An investigation into the relationship between region specific quality of life and adverse tuberculosis treatment outcomes in Istanbul, Turkey.

BACKGROUND AND OBJECTIVE: Istanbul has the highest incidence of tuberculosis (TB) in Turkey. It is also the largest city, with considerable differences in quality of life across its urban regions. The aim of this study is to investigate the relationship between (i) the diverse quality of life across specific urban regions, (ii) TB incidence rates, inclusive of demographic and clinical characteristics of TB patients, and (iii) adverse treatment outcomes. METHODS: This retrospective study included 23,845 new TB patients (recorded in the National TB Registry between 2006 and 2010) in Istanbul. Thirty-nine urban districts of Istanbul were ranked into five groups on the basis of an urban quality of life index. Patient data were matched with these groups, and further categorized according to 'age', 'sex', 'country of birth' and 'antibiotics resistance'. Adverse treatment outcomes and TB incidence rates were extracted from official records. Logistic regression, clustered analyses, 95% CI and p values (STATA) were reported to describe the association between variables. RESULTS: Six per cent of total cases had 'at least one adverse treatment outcome' (default 3.8%, failure 0.5%, death 1.7% in total cases). 'An adverse treatment outcome' was found to be associated with age OR (CI 95%) (1.02 (1.01-1.03)); 'male sex' 1.65 (1.28-2.12); 'other country of birth' 4.82 (3.05-7.62); 100,000 per 'over 60' insidence goups 1.61 (1.32-1.97), the lowest quality of life index 0.65 (0.47-0.83). CONCLUSIONS: Patients with high tuberculosis risk factors living in high incidence regions need to be closely monitored. Patients living in lower ranking regions are more likely to have 'poor treatment outcomes'.

Lung cancer presenting with choroidal metastasis in a pregnant woman.

A 28-year-old, non-smoker pregnant woman who was initially diagnosed to have deep vein thrombosis and pulmonary thromboembolism earlier in pregnancy, presented at 22 weeks of gestation with dyspnoea, visual loss initially in the right eye and then in the left eye. Fundoscopic examination revealed metastatic foci, suggestive of choroid metastases. Computed tomography of the chest revealed a right hilar mass. Fibreoptic bronchoscopy and bronchoscopic biopsy confirmed lung adenocarcinoma. As the patient and family wished to continue with the pregnancy, chemotherapy with cisplatin and was administered from the 31st week of pregnancy and she had undergone Caesarian section in the 32nd week and the baby was healthy. We report this case as it is probably the first reported case of lung cancer presenting with choroidal metastasis in a pregnant woman.

Risk of active tuberculosis in adult household contacts of smear-positive pulmonary tuberculosis cases.

SETTING: Seven public tuberculosis (TB) dispensaries in Istanbul, Turkey. OBJECTIVE: To investigate the risk of active TB among adult household contacts (age > or = 15 years) of newly diagnosed sputum smear-positive pulmonary TB (PTB) cases in Istanbul. DESIGN: A retrospective analysis of adult household contacts of 1570 pulmonary TB cases registered at seven TB dispensaries in Istanbul between 1997 and 2000. RESULTS: A total of 6188 household contacts (mean contact/index case: 3.9) were included in the study, of whom 4114 (67%) were aged > or = 15 years (mean contact/index case: 2.6); 3310 (80.5%) of these participated in a contact investigation. The mean duration of follow-up was 2.2 years (range 1-4 years); 222 active TB cases (rate 5.4%, 95%CI 5.2-5.6) were detected, 171 within the first year. The incidence of active TB was 2491/100 000 (3555/100 000 in the 15-34 year age group and 1195/100 000 in the > or = 35 year age group, P < 0.0001). Rates of active TB were highest in the 15-24 year (8.5%) and 25-34 year (6.5%) age groups. CONCLUSION: The incidence of active TB among adult household contacts of sputum smear-positive PTB cases was high. This high incidence justifies the prescription of chemopropylaxis not only for children but also for all contacts, especially those aged between 15 and 34 years.

Prevalence of Beijing genotype Mycobacterium tuberculosis strains in Istanbul.

To determine the prevalence of Beijing genotype Mycobacterium tuberculosis in Istanbul, 4069 strains were subjected to DNA fingerprinting. This is the first study to reveal the presence of the Beijing genotype in Istanbul. The prevalence rate was estimated as 1.13%, and it was shown that these strains were carried over from countries of the former Soviet Union. The study also showed that the prevalence of the Beijing genotype among at least rifampicin (RMP) resistant strains was significantly higher (2.7%) than among RMP-susceptible strains (0.9%).

Microscopic examination and treatment outcomes of new pulmonary tuberculosis cases in Istanbul dispensaries between 1998 and 2000.

SETTING: Twenty-four public tuberculosis dispensaries in Istanbul. OBJECTIVE: To investigate microscopic examination of new pulmonary tuberculosis (TB) cases and treatment outcomes of smear-positive cases. DESIGN: A retrospective analysis of 12572 new pulmonary tuberculosis cases between 1998 and 2000. METHODS: Microscopic examination of sputum smears of all patients and treatment outcomes of smear-positive cases were evaluated. RESULTS: Of 12572 new TB cases registered between 1998 and 2000, 78.1% (n = 9822) were pulmonary and 21.9% (n = 2750) were extra-pulmonary TB cases. Of 9822 new pulmonary TB cases, 5438 (55.4%) were sputum smear-positive and 2154 (21.9%) had no sputum examination. In smear-positive pulmonary cases, treatment outcomes were classified as follows: 2521 (46.4%) cured, 1926 (35.4%) treatment completed, 128 (2.4%) treatment failure, 514 (9.4%) default, 260 (4.8%) transfer out and 72 (1.3%) died. Treatment success was 81.8% (n = 4447). Between 1998 and 2000, the smear-positive case rate improved from 47.5% to 61.5% and the cure rate improved from 41.8% to 51.1%. CONCLUSION: The microscopic diagnosis and cure rates are low in Istanbul dispensaries. The laboratories should be re-organised and directly observed treatment should be performed.

Clinical and radiographic features of pulmonary tuberculosis in non-AIDS immunocompromised patients.

SETTING: Department of Chest Diseases, Istanbul Faculty of Medicine, Istanbul University. OBJECTIVE: To determine the clinical and radiographic presentation of pulmonary tuberculosis in non-AIDS immunocompromised patients (ICP). DESIGN: A retrospective review of medical records of 143 patients (63 immunocompromised patients and 80 immunocompetent patients) with pulmonary tuberculosis from 1992 to 2001. RESULTS: In ICPs, fever was more frequently observed (84.1% vs. 40%, P = 0.0000002), tuberculosis was more frequently disseminated (23.8 vs. 3.8%, P = 0.0008), and lung infiltrations were more often lobar or segmental consolidation (20.6% vs. 0%, P = 0.00007) and miliary lesions (17.5 vs. 3.8%, P = 0.014) than in the control patients. Hilar and/or mediastinal adenopathy was also more frequently documented in ICPs (14.3% vs. 2.5%, P = 0.01). CONCLUSION: Fever, atypical chest radiograph and disseminated disease are common findings of pulmonary tuberculosis in ICPs.

Evaluation of undergraduate training on tuberculosis at Istanbul Medical School.

SETTING: Undergraduate training on tuberculosis at Istanbul Medical School. OBJECTIVE: To assess whether tuberculosis-related questions asked in chest medicine examinations comply with the World Health Organization's (WHO) learning objectives for tuberculosis training, and to investigate students' skills in interpreting radiology and smears with respect to tuberculosis. DESIGN: Tuberculosis questions set for 4th year medical students (n = 838) were compared with WHO objectives (n = 23): 122 students were each asked to interpret 10 chest X-rays which had been read by three experts as 'typical tuberculosis lesions', 'normal' or 'non-tuberculosis lesions'; 114 students were also each given five smears which had been interpreted by an expert as 'negative' or 'positive' with respect to acid-fast-bacilli (AFB), and were asked to interpret them. RESULTS: Questions covered only nine of the WHO objectives. Among 117 types of questions, 91 (77.8%) were about clinical-radiological findings, treatment and drugs; 334 (65.1%) of 513 X-rays with typical tuberculosis lesions, 77 (21.1%) of 364 normal X-rays and 87 (25.4%) of 343 X-rays with non-tuberculosis lesions were identified as tuberculosis (kappa 0.45). Of 369 AFB-positive smears, 149 (40.4%) were evaluated as false negative, and of 185 AFB-negative smears, 48 (25.9%) were evaluated as false positive (kappa 0.49). CONCLUSION: Examination questions set on tuberculosis at Istanbul Medical School do not adequately reflect WHO learning objectives. Students' skills in interpreting radiology and smears suggest that their practical training on tuberculosis is insufficient.

An unusual radiographic finding in pulmonary parenchymal endometriosis.

Thoracic endometriosis is an uncommon disorder. In most cases, the diagnosis is based on history alone and radiographic findings depend on the menstrual cycle. CT findings include ill-defined or well-defined opacities, nodular lesions, cavities, cystic changes and bullous formation. We report a case of pulmonary parenchymal endometriosis with an unusual radiographic finding.

Pulmonary alveolar lithiasis in two siblings.

Pulmonary alveolar microlithiasis (PAM) is a rare disease of unknown etiology and is characterized by the deposition of calcium phosphate microliths within the alveolar airspaces. We report 2 asymptomatic siblings, a 7-year-old girl and her 13-year-old brother, with PAM. In the girl, chest X-ray and computed tomography revealed diffuse interstitial changes but no uptake of technetium 99m (99mTc) on bone scan was noted in the lung. Microliths stained pink with Papanicolaou dye in bronchoalveolar lavage fluid (BALF) but did not stain with von Kossa. In the brother, characteristic radiological findings and 99mTc uptake in the lung were detected. The microliths stained pink with Papanicolaou in BALF and black with von Kossa as well. We hypothesize that the first case is in the early phase of PAM because of lack of 99mTc uptake.

Respiratory distress with acitretin, reversal by corticosteroid.

The retinoic acid derivatives are used for disorders of keratinization such as psoriasis. Acitretin, which is a synthetic, aromatic derivative of retinoic acid, is frequently used to treat psoriasis. The retinoic acid syndrome (RAS), described with all-trans-retinoic acid (ATRA) in patients with promyelocytic leukemia, is characterized by fever and respiratory distress. In this report we present a 32 year old male who developed high fever, dry cough and dyspnea while undergoing treatment with acitretin. During hospitalization, his acitretin was stopped and he was treated with corticosteroids. Significant improvement was observed within a few days.

Tuberculosis in renal transplant recipients.

BACKGROUND: Tuberculosis is an important cause of morbidity and mortality in renal transplant recipients, but there are insufficient data regarding the efficacy and complications of therapy and of INH prophylaxis. METHODS: This study is a retrospective review of the records of 880 renal transplant recipients in two centers in Turkey. RESULTS: Tuberculosis developed in 36 patients (4.1%) at posttransplant 3-111 months, of which 28 were successfully treated. Eight patients (22.2%) died of tuberculosis or complications of anti-tuberculosis therapy. Use of rifampin necessitated a mean of 2-fold increase in the cyclosporine dose, but no allograft rejection occurred due to inadequate cyclosporine levels. Hepatotoxicity developed in eight patients during treatment, two of whom died due to hepatic failure. No risk factor, including age, gender, renal dysfunction, hepatitis C, or past hepatitis B infection, was found to be associated with development of hepatic toxicity. A subgroup of 36 patients with a past history of or radiographic findings suggesting inactive tuberculosis, was considered to be at high risk for developing active disease, of whom 23 were given isoniazid (INH) prophylaxis. None versus 1 of 13 (7.7%) of cases with and without INH prophylaxis, respectively, developed active disease (P>0.05). None of the patients receiving INH had hepatic toxicity or needed modification of cyclosporine dose. CONCLUSIONS: These data show that tuberculosis has a high prevalence in transplant recipients, that it can effectively be treated using rifampin-containing antituberculosis drugs with a close follow-up of serum cyclosporine levels, and that INH prophylaxis is safe but more experience is needed to define the target population.

Value of bronchoalveolar lavage in lipidoses with pulmonary involvement.

Adult lipid storage disorders with pulmonary involvement are rare and usually diagnosed at autopsy. We report a patient with splenomegaly and reticulonodular pattern on lung computed tomography. Bronchoalveolar lavage was performed and revealed the presence of lipid-containing foamy cells, with the demonstration of both periodic acid-Schiff (PAS) and scharlach red stain positive vacuoles in the cytoplasm of alveolar macrophages. The same cells were found in bone marrow biopsy. As in other rare disorders, bronchoalveolar lavage may be of diagnostic value in lipid storage disorders with pulmonary involvement.

[Exogenous allergic alveolitis caused by mouldy hazel nut leaves]. / Exogene allergische Alveolitis durch schimmelige Haselnusshüllblätter.

A 62-year old farmer woman from the northeastern, very rainy part of Turkey has been collecting large amounts of green and brown involucral hazel-nut leaves for subsequent use as fuel. For the last 20 years she had been complaining of cough, respiratory distress and intermittent fever. In the course of years of continual antigen exposure she developed the clinical and x-ray signs of fibrosis of the lung. Bronchoalveolar lavage produced the typical cell pattern of chronic exogenous allergic alveolitis with predominant CD8 cells. Serum analysis yielded high titres of IgG antibodies against mould fungi partly obtained from hazel-nut husk cultures, as well as thermophilic actinomycetes.