V. Em 92 pacientes (33,6 por cento), uma amostra de escarro foi colhida para exame bacteriológico. Obtivemos amostra válida em 37 casos (13,5 por cento) e diagnóstico etiológico em 26 (9,5 por cento), o que resultou em modificação do tratamento em apenas 9 casos (3,3 por cento). A mortalidade geral foi 18,6 por cento. Idade acima de 65 anos, a gravidade da PAC e a ausência de escarro associaram-se à maior mortalidade. A bacteriologia do escarro não influenciou o desfecho clínico, nem a taxa de mortalidade. CONCLUSÃO: O exame do escarro foi uma ferramenta diagnóstica utilizada na minoria dos pacientes, e não trouxe benefício detectável no manejo clínico dos pacientes com PAC tratados em ambiente hospitalar.

OBJECTIVE: To evaluate the frequency of the use of sputum examination in the clinical management of community-acquired pneumonia (CAP) in a general hospital and to determine whether its use has an impact on mortality. METHODS: The medical records of CAP patients treated as inpatients between May and November of 2004 at the Nossa Senhora da Conceição Hospital, located in Porto Alegre, Brazil, were reviewed regarding the following aspects: age; gender; severity of pneumonia (Fine score); presence of sputum; sputum bacteriology; treatment history; change in treatment; and mortality. RESULTS: A total of 274 CAP patients (134 males and 140 females) were evaluated. Using the Fine score to quantify severity, we classified 79 (28.8 percent) of those 274 patients as class II, 45 (16.4 percent) as class III, 97 (35.4 percent) as class IV, and 53 (19.3 percent) as class V. Sputum examination was carried out in 92 patients (33.6 percent). A valid sample was obtained in 37 cases (13.5 percent), and an etiological diagnosis was obtained in 26 (9.5 percent), resulting in a change of treatment in only 9 cases (3.3 percent). Overall mortality was 18.6 percent. Advanced age (above 65), CAP severity, and dry cough were associated with an increase in the mortality rate. Sputum examination did not alter any clinical outcome or have any influence on mortality. CONCLUSION: Sputum examination was used in a minority of patients and was not associated with any noticeable benefit in the clinical management of patients with CAP treated in a hospital setting.

Associação entre paracoccidioidomicose e tuberculose: realidade e erro diagnóstico / Association between paracoccidioidomycosis and tuberculosis: reality and misdiagnosis

OBJETIVO: Avaliar a freqüência da real associação entre paracoccidioidomicose (PCM) e tuberculose (TB) e a freqüência do diagnóstico errôneo prévio de TB em doentes com PCM entre os pacientes atendidos na Disciplina de Pneumologia do Hospital das Clínicas da Universidade Estadual de Campinas, Campinas (SP). MÉTODOS: Estudo retrospectivo de 227 pacientes adultos com diagnóstico confirmado de PCM (forma crônica) entre 1980 e 2005. RESULTADOS: Dos 227 casos, 36 (15,8 por cento) haviam sido tratados anteriormente para TB. Porém, apenas 18 (7,9 por cento) apresentaram baciloscopia positiva. Os outros 18 (7,9 por cento) nunca tiveram o diagnóstico confirmado pela baciloscopia nem responderam ao tratamento específico para TB. CONCLUSÃO: Apesar de a associação entre PCM e TB existir e estar documentada na literatura, o erro diagnóstico é bastante comum, haja vista a sobreposição e similaridade das apresentações clínicas e radiológicas dessas duas doenças, havendo, portanto, a necessidade do diagnóstico bacteriológico antes de se iniciar o tratamento específico.

OBJECTIVE: To evaluate the frequency of the real association between paracoccidioidomycosis (PCM) and tuberculosis (TB) as well as the rate of previous TB misdiagnosis in individuals with PCM among the patients treated in the Pulmonology Division of the State University of Campinas Hospital das Clínicas, Campinas, Brazil. METHODS: A retrospective study of 227 adult patients with PCM (chronic form) treated between 1980 and 2005. RESULTS: Of the 227 patients studied, 36 (15.8 percent) had been previously treated for TB. However, only 18 (7.9 percent) presented positive sputum smear microscopy results. The remaining 18 (7.9 percent) neither presented positive sputum smear microscopy nor showed improvement after receiving specific anti-TB treatment. CONCLUSION: Although the existence of an association between PCM and TB has been documented in the literature, misdiagnosis is common due to the superimposition of and the similarity between their clinical and radiographic presentations, thereby warranting the need for bacteriological diagnosis before initiating specific treatment.

Perfil dos pacientes com tuberculose e avaliação do programa nacional de controle da tuberculose em Bagé (RS) / Profile of patients with tuberculosis: evaluation of the Brazilian national tuberculosis control program in Bagé, Brazil

OBJETIVO: Realizar um levantamento epidemiológico dos pacientes com diagnóstico de tuberculose, e fatores associados, além de verificar a eficácia do Programa Nacional de Controle da Tuberculose na cidade de Bagé, Rio Grande do Sul. MÉTODOS: Realizou-se um estudo retrospectivo dos casos notificados de tuberculose do Posto Paulo Barcellos, através da revisão de prontuários médicos e dos dados do Sistema Nacional de Agravos de Notificação, entre janeiro de 2001 e dezembro de 2004. RESULTADOS: Neste período, foram realizadas 4.468 baciloscopias, sendo a de escarro a amostra mais numerosa. Resultaram positivas 131 amostras, com prevalência maior do sexo masculino e idade entre 26 e 35 anos, e prevalência menor daqueles com idade acima de 65 anos. Mais de 50 por cento dos pacientes eram da raça branca, tinham apenas 1 a 3 anos de estudo, e exerciam alguma função que lhes garantia algum sustento, com renda mensal baixa (média de 265 reais/mês). Houve equivalência entre os fumantes e não fumantes, e somente um dos 131 casos de tuberculose era HIV positivo. CONCLUSÃO: O número de baciloscopias realizadas em Bagé foi crescente nos últimos quatro anos. Em 2003 e 2004, esse número superou as metas do Programa Nacional de Controle da Tuberculose, o que demonstra a eficácia da busca ativa de casos de tuberculose na cidade, no entanto, houve diminuição de casos novos.

OBJECTIVE: To present epidemiological data on patients diagnosed with tuberculosis, as well as on associated factors, and to determine the efficacy of the National Tuberculosis Control Program in Bagé, Brazil. METHODS: A retrospective study was carried out at the Pablo Barcellos Center, analyzing cases of tuberculosis reported from January 2001 to December 2004. Data were collected through the review of clinical charts and from the National Case Registry database. RESULTS: During this period, of the 4468 sputum smear microscopies performed, 131 were positive, with higher prevalence among males aged 26 to 35 years old. Prevalence was lower among those aged 65 and above. Over 50 percent of the patients were Caucasian, had only 1 to 3 years of schooling and worked in low-income jobs (mean salary, 265 Brazilian reals/month). There was no significant difference between smokers and former smokers/nonsmokers, and only one of the 131 cases was HIV positive. CONCLUSION: The number of sputum smear microscopies performed in Bagé increased in the past four years. In 2003 and 2004, it exceeded the goal of the National Tuberculosis Control Program. However, the number of new cases decreased, demonstrating the efficacy of the active search for tuberculosis cases in the city.

Bronquiectasias en adultos: características clínicas: experiencia de 5 años 1998-2003 / Retrospective evaluation of bronchiectasis characteristics in adults at a chilean general hospital: a 5 years experience (1998-2003)

In order to know the actual characteristics of bronchiectasis in an adult population, we reviewed 18 cases with this pathology confirmed by spiral CT at a general hospital (Hospital Regional de Concepción, Chile), between 1998-2003. Ten patients were males and 8 females, their mean age was 44 +/- 13.9 years old. Most common etiologies of bronchiectasis were pulmonary tuberculosis (44.4 percent) and acute pneumonia (38.8 percent); main sypmtoms were chronic cough (88.8 percent), persistent sputum (77.7 percent) and hemoptysis (44.4 percent). Spirometry detected airway obstruction in smokers (FEV1/FVC = 58 percent) and in non smokers (FEV1/FVC = 68 percent). Microbiological sputum exams showed Hemophilus influenzae (16.6 percent), Neisseria catharralis (15 percent), Pseudomona aeruginosa (13 percent), Streptococcus pneumoniae (15.4 percent) and Candida albicans (4 percent). Spiral CT showed the following distribution of bronchiectasis: unilobular lesion 11.1 percent, bilobar 72 percent and multilobar 16.6 percent. The clinical picture of bronchiectasis in our hospital according to this up to date review, shows that our reality is essentially similar to that previously reported in literature.

Para conocer las características actuales de las bronquiectasias en adultos en nuestro medio se revisan los 18 casos de esta patología comprobados por TAC helicoidal de tórax en el Hospital Regional de Concepción entre 1998-2003. La edad promedio de los pacientes fue de 44 +/ - 13,9 años; 10 hombres y 8 mujeres. Las etiologías más frecuentes de bronquiectasias fueron tuberculosis pulmonar (44,4 por ciento) y neumonía aguda (38,8 por ciento). Los síntomas más relevantes fueron tos crónica (88,8 por ciento), expectoración persistente (77,7 por ciento) y hemoptisis (44,8 por ciento). La espirometría reveló alteración ventilatoria obstructiva tanto en fumadores (VEF1/CVF = 58 por ciento) como en no fumadores (VEF1/CVF = 68 por ciento). La bacteriología de expectoración detectó Hemophilus influenzae (16,6 por ciento), Neisseria catharralis (15 por ciento), Pseudomona aeruginosa (13 por ciento), Streptococcus pneumoniae (15,4 por ciento) y Candida albicans (4 por ciento). La TAC de tórax demostró lesiones bilobares (72 por ciento), multilobares (16,6 por ciento) y unilobares (11,1 por ciento). La realidad de las bronquiectasias en nuestro medio es que no difiere significativamente de lo descrito en la literatura.

Detección de especies de nocardia aisladas de pacientes con compromiso pulmonar crónico en Tucumán (Argentina) / Detection of nocardia species isolated from patients with chronic pulmonary conpromise in Tucuman (Argentina)

Conociendo la escasa información médica sobre las nocardiosis broncopulmonares, nos abocamos a la detección de especies de nocardia en muestras enviadas para análisis bacteriológico de rutina. Se analizaron 250 muestras de esputo y lavado bronquial de pacientes con compromiso pulmonar crónico: bronquitis crónica, enfermedad pulmonar obstructiva crónica (epoc), asma bronquial y tuberculosis. Se aislaron 19 cepas de nocardia, las cuales se identificaron mediante características morfofisiológicas como: nocardia asteroides, n. brasiliensis y nocardia spp. Los resultados del presente estudio permiten alertar al clínico sobre la incidencia de nocardia en afecciones pulmonares en pacientes de nuestro medio