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HIV-1 infection substantially increases the risk of developing tuberculosis (TB). There is extensive depletion of Mycobacterium tuberculosis (M.tuberculosis)-specific CD4+ T cells in blood in early HIV infection, but little is known about responses in the lungs at this stage. Given that mucosal organs are a principal target for HIV-mediated CD4 destruction, we investigated M.tuberculosis-specific responses in bronchoalveolar lavage (BAL), in persons with latent TB infection and untreated HIV-1 co-infection with preserved CD4 counts. M.tuberculosis-specific CD4+ cytokine responses (IFN-, TNF- and IL-2) were discordant in frequency and function between BAL and blood. Responses in BAL were 15-fold lower in HIV-infected compared to uninfected persons (p=0.048), whilst blood responses were 2-fold lower (p=0.006). However, an increase in T cells in the airways in HIV-infected persons resulted in the overall number of M.tuberculosis-specific CD4+ cells in BAL being similar. Our study highlights the important insights gained from studying TB immunity at the site of disease during HIV infection.

Therapeutic options in severe emphysema are limited. Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced emphysema with the aim of obtaining similar functional advantages to surgical lung volume reduction, while reducing risks and costs. There is a growing body of evidence that certain well-defined subgroups of patients with advanced emphysema benefit from ELVR, provided that a systematic approach is followed and selection criteria are met. In addition to endobronchial valves, ELVR using endobronchial coils is now available in South Africa. The high cost of these interventions underscores the need for careful patient selection to best identify those likely to benefit from such procedures.

Summary Prior to the introduction of chemotherapy, tuberculosis management relied upon aerotherapy, heliotherapy and good nutrition. This “treatment”, exemplified by the regimen applied in Swiss and other European mountain resorts, is described by Thomas Mann in the book “The Magic Mountain”. Tuberculosis chemotherapy began in 1944 with the introduction of streptomycin and para-amino-salicylic acid, later augmented by isoniazid. Early experience taught physicians that treatment must be given with multiple drugs to prevent emergence of resistance and that prolonged treatment adherence for 18‐24 months was needed for a permanent cure of tuberculosis. Between 1970 and 1980 rifampicin was introduced and with pyrazinamide it made “short-course” treatment possible. For 30 years, a 6-month directly observed treatment short-course (DOTS) based on the three compounds isoniazid, rifampicin and pyrazinamide was the foundation of tuberculosis control strategies world-wide, and in recent years this was supplemented with ethambutol in view of increasing rates of isoniazid resistance. However, even 6 months of treatment is too long to easily ensure the compliance necessary to permanently cure tuberculosis. The recent spread of the HIV/ AIDS epidemic has placed tuberculosis programmes under severe pressure and is accompanied by an increase in drug-resistance making tuberculosis virtually untreatable in some instances. In 2004 the first of a new generation of anti-tuberculosis drugs entered clinical evaluation. A series of clinical trials, often conducted at sites in Cape Town, South Africa, has shown them to be efficacious and hold promise of being able to shorten tuberculosis treatment and treat drug-resistant tuberculosis. Development and assessment of these drugs is ongoing but there is renewed hope that these new drugs and regimens will assist in finally conquering tuberculosis, preventing a return to Magic Mountain where sunshine and fresh air was all that could be offered to patients.

Therapeutic bronchoscopy has come a long way from removal of foreign bodies to minimally invasive techniques in management of diseases like lung cancer, chronic obstructive pulmonary disease and asthma. This article discusses the exciting new techniques of therapeutic bronchoscopy namely; bronchoscopic lung volume reduction, bronchial thermoplasty, radiofrequency ablation, and use of fiducial markers in external beam irradiation.