Tuberculosis and the atypical pneumonia syndrome.

Literature over the last 30 years has warned of the atypical or unusual characteristics of pulmonary TB. Shifts in the demographic distribution of the disease in the US are ascribed in part to the occurrence of HIV disease outbreaks in group settings, and to recent influxes of immigrants from developing countries. Unsuspected pulmonary TB is particularly common among the elderly. Socioeconomic categories not traditionally thought of as being high risk also are affected. In the low-risk setting, TB can be treacherous because misdiagnosis is likely. Tuberculosis is a great mimicker, and it can appear to be any acute community-acquired pneumonia such as atypical pneumonia. Symptoms and signs are few. A high index of awareness is therefore essential. The approach to atypical pneumonia emphasizes the need to include TB in the differential diagnosis to be aware of the total disease spectrum of TB and understand the risk factors. The atypical pneumonia syndrome is only a portion of the clinical spectrum of TB.

Clindamycin compared with penicillin for the treatment of anaerobic lung abscess.

The clinical efficacy of clindamycin was compared with that of penicillin in a randomized study of the treatment of community-acquired putrid lung abscess. After starting therapy, patients treated with clindamycin had a shorter febrile period and fewer days of fetid sputum than patients treated with penicillin (mean 4.4 versus 7.6 days and 4.2 versus 8.0 days, respectively, p less than 0.05). Four of 20 patients treated with penicillin had clinically significant pulmonary or pleural extension of their infection within 10 days after starting therapy; this was not found in any of 19 patients treated with clindamycin (p less than 0.05). Penicillin treatment failed in two additional patients after 20 days of therapy. Within 1 month after treatment, 1 of 4 patients given penicillin for 3 weeks had relapse, but none of the 13 patients given clindamycin for 3 or 6 weeks, and none of the 5 patients given penicillin for 6 weeks had relapse. Overall, only 8 of 15 patients treated with penicillin who could be followed to the end of the study were cured, whereas all 13 patients treated with clindamycin who could be followed were cured (p less than 0.01). These results suggest that penicillin may not be optimal therapy for anaerobic lung abscess.