Multi drug resistance tuberculosis: pattern seen in last 13 years

Drug resistance in tuberculosis is a serious problem throughout the world especially, after the emergence of multi drug resistant TB strains. To estimate drug resistance in TB patients and compare it with previous studies to see the changing trends. The PMRC Research Centre receives sputum samples from all the leading hospitals of Lahore. This retrospective analysis was done from 1996 to 2008 on the multi drug resistant TB strains that were seen during these years. Five first lines tuberculosis drugs were tested on Lowenstein Jensen medium using standard proportion method. A total of 2661 confirmed isolates of Mycobacterium tuberculosis were seen over the past 13 years. Of the total, 2182 were pulmonary and 479 were extra pulmonary specimens. The patients comprised of those with and without history of previous treatment. These specimens were subjected to drug susceptibility testing. Almost half of the patient had some resistance; multiple drug resistance were seen in 12.3% and 23.0% cases without and with history of previous treatment respectively. overall resistance to rifampicin was 26.4%, isoniazid 24.1% streptomycin 21.6% ethambutol 13.4% and pyrazinamide 28.4% respectively. Statistically significant difference was seen between primary and acquired resistance. When compared with the reports from previous studies from the same area, there was a trend a gradual increase of drug resistance. Resistance to anti tuberculosis drugs in high. TB Control Program should start "DOTS Plus" schemes for which drug susceptibility testing facilities should be available for correctly managing the patients

Clinico-pathological profile and treatment outcome in smear negative pulmonary tuberculosis patients at a teaching hospital

Tuberculosis remains the single highest contributor to the world's morbidity and mortality. Early diagnosis and prompt treatment is essential to prevent its transmission. To see the treatment response of anti tuberculosis drugs in smear negative patients and study the predictors of culture positive among smear negative tuberculosis patients. This descriptive study was carried out at Chest Clinic, Sir Ganga Ram hospital in collaboration with PMRC TB Research Centre Mayo hospital, Lahore. Ninety four sputum smear negative patients clinically and radiologically suggestive of tuberculosis were selected. These patients were put on anti tuberculosis drugs without waiting for their culture results. They were then followed for 8 months to see their treatment outcome. A total of 94 smear negative patients were selected and given anti tuberculosis treatment. Of these 37 [39%] were culture positive and 57 [61%] were culture negative. Of the 37 culture positive patients 36 [97%] showed clinical or radiological improvement as compared to 46 [81%] out of 57 in culture negative cases. Symptoms of cough with sputum production was significantly associated with culture positivity. On x-ray chest moderate lesion with diffuse infiltration was more common finding in 64% while extensive and cavitatory lesion was seen in 24% of all cases. Association of extensive and cavitatory lesion were seen in culture positive group. Response to anti tuberculosis drugs in sputum smear negative tubercolosis suspects was found to be effective in majority of the patients. Cough, sputum and extensive cavitatory lung lesion were the predictors of culture positive cases. There is need to train physicians on the use of anti tuberculosis therapy in smear negative suspected pulmonary tuberculosis cases, especially if they have productive cough and cavitatory lung lesions

Multidrug resistance tuberculosis in Lahore

To estimate drug resistance in TB patients and compare it with the previous studies to see if there is a changing trend. PMRC TB research centre Mayo hospital Lahore which is a specialized centre on research and diagnosis of tuberculosis. The centre receives sputum samples from all the leading hospitals of Lahore. This work was done from 2004 to 2006 where five first lines anti tuberculosis drugs were tested on LJ.medium using standard proportion method. A total of 582 confirmed isolates of Mycobacterium tuberculosis were seen. Of the total 454 were pulmonary and 128 extra pulmonary specimens from 582 patients. These patients comprised of those with and without history of previous treatment. These sputa were subjected to drug susceptibility testing. Almost half of the patients had some resistance; multiple drug resistance [MDR] was seen in 12.8% and 27.0% cases without and with history of previous treatment respectively. Overall resistance to rifampicin was 26.6%, to isoniazid 23.5%, streptomycin 19.5%, ethambutol 11.8%, and to pyrazinamide 29.7%. Statistically significant difference was seen between primary and acquired resistances. When compared with the reports from previous studies from the same area, there was a trend of gradual increase of drug resistance in this area. Resistance to anti tuberculosis drugs is high in Lahore. The current approach may not be adequate and innovative approaches such as DOTS-Plus may have to be employed to effectively control MDR TB

analysis of sputum smear and x-ray results in diagnosis of smear negative pulmonary tuberculosis

To study the role of chest x-ray in the diagnosis of sputum smear negative cases. Descriptive study. The study was carried out in the chest unit of Mayo hospital and PMRC TB research centre Lahore. A total of 220 suspects were analyzed for their AFB smear, culture from sputum and chest X-ray results. Sputum smear negative cases having findings consistent with TB on chest x-ray were matched with culture results for the final diagnosis. Sensitivity, specificity, negative and positive predictive values of the chest x-ray was determined in smear negative cases. Among 124 smear negative cases 85% with extensive lesion and 60% with moderate lesion were culture positive.. Among all 207 cases, the culture positivity was 91% among patients with extensive lesion and 72%in those having moderate lesions. The sensitivity and specificity of x-ray chest in sputum smear negative cases came out to be 94% and 68%, while positive and negative predictive values were 78% and 98%.There are various tools used for diagnosis of smear negative pulmonary TB some of these are expensive and are not available in high burden countries. In a poor resource setting x-ray chest and a course of 14 days antibiotics and clinical evaluation of the patient has been found useful in diagnosing sputum smear negative pulmonary TB cases

Value of three sputum smears microscopy in diagnosis of pulmonary tuberculosis

Early diagnosis and treatment are essential to prevent transmission of tuberculosis in the community. Smear microscopy with Zeihl-Neelsen [ZN] staining is currently the most feasible microbiological method for diagnosis of pulmonary TB in developing countries due to its rapidity, low cost and high positive predictive value for Mycobacterium tuberculosis. This study was carried out to assess the diagnostic yield of three AFB smears microscopy among suspected pulmonary tuberculosis patients of Lahore district. This descriptive study was conducted at PMRC TB Research Centre King Edward Medical University/Mayo Hospital, Lahore Pakistan where DOTS has been implemented. Patients with respiratory symptoms and or abnormal chest X-rays provided three sputum samples each for acid-fast bacilli smear microscopy. Smears were prepared and stained by Ziehl-Neelsen staining method. In 2006 a total of 2,222 TB suspects submitted three sputum samples on two consecutive days [spot, early morning, spot], therefore 6,666 AFB smear microcopy examinations were performed. The smear positivity rate was 11.5% and 257 [11.56%] suspects fulfilled the case definition of having one positive smear confirmed by a second smear. A total of 438 [19.7%] suspects had a least one positive smear; of these 290 [66.2%] were positive in first smear, 105 [24%] were negative in first smear but positive in second and 43 [9.8%] were positive in third smear after two negative smears. At least three smear microscopy examinations are required for proper diagnosis. The higher diagnostic yield of 9.8% in third smear is indicative of the importance of third smear

Pattern of drug resistance in tuberculosis

To estimate drug resistance in TB patients and compare it with previous studies to see the changing trends. This work was done at the TB Research center of Pakistan Medical Research Centre at Mayo hospital Lahore from 2000 to 2003. The center receives specimens from all the leading hospitals of Lahore. Five first line anti tuberculosis drugs were tested on LJ medium using proportion method. A total of 894 confirmed isolates of Mycobacterium tuberculosis [759 pulmonary and 135 extra pulmonary] from 894 patients, with and without history of previous treatment, were subjected to drug susceptibility testing about 50% of the patients had some resistance. Multiple drug resistance [MDR] was found in 12% and 23% without and with history of previous treatment respectively. Overall resistance to rifampicin was 28.6%, isoniazid 25.6%, streptomycin 23.8%, ethambutol 14.5%, and pyrazinamide 29.3%. Statistically significant difference was seen between primary and acquired resistances. Results when compared with the previous studies from the same area showed a gradual increase in drug resistance. Resistance to anti tuberculosis drugs in Lahore is high and needs to be addressed in the national tuberculosis control program and in the implementation of DOTS program in the country

Lower lung field tuberculosis

This study was conducted to define the frequency of lower lung field tubercuiosis.The patients who were AFB smear positive and had infiltrate in the lower lung field on X-ray chest P.A. view were analyzed in detailed for age group, sex proportion, clinical presentations and for their outcome. They were also analyzed for associated diseases and the findings were compared with other reported studies. A retrospective review of 25 cases of lower lung field tuberculosis treated at the institute of tuberculosis and Chest diseases, King Edward Medical College/Mayo Hospital, Lahore during on year period was undertaken. The 25 patients comprise 16 males [64%] and 9 females [36%]. The clinical features of the patients were similar to those of previous reported studies. In one year period 54.45% admission were due to pulmonary tuberculosis. Among them 3.98% had lower lung field tuberculosis. 60% were between 15-55 years, 32% had diabetes mellitus 4% renal failure 8% cirrhosis of liver and 4% were having kyphoscoliosis. We conclude that this atypical presentation i.e. lower lung field tuberculosis should be kept in mind because the clinical features of the disease may be nonspecific. Lower lung field tuberculosis produces much confusion in the diagnosis. The atypical presentation is more common in advance age, patients on steroids treatment, renal or hepatic disease. An early diagnosis of lower lung field tuberculosis is necessary to prevent complications. A high index of suspicion is essential for the early diagnosis in order to avoid delay in therapy and poor out come

comparative study of radiological pattern of pulmonary tuberculosis in diabetics versus non diabetics

Pulmonary tuberculosis continues to be a major health hazard in developing including Pakistan. Radiology plays a very important role in the case finding and diagnosis of pulomonary tuberculosis. A study was carried out to determine the radiological pattern pf pulmonary tuberculosis in diabetics versus non-diabetic adults at department of chest medicine, King Edward Medical College, Mayo Hospital, Lahore. One hundred and fifty chest radiographs were reviewed of patients [75 diabetics and 75 Non-diabetics] who were smear positive for AFB. In diabetics upper zone involvement was seen in 60% as compared to 70% in non-diabetics. No case of tuberculoma was seen in both groups, bilateral involvement was common as compared to unilateral involvement in both groups. Cavitary disease was seen in 64.4% diabetics as compared to 39.6% .In non-diabetic patients. In non-diabetics lower zone involvement was seen in 8% as compared to 14.7% in diabetics. It was concluded that majority of patients still presented with typical pattern but the knowledge of other patterns is also very important especially in diabetics where lower lung field involvement cavitary disease is commoner