Search

Background: Despite an efficient cure, tuberculosis (TB) is a global cause of mortality and morbidity. Patients with treated TB may suffer from sequelae, impairing their quality of life. Aim: Assess the predictive factors linked with the occurrence of sequelae among TB treated patients. Methods: A retrospective (2010-2017) study that included patients with pulmonary tuberculosis (TB) in Pulmonology department C of Abderrahmen Mami Hospital in Tunisia. Sequelae were defined by the persistance of radiographic abnormalities in the chest X-ray after a well conducted treatment. Patients were divided in 2 groups. G1 : patients with sequelae (n=271). G2 : patients without sequelae (n=189). Results: 460 patients were included (mean age : 40.07; 61.3% were men). All patients received anti TB treatment. 59% were diagnosed with TB sequelae. Men developed sequelae more than women (68,5% VS 46%) p Conclusions: Post TB sequelae are worryingly high in our study. It is important to identify all parameters associated with the occurrence of these complications to facilitate diagnosis and treatment.

INTRODUCTION To present the treatment outcome in tuberculosis patients with sputum smear positivity in the third month of category 1 treatment regimes. PATIENTS AND METHODS A total of 1024 patients with tuberculosis treated in Ministry of Health Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital from January 2004 to December 2005 were included in this retrospective cohort study. Categorization and appropriate treatment of tuberculosis was performed according the World Health Organization guidelines. RESULTS Of overall 1024 patients, 655 (64%) were determined to receive category 1 treatment while sputum smear positivity was identified in 11 of them [2%; mean (SD) age: 46 (17.9) years] in the third month. Continuation phase treatment was initiated in these 11 patients. Sputum conversion was evident in six of 10 cases in the 4th month, in three cases in the 5th month and in one case in the 6th month. None had culture positivity after the 3rd month. Of 11 cases, 10 completed therapy with major drugs in six months and treatment outcome was cure. No relapse was identified after five years later. CONCLUSION Based on our data we recommend that the continuing phase should be started in cases with positive sputum smear at the end of the extended initial phase.

Background Tuberculosis is an infection and caused by gentle growing bacteria. The Internet provides opportunities for people with tuberculosis (TB) to connect with one another to address these challenges. Objective The aim of this paper is to introduce readers to the platforms on which Tuberculosis participants interact, to discuss reasons for and risks associated with TB-related activity, and to review research related to the potential impact of individual participation on TB outcomes. Methods Research and online content related to Tuberculosis online activity is reviewed, however, the difficulty in accurate prescribing and adhering to these protocols and the emergence of M. tuberculosis strains resistant to multiple drugs and drug-drug interactions that interfere with optimal treatment of Tuberculosis and co-infected patients with the different disease has generated a pressing need for improved Tuberculosis therapies. Results Together with the ominous global burden of Tuberculosis, those shortcomings of current medication have contributed to a renewed interest in the development of improved drugs and protocols for the medication of Tuberculosis. This article features obstacles related with the enhanced utilization of existing drugs and difficulties related with the advancement of enhanced products, concentrating on perspectives characteristic in Tuberculosis drug clinical improvement. The participation includes peer support, advocacy, self-expression, seeking and sharing TB information, improving approaches to Tuberculosis data management, and humour. Conclusion This article highlights hurdles related to the optimised use of existing drugs and challenges related to the development of improved products, focusing on aspects inherent in Tuberculosis drug clinical development. Concluding comments offer processes for more efficient development of Tuberculosis therapies and increase the quality of life.

Introduction: Hepatotoxicity in patients diagnosed with active tuberculosis is the commonest adverse effect of therapy. We sought to analyse trends in liver function in patients diagnosed with active tuberculosis and to determine predictors of hepatotoxicity. Methods: We studied 275 patients with active TB treated at a tertiary referral centre from 2009-2014 . A retrospective review was undertaken of all patients9 laboratory data and patient correspondence to determine predictors of hepatotoxicity. Results: 170 (62%) male and 105 (38%) female patients with active tuberculosis with a mean age of 44 years were studied. 15 patients (6%) required their medication to be stopped or altered as a consequence of hepatotoxicity. There was a significant difference in age between patients with hepatotoxicity (52.95 years) and those that didn9t (41.33 years) (p=0.00). Irish born patients were more likely to develop hepatotoxicity (p=0.025). There was no significant association between hepatotoxicity and drug abuse (p=0.211), smoking (p=0.95), presence of cavitatory disease (p=0.191), site of disease (p=0.224), alcohol use (p=0.088) or history of alcohol excess (p=0.736). Among patients with tuberculosis, peak AST values did not occur within the first 2 weeks as widely thought but later (week 10). Conclusion: Hepatotoxicity as a consequence of antituberculous therapy is common. Hepatotoxicity was more common in older patients and resulted in drug interruptions and treatment changes. Given the late peak in AST values at week 10 in patients treated with antituberculous therapy, the authors advocate that liver function tests should be monitored regularly throughout the course of treatment.

Tuberculosis is a curable disease, yet it is the largest single infectious cause of death among adults in the world. India accounts for one-third of the global TB burden. Its economic burden in India is enormous as it perpetuates and exacerbates poverty. The revised national Tuberculosis Control Programme (the DOTS Strategy) is currently being implemented in India. The purpose of this study was to compare the costs to tuberculosis patients treated in a DOTS Programme with the costs to patients treated in a non-DOTS Programme in south India. Patients registered between June and December 2000 (455 in DOTS area, 441 in non-DOTS area) in Tiruvallur district were interviewed, collecting information on demographics, socio-economic characteristics of patients, expenditure incurred due to illness, and effect of illness on employment. Results showed that in the DOTS area, treatment success rate was higher, patient costs were less, and patients returned to work early. These findings establish the economic benefits to patients treated under DOTS and lend support to rapid expansion of the programme, particularly in low-income countries.

Background: Pulmonary tuberculosis being the predominant manifestation of the disease extra-pulmonary sites can also involve as a result of dissemination from a chief focus. Extra- pulmonary tuberculosis is more common in HIV cases. The present study aims to determine the presentation and outcome of patients with extra-pulmonary tuberculosis treated with DOTS and to assess any difference in outcome of treatment in HIV positive extra-pulmonary tuberculosis. Methods: Data was collected from cases of tuberculosis patients diagnosed and treated under DOTS at Sri Siddhartha Medical College for the period of one year (during 2015). We evaluated extra-pulmonary cases and recorded sites of involvement in order of frequency. We also studied treatment outcome by recording as per definitions given by the WHO and also evaluated any difference in outcome of extra-pulmonary tuberculosis disease with HIV co-infection. Results: Extra-pulmonary cases accounted for 30.5% of total TB cases. Among 224 cases of extra-pulmonary TB studied, 136 (60.7%) were males and 88 (39.3%) were females. Most common site of extra-pulmonary tuberculosis was pleura (29.9%) followed by meninges (22.5%), abdomen (19.6%) and lymph node (10.7%) tuberculosis. Among these patients 82.2% completed treatment, 7.5% were defaulted, 9.9% died and 0.4% treatment failure. The most common reason for default was irregular treatment (29.5%) followed by alcohol abuse (23.5%). Among 8 HIV reactive patients, 5 patients completed treatment and the remaining 3 patients died during the course of treatment. Conclusions: Extra-pulmonary Tuberculosis accounts for 30.5% of the total cases studied. Pleura is most common site of extra-pulmonary TB in our study. Treatment irregularities and alcohol abuse are the two most common reasons for default. Co-infection with HIV seems to have a poor outcome on patients with extra-pulmonary TB and needs to be studied in large number of samples.

We report the case of extensive thoracolumbar tuberculosis involving eight vertebral bodies, and successful treatment by two-stage surgical procedure using a minimally invasive posterior instrumentation. There have been few reports about widespread spinal tuberculosis in recent years. However tuberculosis is on the rise in the developed countries. This can be attributred to the increase in HIV and immigration from countries where tuberculosis is common. The patient was a 32-year-old female from one of the developing countries with spinal tuberculosis of T7-L2. The delay until diagnosis was about one year. Medical and conservative treatment for eighteen months was not effective to her illness. Two-stage surgical treatment (first: anterior debridement and bone graft; second: minimally invasive posterior instrumentation) was performed. Anterior debridement was adequately performed through the right side thoracotomy at two site, and two weeks after the surgery, posterior instrumentation without additional arthrodesis was performed using a minimally invasive approach. Antituberculous chemotherapy was continued for three months after surgery. Three years after the surgeries, the patient is now completely asymptomatic and has not had a recurrence. The infected anterior site healed and bony fusion was successfully achieved without kyphotic progression.

We reported 8 to 13 years of follow-up of cases of tuberculosis of the hip previously. Now we report on 60 cases of hip tuberculosis treated with total hip arthroplasty. The results have been reasonably acceptable, with the longest follow-up >28 years. Prosthetic life was limited to at most 20 years in our longest cases mainly because of loss of fixation of the acetabular component. There were recurrences of tuberculosis in 5 hips. We confirmed that antituberculous chemotherapy is crucial in total hip arthroplasty reconstruction. Detection of Mycobacterium tuberculosis using polymerase chain reaction may provide rapid diagnosis and follow-up for treatment response.

過去5年間に163例の結核症を経験した。全結核症の中では肺結核症がいずれの年も最も多く, 60%から83%を占めている (全124例, 76%)。次に多いのは結核性胸膜炎で7.3%から24%であった (全27例, 16.6%)。治療薬は一貫してINH, RFP, EB, SMが主体であるが, 近年多剤耐性菌が増加してきてPASやCSなども使用されるようになってきている。治療期間についてはいずれの年も1年から1年半が最も多く, 全体的に短縮される傾向にあった (平成2年の平均的治療期間は17.6か月, 平成5年14.0か月)。しかし入院期間の短縮は認められなかった。肺結核症の中の塗沫陽性患者の割合は平成5, 6年の平均が40%であり平成2年の20%と比較して倍増している。また薬剤耐性菌についてはINH, RFP, EB, SMに対する多剤耐性菌が平成4年以降増加傾向にある。治療終了後に経過観察できた147例中, 再発を1例に認めた (0.7%)。

India’s private medical sector needs to get more involved in the management and control of tuberculosis, researchers reporting in two new studies in Lancet Infectious Diseases have said.1 2 The first study, led by Nimalan Arinaminpathy, senior lecturer at the Department of Infectious Disease Epidemiology, Imperial College London, considered the sales of 189 antituberculosis drugs in India during 2013-14 to calculate the number of patients who were treated in the private sector in that period. It estimated that the number of cases of tuberculosis treated in the private sector in 2014 was 2.2 million, more than double the currently estimated number …

Primary tuberculosis of the chest wall is rare and its clinical presentation may resemble pyogenic abscess or tumour. The diagnosis is difficult, since smears or cultures of aspirate frequently fail to show tubercle bacilli. Seven cases of primary chest-wall tuberculosis treated between 1973 and 1992 are described. All presented with a progressively enlarging mass. The diagnosis was based on bacteriologic and histologic findings, but definitive diagnosis was obtained before treatment in only two cases. Satisfactory results were obtained with surgical debridement and specific chemotherapy in six cases and with chemotherapy alone in one case. From this limited experience, we suggest that primary chest-wall tuberculosis should initially be treated with a combination regimen of antituberculous chemotherapy, which should take more than 9 months. If the lesion progressively enlarges or secondary infection occurs, however, adequate surgical debridement is also required.

Objective : ENT extra-nodal localisation of tuberculosis is an uncommon condition. Clinical symptomatology is misleading, so having the problem of differential diagnosis with tumoral disease. We report 12 cases of extra-nodal localisations of tuberculosis treated in ENT department of the Fattouma Bourguiba hospital of Monastir between 1995 and 2009. The mean patients age is 38 years. Topographic analysis shows 3 laryngeal localisations, 3 on the salivary glands, 2 tonsillar, 2 on the nasopharynx and 2 rhinosinusal. The diagnosis was in all cases histo-pathological. All our patients received an antitubercular treatment with favorable evolution. Keywords : Tuberculosis, larynx, nasopharynx, salivary glands, tonsil

We report here 2 pediatric cases of multidrug-resistant (MDR) tuberculosis (TB) that were observed in Italy. Both families came from an Eastern European country, which is notably an area with a high prevalence of MDR TB. An increase of new cases of MDR TB in developed countries is expected over the next years because of migratory flow, and specific measures and strategies need to be taken to prevent the propagation and dissemination of MDR TB. An efficacious treatment including linezolid and moxifloxacin was administered for 13 months in 1 case. No adverse reactions were detected during close child monitoring. Linezolid and newer fluoroquinolones such as moxifloxacin have been reported to be effective for MDR-TB treatment in adults. On the contrary, there is limited available evidence regarding the effectiveness and safety of these drugs in infants and children with MDR TB. The use of second-line drugs not approved for use in children may be necessary to treat a life-threatening disease such as MDR TB, but it requires careful monitoring to quickly recognize the occurrence of dose- and duration-dependent adverse drug reactions.

Eleven patients with thoracic and lumbar tuberculosis were treated by anterior debridement and fusion combined posterior instrumentation. A one-stage surgery was done on seven patients and a two-stage surgery on four patients. Posterior instruments included seven ISOLA, three Luque rods with sublaminar wiring, and one Spine system. The average range of anterior fusion was 2.4 segments and that of the posterior fixation was 3.8 segments. Seven patients presented paraparesis before surgery and all improved after surgery. None showed persistent or recurrent tuberoculosis. Sagittal alignment, corrected after surgery, was not lost by more than 10 degrees in 10 patients but by 30 degrees in one patient treated with Luque rods. Solid bone union was obtained in all patients. Our study showed that anterior debridement and fusion combined with posterior instrumentation are useful for spinal tuberculosis.

Retrospective case study.We present a retrospective clinical study of 15 patients with lumbar and lumbosacral tuberculosis treated by transforaminal lumbar interbody fusion and posterior instrumentation. The purpose is to determine the clinical efficacy of such surgical treatment for lumbar tuberculosis.The goals of management of tuberculous spondylodiscitis are to eradicate infection and to prevent or treat deformity, instability, and neurologic deficit. Various methods of surgical debridement and fusion have been described for the lumbar spine. However, there have been few reports on the treatment of patients with peridiscal type of lumbar tuberculosis by transforaminal debridement and interbody fusion along with posterior stabilization using pedicle screw fixation.Our study comprises 9 males and 6 females with an average age of 47 years treated with the above given surgical procedure. All patients had single motion segment involvement. The average follow-up is 41 months. We have evaluated the following parameters: healing of disease, deformity correction and its maintenance, improvement in neurology, fusion of affected segment, and functional outcome.The mean preoperative local lordotic angle of -3.7 degrees was corrected surgically to a mean of 5 degrees immediately postoperatively. The mean local lordosis at final follow-up (mean 41 mo, 26 to 69 mo) was 4 degrees. Using the modified radiologic criteria of Lee et al, we found that 13 patients had definitive fusion and 2 patients had probable fusion. All patients had healing of disease and there was no recurrence at final follow-up. Using the criteria of Kirkaldy-Willis et al, the functional outcome was found to be excellent in 8, good in 5, and fair in 2 patients.Transforaminal lumbar interbody fusion with pedicle screw fixation is a simple, safe, and effective procedure for treatment of selected patients suffering from lumbar and lumbosacral tuberculosis.

The presentation and outcome of pediatric cervical spine tuberculosis are different from those of adult cervical spine tuberculosis. We retrospectively reviewed the clinical and radiographic outcome of 58 children with cervical spine tuberculosis treated nonoperatively and operatively between 1996 and 2004. The mean age was 3.7 years (range, 1.9-14 years). The cervicodorsal junction was affected in 27 children, the atlantoaxial complex in 19 children, and the mid-cervical spine in 12 children. Multifocal noncontiguous spinal lesions were observed in 21 patients. Surgery was performed in 25 children for: neurologic deficit (14); drainage of retropharyngeal abscesses (four); atlantoaxial fusion for late C1-C2 instability (three); and progressive deformity and pain (four). Neurologic recovery occurred in all patients. Seven patients were lost to followup within 2 years. The minimum followup was 2.4 years (mean, 3.5 years; range, 2.4-10 years). We attributed the improved functional outcome after anti-TB chemotherapy alone to the remodeling potential of the pediatric cervical spine. Surgery was performed only for neurologic deficit, an atlantodental interval greater than 5 mm on flexion/extension view, and progressive deformity. Four patients developed superficial wound infection, two patients had graft repositioning for a slipped graft, and seven children developed a grade 1 pressure sore over the scalp while on traction.

Introduction Peru is the second country in South America with the highest rate of tuberculosis, approximately 0.5% were tuberculosis spondylitis, being a variant of high morbidity because of the bone destruction, deformity, and neurological deficit potential. Tuberculosis is a difficult disease to treat and control because of poor access to health services and the delay in diagnosis. The treatment has undergone changes over time, from purely medical treatment or laminectomy to aggressive surgical treatment combined with specific chemotherapy; this marks a trend that is reflected in the way of acting in our service. Material and Methods We performed a retrospective case series and describe 14 cases collected between 2008 and 2013 hospitalized in the “Neurotrauma and Column,” database of operative reports is reviewed and files medical records. The data obtained are presented in tables and bar frequency and percentage. Results Of the 14 patients, 12 (86%) are women and 2 (14%) were men, the average age was 45 years. Overall, 13 (93%) underwent some form of surgery. The mean disease duration before surgery was 10.3 months the average time motor deficit before surgery was 5.1 months. The region of the spine was most frequently committed to the dorsal region (79%), 93% had vertebral collapse, and all compatible images with paraspinal abscesses and/or intraspinal. Overall, 12 (86%) to motor deficit and 13 (93%) had pain in affected region. With regard to diagnosis, it had microbiological confirmation in five cases (36%), histopathological diagnosis of specific granuloma in seven (50%), and only epidemiological–clinical–radiographical suspicion in two (14%) cases, in response to specific treatment. Using the classification GATA obtain IA (zero), IB (one), II (seven), and III (five). With regard to treatment, only 1 patient received specific chemotherapy (GATA IB), 13 were treated in combination with surgery: 6 (46%) debridement with or without drainage of abscess, interbody graft more transpedicular fixation by posterolateral approach, 4 (31%) laminectomy more biopsy with or without debridement, and 2 (15%) transpedicular fixation more laminectomy 1 (8%) interbody fusion noninstrumented. Of the 13 patients treated surgically, 11 cases showed motor deficit before surgery, 4 (31%) showed no change in the postoperative relative the motor deficit. Overall, nine (69%) improved at follow-up, two of which currently have no motor deficits. Conclusion Spinal tuberculosis is a major cause of disability; the main symptoms are pain and motor engine. Sometimes, confirmatory microbiological diagnosis cannot be established pathologically, but the response to specific treatment directed diagnosis. The surgical approach and technique used must be compatible with the theoretical basis of neurological decompression, fusion and spinal stability, and surgeon experience. In relation to the motor deficit, most improvement and disability significantly reduced, taking into consideration the duration of the motor deficit before surgery.

We report a case of primary mycobacterial sternal infection. An 81-year-old man with an infected parasternal sinus of non-specific pathology was treated with antibiotics for four months with only palliative effect. On hospital admission CT scan showed thickened first and second intercostal spaces and chest wall, but no bone involvement. At operation, the manubrium was found to be infected also. This was excised with the first three ribs anteriorly. Histology showed caseating granulomata. No other tuberculous foci were found in the patient.

Tuberculosis is an endemic disease in Morocco. Main blood vessels are rarely affected; the few mentioned cases are aneurysmal. We report a 17-year-old patient presenting with renovascular arterial hypertension, revealed thanks to the discovery of an occlusion of the right renal artery in Duplex scan. During the intervention, the observation of pararenal and mesenteric tuberculous polyadenopathy let us suggest the same kind of lesion at the level of the occluded renal artery. Once antituberculosis treatment had been carried out, the right renal artery was revascularized with a right iliorenal bypass using reversed internal saphenous vein. The postoperative course was uneventful, with an 18-month follow-up. Arterial pressure was normal without antihypertensive treatment, and the bypass was patent. As far as we know, this is the first case of renovascular arterial hypertension resulting from tuberculosis treated with an iliorenal bypass.

• In 14 patients with tuberculosis treated with ethambutol hydrochloride, pattern-reversal visual evoked potentials (VEPs) were recorded to monocular, whole-field stimulation before the commencement of treatment and one month and three months subsequently. In six subjects, the VEPs showed changes in the latency and amplitude of the P100 component at the one- or three-month interval. In three cases, the VEP changes reversed after cessation of treatment. In five of the six cases, changes were not associated with a change in visual function, as measured by clinical neuro-ophthalmologic examination. Our findings confirm the usefulness of VEPs in the detection of subclinical optic nerve disease and suggest their use in routine monitoring of ocular function in patients treated with ethambutol.

As of December 1975, there had been 5 to 8½ years of observation on 263 patients with bacteriologically proven tuberculosis who were initially admitted to a general hospital and were treated largely as outpatients by community physicians from July 1967 through December 1970. Ten patients died during hospitalization, and 253 were released to therapy as outpatients. Although smears or cultures of sputum remained positive at discbarge in 136 (54 percent) of the 253 patients, no new infections were subsequently detected among their contacts. During initial therapy, 24 patients died of causes other man tuberculosis. Of me remaining 229 patients, the original 18-month treatment was successful in 197 (86 percent). The treatment failed initially in 11 patients, eight of whom represented relapses from previous therapy. During long-term follow-up of the 229 patients, there were only six relapses (3 percent) after the initial success. An overall rate of successful treatment of 92 percent (211/229) was achieved in the program, with 18 failures of treatment (8 percent); ie, 11 patients were lost to supervision, four died of tuberculosis, and in three, treatment was never successful.

n/a

1.Five consecutive cases of unilobar tuberculosis treated by lobectomy are presented with follow-up data. 2.The classification of patients with minimal lesions into different groups is mentioned. The value of careful selection of patients for lobectomy is considered and the criteria for this selection outlined. 3.The possible advantage of lobectomy in selected cases is discussed and compared with other methods of treatment. 4.It is felt that lobectomy has a place in the treatment of early tuberculosis, although a larger series of cases will be required to substantiate this fully.

1.1. A case is presented in which chronic glanders and cystic tuberculosis of bone coexisted. The causative organisms of both diseases were isolated and identified. ∗ ∗We are indebted to Dr. Roy C. Avery and Dr. G. John Buddingh of the Department of Pathology and Bacteriology, Vanderbilt University School of Medicine, for their assistance in isolating and identifying the micro-organisms from this case. 2.2. Penicillin therapy was ineffective. Treatment with streptomycin seemed to be curative for glanders but in the dosage used had little or no effect upon the tuberculosis of bone.

Summary A well-marked eosinophil leucocytosis developed in 10 out of 36 patients with tuberculosis while under treatment with antibiotics, unaccompanied by any of the associated hypersensitivity reactions recorded in the literature. Though some of these patients have been followed for six months or more, no allergic symptoms have developed. The eosinophilia is not a danger signal. It is suggested that the phenomenon will be found to be quite common.

1. The Arneth count in cases of surgical tuberculosis treated by natural heliotherapy in the Alps does not show so great a left-handed deviation as in similar cases treated in Britain. 2. It is suggested that this may be taken as one of the indications of the success of this method of treatment, and reasons are adduced for this.

Microbiologic assay for antimicrobially active isoniazid was performed on the serum of 57 children with tuberculosis. Comparisons were made with similar assays of serum from 344 adult tuberculous patients. Regardless of the basis for calculating equivalent dosage, the relative proportion of children and adults who were rapid inactivators of isoniazid was roughly the same. Six hours after administration of isoniazid the concentrations in cerebrospinal fluid were equal to or greater than those of the serum. The value of determining the concentrations of isoniazid in serum for individualization of dosage in children was discussed.

1. The long-term results in thirty-one cases of spinal tuberculosis treated by the ambulant method are reviewed. The method has been shown to be successful in early cases.

n/a

Serial electroencephalograms were obtained on 52 cases of tuberculosis treated with isoniazid in combination with other antimicrobial therapy. There were no observable changes in the 166 electroencephalograms as compared with the normal or abnormal records prior to therapy. No signs of symptoms developed which could be attributed to brain involvement.

Twelve patients with tuberculous pericarditis were found among 1,194 patients with tuberculosis treated at the University of Texas Medical Branch over a 10-year period, an incidence of 1%. Surgical treatment was undertaken in 4 patients, and the rest were treated medically. The surgically treated patients had no major complications, and none of them died. In the medically treated group, however, 1 patient died, 1 had an anaerobic empyema, and 1 experienced respiratory arrest. In addition, the average hospital stay was 33 days less in the surgically treated group. Early surgical intervention should be carried out in patients with tuberculous pericarditis who do not respond promptly to adequate antituberculosis chemotherapy.

Vestibular function testing was done regularly on the cases given streptomycin, kanamycin, or enviomycin and a method to detect the cases of vestibular dysfunction at an early stage was discussed, as well as the time these drugs should be discontinued. Subjects were 85 cases of tuberculosis treated with streptomycin, kanamycin, or enviomycin who were admitted to our hospital from December 1984 to May 1986. The method of equilibrium examination performed at regular intervals is as follows: standing test (Romberg test), stepping test, and Meyer zum Gottesberge's head-shaking test were done once a week for a month after starting antituberculous injections and they were re-examined once every 2 weeks for at least 3 months after beginning the injections. After the 3 months these tests were done once a month. Eight cases of vestibular damage due to streptomycin or enviomycin could be easily detected at an early stage by performing Meyer zum Gottesberge's head-shaking test, together with the standing test and the stepping test. Vestibular dysfunction is apt to occur after about 1 month or within a month from the start of daily injections especially with streptomycin. Therefore, the method of equilibrium examination, we suggest, is that the Meyer zum Gottesberge's head-shaking test, the standing test (Romberg test), and the stepping test should be performed once a week during the first month after the start of this drug. When the result of the Meyer zum Gottesberge's head-shaking test is less than 50% and swaying and/or rotation occur in the stepping test, the drugs being given should be discontinued.

As a basis for the conclusions to be drawn in this paper, I have selected nine cases, each illustrating some special point of interest. I have omitted many of the details which would be of little interest to the general practitioner. Case 1. —Mrs. K. E., aged 84 years. Referred by Dr. Ulrich of Chester, Pa. The diagnosis was carcinoma of the right breast. Operation was contraindicated on account of the patient's age and on account of the condition of her heart. The growth was of one year's duration. There was a distinct retraction of the breast below the nipple, making a groove about two and a half inches in length. In connection with this there was a hard mass about the size of a hen's egg. Surrounding this central mass there were other masses of lesser size and of less density. The overlying skin was healthy. There was no axillary

Summary 1. Figures are given of the number of cases of primary intrathoracic tuberculosis treated at Tadworth Court, Surrey, between February 1946 and July 1948, and between July 1948 and December 1950. 2. Figures are given of cases treated entirely as out-patients between July 1948 and December 1950. 3. The work of the outpatient clinic is discussed. 4. A case is made for treating more children at home or for much shorter periods in hospital.

1) Chronic pulmonary tuberculosis during the period of maximum streptomycin effect is characterized by more rapid healing of tuberculous foci, lack of perifocal reaction about pulmonary foci, and absence of laryngeal and gastro-intestinal tuberculosis. 2) With the onset of resistance, new foci developing in the lungs are similar to those in untreated cases, and intestinal and laryngeal tuberculosis again develop. 3) The treatment of laryngeal and intestinal tuberculosis by streptomycin in cases after the bacilli from tuberculous cavities are resistant is of no value. 4) In one case where tuberculous meningitis and chronic pulmonary disease coexisted, the organisms from the pulmonary lesions became resistant while those from the cerebro-spinal fluid remained sensitive. 5) Tuberculous meningitis in cases treated for long periods is characterized by wide areas of caseation surrounded by broad zones of hyalinized connective tissue. 6) Clinico-pathologic correlation of the effects of streptomycin therapy requires frequent sensitivity studies including postmortem material.

Case histories of dramatic recovery from active pulmonary tuberculosis as a result of treatment with streptomycin still are rare enough to warrant reporting. Also, in this case Addison's disease had set in and the patient was rapidly becoming worse. Since Addison's disease is so uniformly fatal, possibility of cure by means of streptomycin represents an important gain in the means of defense against this devastating disease. Reading over the various reports on all types of tuberculosis treated with streptomycin, one notes the extremely cautious conclusions, such as "Streptomycin should be reserved in pulmonary tuberculosis only for patients not doing well on the regular (slow-going) sanatorium regimen of rest, lung deflation and the like." It is evident that much wider study of streptomycin alone and streptomycin in combination with other remedies (para-aminosalicylic acid, "promin" [sodium p,-p′-diaminodiphenylsulfone-N,N′didextrose sulfonate]) is needed before conclusions can be drawn. My patient was treated successfully at home