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Isoniazid is the standard medication used to treat latent tuberculosis infection (LTBI). The lengthy treatment with isoniazid, its perceived hepatotoxicity, and the increasing influx of foreign-born persons from countries with a higher prevalence of isoniazid resistance have compromised this regimen. In 2000, the Centers for Disease Control and Prevention guidelines recommended 4 months of rifampin (4R) as an acceptable alternative regimen to 9 months of isoniazid (9H). In a county chest clinic in northern New Jersey, a self-administered 9H regimen for patients with LTBI was generally prescribed until the year 2002. After recognizing poor completion rates, LTBI treatment was shifted predominantly to the alternative 4R regimen.Medical records of patients placed on LTBI treatment during 2000 (predominantly a 9H regimen) and 2003 (predominantly a 4R regimen) were reviewed. A total of 474 patients were included in the study. chi(2), Fishers exact, two-sample t, and Wilcoxon rank-sum tests and logistic regression were used to analyze the data. The main outcome variable was treatment completion.A total of 80.5% of patients receiving 4R and 53.1% receiving 9H completed treatment (p0.0001); 34.7% of patients receiving 9H were unavailable for follow-up, compared to 12.6% receiving 4R (p =0.0001). Fewer drug reactions were observed in the group receiving 4R compared to the group receiving 9H (3.1% vs 5.8%), although this was not statistically significant. Logistic regression analysis identified treatment regimen as a significant predictor for treatment completion (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.3 to 8.1). Employment was negatively associated with treatment completion in the same model (OR, 0.54; 95% CI, 0.34 to 0.94).Patients receiving 4R were significantly more likely to complete therapy than those receiving 9H.

Study objectives To determine whether an algorithm consisting of a chest radiograph and the diffusing capacity of the lung for carbon monoxide (D lco ) is effective in detecting Pneumocystis carinii pneumonia (PCP) in symptomatic HIV-infected persons; and to establish a benchmark for future comparisons of alternative algorithms. Design Prospective, 64-month study. Setting Multicenter, ambulatory care. Patients 306 HIV-infected subjects enrolled in the Pulmonary Complications of HIV Infection Study who developed 467 episodes of new or worsening respiratory symptoms. Measurements Chest radiography followed by D lco measurement, if the radiograph was normal or unchanged. Results An algorithm combining a chest radiograph followed by a D lco measurement, if the radiograph was normal or unchanged, was effective and detected abnormalities that led to a diagnosis of PCP in 78 of 80 evaluable episodes (97.5%). The radiograph (specific parenchymal abnormality, number of lung zones involved) and the D lco (degree of decrease, degree of decrease from baseline) also provided additional information on the probability of PCP. Conclusions In symptomatic HIV-infected patients suspected of having PCP, the diagnostic evaluation should begin with a chest radiograph, followed by a D lco measurement, if the radiograph is normal or unchanged. If both of these tests are normal, it may be reasonable to conclude the evaluation rather than to proceed on to additional testing. This algorithm can serve as a benchmark for future comparisons.

Study objectives To examine the significance of previously suggested risk factors and assess outcomes associated with Aspergillus identification in respiratory specimens from HIV-seropositive individuals. Design This was a nested case-control study. Patients who had Aspergillus species identified in respiratory specimens were matched at the time of study entry 1:2 with control subjects according to study center, age, gender, race, HIV transmission category, and CD4 count. Setting The multicenter Pulmonary Complications of HIV Infection Study. Participants HIV-seropositive study participants. Measurements and results Between November 1988 and March 1994, Aspergillus species were detected in respiratory specimens from 19 (1.6%) participants. The rate of Aspergillus identification among participants with CD4 counts Conclusions Although Aspergillus is infrequently isolated from HIV-infected persons, the associated high mortality would support serious consideration of its clinical significance in those with advanced disease and risk factors.

Background Conventional contact investigation and molecular fingerprinting of Mycobacterium tuberculosis isolates in tuberculosis (TB) outbreaks have facilitated recognition as well as application of public health control activities. Singing in a choir as an activity that promotes TB transmission has been occasionally recognized. Such avocational transmission in a middle class community can occur with attendant difficulties encountered in contact investigation. Methods Five cases of TB (one index case; three secondary cases; one unassociated case) were identified among members of a famous church gospel choir in Newark, NJ. DNA fingerprinting and susceptibility testing were done on all retrieved strains. Of 306 choir members who had tuberculin tests, 19% were reactors. The presumed outbreak site was investigated. Results Four of the five patients were tenors, and one was an alto. Tenors were approximately twice as likely to be tuberculin reactors than subjects with other vocal ranges combined (relative risk, 2.04; 95% confidence interval, 1.17 to 3.56). An air ventilation outlet was directly in front of the tenor section. Some limited extra-church activity between choir members may have contributed to transmission. Conclusion Conventional contact investigation must be supplemented by newer techniques, such as DNA figerprinting, in identifying possible outbreak transmission. Singing, location of a ventilation outlet, and exposure time may have contributed to TB transmission in this outbreak. Transmission need not only be in congregate settings among well-defined socioeconomic groups but may occur unexpectedly in middle class communities.

OBJECTIVES HIV disease is frequently complicated by episodic acute bronchitis, suggesting the presence of chronic bronchial inflammation. To further examine this concept, we investigated the possible association of nonspecific airway hyperresponsiveness (AHR) and HIV disease. DESIGN Methacholine inhalation challenge studies were performed on 66 HIV-seropositive and 8 HIV-seronegative members of the Pulmonary Complications of HIV Infection Study Cohort. AHR was defined as 20% or more decline in FEV1 from the postdiluent value after inhalation of 125 or less cumulative breath units. The prevalence of AHR in HIV-seropositive cohort members was compared with that in matched control subjects who had undergone methacholine challenge testing for two unrelated studies. Demographic, behavioral, and clinical features in HIV cohort members with and without AHR were contrasted. The relationship between AHR and the occurrence of episodic airway disease or symptoms suggestive of airway disease was examined. RESULTS AHR was not more prevalent in HIV-seropositive cohort members than control subjects (19.3% vs 12.9%; p > 0.1). Within the cohort, AHR was detected more frequently in members with than without a history of asthma (60% vs 16%; p < 0.05). A greater proportion with than without AHR had 1 or more episode of pneumonia within 2 years (46% vs 9%; p < 0.01), 1 or more asthma episode during the study period (39% vs 1.9%; p < 0.001), or wheeze noted during clinic visits (62% vs 17%; p < 0.01). The proportion that experienced acute bronchitis did not differ in the two groups. CONCLUSIONS This study suggest that HIV-infected persons do not have increased prevalence of nonspecific AHR. In HIV disease, AHR is associated asthma, but not episodic acute bronchitis. Thus, the possibility that airway injury without demonstrable AHR might complicate HIV disease remains.

Objective: Several outbreaks of multidrug resistant tuberculosis (MDR-TB) have recently occurred in which healthcare workers and others have become infected. Given the lack of clinical data to guide preventive therapy for such contacts, a Delphi survey of a panel of 31 TB therapy experts was undertaken to identify a consensus regimen. Design: An initial questionnaire presented three scenarios describing persons with significant exposure to MDR-TB and with new tuberculin skin test reactions >15 mm (except one anergic patient) without evidence of disease. Panelists were asked to suggest possible preventive therapy regimens. Methods: During a second round survey, the panel members were asked to review the suggested regimens provided for each scenario and to rank them from one to nine as extremely inappropriate to extremely appropriate. Results of this second survey were tabulated and shared with the members of the panel who were then asked to rerank each regimen in light of the previous cumulative panel responses. Results: No specific regimen achieved initial positive consensus by predefined criteria. In two of the three scenarios the no treatment option, however, was deemed clearly inappropriate. The data were also analyzed by what percentage of respondents who ranked a regimen as at all appropriate (ie, six or more on the nine point scale). For scenarios involving a nurse, an HIV-positive tuberculin reactor, and a patient who was anergic HIV-positive, treatment with pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months received a somewhat appropriate rating from more than 50 percent of respondents. Conclusions: The management of persons exposed to and infected by patients with MDR-TB has become a serious problem in the context of MDR-TB outbreaks. This panel of experts agreed that some form of preventive therapy was warranted; however, they were not able to reach defined consensus on what regimen should be used, although a regimen of pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months was considered somewhat appropriate. Clinical data on the efficacy of alternative preventive therapy regimens for such contacts are urgently needed.

Background The delphi method of decision making was used to address an unusual clinical case in which various aspects of the case required opposing management strategies. Methods A panel of 30 pulmonary experts was surveyed repeatedly until a convergence of treatment approaches was reached for a patient who was considered to have both a universal indication for and a universal contraindication against prevention therapy. Participants were asked to evaluate the appropriateness of proposed treatments on a scale from 1 to 9, with 1 being extremely inappropriate, 5 being equivocal, and 9 being extremely appropriate. The delphi survey data responses were compared using measures of central tendency (ie, the mean and median) and measures of variability (ie, the standard deviation and interquartile range). Results Although no treatment was wholeheartedly supported by the experts, analysis of the three-round delphi survey responses resulted in two possible treatments: rifampin, 600 mg daily, for four months, or no treatment with close observation. Interestingly, the experts working in a non-university setting favored the rifampin treatment, and those working in a university setting favored no treatment with close observation. Conclusions The delphi method has the potential to be used for clinical decision making.

Human immunodeficiency virus infection and extrapulmonary TB are defined as AIDS. The clinical manifestations of the TB are related to the interplay of the organism and the host's immune system. A seven-year follow-up of a woman successfully treated for biopsy- and culture-documented tuberculous brain abscess is described. Antibodies to HIV have been positive on repeated testing, yet CD4 counts remain over 500. Aggressive diagnostic and therapeutic maneuvers for all forms of TB in AIDS are warranted since long-term prognosis may be good.

CHEST, 68: 3, SEPTEMBER, 1975 SUPPLEMENT ing this infection and to seek medical care whenever he has a cough that hangs on more than two to three weeks after a cold, fatigue, loss of weight, or fever of unknown origin. At the urging of the Public Health Service three years ago, a program was undertaken in a rural Arkansas county to identify all persons at risk of developing tuberculosis by instituting a county-wide voluntary tuberculin testing program followed by xray examination of all positive reactors.4 It was found that one could easily test the school children, nursing-home inmates, etc; but it proved atmost totally impossible and certainly impractical to get the adult male population to come in voluntarily for the skin test for tuberculosis. Their wives would often come, but neither we nor the wives were successful in getting the men to come. In summary, I have tried to give the goals for screening of tuberculosis infection and disease and to indicate some of the areas in which screening may be productive. I have mentioned some of the ways that I think are wasteful of time and effort. In looking for disease, it is most productive to look among sick people, such as those going into physicians’ offices and hospitals. For new infections, it is most productive to look at the intimate and household contacts of recently discovered infectious cases and in hospital employees and prison inmates. Beyond this, there is an important control job to be done, but it no longer should include screening healthy populations. While the indications for prophylactic isoniazid therapy have been grossly contracted in recent years, I think that when it is indicated, it is important for us to give it with as much enthusiasm as we use in treating patients with active disease. Screening for tuberculosis is still important in some circumstances, and it should be done in a productive way, as I have outlined.

A prospective, double blind study was conducted to determine the degree of concordance of pen and palpation methods of measuring skin induration to Mantoux tuberculin tests. One hundred thirty-five skin tests were performed in patients with previously bacteriologically proved tuberculous disease. An experienced reader who was only able to see the forearm of the patient measured the induration by the palpation technique. The measurement was then repeated by the pen method under the same conditions, on the same day. Results of the study indicated that the pen method yielded statistically the same frequency distribution of indurations as the palpation method and the pen method appeared to be more sensitive.

An apparently increasing incidence of isoniazid-associated hepatitis concurrent with interest in the problem has led to the universal teaching that patients on isoniazid preventive therapy must be carefully monitored for liver disease. This teaching has been reinforced and endorsed in a recent report of the tuberculosis advisory committee and special consultants to the director of the Center for Disease Control; this report, in turn, led to an American Thoracic Society statement concluding that the use of isoniazid with appropriate safeguards must be based on a comparison of the benefit of preventive therapy with the risk of hepatic injury and, therefore, should be used when necessary, under careful control and follow-up. In New York City, with increasing use of the tuberculin skin test leading to increased numbers of patients receiving this treatment in nurse-operated clinics, a new control form and protocol were designed. These insure that all individuals on preventive therapy are carefully monitored for liver disease as well as compliance in taking the drug. This system also insures the safeguards alluded to, as well as increasing concern and awareness among the health professionals in prescribing the treatment.

Multiple papillomas of the tracheobronchial tree are rare in children and adults. We describe a 42-year-old woman with multiple papillomatous-like tumors involving the trachea and bronchi. The limited tissue samples obtained during fiberoptic bronchoscopy initially lead to a benign histopathologic diagnosis; concurrent cytology studies strongly suggested oat cell carcinoma. The biopsy specimen obtained by rigid bronchoscopy ultimately demonstrated unequivocal oat cell carcinoma. This case illustrates an unusual and previously unreported manifestation of oat cell carcinoma--an endoscopic presentation in a papillary form suggesting benign tracheobronchial papillomatosis. Cytology studies were of increased diagnostic significance in this clinicopathologic setting.