Hospital costs in the US for pulmonary mycobacterial diseases

Pulmonary mycobacterial diseases describe both tuberculosis [TB] and nontuberculous mycobacteria [NTM]. Few data are available measuring the cost burden of mycobacterial diseases at the national level. The purpose of this study is to evaluate the cost burden and measure emerging trends in hospitalization of pulmonary TB and NTM cases in the United States from 2001 through 2012. This study is a retrospective, community-based cost analysis of hospitalized patients with a principal diagnosis of pulmonary mycobacterial diseases from 2001 through 2012. Data for pulmonary TB and NTM were retrieved from the Healthcare Cost and Utilization Project [HCUP], US Department of Health and Human Services. The statistical significance of observed trends of NTM and TB national hospital costs was calculated using Poisson log-linear regression. 20,049 hospital discharges were reported for pulmonary NTM and 69,257 for pulmonary TB in the US from 2001 through 2012. The total associated cost of these discharges was 903,767,292 dollars for pulmonary NTM and 2,078,113,317 dollars for pulmonary TB. During the study period, the national hospital costs of pulmonary NTM increased at a statistically significant rate in the US over each year [P = 0.001]. However, no such increase was found for national hospital costs of pulmonary TB. The national hospital cost of NTM management is increasing. These results emphasize the importance of continued research in pulmonary NTM in order to improve current guidelines in prevention and treatment strategies

Gender susceptibility to mycobacterial infections in patients with non-CF bronchiectasis

Non-tuberculous mycobacteria [NTM] are environmental microbes that cause a variety of diseases both in immunocompromised and immunocompetent patients. Epidemiologic data indicate that there has been a global rise in the incidence of NTM infections. It has also been noted that NTM infections have a predilection to occur in postmenopausal women. In a recent study, it was demonstrated that in patients with non-CF bronchiectasis the probability of NTM isolation was significantly higher in elderly female patients and in those with a low body mass index. However, the mechanisms of causality of these gender differences and morpho-phenotypes remain enigmatic. The present study reviews the data and plausible mechanisms which might provide clues to this gender susceptibility and morphophenotypes of patients with bronchiectasis and NTM

Multidrug- resistant tuberculosis treatment with linezolid-containing regimen

The following is a case of multidrug-resistant pulmonary tuberculosis [MDR-TB] that was treated successfully with a linezolid-containing regimen. It was found that linezolid is an efficient medicine for MDR-TB treatment with an acceptable side effect profile. Treatment was maintained for 18 months, and closely monitoring toxicities did not reveal evidence of any neurologic adverse effects. However, despite our expectation, thrombocytopenia was seen after 2 years follow-up

Comparison of pulmonary TB patients with and without diabetes mellitus type II

There are several studies on the effect of diabetes mellitus [DM] on clinical symptoms and radiological findings of multi-drug resistant tuberculosis [MDR-TB] and bacteriological findings in pulmonary tuberculosis patients. Considering the contradictory results of these studies, this study was conducted for further investigation in this regard. This was a case-control study conducted in Masih-Daneshvari Hospital in Tehran. Forty-seven patients with tuberculosis infection and diabetes type II were selected as the case group and 102 TB cases without diabetes were considered as controls. There were significant differences in hemoptysis, dyspnea and loss of appetite between the two groups, but no significant difference was found in cough, sputum production, chest pain, night sweat, fever or weight loss. Also, there was no significant difference between the 2 groups in terms of MDR-TB and bacteriological findings. On CXR, diabetic patients had a higher prevalence of typical presentations along with cavitary lesion[s] but no significant difference was found between the 2 groups in terms of radiological presentation. In this study, diabetes type II did not have much influence on clinical symptoms and bacteriological findings of TB patients. However, PTB-DM type II cases may be considered more contagious due to the higher prevalence of cavitary lesions compared to those without DM. Prevalence of MDR-TB was the same in both groups

Lymphocytic bronchiolitis as presenting disorder in an undiagnosed adult patient with chronic granulomatous disease

Chronic Granulomatous Disease [CGD] is a rare primary immunodeficiency disease. Although the most affected patients are diagnosed in childhood, there are several reports of the disease presenting in adult patients. Here we present a 40 years old man who was admitted in hospital due to respiratory symptoms and ground glass pattern in high resolution computed tomography of lung. Open lung biopsy revealed lymphocytic bronchiolitis. Because of past medical history of granulomatous lesion in lung and recurrent abscesses of skin and soft tissue, NBT test was conducted which its result revealed that the disorder was compatible with CGD and then it was confirmed by fluorescent cytometry

Increased activation and expansion of a CD57+ subset within peripheral CD8+ T lymphocytes in mycobacterium tuberculosis-infected patients

Mycobacterium tuberculosis-specific CD8+ and CD4+ T lymphocyte responses restrict the spread of extracellular pathogens by limiting M.tuberculosis replication. Alterations in cytolytic function, inappropriate maturation/differentiation, and limited proliferation could reduce their ability to control M.tuberculosis replication. In an attempt to further characterize the immune responses during M.tuberculosis infection, we enumerated delta and alpha beta receptor-bearing T cells expressing CD8 or CD4 phenotype and analyzed the differentiation phenotypes of CD8+ and CD4+ T lymphocyte subpopulations in 47 cases [23 new cases and 24 multidrug resistant patients] and 20 control subjects, using flowcytometry. We found that the CD4/CD8 ratio was significantly lower in newly-diagnosed M.tuberculosis patients compared to multidrug resistant and control subjects [P < 0.003]. Also, we found that a large proportion of CD8+ T lymphocytes in newly-diagnosed patients was defined by increased surface expression of CD57 as compared to the two other settings [P < 0.002]. This increase was more profound in patients with an inverted CD4/CD8 ratio. Analysis of the late activation antigen revealed that this was predominantly HLA-DR+ [P < 0.003]. No significant changes were observed in the percentages of CD8+CD57+ T cells between the different settings. Moreover, the co-stimulatory molecule CD28+ tended to be underexpressed by CD8+ T cells in multidrug resistant patients when compared to newly-diagnosed subjects [P < 0.002], but not to the control subjects. In contrast, the frequency of CD28+ marker on CD4+ T cells was higher in the setting of multidrug resistant compared with those of new cases [P < 0.0001]. No significant changes were observed in percentages of delta receptor-bearing T cells between different groups. We suggest that the increase in the proportion of CD57+ within CD8+ T cells in newly-diagnosed patients results from M.tuberculosis antigenic stimulation, which is a hallmark of many infections and that the protracted accumulation of CD57+ T lymphocytes might reflect an end-stage differentiation phenotype

Short outcome and evaluation of hemoptysis in patients with old pulmonary TB

Data concerning the evaluation of hemoptysis in patients affected by Tuberculosis backs to 1940-1960. Remarkable advances in anti TB agents together with effective treatment strategies such as DOTS [Directly Observed Treatment Short Course] has made the feature of the disease to be less associated with severe complications like hemoptysis due to bronchiectasis or fibrocavernous lesions. The objective of this study was to evaluate the short outcome of the patients with hemoptysis due to old tuberculosis and also the relation of the severity of hemoptysis with length of stay [LOS] in hospital and the severity of the pulmonary lesion in high quality imaging techniques. Forty-five patients with old TB and cardinal sign of hemoptysis were evaluated and after excluding the mycetoma and suggestive tumor formation, the coefficient correlation between the severity of hemoptysis and the LOS and also the correlation of the severity of hemoptysis and different pictures of pulmonary lesions in CT- scan were evaluated with Spearman's rho statistical analysis. All patients were discharged except one who had died because of the reasons other than asphyxia due to hemoptysis. One patient had undergone bronchial artery embolization. Pulmonary resection had been performed in none of the patients. According to the non-parametric coefficient correlation analysis, there were significant correlations between age and the first evidence of residual TB in the lung parenchyma [P=0.00, Spearman rho 0.00] and also between severity of hemoptysis and pulmonary lesions in CT scan at the level of 0.05; but no correlation was observed between the LOS and the severity of hemoptysis [P=0.0769] Hemoptysis due to old destructive pulmonary TB usually has a benign course. This is probably due to lung fibrosis and scarring caused by a prolonged inflammatory process which has led to an increase in vascular anastomosis. In old TB the source of bleeding is usually brochiectatic lesions which are directly correlated with the radiologic features found in chest- x- ray. The authors believe that although pulmonary resection in patients with life threatening hemoptysis is of considerable attention, conservative management of hemoptysis associated with arrested pulmonary TB is the first option

Evaluation of patients with infective endocarditis in a pulmonary referral centre

Despite the decreased incidence of rheumatic fever and use of prophylactic antibiotic the incidence rate of infective endocarditis has not declined. In this research, we have studied the clinical feature and therapeutic response of patients with infective endocarditis presenting with pulmonary manifestations to a pulmonary referral center. All patients with diagnosis of endocarditis that had pulmonary manifestations [based on Duke Criteria] as their primary clinical presentation were entered in this study. Data in regard to individual information, clinical features, laboratory finding and therapeutic responses were noted. All data were analysed using SPSS software [version 11.5]. A total number of twenty patients here entered the study. Mean age was 34.8 +/- 11.6 yr. The commonest clinical features included: fever [95%], cough [65%] and dyspnea [65%]. Also the commonest signs were cardiac murmurs [65%], hepatomegaly [35%] and splenomegaly [35%]. Clubbing was seen in 10%. Sixty percent of the cases were intravenous drug users and 25% were infected with HIV. Also 50% of the patients did not have any background of valvular diseases. However, there was vegetations on one valve in 75% and multiple valves were involved in 25%. The commonest valves affected were trocuspid [50%], mitral [30%] and pulmonic valve [10%]. Staphylococcus aureus [47.3%] and Streptococcus viridans [27.3%] were the commonest microorganisms detected. Pericardial effusion was present in 30% which was higher in IV drug users [p. value=0.042]. Total mortality rate in hospital was 5%. Infective endocarditis should be considered in the list of differential diagnosis in patients suffering from pulmonary symptoms especially in IV drug users

Clinical and radiological presentation of adult tuberculous spondylitis

Tuberculous spondylitis is an uncommon form of extra-pulmonary TB. Delay in establishing diagnosis and management causes spinal cord compression and spinal deformity. We studied to determine clinical and radiological presentations of this dangerous form of TB diseases. During 2002-3 years, all patients over 14 years old who hospitalized with a probable diagnosis of TB spondylitis were evaluated. Everybody with mycobacteriologic or pathologic confirmation was enrolled in study. fourteen patients met our inclusion criteria. The mean age [SD] was 39[16] year. 57% were male. Treatment delay was 8.3 months. Fever reported in 7[50%] patients. Local tenderness was reported in 92.6% of cases. PPD was positive in half of the patients. The most regions involved were T8-T12 [43%] and L1-L3 [36%] respectively. Sputum smear was surprisingly positive in 50% of cases. Most of the patients had received anti-TB drugs for 9-12 months. CT guided aspiration and biopsy of spine lead to correct diagnosis in 93% of patients. Simultaneous pulmonary involvement is evident in half of them

Cutaneous anergy in patients reciveing long term hemodialysis

Hemodialysis patients are at risk of acquiring tuberculosis, which is most often due to reactivation of the infection. As a result, screening for tuberculosis is recommended in hemodialysis patients. In this study, the rate of response to cutaneous PPD along with tetanus and diphteria toxoid antigens have been evaluated to define in hemodialysis patients. This clinical trial was conducted on 67 chronic hemodialysis patients in Labbafi Nejad Hospital during March- May 2001. PPD, tetanus and diphtheria toxoid solutions, with 1/10 dilution were administered by Manteaux technique and the induration was evaluated 48-72 hours, 7 and 9 days after. Of 64 patients, 18.8% had positive PPD tests and 26.6% had negative anergy tests through the first evaluation. The degree of constancy in the results of PPD and anergy tests during the three-time evaluation period were 23.4% and 18.7%, respectively, and the degree of induration was increased or decreased among the rest. Hemodialysis patients are at the increased risk for acquiring tuberculosis. Thus, negative cutaneous PPD results should certainly be revised and evaluated using anergy tests and repetitive readings of the test results. Attention must be paid to the "Delayed Type Hypersensitivity" [DTH] phenomenon presenting for the first time in the analysis of cutaneous test results. Finally, it is recommended to reconsider the value of cutaneous PPD test and its method of analysis in hemodialysis patients

efficacy of interferon-alpha in the treatment of multidrug resistant tuberculosis

Tuberculosis is a major cause of infectious disease modality all over the world. Multidrug resistant tuberculosis [MDR-TB] is a major problem in the management of tuberculosis. With recent advances in understanding the immunopathogenesis of tuberculosis, the use of various cytokine therapies has been suggested. The objective of this study was to evaluate the efficacy of parenteral INF-alpha for treating MDR-TB patients. To conduct the study, 12 MDR- TB patients hospitalised in the clinical mycobacteriology ward of Massih Daneshvari hospital were selected randomly between October 2000 and March 2001. All had chest involvement in radiography, so they were smear and culture positive on two occasions. All had at least resistance to isoniazid and rifampin in antibio gram. They were divided in two groups. One group received INF-alpha; [3,000, 000U, three times a week, subcutaneously] in addition to anti-TB drugs, and the other group received only anti -TB medications as control group. Results indicate that the mean [ +/- SD] degree of sputum smear positivity at the beginning of therapy was 2.4 +/- 0.89 in the case group and 2 +/- 0.89 in the control group which showed no significant difference [p 0.132]. Also, at the beginning of our study, there was no significant difference in the degree of sputum culture positivity between the two groups. At the end of the 8th week, all cases became smear and culture negative, but all control subjects remained smear and culture positive [p= 0.017]. At the end of the 6th month; however, only two cases remained smear negative, one remained culture negative and the rest became positive. All control subjects had positive culture results [p 0.693]. We conclude that cytokines have at least temporary effect on disease remission and can be used as adjunctive therapy