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The diagnosis of pulmonary tuberculosis (PTB) in young children is particularly complex in resource-poor regions where HIV infection is common. This study examines the impact of HIV infection on diagnosis in children with suspected PTB attending Queen Elizabeth Central Hospital, Blantyre. A total of 110 children (4 months-14 years) were studied over a 4-month period. Clinical data were recorded and investigations included Mantoux test, chest X-ray, HIV status (HIV-PCR when younger than 18 months) and sputum, if available. Laryngeal swabs were compared with sputa or gastric aspirates in a subgroup of 60 children. All children were commenced on anti-TB therapy and followed for treatment response. Aware of the clinical overlap between HIV and TB infection, we used more limited criteria than recommended to allocate a final diagnosis following review of all data except HIV status. Final diagnosis included confirmed PTB (n = 8), probable PTB (n = 41), lymphocytic interstitial pneumonitis (n = 10), pulmonary Kaposi sarcoma (n = 3) and bronchiectasis (n = 5). Culture rates of M. tuberculosis were: five (27.8%) of 18 sputa, three (7.1%) of 42 gastric aspirates and four (6.6%) of 60 laryngeal swabs. The HIV infection rate was 70.6% overall and 57.8% in 45 children with confirmed or probable PTB. Although a positive contact history was more common in HIV-infected children, a final diagnosis of confirmed or probable PTB was less common than in HIV-uninfected children (36% vs 63%; p = 0.02). The Mantoux test was positive in 14 (19%) of 72 HIV-infected compared with 15 (50%) of 30 HIV-uninfected children (p < 0.01). A final diagnosis could not be made in 43 (39%) of the study children with suspected PTB, the majority of whom were HIV-infected. HIV-infected children had a significantly poorer response to TB treatment and higher lost-to-follow-up rates.

Objective: To analyze the usefulness of the Mantoux test in the diagnosis of genital tuberculosis in women of childbearing age. Method: In this report, the investigators studied the ability of a tuberculosis (TB) Mantoux test to diagnose pelvic tuberculosis. A positive TB Mantoux test was clearly defined. The positive control group was of 100 women treated for TB (study group C). The negative control group was of 100 postpartum women (study group B). The study group was 100 infertile women undergoing laparoscopy, in some of whom the diagnosis of TB was made (study group A). Result: The Mantoux test had a sensitivity of only 55% and a specificity of 80% in women with laparoscopically diagnosed tuberculosis. Pelvic focal reaction was absent in all groups including infertile women with a positive Mantoux test. Conclusion: Mantoux test has limited utility in diagnosing active genital tuberculosis during the childbearing age. However, in infertile women with positive a Mantoux test, laparoscopy may be advocated early.

Interpretation of the Mantoux test for tuberculous infection can be complicated by cross-reactions caused by infection with non-specific mycobacteria. Thus, the distribution of positive indurations is a mixture of two distributions. To estimate tuberculous infection prevalence, the marginal distribution of indurations needs to be separated into its component distributions. Observations from several populations with different mixes of the two types of infection are required. Homogeneity across populations of distributions of indurations for each type of infection is assumed. A logistic model is specified for the probability of having tuberculous infection conditional on the observed induration size. No other assumptions about the two distributions are made. Maximum likelihood is used to estimate the logistic function. Goodness-of-fit criteria are discussed. The method is applied to a series of tuberculin surveys carried out in (South) Korea. Estimated infection prevalence agrees reasonably well with several ad hoc criteria. The goodness-of-fit test rejects underlying assumptions of homogeneity. One reason appears to be a decline over time in induration sizes caused by tuberculous infection. However, not all reasons for this rejection are obvious. The proposed method of mixture analysis provides an additional tool for the interpretation of prevalence survey data where the diagnostic test lacks specificity as a result of cross-reactions.

Seven serological tests, two immunochromatographic tests, ICT Tuberculosis and RAPID TEST TB, and five enzyme-linked immunosorbent assays, TUBERCULOSIS IgA EIA, PATHOZYME-TB complex, PATHOZYME-MYCO IgG, PATHOZYME-MYCO IgA, and PATHOZYME-MYCO IgM, were evaluated simultaneously with 298 serum samples from three groups of individuals: 44 patients with active tuberculosis, 204 controls who had undergone the Mantoux test (89 Mantoux test-positive and 115 Mantoux test-negative controls), and 50 anonymous controls. The sensitivities of the tests with sera from patients with active tuberculosis were poor to modest, ranging from 16 to 57%. All the tests performed equally with sera from subgroups of those with active tuberculosis, those with pulmonary (33 patients) versus extrapulmonary (11 patients) disease, and those who were smear positive (24 patients) versus smear negative (12 patients) ( P > 0.05). The specificities of the tests ranged from 80 to 97% with sera from the Mantoux test controls and 62 to 100% with sera from the anonymous controls. The TUBERCULOSIS IgA EIA had the highest sensitivity (57%) with sera from patients with active tuberculosis, with a high specificity of 93% with sera from the Mantoux test controls, but a very poor specificity of 62% with sera from the anonymous controls. Overall, ICT Tuberculosis followed by PATHOZYME-MYCO IgG had the best performance characteristics, with sensitivities of 41 and 55%, respectively, with sera from patients with active tuberculosis and specificities of 96 and 89%, respectively, with sera from the Mantoux test controls and 88 and 90%, respectively, with sera from the anonymous controls. By combining all the test results, a maximum sensitivity of 84% was obtained, with reciprocal drops in specificities to 55 and 42% for the Mantoux test controls and anonymous controls, respectively. The best combination was that of ICT Tuberculosis and PATHOZYME-MYCO IgG, with a sensitivity of 66% and a specificity of 86% for the Mantoux test controls and a sensitivity and specificity of 78% for the anonymous controls. While a negative result by any one of these tests would be useful in helping to exclude disease in a population with a low prevalence of tuberculosis, a positive result may aid in clinical decision making when applied to symptomatic patients being evaluated for active tuberculosis.

Background and Objective: The tuberculin (PPD) test is a model reaction for the cell-mediated immune system of the skin. The aim of this study is to compare the non-invasive technique based on electrical impedance for investigation of the tuberculin test with an irritant contact reaction induced by sodium lauryl sulphate, which has already been carefully evaluated using this method. Methods: 0.1 ml of PPD (2 TU) was injected intracutaneously into the volar forearms of 20 adult healthy subjects, all known to be tuberculin sensitized. Assessments were performed 3 and 7 days after the injections, using visual scoring, a new electrical impedance technique and transepidermal water loss (TEWL). Results: In the 16 cases that completed the study, compared to relevant controls and reactions induced by sodium lauryl sulphate statistically significant changes in 3 of the 4 impedance indices were found: both the means of index MIX and index IMIX increased (p ≤ 0.01) and the mean of index PIX decreased (p ≤ 0.05). Furthermore, similar impedance response patterns occurred in another cell- mediated immune reaction that we have studied previously – namely, the allergic contact reaction induced by nickel sulphate. Unlike the irritant reactions, no significant increase in TEWL values in tuberculin reactions were found. This can be explained by the fact that the epidermis is little affected, since the inflammatory process in the tuberculin reaction is located more deeply in the dermis than with the irritant reaction. Conclusion: The current study strongly indicates that electrical impedance in the described version, besides contact dermatitis, also seems suitable for studies of the tuberculin reaction. This will add a new indication for the technique, and studies of further clinical applications are in progress.

ResumenObjetivosEstimar la prevalencia de infección tuberculosa en los niños escolarizados en los cuatro primeros cursos de Educación Primaria, y analizar su distribución según su clase social y la existencia de antecedentes de enfermedad.MétodosSe trata de un estudio transversal mediante la aplicación de prueba diagnóstica y autocumplimentación de encuesta en una muestra representativa de la población escolar de la provincia de Guadalajara en 1997–1998 (diseño muestral polietápico). Se aplicó la prueba de la tuberculina utilizando 2 UT del lote PPD-RT 23, según normas de consenso y lectura por el método de Sokal. La clasificación de ocupaciones y la definición de clase social se hizo según la actualización de la Sociedad Española de Epidemiología.ResultadosSe estudiaron 1.093 niños (50,8% varones) comprendidos entre 6 y 9 años de edad. La prevalencia total de infectados fue de 1,64% (IC: 17–2,3). La distribución de infectados no mostró diferencias significativas para el estrato urbano-rural, antecedentes familiares, clase social, superficie de la vivienda y tipo de actividad ocupacional desarrollada por los padres. La prevalencia aumentó en los cursos superiores y en los niños de mayor edad, siendo de 0,4% (IC: 0,01–1,3) en el primer curso y de 3,53% (IC:2,4–4,6) en el último. En los nacidos en 1988 la prevalencia fue de 3,23 (IC: 1,2–5,1), y de 0,73 (IC: 0–1,7), 1,88 (IC: 0,2–3,51), y 0,4 (IC: 0–1,2) en los nacidos en 1989, 1990 y 1991, respectivamente.ConclusionesLa infección tuberculosa es poco prevalente en nuestro medio escolar en relación a estudios de otras comunidades. Esta baja frecuencia y el tamaño muestral utilizado han impedido la estimación estadística de posibles diferencias en la distribución de infectados en algunos subgrupos estudiados, aunque se puede objetivar una mayor afectación en los más mayores.AbstractObjectivesTo estimate the prevalence of tuberculosis infected children in the first grades of Primary Education and to analyse the distribution of infected people among social class groups and other previous circumstances.MethodsCross-sectional study with diagnostic test application and questionnaire survey, in a representative sample of the school population of the province of Guadalajara, Spain (two stages sampling design). Tuberculin skin tests with 2 I.U. of P.P.D. RT-23 and the Sokal method for lecture were used. For occupational classification and social class definition were used the criteria of the last report of Spanish Epidemiology Society.ResultsA total of 1,093 children (50.8% males) between 6 and 9-year-old were studied. The overall prevalence of infected children was 1.64 (I.C.:1–2.3). The distribution of infection did not show significant differences between urban/rural population, previous disease, family antecedent, social class, dwelling area and occupational activities of parents. The prevalence increased in the older upper school years and among the older children. Prevalence ranged from 0.4% (CI: 0.01–1.3) in the first year to 3.53% (CI: 2.4–4.6) in the last year. Children born in 1988 had a 3.23% prevalence (CI: 1.2–5,1), while those born in 1989; 1990 and 1991 had a prevalence of 0.73 (CI: 0–1.77), 1.88% (CI: 0.2–3.51) and 0.4% (0–1.2), respectively.ConclusionsTuberculosis infection is less prevalent at school ages than other areas of Spain. In spite of the increase prevalence per school year, the low frequency and sample size did not allow to test for other associations.

SummaryThe value of smear and culture of laryngeal swabs as a method of confirming pulmonary tuberculosis was investigated in Indian children. A total of 116 children with ‘suspected’ tuberculosis had a Mantoux test and chest X-ray. Of these, 51 had a positive Mantoux and/or chest X-ray compatible with tuberculosis, and this group had two laryngeal swabs taken on each of 3 consecutive days. The Mantoux test was positive in 37 (73%) of the 51 ‘probable’ cases. Chest X-ray was abnormal in 36 (71%) cases and compatible with tuberculosis in 20 (39.7%). Mycobacterium tuberculosis was cultured from laryngeal swabs in 14 (28%) children and in another three children smears were positive but culture-negative. The overall confirmation rate for tuberculosis was 33%. Laryngeal swabs are a simple method of confirming tuberculosis and may be undertaken in out-patients.

We evaluated an in vitro test of cell-mediated immunity, the tuberculin gamma interferon assay, Quanti FERON-TB (QIFN), in 455 individuals from three groups: group I, 237 immigrants from high-risk countries; group II, 127 health care workers undergoing Mantoux testing; group III, 91 patients being investigated for possible active tuberculosis (79 patients) or Mycobacterium avium-Mycobacterium intracellulare complex infection (12 patients). The QIFN results were compared either to those of the Mantoux test or to microbiological and clinical diagnosis, as appropriate. In each group the correlation between the diameter of induration for the skin test and the magnitude of QIFN response was significant and of moderate strength (Spearman’s rank correlation coefficient; ρ = 0.59 to 0.61; P < 0.001). For group I, the agreement between QIFN and Mantoux results was 89% for Mantoux-negative and 64% for Mantoux-positive individuals. For group II, when ≥10-mm-diameter induration was taken as positive, the agreement was 81% for Mantoux-negative and 67% for Mantoux-positive individuals. For group III, agreement was 81% for Mantoux-negative and 86% for Mantoux-positive patients. For patients being evaluated for active tuberculosis, the performance of the Mantoux test was not statistically different from that of the QIFN assay. In patients with active tuberculosis, the assay had a sensitivity of 77%, not significantly higher for extrapulmonary than pulmonary cases (83% versus 74%). QIFN sensitivity was not significantly different for smear-negative or smear-positive cases (80% versus 71%). The QIFN assay is a potential replacement for the Mantoux test. The acceptability of these performance values and those of similar evaluations will determine the place this test will have in detecting evidence of mycobacterial infection.

The Mantoux test is the only validated method for the diagnosis of acquired immunity against tuberculosis. Its interpretation may be difficult. A standard procedure must be strictly respected in performing and interpreting the test, and the factors that can increase or decrease the intensity of the response must be taken into account.

Objective To evaluate the immune status and vaccination needs of first-year medical students in relation to bloodborne viruses and common vaccine-preventable diseases. Design, setting and participants Survey of first-year medical students at the University of New South Wales, Sydney, NSW, attending a mandatory screening and vaccination clinic, 2002-2005. Main outcome measures Self-reported history of vaccination or natural infection; serological evidence of immunity to measles, mumps, rubella and varicella (presence of specific IgG) and hepatitis B (presence of hepatitis B virus surface antibodies) or infection with hepatitis B and C viruses and HIV; and Mantoux test results. Results 733 students attended the clinic (85% of those enrolled). Four students were positive for HBsAg and four had hepatitis C antibodies. None were HIV-positive. Twenty-nine per cent (216/733) were not immune to hepatitis B, 33% (238/724) to mumps, 26% (190/724) to measles, 13% (91/724) to rubella and 10% (75/724) to varicella. About 23% (91/237) needed further testing for tuberculosis. Immunity corresponded poorly with self-reported history of vaccination. More students reported vaccination against rubella (96%), measles (81%) and mumps (80%) than were immune, and fewer reported vaccination against hepatitis B (44%). Conclusions Many students were not immune to vaccine-preventable diseases, and a small number had a previously undiagnosed bloodborne virus infection (hepatitis B or C). The level of immunity to vaccine-preventable infections was unacceptable and justified the provision of an easily accessible program for screening and vaccination.

A 10-year-old Kenyan girl presented with a 9-month history of a persistent, painful eruption of multiple, tender, non-ulcerated, pigmented nodules involving the calves, shins and soles of the feet. She had recurring fevers particularly at night, lethargy, weight loss and a persistent non-productive cough. The Mantoux test was positive. Chest X-ray revealed mild peribronchial thickening in the hilar region but no evidence of hilar lymphadenopathy, consolidation and/or cavitation suggestive of tuberculosis. Sputum and gastric washings were negative for acid-fast bacilli. Histology on a skin biopsy showed a granulomatous panniculitis with no histological evidence of Mycobacterium tuberculosis, consistent with erythema induratum. In view of her constitutional symptoms, chronic non-productive cough and positive Mantoux test, she was diagnosed with pulmonary tuberculosis despite the non-specific chest X-ray and negative bacteriology. Anti-tuberculous therapy was initiated with pyrazinamide, isoniazid and rifampicin for 2 months followed by dual therapy with isoniazid and rifampicin for a further 4 months. Her constitutional and respiratory symptoms and skin eruption cleared within 6 months with treatment.

The incidence of tuberculosis in The Kingdom of Saudi Arabia remains high. The objective of this study is to determine the prevalence of Tuberculosis among haemodialysis patients, since they are highly susceptible to this infection. A retrospective study, over a 5-year period, was carried out in the Renal Units of two large hospitals in Jeddah. Diagnosis was established by Ziehl Neelsen microscopy and culture of specimens on Lowenstein-Jensen media, radiological and histological examinations. Tuberculosis was diagnosed in 17 of 210 patients on hemodialysis. Pulmonary tuberculosis was present in 10 cases and tuberculous lymphadenitis in 8 cases. One patient had both pulmonary and lymph node involvement while another one had both pulmonary and peritoneal tuberculosis. Mycobacterium tuberculosis was diagnosed in sputum in 5 cases, by lymph node histopathology in 5 cases, and combined radiological and clinical evidence in the remaining patients. The Mantoux test was positive in 9 (60%) cases. Eight patients were diabetics (47%) and there appears to be some association of tuberculosis with diabetes in patients on dialysis. Treatment with first-line anti-tuberculosis agents was continued for 6–18 months. Fourteen (82%) patients were completely cured while 3 showed clinical improvement only. The study showed that successful therapy of tuberculosis in this group of dialysis patients could be achieved but high index of suspicion is required to recognize the unusual presentation in this group of patients so that early diagnosis can be achieved and prompt treatment instituted. Diabetic patients presenting for dialysis, in areas with high endemicity for tuberculosis, chemoprophylaxis with anti-tuberculosis agents should be considered.

We experienced a case of tuberculous sacroiliitis. The patient was a 70-year-old woman. She suffered from general fatigue and febrile, but complained of no pain of the sacroiliac (SI) joint. She had slight tenderness over the right SI joint. Gaenslen test was negative. Roentgenogram revealed diffuse destruction with calcificated masses on the right SI joint. Laboratory on admittance showed no leukocytosis, elevation of erythrocyte sedimentation rate (125mm/hr) and C-reactive protein (3.79mg/dl). Results of the Mantoux test were positive. Needle biopsy from the right SI joint was performed, but the culture of specimens was negative and the pathological findings were not the specific results. We performed curettage and irrigation, and got the specimen of the bone involved. Histologic examination revealed granulomatous inflammation with infiltration of epitheloid cells, tubercle formation, caseous necrosis, and Langhans' giant cells. She was treated with three combined antituberculosis drugs (isoniazid, ethambutol, and rifampicin). At present 6 months after surgery, she has no pain, no fever and feels no fatigue.Sacroiliac joint involvement has been reported in 3-10 percent of patients with skeletal tuberculosis. Lack of awareness of this rare disease now often leads to diagnotic delay and increased morbidity. The direct sampling of the SI joint is necessary to establish the diagnosis. It is important to obtain the specimen involving oteoarticular fragments for the diagnosis.

We conducted a prospective study of 60 patients in a tertiary care referral center to ascertain the status of cell-mediated immunity as determined by delayed hypersensitivity reactions in patients with nasopharyngeal carcinoma (NPC) or allergic rhinitis. Delayed hypersensitivity as detected by Mantoux testing is generally accepted as a reflection of the level of cell-mediated immunoactivity—the less hypersensitivity reaction that occurs, the lower the level of immunoactivity is, and vice versa. Our study population was made up of three groups: 20 newly diagnosed patients with NPC (pretreatment), 20 age- and sex-matched patients with allergic rhinitis, and 20 matched controls without either disease. A negative Mantoux test (0- to 5-mm induration) was seen in 13 patients with NPC (65.0%), in 17 patients with allergic rhinitis (85.0%), and in 16 controls (80.0%); none of these differences was statistically significant. However, it is interesting that while the NPC group had the lowest percentage of negative Mantoux results overall, it had the highest percentage of patients who had no reaction at all (i.e., 0-mm induration); a complete absence of any reaction was seen in 7 of the 13 Mantoux-negative NPC patients (53.8%), compared with 2 of the 17 Mantoux-negative allergic rhinitis patients (11.8%) and 3 of the 16 Mantoux-negative controls (18.8%). An absence of a reaction generally indicates a very limited degree of cell-mediated immunoactivity. Therefore, we conclude that patients with NPC appear to have significantly less cell-mediated immunity than do patients with allergic rhinitis and normal controls; no statistically significant difference was noted between the latter two groups.

Atypical mycobacterial infection in HIV-negative children usually presents with cervical lymphadenopathy. We report on 10 children who are HIV-negative and who presented with pulmonary disease, in whom either culture-proven atypical mycobacterium infection (four), positive avian Mantoux test (five), or lack of response to human tuberculosis treatment (one) had been observed. One case was subsequently diagnosed as chronic granulomatous disease and illustrates that children with atypical mycobacterial pulmonary infection should have their immune status fully investigated. Bronchial obstruction was observed in eight cases, and of these, endobronchial disease was found in six children. The diagnosis of atypical mycobacterial disease is difficult, and a negative avian Mantoux test does not exclude the diagnosis. The availability of clarithromycin and rifabutin has offered new therapeutic options in treating atypical mycobacterial pulmonary infection, but management of these cases can be prolonged and difficult.

We have reviewed 31 patients with Takayasu's arteritis followed at two pediatric nephrology units in Gauteng, South Africa over a 15-year period. There were 25 black patients, 4 white, and 2 of mixed race. The mean age at diagnosis was 8.42+/-3.59 (range 2.4-14.5, median 8) years. The most common presenting sign was hypertension, followed by cardiac failure, bruits, and absent pulses. The Mantoux test was strongly positive in 27 patients (90%, control population 5%). Markers of activity included a raised erythrocyte sedimentation rate (23 patients) or Gallium single photon emission tomography (positive in 12 of 16 patients). Angiography revealed type II (abdominal aorta) and III (arch plus abdominal aorta) lesions to be most common (11 in each group). All patients received antituberculous therapy and most low-dose aspirin for its antithromboxane effect. Corticosteroids and further immunosuppression were used to control disease activity. We added total lymphoid irradiation (TLI) or cyclophosphamide. Twenty-six patients in all received further immunosuppression, with 13 patients in each group. Results were similar in the two groups, with similar pre- and posttherapy systolic blood pressures and creatinine clearances. Two patients in each group relapsed, 3 died in the TLI group and 2 in the cyclophosphamide group. Surgical intervention, usually in the quiescent phase, consisted mainly of renal autotransplantation. Because of the problems with TLI and 2 patients with papillary carcinoma of the thyroid with long-term follow-up, we no longer use TLI. We have shown that with active medical and surgical intervention the aggressive course of this disease in children can be modified.

Background. Adults infected by HIV have increased susceptibility to Mycobacterium tuberculosis and progress more rapidly to disease. HIV and tuberculosis (TB) coinfection in children has been reported but often lacks bacterial confirmation. We report on the clinical picture, special investigations, clinical course and outcome of 14 children with HIV infection and culture-confirmed TB from a developing country. Methods. The clinical records of all children, from 1992 to 1997, with HIV infection and culture-proved TB were reviewed. Results. Fourteen (10.4%) of 135 children with vertically transmitted HIV infection, 93%

Between February 1993 and December 1994, 875 adults underwent tuberculin screening by the Public Health Service of Parma. The adults were randomly assigned to a multipuncture test, Tine or Mono, and contemporarily, as a reference test, received the intradermal Mantoux (IM) in the opposite arm. The tests were then read 72 hours later by two different trained nurses. The error quota due to IM was estimated by repeating both the tests done initially in patients with discordant results. The Mono test revealed a sensitivity of 95%, which was the same as that observed for the Mantoux test. As an 'operative index' of the screening, the number of false positives subsequently tested for every 10 correctly identified was used. The authors retain that the results obtained indicate the validity of the Mono test for screening in the adult population with a prevalence of tuberculous infection above 10%.

A formulation of a eutectic mixture of lidocaine-prilocaine (EMLA) changes basal skin perfusion. Its use for alleviating pain associated with the Mantoux test may modify the recruitment of sensitised lymphocytes and then the response to tuberculin test. Twenty-four healthy BCG-vaccinated volunteers (26.7+/-4.1 years) received on each forearm an intradermal injection of 10IU tuberculin, one of the forearms being randomly pre-treated for 1h with EMLA-patch 5%. Pain associated with the Mantoux test was evaluated using a visual analogue scale. The transversal diameter of the induration was read at 72h. Subjects with 6mm difference between diameters (i.e. twice the usual variation for a Mantoux test) were recorded. Results were compared using a paired t-test. When using lidocaine-prilocaine prior to the test, a three-fold decrease in pain was noted (p0.0001). Reading of the test were not affected by the lidocaine-prilocaine application (p=0.26). Four subjects had 6mm or more difference between their two tests, two of them having an induration greater than 15mm with lidocaine-prilocaine. Lidocaine-prilocaine reduces significantly pain associated with the Mantoux test but does not normally affect the test reading. However, when the induration is more than 15mm, a control without lidocaine-prilocaine has to be considered.

This prospective study was conducted to evaluate the role of hemoglobin level, as a risk factor for Lower Respiratory Tract Infections in children (LRTI).100 children who came to the outpatient department for LRTI were included in the study. Age and sex-matched 100 children, not having any respiratory illness, were taken as control. They were subjected to complete blood count (CBC),C-reactive protein estimation (CRP), Mantoux test and X-ray chest. Peripheral smear, serum ferritin and serum iron binding capacity were done for all anemic children. Results. Radiological evidence of pneumonia was present in 63 children(63%).Hyper inflated lungs were seen in 27 (27%). Mantoux was positive in 22 children (22%) of study group and none among control group. CRP6 mg/L was noted in 45 children (45%) of study group and 14 (14%) of control group. Seventy four of study group (74 %) and 33 of control group (33%) had anemia. Of the anemic children, 60 (60%) had iron deficiency,10 (10%) chronic inflammation and 4 (4%) had hemolytic anemia. These values were 30 (30%), 2 (2%) and 1 (1%)respectively for control group. Low hemoglobin level due to whatever etiology, was a risk factor (p=0.000).Anemic children were 5.75 times more susceptible to LRTI compared to the control group. Prevention of anemia, due to whatever etiology, will reduce the incidence of LRTI.

OBJETIVO: Analisar os achados clínicos da tuberculose ocular e seus aspectos epidemiológicos. MÉTODOS: Foram revisados prontuários médicos de pacientes que foram atendidos no Departamento de Oftalmologia - setor de Uveíte e AIDS da Unifesp-EPM, São Paulo, Brasil, entre janeiro de 1999 e julho de 2002 e que tiveram diagnóstico de tuberculose ocular. Foram inclusos os pacientes que apresentaram PPD forte reator, epidemiologia positiva para tuberculose e lesão ocular que melhorou com tratamento específico. RESULTADOS: Foram analisados prontuários médicos de 17 pacientes, sendo 12 (70,6%) do sexo feminino. A idade média foi de 54 (24-84) anos. O tempo médio entre o início dos sintomas e a primeira consulta foi de 100 dias. Os achados oculares foram inespecíficos nesta ocasião mas prevaleceram as alterações de segmento anterior e 41% dos pacientes apresentavam sinais de tuberculose sistêmica. Alterações como glaucoma, descolamento de retina e hemorragia vítrea foram responsáveis pela redução da acuidade visual. CONCLUSÃO: Embora pouco prevalente, a tuberculose ocular apresenta morbidade elevada. A inespecificidade da apresentação clínica da doença ocular pode atrasar o seu diagnóstico.

The conventional intradermal tuberculin skin test (Mantoux test) is poorly specific and has unknown sensitivity for latent Mycobacterium tuberculosis infection. Two new tests offer the promise of improved tuberculosis diagnosis: the QuantiFERON TM -TB Gold test, based on a whole blood ELISA, and the T-SPOT TM . TB test, based on the ex-vivo enzyme-linked immunospot (ELISpot) assay. These tests are more rapid and offer greater specificity and objectivity than the tuberculin skin tests, and the latter may also offer greater sensitivity. Both tests have yet to be validated in immunosuppressed patients. Available evidence suggests that these techniques will be feasible to apply within tuberculosis control programmes. Ongoing research priorities include head-to-head comparisons, validation in immunosuppressed populations, and longitudinal assessment of the predictive value of a positive blood test in latent infection for progression to active disease.

A 40-year-old man of Pakistani origin presented with a 2-week history of fever (39.5 8C), malaise and arthralgias. He had been living in Spain for 16 years, and he had not travelled to a foreign country in the prior 4 years. Three days before, conjunctival erythema and multiple painful and violaceous-erythematous nodules (red arrows in Panel B) appeared in both pretibial regions, preventing him from walking because of pain. Physical examination showed bilateral metacarpophalangeal, wrist, knee and ankle arthritis. Ophthalmologic examination showed bilateral anterior scleritis, with preserved visual acuity and without signs of uveitis (Panel A). A chest X-ray study demonstrated bilateral hilar and mediastinal adenopathies (blue arrows in Panel C). He was admitted to the internal medicine ward. Serum angiotensin conversor enzyme levels were normal. Human immunodeficiency virus serologies, Mantoux test, three sputum cultures with Ziehl–Neelsen staining and a bronchoalveolar lavage (BAL) ruled out infectious disease. The CD4/CD8 ratio in the BAL was 2:1. A transbronchial biopsy of an adenopathy showed nonnecrotizing granulomas, without microbiological findings. The patient was diagnosed as a case of sarcoidosis, with the clinical presentation of a Lofgren’s syndrome. Lung alterations corresponded to a stage II pulmonary sarcoidosis. The patient was treated with dexamethasone eye drops and oral dexketoprofen. Scleritis, temperature, joint swelling and arthralgias disappeared, and he was discharged home. Two weeks later, he again developed fever and mild dyspnoea. Lung functional tests were normal, with the exception of a slightly lowered carbon monoxide lung diffusion (71 %), which was normalized after volume correction. After ruling out etiologies different from sarcoidosis, oral prednisone 20 mg/day was administered for a 4-week course as indicated in refractory disease, with total disappearance of symptomology. Adenopathies and parenchymal lung alterations remained stable. Currently, he has completed the treatment, and remains asymptomatic. We have presented a case of sarcoidosis with a typical Lofgren’s syndrome, consisting of hilar adenopathies, erythema nodosum and polyarthralgia or polyarthritis. This syndrome is found more frequently in women, and the course is usually benign often with [1] spontaneous remission. Anterior scleritis is an unusual ophthalmologic finding in sarcoidosis, and it has been related with Lofgren’s syndrome in a few cases [2]. Sporadic case reports [3] describe a good response to corticosteroids, but in this case, the scleritis responded well to non-steroidal antiinflamatory medication. The treatment of sarcoidosis with corticosteroids is not recommended [4] for stage II pulmonary sarcoidosis because 50 % of the untreated patients heal spontaneously. Nevertheless, symptomatic Electronic supplementary material The online version of this article (doi:10.1007/s11739-014-1067-6) contains supplementary material, which is available to authorized users.

Tuberculosis is an infectious disease transmitted aerogen and caused by bacteria which belong to the Mycobacterium tuberculosis complex. In the past few years it constitutes an increasing problem of public health with a worldwide incidence rate of 139/100 000 population in the year 2007, while in Europe the incidence was 54 and in Greece 5.9, respectively. The accurate recording of cases contributes to the actual mapping of the burden of the disease leading thus to focused therapeutic interventions, which can be also achieved in our country, according to the goals set by WHO, i.e. the decrease of morbidity and mortality from tuberculosis at least the half until 2015, in comparison to 1990 and the eradication of the disease until 2050. In the present research two epidemiologic studies were carried out, concerning a) the epidemiology of tuberculosis in Western Greece and the evaluation of completeness of TB notifications (2000-2003), b) the estimation of tuberculin status in school population in the Prefecture of Ilia (1994-2000). The aim of the studies was to described and analyze the epidemiological characteristics of tuberculosis in Europe in comparison to Greece, to describe and analyze the epidemiology of tuberculosis in Western Greece (Prefectures Ilia, Achaia, Etoloakarnania) and to evaluate the completeness of TB notifications in order to examine the effectiveness of the surveillance system and the effectiveness of disease control and prevention, as well as to evaluate the tuberculin status in the prefecture of Ilia, in order to examine if satisfactory progress has been achieved in the control and prevention of tuberculosis. For these purposes, official data of WHO, KEELPNO (Hellenic Centre of Disease Control), the local and prefectoral self-administrations were used, as well as records of the hospitals in the examined area and of the Health Centre of Gastouni. Furthermore, a study was carried out, implementing a Directly Observed Treatment Short Course (DOTS) programme in the prefecture of Ilia (Western Greece) and assessing the efficacy of the WHO-recommended strategy in 13 newly detected pulmonary tuberculosis cases in comparison to 41 TB cases managed conventionally. In collaboration with the clinic of pulmonology of the general hospital of Pyrgos a general practitioner who was educated in DOTS strategy carried out home visits and completed a questionnaire in a face-to-face interview with the newly diagnosed patients, the past treated patients as well as the household members of the patients. All statistical analyses were performed using SPSS for Windows (v.11.0 – v.15.0). According to the results of the epidemiological studies, the countries of the European Union present a steady decline of the average incidence of tuberculosis (

We report on three Italian children who presented with unilateral ankle tuberculosis (TB) consecutively during a short time period and in the same geographical area. A 6-year-old-girl with a family history of TB had limited mobility of the right leg at age 9 months; Mantoux test and radiographs at that age yielded normal findings. When severe right tibiotarsal swelling, reddening, pain and restriction of motion became apparent at age 4.6 years, the typical lesions of TB were evident on radiographs and computed tomographic (CT) scans. Mantoux test and synovial biopsy confirmed TB. A three-drug regimen of treatment proved useless: articular cartilage destruction and diffuse osteosclerosis ensued. Only a four-drug prolonged regimen of treatment proved to be somewhat effective. A 5-year-old girl had a 6-month history of painless swelling and limited mobility of the ankle; radiographs and CT showed osteopenia with marginal erosion of cartilages. A 14-month-old boy presented with a 2-week history of painless swelling ankle. Radiographs showed decreased bone density of talocalcanear bones. Mantoux test and synovial biopsy confirmed TB in both patients; treatment with a three-drug regimen greatly reduced symptoms. A careful suspicion of the diagnosis of tuberculosis is paramount in children with chronic or subacute monoarticular arthritis, even in absence of a positive tuberculin test or abnormalities on chest radiograph. When negative early on, the tuberculin test should be repeated after 6 weeks of arthritis, and a needle biopsy of the synovium is required in those children with monoarticular arthritis and a positive tuberculin test. Careful therapy is necessary to avoid sequelae that may lead to severe osteoarticular damage.

Objective. To determine the most effective strategy to encourage adherence with tuberculosis test reading in a high-risk population. Design. Prospective randomized controlled trial. Setting/Participants. Consecutive sample of 627 children ages 1 to 12 years due for a tuberculosis (TB) test in an urban children's hospital outpatient department. One child per family was enrolled. Intervention. All families received education regarding the importance of skin testing for TB and the need for follow-up, and written and verbal instructions regarding test reading. Families were randomly assigned to one of five strategies for follow-up TB test reading at 48 to 72 hours: 1) routine verbal and written instructions, 2) reminder phone call, 3) transportation tokens and toy on return, 4) withholding of school forms until time of reading and need to repeat TB test if not timely read, 5) parents taught to read induration with nurse home visit. Those who did not have tests read at 48 to 72 hours by a trained professional were phoned 1 week later. Results. The five groups did not differ with regard to TB risk factor score, maternal education, transportation source, or perceived importance of TB testing. Before the study the follow-up rate of TB test reading by a trained professional was 45%. Reading rates in this study were 58%, 70%, 67%, 70%, and 72% for groups 1 to 5, respectively. In group 4, only 39% had school forms to be completed and their adherence rate was 84% (53/63). Compared to group 1, the only statistically significant improvement was in group 4, especially for those who needed school forms completed, and in group 5. Those not adhering in groups 1 to 4 did not differ from returnees with regard to TB risk factors, maternal education, transportation, or perceived importance of testing. The most common reasons for failing to return included forgetfulness, transportation, and time constraints. Group 5 was stopped early because of difficulty with nurse visits (N = 98). When told of the nurse visit, 9% (9/98) families could not find a time for the visit. Seventeen percent (17/98) were visited but the child was not home, and 7% (7/98) were not visited because of a nurse scheduling problem. Conclusions. In a high-risk population, adherence with TB test reading is poor. However, education and return of school forms at reading time can significantly improve adherence. Although requiring larger investment in resources, visiting nurses may also aid in test reading.

Background. In January 1994, the American Academy of Pediatrics recommended that annual screening with the purified protein derivative tuberculin skin test, Mantoux method, be used for tuberculosis screening in high-risk children. This test has a better sensitivity and specificity than the previously used multiple puncture test, and patients need to return for a reading done by palpation by a health care professional.Objective. To estimate the prevalence of reactivity to purified protein derivative tuberculin in an urban primary care clinic whose patients meet high-risk criteria and to determine if annual screening is warranted, to determine the adherence to return to the clinic for reading of the skin test, and to describe the characteristics of patients who have tuberculosis infection and disease.Research Design. Cross-sectional study.Setting. Inner-city, hospital-based primary care pediatric clinic in Baltimore, MD.Subjects. A total of 1433 consecutive children attending this clinic from March through September, 1994, who were at risk for tuberculosis because of frequent exposure to poor and medically indigent city dwellers.Methods. The Mantoux test (5TU intradermal injection of purified protein derivative) was administered to children at annual health supervision visits. Patients were tracked to determine those who returned for a reading by a health care professional and find those with a positive Mantoux test. The charts of children with a positive test were reviewed.Results. Five hundred seventy-three (40%) patients returned for a reading by a health care professional. Five patients had a positive Mantoux test, giving a prevalence rate of 0.8% of reactivity to purified protein derivative tuberculin. One child with a positive Mantoux test also had chest radiograph findings consistent with tuberculosis disease but was asymptomatic.Conclusions. In our city with a low prevalence of disease, children whose only risk factor for tuberculosis was exposure to poor and medically indigent city dwellers did not represent a high-risk group. Our results are supportive of the 1996 American Academy of Pediatrics screening statement that annual screening is not warranted. Sixty percent of children did not return for a reading of the Mantoux test by a health care professional. Alternative strategies that are more convenient for parents are needed to obtain accurate readings by health care professionals when skin testing is deemed necessary.

1. Rosalind S. Abernathy, MD* 1. 2. *Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Pediatric Consultant, Tuberculosis, Arkansas State Department of Health, Little Rock, AR. 1. The majority of tuberculosis cases in children are from high-risk populations, that is, African-Americans, Hispanics, immigrants, and those living in poverty and in the inner cities. 2. The only acceptable tuberculin skin test is the intradermal Mantoux test with purified protein derivative (PPD), and three levels of positivity now are accepted. Children exposed to active disease who have findings suggestive of tuberculosis or who have human immunodeficiency virus (HIV) infection are positive at 5 to 9 mm; other high-risk groups are positive at 10 mm. 3. Diagnosis of childhood tuberculosis depends on a high index of suspicion coupled with suggestive epidemiologic data, tuberculin skin test results, and chest radiographic findings. Cultures are not routinely positive, and results are available only after treatment must be started. 4. Treatment is a uniform 6-month course of isoniazid, rifampin, and pyrazinamide for 2 months followed by 4 months of isoniazid and rifampin daily or twice weekly. Additional drugs are needed in cases of drug resistance. 5. Chemoprophylaxis for all children who have a positive tuberculin reaction will prevent future disease. Despite the availability of effective antituberculosis drugs since 1952, tuberculosis remains an important cause of morbidity, mortality, and health care cost in the United States. Tuberculosis case rates declined at a rate of 6% annually for more than 20 years until 1985 when they leveled off (Fig. 1⇓). Factors responsible for this include human immunodeficiency virus (HIV) infection; immigration of individuals from countries where tuberculosis rates are 10 to 30 times that of the United States; transmission of disease in hospitals, homeless shelters, and prisons; and poverty, overcrowded living, and poor access to medical care. While all this was occurring, funds for tuberculosis control by public health programs declined. Fortunately, the number of cases reported annually has decreased by 8.7% in the past 2 years, probably …

Objective: To study 18 cases of sarcoidosis, the hall mark of which was uveitis. Setting: Referrals from peripheral eye clinics. Patients: 18 patients with bilateral almost symmetric uveitis, negative Mantoux test and positive gallium scan were enrolled in the study. Preliminary bronchoscopy and bronchial lavage were not done due to social habits. Results: Age ranged between 7–48 years with median 15 and mean 19 years. Although the patients were multinational, yet all of them were residents of Kuwait. A father and son were affected within 8 months period. 78% were strictly ocular, associated pulmonary and salivary gland affection 11% each. Sole anterior uveitis was found in 28%,associated with intermediate uveitis in 55% and with posterior in16.6% of cases. Clinically detectable dry eyes associated 33% of cases. All our patients developed glaucoma which resolved with treatment of uveitis in 88% of them. Gallium uptake of the eye balls was found in 22%, of the lacrimal glands (panda sign) in 67%, and of the salivary glands or chest 11% each. Positive biopsy was found in 72%, 22% of which was conjunctival. Chest X-ray and SACE were positive in 11%.61% had hypergammaglobulinaemia and all had negative ANA and RF. Conclusions: (1) 61% of ocular sarcoidosis presented below sarcoid age. (2) Multinationality together with father‘s and son‘s affection indicate aclimatic or environmental insult in an already predisposed person. (3) Routine chest X-ray and SACE may not be adequate for diagnosis of ocular sarcoidosis. Gallium should be done in suspected cases. (4)Follow-up for prospects is emphasized.

The purpose of this study was to evaluate the immunological responses against mycobacterial antigens in Eales′ disease. Fifty six patients with Eales′ disease and fifty age-and-sex-matched healthy volunteers with normal fundus findings taken as controls, were subjected to Mantoux test, using 2 TU/0.1 ml of purified protein derivative (PPD), lymphocyte proliferation assay to PPD, and ELISA to detect IgM and IgG antibodies against mycobacterial A-60 antigen. The results of Mantoux test and lymphocytes proliferation assay did not differ significantly in the two groups suggesting a similar cellular immune response. The number of individuals with recent exposure/reexposure to tuberculosis (IgM+) was significantly higher among patients. However the number of people with past exposure (IgM-IgG+) was significantly higher among controls. Our study indicates that there are no statistically significant differences in the humoral and cellular immune responses to mycobacterial antigens between the patients with Eales′ disease and controls, except for a significantly higher IgM positivity among the patients.

A 12-year-old boy was seen with a discharging ulcer over the thoracic spine on July 5, 2002. The boy was apparently well 4 days before, when his mother accidentally noticed a small boil on the middle of the spine, surrounded by erythema and edema. The swelling increased until it burst 1 day prior to the examination, emitting a purulent discharge. The patient had fever with profuse sweating. There was no history of cough or expectoration, nausea, and/or vomiting. There was a history of recurrent chest pain, which was a consequence of pulmonary pathology, as the boy had been taking treatment for a recurrent chest infection for the past 4 years. The parents had also observed a loss of appetite and weight. The child was never vaccinated with bacillus Calmette–Guerin (BCG). His grandfather had succumbed to pulmonary tuberculosis. A history of tuberculosis was elicited in a family friend, as well as in the next-door neighbors. Examination of the skin surface on the back revealed the presence of a 1.5 cm × 1.5 cm ulcer. It had a purulent discharge. The ulcer was angry looking and had everted, undermined, irregular borders. It was tender to the touch and surrounded by erythema and edema. The ulcer was located at the dorso-lumbar spine (Fig. 1a,b). Smear(s) were prepared from the purulent discharge and were stained for the demonstration of acid-fast bacilli (AFB) with Ziehl-Neelsen stain; they were negative on three occasions. Culture result of the purulent discharge showed no growth after 48 h of incubation at 37 °C aerobically. Also, hematoxylin and eosin-stained sections prepared from the representative margin of the ulcer were studied to illustrate its microscopic pathology. It was characterized by a bizarre collection of epithelioid cells and partial foreign body giant cell formation (Fig. 2a,b). Typical tubercles per se, however, were conspicuous by their absence, as were caseation necrosis and tubercle bacilli. Figure 1. Scrofuloderma before (a) and after (b) antitubercular therapy (ATT) Figure 2. Scrofuloderma: bizarre collection of epithelioid cells (a) and a partial foreign body giant cell (b) (hematoxylin and eosin, 40 × 100) Chest examination revealed bilateral diminished air entry. Tympanic resonance was decreased. In addition, bilateral and asymmetric crackling and crepitations were demonstrated on auscultation. The crepitations were prominent on the right apical and right lower lobe. These were supported by the postero-anterior view roentgenograph of the chest, which revealed prominence of both hila. Patchy heterogeneous infiltration occupying the para-cardiac area and the right apex was conspicuous. Sputum examination and gastric lavage were negative for AFB. Mantoux test with intradermal injection of 0.1 mL SPAN's tuberculin (purified protein derivative (PPD)/5 tuberculin unit (5TU)/0.1 mL) was negative after 72 h. Investigations, including total and differential leukocyte counts, serum biochemistry, and renal and liver function tests, were within the normal range, except for the erythrocyte sedimentation rate, which was 55 mm/1st hour (Westergren). X-Ray of the lumbo-sacral area was negative. Tuberculosis-enzyme-linked immunoabsorbent assays (TB-ELISA) and polymerase chain reaction (PCR) were also inconclusive. A working diagnosis of scrofuloderma was made. Accordingly, antitubercular therapy (ATT), comprising 150 mg of rifampicin, 100 mg of isonicotinic acid hydrazide, and 500 mg of pyrazinamide (Rinizide Forte-DT), was advised for oral administration daily for a continuous 8-month period. A remarkable regression of the skin lesion was recorded after a period of 12 weeks (Fig. 1a,b). Corresponding regression of the lesions of the lungs was also seen clinically, as well as on roentgenograph. Accordingly, the patient was advised to continue the treatment for another 5 months. The patient has successfully completed the schedule of treatment. The skin and lung lesions have completely subsided. Currently, he is under surveillance.

A 41-year-old woman presented with a history of a solitary pustular erythematous lesion occurring at the site of a Mantoux test performed 10 months previously. The histopathology examination revealed a suppurative and foreign body giant cell reaction to numerous keratin flakes. Culture of the tissue was negative for both aerobic and anaerobic organisms including mycobacteria. We postulate that the reaction in our patient may have been secondary to the implantation of epidermal keratin or the entrapment of hair into the dermis during the intradermal injection of tuberculin purified protein derivative.

Lupus vulgaris is the most frequent form of cutaneous tuberculosis in industrialized countries. It is a chronic and benign form of cutaneous tuberculosis that usually occurs in patients previously sensitized to Mycobacterium tuberculosis. The histopathological study shows tuberculoid granulomas that usually contain Langhans-type giant cells. Caseous necrosis is not normally found. The culture is negative in most patients. On the other hand, the Mantoux test is usually highly positive. We present the case of a 58-year-old male who developed lupus vulgaris on the left cheek over a nine-year period, and who had another similar lesion on the edge of a residual scar on the left forearm from a probable scrofuloderma suffered during childhood.

An otherwise well 21-year-old man from Northwestern Ontario presented to our emergency department in Winnipeg, Manitoba, with a 2-month history of cough, progressively increasing dyspnea, hemoptysis and a 15-kg weight loss. His symptoms were worsening despite antibiotic treatment for presumed bacterial pneumonia. His past history included work as a seasonal labourer clearing brush. He was not hypoxic on room air, but his chest radiograph revealed a miliary pattern and bilateral infiltrates. A Mantoux test for tuberculosis was non-reactive, and the sputum gram stain was unremarkable. Empiric therapy was initiated for blastomycosis and the diagnosis was confirmed with a calcofluor stain of the sputum. Although blastomycosis is rare in most regions in North America, there is an unusually high incidence of blastomycosis in Northwestern Ontario. This case highlights the intolerance and utility of knowledge of the local epidemiology in establishing difficult diagnoses of regional importance, such as fungal pneumonias.

The decreased incidence of infectious diseases in developed countries may make their diagnosis difficult. Cutaneous tuberculosis is an example of this fact. A 44-year-old man presented with two painful abscesses on his lower extremities, which developed into chronic ulcers. A cutaneous biopsy revealed necrotizing granulomas in the dermis. Ziehl-Neelsen and periodic acid-Schiff stain were negative. Mantoux test was positive. Tc-99m scintigraphy showed increased uptake in the bone tissue of the left ankle and right tibiae, without direct relation to cutaneous lesions. Chest X-ray showed micronodular, apical, bilateral infiltrates, reduced volume of the right lung, and cavitation of the right superior lobe. Mycobacterium tuberculosis was grown from sputum and skin biopsy samples. Isoniazid, rifampin and pyrazinamide treatment for 2 months, followed by isoniazid and rifampin for 12 months, resulted in complete resolution. The clinical features of cutaneous tuberculosis in our patient were characteristic of tuberculous abscesses. Some uncommon findings, such as the low number of lesions, negative acid-fast resistant stains in cutaneous biopsy samples and his preserved general state of health, may be explained by a higher competence of the immune system than is usual in this clinical subset of disseminated tuberculosis. Cutaneous tuberculosis should be included in the differential diagnosis of cutaneous abscesses in immunocompetent patients.

Aims: The aim was to analyze the learning curve of phacoemulsification (phaco) performed by residents without experience in performing extra-capsular cataract extraction (ECCE) in a step-by-step training program (SBSTP). Materials and Methods: Consecutive surgical records of phaco performed from March 2009 to Sept 2011 by four residents without previous ECCE experience were retrospectively reviewed. The completion rate of the first 30 procedures by each resident was calculated. The main intraoperative phaco parameter records for the first 30 surgeries by each resident were compared with those for their last 30 surgeries. Intraoperative complications in the residents’ procedures were also recorded and analyzed. Results: A total of 1013 surgeries were performed by residents. The completion rate for the first 30 phaco procedures was 79.2 ± 5.8%. The main reasons for halting the procedure were as follows: Anterior capsule tear, inability to crack the nucleus, and posterior capsular rupture during phaco or cortex removal. Cumulative dissipated energy of phaco power used during the surgeries was significantly less in the last 30 cases compared with the first 30 cases (30.10 ± 17.58 vs. 55.41 ± 37.59, P = 0.021). Posterior capsular rupture rate was 2.5 ± 1.2% in total (10.8 ± 4.2% in the first 30 cases and 1.7 ± 1.9% in the last 30 cases, P = 0.008; a statistically significant difference). Conclusion: The step-by-step training program might be a necessary process for a resident to transit from dependence to a self-supported operator. It is also an essential middle step between wet lab training to performing the entire phaco procedure on the patient both effectively and safely.

A 20-year-old female patient presented with fever and swelling in the neck accompanied by anorexia and weight loss. The clinical examination revealed a febrile patient with diffuse cervical lymphadenopathy. Routine investigations were negative. A 5TU (tuberculin units) tuberculin skin test (Mantoux test) was positive with an induration of 52 × 40 mm after 72 h with central blistering, exudation and ulceration. Aspiration cytology from the cervical lymph node revealed the presence of caseating granulomas. The patient responded completely to antitubrecular therapy. Enhanced-tuberculin reactions may occur on occasion in tuberculosis.

A 60-year-old non-smoker woman presented with dry cough, breathlessness on exertion and multiple episodes of haemoptysis from past 20 years. She reported nausea and vomiting since 20 days and jaundice since 15 days. She had received multiple courses of antibiotics and antitussives, syrups like levodropropizine 30 mg/ 5 mL, dextromethorphan 10 mg/ 5 mL due to symptoms mimicking chronic pharyngitis. Antitubercular treatment (ATT) was given due to haemoptysis on empirical basis from past 5 months as her mantoux test had shown an induration of 15 mm. Her clinical examination was within normal limit. Multiple chest X-rays taken over the …

Sarcoidosis is a multisystem inflammatory disease of unknown etiology affecting multiple organs. Earlier reports suggested that sarcoidosis was a disease of the developed world. However, recent reports suggest that the disease is found in the developing countries as well. Clinical, radiological, and histopathological similarities with tuberculosis pose a great challenge in countries endemic for tuberculosis. Mantoux test, high resolution computed tomography, and transbronchial lymph node and lung biopsies are diagnostic modalities, which play an important role in the diagnosis of sarcoid. In this review, we look at the epidemiology of sarcoid in tuberculosis-endemic regions, the sarcoidosis-tuberculosis link, clinical profile, diagnostic modalities, dilemma in the diagnosis, and the treatment of this disease.

Background: Tuberculosis remains a major global public health problem and an on-going epidemic. Though the chief objectives of the Revised National Tuberculosis Control Programme (RNTCP) in detecting and curing the infectious pulmonary cases is well taken, there has been a steady rise in the number of Extra Pulmonary Tuberculosis (EPTB) cases as documented in several studies. EPTB which usually constitutes around 15%-20% of the total TB cases is now being increasingly reported due to a combination of better diagnostic facilities, and the HIV pandemic. Though several studies have shown increasing prevalence of EPTB, only few studies are available, especially in the Indian scenario, that study the pattern and risk factors. Hence, this retrospective observational study was undertaken to determine the sites of the involvement, HIV co-infection and usefulness of various diagnostic modalities in EPTB affecting patients attending a medical college DOTS clinic. Material and Methods: One hundred ten EPTB patients referred to the DOTS clinics of the TB & Chest department from the period Dec 2010– Mar 2012 were included in the study. The diagnosis of EPTB was established by combined clinical, microbiological, histopathological &/or imaging modalities. Their medical records were assessed to determine the age distribution, gender and anatomical sites of involvement. The presence of co-morbid conditions like smoking history, alcoholism, diabetic and HIV status were noted. BCG status and Mantoux test readings were recorded. The different diagnostic tests used in confirming EPTB at different sites were recorded. Chest x-ray was analysed for all patients to assess coexisting pulmonary involvement. All patients were followed to assess the outcome of treatment. Results: The mean age of patients was 34.4. The male to female ratio was 58:52 showing a slight male predominance. The most common site of involvement was lymph node followed by pleural effusion and abdominal TB. The prevalence of lymph node TB was noted to be higher in female patients as compared to other sites of EPTB. Mantoux test was positive in 57 (51.8%) patients. HIV co-infection was noted in only 3 (2.7%) patients. Concomitant pulmonary involvement was seen in 19 (17.3%) patients. Conclusions: Lymph node was the most common site involvement showing a significant female preponderance followed by pleural effusion and abdominal TB. The rates of HIV co-infection and diabetes mellitus were 2.7% and 20% respectively. The most useful diagnostic modality was tissue sampling followed by imaging. Mantoux test is not unequivocal for the diagnosis of EPTB.

Background We describe a case of a fever of unknown etiology that was caused by a caseating tubercle granuloma which produced erythropoietin. To our knowledge, this is the first report of an erythropoietin- producing granuloma. Case presentation A 48-year-old Japanese man with a 5-year history of maintenance hemodialysis for diabetic nephropathy presented with an intermittent fever over a few months. During febrile periods he developed erythema nodosum on his legs. Computed tomography showed axillary lymph node enlargement and this was further corroborated by a gallium scan that revealed high gallium uptake in these nodes. A Mantoux test was positive and an interferongamma release assay for tuberculosis diagnosis was also positive. Lymph node tuberculosis was suspected and the patient underwent lymphadenectomy. Histological analysis of the lymph nodes revealed a caseating granuloma that showed positive results on an acid-fast bacteria stain and a Mycobacterium tuberculosis polymerase chain reaction test. After lymphadenectomy, however, the patient’s hemoglobin levels rapidly decreased from 144 to 105 g/L, and this was further compounded by a decrease in serum erythropoietin from 223 mIU/mL to 10.7 mIU/mL by postoperative day 21. We suspected the tubercle to be a source of the erythropoietin and this was further confirmed by in situ hybridization. Conclusions We report for the first time ectopic erythropoietin production by a tuberculous lymph node. Our observations are substantiated by a postoperative decline in his erythropoietin level and a clinical requirement for erythropoietin treatment.

The incidence of tuberculosis has been increasing in recent years. Therefore, routine screening with the Mantoux test is important in persons at high risk of infection or progression to active disease. Test results are interpreted on the basis of each patient's risk factors. Persons at high risk may benefit from preventive therapy. Active tuberculosis is treated with multidrug regimens to avoid the development of bacterial resistance. Healthcare workers at risk for occupational exposure should undergo routine screening. Required notification of the public health department ensures that patients receive appropriate treatment and that proper investigation is done to prevent further spread of the disease.

Background: Reproted risk among health care workers, related to tuberculosis exposure, motivated us to accurately assess this occupational risk at our College of Dentistry. Methods: Our sample population included all dental students entering their junior (third) year (beginning of maximum patient exposure). Screening for tuberculosis infection, with the standardized Mantoux test (purified protein derivative [PDP]), was conducted by the authors; several variables, previously associated with inaccurate test results in the literature, were controlled for during the study. Results: Among the study population of 158 students, the PDD conversion rate, as determined by one-stop testing, after one academic year was 10.6%. To further investigate factors (other than possible workplace exposure) contributing to PPD conversion in the study population, the authors also examined PPD results from previous employee and student screenings and conducted a retrospective chart review of selected patients registered at the college for the same period. Conclusions: We found that being born outside of the United States and having previously received bacille Calmette-Guerin vaccine are associated with positive PPD test results. In addition, PPD conversion among the study group may not be associated with occupational exposure at the College but, in fact, may be related to other factors, including community- and hospital-based clinical exposure. Finally, we recommend further research that examines the possible systemic effects of periodic testing with PPD on test subjects.