C.N. Paramasivan

Association of pulmonary tuberculosis and HLA in south India.

In 204 patients with smear-positive pulmonary tuberculosis HLA-A10, B8 and DR2 were more frequently found than in 404 control subjects (p = 0.01); the greatest attributable risk (0.29) was associated with HLA-DR2. The radiographic extent of disease was also associated with HLA-DR2 (p = 0.0001). In 152 patients with smear-negative pulmonary tuberculosis, the frequencies of HLA-A10 and B8, but not DR2, were greater in the control subjects (p = 0.001 and 0.01 respectively). HLA-DR2 may be involved in the pathogenesis of advanced pulmonary tuberculosis. Study of endogamous, genetically disparate populations (caste) revealed other HLA associations (A3, B12 and DR4) unique to them, suggesting that genes linked with the HLA complex might also be significant in the pathogenesis of tuberculosis.

Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pulmonary tuberculosis in children

OBJECTIVEnThe aim of our study was to find out if bronchoalveolar lavage (BAL) would be better than gastric lavage for the isolation of Mycobacterium tuberculosis from pediatric patients with suspected pulmonary tuberculosis.nnnDESIGNn50 children with suspected pulmonary tuberculosis at a mean age of 5.1 years (range 7 months to 12 years) were studied. Early morning gastric lavage was collected. Flexible bronchoscopy and bronchoalveolar lavage was performed under local anaesthesia after obtaining informed consent from the parents. The BAL fluid and gastric lavage specimens were subjected to smear examination for acid-fast bacilli (AFB) and culture for mycobacteria using established methods.nnnRESULTSnOf the 50 cases, M. tuberculosis was grown in 6 BAL samples (12%) and 16 gastric lavage samples (32%) making a total of 17 culture proven cases (34%). Out of the 6 BAL positive cases, gastric lavage was also positive in 5 cases.nnnCONCLUSIONnWe conclude that gastric lavage is better than BAL for bacteriologic confirmation of pulmonary tuberculosis in children. The overall bacteriologic yield combining both procedures was 34% while gastric lavage alone was positive in 32% of the cases.

Critical assessment of smear-positive pulmonary tuberculosis patients after chemotherapy under the district tuberculosis programme

This is a status report of a retrospectively assembled cohort of 3357 smear-positive patients initiated on anti-tuberculosis chemotherapy in the North Arcot district between April 1986 and March 1988. The patients were contacted once at their homes between November 1988 and June 1989 (6 and 36 months after start of treatment), and information on their status, including death, could be obtained from 76% of them. Regimens were selected by the patients. 2306 (69%) had accepted short course regimens (SCC) and 1051 (31%) had been started on standard chemotherapy (non-SCC), 43% and 35% in SCC and non-SCC respectively had completed 80% or more of their treatment. Overall mortality was 28%. Of those remaining, 31% had active disease and were excreting bacilli, among which 65% of the cultures were resistant to isoniazid and 12% to rifampicin. Combined resistance to isoniazid and rifampicin was seen in 4% and to isoniazid and streptomycin was seen in 19%. A significant finding was that even among those who had taken less than 50% of their treatment, 56% were bacteriologically negative. However, inadequate or irregular chemotherapy resulted in over four times the mortality and about twice the rate of smear positivity as compared with those taking adequate chemotherapy. No comparisons are made between patients on short-course and standard regimens as the patients selected their treatment and the groups are not comparable.

Short course chemotherapy for tuberculous lymphadenitis in children.

OBJECTIVE--To assess the efficacy of a short course chemotherapy regimen for treating tuberculosis of the lymph nodes in children. DESIGN--Open, collaborative, outpatient clinical trial. SETTING--Outpatient department of the Tuberculosis Research Centre, paediatric surgery departments of the Institute of Child Health and Hospital for Children and the Government Stanley Hospital, Madras, South India. PATIENTS--Children aged 1-12 years with extensive, multiple site, superficial tuberculous lymphadenitis confirmed by biopsy (histopathology or culture). INTERVENTIONS--Patients were treated with a fully supervised intermittent chemotherapy regimen consisting of streptomycin, rifampicin, isoniazid, and pyrazinamide three times a week for two months followed by streptomycin and isoniazid twice a week for four months on an outpatient basis. Surgery was limited to biopsy of nodes for diagnosis and assessment. MAIN OUTCOME MEASURES--Response to chemotherapy was assessed by regression of lymph nodes and healing of sinuses and abscesses during treatment and follow up. Compliance with treatment and frequency of adverse reactions were also estimated. RESULTS--197 Patients were admitted to the study and 168 into the analysis. The regimen was well tolerated and compliance was good with 101 (60%) patients receiving the prescribed chemotherapy within 15 days of the stipulated period of six months. Those whose chemotherapy extended beyond that period received the same total number of doses. Clinical response was favourable in most patients at the end of treatment. Sinuses and abscesses healed rapidly. Residual lymphadenopathy (exceeding 10 mm diameter) was present in 50 (30%) patients at the end of treatment; these nodes were biopsied. Fresh nodes, increase in size of nodes, and sinuses and abscesses occurred both during treatment and follow up. After 36 months of follow up after treatment only 5 (3%) patients required retreatment for tuberculosis. CONCLUSION--Tuberculous lymphadenitis in children can be successfully treated with a short course chemotherapy regimen of six months.

Bacteriological investigations for short-course chemotherapy under the tuberculosis programme in two districts of India

To examine the bacteriological profile and the prevalence of drug resistance among patients attending the health facilities where the District Tuberculosis Programme (DTP) was in operation with short-course chemotherapy (SCC) regimens, sputum specimens were collected on admission and the end of treatment in North Arcot district and Pondicherry region. In North Arcot district, rifampicin, isoniazid and pyrazinamide were given twice weekly for the first 2 months followed by rifampicin and isoniazid twice a week for the next 4 months under fully supervised administration. In Pondicherry, rifampicin, isoniazid and pyrazinamide were given daily for the first 2 months followed by rifampicin and isoniazid twice weekly for the next 4 months. Of the patients who had received 80% or more of the drugs, 80% from North Arcot and 92% from Pondicherry were rendered culture-negative for Mycobacterium tuberculosis at the end of treatment. Even among patients with initially resistant bacilli, a high proportion had a favourable response. Before start of treatment, of the 2779 patients from North Arcot, 25% had resistance to one or more drugs including 2% with resistance to rifampicin. In Pondicherry, 13% of the patients had initial resistance to one or more drugs. Initial resistance to rifampicin was observed in 0.9%. None of the initially drug-sensitive patients had acquired resistance to rifampicin at the end of treatment.

Localized Pulmonary Mycobacterium avium Disease in HIV-Infected Patients Without Access to HAART.

Mycobacterium avium complex (MAC) is known to ncause disseminated disease in patients with AIDS,1 and nthe incidence of dissemination is strongly correlated to nthe level of immunosuppression. Localized pulmonary nMAC without dissemination is relatively rare in the nsetting of advanced AIDS,2 and not many cases of pulmonary nMAC have been reported from tuberculosisendemic ncountries.3 In countries with widespread naccess to antiretroviral therapy, the incidence of both ndisseminated and pulmonary MAC has fallen sharply. nIn this report, we describe 5 patients with AIDS and nfocal pulmonary Mycobacterium avium infection, all of nwhom lacked evidence of disseminated disease.

Non-fermenting Gram Negative Bacilli Associated with Acute Respiratory Infections in Children in Madras

Non-fermenting Gram negative bacilli (NFGNB) were isolated as the most predominant organism from nchildren suffering from acute respiratory illness (ARI) and accounted for 40 out of 151 children reported nin the study. Five of the NFGNB were isolated in pure culture and all of them were from children having nlower respiratory infection. The isolation of NFGNB was higher when the duration of illness exceeded 7 ndays (44 per cent) as compared to 22 per cent with less than 7 days duration (P= 0.03). Detailed identification nstudies on 61 isolates of NFGNB showed that 56 (92 per cent) of them belonged to Pseudomonas npseudoalkaligenes alkaligenes group. Four strains were identified as Ps. pseudomallei group and one as nPs. stutzeri. The majority of the NFGNB isolates showed multidrug resistance.