Toxicon, 1999 Sep, 37(9), 1241 - 58 Doctor Albert Calmette 1863-1933: founder of antivenomous serotherapy and of antituberculous BCG vaccination; Hawgood BJ; In 1891 in Saigon (now Ho Chi Minh City), Dr . Albert Calmette established the first daughter Pasteur Institute for the protection of the local population against rabies and smallpox . Inspired by the discovery of diphtheria antitoxin by Behring, Calmette studied ways of raising serum against cobra venom . In 1895, now in Lille at the second daughter institute that he established, Calmette produced anticobra serum for therapeutic use that was to revolutionize the treatment of snakebite worldwide . The incidence of tuberculosis in the working class of the industrial north shocked Calmette . In response, firstly he organized an antituberculous dispensary to provide assistance to the sick and help limit the spread of the disease by improving social hygiene and secondly he devoted himself, with the assistance of Camille Guerin, to obtaining an attenuated live strain of tubercle bacilli with fixed biological characteristics for use as a vaccine . Such a strain developed during repeated passage of a culture of Mycobacterium bovis grown on a bile potato medium . In 1919, Dr . Albert Calmette took up the appointment of Sub-Director of the Pasteur Institute of Paris . Prolonged trials of BCG (Bacille Calmette-Guerin) vaccine showed it to be safe and vaccination of very young infants born of tuberculous mothers commenced in 1921 . The use of BCG vaccine as a prophylactic against tuberculosis spread world-wide and has remained important in combatting this scourge. J Mal Vasc, 1999 May, 24(2), 135 - 8 {Infection and angiomatous cutaneous lesions}; Janier M; The occurrence of angiomatous cutaneous lesions in the presence of an infective process is not a frequent phenomenon . Most infectious diseases are associated with an exanthematous reaction . The combination of an infective illness and angiomatous lesions is seen essentially in the bartonelloses and in Kaposi's disease . Bartonelloses: group of infections due to alpha-proteobacteria such as Bartonella . Bartonella bacilliformis (BB), is the causal agent of Carrion's disease, the chronic cutaneous form of which (verruga peruana), in which the vector is an arthropod of the Lutzomyia species found in South America, presents superficial and deep angiomatous cutaneous nodules . Spontaneous regression occurs in a few months or years . Bartonella henselae (BH) and Bartonella quintana (BQ), are the causal agents of bacillary angiomatosis (BA), described in 1983, in which angiomatous papules or nodules with an appearance like botryomycomas, are associated with visceral lesions . The characteristic histological features (with the demonstration or the bacilli by Warthin-Starry stain) together with culture of the bacterium in various tissues (including the blood) are diagnostic . BA occurs most commonly, but not exclusively, in patients with HIV infection . Furthermore, BH is responsible for cat scratch disease while BQ causes trench fever . The reservoir of BH is the cat . The bartonella produce angiogenic factors responsible for the neovascularisation seen in angiomatous lesions . The differential diagnosis is between botryomycomas and Kaposi's disease . Numerous antibiotics are effective against botryomycomas, particularly chloramphenicol and penicillin for BB and macrolides, cyclins and fluoroquinolones for BH and BQ . Kaposi's disease (KD): whether classical, endemic or epidemic (due to HIV infection) is characterised by cutaneous and visceral angiomatous lesions: these are associated with multifocal tumorous proliferations (of endothelial and fusiform cells) affected by angiogenic growth factors (PDGF, FGF, IL6, alphaTGF, HIVtat, androgens) and strongly linked to the lymphocytic and endothelial tropism of a gamma herpes virus (HHV8, Chang and Moore 1994) . HHV8 infection, probably sexually transmitted, is also the cause of lymphomas occurring in cavities and of Castleman's disease . The course of KD is very variable: from the indolent form in elderly HIV-ve patients, to the explosive forms in the immunodepressed (particularly in HIV+ve patients. Crit Care Med, 1999 Jun, 27(6), 1090 - 5 Colonization with broad-spectrum cephalosporin-resistant gram-negative bacilli in intensive care units during a nonoutbreak period: prevalence, risk factors, and rate of infection; D'Agata EM et al.; OBJECTIVE: To define the epidemiology of broad-spectrum cephalosporin-resistant gram-negative bacilli in intensive care units (ICUs) during a nonoutbreak period, including the prevalence, the risk factors for colonization, the frequency of acquisition, and the rate of infection . DESIGN: Prospective cohort study . SETTING: Tertiary care hospital . PATIENTS: Consecutive patients admitted to two surgical ICUs . MAIN OUTCOME MEASUREMENTS: Serial patient surveillance cultures screened for ceftazidime (CAZ) resistance, antibiotic and hospital exposure, and infections . RESULTS: Of the 333 patients enrolled, 60 (18%) were colonized with CAZ-resistant gram-negative bacilli (CAZ-RGN) at admission . Clinical cultures detected CAZ-RGN in only 5% (3/60) of these patients . By using logistic regression, CAZ-RGN colonization was associated with duration of exposure to cefazolin (odds ratio, 10.3; p < or = .006) and to broad-spectrum cephalosporins/penicillins (odds ratio, 2; p < or = .03), Acute Physiology and Chronic Health Evaluation III score (odds ratio, 1.2; p < or = .008), and previous hospitalization (odds ratio, 3.1; p < or = .006) . Of the 100 patients who remained in the surgical ICU for > or = 3 days, 26% acquired a CAZ-RGN . Of the 14 infections caused by CAZ-RGN, 11 (79%) were attributable to the same species present in surveillance cultures at admission to the surgical ICU . CONCLUSIONS: Colonization with CAZ-RGN was common and was usually not recognized by clinical cultures . Most patients colonized or infected with CAZ-RGN had positive surveillance cultures at the time of admission to the surgical ICU, suggesting that acquisition frequently occurred in other wards and institutions . Patients exposed to first-generation cephalosporins, as well as broad-spectrum cephalosporins/penicillins, were at high risk of colonization with CAZ-RGN . Empirical treatment of nosocomial gram-negative infections with broad-spectrum cephalosporins, especially in the critically ill patient, should be reconsidered. Am J Clin Pathol, 1999 Jul, 112(1), 63 - 8 Granulomatous myositis . Clinicopathologic study of 12 cases; Prayson RA; Granulomatous inflammation is infrequently encountered in skeletal muscle biopsy material . Of 2,985 muscle biopsy specimens reviewed over 12 years, 12 (0.4%) with granulomatous inflammation were identified . The patients included 9 women who ranged in age from 24 to 76 years (mean 50.3 years) . The most common clinical findings included decreased strength or weakness in the extremities (n = 8), muscle pain (n = 5), and weight loss (n = 3) . All muscles exhibited nonnecrotizing granulomas; an associated vasculitic process was identified in 2 . Endomysial chronic inflammation consisting primarily of lymphocytes and plasma cells was present in 10 muscles, and perivascular chronic inflammation in 8 . Degenerating muscle fibers were noted in 10 cases, and regenerating fibers in 11 . Evidence of neurogenic atrophy was seen in 8 muscles . Increased endomysial fibrosis was observed in 5 muscles, and type II muscle fiber atrophy in 5 muscles . Stains for acid-fast bacilli and Gomori methenamine silver stain were performed in all but 2 cases and failed to demonstrate organisms . In 3 cases, concomitant sural nerve biopsies were performed, and granulomas were identified in 2 of those cases . Clinicopathologic diagnoses included sarcoidosis (n = 6), vasculitis (n = 2), and granulomatous myositis not otherwise specified (n = 2) . In 2 cases, there was insufficient clinical information or follow-up data to determine a cause . In conclusion, granulomatous myositis is infrequently found in muscle biopsy specimens (0.5% of all biopsies in this series); most muscles demonstrate evidence of chronic endomysial or perivascular inflammation accompanied by muscle fiber degeneration and regeneration; and the most common cause for granulomatous myositis was sarcoidosis in this series. Infect Control Hosp Epidemiol, 1999 Jun, 20(6), 421 - 5 Nosocomial tuberculosis exposure in an outpatient setting: evaluation of patients exposed to healthcare providers with tuberculosis; Bock NN et al.; OBJECTIVE: To evaluate the risk of tuberculosis (TB) transmission to patients potentially exposed to two healthcare providers who worked in outpatient settings for several weeks prior to being diagnosed with acid-fast bacilli smear-positive pulmonary TB . DESIGN: Potentially exposed patients were notified by letter and television reports of the recommended evaluation for TB infection or disease and availability of free screening at the hospital . Prevalence of infection in the screened patients and the incidence rate of TB over the subsequent 2 years were compared to those of a control group of unexposed outpatients . SETTING: An urban inner-city hospital . PATIENTS: 1,905 patients with potential exposure to the ill healthcare workers; 487 (25%) presented for evaluation . Controls consisted of 951 unexposed patients . RESULTS: 361 potentially exposed patients had their tuberculin test read; 97 (27%) had a purified protein derivative > or = 10 mm . In the comparison group, 148 (25%) of 600 with test readings had a > or = 10-mm reaction (risk ratio, 1.18; 95% confidence interval, 0.86-1.60) . In multivariate analysis, male gender, non-white race, and older age were significantly associated with a positive tuberculin test; exposure was not . No TB cases were identified during screening . Two years after the exposure, 7 TB cases had been reported to the state registry among 1,905 potentially exposed patients (184 cases/100,000 person-years) versus 4 cases in the comparison group of 951 (210 cases/100,000 person-years) . CONCLUSIONS: Evaluation of patients exposed to healthcare workers with TB disease in ambulatory settings of an inner-city hospital revealed no evidence of transmission of Mycobacterium tuberculosis due to the exposure. Pneumonol Alergol Pol, 1998, 66(11-12), 551 - 4 {Familial occurrence of tuberculosis--a report of vice cases in a seven-person family in a period of 14 years}; Zalc-Swierczewska E et al.; Tuberculosis in five persons among the seven family members is reported . The main reasons for occurrence of tuberculosis in the majority of the family members were alcoholism and non-compliance with doctor's recommendations, then resistance of tubercle bacilli to antituberculous drugs, due to the above mentioned reasons . Even chemoprophylaxis in two of the family members did not protect then from the disease. Am J Respir Crit Care Med, 1999 Jul, 160(1), 203 - 10 Measurement of sputum Mycobacterium tuberculosis messenger RNA as a surrogate for response to chemotherapy; Desjardin LE et al.; Effective treatment regimens for pulmonary tuberculosis are difficult to assess because of the slow growth rate of Mycobacterium tuberculosis in culture and its protracted clearance from sputum . A rapid method that reflects effective antimicrobial activity would markedly advance evaluation of treatment and promote the assessment of new antituberculosis drugs . Conventional methods measure the progressive reduction of numbers of acid-fast bacilli in the sputum smear and the clearance of organisms in sputum culture . In this study, we measured levels of M . tuberculosis 85B (alpha antigen) messenger RNA (mRNA), 16S ribosomal RNA (rRNA), and IS6110 DNA in patients' sputa to ascertain whether they could serve as potential surrogate markers of response to chemotherapy . Sputum specimens were sequentially collected for up to a year from 19 smear-positive pulmonary tuberculosis patients receiving an optimal drug treatment regimen . Nucleic acids were isolated from these specimens, and two M . tuberculosis molecular targets (mRNA, DNA) were quantified, using the ABI Prism 7700 Sequence Detection System . The Mycobacterium genus-specific 16S rRNA was quantified with a limiting dilution RT-PCR assay . Results show that levels of 85B mRNA declined after initiation of therapy, as did viable M . tuberculosis colony counts, with 90% of patients becoming negative for both markers after 2 mo of treatment . The rapid disappearance of M . tuberculosis mRNA from sputum suggests that it is a good indicator of microbial viability and a useful marker for rapid assessment of response to chemotherapy. Kekkaku, 1999 May, 74(5), 457 - 61 {The combination therapy of clarithromycin and sparfloxacin for pulmonary Mycobacterium gordonae infection}; Tomiyama Y et al.; Seventy years old woman had fever and hemosputum at May 1997 . She was diagnosed as mycobacteriosis because of the positive acid fast bacilli smear from sputum . Mycobacterium gordonae was isolated from sputum, gastric juice, and bronchial aspirate . The combination therapy of isoniazid, rifampicin, ethambutol, and clarithromycin was administrated; however, M . gordonae was not eradicated from sputum . Sparfloxacin was administered instead of isoniazid based on the result of drug susceptibility test . The smear became negative and M . gordonae was eradicated from sputum one month after the initiation of treatment with the combination of clarithromycin and sparfloxacin. Kekkaku, 1999 May, 74(5), 453 - 6 {A case of middle ear tuberculosis; PCR of the otorrhea was useful for the diagnosis}; Inoue T et al.; A 26-year-old female was admitted to our hospital with complaints of fever, cough, otorrhea and otalgia and progressive hearing loss of her left ear . Smears of her sputum were positive for acid-fast bacilli . Smears of her otorrhea were negative for acid-fast bacilli but PCR of her otorrhea was positive . Chest X-ray showed infiltrative shadows with the cavity . She was diagnosed as middle ear tuberculosis associated with pulmonary tuberculosis . After anti-tuberculous chemotherapy, fever, cough, otorrhea and pain of her left ear were improved, but her hearing level was not improved . In the case of middle ear tuberculosis, it is necessary to make an early diagnosis and treatment . This is the first reported case in Japan in which PCR of the otorrhea is positive. Kekkaku, 1999 May, 74(5), 433 - 9 {Evaluations of MTD and Amplicor Mycobacterium for direct detection of Mycobacteria from clinical specimens}; Sato A et al.; MTD (GEN-PROBE AMPLIFIED MYCOBACTERIUM TUBERCULOSIS DIRECT TEST) for Mycobacterium tuberculosis, and Amplicor Mycobacterium for Mycobacteria (AMP-M . tb for M . tuberculosis, AMP-M . av for M . avium and AMP-M . in for M . intracellulare) were used for the detection of relevant Mycobacterium . Their sensitivity and specificity were evaluated . Total 244 clinical specimens including 164 sputa were examined by the above two tests . The results were compared with those obtained by the conventional methods . Of 244 samples, number of the M . tuberculosis positive samples by microscopy, cultural test, MTD and AMP-M . tb were 32, 33, 38 and 35, respectively . Among 33 culture positive samples, 25 were MTD positive and 26 were AMP-M . tb positive . Therefore, sensitivity of MTD and AMP-M . tb were 75.8% and 78.8%, and their specificity were 93.8% and 95.7%, respectively . When only sputa were used for the tests as the clinical specimens, both sensitivity of MTD and AMP-M . tb were increased to 94.4% . For MAC, positive samples of M . avium complex by culture, M . avium by AMP-M . av and M . intracellulare by AMP-M . in were 13, 16, and 8, respectively . Sensitivity and specificity of AMP-M . av/M . in were 100% and 95.2%, respectively . Clinical findings of the patients whose MTD tests were positive but negative by culture were reexamined . Three of 9 specimens were also positive in AMP-M . tb . From the records of the isolations of tubercle bacilli or other important pathogens from the other kind of clinical specimens, smear tests and patients' response to tuberculosis chemotherapy, four of 9 specimens were confirmed as true positive, three were suspected as positive, and two other specimens were false positive which might be caused by contamination . From these observations, it could be concluded that MTD and AMP-M . tb are more sensitive than conventional culture method, and MTD is more sensitive than AMP-M . tb but needs more careful treatment to avoid the contamination. Kekkaku, 1999 May, 74(5), 425 - 32 {The prevalence survey on chronic tuberculosis patients with bacilli discharge in Osaka prefecture}; Mui K et al.; This survey was made at the end of 1996 in Osaka prefecture including three ordinance designated cities of Osaka, Sakai and Higashiosaka . As of December 31 1996, 109 or 3.3% of active tuberculosis cases were found to be chronic tubercle bacilli excreters in Osaka city, and 128 or 3.6% in Osaka prefecture other than Osaka city, respectively . In the area called Airin at Nishinari-ward, Osaka, which has been an area with high prevalence of the disease, 33 or 5.8% were chronic tubercle bacilli excreters, and the rate was slightly higher than the other areas . Compared to the survey conducted 10 years ago, while the number of the chronic tubercle bacilli excreters decreased by half to 109 from 200 in Osaka city, to 128 from 211 in Osaka prefecture excluding Osaka city, the rate of chronic excreters to total active tuberculosis showed almost no change . Various factors such as difficult living conditions often attributed to defaulting of active tuberculosis patients from their treatment, thus resulting to development of chronic excretion . It is highly recommended to apply DOTS strategy for the completion of their treatment . Public health centers that have personal clinical records of each patient should be familiar with the results of their bacillus examinations . They should also be required to cooperate with medical institutions to cope with those who need retreatment. Kansenshogaku Zasshi, 1999 May, 73(5), 482 - 5 {Pulmonary infection caused by Mycobacterium gordonae}; Yanagisawa N et al.; A 57-year-old woman who had been operated on for colon cancer and given chemotherapy, presented in September 1995 with worsening cough and abnormalities on her chest X-ray film . Acid-fast bacilli were isolated from the sputum . The organism was classified as M . gordonae by biochemical tests and DNA/DNA hybridization . The patient was treated with rifampicin and clarithromycin . Subsequently, sputum cultures became negative and the chest x-ray film showed a decrease infiltration . The findings in the present case suggest that M . gordonae may cause pulmonary infection and should be considered as an opportunistic pathogen. J Immunol, 1999 Jul 1, 163(1), 312 - 21 Surfactant protein D binds to Mycobacterium tuberculosis bacilli and lipoarabinomannan via carbohydrate-lectin interactions resulting in reduced phagocytosis of the bacteria by macrophages; Ferguson JS et al.; Surfactant protein-D (SP-D) is a collectin produced in the distal lung airspaces that is believed to play an important role in innate pulmonary immunity . Naive immunologic responses to Mycobacterium tuberculosis (M.tb) are especially important in the lung, since entry of this inhaled pathogen into the alveolar macrophage is a pivotal event in disease pathogenesis . Here we investigated SP-D binding to M.tb and the effect of this binding on the adherence of M . tb to human macrophages . These studies demonstrate specific binding of SP-D to M.tb that is saturable, calcium dependent, and carbohydrate inhibitable . In addition to purified SP-D, SP-D in bronchoalveolar lavage fluids from healthy donors and patients with alveolar proteinosis also binds to M.tb . Incubation of M.tb with SP-D results in agglutination of the bacteria . In contrast to its binding to M.tb, SP-D binds minimally to the avirulent Mycobacterium smegmatis . SP-D binds predominantly to lipoarabinomannan from the virulent Erdman strain of M.tb, but not the lipoarabinomannan from M . smegmatis . The binding of SP-D to Erdman lipoarabinomannan is mediated by the terminal mannosyl oligosaccharides of this lipoglycan . Incubation of M.tb with subagglutinating concentrations of SP-D leads to reduced adherence of the bacteria to macrophages (62.7% of control adherence +/- 3.3% SEM, n = 8), whereas incubation of bacteria with surfactant protein A leads to significantly increased adherence to monocyte-derived macrophages . These data provide evidence for specific binding of SP-D to M . tuberculosis and indicate that SP-D and surfactant protein A serve different roles in the innate host response to this pathogen in the lung. Int J Tuberc Lung Dis, 1999 Jun, 3(6), 521 - 7 The role of tissue studies in facilitating early initiation of antimycobacterial treatment in AIDS patients with disseminated mycobacterial disease; Hsieh SM et al.; SETTING: The question of whether aggressive investigations are useful in diagnosis and initiation of treatment in AIDS patients with disseminated mycobacterial disease (DMD) is still under debate . OBJECTIVE: To define the role of tissue studies in facilitating early initiation of antimycobacterial treatment and in establishing diagnosis in AIDS patients with DMD . DESIGN: From July 1994 through June 1997, 167 AIDS cases with fever were evaluated by stepwise investigation using a standardized protocol . Data of DMD cases were analyzed to define the role of tissue studies . RESULTS: A total of 40 cases of culture-proven DMD were identified . Antimycobacterial treatment was initiated due to positive acid-fast bacilli smears of sputum in only five cases . In the remaining cases, positive pathologic findings from tissue biopsies (lymph node, bone marrow or liver) facilitated early initiation of treatment in 60% (21/35) . In 50% of all cases (20/40), the diagnosis could not have been established if cultures of tissue biopsies had not been performed . Both the pathologic examinations and mycobacterial cultures from liver biopsies had positivity rates of more than 50% (53.8% and 69.2%, respectively) . CONCLUSIONS: Tissue studies were useful in facilitating early initiation of treatment and establishing diagnosis at least in half of the AIDS cases with DMD . Liver biopsy is worthwhile if the cause of fever is not discovered using less invasive investigations. Int J Tuberc Lung Dis, 1999 Jun, 3(6), 515 - 20 Chemotherapy of tuberculosis in mice using single implants of isoniazid and pyrazinamide; Gangadharam PR et al.; OBJECTIVE: To establish the chemotherapeutic value of a depot drug preparation of isoniazid and pyrazinamide against experimental tuberculosis . DESIGN: To see whether sustained levels of pyrazinamide are available for prolonged periods after a single subcutaneous administration of a biodegradable polylactic-glycolic acid (PLGA) polymer containing the drug, studies were done to ascertain whether a single administration of isoniazid and pyrazinamide in separate PLGA polymers could offer chemotherapeutic protection against a heavy intravenous challenge of susceptible mice with a virulent strain of Mycobacterium tuberculosis similar to that rendered by daily administration of the two drugs for 8 weeks . RESULTS: Even with three times the daily dose of pyrazinamide contained in the single PLGA polymer implant, no abnormally high (burst) levels of the drug were evident after administration, but sustained levels of the drug were seen up to 54 days . The chemotherapeutic activity of the single PLGA polymer implants was similar to that obtained with standard oral treatment with the two drugs given daily for the entire 8 weeks, as judged by mortality and colony forming unit (CFU) counts of tubercle bacilli from lungs and spleen . CONCLUSION: Treatment with single implants of the PLGA polymer containing anti-mycobacterial drugs offers a strong possibility of circumventing the compliance problem. J Antimicrob Chemother, 1999 May, 43(5), 659 - 66 Bismuth-mediated disruption of the glycocalyx-cell wall of Helicobacter pylori: ultrastructural evidence for a mechanism of action for bismuth salts; Stratton CW et al.; The mechanism of bismuth's bactericidal activity against Helicobacter pylori was investigated using transmission electron microscopy (TEM) and analytical electron microscopy (AEM); time-kill kinetic methods evaluated the effect of excess divalent cations . TEM analysis of untreated H . pylori revealed a normal morphology . In contrast, H . pylori exposed to bismuth salts had swollen, distorted cells with membrane-cell wall blebbing and a cytoplasm containing electron-dense, sometimes crystalline aggregates . By AEM, swollen cells contained bismuth at the cell periphery, whereas bacillary forms contained cytoplasmic bismuth localizations . Time-kill studies showed that the bactericidal activity of bismuth could be prevented by pretreatment with divalent cations . The effects of bismuth salts on the glycocalyces-cell walls of H . pylori with reversal of bactericidal activity by divalent cations are identical to those produced by other polycationic agents on various gram-negative bacilli . We conclude that disruption of the glycocalyces-cell walls of H . pylori is one mechanism of action for bismuth salts. Chest, 1999 Jun, 115(6), 1570 - 5 Oropharyngeal Gram-negative bacillary carriage: a survey of 120 healthy individuals; Mobbs KJ et al.; BACKGROUND: The presence of aerobic Gram-negative bacilli (AGNB) in the oropharynx can be either temporary or persistent . Prolonged colonization (ie, carriage) is distinguished from transient presence (ie, acquisition), which often occurs in healthy individuals but less frequently in those with underlying disease . Prevalence rates of up to 61.1% quoted previously for healthy individuals were obtained by using single sample surveys, which fail to differentiate acquisition from carriage . STUDY OBJECTIVES: To illustrate the need to distinguish carriage from acquisition in a healthy population at risk of acquisition of AGNB, and to show that although differing groups of healthy individuals may acquire oropharyngeal AGNB at differing frequencies, carriage is rare in healthy individuals . PARTICIPANTS: Two oral rinses were obtained within a 2-day interval from 120 healthy individuals comprising 40 nurses, 40 students, and 40 laboratory-associated persons . DESIGN: Two hundred forty oral rinses were quantitatively (1:10 dilution series) cultured for AGNB by using broth enrichment . MEASUREMENTS AND RESULTS: The rate of AGNB carriage based on two consecutive samples positive for the same AGNB was 6.6%; the rate of AGNB acquisition based on one positive sample was 35.8% . The concentrations of all carried and acquired AGNB were < or = 103 cfu/mL . AGNB acquisition was significantly higher in students (52.5%) compared to nurses (32.5%) and laboratory-associated persons (22.5%; p < 0.05) . CONCLUSION: Healthy individuals rarely carry oropharyngeal AGNB, suggesting effective oropharyngeal clearance in a healthy population predisposed to acquisition . Apparently, the oropharyngeal mucosa in healthy individuals is not receptive to adhesins of AGNB, resulting in rapid elimination of these bacteria. Eur Radiol, 1999, 9(5), 886 - 9 Acute hepatobiliary tuberculosis: a report of two cases and a review of the literature; Hickey N et al.; Two cases of hepatobiliary tuberculosis are described . Case one, the macronodular type of hepatic tuberculosis, presented as pyrexia of unknown origin and was eventually diagnosed by sectional imaging when a mass lesion developed in the liver and aspiration revealed acid-fast bacilli . Case two presented with jaundice due to a hilar bile duct stricture . The patient was successfully treated by repeated bile duct stenting and later chemotherapy for tuberculosis . In both cases previous positive histology or culture would have expedited diagnosis and treatment . Acute hepatobiliary tuberculosis remains a rare disease . Suspicion of the disease and adequate biopsy are important to allow prompt appropriate treatment. Surg Neurol, 1999 Jun, 51(6), 602 - 7 Atypical forms of spinal tuberculosis: case report and review of the literature; Naim-Ur-Rahman et al.; OBJECTIVE: The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis . Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer . CLINICAL PRESENTATION: An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented . Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis . The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block . Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis . The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion . Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits . CONCLUSION: Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases. Am J Surg Pathol, 1999 Jun, 23(6), 656 - 61 Spindle cell tumors associated with mycobacteria in lymph nodes of HIV-positive patients: 'Kaposi sarcoma with mycobacteria' and 'mycobacterial pseudotumor'; Logani S et al.; Patients infected with HIV often have unusual manifestations of common infections and neoplasms . One such example is "mycobacterial pseudotumor," an exuberant spindle cell lesion induced in lymph nodes by mycobacteria . Kaposi sarcoma also produces a spindle cell proliferation in lymph nodes of HIV-positive patients . These two entities must be differentiated from one another because of differences in treatment and prognosis . We report here, however, three cases of intranodal Kaposi sarcoma with simultaneous mycobacterial infection, the occurrence of which has not been clearly documented . For comparison, we also studied three cases of mycobacterial pseudotumor, of which 14 cases have been described to date . There was considerable histologic overlap between these two lesions . Acid-fast bacilli were present in all cases, predominantly in the more epithelioid histiocytes in the cases of Kaposi sarcoma, and in spindle and epithelioid cells in the cases of mycobacterial pseudotumor . The morphologic features that favored Kaposi sarcoma over mycobacterial pseudotumor were the prominent fascicular arrangement of spindle cells and slitlike spaces, the lack of granular, acidophilic cytoplasm, and the presence of mitoses . Immunohistochemistry was a reliable adjunct study in the differential diagnosis, as the spindle cells in mycobacterial pseudotumor were positive for S-100 protein and CD68 whereas those of Kaposi sarcoma were CD31- and CD34-positive but negative for S-100 protein and CD68 . Awareness that Kaposi sarcoma may coexist with mycobacterial infection in the same biopsy specimen is important because these lesions may be misdiagnosed as mycobacterial pseudotumor . The clinical impact of distinguishing between Kaposi sarcoma with mycobacteria and mycobacterial pseudotumor is significant because the presence of Kaposi sarcoma alters treatment and prognosis. Am J Pathol, 1999 Jun, 154(6), 1793 - 804 Immunohistological analysis of in situ expression of mycobacterial antigens in skin lesions of leprosy patients across the histopathological spectrum . Association of Mycobacterial lipoarabinomannan (LAM) and Mycobacterium leprae phenolic glycolipid-I (PGL-I) with leprosy reactions; Verhagen C et al.; The presence of mycobacterial antigens in leprosy skin lesions was studied by immunohistological methods using monoclonal antibodies (MAbs) to Mycobacterium leprae-specific phenolic glycolipid I (PGL-I) and to cross-reactive mycobacterial antigens of 36 kd, 65 kd, and lipoarabinomannan (LAM) . The staining patterns with MAb to 36 kd and 65 kd were heterogeneous and were also seen in the lesions of other skin diseases . The in situ staining of PGL-I and LAM was seen only in leprosy . Both antigens were abundantly present in infiltrating macrophages in the lesions of untreated multibacillary (MB) patients, whereas only PGL-I was occasionally seen in scattered macrophages in untreated paucibacillary lesions . During treatment, clearance of PGL-I from granulomas in MB lesions occurred before that of LAM, although the former persisted in scattered macrophages in some treated patients . This persistence of PGL-I in the lesions paralleled high serum anti-PGL-I antibody titers but was not indicative for the presence of viable bacilli in the lesions . Interestingly, we also observed a differential expression pattern of PGL-I and LAM in the lesions of MB patients with reactions during the course of the disease as compared with those without reactions . In conclusion, the in situ expression pattern of PGL-I and LAM in MB patients may assist in early diagnosis of reactions versus relapse. Singapore Med J, 1999 Jan, 40(1), 44 - 5 Cutaneous tuberculosis mimicking cellulitis in an immunosuppressed patient; Chin PW et al.; A 28-year-old lady suffering from systemic lupus erythomatosus (SLE) with diffuse proliferative glomerulonephritis (DPGN) and who was on oral cyclophosphamide and prednisolone presented with left lower limb 'cellulitis' . The 'cellulitis' of the left lower limb failed to respond to usual antibiotics which prompted evaluation of the clinical diagnosis . The diagnosis is made based on the presence of granulomas, multinucleated giant cells and acid fast bacilli on the skin biopsy. Cell Immunol, 1999 May 25, 194(1), 12 - 20 Differential regulation of IFN-gamma, TNF-alpha, and IL-10 production by CD4(+) alphabetaTCR+ T cells and vdelta2(+) gammadelta T cells in response to monocytes infected with Mycobacterium tuberculosis-H37Ra; Tsukaguchi K et al.; Mycobacterium tuberculosis bacilli readily activate CD4(+) and gammadelta T cells . CD4(+) and gammadelta T cells were compared for their ability to regulate IFN-gamma, TNF-alpha, and IL-10 production, cytokines with significant roles in the immune response to M . tuberculosis . PBMC from healthy tuberculin positive donors were stimulated with live M . tuberculosis-H37Ra . CD4(+) and gammadelta T cells were purified by negative selection and tested in response to autologous monocytes infected with M . tuberculosis . Both subsets produced equal amounts of secreted IFN-gamma . However, the precursor frequency of IFN-gamma secreting gammadelta T cells was half that of CD4(+) T cells, indicating that gammadelta T cells were more efficient producers of IFN-gamma than CD4(+) T cells . TNF-alpha production was markedly enhanced by addition of CD4(+) and gammadelta T cells to M . tuberculosis infected monocytes, and TNF-alpha was produced by both T cells and monocytes . No differences in TNF-alpha enhancement were noted between CD4(+) and gammadelta T cells . IL-10 production by M . tuberculosis infected monocytes was not modulated by CD4(+) or gammadelta T cells . Thus CD4(+) and gammadelta T cells had similar roles in differential regulation of IFN-gamma, TNF-alpha, and IL-10 secretion in response to M . tuberculosis infected monocytes . However, the interaction between T cells and infected monocytes differed for each cytokine . IFN-gamma production was dependent on antigen presentation and costimulators provided by monocytes . TNF-alpha levels were increased by addition of TNF-alpha produced by T cells and IL-10 production by monocytes was not modulated by CD4(+) or gammadelta T cells . Kekkaku, 1999 Apr, 74(4), 377 - 84 {Nontuberculous mycobacteriosis; the present status of epidemiology and clinical studies}; Sakatani M; In Japan, The Mycobacteriosis Research Group at the Japanese National Chest Hospitals has continuously made the clinico-epidemiological study of nontuberculous mycobacteriosis (NTM) since early 1970s . The prevalence rate was determined as 0.82, 0.91, 1.22, 1.74 and 2.43 per 100,000 population per year in 1971, 1975, 1980, 1985 and in 1990 respectively . The newest datum in 1997 was 3.52 . These data indicates the prevalence rate has continuously increased and became 3.8 times than 25 years ago . While on the other hand, the prevalence rate of lung tuberculosis has decreased from 133.1 to 15.2, becoming one nines in the same period . The numbers of newly detected patients of lung mycobacteriosis in 1996 were also studied at 12 hospitals in Kinki district . The rate of NTM was 16.6% in 4 sanatorium hospitals, being about the same to the datum of The Mycobacteriosis Research Group . The rate of NTM in 8 general hospitals was surprisingly high, 40.0% . The 70% of NTM patients were infected with Mycobacterium avium complex (MAC) . The 24% were with M . kansasii, and the only 6% were with other miscellaneous species . That is, the about one thirds or more of total NTM patients were female MAC desease patients, another one thirds or less were male MAC patients, and the more than 90% of M . kansasii patients (about one fourth of total patients) were male . These 3 groups took the most part of NTM patients . The rate of female MAC patients with small non-cavitary lesion without underlying diseases showed a tendency to increase, and the rate of male MAC patients with cavitary lesions with underlying lung or systemic diseases decreased . In 1997, American Thoracic Society (ATS) published the official statement about the diagnosis and treatment of NTM disease . The table-1 in that statement showed the new criteria for diagnosis of NTM pulmonary disease . It is useful for precise diagnosis of lung NTM disease, and the old criteria made by The Mycobacteriosis Research Group of the Japanese National Chest Hospitals is also useful for rough diagnosis . In the ATS statement, for adult HIV-negative MAC patients, minimum three drug regimen of clarithromycin (or azithromycin), rifabutin (or rifampin) and ethambutol, with intermittent streptomycin which is option for extensive disease, is recommended . This regimen is the same that most of the Japanese specialists for NTM disease recommended . The follow-up study of 47 Japanese MAC patients treated by the regimen contained clarithromycin with other anti-tuberculous drugs revealed that 80% of cases converted into bacilli negative and that the regimen had durable effect for at least 24 months . The resectional surgery may be considered for localized disease, and supportive nutritional treatment must also be considered for the MAC patients to whom the drug therapy was not effective, as if for the tuberculosis patients of multi-drug resistant. Kekkaku, 1999 Apr, 74(4), 361 - 4 {A case of pulmonary tuberculosis case with pancytopenia accompanied to bone marrow gelatinous transformation}; Sasaki Y et al.; A 45-year-old man did not visit a doctor in spite of his complains, cough and sputum lasting, for six months, and he finally could not eat without beer, and as a result, he lost his body weight and currently 52 kg . He became unconsciousness, was carried to a hospital, and was referred to our hospital . His sputum examination for acid fast bacilli was smear positive, Gaffky 6, for M . tuberculosis . His chest roentogenogram revealed large cavitary lesions in bilateral lung fields . On blood examination, WBC was 1100/microL, RBC was 256 x 10(4)/microL, and PLT was 13.4 x 10(4)/microL . Total protein was 4.7 g/dl, albumin was 1.9 mg/dl, and total cholesterol was 65 mg/dl . We tried to aspirate bone marrow from his sternum, but it was impossible . Hence we did biopsy of his ilium . The pathology of his bone marrow revealed gelatinous transformation . It was thought that the marked delay in visiting a doctor caused general consumption and loss of apetite, thus led to gelatinous transformation and finally pancytopenia. Kekkaku, 1999 Apr, 74(4), 353 - 60 {Six-months chemotherapy (2HRZS or E/4HRE) of new cases of pulmonary tuberculosis--six year experiences on its effectiveness, toxicity, and acceptability}; Wada M et al.; The incidence of tuberculosis in Japan, 33.7 per 100,000 in 1997, is very high compared with USA or Western European countries . The decrease in the incidence has slowed down from the early 1980s, and the average annual rate of decrease has been 3.8% in the last 5 years . About 9 percent of tuberculosis patients defaulted from the nine-month regimen (6HRS or E/3HR) in urban areas . Regimens shorter than nine-month are needed to achieve high effectiveness of tuberculous chemotherapy . Out of 1128 new pulmonary tuberculosis patients, six-hundred twenty started treatment with six-month (2HRZS or E/4HRE) in Fukujuji Hospital, JATA, in Tokyo from January 1991 to December 1996 . Out of 620, four-hundred twenty eight were both smear and culture positive, 136 were smear negative and culture positive and 56 were bacilli negative . Out of 564 bacilli positive cases, 530 were susceptible to INH and RFP . Out of 530 drug susceptible cases three hundred ninety-three patients completed the regimen . Ninety-three percent of these patients had converted to negative at two months of chemotherapy and all of them at five months . Out of 450, two-hundred ninety five completed 6-month regimen, one-hundred fifty-five were changed their regimen or prolonged duration of chemotherapy . Out of 295, nine patients (3.1%) relapsed after the completion of 6-month chemotherapy . Mean follow-up period was 17.2 months and the median was 15.5 months . The relapse rate was 2.2 per 100 person-years . Six of the relapsed cases were complicated with Diabetes Mellitus . Relapse rate was higher in patients with Diabetes Mellitus than in patients without (6/54, 7.9 per 100 person-years vs 3/237, 0.8 per 100 person-years) (p < 0.001) . Drug-induced hepatotoxicity was defined as elevated serum transaminase level with clinical symptoms of hepatitis or elevated serum transaminase level more than 5 times of upper limit of normal range with or without symptoms . Drug-induced hepatotoxicity developed in 43 (8.0%) of 535 with initial normal liver function test results, this rate was similar to that in patients treated with nine-month regimen (34/420, 8.1%) . But the frequency of hepatotoxicity of more than 400 IU/ml of serum transaminase level was higher in patients treated with PZA-containing regimen than with nine-month regimen (16/536, 3.0% vs 4/420, 1.0%), but this deference was not statistically significant . Hepatotoxicity developed in 13/85 (15.3%) of patients treated with PZA-containing regimen with abnormal liver function tests at the beginning of chemotherapy, and this frequency was similar to 7/65 (10.8%) in patients with nine-month regimen . The relapse rate in patients with Diabetes Mellitus was statistically higher than in without Diabetes Mellitus (7.9 vs 0.8 per 100 person-years) . We concluded that the six-month regimen was highly effective, but the frequency of severe hepatotoxicity was relatively higher than in nine-month regimen and the duration of chemotherapy was not enough for patients complicated with Diabetes Mellitus . Further study is needed for sufficient chemotherapy in patients with Diabetes Mellitus. Pneumonol Alergol Pol, 1998, 66(7-8), 404 - 11 {Analysis of tuberculosis mortality in the Toruń province in the years 1990-1993}; Sipak M et al.; There were 75 deaths from tuberculosis in Torun Vojevodship province in 1990-1993 . In 26 of them the diagnosis was made only after death during the autopsy examination and/or by positive culture for tubercle bacilli . In 27 patients diagnosis of tuberculosis was made very late, 15 days before death in 12, and 30 days in other 15 patients . In 19 patients the diagnosis was made 30 days or more before death . In majority of them, however, the treatment was interrupted or taken irregularly . We conclude that the main cause of death from tuberculosis in Torun province in the years 1990-1993 was the late diagnosis . The late diagnosis of tuberculosis was established mainly in those who died at home and also in those who were admitted to hospital in critical state and died during the first two weeks of hospitalization. Neurogastroenterol Motil, 1999 Jun, 11(3), 141 - 61 The patterns of small bowel motility: physiology and implications in organic disease and functional disorders; Husebye E; The physiology and pathophysiology of small bowel motility are reviewed with particular focus on the motility patterns and periods that are detected by intraluminal manometry . Motility patterns are groups of phasic pressure waves resulting from contractions of the circular muscle layer of the small bowel that are organized by the enteric nervous system . Phase III of the migrating motor complex, the hallmark of the fasting motility period, thus reflects enteric neuromuscular function . Response to meal challenge also involves the CNS, reflexes beyond the gut and endocrine responses . Although specific disease diagnosis cannot be made by motility studies of the small bowel, the functional integrity is revealed . The normal occurrence of the essential patterns and periods of motility and the absence of distinctly abnormal patterns evidence preserved function, whereas the opposite indicates clinically significant dysmotility . Certain motility patterns are occasionally seen both in health and disease, and increased prevalence indicates a moderate dysfunction of yet unclear significance . Bacterial overgrowth with Gram-negative bacilli is the consequence of severe small bowel dysmotility, and a diagnosis that can be predicted by a motility study . Testing can be useful in the clinical management of paediatric and adult patients also by predicting the prognosis and response to enteral nutrition and medical therapy . Further studies are, however, needed to take full advantage of motility testing in clinical practise. J Vet Diagn Invest, 1999 May, 11(3), 252 - 8 Isolation of cilia-associated respiratory (CAR) bacillus from pigs and calves and experimental infection of gnotobiotic pigs and rodents; Nietfeld JC et al.; Filamentous, gram-negative bacteria morphologically similar to cilia-associated respiratory (CAR) bacillus of rodents and rabbits were isolated from the tracheas of 5 pigs and 4 calves . All pigs but none of the calves had histologic lesions of chronic tracheitis . In silver-stained histologic sections, CAR bacilli were adhered to the tracheal epithelium of each pig but were not found in the calves . Like CAR bacillus of rats, the bacteria displayed gliding motility and grew only in cell culture or cell culture medium supplemented with fetal serum . Initially, all isolates were contaminated by Mycoplasma spp . This contamination was eliminated from 4 pig isolates by limiting dilutions, and mycoplasma-free isolates were used to intranasally inoculate gnotobiotic pigs and CAR bacillus-free mice and rats and to immunize guinea pigs . The gnotobiotic pigs remained healthy, and when they were necropsied 4 and 7 weeks after infection no macroscopic or microscopic lesions were found in the respiratory tract . However, CAR bacillus was isolated at both times from the nasal cavities and tracheas of inoculated pigs, and the ciliated tracheal epithelium of infected pigs necropsied 7 weeks after infection was colonized by low numbers of CAR bacillus-like bacteria . The rats and mice remained healthy through week 12 postinoculation, and evidence of short- or long-term colonization was not detected by histologic examination or culture . When used as primary antibody for immunohistochemical staining, sera from guinea pigs immunized with pig CAR bacillus specifically stained CAR bacilli colonizing the respiratory epithelium of naturally infected pigs, whereas sera collected prior to immunization failed to react with the bacteria . These results indicate that CAR bacilli are unlikely to be primary pathogens of pigs or cattle and that rodents do not act as reservoirs. Infect Control Hosp Epidemiol, 1999 May, 20(5), 337 - 40 Trends in compliance with the guidelines for preventing the transmission of Mycobacterium tuberculosis among New Jersey hospitals, 1989 to 1996; Manangan LP et al.; OBJECTIVE: To determine trends in compliance with the guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities among New Jersey hospitals from 1989 through 1996 . DESIGN: A voluntary questionnaire was sent to all 96 New Jersey hospitals in 1992 . The 53 that responded were resurveyed in 1996 . RESULTS: Of the 96 hospitals surveyed in 1992, 53 (55%) returned a completed questionnaire; 33 (64%) were community, nonteaching hospitals . In 1991, patients with tuberculosis (TB) were admitted at 38 (72%) of 53 hospitals, and from 1989 through 1991, patients with multidrug-resistant (MDR) TB were admitted at 15 (29%) of 52 hospitals . Twenty-nine (57%) of 51 reported having rooms meeting the Centers for Disease Control and Prevention (CDC) criteria for acid-fast bacilli (AFB) isolation . A nonfitted surgical mask was used as a respiratory protective device by healthcare workers (HCWs) at 28 (55%) of 51 hospitals . Attending physicians were included in tuberculin skin-testing (TST) programs at 5 (11%) of 45 hospitals . In the 1996 resurvey, 48 (94%) of 53 surveyed hospitals returned a completed questionnaire; 34 (81%) of 42 had TB patient admissions, and 4 (9%) of 43 had MDR TB patient admissions in 1996 . Forty-five (96%) of 47 reported having rooms that met CDC criteria for AFB isolation . N95 respiratory devices were used by HCWs at 45 (94%) of 48 hospitals . Attending physicians were included in the TST programs at 22 (54%) of 41 hospitals . CONCLUSION: New Jersey hospitals have made improvements in availability of AFB isolation rooms, use of proper respiratory protective devices, and expansion of TST programs for HCWs from 1989 through 1996. Int J Lepr Other Mycobact Dis, 1998 Dec, 66(4), 464 - 74 Susceptibility to Mycobacterium leprae of ALY (alymphoplasia) mice and IFN-gamma induction in the culture supernatant of spleen cells; Yogi Y et al.; The aly/aly (alymphoplasia) mice from a mutation of a colony of the C57BL/6J mouse strain, which has a systemic absence of lymph nodes and Peyer's patches, are deficient in both T- and B-cell-mediated immune functions . We have undertaken a comparison of susceptibility to Mycobacterium leprae of ALY (aly/aly, aly/+) mice with C57BL/6J mice . The aly/aly mouse was found to have an excellent high susceptibility to M . leprae with no distinction between female and male . The aly/+ mouse also was more susceptible to M . leprae at an earlier stage than the C57BL/6J mouse . Therefore, we examined and compared the cytokine gene expression and gamma interferon (IFN-gamma) induction in the splenocytes of ALY mice . The expression of interleukin 4 (IL-4), IL-10 and IL-12 mRNA was weakly stimulated with ML-lysate in inoculated aly/aly mice but IL-2, IL-6, IGIF/IL-18 and IFN-gamma mRNA were not observed . None of the cytokine genes used appeared, except the mRNA for IL-1-alpha, when uninfected cultured spleen cells were stimulated with ML-lysate . Also, IFN-gamma production was not induced . However, the appearance of these cytokine genes was observed when stimulated with concanavalin A (ConA), and IFN-gamma production was also induced in the culture supernatant by aly/+ and even aly/aly mice stimulated with ConA . To examine the reason why IFN-gamma cannot be produced by splenocytes of ALY mice inoculated with M . leprae, we detected cytokine gene expression and IFN-gamma induction in the presence of recombinant murine IL-12 or IGIF/IL-18 . IL-2 mRNA expression was detected in all of the mice tested in the presence of IL-12 but not in aly/aly mice under IGIF/IL-18, and iNOS mRNA expression was not observed in aly/aly mice under IL-12 or IGIF/IL-18 . IL-4 and IL-10 mRNA were detected by aly/aly mice only by exposure to IGIF/IL-18 . In culture, the supernatant with ML antigens of the aly/aly mice did not produce IFN-gamma in spite of the presence of IL-12 and IGIF/IL-18, while IFN-gamma was weakly induced in aly/+ mice stimulated with ML-lysate and in the presence of IGIF/IL-18 . Nevertheless, IFN-gamma production was observed in splenocytes of the aly/aly mice stimulated with ConA and also with IGIF/IL-18 plus anti-CD3 antibody . Our results suggest that ALY mice might be showing a high susceptibility to M . leprae because of deficient priming for activation of T cells with the leprosy bacilli infection . Moreover, it is possible that the phagocytic activities of the macrophages of ALY mice are also impaired. Int J Clin Pract, 1999 Jan-Feb, 53(1), 77 - 9 An unusual case of ileocaecal tuberculosis in an 80-year-old Caucasian male; Kelly J et al.; An 80-year-old Caucasian male presented with a seven-week history of diarrhoea and weight loss . Distal duodenal biopsies showed partial villous atrophy but he failed to respond to a gluten-free diet . Subsequently he developed a right iliac fossa mass associated with radiological evidence of ileocaecal ulceration . Colonoscopic biopsies from the caecum showed non-caseating granulomata and Ziehl-Neelsen (ZN) staining and culture for acid-fast bacilli (AFB) were negative . Crohn's disease was diagnosed and he was started on steroids . Although he showed an initial response, his condition then deteriorated and he died after six weeks . ZN staining of tissue at postmortem showed AFBs . Although a rare diagnosis in the UK, a high index of suspicion should be maintained for ileocaecal TB in patients with appropriate clinical features, even if classical risk factors for TB are absent. Diagn Microbiol Infect Dis, 1999 May, 34(1), 45 - 50 Blood and charcoal added to acidified agar media promote the growth of Mycobacterium genavense; Realini L et al.; Ten different agar media were tested for the in vitro growth of Mycobacterium genavense in primary cultures and in subcultures from BACTEC vials . These agar media were based on Middlebrook 7H9, 7H10 and 7H11, and supplemented with additives: mycobactin J, yeast extract, charcoal, or defibrinated sheep blood . Some media were acidified with phosphoric acid to a final pH of 6.2 +/- 0.2 . Fourteen M . genavense strains from nude mouse organs as well as one decontaminated clinical specimen (from a bird) were tested . The optimal medium for primary cultures of M . genavense was Middlebrook 7H11 acidified to pH 6.2 +/- 0.2 and supplemented with charcoal and sheep blood: on this medium, all strains produced colonies within 6-12 weeks of incubation in numbers approaching the number of bacilli inoculated . It was also the only medium to support the growth of the decontaminated clinical specimen . Added blood and charcoal appeared not as essential for subcultures as for primary cultures . Three media supported the growth of all strains within 1 month incubation: they were acidified, and were supplemented with yeast extract or pancreatic digest of casein, and with either blood or charcoal. Am J Respir Cell Mol Biol, 1999 Jun, 20(6), 1260 - 7 Ovalbumin (OVA) and Mycobacterium tuberculosis bacilli cooperatively polarize anti-OVA T-helper (Th) cells toward a Th1-dominant phenotype and ameliorate murine tracheal eosinophilia; Sano K et al.; A recent increase in allergic disorders has coincided with a decrease in infections, including tuberculosis . Although an inverse association between tuberculin responses and atopic disorders was reported, it was not known how T-helper (Th)1-biased immune responses to Mycobacterium tuberculosis influenced Th2-dominant responses to allergens . We examined whether M . tuberculosis could modulate ovalbumin (OVA)-induced eosinophilic inflammation in the murine trachea in a manner that transcended the barrier of antigen specificity . We found that CD4(+) T cells primed with OVA in complete Freund's adjuvant (CFA) inhibited OVA-induced tracheal eosinophilia through interferon (IFN)-gamma secretion . Immunization with an irrelevant antigen in CFA or with OVA in incomplete Freund's adjuvant failed to induce suppressor cells . In vitro experiments confirmed that both M . tuberculosis and OVA (as opposed to either one alone) were necessary to evoke polarized development toward a Th1-like phenotype through interleukin-12 secretion . These results indicate that exposure to an allergen along with M . tuberculosis switches development of allergen-specific T cells toward a Th1 phenotype, which, in turn, downregulates allergic manifestations in an antigen-specific manner . The possible implications of these results are discussed in the context of the causal relationship between a decrease in tuberculosis and an increase in allergic disorders. J Fr Ophtalmol, 1999 Apr, 22(3), 371 - 6 {Bacillary endophthalmitis . Four case reports}; Maucour MF et al.; PURPOSE: Bacillary endophthalmitis occurring after penetrating ocular trauma with an intraocular foreign body is always associated with poor visual outcome . Bacilli cause fulminant infection associated with tissue damage in the intraocular structures . CASE REPORTS: Our series consisted of four patients with penetrating ocular trauma and endophthalmitis caused by B . cereus or B . licheniformis . Three eyes ultimately developed phtisis . Only on eye recovered good vision (2.5/10 P4) . DISCUSSION: Recommended early treatment includes topical, subconjunctival, parenteral antibiotics . A review of the literature indicates that intravitreal antibiotic infusion is crucial for sufficient concentration to control infection . Early vitrectomy is recommended in the management of endophthalmitis . Vitreous and intraocular foreign bodies should be cultured to identify pathogens and ascertain antibiotic susceptibilities. J Allergy Clin Immunol, 1999 May, 103(5 Pt 1), 789 - 95 Diagnostic criteria for sarcoidosis of the sinuses; deShazo RD et al.; BACKGROUND: Although newer technologies facilitate its diagnosis and treatment, little is known about sarcoidosis of the paranasal sinuses . OBJECTIVES: We sought to better characterize sarcoidosis of the sinuses and establish criteria for diagnosis . METHODS: Case-finding criteria were established, and over 50 reports of sarcoidosis of the sinuses in the medical literature were reviewed . Nine case reports of patients fulfilling the case-finding criteria were identified, as were 6 additional patients from our clinics . RESULTS: Nasal obstruction and chronic sinusitis were the usual initial complaints from patients and were associated with mucosal crusting, studding, plaque-like changes, or polyps in the nose in 5 of 6 of our patients . The most consistent finding in nose and sinuses was an erythematous, edematous, friable, hypertrophied mucosa . Like 5 of 6 of our patients, most patients had extra-pulmonary sarcoidosis involving multiple organs, but some had isolated upper respiratory disease . Radiologic studies showed extensive and often complete opacification of the sinuses and nose similar to that seen in diffuse polyposis associated with chronic bacterial and fungal sinusitis . No specific histopathologic findings distinguished sinus disease from those reported with pulmonary involvement . Pharyngeal involvement was present in 2 case reports and caused the apparent asphyxiation of 1 of our patients . CONCLUSION: Sarcoidosis of the sinuses should be considered in the differential diagnosis of sinusitis, especially in association with nasal polyposis, even when the sarcoidosis has not been otherwise diagnosed . On the basis of this experience, we propose diagnostic criteria for sarcoidosis of the sinuses . These include (1) radiologic evidence of sinusitis, (2) histopathologic confirmation of noncaseating granuloma in the sinus tissue supported by negative stains for fungus and acid-fast bacilli, (3) negative serologic test results for syphilis and antineutrophil cytoplasmic antibodies, and (4) no clinical evidence of other disease processes associated with granulomatous nasal and sinus inflammation . These criteria will provide the basis for further studies to assess both the natural history and the effectiveness of treatment in sarcoidosis of the sinuses. Am J Pathol, 1999 May, 154(5), 1611 - 20 Localization of Mycobacterium leprae to endothelial cells of epineurial and perineurial blood vessels and lymphatics; Scollard DM et al.; Infection of peripheral nerve by Mycobacterium leprae, the histopathological hallmark of leprosy, is a major factor in this disease, but the route and mechanisms by which bacilli localize to peripheral nerve are unknown . Experimentally infected armadillos have recently been recognized as a model of lepromatous neuritis; the major site of early accumulation of M . leprae is epineurial . To determine the epineurial cells involved, 1-cm segments of 44 nerves from armadillos were screened for acid-fast bacilli and thin sections were examined ultrastructurally . Of 596 blocks containing nerve, 36% contained acid-fast bacilli . Overall, M . leprae were found in endothelial cells in 40% of epineurial blood vessels and 75% of lymphatics, and in 25% of vessels intraneurally . Comparison of epineurial and endoneurial findings suggested that colonization of epineurial vessels preceded endoneurial infection . Such colonization of epineurial nutrient vessels may greatly increase the risk of endoneurial M . leprae bacteremia, and also enhance the risk of ischemia following even mild increases in inflammation or mechanical stress . These findings also raise the possibility that early, specific mechanisms in the localization of M . leprae to peripheral nerve may involve adhesion events between M . leprae (or M . leprae-parasitized macrophages) and the endothelial cells of the vasa nervorum. J Clin Microbiol, 1999 Jun, 37(6), 2016 - 9 Species-specific identification of Mycobacterium leprae by PCR-restriction fragment length polymorphism analysis of the hsp65 gene; Rastogi N et al.; PCR-restriction fragment length polymorphism analysis (PRA) of the hsp65 gene present in all mycobacteria was used in the present investigation to characterize Mycobacterium leprae . Bacilli were extracted and purified from different organs from experimentally infected armadillos and nude mice (Swiss mice of nu/nu origin) . A total of 15 samples were assayed in duplicate, and the results were compared with those obtained for a total of 147 cultivable mycobacteria representing 34 species . Irrespective of its origin or viability, M . leprae strains from all the samples were uniformly characterized by two fragments of 315 and 135 bp upon BstEII digestion and two fragments of 265 and 130 bp upon HaeIII digestion . PRA is a relatively simple method and permits the conclusive identification of M . leprae to the species level. J Am Geriatr Soc, 1999 May, 47(5), 539 - 46 Community-acquired pneumonia in the intensive care unit: epidemiological and prognosis data in older people; Leroy O et al.; OBJECTIVES: To compare epidemiological data, etiology, and prognosis of severe community-acquired pneumonia (CAP) in the intensive care unit (ICU) according to age (< or > or = 65 years) and to determine prognostic factors of CAP in older people . DESIGN: A retrospective (1987-1992) and prospective (1993-95) multicenter study . SETTING: Six ICUs in the north of France . PATIENTS: Five hundred five patients admitted to an ICU for severe CAP . MEASUREMENTS: Patient characteristics were compared with regard to age . Prognosis of CAP in older patients was studied by stepwise discriminant analysis . RESULTS: Two hundred seventy-eight patients (55%) were aged 65 years or older . Comparison of epidemiological data between older and younger patients revealed a higher prevalence of women (38% vs 29%), more severe underlying comorbidities (anticipated death within 5 years: 59% vs 26%), and more frequent chronic respiratory insufficiency (48% vs 33%) in the older patients . In this study group, 224 organisms were isolated from 172 patients (62%); those identified most frequently were Gram-negative bacilli (34%), S . pneumoniae (32%), and Staphylococcus sp . (19%) . Compared with younger patients, no significant differences in bacteriological data were observed . However, crude and attributable mortality rates were significantly higher in the older patients (33% vs 21% and 30% vs 19%, respectively) . Prognosis analysis identified four independent predictors of mortality in the older patients: initial septic shock (relative risk (RR) = 3), sepsis-related complications (RR = 4.3), hospital-acquired lower respiratory tract superinfections (RR = 2), and nonspecific pneumonia-related complications (RR = 2.8) . CONCLUSION: The bacterial etiology provides some approaches to empirical therapy for older patients with severe community-acquired pneumonia . In addition, the inappropriateness of withholding intensive care for reasons of age alone is emphasized. Mol Microbiol, 1999 May, 32(3), 643 - 55 Identification of variable regions in the genomes of tubercle bacilli using bacterial artificial chromosome arrays; Gordon SV et al.; Whole-genome comparisons of the tubercle bacilli were undertaken using ordered bacterial artificial chromosome (BAC) libraries of Mycobacterium tuberculosis and the vaccine strain, Mycobacterium bovis BCG-Pasteur, together with the complete genome sequence of M . tuberculosis H37Rv . Restriction-digested BAC arrays of M . tuberculosis H37Rv were used in hybridization experiments with radiolabelled M . bovis BCG genomic DNA to reveal the presence of 10 deletions (RD1-RD10) relative to M . tuberculosis . Seven of these regions, RD4-RD10, were also found to be deleted from M . bovis, with the three M . bovis BCG-specific deletions being identical to the RD1-RD3 loci described previously . The distribution of RD4-RD10 in Mycobacterium africanum resembles that of M . tuberculosis more closely than that of M . bovis, whereas an intermediate arrangement was found in Mycobacterium microti, suggesting that the corresponding genes may affect host range and virulence of the various tubercle bacilli . Among the known products encoded by these loci are a copy of the proposed mycobacterial invasin Mce, three phospholipases, several PE, PPE and ESAT-6 proteins, epoxide hydrolase and an insertion sequence . In a complementary approach, direct comparison of BACs uncovered a third class of deletions consisting of two M . tuberculosis H37Rv loci, RvD1 and RvD2, deleted from the genome relative to M . bovis BCG and M . bovis . These deletions affect a further seven genes, including a fourth phospholipase, plcD . In summary, the insertions and deletions described here have important implications for our understanding of the evolution of the tubercle complex. Proc Natl Acad Sci U S A, 1999 May 11, 96(10), 5657 - 62 Tumor necrosis factor alpha is a determinant of pathogenesis and disease progression in mycobacterial infection in the central nervous system; Tsenova L et al.; The pathogenesis of tuberculous meningitis, a devastating complication of tuberculosis in man, is poorly understood . We previously reported that rabbits with experimental tuberculous meningitis were protected from death by a combination of antibiotics and thalidomide therapy . Survival was associated with inhibition of tumor necrosis factor alpha (TNF-alpha) production by thalidomide . To test whether cerebrospinal fluid (CSF) levels of TNF-alpha correlated with pathogenesis, the response of rabbits infected in the central nervous system (CNS) with various mycobacterial strains was studied . CNS infection with Mycobacterium bovis Ravenel, M . bovis bacillus Calmette-Guerin (BCG) Pasteur, and M . bovis BCG Montreal were compared . M . bovis Ravenel induced the highest levels of TNF-alpha in the CSF in association with high leukocytosis, protein accumulation, and severe meningeal inflammation . BCG Pasteur had intermediate effects, and BCG Montreal was the least virulent . In addition, M . bovis Ravenel numbers were highest in the brain and CSF and the bacilli also disseminated more efficiently to distant organs, compared with BCG Pasteur and BCG Montreal . In subsequent experiments, rabbits were infected with either recombinant M . bovis BCG Montreal (vector), or BCG Montreal expressing the murine gene for TNF-alpha (BCG mTNF-alpha) . BCG Montreal was rendered virulent by the expression of murine TNF-alpha, as demonstrated by high CSF leukocytosis, high protein accumulation, severe meningeal inflammation, persistent bacillary load, and progressive clinical deterioration . Taken together, these results demonstrate that the level of TNF-alpha produced during mycobacterial CNS infection determines, at least in part, the extent of pathogenesis. Nurs Clin North Am, 1999 Jun, 34(2), 427 - 42 Emerging infectious diseases and pathogens; Chou T; Emerging infectious diseases are caused by old, new, and mutant microorganisms . Emergence of these pathogens can be attributed to changes in the characteristics and risk factors of patients, the widespread use of antibiotics, changes in the environment, the role of xenotransplantation, and international travel . In the United States, the incidences of C . difficile, cyclosporiasis, enterohemorrhagic E . coli gastroenteritis, Hantavirus, hepatitis C virus infection, and Lyme disease have increased significantly over the past two decades . Malassezia pachydermatis, extended spectrum beta lactamase (ESBL), Gram negative bacilli, and antibiotic resistant Enterococci, S . aureus, S . pneumoniae, and M . tuberculosis have also emerged prominently . Although not yet seen in the United States, variant Creutzfeldt-Jakob disease has made a great emotional impact on this country . Identifying, treating, and controlling emerging infectious disease and pathogens have created enormous challenges. Mikrobiologiia, 1998 Nov-Dec, 67(6), 788 - 91 {Defective pages as an antagonistic factor in closely-related bacilli}; Lotareva OV et al.; The antagonistic effect produced by the detective phage PBSX during cocultivation of the mutant strain B . subtilis 168, in which this phage is heat-inducible, and strain B . subtilis NRS231, which also bears a defective phage, was investigated . As soon as in the first hours of cocultivation under conditions of PBSX induction, the number of viable cells of strain NRS231 decreased by two orders of magnitude . However, the effect was not observed if the temperature of cocultivation was noninducing . The results confirm the supposition that defective phages may play a role in the competition between closely related bacilli. Arch Histol Cytol, 1999 Mar, 62(1), 83 - 95 Roles of a macrophage receptor with collagenous structure (MARCO) in host defense and heterogeneity of splenic marginal zone macrophages; Ito S et al.; Class A type I and type II macrophage scavenger receptors (MSR-A) and a macrophage receptor with collagenous structure (MARCO) are trimeric membrane glycoproteins mediating the uptake of chemically modified low density lipoproteins . MSR-A is expressed constitutively in several tissue macrophages and in liver sinusoidal endothelial cells, whereas MARCO is expressed constitutively in splenic marginal zone macrophages and in macrophages and endothelial cells in the lymphatic medullary sinuses of lymph nodes . The administration of LPS, zymosan, BCG, or L . monocytogenes to mice resulted in marked and transient MARCO expression and in the upregulation of MSR-A expression in the liver and spleen . In osteopetrotic (op) mutant mice defective in the production on M-CSF, ER-TR9-positive marginal zone macrophages and MOMA-1-positive marginal metallophilic macrophages were absent, whereas MARCO-expressing marginal zone macrophages were present, indicating the heterogeneity of marginal zone macrophages . Intravenous administration of BCG resulted in marked accumulation of BCG bacilli in the both marginal zone macrophages and marginal metallophilic macrophages in littermate control mice . In contrast, BCG bacilli were incorporated almost exclusively by MARCO-expressing marginal zone macrophages in op/op mice . These results indicate that MARCO is not only expressed constitutively in specific macrophage subpopulations but is also induced by various bacterial antigens and plays a role in host defense against bacteria. Postgrad Med, 1999 Apr, 105(4), 117 - 24 Severe pneumonia . When and why to hospitalize; Kohler RB; Relatively simple objective criteria are now available to predict which patients are at risk for bad outcomes from community-acquired pneumonia . In general, these include older patients and those with certain coexisting illnesses (especially neoplastic disease) or findings of altered mental status, hypotension, severe tachycardia, tachypnea, fever, acidemia, azotemia, hypoxemia, hyperglycemia, anemia, or hyponatremia . The major causes of severe pneumonia are S pneumoniae, H influenzae, and L pneumophila . Less common causes include mixed aerobic and anaerobic mouth flora, as well as M pneumoniae, C pneumoniae, gram-negative bacilli, and S aureus . Specific diagnosis is hampered by a lack of reliable diagnostic tests, but Gram's stain of expectorated sputum and cultures of sputum and blood may occasionally be helpful . Many empirical treatment regimens have been recommended, including those of the American Thoracic Society and the Infectious Diseases Society of America, which are reviewed here . It is hoped that better diagnostic tools will permit future targeting of microbes with narrow-spectrum therapy to diminish the risk of selection of resistant strains with empirical regimens. Monaldi Arch Chest Dis, 1999 Feb, 54(1), 49 - 54 The Italian AIPO study on tuberculosis treatment results, report 1995 . National AIPO "Tuberculosis" Study Group; Ambrosetti M et al.; In Italy, no national data on tuberculosis (TB) treatment results were available . In 1995, the AIPO (Italian Association of Hospital Pneumologists) TB Study Group, in collaboration with the Istituto Superiore di Sanita (technical branch of the Ministry of Health), started a prospective monitoring activity based on World Health Organization (WHO) and International Union against Tuberculosis and Lung Disease (IUATLD) recommendations . Data were collected from a nationwide network of 41 TB units, managing a significant proportion of all TB cases notified in Italy each year . The aim of this study was to analyse the case findings and treatment results for the year 1995 . Seven hundred and seventy eight TB cases were reported (59% males; 21% immigrants), 640 (82%) being new cases . Of these cases, 517 (66%) were pulmonary, 239 (31%) extrapulmonary and 22 (3%) both pulmonary and extrapulmonary . The main risk factors for TB were a history of recent contact and alcohol abuse among native Italians and human immunodeficiency virus-seropositive status among immigrants . The majority of immigrants were from Africa and South America, and had been in Italy > 24 months before diagnosis of TB . Thirty-seven per cent of patients had a positive direct sputum smear examination for alcohol acid-fast bacilli; 20% were resistant to any drug (monoresistance to isoniazid 3.5%; multidrug resistance 5.2%) . In 95% of cases, the duration of treatment was < 12 months . The overall success rate (cured plus treatment completed) was 81.1% . A significantly higher percentage of deaths was found in native Italians (being age-related), whereas immigrants had a higher default rate. Kansenshogaku Zasshi, 1999 Feb, 73(2), 130 - 7 {Computed tomography with normal chest radiography in childhood tuberculosis}; Katakura S et al.; During the recent 2 years we experienced 5 children (2 months-5 years old) with lung tuberculosis, all of whom had positive tuberculin skin-tests, and were in close contact with their family members who had active tuberculosis . However, no abnormal findings on chest X-ray films were pointed out by 2 independent roentogenologists, and no increased levels of inflammatory markers including WBC numbers, CRP, and ESR were detected in all but one child . Moreover, mycobacterial examination of sputa and/or gastric aspirates by microscope, culture technique, and PCR amplification revealed no causative bacilli in 4 children . To clarify whether these children were affected by Mycobacterium tuberculosis, chest CT scan was applied . Surprisingly, all 5 children were revealed to have abnormal changes including primary complexes in the lung field . Taken together, it is important to pursuit the apparent lung tuberculosis in children with a positive family history and positive tuberculin skin-test. Mol Cell Probes, 1999 Apr, 13(2), 115 - 26 PCR-restriction endonuclease analysis for identification and strain typing of Mycobacterium avium subsp . paratuberculosis and Mycobacterium avium subsp . avium based on polymorphisms in IS1311; Marsh I et al.; Point mutations in the IS 1311 sequences from sheep and cattle strains of Mycobacterium avium subsp . paratuberculosis (M . paratuberculosis) and M . avium subsp . avium (M . avium) were targeted to develop a polymerase chain reaction (PCR) that would be useful in the diagnosis and control of Johne's disease . Candidate PCR tests were evaluated for sensitivity, specificity and ease of interpretation of the restriction endonuclease analysis (REA) products . One IS 1311 PCR, amplifying a 608 base pair product, was shown to be suitable when the amplified product was digested with Hinf I and Mse I . The PCR detected 50 fg of template DNA from M . paratuberculosis strain 316 V, the equivalent of 10 organisms . The test was evaluated further using purified DNA from M . paratuberculosis and M . avium isolates and diagnostic samples including primary radiometric cultures . All 89 M . paratuberculosis samples were correctly identified and typed according to host species or IS 900 restriction fragment length polymorphism (RFLP) type . All 28 isolates of M . avium were also correctly identified . A second PCR/REA strategy based on a shorter fragment of IS 1311 was developed for formalin-fixed paraffin-embedded tissue samples . It correctly differentiated sheep and cattle strains of M . paratuberculosis in 27 tissue samples in which acid fast bacilli had been observed in Ziehl Neelsen stains and in which sufficient amplified product was present for REA with Hinf I . Both tests were specific for M . paratuberculosis when tested against 24 other mycobacterial species . These simple and rapid tests can be used on a range of diagnostic samples for the confirmation of Johne's disease and will be of benefit in control and eradication programmes for this disease . Int J Tuberc Lung Dis, 1999 Apr, 3(4), 330 - 6 Risk factors for negative sputum acid-fast bacilli smears in pulmonary tuberculosis: results from Dakar, Senegal, a city with low HIV seroprevalence; Samb B et al.; SETTING: Two teaching hospitals in Dakar, Senegal, a West African country with a low prevalence of human immunodeficiency virus (HIV) infection . OBJECTIVE: To determine whether patients with HIV-associated pulmonary tuberculosis have fewer acid-fast bacilli (AFB) in their sputum as assessed by routine microscopy, and to correlate the findings with systematically obtained clinical, radiographic and laboratory variables . DESIGN: Prospective study from November 1995 to October 1996 of 450 consecutive patients diagnosed with pulmonary tuberculosis . RESULTS: Tuberculosis was diagnosed in 380 patients (84.4%) by positive bacteriology, in 61 (13.6%) by a favorable response to anti-tuberculosis chemotherapy, and in nine (2.0%) by the presence of a miliary radiographic pattern . Forty (8.9%) patients were HIV-seropositive . AFB-negative smears were found in 14/40 (35.0%) of the HIV-seropositive patients with pulmonary tuberculosis compared with 71/410 (17.3%) of the seronegative patients (risk ratio {RR} = 2.02, 95% confidence interval {CI} 1.26-3.24, P = 0.01) . Multivariate analysis revealed that AFB smear negativity was associated with absence of cavitation (P = 0.002), lack of cough (P = 0.005), the presence of HIV seropositivity (P = 0.02), a CD4+ cell count above 200/mm3 (P = 0.02), and age over 40 years (P = 0.03) . CONCLUSIONS: Compared with HIV-seronegative patients with pulmonary tuberculosis, seropositive patients in Dakar, Senegal, are more likely to have negative sputum-AFB smears . This phenomenon has now been observed in seven of eight sub-Saharan African countries with varying HIV seroprevalence from which reports are available. J Clin Microbiol, 1999 May, 37(5), 1419 - 25 Clinical evaluation of the enhanced Gen-Probe Amplified Mycobacterium Tuberculosis Direct Test for rapid diagnosis of tuberculosis in prison inmates; Bergmann JS et al.; The reliability of the enhanced Amplified Mycobacterium Tuberculosis Direct Test (E-MTD; Gen-Probe, Inc., San Diego, Calif.) for rapid diagnosis of pulmonary tuberculosis (TB) was evaluated by testing 1, 004 respiratory specimens from 489 Texas prison inmates . Results were compared to those of mycobacterial culture (BACTEC TB 460 and Middlebrook 7H11 biplates), smear for acid-fast bacilli (AFB; auramine O), and clinical course . After chart review, three patients (nine specimens) who were on antituberculosis therapy before the study began were excluded from final analysis . Of the remaining 995 specimens, 21 were AFB smear positive: 13 grew Mycobacterium tuberculosis complex (MTBC), 6 grew nontuberculous mycobacteria, and 2 (from two patients diagnosed with TB and started on therapy after the study began) were culture negative . Twenty-eight specimens (20 patients) were positive for MTBC by culture and E-MTD . Seven specimens (seven patients) were positive by culture alone; three were from patients who had other E-MTD-positive specimens, two were false-positive cultures, and two were false-negative E-MTD results . Eight specimens were positive by E-MTD only; four specimens (four patients) were false-positive E-MTD results, and four specimens were from two patients with earlier E-MTD-positive specimens that grew MTBC . Thus, there were 22 patients with TB (10 smear positive and 12 smear negative) . The sensitivity and specificity of the AFB smear for diagnosis of TB, by patient, were 45.5 and 98.9%, respectively . After resolving discrepancies, these same values for E-MTD were 90.9 and 99.1% overall, 100 and 100% for the smear-positive patients, and 83.3 and 99.1% for the smear-negative patients . Excluding the one smear-negative patient whose E-MTD-negative, MTBC culture-positive specimen contained inhibitory substances, the sensitivity of E-MTD was 95.2% overall and 90.9% in smear-negative patients . The specificity and positive predictive value of E-MTD can be improved, without altering other performance characteristics, by modifying the equivocal zone recommended by the manufacturer . These data suggest that E-MTD is a reliable method for rapid diagnosis of pulmonary TB, irrespective of the AFB smear result . Guidelines for the most appropriate use of E-MTD with smear-negative patients are needed. Surg Neurol, 1999 Apr, 51(4), 443 - 6; discussion 446-7 Role of stereotactic aspiration in the management of tuberculous brain abscess; Mohanty A et al.; BACKGROUND: Intracranial tuberculous abscesses are uncommon clinical entities, even in countries where tuberculosis is endemic . Surgical excision and antituberculous treatment is the treatment of choice . The role of stereotactic aspiration in the management of these lesions is highlighted in this communication . METHODS: Three patients, all receiving treatment for pulmonary tuberculosis, presented with symptoms of raised intracranial pressure and neurological deficits . Computed tomography (CT) scans revealed cystic lesions with enhancing rim in the thalamus in two patients and multiple coalescing cystic lesions in the deep temporal region in another . RESULTS: Stereotactic aspiration of the cyst and biopsy of the cyst wall were performed in all . In two, the pus revealed acid fast bacilli (AFB) . In another, though the pus did not reveal any AFB, the wall showed tuberculous granuloma . Antituberculous treatment was continued in all the patients . Follow-up CT revealed resolution of the lesions in all patients . CONCLUSION: Stereotactic aspiration is an useful alternative modality of management of tuberculous abscesses in a selected group of patients. J Gastroenterol Hepatol, 1999 Mar, 14(3), 258 - 61 Isolated gastric tuberculosis of the cardia; Lin OS et al.; BACKGROUND: Isolated gastric tuberculosis is extremely rare, especially in the subcardiac region, where the low pH, high motility and absence of lymphoid tissue result in an unfavourable environment for the development of tuberculous lesions . METHODS AND RESULTS: Here we present a case of isolated gastric tuberculosis in the gastric cardia with no evidence of pulmonary involvement . Our patient was a young man with vague gastrointestinal symptoms and no previous history of tuberculosis . His condition was first detected on upper endoscopy as a raised subcardiac ulcer similar in appearance to a submucosal tumour . An endoscopic forceps biopsy showed the presence of caseating granulomata and acid-fast bacilli . The lesion resolved completely with 12 months of oral anti-tuberculosis therapy . CONCLUSIONS: This case illustrates the need for a high index of suspicion in order to diagnose this rare condition, as it can present in patients with no particular risk factors or symptoms . Once diagnosed, a complete cure can often be achieved with a course of oral anti-tuberculosis medication, with surgery being reserved for severely symptomatic or refractory lesions. Semin Respir Infect, 1999 Mar, 14(1), 82 - 7 Tuberculous empyema; Sahn SA et al.; Tuberculous empyema represents a chronic, active infection of the pleural space that contains a large number of tubercle bacilli . It is rare compared with tuberculous pleural effusions that result from an exaggerated inflammatory response to a localized paucibacillary pleural infection with tuberculosis . The inflammatory process may be present for years with a paucity of clinical symptoms . Patients often come to clinical attention at the time of a routine chest radiograph or after the development of bronchopleural fistula or empyema necessitatis . The diagnosis of tuberculous empyema is suspected on computed tomography imaging by finding a thick, calcific pleural rind and rib thickening surrounding loculated pleural fluid . The pleural fluid is grossly purulent and smear positive for acid-fast bacilli . Treatment consists of pleural space drainage and antituberculous chemotherapy . Problematic treatment issues include the inability to re-expand the trapped lung and difficulty in achieving therapeutic drug levels in pleural fluid, which can lead to drug resistance . Surgery, which is often challenging, should be undertaken by experienced thoracic surgeons. J Clin Invest, 1999 Apr, 103(7), 1023 - 9 Macrophages are a significant source of type 1 cytokines during mycobacterial infection; Wang J et al.; T-helper 1 (Th1) cells are believed to be the major producer of the type 1 cytokine interferon-gamma (IFN-gamma) in cell-mediated immunity against intracellular infection . We have investigated the ability of macrophages to release type 1 cytokines and their regulatory mechanisms using both in vivo and in vitro models of pulmonary mycobacterial infection . During pulmonary infection by live Mycobacterium bovis bacilli Calmette-Guerin (BCG) in wild-type mice, lung macrophages released interleukin-12 (IL-12), IFN-gamma, and tumor necrosis factor-alpha (TNF-alpha), and expressed surface activation markers . However, macrophages in infected IL-12(-/-) mice released TNF-alpha but not IFN-gamma and lacked surface activation makers . In freshly isolated lung macrophages from naive IL-2(-/-) mice, mycobacteria alone released TNF-alpha but not IFN-gamma, whereas exogenously added IL-12 alone released a minimum of IFN-gamma . However, these macrophages released large quantities of IFN-gamma upon stimulation with both mycobacteria and IL-12 . In contrast, mycobacteria and exogenous IFN-gamma released only a minimum of endogenous IFN-gamma . Endogenous IL-18 (IFN-gamma-inducing factor) played little role in IFN-gamma responses by macrophages stimulated by mycobacteria and IL-12 . Our data reveal that macrophages are a significant source of type 1 cytokines during mycobacterial infection and that both IL-12 and intracellular pathogens are required for the release of IFN-gamma but not TNF-alpha . These findings suggest that macrophages regulate cell-mediated immunity by releasing not only IL-12 and TNF-alpha but also IFN-gamma and that full activation of IFN-gamma response in macrophages is tightly regulated. Int J Dermatol, 1999 Feb, 38(2), 122 - 7 Detection of Mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids; Tan SH et al.; BACKGROUND:The objective of this study was to explore the role of the polymerase chain reaction (PCR) fo the detection of Mycobacterium tuberculosis DNA as a diagnostic aid in cutaneous tuberculosis using routinely processed skin biopsy specimens . METHODS AND RESULTS: A wide range of clinical specimens representing different forms of cutaneous tuberculosis and so-called tuberculids were studied . A sensitive and specific PCR assay targeting the sequence IS6110 of Mycobacterium tuberculosis complex was used . The specimens were categorized as follows . 1 Acid-fast bacilli (AFB) positive on biopsy (nine specimens from seven patients who were immunocompromised) . PCR was positive in five specimens . Of these, one specimen was culture positive and three specimens were culture negative . 2 AFB negative on biopsy: (a) tuberculosis verrucosa cutis (23 specimens); (b) lupus vulgaris (three specimens); (c) cutaneous tuberculosis clinically suspected (six specimens) . PCR was negative in all specimens . 3 Tuberculids.' (a) erythema induratum/nodular vasculitis (20 specimens); (b) papulonecrotic tuberculid (two specimens); (c) erythema nodosum (20 specimens) . PCR was negative in all specimens . CONCLUSIONS: The role of PCR in clinical dermatologic practice, at this stage, may be in differentiating between cutaneous tuberculosis and atypical mycobacterial infections in the context of an immunocompromised patient where AFB can be demonstrated on biopsy and cultures may be negative . In this clinical situation, PCR allows the prompt diagnosis and early institution of appropriate therapy . We have not found PCR to be a useful complement to the clinical and histologic diagnosis of "paucibacillary" forms of cutaneous tuberculosis. Wien Klin Wochenschr, 1999 Feb 26, 111(4), 157 - 60 Fulminant lethal tuberculous pneumonia (Sepsis tuberculosis gravissima) with ARDS in a non-immunocompromised western European middle-aged man; Peck-Radosavljevic M et al.; We report the case of a 42 years old, non-immunocompromised native Austrian living in Vienna . He presented at home with severe dyspnea and had to be intubated immediately . Shortly after hospital admission, he developed severe adult respiratory distress syndrome (ARDS) and septic shock with massive, bilobar patchy to confluent infiltrations and a need for norepinephrine . A CT-scan revealed severe loss of functional lung tissue with areas of consolidation and multiple communicating cystic spaces . Air leaking into the mediastinum through fistulas produced pneumomediastinum, pneumoperitoneum, and a massive soft tissue emphysema . Bronchoalveolar lavage performed within the first 24 hours of admission revealed + of acid-fast bacilli . Even though appropriate tuberculostatic medication was started immediately, the patient succumbed the next day to ARDS due to massive tuberculous pneumonia and miliary disease (Sepsis tuberculosis gravissima). Kekkaku, 1999 Feb, 74(2), 151 - 6 {Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients . 5 . The management of the patients excreting tubercle bacilli in a university hospital without isolation ward for tuberculosis}; Kato H et al.; The Japanese low ruled that the patients excreting tubercle bacilli should be treated in the isolated ward for tuberculosis . However, it is often difficult to transfer a patient with serious illness to the isolated ward with insufficient medical facilities . We investigated retrospectively the manner of the management of patients excreting tubercle bacilli in the Aichi Medical University Hospital without the isolation ward for tuberculosis . Materials were 166 patients (0.17%) out of 97,275 in-patients during 11 years since 1986 to 1996 . Respiratory symptoms were observed in 114 patients (68.7% of 166 patients) on admission . The initial bacteriological examination was ordered by the attendant doctor within a week in 93 patients (81.6%) of 114 patients with respiratory symptoms . On the other hand, a half of the 52 patients without respiratory symptoms on admission were not examined for sputum bacteriology beyond a week . Anti-tuberculous treatment was started within a week after positive bacteriological results in 129 patients (77.7% of the whole 166 patients), while the treatment was not carried out or delayed in 21 patients (12.6%) because of the communication failure of the bacteriological report to the physicians . Some complications were observed in 101 patients: 21 diabetes mellitus, 20 cancers, 15 hematological disorders, 9 collagen diseases, 6 renal failures on dialysis . Serious illnesses were observed in 33 patients (20.6% of the 166 patients) . Twenty-four patients (73% of the seriously ill patients) were died of renal failure, pancytopenia, cancer or respiratory failure . We considered that an isolated room for infectious tuberculosis with independent air conditioning system in a general hospital or a educational hospital was very convenient not only to the treatment of the patients with serious complications, but also to the education and training on tuberculosis for the medical student or medical stuffs. Kekkaku, 1999 Feb, 74(2), 145 - 50 {Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients . 4 . Actual status of the management of tuberculosis patients in a university hospital without isolation wards for infectious diseases}; Kako K et al.; We retrospectively evaluated clinical findings and the actual status of management of 69 tuberculosis patients admitted to the Fujita Health University Hospital, a hospital without isolation wards for infectious diseases, between 1991 and 1994 . Forty-nine patients were smear-positive and 22 patients were smear-negative and culture-positive . Twenty-five cases (36.2%) were classified as type II (cavitary) and 29 cases (42.0%) as type III (non-cavitary) according to the GAKKAI classification of findings on chest X-ray films for pulmonary tuberculosis . Physicians in charge did not diagnose twenty-four patients (34.8%) as tuberculosis on admission . Physicians in charge tended not to suspect smear-negative patients of tuberculosis . Most of the patients with cavities on their chest X-ray films were strongly suspected of tuberculosis on admission, but in some of them, tuberculosis was not considered at all . Smear-positive patients with strongly suspected tuberculosis were diagnosed with the disease within three hospital days, while it took about three weeks in patients who were not considered as tuberculosis on admission to be diagnosed as tuberculosis . In the case of smear-negative patients, it took about one month and two months respectively to diagnose the case as tuberculosis . About half (51.1%) of the smear-positive patients were admitted and treated in single-bed rooms while 44.7% were attended in multiple-bed rooms for 11 days before they were transferred to single-bed rooms . When acid-fast bacilli were detected, 57.4% of the smear-positive patients were transferred to hospitals with isolation wards for infectious diseases, while the remaining smear-positive patients were treated in single-bed rooms at the university hospital . About one-third (31.7%) of the smear-negative patients had already left the hospital when specimens were found to be culture positive for tubercle bacilli . In conclusion, it is utmost important for physicians to suspect to tuberculosis for the early diagnosis of the disease. Kekkaku, 1999 Feb, 74(2), 133 - 7 {Management of mycobacteriosis in general hospital without isolation ward for tuberculosis patients . 2 . The problems of management of the patients diagnosed pulmonary tuberculosis after admission to the respiratory ward of university hospital having no an isolation ward for the tuberculous patients}; Hiraoka H et al.; The management of 28 patients, diagnosed pulmonary tuberculosis by bacteriological or pathologic findings after the administration to the Koshigaya Hospital of Dokkyo university school of Medicine from January 1994 through September 1997, which had no an isolation ward for tuberculosis patients was analyzed . The mean age of the patients was 50.6 +/- 16.7 (18-85), and the number of male and female patients was 22 and 6 respectively . The underlying diseases found in 10 patients were gastric cancer, breast cancer, osteochondrosarcoma, collagen disease, diabetes mellitus, liver cirrhosis, pneumoconiosis, and bronchial asthma . Two patients were complicated by a lung cancer . Six of 28 patients showed smear-positive and culture-positive specimens and 22 of 28 patients showed smear-negative and culture-positive specimens . The detection of mycobacterial DNA in the samples after amplification by the polymerase chain reaction (PCR) used in 15 patients and was positive for 7 of 15 patients . The pathological study of the specimens obtained by Transbronchial lung biopsy was performed for 14 patients . The pathological findings were compatible with tuberculosis in 7 of 14 patients . The chief complaints of the 11 patients admitted to the hospital with in 3 days after first visit, were fever in all patients and in 5 patients with pleural effusion . A few patients showed smear-negative and PCR positive specimens and complicated by lung cancer or other malignancy, were treated in non isolation ward in the particular case of emergency evacuation before admission, careful examination such as a tuberculin test, bacterial examination, and PCR of sputum should be performed in the patients suspected of having pulmonary tuberculosis . The patients isolating tubercule bacilli after administration should be transferred to the hospital with isolated ward for tuberculosis or isolated room in general hospital in the particular case of emergency evacuation with the greatest care. Kekkaku, 1999 Feb, 74(2), 99 - 105 {Characteristics of the medical status and living conditions of the homeless registered as tuberculosis patients in Nagoya City}; Yamanaka K et al.; An Investigation by questionnaire was conducted in 1996 to know the tuberculosis (TB) status and living conditions of 50 homeless people registered as TB patients at one of Nagoya city's 16 health centers . 1 . All patients had one or more symptoms of TB, 64% of them showed positive TB bacilli on smear, and 35.3% of them had a previous history of TB treatment . However, only 15.2% suspected they had TB at the onset of symptoms . 2 . Main reasons of seeking medical treatment: 28.6% arrived by ambulance after falling down from exhaustion, 25.7% had consulted with welfare agencies after the onset of symptoms, and 20.0% had been diagnosed during the treatment of other diseases . 3 . When they were admitted to the hospital they had many concerns: 29.0% loss of income, 19.4% living expenses, 19.4% smoking prohibition, 12.9% admission fee, and 9.7% privacy . 4 . They lived in the following: 42.9% construction camps, 20.0% parks or streets, 17.1% single room occupancy hotels, 17.1% daily or monthly paid apartments, and 11.4% sauna baths . 5 . Past medical histories of the subjects included 40.6% injuries by labor accidents, and 25.0% stomach ulcers . Current diseases were 15.6% mental diseases, 15.6% liver diseases, 15.6% diabetes mellitus, and 9.4% alcoholic dependence . Seventy percent of them consumed alcohol daily (average pure ethanol 125 ml per day) . 6 . From the results outlined above, the following proposals relating to TB control of the homeless should be considered . 1) Educating the homeless as to the need for a health check when TB symptoms are present . 2) Opening a clinic for the homeless for easy access to consultation on TB . 3) Directly observed therapy short-course, for TB in the homeless . 4) Health examination of the employees of single-room occupancy hotels and sauna baths which are used frequently by the homeless . 5) A fundamental countermeasure to deal with alcoholic dependency among the homeless. Kekkaku, 1999 Feb, 74(2), 83 - 90 {Global situation of TB and its control}; Shimao T; Tuberculosis occupies 4th place among major causes of death, and the number of new cases is estimated at 7.25 million in 1997, and 99% of TB deaths and 95% of new TB cases are seen in developing countries . TB had been brought under control in developed countries by applying modern TB control programme including chemotherapy, as basic health infrastructure was already well developed, and their economy can afford cost of control programme including TB drugs . The rapid decline of TB due to the success of TB control in developed countries had lowered the concern on TB, thus bought about the reduction in research grant for TB and difficulty in bringing up successors engaging in TB control . Similar trend was seen also in developing countries, where TB still remains one of most important health problems due to poor quality of the programme caused by poorly developed health infrastructure including man-power, budget and institutions . New obstacles which hinder the smooth implementation of TB control programme have appeared, and they are the rapid expansion of global population, the move of population, the impact of HIV epidemic on TB and the multi-drug-resistant TB (MDRTB) . The growth of population automatically increases the number of TB cases and gives heavier burden for TB control . TB has moved from developing to developed countries with the move of the population, and currently approximately half of new TB cases in developed countries is occupied by foreign born patients . Among several opportunistic infections seen in AIDS cases, TB comes out first as the virulence of tubercle bacilli is much higher than the other germs causing opportunistic infections . The pathogenesis of TB changes markedly among HIV positives, and the incidence becomes much higher, and the time interval from the primary infection to the disease, and that from the detection of the disease to death without any effective treatment are shortened, and the fatality rate becomes much higher . Because of the atypical clinical picture, attenuated tuberculin sensitivity and high incidence of side-effects of TB drugs, in particular thiacetazone, clinical management of HIV positive TB is much more difficult than ordinary TB . MDRTB is produce by the bad quality of TB control, and by improving treatment completion rate as well as the cure rate, decline in the prevalence of drug resistance, both primary and acquired, could be expected together with the decline of TB itself . WHO has made a great challenge with TB after the nomination of Dr Kochi to chief medical officer, TUB in 1989 . Currently, Global TB Programme (GTB) is promoting so-called DOTS strategy of TB control, consisting of the commitment of the government to give high priority to TB control, passive case-finding with sputum smear examination by microscopy, directly observed treatment by standardized short-course regimen of chemotherapy, well-organized logistics for TB drugs, and the provision of reporting and monitoring system of TB including the evaluation of treatment outcome by cohort analysis . Marked achievements have been obtained in several countries introduced DOTS strategy . Japan is asked to intensify its efforts in international cooperation in TB control. Indian J Lepr, 1998 Oct-Dec, 70(4), 397 - 403 Identification of M.leprae in conjunctiva of leprosy patients using the superior tarsal conjunctiva scrape technique; Campos WR et al.; The technique of superior tarsal conjunctiva scrape was used for identifying M.leprae in the conjunctiva in 56 leprosy patients (all of them multibacillary, some untreated and others treated with multidrug therapy) . The technique of tarsal conjunctiva scrape was shown to be more suitable than conjunctival biopsy for identifying lepra bacilli . This technique is also easier to perform and has shown a statistical relation between bacilloscopical index of skin (BIsk) and bacilloscopical index of tarsal conjunctiva (BIconj) values . Thus, if the bacilli can be identified at tarsal conjunctiva we can assume greater systemic bacillary load in the patients. Indian J Lepr, 1998 Oct-Dec, 70(4), 389 - 95 Quality control tests for vaccines in leprosy vaccine trial, Avadi; Sreevatsa et al.; All the vaccines supplied for the large scale comparative leprosy vaccine trial of ICRC bacilli, M.w, BCG plus killed M . leprae (candidate vaccines), BCG and normal saline (control arms) at CJIL Field Unit, Chennai were tested for quality control by the suppliers following the procedures laid down in the WHO protocol for killed M . leprae . Quality control for BCG was carried out at BCG vaccine laboratory as per protocol . Toxicity and sterility tests were done on all the vaccine batches/lots received . As part of the quality control, bacterial count, and protein estimation were also done . Studies showed that the bacterial content and protein concentration were comparable with the original preparations . Vaccines were free from micro-organisms, toxic materials and safe for human use . Thus the quality of all vaccine preparations was satisfactory. Aviat Space Environ Med, 1999 Mar, 70(3 Pt 2), A137 - 40 Effects of low frequency noise upon the reaction of pleural milky spots to mycobacterial infection; Oliveira MJ et al.; INTRODUCTION: Milky Spots (m.s.), also known as Kampmeier's foci, are confined to the parietal leaflet and act as a barrier to mediastinum infections, having very important phagocytic functions . Previous studies have made clear that large pressure amplitude and low frequency (LPALF) noise (> or = 90 dB, < or = 500 Hz) induces morphofunctional changes on the pleural mesothelium . The purpose of this study was to investigate the dynamics of m.s., namely the response to infectious agents reaching the pleural space under noise stress . METHODS: Wistar rats (n = 20) were used; 5 as control and sham operated, 5 exposed to infection but not to noise, 5 exposed to 1696 cumulative hours of LPALF noise, and 5 exposed to 2184 cumulative hours . Following noise exposures, all rats except the 5 controls were injected with 0.2 ml of saline solution containing 2 x 10(8) viable mycobacterium avium bacilli (ATCC-25291 strain, sereotype 2) . The rats were sacrificed 21 d after infection and sections of the retrocardiac pleural leaflets were observed with a light microscope using the Ziehl-Neelsen staining method . RESULTS: There was an increase in the number and diameter of the m.s . due to hypercellularity, mainly caused by the increase of mononuclear cells, and there was formation of large granulomas containing many mycobacteria . Rats submitted to noise also presented alterations of the standard morphological changes, namely partial necrosis of the m.s . CONCLUSION: The data suggest that exposure to LPALF noise can interfere with the normal immune response to bacterial infection in rats . This can be an important contribution to the understanding of the disorders in the pleural space of vibroacoustic disease patients. Pediatrics, 1999 Apr, 103(4 Pt 1), 719 - 23 Factors that predict preexisting colonization with antibiotic-resistant gram-negative bacilli in patients admitted to a pediatric intensive care unit; Toltzis P et al.; OBJECTIVE: To predict which patients hospitalized in a pediatric intensive care unit (ICU) are colonized with antibiotic-resistant gram-negative rods on admission . METHODS: Consecutive children admitted to a pediatric ICU over a 6-month period were entered into the study . A questionnaire soliciting information regarding the child's medical history and home environment was completed by the parent or guardian . Nasopharyngeal and rectal cultures were obtained on each of the first 3 days of ICU admission, and organisms resistant to ceftazidime or tobramycin were identified . Only clonally distinct organisms, as confirmed by pulsed field gel electrophoresis, were analyzed . The association between identification of colonization with an antibiotic-resistant gram-negative rod within 3 days of ICU admission and factors included in the questionnaire was tested by chi2 or t test . RESULTS . In 64 (8.8%) of 727 admissions, an antibiotic-resistant gram-negative bacillus was isolated within the first 3 ICU days . More than half were identified on the day of admission . Colonization was associated with two factors related to the patient's medical history, namely, number of past ICU admissions (1.98 vs.87) and administration of intravenous antibiotics within the past 12 months (67.9% vs 28.2%) . No association was found between colonization and exposure to oral antibiotics . In addition, factors related to the child's environment were also associated with presumed importation of an antibiotic-resistant gram-negative rod into the ICU . Specifically, residence in a chronic care facility was strongly associated with colonization (28.3% vs 2.6%); exposure to a household contact who had been hospitalized in the past 12 months also predicted colonization (41.7% vs 18.5%) . CONCLUSIONS: These data suggest that a profile can be established characterizing children colonized with resistant gram-negative bacilli before admission to a pediatric ICU . Infection control measures may help to contain these potentially dangerous bacteria once they have been introduced into the unit. Acta Cytol, 1999 Mar-Apr, 43(2), 153 - 7 Fine needle aspiration diagnosis of mycobacterial lymphadenitis . Sensitivity and predictive value in the United States; Ellison E et al.; OBJECTIVE: Fine needle aspiration (FNA) has proven valuable in diagnosing tuberculous lymphadenitis in countries with endemic mycobacterial infection (MI) . Its role in developed countries, where sensitivity and positive predictive value are likely to be lower, has not been adequately explored . STUDY DESIGN: This retrospective, five-year study from a public hospital in the United States examined the predictiveness of 238 nodal FNAs in patients with MI; 59% of patients were also HIV+ . RESULTS: Diagnostic results (stainable acid-fast bacilli or positive culture) were present in nearly half the aspirates; sensitivity was 46%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 94% . If granulomatous inflammation (GI) was also considered a positive result, sensitivity increased to 53%; false positive cases of GI reduced PPV to 80%, while specificity (98%) and NPV (95%) changed little . Considered alone, GI had the lowest sensitivity (25%) and PPV (65%) . CONCLUSION: FNA was useful in this U.S . population with MI, identifying almost half the affected patients . However, nondiagnostic results, such as granulomatous inflammation, should be interpreted with caution. Int J Tuberc Lung Dis, 1999 Mar, 3(3), 231 - 8 Evaluation of the MycoDot test in patients with suspected tuberculosis in a field setting in Tanzania; Somi GR et al.; SETTING: Rapid, simple and inexpensive methods are needed to improve the diagnosis of tuberculosis in low-income countries . The MycoDot test has these characteristics . OBJECTIVE: To assess the utility of the MycoDot test in screening patients with suspected tuberculosis . DESIGN: Ambulatory patients presenting with symptoms of pulmonary tuberculosis were evaluated by physical examinati