[Intensive chemotherapy tolerance in old patients with pulmonary tuberculosis]. / Perenosimost' intensivnoi khimioterapii bol'nymi starcheskim tuberkulezom.

In accordance with the WHO recommendations, the intensive stage of chemotherapy was performed in 100 patients aged 60 to 87 years who had pulmonary tuberculosis. Most (n = 78) patients successfully completed this stage and the remaining 22 patients developed intractable adverse reactions and they had to receive individual chemotherapy regimens. In addition, 27 more patients had adverse reactions that could be eliminated by routine methods, without discontinuing standard treatment. The distinctive feature of intractable reactions were their occurrence within the first 10-20 days after the onset of treatment, they were markedly toxic and allergic and appeared as changes in some organ systems. They are most likely to develop in patients with significant cardiovascular diseases (hypertensive disease, coronary heart disease) accompanied by pronounced focal and diffuse myocardial changes, as evidenced by ECG and in those with signs of prior myocardial infarction. Correctable adverse reactions generally occur in the final period of intensive chemotherapy, they are mainly toxic and differ from intractable reactions of less extent.

[Efficiency of an intensive stage of chemotherapy for tuberculosis in elderly and senile patients]. / Effektvnost' intensivnogo étapa khimioterapii tuberkuleza u lits pozhilogo i starcheskogo vozrasta.

A hundred new cases of active pulmonary tuberculosis whose age was 60 to 87 years were treated by the intensive chemotherapy regimen recommended by the WHO. Most (n = 78) patients satisfactorily tolerated the intensive stage, fully completed the regimen, and made up a study group (Group 1). Group 2 comprised the remaining 22 patients who had, due to its poor tolerance, to transfer to their individual regimen. The higher incidence of significant cardiovascular diseases in Group 2 patients is the only significant difference between these two identified groups. The advantages of the standard chemotherapy regimen are the more rapid elimination of symptoms of tuberculous intoxication; the earlier and more frequent disappearance of Mycobacterium tuberculosis from the sputum even with the primary drug resistance of the causative agent; as well as a more frequent closure of decay cavities. The findings make it possible to recommend a wider use of the standard intensive chemotherapy regimens for elderly and senile patients with tuberculosis.

[Clinical picture of tuberculosis with concomitant hemoblastoses]. / Klinicheskaia kartina techeniia tuberkuleza pri sochetanii s gemoblastozami.

AIM: To study clinical symptoms, course and diagnosis of tuberculosis in patients with hemoblastosis (HB). MATERIAL AND METHODS: 79 patients with tuberculosis and HB were examined. HB was represented by lymphoproliferative diseases (n = 61), acute leukemia (n = 4), chronic myeloproliferative diseases (n = 14). RESULTS: Pulmonary tuberculosis was in 61 (77.2%) patients: in 46 with lymphoproliferative disease (LPD), 4 with acute leukemia (AL) and 11 with myeloproliferative disease(MPD). Generalized tuberculosis was detected in 8 (10.1%) patients (7 with LPD and 1 with MPD) and extrapulmonary tuberculosis was in 10 (12.7%) patients (8 with LPD and 2 with MPD). Infiltrative, disseminated and military tuberculosis of the lungs developed in 55.7, 6.6 and 1.6% HB patients. CONCLUSION: Persistent fever in HB patients may point to developing tuberculosis infection. Fever syndrome and intoxication in patients with HB remission may serve a diagnostic marker of tuberculosis.

[Effectiveness of an intensive chemotherapy stage in new cases of pulmonary tuberculosis and diabetes mellitus]. / Effektivnost' intensivnogo étapa khimioterapii u bol'nykh vpervye vyiavlennym tuberkulezom legkikh i sakharnym diabetom.

Intensive chemotherapy for first detected pulmonary tuberculosis was initiated in 110 patients with diabetes mellitus (DM). Types 1 and 2 DM was present in 52 and 58 patients, respectively. In accordance with the WHO recommendations, isoniazid, rifampicin, pyrazinamide, and streptomycin or ethambutol were given to the patients at the first loading stage. Following 2-3 months, they were treated with isoniazid and rifampicin (as well as with pyrazinamide in some cases). A good or fair tolerability of the first stage of chemotherapy was noted in 86 (78.2%) patients with concurrent pathology (Group 1). The signs of intolerability developed in the remaining 24 (21.8%) patients forced them have an individually chosen chemotherapy regime instead of the standard one (Group 2). Both groups were comparable by age, gender, the pattern of a pulmonary process, the types and severity of DM. The effect of treatment was much higher in Group 1 patients. According to the data of bacterioscopy and inoculation, bacterial isolation ceased in them earlier and achieved more frequently than in Group 2 patients (83.7 and 54.5%, respectively; p < 0.05). Better X-ray lung changes were revealed after 4-month therapy. Decay cavity closure after 10 months of treatment was achieved in 69.3 and 30% of the patients in Groups 1 and 2, respectively (p < 0.05). Thus, most patients with DM tolerated intensive chemotherapy for pulmonary tuberculosis well or satisfactorily. The higher efficiency of this therapy than that of individually selected regiment allows the author recommend its wider use in patients with this concomitant pathology.

[Pulmonary tuberculosis in patients with different types of diabetes mellitus]. / Tuberkulez legkikh u bol'nykh s razlichnymi tipami sakharnogo diabeta.

Comparing the clinical and X-ray characteristics of pulmonary tuberculosis developed in 110 patients with type 1 diabetes mellitus (Group 1) and in 40 patients with type 2 (Group 2) revealed significant differences between these groups. An acuter onset and rapid progression, formation of extensive lesions with multiple, but small decay areas were typical for type 1 diabetes patients. Intensive chemotherapy for tuberculosis according to the standard WHO regimens is successfully tolerated by patients with different types of diabetes mellitus. Slight changes in hepatic functions (elevated levels of total bilirubin and aminopherases) are not beyond the ranges of allowable fluctuations and they do not prevent the first stage of treatment to be performed. The short duration of this stage of treatment is a determinant of a satisfactory tolerance of intensive chemotherapy at its first most loaded stage. The outcomes of the therapy were more favourable in patients with type 1 diabetes mellitus. Their bacterial isolation ceased early and more frequently and decay cavities closed in a larger number of cases as compared with patients with type 2 diabetes mellitus. The higher efficiency of treatment in Group 1 patients was caused not only by the specific features of the genesis of a tuberculous process and the nature of its clinical and X-ray manifestation, but also by differences in isoniazid inactivation processes. The significantly higher incidence of a slight inactivation of this drug in Group 1 patients determined its higher blood concentration and more pronounced therapeutical effect.

[Tuberculosis in patients with hemoblastoses]. / Tuberkulez u bol'nykh gemoblastozami.

Examining 2321 patients admitted for various forms of hemoblastoses (HB) to the Hematology Research Center, Russian Academy of Medical Sciences, in 1990-1999 revealed active forms tuberculosis in 60 (2.6%) patients. Among them generalized tuberculosis and predominantly extrapulmonary tuberculosis were detected in 8 (10.1%) and 10 (12.7%) patients, respectively. Bacteriological and morphological studies confirmed the diagnosis only in 22 (27.8%) patients, including in 15 (22.9%) patients with pulmonary tuberculosis. In the bulk of patients [n = 51 (64.6%)], the diagnosis of tuberculosis was suspected on the basis of a complex of clinical and X-ray data and evidenced by the beneficial effect of antituberculous chemotherapy. The clinical and X-ray manifestations of tuberculosis were similar in patients with different forms of HB. They are characterized by an aptness to hematogenous dissemination of the process, by the incidence of generalized and extrapulmonary lesions involving blood-forming organs, and by the significant extent of infiltrative changes in the lung with a relatively formation of single and small decay cavities. Antituberculous chemotherapy according to the standard regimen recommended by the WHO yielded a prompt and significant effect by improving the patients' status, eliminating fever, and ceasing bacterial isolation. Deaths occurred in 6 (7.6%) patients with lifetime undiagnosed generalized tuberculosis untreated with antituberculous drugs.

[Various approaches to tuberculosis diagnosis in patients with hemoblastosis]. / Osobennosti podkhoda k diagnostike tuberkulëza u bol'nykh gemoblastozami.

AIM: To characterize diagnosis of tuberculosis in hemoblastosis patients. MATERIAL AND METHODS: Diagnosis of active tuberculosis in 2.6% from 2123 hemoblastosis patients admitted to Hematological Research Center in 1990-1999 shows that such patients can be referred to high risk group in relation to tuberculosis infection. Methods and terms of tuberculosis diagnosis in hemoblastosis patients are analysed. RESULTS: Bacteriological and histological tests were positive in 27.8% examinees with hemoblastosis. In extrapulmonary tuberculosis location, histological diagnosis was positive in 60%. Especially helpful is a complex of clinical and x-ray examinations in high tuberculosis alertness. This allowed to suspect the infection in 51.9% patients (63.9% had pulmonary location). A marked positive response to antituberculosis treatment proved tuberculosis diagnosis. CONCLUSION: Difficulties of tuberculosis diagnosis in hemoblastosis patients are explained by low informative effectiveness of most common methods of this infection verification. Therefore, in addition to bacteriological and histological examinations, clinical diagnostic techniques should be employed keeping alert in relation of tuberculosis in hemoblastosis patients who are at risk to catch this infection.

[Features of isoniazid activation in patients with tuberculosis and diabetes mellitus]. / Osobennosti inaktivatsii izoniazida u bol'nykh tuberkulezom i sakharnym diabetom.

Isoniazid inactivation was studied in 60 patients with concomitant diseases (pulmonary tuberculosis and diabetes mellitus). Thirty three patients had type 1 diabetes mellitus (Group 1) and 27 had type 2 (Group 2). Weak isoniazid inactivators were 81.2% in Group 1 and 51.9% (p < 0.02), which was much greater than those in patients with tuberculosis alone. The distinctive features of isoniazid metabolism in patients with diabetes mellitus were decreased acetylation of the drug and appropriate increased splitting and oxidation. In patients with type 1 diabetes mellitus, the prevalence of weak drug inactivation may both promote higher chemotherapeutical efficiency and enhance the likelihood of side effects.

[Liver function at the stage of intensive tuberculosis treatment of patients with diabetes mellitus]. / Funktsiia pecheni na étape intensivnoi terapii tuberkuleza u bol'nykh sakharnym diabetom.

Intensive pulmonary tuberculosis treatment was performed in 65 patients with this disease concurrent with diabetes according to the WHO recommendations. Among them there were 44 new cases and 21 cases with relapse. Comparing the hepatic functional parameters before the first intensive stage of treatment and after its termination (following 2-3 months) showed a regular and statistically significant increase in the activity of aminotransferases and a clear tendency for increases in the values of total bilirubin and thymol tests. These changes were equally pronounced with both treatment regimens in patients with types both I and II diabetes mellitus and within normal ranges and allowed the drug treatment regimens to be continued.

[Specific features of pulmonary tuberculosis course in patients with insulin-dependent diabetes mellitus in relation to a varying HLA phenotype]. / Osobennosti techeniia tuberkuleza legkikh u bol'nykh insulinozavisimym sakharnym diabetom v zavisimosti ot razlichnogo HLA-fenotipa.

The examination and treatment of 67 new cases of infiltrative pulmonary tuberculous developed in the presence of insulin-dependent diabetes revealed two different types of the course of a tuberculous process. Due to therapy there was nearly complete resolution of inflammatory changes in 36 (54%) patients (Group 1). Large caseous foci of the tuberculoma type were formed in 31 (46%) patients (Group 2), including in 19 on admission and in 12 during chemotherapy Group 1 more frequently showed antigens of HLA A1 (p < 0.02) and DR2 (p < 0.01). Antigens of HLA B15 and DR6 were encountered only in this group. Those of HLA A2 (p < 0.01), DR3 (p < 0.01) were more commonly detected in Group 2. The HLA phenotype may be assumed to be an important factor that influences the course of pulmonary tuberculosis in patients with insulin-dependent mellitus and it may be of prognostic value.

[Specific features of cellular immunity of pulmonary tuberculosis in patients with diabetes mellitus]. / Osobennosti kletochnogo immuniteta pri tuberkuleze legkikh u bol'nykh sakharnym diabetom.

The parameters of cellular immunity were studied in 64 patients with pulmonary tuberculous developed in the presence of type 1 diabetes mellitus and compared with those in 36 patients with pulmonary tuberculosis alone. Patients with concomitant abnormalities showed higher depression of cellular immunity appeared as fewer T lymphocytes and their decreased capacity for blast-cell transformation than those with tuberculosis alone. Immunological parameters became normal only due to complex chemo- and immunotherapies (with T-activin). In addition, treatment outcomes improve and more rapid and frequent abacillation occurs. The development of tuberculosis in patients with diabetes mellitus is an additional indication for immunostimulant therapy with T-activin.

[Exacerbation of pulmonary tuberculosis during chemotherapy]. / Obostreniia tuberkuleza legkikh v protsesse khimioterapii.

Progression of a tuberculosis process during antituberculous therapy is most commonly evoked by its inadequacy. The latter may be associated with undiagnosed drug resistance, patients' incompliance due to the lack of their consciousness or discipline. In these circumstances, the use of stimulating pathogenetic treatments can provoke an exacerbation. Decreased immune defense mechanisms after experienced intercurrent infections may also serve as one of the common causes of tuberculosis exacerbations. Only in rare cases, progression of clinical and X-ray symptoms is explained by the massive pathogen lysis syndrome (Jarisch-Herxheimer's syndrome) The management policy for these patients should be different due to the causes of exacerbations.

[Lung microangiopathy in diabetics with lung tuberculosis]. / Legochnaia mikroangiopatiia pri tuberkuleze legkikh, razvivshemsia u bol'nykh sakharnym diabetom.

Histological and electron-microscopic studies of intact lung specimens were carried out in 30 patients with pulmonary tuberculosis developing in the presence of type I (insulin-dependent) diabetes mellitus. Material for investigation was obtained by intrapulmonary biopsy carried out during diagnostic bronchoscopy. Signs of adenopathy were detected in lung areas distant from tuberculous in foci all the cases. The diabetic origin of this condition was confirmed by expressed correlation with changes in the retinal and renal vessels and absence of correlation with the duration of tuberculous process. The degree of pulmonary adenopathy has a negative impact on the course of tuberculosis and efficacy of its therapy.