Devasahayam Jesudas Christopher

Lethal interaction: the colliding epidemics of tobacco and tuberculosis

Tobacco consumption ranks high among the leading health risks and tuberculosis (TB) is a major public health issue in countries where the smoking problem has reached epidemic proportions. Given that both smoking and TB are major health concerns and are widely prevalent in several countries, it is surprising that the association between smoking and TB is still a matter of debate and controversy. Although several studies have evaluated the effect of smoking on TB, the association has been largely overlooked by the TB and public health communities at large. Three recent reviews, including two meta-analyses, have summarized a large body of published literature on the association between smoking and various TB outcomes. These reviews show that there is considerable evidence that tobacco smoking is associated with TB. The evidence is strong for TB disease but less strong for TB infection and mortality. Even if the effect is relatively modest, the population-attributable risk is likely to be substantial due to the widespread nature of tobacco exposure. TB control programs must begin to address tobacco control as a potential preventive intervention. Since tobacco control will have multiple health benefits, it is likely to be a highly cost-effective intervention from a societal perspective.

Adjunctive vitamin D for treatment of active tuberculosis in India: a randomised, double-blind, placebo-controlled trial

BACKGROUND Vitamin D has immunomodulatory effects that might aid clearance of mycobacterial infection. We aimed to assess whether vitamin D supplementation would reduce time to sputum culture conversion in patients with active tuberculosis. METHODS We did this randomised, double-blind, placebo-controlled, superiority trial at 13 sites in India. Treatment-naive patients who were sputum-smear positive, HIV negative, and had pulmonary tuberculosis were randomly assigned (1:1), with centrally labelled, serially numbered bottles, to receive standard active tuberculosis treatment with either supplemental high-dose oral vitamin D3 (four doses of 2·5 mg at weeks 0, 2, 4, and 6) or placebo. Neither the patients nor the clinical and laboratory investigators and personnel were aware of treatment assignment. The primary efficacy outcome was time to sputum culture conversion. Analysis was by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00366470. FINDINGS Between Jan 20, 2010, and Aug 23, 2011, we randomly assigned 247 participants to the vitamin D group (n=121) or the placebo group (n=126), of whom 211 participants (n=101 and n=110, respectively) were included in the primary efficacy analysis. Median time to culture conversion in the vitamin D group was 43·0 days (95% CI 33·3-52·8) versus 42·0 days (33·9-50·1) in the placebo group (log-rank p=0·95). Three (2%) patients died in the vitamin D group and one (1%) patient died in the placebo group; no death was considered attributable to the study intervention. No patients had hypercalcaemia. INTERPRETATION Our findings show that vitamin D supplementation did not reduce time to sputum culture conversion. Further studies should investigate the role of vitamin D in prevention or reactivation of tuberculosis infection. FUNDING Dalhousie University and Infectious Diseases Training and Research Centre.

Tuberculosis infection among young nursing trainees in South India.

Background Among healthcare workers in developing countries, nurses spend a large amount of time in direct contact with tuberculosis (TB) patients, and are at high risk for acquisition of TB infection and disease. To better understand the epidemiology of nosocomial TB among nurses, we recruited a cohort of young nursing trainees at Christian Medical College, a large, tertiary medical school hospital in Southern India. Methodology/Principal Findings Among 535 nursing students enrolled in 2007, 468 gave consent to participate, and 436 underwent two-step tuberculin skin testing (TST). A majority (95%) were females, and almost 80% were under 22 years of age. Detailed TB exposure information was obtained using interviews and clinical log books. Prevalence of latent TB infection (LTBI) was estimated using Bayesian latent class analyses (LCA). Logistic regression analyses were done to determine the association between LTBI prevalence and TB exposure and risk factors. 219 of 436 students (50.2%, 95% CI: 45.4–55.0) were TST positive using the 10 mm or greater cut-off. Based on the LCA, the prevalence of LTBI was 47.8% (95% credible interval 17.8% to 65.6%). In the multivariate analysis, TST positivity was strongly associated with time spent in health care, after adjusting for age at entry into healthcare. Conclusions Our study showed a high prevalence of LTBI even in young nursing trainees. With the recent TB infection control (TBIC) policy guidance from the World Health Organization as the reference, Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement TBIC interventions, and enhance capacity for TBIC at the country level. Young trainees and nurses, in particular, will need to be targeted for TBIC interventions.

Performance of Xpert MTB/RIF on pleural tissue for the diagnosis of pleural tuberculosis

To the Editor: Tuberculosis (TB) remains the second leading cause of death from an infectious disease in adults. Extrapulmonary TB (EPTB) accounts for about 25% of all cases of active TB. Pleural TB is the second most common manifestation of EPTB. Existing tests for the diagnosis of pleural TB have major limitations in terms of accuracy, time to diagnosis and drug resistance testing, and require special expertise for sample acquisition and interpretation of the results. Biopsy of the pleural tissue for combined histological examination and culture is considered the diagnostic gold standard, albeit imperfect [1, 2]. The Xpert MTB/RIF assay (Xpert; Cepheid, Sunnyvale, CA, USA) is a rapid, World Health Organization (WHO) endorsed, automated PCR test optimised for respiratory specimens that can detect both Mycobacterium tuberculosis (MTB) and rifampicin resistance [3, 4]. Given the limitations of available tests for the diagnosis of pleural TB, several studies have evaluated the performance of Xpert using pleural fluid as a sample type. Overall, these studies show limited accuracy with sensitivity averaging around 44% [5–7]. However, the preferred specimen for the diagnosis of pleural TB is pleural tissue. To date, the evaluation of Xpert performed on pleural tissue has been limited to isolated samples within larger studies [4, 6, 7]. We enrolled consecutive adult patients that were evaluated for pleural TB in the pulmonary clinic and inpatient ward at the Christian Medical College, Vellore, India. Pleural TB was suspected based on clinical symptoms and radiographic evidence of a pleural effusion. Information on demographics, comorbidities, presenting symptoms and results of diagnostic evaluation were collected prospectively. The institutional review boards of the Christian Medical College …

High annual risk of tuberculosis infection among nursing students in South India: a cohort study.

Background Nurses in developing countries are frequently exposed to infectious tuberculosis (TB) patients, and have a high prevalence of TB infection. To estimate the incidence of new TB infection, we recruited a cohort of young nursing trainees at the Christian Medical College in Southern India. Annual tuberculin skin testing (TST) was conducted to assess the annual risk of TB infection (ARTI) in this cohort. Methodology/Principal Findings 436 nursing students completed baseline two-step TST testing in 2007 and 217 were TST-negative and therefore eligible for repeat testing in 2008. 181 subjects completed a detailed questionnaire on exposure to tuberculosis from workplace and social contacts. A physician verified the questionnaire and clinical log book and screened the subjects for symptoms of active TB. The majority of nursing students (96.7%) were females, almost 84% were under 22 years of age, and 80% had BCG scars. Among those students who underwent repeat testing in 2008, 14 had TST conversions using the ATS/CDC/IDSA conversion definition of 10 mm or greater increase over baseline. The ARTI was therefore estimated as 7.8% (95%CI: 4.3–12.8%). This was significantly higher than the national average ARTI of 1.5%. Sputum collection and caring for pulmonary TB patients were both high risk activities that were associated with TST conversions in this young nursing cohort. Conclusions Our study showed a high ARTI among young nursing trainees, substantially higher than that seen in the general Indian population. Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement internationally recommended TB infection control interventions to protect its health care workforce.

Chylothorax following Innominate Vein Thrombosis – A Rare Complication of Transvenous Pacemaker Implantation

A case of chylothorax following innominate vein thrombosis which developed as a late complication of transvenous pacemaker implantation is discussed. A 78-year-old man presented with a refractory left-sided pleural effusion, which turned out to be a chylothorax. He had undergone a transvenous pacemaker implantation 6 years earlier for sick sinus syndrome. Aetiological work-up showed occlusion of the innominate vein as the cause for the chylothorax. The chylothorax resolved following pleurodesis with talc slurry, and the innominate vein was recanalized by angioplasty. To our knowledge, this is the first report of a case of this nature.

MDR- and XDR-TB among suspected drug-resistant TB patients in a tertiary care hospital in India

Aim:  To study the anti‐tubercular drug resistance pattern among suspected cases of drug‐resistant TB.

Clinico-pathologic study of pulmonary carcinoid tumours – A retrospective analysis and review of literature

OBJECTIVE To determine the characteristic clinico-pathologic features of pulmonary carcinoid tumours in India. METHODS Retrospective analysis of the clinico-pathologic and radiologic data of patients with pulmonary carcinoid tumours from the department of Pulmonary Medicine of the Christian Medical College, a tertiary care teaching hospital in Southern India, over a study period of 3 years (2001-2004). RESULTS There were 25 cases of pulmonary carcinoid tumours: typical 22 (88%) and atypical 3 (12%). The ratio of female to male was 0.8:1. There were 3 smokers (all of whom were males) in the typical carcinoid group and none in the atypical carcinoid group. Haemoptysis and cough were the commonest presenting symptoms. The common radiologic findings were post-obstructive pneumonitis or atelectasis, and mass lesion. Carcinoid syndrome was not present in any patient. Most of the tumours were central (n=23; 92%) and in the main bronchi (n=13; 52%). The most common site was the right main bronchus (n=9; 36%). Diagnosis was made by flexible bronchoscopy and bronchial biopsy in 23 patients (92%). The tumour bled significantly following biopsy in most patients; however, there was no mortality, and only 1 patient required blood transfusion. Surgical option was offered to most; 13 patients (52%) had pneumonectomy and 4 patients (16%) had lobectomy. A review of large series from the literature is also presented. CONCLUSION The clinico-pathologic and radiologic features of pulmonary carcinoid tumours are presented. We report the first series of pulmonary carcinoid tumours from India.

RePORT International: Advancing Tuberculosis Biomarker Research Through Global Collaboration

Progress in tuberculosis clinical research is hampered by a lack of reliable biomarkers that predict progression from latent to active tuberculosis, and subsequent cure, relapse, or failure. Regional Prospective Observational Research in Tuberculosis (RePORT) International represents a consortium of regional cohorts (RePORT India, RePORT Brazil, and RePORT Indonesia) that are linked through the implementation of a Common Protocol for data and specimen collection, and are poised to address this critical research need. Each RePORT network is designed to support local, in-country tuberculosis-specific data and specimen biorepositories, and associated research. Taken together, the expected results include greater global clinical research capacity in high-burden settings, and increased local access to quality data and specimens for members of each network and their domestic and international collaborators. Additional networks are expected to be added, helping to spur tuberculosis treatment and prevention research around the world.

Inflammatory pseudotumour of the lung with sarcomatous brain metastasis.

J. JEBA, md, lecturer, Department of Radiation Therapy, Christian Medical College and Hospital, Vellore, S. JOHN, dmrt, md, mams, professor, Department of Radiation Therapy, Christian Medical College and Hospital, Vellore, S. BACKIYANATHAN, md, dnb, reader, Department of Radiation Therapy, Christian Medical College and Hospital, Vellore, D.J. CHRISTOPHER, dnb, fccp, professor, Department of Pulmonary Medicine, Christian Medical College and Hospital, Vellore, & S. KURIAN, md, professor, Department of General Pathology, Christian Medical College and Hospital, Vellore, India