Antimicrob Agents Chemother, 1997 Mar, 41(3), 578 - 82 In vitro susceptibilities of Bartonella henselae, B . quintana, B . elizabethae, Rickettsia rickettsii, R . conorii, R . akari, and R . prowazekii to macrolide antibiotics as determined by immunofluorescent-antibody analysis of infected Vero cell monolayers; Ives TJ et al.; The in vitro susceptibilities of Bartonella (Rochalimaea) henselae, B . quintana, B . elizabethae, Rickettsia akari, R . conorii, R . prowazekii, and R . rickettsii to different concentrations of azithromycin, clarithromycin, dirithromycin, erythromycin, and roxithromycin in Vero cell cultures were evaluated . Bartonella and Rickettsia spp . were allowed to initiate infection of the antibiotic-free Vero cell monolayers, which were maintained in 16-chamber microscope slides in the absence of antibiotics at 32 degrees C in a CO2-enriched atmosphere . The monolayers were then incubated for 3 h to allow for initial host cell intracellular penetration by infecting species . After inoculation, inocula were replaced and tested with media containing 12 different concentrations of each antibiotic in replicate (10 wells of each antibiotic dilution) for each species, and the monolayers were reincubated . Tetracycline served as the control . Growth status of Bartonella spp . and Rickettsia spp . was determined by evaluation of immunofluorescent staining bacilli . Five days later, when antibiotic-free, control-infected cell monolayers demonstrated significant fluorescence, media were removed for all cell monolayers, the monolayers were fixed, and all specimens were stained with standard indirect immunofluorescent antibody reagents . Fluorescent foci were enumerated by counting such foci on random fields visualized with an epifluorescence microscope . The extent of antibiotic-induced focus inhibition was recorded for each dilution of antibiotic and compared with that of an antibiotic-negative control . Effective antibiotic dilution endpoints for inhibition of Bartonella and Rickettsia proliferation, as judged by absence of increase of significant fluorescence (as compared with no-growth controls), were enumerated by determining the number of cell culture chambers at various antibiotic dilutions that were negative or positive for significant Bartonella- or Rickettsia-specific fluorescence . All of the macrolide agents tested were readily active against all three Bartonella organisms, and azithromycin, clarithromycin, and roxithromycin may have potential in the treatment of Rickettsia infections . Animal model-based clinical trials are warranted to define the specific treatment role of the newer macrolide antibiotics. Am J Clin Pathol, 1997 Mar, 107(3), 317 - 20 Fine-needle aspiration of peripheral lymph nodes in patients with tuberculosis and HIV; Lapuerta P et al.; Previous studies of fine-needle aspiration (FNA) specimens from lymph nodes of patients with tuberculosis (TB) and infection with the human immunodeficiency virus (HIV) have often involved small numbers of specimens and have produced conflicting results . We reviewed 93 FNA specimens from peripheral lymph nodes in a consecutive series of 79 patients with TB to compare results for patients with and without HIV infection . The 45 patients with HIV infection in the series were more frequently male, more likely to have negative results on a purified protein derivative tuberculin skin test, and they had more disseminated disease . Granulomatous inflammation, a positive result on a culture, acid-fast bacilli, or necrosis was found in 71% of the studies . Identification of granulomatous inflammation occurred at a similar rate in FNA specimens from patients with HIV infection (16%) and without HIV infection (21%; P = .56) . Necrosis was the sole reported finding in a significant subset of cases (16%), occurring in patients with and patients without HIV infection . FNA of peripheral lymph nodes of patients with TB was an effective diagnostic test . Granulomatous inflammation and other FNA findings in peripheral lymph nodes of patients with TB were similar in those with and those without HIV infection. J Immunol, 1997 Feb 15, 158(4), 1742 - 8 Differential responses to challenge with live and dead Mycobacterium bovis Bacillus Calmette-Guérin; Chambers MA et al.; Bacillus Calmette-Guerin (BCG) vaccination has been shown to protect against challenge with virulent Mycobacterium tuberculosis in a range of experimental animal models: in each case, protective efficacy requires vaccination with live bacteria . With the goal of moving to a new generation of safer, nonliving vaccines, efforts have been made to identify the factors that determine the efficacy of live vaccination . We show that injection of live, but not dead, BCG induces localized swelling in the mouse footpad model . Live and dead bacteria induce similar responses during the first week after vaccination as determined by immunohistochemical analysis of the site of injection and of the draining lymph node . The subsequent differential response is characterized by migration of acid-fast bacilli to the draining lymph node in the case of the live vaccine . This is accompanied by an increase in mononuclear cells in the lymph node and by expression of inducible nitric oxide synthase (iNOS) both in the lymph node and at the site of injection . The ability of the bacteria to migrate to the lymph node may be an important element in the efficacy of live BCG vaccination. Ryumachi, 1997 Feb, 37(1), 36 - 41 {A case with systemic lupus erythematosus complicated with tuberculosis sacroiliac arthritis}; Sugiyama K et al.; A 26-year-old woman was admitted to our hospital because of fever of unknown origin . She had been treated with prednisolone, elcatonin and alfacalcidol under the diagnosis of systemic lupus erythematosus (SLE) and aseptic necrosis of femoral bone head . Six months ago she began to have a fever and subsequently left low back pain, for which extensive examinations were performed in other hospital but their causes remained unclear . She was referred to our hospital for further evaluation and therapy in October 1995 . Bacteriological, immunological or serological examinations did not reveal the origin of fever . CT and ultrasonic examination did not show any abnormality . However, MRI, which was taken for the evaluation of aseptic necrosis of femoral bone head, showed the abscess shadow in sacroiliac joint . Open biopsy was performed and Mycobacterium tuberculosis bacilli were detected from the abscess . To our best knowledge, this is the first report of SEE with tuberculosis sacroiliac arthritis. Postgrad Med J, 1997 Feb, 73(856), 89 - 92 Tropical liver abscess; Yeoh KG et al.; Forty-one consecutive cases of liver abscesses seen at the National University Hospital, Singapore from 1988 to 1994 were reviewed . Twenty-seven cases (65%) were pyogenic, six (15%) amoebic, two (5%) tuberculous and six (15%) indeterminate . The predominance of pyogenic abscesses is in marked contrast to previous studies from the region a decade ago in which amoebic abscesses were the commonest type . The commonest pathogen causing pyogenic abscess was Klebsiella pneumoniae . Two cases were due to Mycobacterium tuberculosis, and this organism needs to be actively looked for in smears and cultures of aspirated material . As the majority of organisms isolated were resistant to ampicillin, empirical antibiotic treatment for suspected pyogenic abscess should include gentamicin or a cephalosporin . Percutaneous needle aspiration of the abscess was performed for 85% of pyogenic abscesses and surgery was necessary in only two cases because of complications . We found that percutaneous aspiration of liver abscess is helpful to confirm the diagnosis, provides a better bacteriological culture yield, gives a good outcome, and may uncover clinically unsuspected conditions like malignancy and tuberculoma which may mimic the presentation of liver abscesses . We recommend routine cytological examination of aspirated abscess material as well as stains and cultures for acid-fast bacilli. Infect Control Hosp Epidemiol, 1997 Feb, 18(2), 136 - 7 A pseudo-outbreak of Mycobacterium chelonae infections related to bronchoscopy; Cox R et al.; Mycobacterium gordonae and rapidly growing "atypical" mycobacteria including Mycobacterium chelonae are commonly found in tap water . This article describes a pseudo-outbreak of M chelonae infections related to bronchoscopy . Because patients may be treated and isolated unnecessarily when positive with acid-fast bacilli before the species are known, the financial burden for patients and hospitals may be great. Kekkaku, 1997 Feb, 72(2), 99 - 107 {Saprophytic and invasive pulmonary aspergillosis}; Nagai H; The characteristics of chest x-ray films in 19 patients with saprophytic pulmonary aspergillosis secondary to acid-fast bacilli infection were reported . The saprophytic form, exemplified by the classic fungus ball or mycetoma, results from the growth of fungal mycelia within a pre-existing area of destroyed lung, typically a pre-existing cavity such as that resulting from tuberculosis . Aspergillus fumigatus was detected in 52.6% of sputum cultures from 19 patients . Aspergillus precipitin test was positive in 68.4% of patients . Thickening of cavitary walls was first found in 85% of chest x-ray films . Eighty percent of patients had pulmonary aspergillosis within 3 years after cavitary lesions were stable . Invasive pulmonary aspergillosis (IPA) is characterized by hyphal invasion and destruction of pulmonary tissue . The risk of acquiring IPA correlates with the duration and degree of immunosuppression or neutropenia . IPA recently has been encountered in patients with human immunodeficiency virus (HIV) infection . The number of case reports on chronic necrotizing pulmonary aspergillosis is increasing, but it is supposed the clinical entity of this disease still has not been established. Kekkaku, 1997 Feb, 72(2), 73 - 7 {A case of acquired immunodeficiency syndrome with disseminated Mycobacterium avium complex infection in which M . avium was isolated from bone marrow}; Ohse H et al.; A 46-year old man was admitted to a hospital because of cough and dyspnea . He was diagnosed as interstitial pneumonia and was treated with prednisolone (PSL) and antibiotics . The symptoms improved temporarily but he soon developed acute respiratory failure and was transferred to our hospital . Chest X-ray and CT revealed ground-glass opacities in both lung fields . He was treated with methyl PSL, antibiotics, and antimycobacterial drugs but he died on the fourth hospital day . Retrospectively, hematologic laboratory examinations revealed that CD4+ cell count was 0/microliter and serological tests for HIV were positive by both EIA and Western blot methods . The culture of the bone marrow specimens was positive for mycobacteria other than M . tuberculosis, and the bacilli were identified as Mycobacterium avium . Thus, his disease was eventually diagnosed as disseminated Mycobacterium avium complex (MAC) infection . In the past reports, the diagnosis of disseminated MAC infection was most often made by blood cultures, however, the isolation of MAC from bone marrow is another sensitive and specific method for the diagnosis of this infection . In some cases, bone marrow examination would be useful to diagnose disseminated MAC infection. Kekkaku, 1997 Feb, 72(2), 67 - 72 {Clinical course of HIV-infected tuberculosis patients who admitted to the tuberculosis isolation ward: current problems of medical care}; Fujita A et al.; To clarify the problems of medical care of HIV-infected tuberculosis patients, we investigated clinical course of six cases admitted to our tuberculosis isolation ward . All cases were sputum smear positive for tubercle bacilli at the time of diagnosis of tuberculosis . HIV-positive was confirmed at the same time or soon after the diagnosis of tuberculosis in four cases . CD4+ cell count was on the average 21/mm3 on admission, and all cases were defined as acquired immunodeficiency syndrome (AIDS) by the criteria of AIDS surveillance committee in Japan . Two patients presented with miliary tuberculosis and five documented evidence for intrathoracic and/or cervical lymph node involvement . All cases but one responded well to antituberculosis drugs, and sputum smears and cultures became negative soon after the initiation of therapy . However, the patients were still needed to be hospitalized for the treatment and control of complications other than tuberculosis after sputum negative conversion, and they stayed in the isolation rooms of our tuberculosis ward for 110 +/- 49 days . During the treatment for tuberculosis, each patient developed 3 to 8 complications of HIV infection such as pneumocystis carinii pneumonia (PCP) (four cases), bacterial infection (four cases), neuropathy (four cases), and HIV encephalopathy (three cases) . The last two complication worsened active daily life . White blood cell count was more likely to fall when sulfamethoxazole/trimethoprim mixture for the prevention of PCP and antituberculosis drugs were administered together . In three cases, ST mixture could not be continued, then two patients developed PCP after changing to an alternative pentamidine inhalation . Although three patients discharged from our tuberculosis ward, four died of AIDS related complications other than tuberculosis, one died of tuberculosis (multidrug-resistant M . tuberculosis strain was not documented initially but was detected five months later), one died of tuberculosis meningitis after the discharge, and one was lost because he returned to his own country . The survival time between the start of treatment and death ranged from 90 to 244 days in five cases . Integrated medical care system both for HIV and tuberculosis is warranted for the management of HIV-infected tuberculosis patients since they suffer many complication in addition to tuberculosis . A guideline of methods and duration of isolation for tuberculosis is needed for the most effective care of HIV-infected tuberculosis patients in Japan. Histopathology, 1997 Feb, 30(2), 129 - 34 Nodular granulomatous phlebitis of the skin: a fourth type of tuberculid; Hara K et al.; We present five cases of granulomatous phlebitis of the skin and compare them with a case of miliary tuberculosis with granulomatous phlebitis . All five patients were hypersensitive to purified protein derivative, but without active tuberculosis . Although anti-tuberculous drugs were effective, no tubercle bacilli were isolated from the skin . Clinically, subcutaneous nodules were felt along the course of the leg vein . Histologically, epithelioid cell granulomas with Langhans' giant cells were observed within the walls of the cutaneous veins . In a later stage, granulomatous panniculitis was often associated . Using the polymerase chain reaction method . Mycobacterium tuberculosis DNA was detected in four of the five cases of granulomatous phlebitis of the skin . Granulomatous phlebitis of the skin seems to represent a relatively early phase of delayed-type hypersensitivity reactions to Mycobacterium tuberculosis and may represent a distinct entity different from other types of tuberculid-a new tuberculid . Nevertheless, before making the diagnosis, the possibility of true tuberculosis must always be excluded . Nodular granulomatous phlebitis of the skin would be an appropriate name for the newly described condition. J Natl Med Assoc, 1997 Feb, 89(2), 142 - 3 Elevation of carcinoembryonic antigen and CA-125 in a patient with multivisceral tuberculosis; Mansour M et al.; A case of a middle-aged African-American woman with weight loss, ascites, a bilateral pleural effusion with no infiltrate, and a clinical diagnosis of a metastatic gynecological tumor is presented . Her carcinoembryonic antigen (CEA) and CA-125 levels were elevated (400 micrograms/L and 331 micrograms/L, respectively) . She underwent an exploratory laparotomy and a dilation & curettage for biopsies and cultures . Pathological examination showed Langhans' type giant cells on peritoneal biopsy . An endometrial curette biopsy showed granulomatous endometritis and acid-fast bacilli . Cultures grew Mycobacterium tuberculosis . The patient presented with a fibroid tumor that could have contributed to her elevated CA-125 level, but after antituberculous treatment was started and tumor markers were repeated after 1 year, the CEA level decreased to 1.2 micrograms/L and CA-125 to 9 micrograms/L without surgical resection of the tumor . A review of the literature revealed only three cases in which patients had elevated CA-125 in multivisceral tuberculosis . No cases were reported in which both CEA and CA-125 levels were elevated in multivisceral tuberculosis . Possible causes of elevated CEA and CA-125 levels are discussed. Am J Clin Pathol, 1997 Feb, 107(2), 224 - 8 Evaluation of cultures of percutaneous core needle biopsy specimens in the diagnosis of pulmonary nodules; Chitkara YK; The value of cultures of tissue obtained by image-directed core needle biopsy of lung nodules has not been determined . Of the 250 biopsies performed during a 5-year period in an area endemic for coccidioidomycosis, 225 (90%) were diagnostic . Granulomas were identified in 75 specimens, whereas 3 specimens revealed abscess . Ziehl-Neelsen stain was positive for acid-fast bacilli (AFB) in 2 cases . Spherules of Coccidioides immitis were seen in 54 of the biopsy specimens with granulomas . Microbiologic cultures were positive for C immitis in 5 (9.6%) of 52 biopsy specimens . Both of the AFB-positive cases were negative by culture . Organisms were demonstrated in cases with abscess; however, the cultures submitted in 2 cases were negative . Cultures were uniformly negative in cases where special stains failed to reveal organisms . Cultures of core needle biopsy specimens are insensitive in the detection of specific microorganisms and need not be routinely performed. Infect Immun, 1997 Feb, 65(2), 387 - 94 Analysis of culture filtrate and cell wall-associated antigens of Mycobacterium paratuberculosis with monoclonal antibodies; Mutharia LM et al.; Proteins secreted by Mycobacterium species have been suggested as major immune targets in the early phase of infection . In this study, we sought to identify specific antigens in culture filtrates and in soluble cell extracts of Mycobacterium paratuberculosis . The release of antigens into the culture medium during growth of the bacilli and the distribution of specific epitopes within the Mycobacterium species were investigated by immunoblot analysis with monoclonal antibodies (MAbs) raised against M . paratuberculosis antigens . MAb B6A interacted with a cellular antigen with an apparent molecular mass of 34.5 kDa in lysates of M . paratuberculosis . MAb B6A did not interact with lysates from any other mycobacterial species, suggesting recognition of an M . paratuberculosis species-specific epitope . MAb FL1-A1 reacted with an antigen of 44.3 kDa in M . paratuberculosis and a 9-kDa antigen in Mycobacterium kansasii . MAb PII-B1 reacted with concanavalin A (ConA)-binding cellular and filtrate molecules of M . paratuberculosis and with lysates of Mycobacterium kansasii and Mycobacterium avium 18 . The affinity-purified glycosylated antigens migrated as a diffuse band of between 35 and 45.6 kDa and reacted strongly with ovine and bovine paratuberculosis serum and polyclonal serum against M . tuberculosis lipoarabinomannan antigens . These glycoconjugates were the earliest antigens detected in culture filtrates of M . paratuberculosis . Deglycosylation of the ConA-binding molecules with alpha-mannosidase enzyme abolished the reaction with MAb PII-B1 and with bovine but not ovine paratuberculosis serum, suggesting selective immunogenicity in the different animal species. J Clin Microbiol, 1997 Feb, 35(2), 364 - 8 Comparison of the Mycobacteria Growth Indicator Tube (MGIT) with radiometric and solid culture for recovery of acid-fast bacilli; Pfyffer GE et al.; In a multicenter study involving three reference centers for mycobacteria, the rate of recovery of acid-fast bacilli (AFB) and the mean time to their detection from clinical specimens was determined by using the Mycobacteria Growth Indicator Tube (MGIT) . These parameters were compared to those assessed by the radiometric BACTEC 460 TB system and by cultivation on solid media . Clinical specimens (n = 1,500) were pretreated with N-acetyl-L-cysteine (NALC)-NaOH . The contamination rates for MGITs were 2.0% (center 1), 13.8% (center 2), and 6.1% (center 3) . A total of 180 mycobacterial isolates were detected (M . tuberculosis complex, n = 113; nontuberculous mycobacteria {NTM}, n = 67) . When using a combination of liquid and solid media (the current "gold standard" for culture), MGIT plus solid media detected 156 (86.7%) of the isolates, whereas BACTEC plus solid media recovered 168 (93.3%) of all AFB . Between these two gold standards there was no statistically significant difference (P > 0.05) . The combination of MGIT plus BACTEC detected 171 (95.0%) of all isolates (compared with MGIT plus solid media, P < 0.01; compared with BACTEC plus solid media, P > 0.05) . Considering the efficacies of the different media separately, MGIT was superior to solid media (although not significantly; P > 0.05) in detecting AFB but was inferior to the BACTEC system (P < 0.01) . The mean time to the detection of M . tuberculosis complex was 9.9 days with MGIT, 9.7 days with BACTEC, and 20.2 days with solid media . NTM needed, on average, 11.9, 13.0, and 22.2 days to appear by the three methods, respectively . In conclusion, MGIT proved to be a valuable alternative to the radiometric cultivation system. J Urol, 1997 Feb, 157(2), 492 - 8 Evolution and clinical significance of the T cell proliferative and cytokine response directed against the fibronectin binding antigen 85 complex of bacillus Calmette-Guerin during intravesical treatment of superficial bladder cancer; Zlotta AR et al.; PURPOSE: The antitumorigenic effect of intravesical bacillus Calmette-Guerin (BCG) in superficial bladder cancer was reported to be initiated by the attachment of BCG to the bladder wall via fibronectin . The antigen 85 complex secreted in BCG culture filtrate binds specifically to fibronectin and is a powerful T cell stimulus . Therefore, we investigated the evolution and clinical significance of the cellular proliferative response and cytokine production during intravesical BCG therapy against this purified antigen 85 complex . MATERIALS AND METHODS: Evolution of the lymphoproliferation, interleukin-2 and interferon-gamma production of peripheral blood lymphocytes against tuberculin (purified protein derivative), purified antigen 85, BCG culture filtrate, whole BCG bacilli and pokeweed mitogen was tested before and after 6 weekly intravesical BCG instillations in 29 patients with superficial bladder cancer at intermediate or high risk for recurrence . RESULTS: A major increase in the lymphoproliferative response against purified protein derivative, antigen 85, BCG culture filtrate, whole BCG and pokeweed mitogen was observed in 69.0, 65.5, 79.3, 48.3 and 65.3% of the patients, respectively, analyzed after BCG therapy . Reactivity returned to baseline values at 6 months of followup . Of the patients who received a second BCG course because of tumor recurrence 66% had a novel increase in lymphoproliferation against antigen 85 . An increase in the production of interleukin-2 and interferon-gamma by peripheral lymphocytes against antigen 85 was noted in 42.1 and 50% of the treated patients, respectively, after a single BCG course . During a mean followup of 23.11 months 48.5% of the patients remained tumor-free . No correlation could be found between the immunological response against any of the BCG antigens and the clinical evolution of the response . CONCLUSIONS: Intravesical BCG instillations induce a transient (less than 6 months) peripheral immune activation against several purified BCG antigens and among them the fibronectin binding antigen 85 complex . Reactivation is observed in most cases after additional BCG courses . The absence of long lasting immune activation after a single 6-week course of BCG could be related to the increased clinical efficacy observed with BCG maintenance instillations. Schweiz Rundsch Med Prax, 1997 Jan 21, 86(4), 98 - 101 {Therapy of spontaneous bacterial peritonitis}; Grater H; The outcome of untreated spontaneous bacterial peritonitis (SBP) is fatal . In the onset of SBP clinical manifestations may be subtle, therefore every patient with hepatogenic ascites has to be examined for SBP at admission . If polynuclear cell count in ascitic fluid exceeds 250/microliter, antibiotic therapy has to begin immediately, until irreversible complications develop . Aerobic gram-negative bacilli of the normal intestinal flora are responsible for most cases of SBP, followed by gram-positive organisms and anaerobes . Antibiotic agents with extended spectrum, such as third-generation cephalosporins are considered the drugs of choice for SBP . In severe cases combination with metronidazole is recommended . As soon as repeated paracenteses show polynuclear cells beyond 250/microliter, the antibiotic therapy can be stopped . Selective decontamination of the gut with norfloxacin is effective to prevent SBP in high-risk patients . Trimethoprim-sulfamethoxazole is superior due to its activity even against gram-positive organisms . Overall prognosis of patients with SBP, however, is determined mainly to complications specific for cirrhosis, e.g . variceal bleeding, coma etc. Dtsch Med Wochenschr, 1997 Jan 17, 122(3), 51 - 3 {Cervical lymphadenitis in an immunocompetent patient: Mycobacterium gordonae as the cause?}; Fleisch F et al.; HISTORY AND FINDINGS: A 76-year-old man went to an ENT outpatient clinic because of stabbing pain in the left throat and difficult swallowing . He was found to have tonsillitis on the left and cervical lymphadenitis . The symptoms regressed on treatment with amoxycillin and clavulanic acid, but the cervical lymphadenitis persisted . Fine-needle biopsy of the cervical swelling was not diagnostic . Computed tomography of the neck showed an encapsulated liquid space-occupying lesion with infiltration of surrounding soft tissues . TREATMENT AND COURSE: The cervical lymph-node mass was excised and histologically found to contain epithelioid granulomas with a few giant cells and scattered centrally caseous necroses . Tuberculostatic treatment was started; drainage fluid from the wound grew acid-fast bacilli, identified by gene probe as Mycobacterium gordonae . CONCLUSIONS: Mycobacterium gordonae is ubiquitous in the environment and is being identified ever more frequently in microbiological laboratories, usually as contaminant . It rarely causes infections of soft tissues and the lungs or systemically. Lancet . 1997 Jan 4;349(9044):31. Finger clubbing and HIV infection in Malawian children; Graham SM et al.; PIP: While it is unusual for children to present with finger clubbing, the authors began to frequently see such cases in the University of Malawi's Department of Pediatrics, College of Medicine . Clubbing was recognized in 52 children during February-May 1996 . An 8-year-old boy died with a diagnosis of endomyocardial fibroelastosis . The remaining 51 children were aged 4 months to 12 years of mean age 37 months . 26 of the 31 children tested for infection with HIV were HIV-ELISA seropositive . A clinical diagnosis of pediatric AIDS according to the World Health Organization criteria was made in 35 cases . A provisional diagnosis of pulmonary tuberculosis was made in 29 . Two of the older children had acid-fast bacilli in sputum; one was HIV-positive . Digital clubbing in Malawian children may be associated with chronic lung disease and HIV infection, presenting as early as infancy . In regions where childhood HIV infection is common and resources are scarce, clinical findings which improve diagnostic specificity could prove useful . Bull Soc Pathol Exot, 1997, 90(2), 75 - 7 {A case of Mycobacterium shimoïdei lung infection in Madagascar}; Auregan G et al.; In 1980, a 32 years-old Madagascan female developed a pulmonary tuberculosis, bacteriologically confirmed . She cured with right apical cavitary sequellae . In 1989, she presented haemoptysis again . Antituberculous treatment was adopted without bacteriological confirmation and did not improve clinical symptoms . In 1991 and 1992 cultures from sputa and bronchi aspiration yielded acid-fast bacilli identified as Mycobacterium shimoidei . M . tuberculosis could not be detected . The patient died during treatment . This case is the fourth one in the literature . Whereas previous cases have been reported in Europe, Australia, Asia, this new case shows M . shimoidei is also present in Africa. J Gynecol Obstet Biol Reprod (Paris), 1997, 26(4), 367 - 73 {Peritoneal tuberculosis . Value of laparoscopy}; Kasia JM et al.; We report 6 cases of tuberculous peritonitis, focusing on the contribution of laparoscopic exploration . The initial diagnosis was erroneus in all cases: the polymorphous clinical presentations suggested another infectious disease or cancer disease . Laparoscopy was performed in 5 patients who had ascitis and in 1 with plastic peritonitis . At laparoscopy, the peritoneum showed miliary granulations and inflammatory adherences on the visceral or parietal sheats . Bacteriological analyses of the ascitic fluid were positive in only one case . The diagnosis was confirmed after culture of biopsy specimens and identification of the Kock bacilli or on the basis of objective evidence of an epithelioid giant-cell granuloma with caseous necrosis . Outcome was favorable after appropriate antibiotic therapy. Respiration, 1997, 64(4), 300 - 3 Pulmonary infection due to Mycobacterium gordonae in an adolescent immunocompetent patient; Resch B et al.; We report the case of 17-year-old male adolescent immunocompetent patient with an operated transposition of the great arteries after the Mustard technique admitted to our hospital because of a cough and hemoptysis . Two nodules and an area of ground glass appearance located in the lower lobe of the left lung were diagnosed by ultrafast computed tomography (UF-CT) after ruling out cardiovascular complications . The gastric aspirate revealed acid-fast bacilli despite a repeatedly negative tuberculin skin test identified as Mycobacterium gordonae by the Gen-Probe Rapid Diagnostic Test . After an initial standard antimycobacterial therapy with isoniazid, rifampin and pyrazinamide the therapy was changed to clarithromycin and after a treatment course of 14 days, the UF-CT revealed a normal scan of both lungs . The case described suggests that one has to consider M . gordonae as a rare cause of infection even in immunocompetent patients. Scand J Infect Dis, 1997, 29(3), 297 - 300 Influence of low dose ciprofloxacin on microbial colonization of the digestive tract in healthy volunteers during normal and during impaired colonization resistance; van de Leur JJ et al.; Ciprofloxacin in low doses is, in volunteers, effective for decontaminating the digestive tract {elimination of aerobic Gram-negative bacilli (GNB)} without disturbing colonization resistance . Before using this concept in neutropenic patients, we investigated if a low dose quinolone is still effective when the colonization resistance is disturbed by another antimicrobial agent . Ciprofloxacin 20 mg daily was effective in eliminating Gram-negative bacilli from the digestive tract in 4/5 volunteers, in 1 volunteer the GNB persisted in low concentration . No colonization with exogenous resistant GNB occurred . Following impairment of colonization resistance by addition of clindamycin 300 mg daily, 3/5 volunteers became colonized by spontaneously acquired exogenous GNB resistant to ciprofloxacin . We conclude that selective decontamination with a quinolone in low dosage cannot be recommended in neutropenic patients because there is, in the case of disturbed colonization resistance, a real risk of acquisition of quinolone-resistant strains. J Hepatol, 1997 Jan, 26(1), 88 - 95 Spontaneous bacterial peritonitis in patients with cirrhosis undergoing selective intestinal decontamination . A retrospective study of 229 spontaneous bacterial peritonitis episodes; Llovet JM et al.; BACKGROUND/AIMS: Selective intestinal decontamination with norfloxacin is widely used to prevent spontaneous bacterial infections in cirrhosis . The study was performed to compare the spontaneous bacterial peritonitis occurring in patients with and without prophylactic norfloxacin . METHODS: Two hundred and twenty-nine consecutive episodes of spontaneous bacterial peritonitis, (193 in patients without (Group A) and 36 in patients with norfloxacin prophylaxis (Group B)), were retrospectively analyzed . In 100 episodes (86 and 14, respectively), the responsible organism was isolated in ascitic fluid . RESULTS: Clinical and laboratory data at diagnosis were comparable in both groups . There were marked differences (p < 0.001) between group A and B in the frequency of peritonitis caused by gram-negative (67.4% vs . 14.3%) and gram-positive (30.2% vs . 78.6%) bacteria . There were three polymicrobial episodes . Bacteria resistant to cefotaxime and gram-negative bacilli resistant to quinolones were isolated in ascitic fluid in nine (seven in Group A and two in Group B) and three episodes (all in Group A), respectively . No differences in the course of infection and patient survival were observed between groups . CONCLUSIONS: Spontaneous bacterial peritonitis in patients with and without prophylaxis with norfloxacin are not different in clinical features, response to treatment and prognosis . Spontaneous bacterial peritonitis caused by gram-negative organisms resistant to quinolones is extremely uncommon in patients with cirrhosis receiving prophylactic norfloxacin. Indian J Pathol Microbiol, 1997 Jan, 40(1), 51 - 4 Cultivation of Mycobacterium tuberculosis from pleural tissue and its histopathology in suspected cases of tuberculous pleural effusion; Katiyar SK et al.; The majority of idiopathic pleural effusion are considered to be of tuberculous etiology . The culture of bacilli provide most authentic evidence of disease process . This study was carried out on 21 cases of suspected tuberculous pleural effusion . The pleural fluid and tissue was subjected for smear examination, and cultivation of tubercle bacilli along with pleural biopsy . Overall the diagnosis could be made out of 8 (38.09%) cases . The cultivation of Mycobacterium tuberculosis from pleural tissue was more sensitive (33.33%) as compared to histopathology (19.05%) . However, the triad of cultivation of Mycobacterium tuberculosis from pleural tissue, pleural histopathology and pleural fluid smear examination or culture should be done in each suspected case of tuberculous effusion. Z Kardiol, 1997 Jan, 86(1), 15 - 9 {Isolated tuberculosis of the heart: a clinical and echocardiography follow-up}; Immer FF et al.; A case of isolated right ventricular myocardial tuberculoma with pericardial effusion is presented . The diagnosis of myocardial tuberculoma was initially suggested by echocardiography and later by magnetic resonance imaging . The diagnosis of cardiac tuberculosis was confirmed by demonstration of tubercle bacilli in the pericardial fluid . This is a very rare condition which is usually diagnosed only by necropsy . Myocardial tuberculoma should figure on the list of intraparietal masses visualized at echocardiography. Mikrobiologiia, 1997 Jan-Feb, 66(1), 42 - 9 {Formation of resting cells in microbial suspensions undergoing autolysis}; Muliukin AL et al.; Under experimentally selected conditions favoring spontaneous or induced autolysis of cell suspensions, the asporogenous bacteria Escherichia coli and Methylococcus capsulatus, the bacilli Bacillus cereus (under conditions of suppressed sporulation), and the yeast Saccharomyces cerevisiae were shown to be capable of forming cystlike resting cells . Their number was influenced by (1) cell density in the suspensions; (2) the presence of Ca2+ ions in nutrient-limited medium; (3) pH of medium; and (4) autolysis rate, dependent on the concentration of oleic acid (a chemical analogue of the autolysis-inducing d2 factor) introduced into the cell suspensions. Surg Today, 1997, 27(5), 447 - 9 Bacterial translocation as a cause of septic shock in humans: a report of two cases; Tani T et al.; While bacterial translocation has been reported to occur under numerous conditions in animal models, there has been no paper to date focusing on bacterial translocation as a direct cause of septic shock in humans . We present herein the cases of two patients who developed septic shock believed to have been directly caused by bacterial translocation . Neither of the patients had a focus of infection, the intestinal walls were intact in gross appearance, and the peritoneal cavity had not been contaminated by surgery . Moreover, in both patients, the same organisms were detected in the blood, ascites fluid, and mesenteric lymph nodes, and bacilli were found in the intestinal wall. Ann Biol Clin (Paris), 1997 Jan-Feb, 55(1), 33 - 5 {Isolation of Escherichia vulneris in drinking water}; Le Querler L et al.; Over a 2-year period, we performed 33 bacteriological controls of drinking water supplied by refrigerated fountains located in a nursing home . Amongst 24 strains of gram-negative bacilli isolated from 16 samples . 10 were identified as belonging to the species Escherichia vulneris . Viable bacterial counts were always less than 10 ufc/100 ml . During the same period no clinical isolate of E . vulneris was recovered from the nursing home . The signification of E . vulneris in drinking water is unknown . However, considering that E . vulneris has been implicated as cause of various infections, its presence in potable water supply systems would seem to be a potential risk factor for severely immunocompromised patients. Eur Urol, 1997, 31 Suppl 1, 31 - 41 BCG update: intravesical therapy; Martinez-Pineiro JA et al.; BCG is currently the most active immunotherapy agent for intravesical use and is considered the first-line treatment for patients with aggressive T1 G3 and Tis superficial tumors of the bladder . Its main drawback, toxicity, is being addressed by several prospective studies that try to find the lowest active dose and optimal schedule, as well as by studies investigating the efficacy of antigenic bacterial fractions, devoid of the toxicity of the living bacilli . Efforts to improve the efficacy by combination with chemotherapy and biomodulating natural remedies are also under way . In this review we discuss: (1) the indications, limits and contraindications of BCG; (2) the efficacy; (3) the strains; (4) route of administration; (5) dose; (6) schedule; (7) the problem of toxicity, and (8) how to improve BCG therapy. Nihon Kyobu Shikkan Gakkai Zasshi, 1997 Jan, 35(1), 61 - 6 {Tuberculosis in the crew of a submarine}; Suzuki S et al.; We report the apparent spread of mycobacterial tuberculosis among a submarine crew from a crew member with a low grade of infectivity . The air-conditioning system of submarines requires completely closed recirculation of ambient air . If a person with pulmonary tuberculosis were in a submarine, one would expect to find a high incidence of tuberculosis among others on the ship . The index patient was a 35-year-old member of a submarine crew . An abnormal shadow was found on a chest roentgenogram during an annual medical checkup, and he was hospitalized for examination . Acid-fast bacilli were found in his gastric secretions, but he did not complain of coughing and no tuberculosis bacilli were found in his sputum . All members of the submarine crew were examined, and some who were on board with the index patient reacted strongly . Because those who were also suspected to be infected were usually not close to the index patient's living quarters and had little contact with the patient in the submarine, we strongly suspect that the closed ventilation system contributed to the spread of the infection . Control of tuberculosis in a sealed environment requires detailed investigation of the environment and completion of chemoprophylaxis . Adequate ventilation and ultraviolet radiation are more effective than decontamination with disinfectants for the control of infectious droplet nuclei . Ships should be equipped with those systems. Respir Med, 1997 Jan, 91(1), 21 - 9 Immunotherapy with Mycobacterium vaccae in the treatment of tuberculosis in Romania . 2 . Chronic or relapsed disease; Corlan E et al.; In this study of 102 patients with culture-positive chronic treatment failure or repeatedly relapsed pulmonary tuberculosis receiving chemotherapy, 56 received an injection of killed Mycobacterium vaccae as immunotherapy after 1 month of treatment . At the start of treatment, there was little difference between those receiving immunotherapy and the 46 patients in the control group receiving chemotherapy alone . Thereafter, the two groups diverged so that 1 yr later, 43 of 56 (77%) patients receiving M . vaccae had a successful outcome, in comparison with 24 of 46 (52%) patients receiving chemotherapy alone (P < 0.02) . Successful results were obtained from patients infected with drug-resistant bacilli, 20 of 32 (63%) patients compared with 11 of 25 (44%) patients, respectively, as well as from fully drug-sensitive cases (23 of 24 compared with 12 of 21 patients; P = 0.004) . At the final follow-up after 22 months, 13 of 56 patients receiving immunotherapy had an unfavourable outcome compared with 26 of 46 members of the control group (P = 0.0006) . During the study, 16 patients died of tuberculosis (six after immunotherapy), and 12 were lost to follow-up . Not only was bacteriological success improved by immunotherapy, chest X-ray showed markedly better resolution of cavities and other radiological lesions, recovery of body weight was improved, and the mean erythrocyte sedimentation rate returned almost to normal (P < 0.001) in comparison with those receiving chemotherapy alone . These changes were seen even in those failing bacteriological cure, suggesting that the immunotherapy had been effective, but that bacilli were replicating in an extracellular situation, protecting them from its effects. Respir Med, 1997 Jan, 91(1), 13 - 9 Immunotherapy with Mycobacterium vaccae in the treatment of tuberculosis in Romania . 1 . Newly-diagnosed pulmonary disease; Corlan E et al.; In this study, 206 previously untreated patients with sputum culture positive pulmonary tuberculosis were randomized to receive an injection of killed Mycobacterium vaccae as immunotherapy, or of saline as placebo, after 1 month of a 6-month chemotherapeutic regime . Not surprisingly in a disease for which there is good chemotherapy, the difference in numbers which were culture negative at the end of treatment was small, and the final outcome at the latest post-treatment follow-up did not reach statistical significance between the two arms of the study . Nonetheless, those receiving immunotherapy showed better progression in every parameter measured, suggesting faster and more complete cure . Whereas seven of 97 patients receiving immunotherapy required a course of re-treatment and five still had active disease after a mean follow-up of 2 yr, 13 of 109 placebo recipients required re-treatment and nine still had active disease at the end of the study . Only one patient receiving M . vaccae plus chemotherapy died of tuberculosis, compared with four of those receiving chemotherapy alone . A degree of drug resistance was shown by the bacilli cultured from 25 of 175 (14%) patients, and seven of them (4.0%) were multi-drug resistant . Fourteen patients received immunotherapy of whom 13 were cured, including all three of those showing multi-drug resistance . Of the 11 patients with drug resistance in the control group, eight were cured, and one patient with multi-drug-resistant disease died of tuberculosis during re-treatment. J Submicrosc Cytol Pathol, 1997 Jan, 29(1), 85 - 90 Subcellular localization of the 65-kDa heat shock protein in mycobacteria by immunoblotting and immunogold ultracytochemistry; Esaguy N et al.; The 65-kDa heat shock protein (hsp65) is an immunodominant antigen in mycobacterial infections and also the key etiologic factor in mycobacteria-induced autoimmune arthritis . Because the subcellular distribution of hsp65 in the mycobacteria may be relevant to understand its immunoreactivity, we have investigated the presence of hsp65 in the envelope and cytoplasmic compartments of the bacilli . Anti-hsp65 antibodies were used in western blottings to investigate the presence of hsp65 in cell fractions (membrane, envelope and cytosol) of Mycobacterium avium and M . smegmatis, and also to label hsp65 in situ by the immunogold method on thin-sectioned mycobacteria, including the non-cultivable M . leprae, that were studied by transmission electron microscopy . All of the three subcellular mycobacterial fractions showed significant labelling by anti-hsp65 antibodies . Immunogold ultracytochemistry revealed the presence of hsp65 in both the cytoplasm and the envelope of mycobacteria . The data indicate that hsp65 molecules are commonly present not only in the cytoplasm but also in the envelope of mycobacteria . The latter topography of hsp65 may contribute to the strong immunogenicity of hsp65 since it may correspond to export hsp65 molecules captured before being secreted into the extracellular milieu, thus making hsp65 a mycobacterial antigen readily available for presentation to the immune system of infected hosts. Acta Derm Venereol, 1997 Jan, 77(1), 49 - 51 Histopathological and bacteriological findings in prurigo nodularis; Mattila JO et al.; Prurigo nodularis is a chronic disease with unknown aetiology . Biopsy specimens of 43 patients with prurigo nodularis were taken for histopathological and mycobacteriological analyses . By conventional histopathology, 25 (58%) samples, and by immunostaining for S100 protein, 31 (72%) samples had changes relevant to prurigo nodularis . Twelve (28%) of the samples were positive for acid fast bacilli in tissue staining by Ziehl-Neelsen technique, including 4 of the 6 samples also positive for mycobacteria in cultivation . The results verified the usefulness of S100 staining in detection of neural hyperplasia in dermal nerves, a feature regarded as diagnostic for prurigo nodularis . They also indicated that atypical mycobacteria may be a contributing factor in prurigo nodularis. Infection, 1997 Jan-Feb, 25(1), 60 - 2 Diagnosis of tuberculosis and other diseases caused by mycobacteria; Salfinger M; The adequate diagnosis and treatment of tuberculosis depends on many events, including rapid pathogen detection, patient isolation, species identification, and drug susceptibility testing . Well trained staff, using state-of-the-art technology, are necessary in the mycobacteriology laboratory to produce timely results that are necessary for the patients' care and public health measures . Mycobacteriology laboratories still play a pivotal role in the control of tuberculosis, which is especially true in view of the spread of multidrug-resistant tuberculosis . One way to optimize diagnostic efforts in spite of limited financial resources might be to sort and allocate specimens according to a system of priorities, e.g., diagnostic versus follow-up specimens . A "fast track" program for tuberculosis testing, which should be established as part of a dynamic diagnostic network, should focus on the highly infectious patient population . Collaboration between clinicians and mycobacteriologists remains the basis of dynamic diagnostic teamwork . Immediate screening of smears for acid-fast-bacilli in patients suspected of tuberculosis, followed by immediate processing of smear-positive specimens using modern mycobacteriological technology, should be given high priority . Diagnosis of disease due to nontuberculous mycobacteria can be difficult . Nontuberculous mycobacteria are commonly found in nature, and assessment as to whether a nontuberculous mycobacterium isolate is clinically significant can be a difficult task. Kekkaku, 1997 Jan, 72(1), 53 - 6 {The indication of surgical management in patients with pulmonary disease caused by Mycobacterium avium-intracellulare complex}; Maekura R; The surgical management of patients with nontuberculous Mycobacteriosis caused by Mycobacterium avium complex (MAC) was studied regarding the following cases: (1) We investigated whether there had been an appropriate time for surgical management of patients with MAC who had not responded to medication and who died after their conditions became worse retrospectively . During the past 10 years, 49 patients diagnosed with MAC died at the Toneyama national hospital . 26 patients of them died of respiratory failure, apparently due to the worsening of MAC . Excluding 2 patients who were extremely elderly, we investigated whether surgical management could have been applied in the remaining 24 patients . We found that surgical management would have been possible in only one patient, and that at the time of diagnosis of MAC in 23 patients, surgical management was already not possible . (2) There are patients with MAC who do not respond to medication and who continue to excrete bacilli, chest X-ray findings gradually become worse for several years . In 1989 we retrospectively studied chest X-ray findings from MAC patients and found that 36 out of 103 patients (35%) showed worsening chest X-ray findings . The strains were identified in 44 of the 103 patients by the DNA probes method . However, of 37 patients with M.avium (41%), 15 had worsening of chest X-ray findings, while none out of 7 patients with M . intracellulare had worsening of chest X-ray findings . We then observed the clinical course of 37 patients who showed continuous excretion of bacilli and whose serotypes had been identified (20 with serovars 4, 1 with serovars 6, 6 with serovars 8, 2 with serovars 12, 4 with serovars 14 and 5 with serovars 16) by using the fast-atom bombardment mass spectrometry (FAB/MS) . Chest X-ray findings later worsened in 14 (70%) of 20 patients with serovars 4 . Nine of these patients have since died; excluding one patient who had liver cancer, eight died of respiratory failure due to worsening of MAC . In 17 patients with serotypes except serovars 4, 4 (24%) patients had worsening of chest X-ray findings, but none of the 5 deaths in this group were due to respiratory failure owing to worsening of MAC . These results suggest that it is difficult to establish the indication of surgical management in MAC patients, except for patients with repeated hemoptysis at present . The prognosis and surgical management of pulmonary disease caused by M . avium complex should be considered. Kekkaku, 1997 Jan, 72(1), 39 - 42 {The role of surgery for chronic empyema of the advanced ages}; Iuchi K et al.; Chronic empyema, a sequelae of pulmonary tuberculosis, is now a only tuberculosis-related disease which was remained to be treated surgically . The candidates who have basically poor respiratory function are now attained advanced age . Over a 15 years period (1980-95), 22 patients 70 years of age or older underwent surgical intervention for chronic empyema at our hospital . There were 17 men and 5 women, ranging from 70 to 80 years of age (median age 75.0) . They were 15.3% of all 145 surgically treated patients during same period . The empyema continued latent from 25 to 58 years (average 39.8 years) . On admission they complained of productive cough (9), fever (9), hemosputam (5) and mass on the chest wall . Their Hugh-Johnes classification for dyspnea was I.: 4, II.: 6, III.: 11, IV.: 1 respectively . Their %VC ranged from 31.5 to 79.0 (average 54.8) . In fifteen patients, tubercle bacilli (5), aspergillus (3) and other bacteria (9) were discovered in the empyema space . Surgical procedures consisted of 1 pneumonectomy (4.5%), 12 decortication or curettage of empyema wall (54.5%), 4 extraperiosteal air plombage (18%) and 5 other procedures (muscle or omental plombage, thoracoplasty, fenestration and others) (22.7%) . There were no operative death and no lethal postoperative complication . In contrast, lethal postoperative complications such as GVIID, MOF and gastrointestinal bleeding occurred in the younger group . There were 2 cases of late respiratory failure in 70 years or older and 6 cases in younger group . Seventy-four years man who, preoperative %VC 33.0, underwent pneumonectomy died of asphyxia 6 month postoperatively . Another 74 years man who, preoperative %VC 76.1, developed respiratory failure after relapse of pulmonary tuberculosis . Four patients of younger group who developed late respiratory failure had all received thoracoplasty as a second operation . Other 2 patients, preoperative %VC 33.0 and 27.4 respectively, had undergone pneumonectomy . The risk of lethal postoperative complication or late respiratory failure were dependent mainly on preoperative respiratory function or surgical procedure selected rather than the age of patients. Kekkaku, 1997 Jan, 72(1), 35 - 8 {Surgically unsuccessful cases with pulmonary tuberculosis}; Yano M et al.; Because of the development of effective drugs, surgical treatment for pulmonary tuberculosis has decreased in recent years, but there are some cases which require surgical operation in patients with drug resistant tuberculosis . Between 1979 and 1994, 52 patients with pulmonary tuberculosis underwent surgical operations for the negative conversion of drug resistant bacilli . Pulmonary resection was the principal procedure and when a patient was not tolerant to this procedure, thoracoplasty or cavernostomy was selected . Continuation of bacilli positive sputum after the operation was seen in 12 cases (23.1%) . The main causes of the failure were multiple drug resistance and remaining lesions . The unsuccessful rate in the patients with bacilli completely resistant to all of the 5 main drugs (SM, KM, INH, RFP, EB) was extremely high amounting to 57.1% . When 2 or more of the 5 main drugs were effective, the unsuccessful rate was 11.1% . A total of 21 cases had tuberculous lesions remaining in the lung postoperatively, because of bilateral lesions or poor lung function . In such cases, the unsuccessful rate was 42.3% . In the 31 cases that had no remaining lesion, the rate was 9.7% . There was no unsuccessful case in the patients who had 2 or more effective drugs and no remaining lesion . We reoperated on 6 patients and 5 of them got negative conversion . In the 2 of other patients who didn't undergo reoperation, their sputum became negative after long term postoperative chemotherapy, and the other 2 patients had only a few bacilli in ther sputum postoperatively . Nine cases were able to return to normal daily life. Kekkaku, 1997 Jan, 72(1), 25 - 34 {Surgical treatment of multidrug resistant pulmonary tuberculosis cases}; Nakajima Y; We report on the results of surgical treatment of pulmonary tuberculosis cases intractable to ordinary therapy due to acquired drug-resistance against multiple anti-tuberculosis drugs (MDR-Tbc) . MATERIAL AND METHOD: From 1983 to 1994, 54 patients were administered surgical treatments (60 interventions in all) for pulmonary tuberculosis . Among them, 46 were MDR Tbc cases (52 interventions in all) and were enrolled for this study . The Japanese criteria for drug resistance were referred to, the threshold of resistance in each drug being as follows, INH 0.1, RFP 50, EB 2.5, SM 20, KM 100, TH 25, EVM 100, CPM 100, CS 40, PAS 1 microgram/ml . Bacteriological examinations of sputa were repeated in the postoperative period until upto several years, and the continued absence of Tbc . bacilli for more than 12 months was considered as cured . RESULTS: (1) 37 patients underwent removal of lung mass including tuberculous foci mainly fibrous cavitary lesions (40 interventions in all) . The procedures are as follows 22 upper lobectomies and/or partial resections of adjacent lobes . 1 middle lobectomy . A lower lobectomy, 14 pneumonectomies, 2 segmentectomies . In 3 cases, multiple operations were carried out on 2 occasions; 2 upper lobectomies followed by completion pneumonectomies . 1 right upper lobectomy followed by left S3 segmentectomy . Except 2 cases having died of pneumonia and suicide within 12 months after operation, we have 38 cases available for evaluation . Bacteriological relapses were confirmed in 7 among 38 cases postoperatively . 2 of these 7 relapsed cases underwent additional completion pneumonectomies and attained complete cure . Bacteriological relapse-rate was therefore 18.4% (7/38) and the ultimate cure rate of pulmonary MDR-Tbc was 88.6% (31/35) . (2) 7 patients underwent thoracoplasties (not corrective, once for each patient) . In 2 cases bacteriological relapse was confirmed . Other 5 cases remained bacteriologically silent over a long postoperative period . (3) 4 patients underwent cavernostomies, 3 of them got satisfactory result in reducing the bacterial presence in the sputum (preoperative abundant bacilli (Gaffky 7, 8) turned mean-negative within 2 months after cavernostomy) . CONCLUSION: With the above-mentioned results we conclude that surgical treatment is highly effective in intractable pulmonary MDR Tbc cases. Kekkaku, 1997 Jan, 72(1), 15 - 20 {2 cases of lung disease caused by Mycobacterium avium complex occurred in middle-aged women without underlying disorders, which we observed for more than 30 years}; Takakura S et al.; We reported 2 cases of Mycobacterium avium complex lung disease occurred in middle-aged women without underlying disorders, which we could observe for more than 30 years . One case was a 42-year-old woman started with bloody sputum, and the other was a 43-year-old woman with cough and sputum . In both cases, chest X ray films were normal on their first visit . More than 15 years after their first visit, Mycobacterium avium complex was isolated from their sputum or bronchial washing . During the observation, a cluster of small nodules in the periphery of the lung and bronchiectasis appeared and deteriorated, and excretion of the bacilli increased gradually . Their past history and family history were normal . Since lung disease caused by Mycobacterium avium complex progresses very slowly, long-time observation would be necessary to consider its pathogenesis. Kekkaku, 1997 Jan, 72(1), 9 - 13 {The combination of amoxicillin-clavulanic acid and ofloxacin in the treatment of multidrug-resistant Mycobacterium tuberculosis}; Iwanaga T et al.; A 67-year-old {correction of 53} man with multidrug resistant tuberculosis (MDR-TB) had been persistently positive for acid-fast bacilli (AFB) both on sputum smear and also on culture with the Ogawa egg medium for 30 years since 1951 . The case had been treated previously with isoniazid, rifampin, streptomycin, ethambutol, kanamycin, ethionamide, paraaminosalicylate and cycloserine; however, M . tuberculosis strains isolated from this patient acquired a high resistance to all of these agents . Then, a new regimen of chemotherapy, INH combined with ofloxacin (OFLX) and amoxicillin-clavulanic acid (AMPC/ CVA), was applied to the case . He was successfully treated with this regimen, and a marked decrease in the amount of AFB on smear as well as on culture was observed during the course of chemotherapy . No adverse effects were seen meanwhile . These data suggest that it is worth while to try a regimen containing AMPC/CVA and OFLX in the treatment of MDR-TB. Kekkaku, 1997 Jan, 72(1), 1 - 7 {The clinical study of clarithromycin for pulmonary Mycobacterium avium-intracellulare complex infection}; Yamamoto M et al.; A nationwide study was conducted to investigate the efficacy of Clarithromycin (CAM) on pulmonary atypical mycobacteriosis caused by the Mycobacterium avium-Mycobacterium intracellulare complex, including intractable cases . Out of total 97 patients examined, the analysis for bacteriological efficacy was possible in 69 cases . The negative conversion of bacilli was observed in 18 cases (26.1%), and 5 out of 12 cases in which the follow-up was conducted turned out continued negative status . The efficacy of CAM was relatively high in the following cases: the duration of the disease was less than 6 months the extent of pulmonary lesions on chest roentogenograms was limited or moderate; and antituberculous agents which were previously unused were applied in combination with CAM . Also, the efficacy was high in cases where the dose of CAM was 600 mg/day or higher . Major side effect was mill to moderate digestive symptoms . In conclusion, at daily dose of 600 mg or higher, CAM was effective in the elimination or reduction of M avium M . intracellulare complex that caused atypical mycobacteriosis, without developing serious side effect . Treatment with this drug should be attempted in intractable cases. Immunol Invest, 1997 Jan-Feb, 26(1-2), 105 - 16 Critical assessment of gene amplification approaches on the diagnosis of tuberculosis; Forbes BA; The resurgence of tuberculosis prompted the development of a number of new options for the rapid laboratory diagnosis of Mycobacterium tuberculosis (MTB) . One of the most promising and exciting methodologies has been the introduction of assays employing amplification technology to detect MTB directly in clinical specimens . Although amplification assays hold significant promise to improve the laboratory diagnosis of tuberculosis, the decision to perform or not perform these assays is complicated . The performance of in-house polymerase chain reaction (PCR) assays and two commercially-prepared assays . GenProbe's AMTD test and Roche's AMPLICOR PCR assay are reviewed . Regardless of the amplification format, all assays have decreased sensitivity with specimens that are acidfast bacilli (AFB) stain-negative . Data from these studies and others indicate possible potential pitfalls of amplification assays, those being sampling errors, the presence of substances in clinical specimens that inhibit the amplification assay, and clinical utility . In light of these findings, the possible roles for these assays in the clinical microbiology laboratory are reviewed . In addition, factors such as cost, assay performance, etc . are discussed in order to facilitate the decision-making process concerning whether an amplification assay would be appropriate in a particular laboratory setting. Infect Control Hosp Epidemiol, 1997 Jan, 18(1), 28 - 31 Correlation between frequency of tuberculosis and compliance with control strategies; Roy MC et al.; OBJECTIVE: To determine if compliance with annual tuberculosis skin testing correlated with the number of cases of tuberculosis seen in patients and healthcare workers . DESIGN: Survey using a written questionnaire . SETTING AND PARTICIPANTS: 159 Veterans' Administration facilities . RESULTS: Hospitals that reported that > 80% of their healthcare workers received annual skin tests saw 12.7 patient cases per 10,000 admissions and 4.0 healthcare worker cases per 10,000 personnel . Facilities in which < 20% of their healthcare workers were given annual skin tests saw 4.5 cases per 10,000 admissions and 1.6 cases in healthcare workers per 10,000 personnel (P < .001 for patients and P = .31 for healthcare workers) . The ratio of the median number of patients placed in acid-fast bacilli (AFB) isolation to the median number of patients with confirmed tuberculosis was 12 . There was no correlation of this ratio with the number of cases of tuberculosis in patients or healthcare workers seen in each facility . CONCLUSION: Compliance with annual tuberculosis skin testing was related directly to the rate of tuberculosis seen in patients . More standardized policies for placing patients in AFB isolation are needed to control for potentially costly variation among facilities . These measures should have highest priority in the control of tuberculosis in the healthcare setting, before implementing still more expensive interventions. Antimicrob Agents Chemother, 1997 Jan, 41(1), 17 - 23 Therapeutic efficacy of liposomal clofazimine against Mycobacterium avium complex in mice depends on size of initial inoculum and duration of infection; Kansal RG et al.; The therapeutic efficacy of liposomal clofazimine (L-CLF) against Mycobacterium avium complex (MAC) was evaluated in the acute and chronic infection models of the beige mouse (C57BL/6J bgj bgj) . The maximum tolerated dose of L-CLF was inversely proportional to the infection level . L-CLF showed higher antibacterial activity than free clofazimine . Treatment with 25 mg of L-CLF per kg of body weight (intravenously) was started at days 1, 8, 15, and 22 postinfection and was studied at three levels of MAC infection (10(4), 10(5), and 10(6) bacilli/mouse) . L-CLF treatment caused a significant (P < 0.05 to 0.001) reduction in the numbers of viable bacteria in lung, liver, and spleen at all infection levels, irrespective of time of treatment . However, the best results were obtained when an already established infection was treated (day 22) . The organ-related differences in response to the treatment were also affected by the level of infection . A marked reduction in the numbers of CFU was observed in the lungs of mice with lower infection levels, whereas liver and spleen were treated more efficiently at higher infection levels . These studies might help in evaluations of host responses to therapy. Infect Immun, 1997 Jan, 65(1), 305 - 8 Sequestration of Mycobacterium tuberculosis in tight vacuoles in vivo in lung macrophages of mice infected by the respiratory route; Moreira AL et al.; Following aerosol infection of mice with Mycobacterium tuberculosis, single mycobacteria or pairs of bacilli were observed within individual phagocytic vacuoles bound by tightly apposed vacuolar membranes . The virulent organism was not observed free in the cytoplasm of the parasitized cells or in the extracellular space of the lung granulomata . This study indicates that in vivo, virulent mycobacteria survive and probably replicate within a unique tight vacuole in the infected phagocyte within the lung. J Clin Microbiol, 1997 Jan, 35(1), 307 - 10 Direct detection of Mycobacterium tuberculosis complex in nonrespiratory specimens by Gen-Probe Amplified Mycobacterium Tuberculosis Direct Test; Gamboa F et al.; The Gen-Probe Amplified Mycobacterium Tuberculosis Direct Test (AMTDT) was adapted for the detection of Mycobacterium tuberculosis complex in 224 nonrespiratory specimens from 188 patients . The sensitivity and specificity of the AMTDT for such specimens, after resolution of discrepant results, were 85.7 and 100%, respectively . Pretreatment of nonrespiratory specimens with sodium dodecyl (lauryl) sulfate is mandatory to obtain consistent and reproducible AMTDT results . The use of 500 microliters of decontaminated specimen improves the sensitivity of the test . Because the AMTDT detects stable rRNA from noncultivable bacilli, it is not useful for monitoring patients receiving treatment. J Clin Microbiol, 1997 Jan, 35(1), 213 - 6 Comparison of identifications of human and animal source gram-negative bacteria by API 20E and crystal E/NF systems; Peele D et al.; This study compared the abilities of API 20E and BBL Crystal E/NF identification systems to correctly identify human and animal source gram-negative bacilli of known identifications, as provided by the American Type Culture Collection, Rockville, Md., and the Research Diagnostic and Investigative Laboratory, Columbia, Mo . Also addressed in the comparison are the cost, the relative ease of performing and interpreting the tests, and the potential problems surrounding each system . The two systems were comparable in terms of their respective costs and abilities to identify the bacteria tested . The cost per test was calculated as $4.69 for API 20E and $4.62 for Crystal E/NF . Of the animal source bacteria tested, Crystal E/NF identified 68% to the correct genus and species and 90% to the correct genus or group . The remaining 10% of the animal source bacteria were unidentified by Crystal . Human source bacteria tested by BBL Crystal E/NF gave very similar results: 47% correctly identified to genus and species, 90% correctly identified to genus or group, 7% unidentified, and 3% incorrectly identified . API 20E results were as follows for animal source bacteria: 53% correctly identified to genus and species, 76% correctly identified to genus or group, and 24% unidentified; the results for human source bacteria were as follows: 40% correctly identified to genus and species, 83% correctly identified to genus or group, and 17% unidentified . API 20E has a slightly more labor-intensive protocol for setting up the test than BBL Crystal E/NF but produced fewer questionable results. J Clin Microbiol, 1997 Jan, 35(1), 106 - 10 Rapid differentiation of bovine and human tubercle bacilli based on a characteristic mutation in the bovine pyrazinamidase gene; Scorpio A et al.; Bovine tuberculosis (TB) caused by Mycobacterium bovis is an important veterinary disease that can also afflict humans . Although M . bovis shares an almost identical genome with M . tuberculosis, subtle differences in host specificity and several biochemical parameters can be used to distinguish the two closely related species . The current method for distinguishing M . bovis from M . tuberculosis relies on tedious testing of biochemical parameters, including natural resistance to pyrazinamide and defective pyrazinamidase (PZase) activity of M . bovis strains . In this study, we report the development of a rapid PCR-single-strand conformation polymorphism (SSCP) assay to differentiate M . bovis from M . tuberculosis strains, based on the detection of a single characteristic point mutation in the PZase gene (pncA) of M . bovis . Eighty-seven of 89 M . bovis strains could be distinguished from M . tuberculosis strains . Surprisingly, two animal isolates which were initially identified as M . bovis were shown to be M . africanum because they had a wild-type pncA sequence with positive PZase . These two M . africanum strains contain multiple (three and six) copies of insertion sequence IS6110, a feature they have in common with M . tuberculosis . The implication of this finding for the taxonomy of M . tuberculosis complex is discussed in relation to host preference and epidemiology . The development of a rapid PCR-SSCP test for distinguishing M . bovis from M . tuberculosis will be useful for monitoring the spread of bovine TB to humans in areas where bovine TB is endemic and for directing the treatment of human TB caused by M . bovis. Schweiz Med Wochenschr, 1996 Dec 28, 126(51-52), 2241 - 3 {An unusual presentation of tuberculosis}; Lefkovits M et al.; A 67-year-old male was hospitalized because of nonspecific symptoms and bilateral pleural effusions . He gave no history of cough, dyspnea or thoracic pain . The blood counts showed moderate anemia and high-grade lymphopenia . The tuberculin test and the anergy-panel were both negative . Testing for HIV was negative . Analysis of pleural fluid showed an exudate with 47% lymphocytes and absence of acid-fast bacilli on Ziehl-Neelsen smear . On histologic examination, the pleural tissue showed no evidence of granuloma . However, cultures for mycobacteria of pleural tissue yielded M . tuberculosis . In this case of pleural tuberculosis, leading symptoms were absent and the tuberculin test was negative in the presence of active tuberculosis . In addition, the cells in the pleural effusion were not predominantly lymphocytic . Patients presenting with unclear effusion should undergo extensive investigations, including a tuberculin test, and anergy panel, pleural fluid cultures, and pleural biopsy with cultures for microorganisms, with the object of establishing or ruling out pleural tuberculosis. J Toxicol Environ Health, 1996 Dec 27, 49(6), 619 - 30 Effect of influenza virus infection on ovalbumin-specific IgE responses to inhaled antigen in the rat; Lebrec H et al.; Upper respiratory tract viral infections have been reported in clinical studies to serve as risk factors for allergic sensitization . In order to study the relationship linking influenza virus illnesses to development of allergy, murine models of allergen sensitization were previously employed . These models showed that lethal influenza viruses were able to trigger allergen-specific immunoglobulin E (IgE) production and to inhibit tolerance to repeated exposure to aerosolized allergen in the mouse . The disadvantage of these murine models consists in the utilization of virulant and lethal strains of influenza virus . A nonlethal rat-adapted influenza virus (RAIV) host resistance model has been developed in our laboratory . It was used to evaluate the effect of influenza virus infection on IgE responses to inhaled ovalbumin (OA) in the rat . The high IgE-responder Brown-Norway (BN) rat was chosen for further study after comparing the IgE response to OA in Fischer 344 (F344) and BN rats . On d 1, BN rats were sensitized by administration of 1 mg OA subcutaneously alone or together with aluminum hydroxide (200 mg) and Bordetella pertussis (15 x 10(9) killed bacilli per rat in 1 ml), or only received saline . Rats were either infected with RAIV or sham-infected on d 0 (24 h prior to sensitization) or on d 15, 17, or 57 . Rats were exposed for 3 min to aerosolized OA (OA 3% in phosphate-buffered saline) every week, starting on d 18 . Serum OA-specific IgE was evaluated by reverse enzyme-linked immunosorbent assay (ELISA) 3 d after each OA challenge . BN rats elicited a detectable OA-specific IgE response that decreased after repeated aerosol exposures . Influenza virus infection transiently increased the OA-specific IgE response when rats were immunized with OA alone and were infected 1 d prior to the first challenge and also when rats received only saline on d 1, were exposed each week to aerosolized OA, and were infected prior to the seventh challenge . These results, with data previously reported in mice, emphasize the importance of upper respiratory tract viral infection in increasing IgE responses to allergens and may be of importance in human disease. Southeast Asian J Trop Med Public Health, 1996 Dec, 27(4), 734 - 7 In vitro activity of cefoperazone-sulbactam: Singapore experience; Kumarasinghe G et al.; In vitro activity of commonly used antimicrobial agents against consecutively isolated 521 strains of Gram negative bacilli causing serious infections in the National University Hospital, Singapore were tested in parallel with cefoperazone-sulbactam combination . With the combination complete resistance of 2% and intermediate resistance of 5% were noted among the 521 strains tested . Resistance to imipenem was low (5%) but resistance against other antimicrobial agents varied from 12% (amikacin) to 80% (ampicillin) . In vitro data demonstrated a possible future role for cefoperazone-sulbactam in the treatment of sepsis caused by Gram negative bacilli in our hospital. Tuber Lung Dis, 1996 Dec, 77(6), 491 - 5 Combined effect of pyrazinamide and ofloxacin within the human macrophage; Sbarbaro JA et al.; SETTING: Recent reports of outbreaks of multidrug resistant tuberculosis have raised questions as to the most appropriate therapeutic response for those exposed to such organisms . A recent Centers for Disease Control National Action Plan suggests the combination of pyrazinamide (PZA) and a quinolone as a potential preventive therapy regimen . OBJECTIVE: Prior studies in the ex-vivo human macrophage model have shown PZA to have only a bacteriostatic effect and, in addition, to diminish the bactericidal effect of rifampin . This study was designed to quantify the intramacrophage antimycobacterial effect of PZA when combined with a quinolone (ofloxacin) . DESIGN: Forty micrograms/ml of PZA was combined with varying concentrations of ofloxacin and administered to human macrophages infected with virulent tubercle bacilli; drug sequencing was also studied . RESULTS: A clinically achievable level of PZA enhances the antimycobacterial effect of low, non-bactericidal levels of ofloxacin and does not impede the bactericidal effect of a higher clinically effective level of ofloxacin . Unlike the combination of PZA and rifampin, these interactive effects are not affected by the sequence of drug administration . CONCLUSIONS: Findings support the use of these agents as a potentially effective preventive therapy combination for individuals exposed to multidrug resistant tuberculous organisms. J Dermatol, 1996 Dec, 23(12), 883 - 9 Squamous cell carcinoma arising from lupus vulgaris on an old burn scar: diagnosis by polymerase chain reaction; Hagiwara K et al.; A 66-year-old Japanese woman with a squamous cell carcinoma (SCC) arising from lupus vulgaris (LV) on an old burn scar on the left lower extremity is described . Ziel-Neelsen stain of a direct smear from the surface exudate showed acid-fast bacilli . Repeated culture for tubercle bacilli was negative, probably due to a technical error . The diagnosis of LV was successfully made by polymerase chain reaction (PCR) . LV and burn scar are common preceding diseases for SCC . The former is rare in the U.S., Europe, and Japan . We were unable to determine whether only one of the two conditions or a combination of both was the true predisposing factor responsible for the development of this SCC . However, this case may be the first report of SCC arising from coexistent LV and a burn scar in which the diagnosis was confirmed by PCR. Int J Lepr Other Mycobact Dis, 1996 Dec, 64(4), 428 - 32 Pterygium in lepromatous leprosy; Daniel E et al.; Pterygia from the eyes of three lepromatous leprosy patients were histopathologically studied . All of the specimens contained acid-fast bacilli (AFB) and exhibited features of chronic inflammation . In the etio-pathogenesis of the pterygium that occurs in leprosy patients, the chronic inflammation that is a feature of the disease, the involvement of the nerves within the pterygium, the increased exposure to sunlight, dust and wind (especially in patients having lagophthalmos), and the ostrasization by society that necessitates living predominantly outdoor lives, should be taken into account. Int J Lepr Other Mycobact Dis, 1996 Dec, 64(4), 417 - 27 Enzyme-linked immunosorbent assay (ELISA) with mycobacterial crude antigens for the sero-epidemiological diagnosis of active tuberculosis; Escobar-Gutierrez A et al.; In search for reliable, nonexpensive procedures for tuberculosis diagnosis suitable for seroepidemiological studies in leprosy-endemic areas, enzyme-linked immunosorbent assays (ELISAs) with whole intact bacilli, whole lipid-free bacilli and protein-enriched soluble extracts from the H37Rv Mycobacterium tuberculosis strain were evaluated . Sera tested came from 47 active, pulmonary tuberculosis adult cases, 60 household contacts of active tuberculosis cases, 20 lepromatous leprosy adult patients, and 67 healthy adult controls obtained from low and high leprosy and tuberculosis endemicity areas . There was no influence of such endemicity levels in the number of positive results in control sera . Antibody levels obtained with each of the antigens in ELISAs were significantly different in tuberculosis patients and the control groups . Ten percent of tuberculosis contacts were positive with some of the antigens and three of them showed suggestive chest radiographs . The best combination for a high number of positive results with tuberculosis sera and low positive results with leprosy sera was the BCG soluble extract (91% and 15%, respectively) . This preparation also yielded excellent sensitivity and specificity values for tuberculosis (91.5% and 92.5%, respectively) . These data suggest that BCG soluble extract ELISAs could provide helpful information to estimate tuberculosis prevalence only in leprosy-free areas, under a situation of unavailability of purified antigens . In pulmonary cases, sputum microscopic examination and culture have higher sensibility than serodiagnosis; therefore, the utilization of BCG soluble extract ELISAs as a diagnostic aid in individual patients with suspected active tuberculosis only can be useful in extrapulmonary cases. Int J Lepr Other Mycobact Dis, 1996 Dec, 64(4), 409 - 16 Detection of M . leprae by gene amplification; combined ethidium-bromide staining and probe hybridization; Sharma RK et al.; Biopsy and skin-scraping specimens from 130 leprosy cases across the disease spectrum (56 TT/BT/I, 73 BB/BL/LL, and 1 neuritic case) and 50 healthy contacts were studied to assess the application of gene amplification . The nucleic acids from these clinical specimens were extracted by an integrated freeze-thawing--optimized lysozyme-/proteinase-k treatment-purification and fractionation procedure . The nucleic acids from cultured organisms were isolated by the stepwise procedure earlier standardized at this laboratory . Gene amplification for a 360-bp fragment of the 18-kDa protein gene was carried out using primer and the procedure described by its developers, and a 360-bp fragment on Southern blot was taken as the yardstick of positivity . The polymerase chain reaction product was analyzed by electrophoresis, ethidium-bromide (EB) staining, and blot (B) hybridization . Overall sensitivity ranged from 71% in specimens with undetectable acid-fast organisms to 100% in specimens with demonstrable acid-fast bacilli . A positivity of 73% in TT/BT/I specimens and 93% in BB/BL/LL specimens was observed . Four combinations were discerned: EB+, B+ (71%); EB-suspicious, B+ (14%); EB-, B+ (3%) and EB-, B- (12%) . By combining the blot hybridization with EB staining, the sensitivity could be significantly improved as compared to EB staining alone . The test was found to be absolutely specific by the absence of any false positivity in control specimens as well as with purified DNAs from mycobacterial as well as non-mycobacterial organisms, grown from these specimens . It is recommended that for optimum sensitivity and specificity both EB staining and blot hybridization should be done. Int J Lepr Other Mycobact Dis, 1996 Dec, 64(4), 404 - 8 Polymerase chain reaction of nasal swabs from tuberculosis patients and their contacts; Warndorff DK et al.; Previous studies have found Mycobacterium leprae in nasal swabs from leprosy patients, their contacts, and persons living in endemic areas . It might be expected that M . tuberculosis would be present on nasal mucosa of pulmonary tuberculosis patients, but whether they can be detected in patients or contacts is unknown . We used the polymerase chain reaction (PCR) technique on nasal swabs from tuberculosis patients, contacts of tuberculosis patients, leprosy patients, and London controls to look for both M . tuberculosis and M . leprae . Swabs dipped in sputum specimens from smear-positive patients were used as positive controls . The PCRs were conducted in two independent laboratories . M . tuberculosis was detected in nasal swabs from 6/16 smear-positive tuberculosis patients and from 1/10 household contacts by one of the laboratories . All of the sputum swabs were positive for M . tuberculosis, and all of the London controls were negative . M . leprae were found in nasal swabs from 2/5 leprosy patients, but one laboratory also reported M . leprae in swabs from 4/21 tuberculosis patients and from one sputum specimen . The results show that M . tuberculosis can be found in the noses of some tuberculosis patients, and suggest that the bacilli also may be detected in some household contacts . The comparisons with M . leprae and between the two laboratories give further insights into the sensitivity and specificity of the technique. Int J Lepr Other Mycobact Dis, 1996 Dec, 64(4), 392 - 5 Short-term follow up of patients with multibacillary leprosy and HIV infection; Jacob M et al.; During a period of 9 years, four male patients with HIV and Hansen's disease were detected in Tamil Nadu, South India . The sequence as to which infection came first is not known . All had high-risk sexual behavior with commercial sex workers and a past history of genital ulcer disease . Their spectrum of leprosy was multibacillary . Patient no . 1 had pure neural leprosy of the lepromatous type, which is rare . He also had a single episode of type 1 reaction which did not require steroid therapy . Despite having taken inadequate treatment, patient no . 2 remained clinically and bacteriologically quiescent after 4 years of follow up . He had a low CD4 count of 330 cells/mm3 . The third patient completed a full course of multibacillary multidrug therapy, and a year later is clinically and bacteriologically inactive . The fourth patient died of AIDS within 2 months of the dual diagnosisPIP: Since the detection of HIV infection in the Christian Medical College and Hospital, Tamil Nadu, in 1986, patients attending the sexually transmitted disease (STD) clinic are counselled and screened for HIV antibodies using ELISA . Over the course of 9 years, 4 males, all from Tamil Nadu, were identified at the clinic with concurrent HIV infection and leprosy . The men were aged 20-27 years and had had multiple heterosexual contacts with prostitutes and a past history of genital ulcer disease . They were in the multibacillary (MB) spectrum of the disease as evidenced by the presence of numerous acid-fast bacilli in the nerve biopsy in 1 case and positive skin smears in the other 3 cases . Mitsuda tests conducted in 3 patients were negative, consistent with the MB spectrum of Hansen's disease (HD) . The patients had concurrent infections, but it is unclear which infection occurred first . One patient developed a type 1 reaction which rapidly recovered with nonsteroidal antiinflammatory drugs . Observation of the patient over 3 years revealed no further episodes of reaction . No patient developed an erythema nodosum leprosum (ENL) reaction . One patient died 2 months after being diagnosed with HIV and HD . The other patients were followed for 3-5 years after the diagnosis of dual infection . Over that period, neither their leprosy worsened nor did their HIV infection progress to clinical AIDS . HIV infection therefore does not appear to influence an infection with Mycobacterium leprae . Kekkaku, 1996 Dec, 71(12), 655 - 61 {Serodiagnosis of tuberculosis by detection of antituberculous glycolipid antigen (TBGL antigen) antibodies in serum using enzyme-linked immunosorbent assay: clinical evaluation of anti-TBGL antibodies assay kit}; Toyoda T et al.; Kyowa Medex Co., Ltd . developed the kit for the sero-diagnosis of tuberculosis, which detects IgG antibodies against tuberculous glycolipids antigen containing cord factor (TBGL antigen) prepared from M . tuberculosis using the enzyme-linked immunosorbent assay technique . We evaluated the kit using clinical specimens and the results are as follows: 1) In total, 34 out of 39 cases (87.2%) with active pulmonary tuberculosis showed positive anti-TBGL antibody . 2) Patients with cavity, patients with extensive lesions and patients excreting large amount of acid fast bacilli tended to show high positivity rates . 3) The antibody titers increased in 7 out of 11 cases after starting the antituberculous chemotherapy . 4) The use of the antibody is unsuitable for the determination of the activity of tuberculosis since the antibody titers only slightly decreased even after chemotherapy for two years . 5) Two out of four nontuberculous mycobacteriosis cases showed high antibody titers 6) All three AIDS patients with tuberculosis showed low antibody titers . 7) The antibody was negative in almost all healthy controls showing a positive PPD skin test after vaccination with BCG, and it was therefore assumed that the antibody titer is not increased by BCG vaccination . 8) The antibody titers of the staff members working in the tuberculosis wards were not high compared with those of staff members working in the other wards. J Formos Med Assoc, 1996 Dec, 95(12), 923 - 8 Clinical features of tuberculosis associated with HIV infection in Taiwan; Hsieh SM et al.; To understand the clinical characteristics and outcome of tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan, we reviewed the medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995 . Among them, 29 (24.6%) had TB . The mean age of the AIDS patients with TB was 37 years (range, 25-66 yr) . Most patients were in the advanced stages of AIDS when human immunodeficiency virus (HIV) infection and/or TB were first diagnosed . The mean CD4+ lymphocyte count was 0.037 x 10(9)/L (range, 0-0.152 x 10(9)/L) at the time TB was diagnosed . There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement . Twenty-two patients (75.8%) had extrapulmonary TB with the most common site being the lymph nodes (72.7%) . Clinical symptoms were nonspecific, and the chest physical examination was not helpful in the diagnosis . Acid-fast bacilli were detected in sputum smears from eight patients (36.4%) . A primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB . The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement . Atypical patterns (diffuse interstitial infiltrates mimicking Pneumocystis carinii pneumonia or other patterns) and normal chest radiographs were noted in nearly one-third of the patients with pulmonary TB . A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection . Early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDSPIP: The medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995 were reviewed to gain insight into the clinical characteristics and outcome of tuberculosis (TB) among people with AIDS in Taiwan . The 29 AIDS patients with TB were of mean age 37 years and most were in the advanced stages of AIDS when HIV infection and/or TB were first diagnosed . The mean CD4+ lymphocyte count was 0.0037 x 109/liter when TB infection was diagnosed . There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement . 22 patients had extrapulmonary TB most commonly (72.7%) located in the lymph nodes . Clinical symptoms were nonspecific and the chest physical examination was not helpful in the diagnosis . Acid-fast bacilli were detected in sputum smears from eight patients, while a primary TB pattern in chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB . A reactivation pattern was found only in cases of pulmonary TB without extrapulmonary involvement . Atypical patterns and normal chest radiographs were noted in almost one-third of the patients with pulmonary TB . A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection . The early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDS . J Pediatr Gastroenterol Nutr, 1996 Dec, 23(5), 538 - 46 Surface features of small-intestinal mucosa in childhood diarrheal disorders; McClean P et al.; The pathophysiology of diarrhea, especially in the otherwise healthy child, is still poorly understood . The aim of this study was to use the scanning electron microscope (SEM) to examine the surface of the jejunal mucosa of children with chronic nonspecific diarrhea (CNSD) (n = 9) and to compare the findings with specimens obtained from children with (n = 21) and without (n = 11) other gastrointestinal diseases . Light microscopy of the specimens from children with CNSD was normal . However, SEM showed the presence of bacterial colonization with predominantly coccoid organisms in 100% of cases . This colonization was associated with loss of glycocalyx and clumping of the microvilli . The children with celiac disease (n = 9) all showed characteristic appearances with light microscopy, but only one had bacterial colonization on SEM . The surface features of specimens from children with other gastrointestinal disorders (food intolerance, postenteritis syndrome, protracted diarrhea of infancy, and immune deficiency states) were very similar to those from the CNSD group . Bacteria were visible on 89% of specimens, and in half of these cases the organisms were bacilli . SEM of specimens from children with no gastrointestinal disease (ages 11-107 months) suggested an increased density of villi/unit area with advancing age . Bacteria were present in only two cases and did not include bacilli . The findings suggest that bacterial colonization of the surface of the small intestine is common in children with several gastrointestinal diseases and may play a part in their pathogenesis . Routine SEM examination of jejunal biopsies provides information not available from standard light microscopy, which may be relevant to the treatment of children with chronic diarrhea. Am J Respir Cell Mol Biol, 1996 Dec, 15(6), 760 - 70 Selective receptor blockade during phagocytosis does not alter the survival and growth of Mycobacterium tuberculosis in human macrophages; Zimmerli S et al.; Mycobacterium tuberculosis survives and replicates within human macrophages, but the mechanisms whereby tubercle bacilli resist killing are incompletely understood . We tested the general model in which M . tuberculosis evades killing by entering naive macrophages through receptors that are unable to activate cellular microbicidal activities . Complement receptor types 1 (CR1), 3 (CR3), and 4 (CR4) were blocked with monoclonal antibodies, and mannose receptors were blocked with a competitive ligand, mannosylated bovine serum albumin (MBSA) . Survival and replication of M . tuberculosis (Erdman) were evaluated after the bacteria were phagocytosed in the presence of blocking agents (directing binding to the unblocked receptors) . Although there was significant variation in the growth rate of virulent M . tuberculosis in monocyte-derived macrophages from different donors, the intracellular survival and replication of mycobacteria were equivalent regardless of the receptor(s) used for binding and phagocytosis . We conclude that the mechanisms whereby M . tuberculosis evades killing by human macrophages are independent of the receptor-mediated route of entry, and operate at one or more steps common to all entry pathways . Blocking complement and mannose receptors in combination did not completely abrogate binding of M . tuberculosis to macrophages . However, we found that two polyanionic scavenger-receptor ligands exhibited a concentration-dependent ability to block binding of M . tuberculosis to macrophages . Moreover, blocking class A scavenger receptors abrogated nearly all binding that persisted after blocking complement and mannose receptors . This indicates that class A scavenger receptors are quantitatively important mediators of M . tuberculosis-macrophage interactions . M . tuberculosis has evolved multiple mechanisms to promote its efficient entry into macrophages . This suggests that passage of the organism through macrophages may be an essential early step in the pathogenesis of tuberculosis. Am J Gastroenterol, 1996 Dec, 91(12), 2602 - 4 Endoscopic diagnosis and management of hepatobiliary tuberculosis; Bearer EA et al.; Primary hepatobiliary tuberculosis is difficult to diagnose and treat . We describe a woman with obstructive jaundice, a common hepatic duct stricture, and granulomatous hepatitis diagnosed with biliary tract tuberculosis when acid-fast bacilli were found in bile aspirated during endoscopic retrograde cholangiopancreatography (ERCP) . The hilar stricture resulted from either primary biliary tuberculosis or secondary inflammation related to tuberculous periportal adenitis and persisted despite adequate medical treatment for tuberculosis, apparently the result of postinflammatory stenosis . After 20 months, the patient had persistently elevated bilirubin due to the stricture, and liver biopsy revealed early secondary biliary cirrhosis . Placement of a permanent metal biliary stent produced excellent results . Both diagnosis of hepatobiliary tuberculosis by bile aspirate and treatment of a biliary stricture with a permanent metal biliary stent are newly described advances in the management of biliary tuberculosis made possible by ERCP. J Clin Microbiol, 1996 Dec, 34(12), 3206 - 7 Improved sensitivity of direct microscopy for acid-fast bacilli: sedimentation as an alternative to centrifugation for concentration of tubercle bacilli; Miorner H et al.; There is a great need for improved methods for the diagnosis of tuberculosis by techniques that are appropriate for control programs in low-income countries . Liquefaction of sputum with sodium hypochlorite followed by concentration of bacilli through overnight sedimentation significantly increases the sensitivity of direct microscopy, and this method could be an alternative for diagnostic centers not equipped with a centrifuge. Ned Tijdschr Geneeskd, 1996 Nov 2, 140(44), 2181 - 7 {Shortening of therapy duration in patients with pulmonary tuberculosis from 9 to 6 months only justifiable on the basis of published data}; van Loenhout-Rooyackers JH et al.; OBJECTIVE: To determine if in the Netherlands, just like in other countries, the treatment of pulmonary tuberculosis with adequately sensitive tubercle bacilli may be shortened from 9 to 6 months . DESIGN: Literature study . SETTING: Municipal Health Service, Nijmegen, the Netherlands . METHOD: The relevant literature was analysed, using the percentage of recurrences as the criterion . The study was restricted to patients with pulmonary tuberculosis in whom the diagnosis had been confirmed bacteriologically and in whom a human, normally sensitive tubercle bacillus had been isolated . The treatment schedule had to include at least isoniazid, rifampicin and pyrazinamide . There were no studies with treatment of 9 months' duration . The studies with 6 months' treatment were selected on the basis of the predetermined criteria from among articles included in Medline in 1980-1991 . RESULTS: The treatment schedules of 6 months' duration (n = 44) from 25 articles were suitable for analysis . Treatment for 6 months' resulted in a proportion of recurrences of tuberculosis of 2.4% (95%-confidence interval: 2.0-2.8), with follow-up periods of 12 to 94 months after discontinuation of the treatment . Addition of streptomycin or ethambutol during the initial phase, self-medication or controlled treatment, daily or intermittent treatment made no difference as regards the ultimate results . No comparison with the proportion of recurrences of 1% (0.2-2.9) after 9 month's treatment without pyranizamide was possible . A recent calculation of the number of Dutch nationals with recurrent tuberculosis resulted in a proportion of recurrences of 2.5 (1.8-3.2) . The guideline adopted was that mentioned by the American Thoracic Society, a proportion of recurrences of < 5% . CONCLUSION: On the basis of the known percentages of recurrence, it could be decided in the Netherlands as well to shorten the duration of treatment from 9 to 6 months. Am J Kidney Dis, 1996 Nov, 28(5), 747 - 51 Optimal treatment and long-term outcome of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis; Lui SL et al.; A retrospective study of the treatment and short- and long-term outcomes of tuberculous peritonitis (TBP) complicating continuous ambulatory peritoneal dialysis (CAPD) among our dialysis patients over a 6-year period was performed . Ten cases of TBP complicating CAPD were identified among 601 dialysis patients between January 1988 and December 1994 . There were four male and six female patients . The most common clinical features were abdominal pain, fever, and cloudy peritoneal fluid (PDF) . Two patients had concurrent bacterial peritonitis . Extraperitoneal tuberculosis was not observed . The majority of the patients showed neutrophil predominance in the PDF . Only one patient had a positive acid-fast bacilli smear of the PDF . The acid-fast bacilli culture of the PDF was positive in all patients . The patients were treated with isoniazid, rifampicin, and pyrazinamide for 9 to 12 months (mean, 11 months) . Continuous ambulatory peritoneal dialysis was continued in all patients . Two patients died, one from multiorgan failure at 2 months and the other from sudden cardiac death at 9 months . Two patients were converted to hemodialysis at 3 months . Six patients continued to receive CAPD after completion of the antituberculous treatment . Four of these six patients were still alive 5 years after the TBP . Three patients were still undergoing CAPD with satisfactory ultrafiltration and solute clearance . None of the patients developed relapse of TBP . We concluded that (1) TBP is a rare but important complication of CAPD, (2) removal of the Tenckhoff catheter is not mandatory in the management of TBP complicating CAPD, and (3) long-term continuation of CAPD is possible after TBP. Sante, 1996 Nov-Dec, 6(6), 389 - 92 {Preliminary study on tuberculin sensitivity in north Lebanon}; Hamze M et al.; Tuberculosis remains a severe public health problem, and is a major cause of infant disease in North Lebanon . We investigated tuberculin sensitivity in 1,405 school children (2 to 15 years old) not previously vaccinated with BCG in a deprived suburb of Tripoli (Lebanon) . The Intra-Dermal Reaction (IDR) technique was used with 10 units of tuberculin (Pasteur-Merieux, France) . The prevalence was 4.3% . The score was higher in the lowest socio-economic group (5.7%) than in the middle socio-economic group (2.4%) . No members of the upper socio-demographic group live in this area . There were no significant differences between the sexes . The diameter of induration was over 10 mm in 83.6% of cases (95.6% in the lower class and 46.6% in the middle class) . The prevalence was higher among children over 10 years old . Chest X-rays were obtained for children with a positive reaction, and all were normal . Similarly, their sputum was tested for Acid Fast Bacilli (AFB) by a double staining technique (Ziehl-Nielsen and auramine), and all scored negative. Nihon Hansenbyo Gakkai Zasshi, 1996 Nov, 65(3), 174 - 9 {An experimental nerve lesion simulating leprous neuropathy produced in the nude mice by the inoculation of a leproma-derived and cultivable mycobacterium HI-75}; Sidik H; Among the lesions caused by mycobacteriosis, peripheral neuropathy has been regarded as the pathognomonic one peculiar to leprosy which is caused only by M . leprae (ML) which can not be cultivated . If that whole sentence is correct, no past report should be in existence concerning the peripheral neuropathy caused by the experimental inoculation of certain cultivated mycobacterium and not of ML . There was, however an exception challenging to that theory which was done by Sasaki et al . in 1985 . The author, therefore, tried to reproduce this type of lesion in the nude mice modifying their method to know whether a leproma derived and cultivable mycobaceterium HI 75 (III 75) still have the ability to cause neuropathy as they observed . The mycobacterium utilized in the study was originally separated from a leproma by Skinsnes et al . as M . leprae (ML) III 75 in 1975 and was identified as M scrofulaceum (MS) by Stanford et al . in 1977 . The strain was kept on cultivating in his laboratory till 1984 and in our thereafter . The groups of mice served for the present experiments consisted of two . The mice in the first group were infected intravenously and those in the latter group were by subcutaneous injections in the cheeks mixed with hyaluronic acid . The first one was unsuccessful to make remarkable neuropathy, however, the second one showed the marked invasions of the bacilli in peripheral nerves encompassed by numerous macrophages which were heavily loaded with the mycobacteria . The author believes that the present result is helpful to solve the question about the differences of the characteristics of HI-75 before and after causing neuropathy in vivo, the mutual relationship between ML, MS and III 75 and the causative organism beside ML if present. Pediatr Pathol Lab Med, 1996 Nov-Dec, 16(6), 995 - 1001 Recurrent villitis of bacterial etiology; Redline RW; Recurrent placental villitis is an uncommon clinicopathologic entity associated with a very high perinatal mortality rate . While most cases are idiopathic, other cases may have a treatable infectious cause . Here, a mother with recurrent fetal losses, each showing chronic villitis associated with rod shaped bacilli as demonstrated by Steiner stain, is presented . The key feature separating this and other similar cases from idiopathic villitis is a pleomorphic inflammatory infiltrate including lymphocytes, macrophages, eosinophils, plasma cells, and neutrophils. J Formos Med Assoc, 1996 Nov, 95(11), 857 - 65 Low-grade gastric B-cell lymphoma of mucosa-associated lymphoid tissue: clinicopathologic analysis of 19 cases; Chiang IP et al.; Low-grade gastric B-cell lymphoma of mucosa-associated lymphoid tissue type (MALToma) is a recently recognized disease entity . We report the clinicopathologic features of 19 patients with MALToma in Taiwan . The 19 patients included eight men and 11 women, ranging in age from 26 to 77 years, with a mean age of 58.8 years . Most complained of abdominal pain or gastrointestinal bleeding . The endoscopic and gross features of the gastric lesions revealed erosion (flat type), ulceration (depressed type), cobblestone appearance or abnormal gastric folds (elevated type), mimicking chronic gastritis, ulcer or early gastric carcinoma . Typical histopathologic features included lymphoepithelial lesion and extensive mucosal infiltration of centrocyte-like cells in all cases . Clonality analysis of the variable-diversity-joining region of the immunoglobulin gene by semi-nested polymerase chain reaction demonstrated monoclonality in 72% of the cases . Helicobacter pylori bacilli (H . pylori) could be identified on histologic sections in 15 cases (78.9%); the serologic test for H . pylori was positive in 12 of 13 patients tested (92%) . In six patients receiving triple therapy (amoxicillin, bismuth subcitrate and metronidazole), five showed significant histologic regression with eradication of H . pylori 4 to 6 months after the start of treatment; one patient showed persistent lesions and presence of H . pylori . However, persistence of residual lymphoid cells and monoclonality of the immunoglobulin gene, could still be demonstrated in four cases . Of nine patients treated with surgery or chemotherapy, two died: one due to concomitant gastric carcinoma and the other one due to sudden apnea . No recurrence was observed in the remaining seven patients . The remaining four patients were lost to follow-up . Our experience confirmed that gastric MALToma is a low-grade neoplastic process . The dramatic response of gastric MALToma to anti-H . pylori treatment suggests that H . pylori infection is closely related to the pathogenesis of low-grade gastric MALToma . However, long-term follow-up is mandatory due to the persistence of the monoclonality of the immunoglobulin gene in the residual lymphoid cells after treatment. Nihon Kyobu Shikkan Gakkai Zasshi, 1996 Nov, 34(11), 1264 - 70 {Two cases of pulmonary disease caused by Mycobacterium chelonae subsp . abscessus}; Naoki K et al.; We encountered two-cases of pulmonary disease caused by M . chelonae subsp . abscessus, {Case 1} A 72-year-old man was admitted to the hospital because of fever . He had been observed for one year after being given a diagnosis of pulmonary disease caused by Myocobacterium avium complex . Sputum examination revealed acid-fast bacilli (Gaffky 9) . He recovered after administration of clarithromycin (CAM) and other drugs . {Case 2} A 61-year-old man was admitted to the hospital because of coughing and sputum production . He had been observed for 4 years after being given a diagnosis of pulmonary M . fortuitum disease . Sputum examination revealed acid-fast bacilli (Gaffky 7) . His symptoms deteriorated even though he received anti-tuberculosis agents and CAM . After measurement of minimal inhibitory concentration (MIC), he was given amikacin (AMK) . In both cases, the bacilli found in sputum obtained on admission were identified as M . chelonae subsp . abscessus by DNA hybridization . They were completely resistant to all anti-tuberculosis agents . However, the disk method show that they were sensitive to AMK, imipenem and CAM . The MIC value of those strains to CAM was 0.78 microgram/ml in case I and more than 100 micrograms/ml in case 2 . The results obtained by MIC measurement were consistent with the clinical outcome . AMK, cefoxitin (CFX), and CAM had been used to treat M . chelouae subsp . abscessus in Europe, but the MIC value differed from strain to strain within a species . Thus the present data suggest that measurement of the MIC value of CAM would be necessary to predict its therapeutic effect. Acta Cytol, 1996 Nov-Dec, 40(6), 1253 - 6 Tuberculous orchitis diagnosed by fine needle aspiration cytology; Kumar PV et al.; OBJECTIVE: To study the role of the fine needle aspiration cytology (FNAC) in the diagnosis of testicular lesions . STUDY DESIGN: Seven adult males (55-68 years) presented to the clinic with unilateral enlargement of the testis for the previous few months . Clinically, a malignant tumor was suspected . Fine needle aspiration was performed for rapid diagnosis . RESULTS: The smears revealed many groups of epithelioid histiocytes, giant cells, a few plasma cells and occasional spindle-shaped fibroblasts . Acid-fast stain revealed a few acid-fast bacilli . The cases were diagnosed as tuberculosis and treated with orchiectomy and antituberculous drugs . The patients did well . Histologic sections confirmed the cytologic diagnosis . CONCLUSION: FNAC is useful in the diagnosis of tuberculous orchitis. Kekkaku, 1996 Nov, 71(11), 603 - 6 {The usefulness of induced sputum in the diagnosis of pulmonary tuberculosis}; Kawada H et al.; This study was designed to compare the results of culture for tubercle bacilli using induced sputum by an ultrasonic nebulizer and gastric aspirates from same patients who were suspected of having active tuberculosis with little or no sputum and had received no prior chemotherapy . 22 patients included in this series were either culture positive for tubercle bacilli or showed unequivocal radiographic improvement after three months of therapy with three anti-tuberculosis drugs . Induced sputum from 17 patients and gastric aspirates from seven patients were culture positive for M.tuberculosis . This difference is significant (p < 0.01) . Paired induced sputum and gastric aspirates were both positive for tubercle bacilli in seven patients . The finding of acid-fast bacilli on microscopy or tubercle bacilli in culture in four of the seven patients were available much earlier with induced sputum than with gastric aspirates . Positive gastric aspirates and negative induced sputum for tubercle bacilli was not seen . These results suggest that induced sputum by an ultrasonic nebulizer is superior to gastric aspirates in terms of high sensitivity and early finding for tubercle