Lancet, 1994 Nov 12, 344(8933), 1323 - 8 Randomised trial of thiacetazone and rifampicin-containing regimens for pulmonary tuberculosis in HIV-infected Ugandans . The Makerere University-Case Western University Research Collaboration; Okwera A et al.; Among HIV-positive patients who received treatment for active tuberculosis, thiacetazone has been associated with cutaneous hypersensitivity and recurrent tuberculosis . No controlled trials have investigated the safety and efficacy of thiacetazone-containing regimens compared with alternative regimens among patients with HIV . In a randomised clinical trial of 191 HIV-positive patients with active pulmonary tuberculosis, we examined the safety and short-term efficacy of isoniazid, rifampicin, and pyrazinamide for two months followed by isoniazid and rifampicin for seven months (RHZ) compared with streptomycin, thiacetazone, and isoniazid for two months followed by thiacetazone and isoniazid for ten months (STH) . Between May, 1990, and September, 1991, 191 HIV-positive adult Ugandan patients with acid-fast bacilli sputum smear-positive pulmonary tuberculosis (93% confirmed by culture) received either STH or RHZ . Subjects had a standard evaluation that included Mantoux skin test, complete blood count with differential white blood cell count, and chest radiography . After starting therapy, subjects were followed-up over one year for three outcomes: complications of anti-tuberculosis therapy, early sterilisation of cultures, and survival . Of 191 eligible subjects, 90 received STH and 101 received RHZ . The overall one-year survival was similar for STH and RHZ (65% vs 72%), but when controlled for baseline differences in Mantoux reaction size and absolute lymphocyte count, the relative risk of death for STH compared with RHZ was 1.57 (95% CI 1.0-2.48) . Overall, 12 adverse drug reactions occurred in the STH arm (18.2 reactions per 100 person years {PYO}) compared with one in the RHZ arm (1.6 reactions per 100 PYO) for a relative risk of 11.7 (95% CI 1.52-90.0) . 10 cutaneous reactions occurred in the STH arm (15.2 events per 100 PYO) compared with one event in the RHZ arm (1.6 events per 100 PYO) for a relative risk of 9.7 (95% CI: 1.24, 75.8) . A greater proportion of RHZ patients compared with STH patients had sterilised their sputum within two months (74% vs 37%, p < 0.001) . In developing countries, rifampicin-containing regimens should be given, when possible, to HIV-positive patients to reduce drug toxicity and to prolong survival. Lancet, 1994 Nov 5, 344(8932), 1245 - 9 Delayed-type hypersensitivity, mycobacterial vaccines and protective immunity; Fine PE et al.; There is a longstanding debate over the implications of natural and vaccine-induced delayed type hypertensivity for protective immunity to mycobacterial infections . The identification of correlates of vaccine-induced protective immunity should help explain the inconsistent behaviour of BCG vaccines in different populations and assist in efforts to devise improved vaccines . More than 70,000 subjects in Karonga District, northern Malawi were skin tested with soluble antigens of the tubercle and leprosy bacilli, and then followed up for five years for tuberculosis and leprosy incidence . Incidence rate ratios were calculated to compare subjects with different levels of prior skin test sensitivity, after controlling for the effects of age, sex and previous BCG vaccination . BCG vaccination protected against leprosy without persistent delayed-type hypersensitivity to tuberculin or to soluble antigens of the leprosy bacillus . In subjects who had not received BCG, hypersensitivity to tuberculin or to antigens of the leprosy bacillus was associated with strong protection against leprosy . In BCG-vaccinated and unvaccinated subjects, there was a J-shaped relation between hypersensitivity to tuberculin and subsequent rates of tuberculosis, with lowest rates associated with low grade sensitivity (induration 1-10 mm) . This study shows that delayed-type hypersensitivity to mycobacterial antigens has different implications for tuberculosis and leprosy: low-level hypersensitivity (probably attributable to environmental mycobacteria) is associated with protection, but persistent vaccine-associated hypersensitivity to mycobacterial antigens is not a correlate of vaccine-derived protection against mycobacterial diseases. Isr J Med Sci, 1994 Nov, 30(11), 805 - 10 A 10 year survey on Mycobacterium tuberculosis isolates in Israel and their drug resistance; Lavy A et al.; An increased incidence of tuberculosis has been observed in Israel in 1985, 1986 and since 1990--years of large waves of immigrations . A very similar trend of disease was observed in the Mycobacterium Reference Laboratory of Israel, and consequently a survey was undertaken among the 1,181 bacteriologically confirmed tuberculosis cases newly registered there in 1983-92 . The overall percent distribution of drug-resistant Mycobacterium tuberculosis during this period was 12.6% (7.3% resistant to one drug and 5.3% (multiple drug resistance) . The highest percent distribution of drug-resistant bacilli was found among immigrants from the former Soviet Union (37.3%) and Ethiopia (16.2%) . The highest incidence of disease was found in males and in patients aged > 30 . Pulmonary disease was the most common form for all patients: among the extrapulmonary cases, the most frequently involved site was the genitourinary system in Israelis and the lymph nodes in Ethiopians . Most isolates fit into one variant by biochemical analysis, indicating the need for a more sensitive method to type M . tuberculosis for epidemiological purposes . The data included in this survey provide information useful for a national tuberculosis program. Chest, 1994 Nov, 106(5), 1329 - 32 CT-guided fine needle aspiration biopsy in the diagnosis of mediastinal tuberculosis; Khan J et al.; Twenty-two patients with mediastinal tuberculosis were reviewed . The most common symptoms were chest pain, cough, fever, and weight loss . Results of the physical examination were unremarkable . The chest radiographs of all 22 patients showed abnormal mediastinum with no evidence of extramediastinal disease . Most (62%) had right-sided paratracheal lymphadenopathy . Mantoux skin test was positive (> 15 mm) in all patients, whereas sputum smears and cultures for acid-fast bacilli were negative . Computed tomographic (CT) guided fine needle aspiration biopsies (FNAB) were performed in 12 patients using 22- to 25-gauge needles . Ten patients had fiberoptic bronchoscopic (FOB) examination with brushings and biopsies . Mediastinoscopy (n = 8) or thoracotomy (n = 6) was performed in patients where either FNAB or FOB was not diagnostic or where lymphoma was suspected clinically . The rates of true-positive diagnoses were 20%, 66%, 75%, and 100% for FOB, FNAB, mediastinoscopy, and thoracotomy, respectively . The rate of false-negative for FNAB was 34% . Only one patient developed nonsignificant pneumothorax after FNAB . These findings suggest that CT-guided FNAB is a useful and safe procedure and should be considered in the initial evaluation of patients suspected of having mediastinal tuberculosis. J Acquir Immune Defic Syndr, 1994 Nov, 7(11), 1157 - 68 Natural history of HIV infection in Filipino female commercial sex workers; Manaloto CR et al.; A prospective follow-up study of the progression of HIV infection, from seroconversion to onset of opportunistic infections (OI) indicative of immune deficiency and to death, was performed in a cohort of 54 HIV-1 antibody positive Filipino female commercial sex workers (FCSW) . The cumulative probability of having a CD4+ T cell count of < 200/mm3 and/or an OI indicative of severe immune deficiency was 52.9% within 5 years and 73.8% within 6 years after seroconversion . The cumulative probability of death was 52.1% within 6.5 years following seroconversion and 52.7% within 1.5 years after a depressed (< 200/mm3) CD4+ T cell or onset of an OI . Although several OI associated with immune impairment were observed, a CD4+ cell count of < 200/mm3 was the initial indicator of a failing immune system in more than 50% of the patients . Mycobacterium tuberculosis or unidentified acid fast bacilli (presumed to be M . tuberculosis) and Pneumocystis carinii pneumonia were the initial indicators of immune deficiency in the remaining patients. Mil Med, 1994 Nov, 159(11), 715 - 7 Tuberculous peritonitis in a young female diagnosed using mini-laparotomy: a case report; Wittich AC et al.; An 18-year-old female Pacific Islander with abdominal pain, ascites, and fever was transferred to our hospital with suspected ovarian malignancy . These nonspecific clinical features of tuberculous peritonitis in a female frequently contribute to misdiagnosis . Preoperative findings included negative sputums, negative purified protein derivative, and no acid-fast bacilli (AFB) found in peritoneal fluid or fine needle biopsy of the omentum . Tuberculous peritonitis was diagnosed after omental biopsy obtained at mini-laparotomy showed granulomatous inflammation and positive isolation of AFB. No To Shinkei, 1994 Nov, 46(11), 1101 - 11 {A 65-year-old woman with headache, facial pain, and progressive multiple cranial neuropathy}; Miyasaka H et al.; We report a 65-year-old woman with progressive multiple cranial neuropathy . She had been suffered from bronchial asthma since 1979 for which prednisolone had been prescribed . She noted an onset of pain around her nose in October, 1989, which extended into the periorbital regions bilaterally . In February, 1990, she was treated with stellate ganglion block and trigeminal nerve block; these treatments partially alleviated her pain . In May of 1991, she noted a difficulty in swallowing solid foods . In November of the same year, she developed right facial paresis; two weeks later, she noted numbness in her left face, and was hospitalized to our service on December 16, 1991 . On admission, she was afebrile and general physical examination was unremarkable except for piping rales in her both lung fields . On neurologic examination, she was alert and oriented to all spheres; higher cerebral functions were intact . In the cranial nerves, her olfactory sense was lost bilaterally; her vision was markedly diminished bilaterally only to recognize hand movements; the optic fundi appeared normal; the pupils were isocoric and reacted to light promptly . The extraocular muscles were moderately weak to most of the directions more on the left; no nystagmus was present . Facial sensation was diminished bilaterally; the jaw deviated to right; right facial paresis of peripheral type was present; her hearing was diminished bilaterally more on the right . The movement of the soft palate was diminished on the right side; dysphagia was present; her voice was horse; the gag reflex was diminished . The sternocleidomastoid muscle was weak bilaterally; the tongue appeared normal . Examination of gait was differed because of headache, however, no apparent motor weakness was present . No ataxia or involuntary movement was noted . Deep reflexes were normally elicited and symmetric . Plantar response was flexor . Sensation in the extremities was intact . Kernig's sign was positive at 70 degree leg extension; eyeball tenderness was also present bilaterally, however, no nuchal stiffness was noted . Following abnormalities were present in the laboratory examination: WBC 11,400/microliters, ESR 50 mm/hr, CRP 6.1 mg/dl . The lumbar CSF was under a normal pressure containing 29 WBC/microliters (neutrophils 7, lymphocytes 20, others 2), 67 mg/dl of protein, and 53 mg/dl of sugar; cultures for acid-fast bacilli as well as for other bacteria were negative; no malignant cells were found . A cranial CT scan revealed an isodensity mass in the orbit and ill-defined low density areas in the white matters of the frontal lobes.(ABSTRACT TRUNCATED AT 400 WORDS) Antimicrob Agents Chemother, 1994 Nov, 38(11), 2557 - 63 A bone marrow-derived murine macrophage model for evaluating efficacy of antimycobacterial drugs under relevant physiological conditions; Skinner PS et al.; Even though the macrophage is the host cell for the intracellular bacterial parasite Mycobacterium avium, macrophages have undergone only limited evaluation as models for determining the capacities of antimycobacterial drugs to inhibit the growth of M . avium within this relevant intracellular environment . In the present study, we demonstrated that a panel of M . avium isolates could actively infect homogeneous monolayers of murine bone marrow-derived macrophages . A number of established and experimental antimycobacterial drugs were then added to these cultures at a range of concentrations, and their effects on the numbers of surviving bacilli were determined 8 days later . By plotting such numbers versus drug concentrations it was then possible to clearly distinguish between compounds with bactericidal activity (such as rifabutin and PD 125354) and those with bacteriostatic effects (such as clarithromycin), even though several of these compounds had very similar MICs . In addition, an estimate of the potential therapeutic efficiency of each drug could be made by determining the concentration needed to destroy an arbitrary percentage of the inoculum (in this case, the bactericidal concentration destroying 99% of the inoculum) . Such values were considerably in excess of the MICs and may more realistically reflect the concentrations in serum required to effectively reduce the bacterial burden in vivo. Pharmacology, 1994 Nov, 49(5), 314 - 8 Suppressive effects of eugenol and ginger oil on arthritic rats; Sharma JN et al.; This study examined the effect of eugenol and ginger oil on severe chronic adjuvant arthritis in rats . Severe arthritis was induced in the right knee and right paw of male Sprague-Dawley rats by injecting 0.05 ml of a fine suspension of dead Mycobacterium tuberculosis bacilli in liquid paraffin (5 mg/ml) . Eugenol (33 mg/kg) and ginger oil (33 mg/kg), given orally for 26 days, caused a significant suppression of both paw and joint swelling . These findings suggest that eugenol and ginger oil have potent antiinflammatory and/or antirheumatic properties. Clin Pharmacokinet, 1994 Nov, 27(5), 377 - 92 Pharmacokinetic contributions to postantibiotic effects . Focus on aminoglycosides; Zhanel GG et al.; The postantibiotic effect (PAE) refers to a period of time after complete removal of an antimicrobial during which there is no growth of the target organism . The PAE appears to be a feature of most antimicrobial agents and has been documented with a variety of common bacterial pathogens . Various factors influence the presence or duration of the PAE including the type of organism, type of antimicrobial, concentration of antimicrobial, duration of antimicrobial exposure, antimicrobial combinations, and inoculum and medium used . beta-Lactams demonstrate a PAE against Gram-positive cocci, but produce only a short PAE with Gram-negative bacilli . Antimicrobial agents that inhibit RNA or protein synthesis have a PAE against Gram-positive cocci and Gram-negative bacilli . In vivo studies of aminoglycosides suggest that area under the plasma concentration-time curve is the pharmacokinetic parameter that best correlates with clinical efficacy . This is thought to be due to the concentration-dependent killing and PAE possessed by these antimicrobials . Animal and human studies have reported that once-daily administration of aminoglycoside is as effective as, or more effective than, and possibly less toxic than traditional multiple daily administration. World J Surg, 1994 Nov-Dec, 18(6), 926 - 31; discussion 931-2 Selective decontamination of the colon before elective colorectal surgery . West of Scotland Surgical Infection Study Group; Taylor EW et al.; The controversy over the route of administration of antibiotic prophylaxis in patients undergoing elective colorectal operations persists for oral, parenteral, and a combination of the two routes . The oral antibiotics commonly administered for colorectal prophylaxis, neomycin and eythromycin base, are not absorbed in the gastrointestinal tract (GIT) . However, the 4-fluoroquinolones are absorbed in the upper GIT and are excreted in part by the colonic mucosa . Their action is then to remove, or severely depress, the gram-negative aerobic bacilli leaving the anaerobic flora unaffected . This action is the principle of selective decontamination . We have assessed the efficacy of oral ciprofloxacin in a prospective randomized clinical trial in which all patients received piperacillin 4 g i.v . as single-dose parenteral prophylaxis . A group of 327 evaluable patients were randomized to receive ciprofloxacin 500 mg b.i.d . with the preoperative cathartic (group OA, n = 159) or no oral antibiotic (group NOA, n = 168) . Postoperative wound infection occurred in 18 (11.3%) patients in group OA and 39 (23.2%) patients in group NOA (chi 2 = 7.2, p = 0.007) . Operation-related infection of any type occurred in 23 (14.5%) patients in group OA compared with 55 (32.7%) in group NOA (chi 2 = 14.0, p = 0.0002) . The median postoperative hospital stay was 11 days (interquartile range 4.5 days) for group OA and 12 days (interquartile range 8 days) for group NOA (Mann Whitney U test, p = 0.005) . Ignoring the treatment group, the median postoperative hospital stay was 17 days (interquartile range 10 days) for infected patients and 11 days (interquartile range 4 days) for those not infected.(ABSTRACT TRUNCATED AT 250 WORDS) Kekkaku, 1994 Nov, 69(11), 719 - 23 {Analysis of host defense mechanism against mycobacterial infection and its application to therapy with biological response modifiers}; Kawakami K; Recently, tuberculosis have been increasing among the immunocompromised patients . In patients with acquired immunodeficiency syndrome (AIDS), multi-drug resistant mycobacteria are often detected, which make the therapy difficult . In these patients, chemotherapy alone is often insufficient and some treatment to augment their host defense activity has been desired . Therefore, to know the host defense mechanism against mycobacterial infection will be helpful to develop an adjuvant therapy for intractable tuberculosis . In this study, IFN-gamma mRNA was induced in murine lungs after mycobacterial infection, and anti-IFN-gamma monoclonal antibody (mAb) prevented the activation of pulmonary intraparenchymal macrophages by M . bovis BCG and the elimination of M . tuberculosis from lungs . In addition, this mAb inhibited the activation of Mac1+CD4-CD8- T cells bearing alpha beta antigen receptor by BCG, which were found in murine lungs and might be involved in the host defense mechanism against mycobacterial infection, and administration of IFN-gamma significantly increased this population in lungs . Thus, IFN-gamma was suggested to be a candidate cytokine for the treatment of intractable tuberculosis . Next, CD4+ T cell-depleted mice were prepared by injecting anti-CD4 mAb and used as an immunocompromised model . When infected with M . tuberculosis, the multiplication of the bacilli within the lungs of such immunocompromised mice was much more enhanced in comparison with the control mice with intact CD4+ T cells . Administration of IFN-gamma significantly reduced the number of the bacilli in lungs . Further, in an in vitro study with human lung macrophages, IFN-gamma enhanced the killing activity of macrophages against M . tuberculosis in a dose dependent manner, and suboptimal dose of 1 alpha, 25-dihydroxyvitamin D3 synergistically augmented the effect of IFN-gamma. Kekkaku, 1994 Nov, 69(11), 693 - 8 {A case of pulmonary tuberculosis with HIV infection--review of 5 cases in Japan}; Koyama R et al.; Recently we encountered a case of pulmonary tuberculosis with HIV infection . The patient was 54-years old male . His chief complaints were anemia, emaciation and severe diarrhea . He was admitted to our hospital on September 18, 1992 . He had been diagnosed in another clinic as having pulmonary tuberculosis before the admission to our hospital . His chest films taken on admission revealed homogeneous infiltrates with cavitation in right upper lobe . Serial chest X-rays consisted with the findings of post-primary tuberculosis . Sputum smear for acid fast bacilli was positive . From his clinical manifestations and life-history, we had a suspicion that he had infected with HIV . Laboratory findings were as follows: serum albumin level was 1.9 g/dl, CRP was 10.2 mg/dl, serological tests for HIV were positive by EIA, IFA and western blott method, total lymphocyte count was 819/microliters, CD4+ T lymphocyte count was 120/microliter CD4+/CD8+ ratio was 0.2 . He was treated with AZT, isoniazid, streptomycin and rifampicin . The disease progressed rapidly and interstitial pneumonia, jaundice and clouding of consciousness appeared at the terminal stage . He expired on October 14, 1992 . In this paper, the authors reported a case of pulmonary tuberculosis with HIV infection and also reviewed 5 cases of pulmonary tuberculosis associated with HIV in Japan. Kekkaku, 1994 Nov, 69(11), 689 - 92 {A case of tuberculous anal fistulae complicated by pulmonary tuberculous}; Onizuka O et al.; Tuberculous involvement of the anus is very rare at present as the result of BCG-Vaccination and improvement of public health . We report a juvenile case of tuberculous anal fistulae complicated to pulmonary tuberculosis . A 22-year-old male was admitted with symptoms of 13 month- history of intermittent anal pain, low grade fever and cough . Chest X-ray showed bilateral middle zone infiltrates with cavitation . Perianal inspection revealed a large ulcer with purulent exudate and a few fistulae . Sputum smears showed acid fast bacilli . A biopsied specimen of perianal fistulae showed granulomatous lesions with central necrosis, epitheloid cells and multi-nucleated giant cells . With three-drug antituberculous regimen, his symptoms resolved, radiographic infiltrates improved, and the perianal fistulae were cured . It was speculated that the tuberculous anal fistulae in this case were caused by the dissemination from the pulmonary focus via the hematogeneous and lymphogeneous routes, because any tuberculous lesion was not detected in the gastrointestinal tract and rectum. Kekkaku, 1994 Nov, 69(11), 681 - 7 {Clinical studies on nine cases with miliary tuberculosis: serum level of tumor markers and bronchoscopy in differential diagnosis}; Hamamoto Y et al.; We analyzed retrospectively the clinical data of 9 patients with miliary tuberculosis who had been treated in Kyoto City Hospital during the past 12 years . Majority of our patients were female (7 of 9) and were of elder age-groups (mean age: 68.5 years, range: 56-85 years) . The most common symptoms at the first visit were fever, fatigue and loss of appetite, but respiratory symptoms were rather rare and moderate . Some cases showed normal chest radiograms at the onset, but during the course of the disease miliary shadows were noticed in all cases . Tuberculin test and smear examination of sputum were not diagnostic . In 4 cases, fiberoptic bronchoscopy had been performed together with bronchoalveolar lavage (BAL), bronchial washing and transbronchial lung biopsy (TBLB) . Smear examination BAL-fluid or bronchial washing for acid-fast bacilli was positive in all 4 cases tested . In 7 cases, serum level of tumor markers (CEA, TPA, SLX, NSE, SCC, CA19-9, CA125, DU-PAN 2 and Elastase I) had been measured under the suspicion of malignant diseases . CEA had elevated in 6 cases, NSE in 2 cases, SLX, TPA, CA19-9, CA125 and DU-PAN 2 in 1 case each, and, as a whole, at least one tumor marker had elevated in 6 of 7 cases tested . Though the degree of such elevation of tumor markers had not been so remarkable except for CA125 in a patient who had been complicated with tuberculous peritonitis, but from these results malignancy had not been' able to rule out.(ABSTRACT TRUNCATED AT 250 WORDS) Antibiot Khimioter, 1994 Nov, 39(11), 53 - 5 {Characterization of microflora in pyo-destructive lung diseases}; Ovsiankin AV et al.; The microflora pattern of the endobronchial secretion was investigated in 74 patients with purulent destructive diseases of the lungs . Specimens of the endobronchial secretion were collected by transtracheal aspiration and bronchoalveolar lavage . The anaerobic isolates were cultivated in anaerostats (OXOID, England) with the use of GasPacks . Bacteriological identification of the pathogens was carried out with respect to 67 patients (90.5 per cent) . Non-sporulating anaerobic microflora was isolated from 51 patients (76.1 per cent) . Anaerobic causative agents in the patients with complicated pulmonary destructions were detected in 54.3 per cent of the cases . Mono-infection represented by one species of the anaerobes was stated in 23 patients (34.4 per cent) . Associations of aerobes and anaerobes were isolated from 28 patients (41.7 per cent) . Associations of one strain of the anaerobic causative agents and aerobic microflora were detected in 17 patients (60.7 per cent) . In 11 patients the microflora pattern was polymicrobial (89.3 per cent) . A total of 66 strains of non-sporulating anaerobic pathogens were isolated . Gram-negative bacilli represented by Prevotella spp., Porphiromonas asaccharolitica and Bacteroides spp . were the most frequent isolates. Nippon Ronen Igakkai Zasshi, 1994 Nov, 31(11), 829 - 34 {Gastroesophageal reflux and respiratory tract infection in tube-fed elderly patients--a comparison between scintigraphy and 24-h pH monitoring}; Ogawa S et al.; Aspiration pneumonia in patients who received enteral feeding via a nasogastric tube may result from retrograde colonization from the stomach, and this may be more likely when the gastroesophageal reflux is severe and the gastric pH is relative high . We investigated 11 elderly patients fed via nasogastric tube with suspected recurrent aspiration pneumonia by means of esophageal scintigraphy, 24-h pH monitoring, gastric pH and concentrations of gram-negative bacilli in gastric aspirates . The grade of respiratory tract infection (RTI) was evaluated by the frequency of episodes of fever with respiratory symptoms . The correlation between the grade of RTI and reflux index by scintigraphy was statistically significant (p < 0.05), but the correlation between the grade of RTI and reflux rate by 24-h pH monitoring was not statistically significant . Although the correlation between gastric pH and log (base 10) concentration of gram-negative bacilli/ml of gastric aspirates was statistically significant (p < 0.001), the correlation between the grade of RTI and gastric pH was not statistically significant . Scintigraphy was superior for evaluation of gastroesophageal reflux resulting in aspiration pneumonia in the tube-fed elderly patients. Eur J Clin Microbiol Infect Dis, 1994 Nov, 13(11), 961 - 79 The new diagnostic mycobacteriology laboratory; Salfinger M et al.; Recent surveys in the USA show that many mycobacteriology laboratories continue to use less-than-optimum culture and susceptibility testing methods . This seems to be true for European countries as well . The past few years have brought significant changes to the clinical tuberculosis laboratory . High-performance liquid chromatography and direct detection of acid-fast bacilli in clinical specimens aim at the same goal: increased sensitivity and specificity of the diagnostic approach and reduction of turnaround time . This review outlines a brief comparison between contemporary traditional methods and the latest developments in the direct detection of acid-fast bacilli . If patient care and public health are always considered paramount, regardless of admission time, hospital type, etc., the current concept of services has several shortcomings . One way to manage this situation is to sort and allocate specimens according to a system of priorities . There is a growing realization that no single method by itself is the best . To streamline the best choice for laboratory diagnosis, an additional dynamic acid-fast network is presented: 'Point-of-Care,' 'Fast Track,' and 'Specialty' laboratories . The physician interacts with all three types of laboratories, so ongoing communication between the physician and the laboratory is essential . Laboratorians must work together in the formation of this dynamic acid-fast network to improve service rendered for our patients. Eur J Clin Microbiol Infect Dis, 1994 Nov, 13(11), 908 - 14 Dormancy of Mycobacterium tuberculosis and latency of disease; Wayne LG; There is ample circumstantial evidence from observation of the natural history of tuberculosis in humans and experimental animals that Mycobacterium tuberculosis is capable of adapting to prolonged periods of dormancy in tissues, and that these dormant bacilli are responsible for latency of the disease itself . Furthermore, the dormant bacilli are resistant to killing by antimycobacterial agents . A systematic evaluation of the mechanism of dormancy, and of attempts to abrogate latency will require a better understanding of the physiologic events that attend the shiftdown into dormancy . There are probably two or more stages in the shiftdown of Mycobacterium tuberculosis from active replication to dormancy as bacilli in unagitated cultures settle through a self-generated O2 gradient into a sediment where O2 is severely limited . One step involves a shift from rapid to slow replication . The other involves complete shutdown of replication, but not death . Presumably this last step includes completion of a round of DNA synthesis . The shiftup on resumption of aeration includes at least three discrete sequential steps, the production of RNA, the ensuing synchronized cell division and, finally, the initiation of a new round of synthesis of DNA . Three markers of the process of shiftdown of Mycobacterium tuberculosis to dormancy have been described, namely the changes in tolerance to anaerobiosis, the production of a unique antigen and the ten-fold increase in glycine dehydrogenase production . Additional markers represented in the shiftup and shiftdown process may yet be discovered, and determination of their specific functions should provide insights into the mechanisms of dormancy and latency in tuberculosis, and into strategies for preventing reactivation of the bacilli and development of disease. Rev Prat, 1994 Oct 15, 44(16), 2214 - 9 {Tuberculous meningitis}; Bazin C; The incidence of tuberculosis has been increasing since 1985 . Favourable host factors associated with non specific neurologic abnormalities must lead to the hypothesis of a meningeal tuberculosis . Blood analysis and radiological findings rarely contribute to the diagnosis . The diagnosis is established when tubercle bacilli are identified in the cerebral-spinal-fluid, sometimes immediately but most often after 4 to 6 week culture . New faster methodes are being developed, but they are not yet routinely available . The treatment must be started before the identification of the tubercle bacilli . Usually, for immunocompetent patient, short-course treatment is chosen, consisting of an initial 2-month intensive treatment (rifampycin, isoniazid, and pyrazinamide) followed by a 4-month maintenance therapy with isoniadid and rifampicin, ethambutol should be included systematically during the first 16 weeks in prevention of isoniazid resistance. Am J Surg Pathol, 1994 Oct, 18(10), 1065 - 8 Spindle cell pseudotumors in the lungs due to Mycobacterium tuberculosis in a transplant patient; Sekosan M et al.; A rare spindle cell pseudotumor in the skin, lymph nodes, and bone marrow has been previously reported in immunosuppressed transplant patients and patients with acquired immunodeficiency syndrome . All reported cases were caused by Mycobacterium avium-intracellulare or other nontuberculous mycobacteria . We are reporting spindle cell pseudotumors in the lungs caused by Mycobacterium tuberculosis . The patient had insulin-dependent diabetes mellitus and was status post cadaveric renal and pancreatic transplants . His hospital course was complicated by pulmonary tuberculosis due to M . tuberculosis . At autopsy, the lungs showed numerous bilateral gray nodules ranging from 0.2 to 2.5 cm . Microscopic examination uncovered a cellular proliferation composed of spindle cells arranged in fascicles . There were no granulomata . An acid-fast stain showed numerous acid-fast bacilli within the spindle cells . To our knowledge, this is the first case of spindle cell pseudotumor caused by M . tuberculosis of the lungs . Awareness of this unusual manifestation of mycobacterial infection in immunosuppressed patients underscores the need for acid-fast staining of biopsies with spindle cell proliferation even in the absence of overt granulomatous lesions in order to prevent misdiagnosis. J Exp Med, 1994 Oct 1, 180(4), 1499 - 509 Apoptosis, but not necrosis, of infected monocytes is coupled with killing of intracellular bacillus Calmette-Guérin; Molloy A et al.; We have examined the effect of killing of host monocytes infected with bacillus Calmette-Guerin (BCG) on the viability of the intracellular mycobacteria . Peripheral blood monocytes were infected in vitro with a single bacillus per cell and maintained in culture for 6-8 d to allow the bacilli to replicate . Replicating viable BCG were found singly in perinuclear vacuoles bounded by tightly apposed lipid bilayers . Monocytes were then exposed to toxic mediators that induced killing of cells as evaluated by 51Cr release into the culture medium . Both hydrogen peroxide (H2O2) (an inducer of cell necrosis) and adenosine triphosphate (ATP4-) (an inducer of cell apoptosis) treatment killed infected monocytes . H2O2-induced killing had no effect on BCG viability . ATP-induced cell death was accompanied by DNA fragmentation and nuclear condensation . Apoptosis was associated with a swelling of the phagocytic vacuoles which became multibacillary and with a reduction of BCG viability as enumerated by colony-forming units. Infect Immun, 1994 Oct, 62(10), 4250 - 5 Vaccination with pure Mycobacterium leprae proteins inhibits M . leprae multiplication in mouse footpads; Gelber RH et al.; In this study, we evaluated vaccination with a number of purified, as well as recombinant, Mycobacterium leprae proteins for protective efficacy in mice . BALB/c mice were immunized intradermally with various native somatic (purified) or recombinant M . leprae proteins and their synthetic polypeptides emulsified in Freund's incomplete adjuvant . The protective efficacy of these preparations was assessed by enumeration of bacilli in the footpads of mice challenged with viable M . leprae 1 to 2 months following immunization . Protection was afforded by the purified and recombinant 10-kDa M . leprae cytoplasmic heat shock protein, the recombinant cell wall-associated 65-kDa M . leprae heat shock protein, and to a lesser extent, the purified 28-kDa M . leprae cytoplasmic protein (superoxide dismutase) . Vaccination with either the purified or recombinant 35-kDa M . leprae cell membrane protein, the synthetic 27-amino-acid N-terminal peptide of the 10-kDa protein, the recombinant 18-kDa M . leprae protein, or the purified 22-kDa cell membrane protein was ineffective . When the interval between immunization and challenge was increased to 6 months, the purified 10-kDa M . leprae protein and the recombinant 65-kDa M . leprae protein lost vaccine efficacy, while a sodium dodecyl sulfate-soluble protein fraction of the M . leprae cell wall (soluble proteins), as had been found previously, continued to protect, suggesting that multiple M . leprae protein epitopes are critical for solid vaccine protection. Radiology, 1994 Oct, 193(1), 115 - 9 Active pulmonary tuberculosis in patients with AIDS: spectrum of radiographic findings (including a normal appearance); Greenberg SD et al.; PURPOSE: To assess the efficacy of chest radiography in the detection of active pulmonary tuberculosis in patients with acquired immunodeficiency syndrome (AIDS) . MATERIALS AND METHODS: Initial interpretations of chest radiographs of 133 adult patients with AIDS and positive sputum or bronchoalveolar lavage cultures for Mycobacterium tuberculosis were reviewed . Radiographic findings were correlated with CD4 T-cell counts, sputum stains for acid-fast bacilli (AFB), and antituberculous drug sensitivity . RESULTS: Forty-eight (36%) patients had a primary M tuberculosis pattern, 38 (28%) had a postprimary M tuberculosis pattern, 19 (14%) had normal radiographs, 17 (13%) had atypical infiltrates, seven (5%) had minimal radiographic changes, and four (3%) had a miliary pattern . Normal chest radiographs were seen for 10 (21%) of 48 patients with less than 200 T cells per microliter and one (5%) of 20 patients with more than 200 T cells per microliter . Drug sensitivity and sputum staining for AFB did not correlate with radiographic findings . Overall, 19% of cases had multidrug resistance to antituberculous medications . CONCLUSION: Chest radiographs did not suggest active tuberculosis in 43 (32%) of 133 AIDS patients with active pulmonary tuberculosis. Tuber Lung Dis, 1994 Oct, 75(5), 348 - 52 Six years' experience with the discontinuation of BCG vaccination . 4 . Protective effect of BCG vaccination against the Mycobacterium avium intracellulare complex; Trnka L et al.; SETTING: In 1986, mass BCG vaccination of newborns was discontinued in an extensive territorial sample of neonates in the Czech Republic (30,000 infants annually) . The non-vaccinated children have since been tuberculin tested at two-year intervals; those with continual or repeated intensive contact with animals in households or on farms were also tested with Mycobacterium avium intracellulare complex sensitin in addition to tuberculin . OBJECTIVE: Within the frame work of the surveillance programme the incidence of infection and disease caused by M . avium intracellulare complex (M . avium complex) was evaluated and the protective effect of BCG vaccination analysed . DESIGN: In 1986-93, out of 190,874 non-vaccinated children, 36 were found to be infected by M . avium complex; 27 of them developed disease, i.e . mycobacteriosis other than tuberculosis (MOTT) . RESULTS: The annual risk of infection with M . avium complex was 4.8/100,000 children per year, of whom 3.6/100,000 developed mycobacteriosis . 24 patients suffered from swelling of cervical lymph nodes, 2 of mediastinal lymph nodes and one child had the disease localized both in cervical and mediastinal lymph nodes . The disease was verified bacteriologically in 9 children . Most of the diseased children had impaired immunity; a marked skin reactivity of M . avium complex sensitin was present in all infected children . Animal sources infected by M . avium complex were detected in 5 cases . Another 14 children also had close contact with animals but without proven M . avium complex infection . CONCLUSION: In non-BCG vaccinated children the incidence of lymphadenitis caused by M . avium complex was considerably higher than in vaccinated children . BCG cells possess antigenic determinants which confer protective immunity probably both against M . tuberculosis and against M . avium complex infections . It may thus be assumed that BCG vaccination protects both against pathogenic tubercle bacilli and M . avium complex . This should be taken into consideration before recommending discontinuation of mass BCG vaccination of newborns in areas with a high prevalence of M . avium complex infection. Antimicrob Agents Chemother, 1994 Oct, 38(10), 2346 - 50 Effectiveness of rifabutin alone or in combination with isoniazid in preventive therapy of mouse tuberculosis; Jabes D et al.; The ever-increasing incidence of tuberculosis calls for the implementation of control measures, including new efficient, short-term preventive therapies to replace 6 to 12 months of isoniazid therapy . The efficacies of 12-week regimens of rifabutin or isoniazid given daily and the combination of the two drugs administered intermittently were evaluated in mice infected with Mycobacterium tuberculosis after vaccination with the bacillus Calmette-Guerin (BCG) to imitate some features of the natural infection in humans with a low number of persisting bacteria . Rifabutin at 10 mg/kg of body weight per day was highly effective as early as the eighth week of treatment: all spleens were sterilized and the number of bacteria was drastically reduced in the lungs (mean +/- standard deviation log CFU, 0.2 +/- 0.3, compared with 5.9 +/- 0.6 for untreated controls) . No bacilli were found in the spleens or lungs of any of the animals treated for 12 weeks . The combination of rifabutin at 10 mg/kg plus isoniazid at 25 mg/kg twice weekly was almost as effective as rifabutin daily: after 8 weeks of treatment only two of six mice harbored a small number of mycobacteria in their spleens and lungs; at week 12, all spleens were sterilized and a total of eight colonies were isolated from the lungs of two of six mice . Daily isoniazid and once-weekly rifabutin plus isoniazid therapies were less effective . Colonies randomly isolated from the spleens and lungs of mice from different experimental groups were also tested for their susceptibilities to the two drugs . The three surviving colonies from rifabutin-treated mice and all colonies from those administered rifabutin plus isoniazid remained fully susceptible to either drug . In contrast, 2 (18%) of the 11 colonies randomly selected from isoniazid-treated mice became resistant to isoniazid (MIC, > 2 micrograms/ml), although they were still susceptible to rifabutin . Three months of treatment with rifabutin, either daily alone or twice a week combined with isoniazid, proved to be a valid candidate for tuberculosis preventive therapy. J Pediatr Surg, 1994 Oct, 29(10), 1323 - 7 230 patient years of experience with home long-term parenteral nutrition in childhood: natural history and life of central venous catheters; Moukarzel AA et al.; The records of 27 pediatric patients who required parenteral nutrition (PN) for 5 to 14.5 years (mean +/- SD, 8.5 +/- 3.8) were analyzed to determine the frequency of complications with their central venous catheters (CVC) . This represents a 230 patient-year experience . Patients with short bowel syndrome and chronic intestinal pseudoobstruction syndrome (CIPS) accounted for all but two of the patients . Unsuccessful medical management of the exit site or CVC infection was responsible for removal of 62% of the 123 CVCs . Ninety-five episodes of line infection occurred in 24 patients . Fifty (52%) were successfully treated without catheter removal . The organisms responsible for catheter removal were fungal (14), mycobacterium species (5), gram-positive cocci (22), or gram-negative bacilli (19) . The CVCs were infected an average of once every 884 days . The life of the second CVC (23.5 +/- 17.9 months) was significantly longer than that of the first (P < .05) . Clotting of the CVC with unsuccessful lysis of the clot was responsible for removal of 24%, and breakage or unsuccessful repair was responsible for 14% . In no patient were all possible venous sites for CVC placement exhausted . Patients with CIPS had substantially fewer catheter complications (P < .05) than did those with short bowel syndrome . In conclusion, CVCs can "survive" without major complications for more than a decade . Numerous factors contribute to the increased rate of CVC survival over time, including improvement in PN self-care with greater experience, improvement in teaching, regular follow-up of patients, better management of infection, and better ability to treat CVC thrombosis or breakage. Clin Infect Dis, 1994 Oct, 19(4), 789 - 91 Paranasal sinus infection due to atypical mycobacteria in two patients with AIDS; Naguib MT et al.; Atypical mycobacteria, which are common opportunistic pathogens in patients with AIDS, have not been previously implicated in the pathogenesis of paranasal sinus infections; we describe two such patients . Clinical and radiographic evidence of bilateral maxillary and ethmoid sinusitis was observed for one patient; his infection proved resistant to therapy with conventional antimicrobials and decongestants . Endoscopic ethmoid sinus biopsy yielded a specimen containing acid-fast bacilli (AFB) that were later identified as Mycobacterium kansasii . Antimycobacterial therapy had not resulted in amelioration of the sinusitis > 2 months later, at which time he died of cerebral toxoplasmosis . The second patient presented with a tender right frontotemporal soft-tissue mass; a computed tomogram disclosed that it extended through the frontal bone to the frontal sinus . Inflamed tissue debrided from the sinus contained AFB; cultures first yielded M . kansasii and later Mycobacterium avium complex . Bacteremia due to both organisms was also demonstrated . Infection progressed despite therapy. Kekkaku, 1994 Oct, 69(10), 627 - 49 {The 69th annual meeting symposium . II: Mechanism of necrotizing granuloma formation and its function} {A therapeutic trial of experimental tuberculosis with gamma-interferon in an immunocompromised mouse model} Kawakami K, Teruya K, Tohyama M, Kudeken N, Saito A. First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus, Okinawa, JapanIt has been well documented that IFN-gamma plays an important role in the host defense against Mycobacterium tuberculosis infection through activating macrophages to kill the organism . In the present study, we studied the effects of in vivo injection of monoclonal antibody against IFN-gamma (anti-IFN-gamma mAb) on the mycobacterial infection to confirm the role of this cytokine . The injection of anti-IFN-gamma mAb suppressed the enhanced expression of MHC class II and ICAM-1 on pulmonary parenchymal macrophages induced by intravenous injection of Mycobacterium bovis BCG . The number of bacilli recovered from lung of mice treated with anti-IFN-gamma mAb and injected with Mycobacterium tuberculosis H37Rv was significantly larger than that of the control infected mice . From these results, it was indicated that anti-IFN-gamma mAb blocked the activities of endogenously synthesized IFN-gamma, thus inhibited the activation of macrophages to kill the bacilli . Next, CD4+ T cell-depleted mice were prepared by injecting anti-CD4 mAb and used as immunocompromised animal . When infected with M . tuberculosis, the multiplication of the bacilli within the lungs of such immunocompromised mice was much more enhanced in comparison with the control mice with intact CD4+ T cells . Administration of IFN-gamma significantly reduced the number of the bacilli in lung . Further, in an in vitro study with human lung macrophages, IFN-gamma enhanced the killing activity of macrophages against M . tuberculosis in a dose dependent manner, and suboptimal dose of 1 alpha, 25-dihydroxyvitamin D3 synergistically augmented the effect of IFN-gamma.(ABSTRACT TRUNCATED AT 250 WORDS) Indian J Chest Dis Allied Sci, 1994 Oct-Dec, 36(4), 187 - 91 Correlative study of histopathology and bacteriology in patients of tubercular lymphadenitis; Kamboj S et al.; Histopathology as well as bacteriology of lymph node specimen are useful diagnostic tools for tuberculous lymphadenitis . In the present study, a total of 71 cases of lymphadenitis were selected for histopathological and bacteriological studies . Only 46 patients had caseating type and 4 had non-caseating type of tuberculous lymphadenitis while 21 patients revealed non-specific chronic lymphadenitis on histopathological examination . Only 6 lymph node smears were positive for acid fast bacilli (AFB), 19 cases were positive for mycobacterial culture growth . Thus, it is not necessary that the cases which are histopathologically positive will be positive for culture as well . Therefore, both bacteriology and histopathology are complimentary diagnostic tools for tuberculous lymphadenitis. J Formos Med Assoc, 1994 Oct, 93(10), 836 - 41 Current role of surgery in the management of pleuropulmonary tuberculosis; Lee YC et al.; This article reviews the recent surgical treatment of patients with pleuropulmonary tuberculosis in the northern Taiwan area . With the advent of effective chemotherapeutic agents and fewer failed medical treatments, the need for surgery has decreased . During the period 1985 to 1991, a total of 62 patients in the northern Taiwan area received surgical treatment for lesions or complications associated with pleuropulmonary tuberculosis . In the majority of cases, patients underwent operations for undiagnosed tumors . Other indications for surgery included tuberculosis cavity with aspergilloma, localized cavity or anatomic residue with a positive acid fast bacilli smear, complications with altered anatomy secondary to tuberculosis and chronic tuberculous empyema . The appropriate selection of patients for surgical intervention should ensure satisfactory surgical results . Surgery continues to play a vital role in the management of certain patients with pleuropulmonary tuberculosis. Bull Cancer, 1994 Oct, 81(10), 871 - 6 {Value of mono-antibiotic therapy using piperacillin associated with sulbactam and possibly followed by vancomycin in febrile neutropenia in solid tumors}; Abs L et al.; We evaluated the efficacy and safety of a monotherapy by piperacillin and sulbactam potentially associated to vancomycin as an empiric antimicrobial therapy in febrile neutropenic patients treated with nephrotoxic chemotherapy for solid tumors . Twenty-three patients were treated during 32 episodes with piperacillin 4 g i.v . every 8 hours and sulbactam 1 g IV every 8 hours . If the patient remained febrile after 48 hours, 1 g of vancomycin i.v . was added every 12 hours as indicated by our study design . The mean duration of neutropenia was 5.5 days (2-13 days) . In ten episodes, the granulocyte nadir was < 100/mm3 . Infection was microbiologically documented in seven episodes (22%) with six Gram negative bacilli and 3 Gram positive cocci . There were 19 apyrexia with piperacillin and sulbactam (59%) and further seven were resolved by the addition of vancomycin (total success: 81%) . Failure was observed in six episodes consecutive to germ resistance (one episode), clinical deterioration (one episode), relapsing fever related to Pseudomonas infection (one episode), persistent fever despite withdrawal of neutropenia and no microbiological documentation (two episodes) and protocol violation (one episode) . Neither septic death nor toxicity were observed . We conclude that this empirical treatment is active and safe in short period febrile neutropenic episodes in patients heavily treated with nephrotoxic chemotherapy for solid tumors. Indian J Lepr, 1994 Oct-Dec, 66(4), 455 - 62 Comparative assessment of viability of M.leprae by mouse foot-pad and fluorescent staining techniques; Sreevatsa et al.; Morphological characteristics have been used as a parameter to assess the viability of M.leprae in leprosy patients . However, with the advent of the mouse foot-pad technique, viability of M.leprae is determined by growing the bacilli in the mouse foot-pad . In recent years, a fluorescent staining technique using fluorescent diacetate-ethidium bromide (FDA-EB) has been used to assess the viability of cultivable mycobacteria as well as M.leprae . The purpose of this study was to compare the viability of M.leprae by both mouse foot-pad and fluorescent staining techniques . M.leprae strains from both untreated and treated patients as well as mouse passaged strains of M.leprae were used for the comparison . Percentage of green-stained bacilli in the inoculum was compared with that of multiplication of M.leprae in the mouse foot-pad . It was observed that there was no correlation between the estimates of viable M.leprae by fluorescent staining and by mouse foot-pad inoculation . FDA-EB staining appears to reflect only trends as absence of green staining cells had overall general correlation with loss of infectivity to mouse foot-pad but, the converse was not found to be true. Indian J Lepr, 1994 Oct-Dec, 66(4), 435 - 42 A clinico-pathological study of macular lesions in leprosy; Kar PK et al.; One hundred twenty histologically confirmed cases of leprosy having macular lesions were evaluated clinically and histopathologically according to Ridley-Jopling classification . Of these 120 cases, the majority (91 or 75.8%) were young adults . The main clinical findings were: a single macule in 42 patients (35%), multiple macules 2-5 in numbers in 35 patients (29.1%), 6-10 macules in 17 patients (14.1%) and more than 10 macules in 26 patients (21.6%) . Impairment of sensation over the macular lesions was present in 62 cases (51.6%), total loss of sensation was noticed in 31 patients (25.8%) and sensation was intact in 27 patients (22.5%) . Acid-fast bacilli were detected in 11 cases (9.1%) by slit-skin smear examination . Clinical examination of the 120 cases revealed features of TT in 16 (13.3%), BT in 41 (34.1%), BB in 11 (9.1%), BL in 13 (10.8%), LL in 7 (5.8%) and indeterminate leprosy (IL) in 32 patients (26.6%) . On the contrary, histologically there were 22 cases of TT (18.3%), 38 cases of BT (31.6%), 8 (6.5%) BB, 10 BL (8.3%), 7 LL (5.8%) and 35 cases of IL (29.1%) . Histopathological features were consistent with the clinical picture in 84 patients (70%). Immunobiology, 1994 Oct, 191(4-5), 461 - 73 Roles of cytotoxic delayed-type hypersensitivity and macrophage-activating cell-mediated immunity in the pathogenesis of tuberculosis; Dannenberg AM Jr; The tubercle bacillus is a facultative intracellular parasite that grows well in non-activated macrophages . When large numbers of these bacilli have grown intracellularly within such macrophages, a cytotoxic immune response, herein called tissue-damaging (or necrotizing) delayed-type hypersensitivity (DTH), kills the macrophages (and usually some of the surrounding tissue), forming the caseous center of the developing tubercle . In solid caseum, tubercle bacilli may survive, but do not multiply . When bacilli escape from the edge of the caseum, they are rapidly ingested by nearby viable macrophages . If these macrophages have not been activated, the bacilli again multiply intracellularly, and the cytotoxic immune response kills the bacilli-laden macrophages (and surrounding tissue), thus enlarging the caseous center . In hosts that develop poor activation of macrophages, this process is repeated until much of the lung is destroyed . In hosts that can develop good activation of macrophages (by cytokines from antigen-specific T cells), herein called cell-mediated immunity (CMI), the caseous centers become surrounded by these activated macrophages, which ingest and destroy the bacilli escaping from the caseum . This process can arrest the disease . Unfortunately, the caseous center may liquefy in such resistant hosts . In the liquefied menstruum, the bacilli may grow extracellularly (for the first time during the course of the disease), reaching tremendous numbers . The cytotoxic immune response to these numerous bacilli and their tuberculin-like products causes much tissue necrosis, including erosion of the walls of small bronchi, which results in cavity formation . From such cavities, the bacilli spread to other parts of the lung and to the environment . The extracellular multiplication of tubercle bacilli in the liquefied caseum is the main reason why tuberculosis perpetuates itself in mankind . It is also the reason why antimicrobial drug-resistant bacillary strains develop . To elucidate the various mechanisms involved in macrophage activation, caseation, and liquefaction is a major challenge for tuberculosis researchers today. Immunobiology, 1994 Oct, 191(4-5), 395 - 401 Mycobacterial infection in guinea pigs; Balasubramanian V et al.; We described published reports of the chaos which exists in research concerning laboratory animal models for assay of tuberculosis (TB) vaccines and proposed a "rational animal model" as a solution to the problem . This animal model, an aerosol challenge model in guinea pigs, was recently applied to the problem of differences in growth characteristics of sputum isolates of low and high virulence . The same model was used to investigate the protective effect of high dose BCG given aerogenically . Based on studies in the guinea pig model of experimental airborne TB, and a review of the literature on pathogenesis of human TB, we described an "integrated model" for the pathogenesis of TB, a model which includes a role for both the endogenous reactivation and the exogenous reinfection pathways . Our hypothesis is that tubercle bacilli must be able to gain access to the "vulnerable region" in the lung apex in order to survive the effects of the CMI response . In endogenous reactivation TB (virulent tubercle bacilli), this access occurs via the bloodstream . Whereas in exogenous reinfection TB, access to the vulnerable region occurs via multiple exposures via the respiratory tract . Central to our perspective is the acceptance of the evidence that during first infection with virulent organisms, tubercle bacilli enter the bloodstream via the efferent lymphatics . We believe the hypotheses we have proposed have the potential to lead to a further increase in our knowledge of these mechanisms and are a prerequisite to studies aimed at the development of new vaccines. Immunobiology, 1994 Oct, 191(4-5), 354 - 68 Immunohistochemical analysis of cell composition and in situ cytokine expression in HIV- and non-HIV-associated tuberculous lymphadenitis; Muller H et al.; Inflammatory cells in lymph nodes of eighteen patients suffering from culture-proven tuberculous lymphadenitis were examined by histological and immunohistochemical techniques . Ten patients suffered from symptomatic HIV-infection and eight patients were immunocompetent individuals without HIV-1 serology . Characteristic granulomas with or without caseation were observed in eight immunocompetent and four HIV-1-infected patients with less marked lymphopenia of CD4 positive peripheral blood lymphocytes . No epitheloid cell formation was present in lymph nodes of HIV1-infected patients with more severe depression of CD4 positive peripheral blood lymphocyte count . Foamy macrophages were found instead of these cells . While many cells--predominantly lymphocytes--express CD25 (IL-2 receptor) in cases with typical epitheloid granulomas there is no such CD25 expression in cases without any epitheloid cell formation . This result suggest that T cell function is necessary for epitheloid granuloma formation in human tuberculosis . The phenotype of macrophages underwent progressive changes parallel to decreasing numbers of CD4 positive peripheral blood lymphocytes . Foamy macrophages in Mycobacterium avium-intracellulare infection represented an end-stage phenotype . They were positive for S100 protein and they did not express lysozyme, alpha-1-anti-chymotrypsin, L1 antigen (Mac387) and CD4, whereas positivity for HLA-DR, CD68 and Ki-M8 was preserved . In situ immunohistochemical demonstration of IFN-alpha, IFN-beta, TNF-alpha, IL-1 and IL-6 revealed that foamy cells in M . tuberculosis infection were highly active effector cells . They contained higher concentrations of the examined cytokines than epitheloid cells in the lesions of HIV+ and HIV-patients . Corresponding to these findings the histological proof of acid-fast bacilli was generally not successful in typical HIV-associated tuberculosis . The foamy appearance may result from the lipid-rich cell membranes of destroyed acid-fast bacilli . In contrast acid-fast bacilli-packed foamy macrophages in AIDS patients with M . avium-intracellulare (MAI) infection did not produce any of the examined cytokines. Immunobiology, 1994 Oct, 191(4-5), 325 - 36 Tuberculosis: distribution, risk factors, mortality; Kochi A; About a century after Koch's discovery of the TB bacilli the tuberculosis epidemic which had appeared to be under control was again recognized as a major global health threat . The decline in the epidemic in this century had been largely through the improved living standards and, eventually, the availability and use of effective antibiotics . While tuberculosis gradually disappeared from the health agenda in the western world it remained a big killer throughout the century and in 1992 an estimated 2.7 million TB deaths occurred; 30 million will die from TB during the 1990s if current trends are not reversed . The annual number of new cases will increase from 7.5 million estimated in 1990 to more than 10 million in the year 2000 . The main factors for this increase are demographic forces, population movements, the HIV epidemic and increasing drug resistance . The impact of the HIV epidemic is already felt in many sub-Saharan African countries and now threatens Asia where almost two-thirds of the world's TB infected population live and where HIV is spreading . Tuberculosis has also reemerged as a major public health problem in industrialized countries due to international migration, the breakdown of health services, including TB services etc . The control of the epidemic can only be through a concerted action to reinstate TB as priority among health concerns, reflected in national and international resources . A coalition of public and private supporters must be mobilized to support the effort to fight the disease . Governments, non-governmental organizations, the business community, refugee organizations, medical institutions, and other UN agencies are invited to join with WHO in this effortPIP: Robert Koch discovered the tuberculosis (TB) bacilli about a century before the epidemic that had appeared to be under control was again recognized as a major global health threat . The decline in the epidemic in this century had been largely through improved living standards and, eventually, the use of antibiotics . While TB gradually disappeared from the health agenda in the Western world, at the end of the 20th century TB is the most important cause of death among infectious diseases . In 1992 an estimated 2.7 million TB deaths occurred, and the global TB death rate was about 50/100,000, with more than 95% of deaths in developing countries . 30 million will die from TB during the 1990s if current trends are not reversed . The annual number of new cases will increase from 7.5 million estimated in 1990 to more than 10 million in the year 2000 . The main factors for this increase are demographic forces, population movements, the HIV epidemic, and increasing drug resistance . The impact of the HIV epidemic is already felt in many Sub-Saharan African countries and now threatens Asia, where almost 2/3 of the world's TB infected population live and where HIV is spreading . One third of the world's population had been infected by TB in mid-1993 and more than 5 million of these were dually infected with HIV and TB . TB has also reemerged as a major public health problem in industrialized countries owing to international migration and the breakdown of health services including TB services . In the US between 1985 and 1991 the number of reported cases increased by 20%, causing 39,000 more cases than expected . Similarly, in eastern Europe and the former Soviet Union the TB situation is deteriorating . In western Europe the low rates of TB have been offset by increasing incidence among foreign born residents . The epidemic can only be controlled through concerted national and international action . J Clin Microbiol, 1994 Oct, 32(10), 2487 - 9 Detection of acid-fast bacilli in concentrated primary specimen smears stained with rhodamine-auramine at room temperature and at 37 degrees C; McCarter YS et al.; Many laboratory workers prefer the rhodamine-auramine method of staining acid-fast bacilli (AFB) in primary specimen smears rather than carbol fuchsin stains because the stain is more readily interpreted and yields greater sensitivity . The increasing incidence of AFB infections serves as an impetus to optimize the rhodamine-auramine stain . A total of 782 primary smears were evaluated blindly by the rhodamine-auramine method at both room temperature and 37 degrees C . Thirty-five smears (4.5%) were positive for AFB, 30 were positive by both methods, and 5 were positive at 37 degrees C only . Room temperature staining detected only 85.7% of the positive primary smears . Of the 30 smears positive by both methods, 13 (43.3%) had equal numbers of AFB on both smears, 13 (43.3%) had more AFB on the smear stained at 37 degrees C, and 4 (13.3%) had greater numbers of AFB on the smear stained at room temperature . No smears were positive only when stained at room temperature . The increasing diagnostic emphasis placed on the primary smear underscores the importance of optimizing AFB smear methods, and rhodamine-auramine staining at 37 degrees C enhances the detection of AFB compared with conventional staining at room temperature. Am J Clin Pathol, 1994 Oct, 102(4), 503 - 7 Coccoid forms of Helicobacter pylori in the human stomach; Chan WY et al.; Helicobacter pylori (HP) may transform from helical bacillary forms to coccoid forms after several days' in vitro incubation . The authors examined 111 consecutive gastrectomy specimens for the presence of coccoid forms of H pylori . Tissues from 64 stomachs (57.7%) showed colonization by H pylori, including 49 cases (76.6%) of adenocarcinoma, 14 cases (21.9%) of benign peptic ulcer, and 1 case (1.6%) of malignant lymphoma . Of these, coccoid forms of H pylori were identified in 53 cases (82.8%) . In hematoxylin-and-eosin-stained sections coccoid forms of H pylori appeared as solid, round, basophilic dotlike structures . Under an electron microscope, coccoid forms of H pylori appeared as U-shaped bacilli, with the ends of the two arms joined by a membranous structure . Ultrastructural findings were identical to those from cultures of H pylori . With anti-Helicobacter antibody, coccoid forms of H pylori were positively stained by immunoperoxidase . Helical bacillary forms of H pylori invariably coexisted with the coccoid forms . By semiquantitative analysis, the number of coccoid forms in adenocarcinoma was significantly (P > .01) greater than that in benign peptic ulcers . This study confirms that H pylori can exist in coccoid forms in the human stomach . Coccoid forms should be distinguished from the pathogenic or nonpathogenic bacterial cocci, fungal spores, and cryptosporidia that may colonize the human stomach. J Immunol, 1994 Sep 15, 153(6), 2568 - 78 Intracellular trafficking in Mycobacterium tuberculosis and Mycobacterium avium-infected macrophages; Xu S et al.; Despite the potential role of the macrophage in the eradication of invading microbes, Mycobacterium species have evolved mechanisms to ensure their survival and replication inside the macrophage . Particles phagocytosed by macrophages normally will be delivered into acid lysosomal compartments for degradation . Mycobacterium must, in some way, avoid this fate by modulation of their phagosome . Immunoelectron microscopy of macrophages infected with Mycobacterium avium or Mycobacterium tuberculosis indicates that the vacuolar membrane surrounding the bacilli possesses the late endosomal/lysosomal marker, LAMP-1 (lysosomal-associated membrane protein-1), but lacks the vesicular proton-ATPase . Analysis of the intersection of the bacteria-containing vacuoles with the endocytic network of the macrophage supports previous studies indicating that these bacilli restrict the fusion capability of their intracellular compartments . The occurrence of vesicles containing lipoarabinomannan, discrete from those containing Mycobacterium, indicate that material does traffic out from the mycobacterial vacuole . To compensate for this loss of membrane, the vacuole must remain dynamic and fuse with LAMP-1-containing vesicles to maintain the density of this marker. Ugeskr Laeger, 1994 Sep 5, 156(36), 5126 - 30 {Pneumonia among patients admitted to intensive care units . An epidemiological multicenter study of APACHE II score, incidence and course}; Petersen IS et al.; Pneumonia in patients in intensive care units (ICU) is associated with several diagnostic difficulties and high mortality . This study was conducted to describe the diagnostic procedures and clinical characteristics of the pneumonic and critically ill patient in relation to APACHE II score . The material consisted of 193 patients admitted to seven Danish ICUs and is also included in a European epidemiologic survey (EURO.NIS) . Twenty-eight (14.5%) developed pneumonia and 18 (9.3%) of these were nosocomial (> 48h after admission) . Patients with pneumonia had a significantly higher APACHE II score, duration of stay and mortality . The techniques used to diagnose pneumonia were mainly conventional and did not or only seldom include protected brush, bronchoalveolar lavage or pulmonary biosy . The predominant pathogens isolated in tracheal aspirate were Gram-negative bacilli (50%) . The APACHE II scoring system was found to stratify patients with respect to mortality, duration of stay and pneumonia diagnosed in ICU. Scand J Immunol, 1994 Sep, 40(3), 345 - 9 Characterization of purified protein derivative of tuberculin by use of monoclonal antibodies: isolation of a delayed-type hypersensitivity reactive component from M . tuberculosis culture filtrate; Klausen J et al.; Nine monoclonal antibodies were raised against purified protein derivative (PPD) of tuberculin in mice previously treated with Bacilli Calmette Guerin (BCG) . The antibodies also reacted with a culture filtrate from Mycobacterium tuberculosis strain H37Rv . In immunoblotting after SDS-PAGE the reaction with PPD was seen as a diffuse smear, whereas ammonium sulphate-precipitated proteins from H37Rv gave well-defined bands ranging from 10 to 65 kDa . Enzyme immunoassay showed that both PPD and H37Rv antigens were able to inhibit binding of the antibodies to PPD coated microtitre wells, suggesting that the antibodies reacted with continuous epitopes . A 12 kDa protein purified by immunoaffinity chromatography from H37Rv antigens was tested intradermally in M . tuberculosis MNC3 sensitized guinea pigs and gave a delayed type hypersensitivity reaction. J Dermatol Surg Oncol, 1994 Sep, 20(9), 613 - 8 Cutaneous-malignancy and leprosy . Report of a patient with Mycobacterium leprae and basal cell carcinoma concurrently present in the same lesion; Ratoosh SL et al.; BACKGROUND . Leprosy is a chronic systemic infection caused by the bacillus Mycobacterium leprae . Cutaneous neoplasms have been observed in patients with leprosy . Also, albeit less commonly, M . leprae have been documented in the lesions of skin cancer . OBJECTIVE . To describe a 62-year-old man with chronic sun exposure and exposure to armadillos who subsequently developed lepromatous leprosy, to discuss the cutaneous malignancies that have occurred in patients with leprosy, and to review the literature concerning the concurrent presence of an infectious pathogen and a cutaneous neoplasm in the same lesion . METHODS . Our patient's basal cell carcinomas were excised, his abdominal plaques were biopsied, and his leprosy infection was treated with dapsone and rifampin . The types of cutaneous malignancies in leprosy patients and infectious pathogens concurrently found in lesions of skin tumors were summarized after evaluating previously published reports . RESULTS . Skin biopsies from our patient demonstrated M . leprae bacilli not only in his abdominal plaques, but also in all of his basal cell carcinoma lesions . Fungal, mycobacterial, and viral pathogens have concurrently been observed in skin lesions of basal cell carcinomas, Kaposi's sarcoma, melanoma, mycosis fungoides, and squamous cell carcinoma . CONCLUSION . Patients with leprosy can develop skin cancers and the histologic interpretation of those skin cancers can show evidence of leprosy . It is uncertain to what degree the decreased cell-mediated immunity in patients with lepromatous leprosy either enhances their susceptibility to and/or influences the course of their cutaneous neoplasms; also, in these patients, the coexistence of M . leprae organisms and cutaneous malignancy in the same lesion is likely to be secondary to the high bacillary load that is present. J Infect Dis, 1994 Sep, 170(3), 729 - 32 Efficacy of topical amoxicillin plus clavulanate/ticarcillin plus clavulanate and clindamycin in contaminated head and neck surgery: effect of antibiotic spectra and duration of therapy; Grandis JR et al.; This prospective, randomized trial was designed to determine the efficacy and mechanism of action of topical mouthwash versus parenterally administered perioperative prophylactic antibiotics in contaminated head and neck surgery . Patients were randomly assigned to 1 of 4 treatment groups: 1 day of parenteral clindamycin (standard prophylaxis), 1 day of topical clindamycin, 5 days of topical clindamycin, or 1 day of topical amoxicillin plus clavulanate/ticarcillin plus clavulanate . Patients who received the latter regimen had fewer bacteria postoperatively compared with the other 3 treatment groups . The number of gram-negative aerobic bacilli on postoperative oral cavity cultures was increased in all 3 clindamycin groups but not in the amoxicillin plus clavulanate/ticarcillin plus clavulanate group . Parenteral clindamycin appears to exert its effect by being in the neck tissues at the time of surgery; however, all 3 topical regimens were more effective at reducing the number of bacteria in the neck viscera . Topical antibiotic prophylaxis was simple, safe, effective, and well tolerated. Infect Immun, 1994 Sep, 62(9), 4066 - 71 Experimental infection of young chicks with attaching and effacing Escherichia coli; Sueyoshi M et al.; Young chicks were inoculated with six different strains of attaching and effacing Escherichia coli isolated from the feces of calves, pigs, chicks, and humans . Colibacilli of some serotypes had colonized the cecum of chicks by 7 days after inoculation . The characteristic lesions associated with bacterial attachment were also seen on the mucosal surface of the cecum . Electron microscopy revealed numerous colibacilli closely attached to the surface membrane of enterocytes . Cell membranes formed cups and pedestals at the base of the attached bacilli . The results of this study support the conclusion that young chicks can be used as a model for the study of the lesions caused by attaching and effacing E . coli strains. Geburtshilfe Frauenheilkd, 1994 Sep, 54(9), 537 - 8 {Tuberculous meningoencephalitis in post-embryo transfer status}; Muller C et al.; A 30-year old pregnant woman, who received an embryo transfer, suffered since the 12th week of pregnancy from therapy-resistant attacks of fever for several weeks . With progressive deterioration, the increasingly somnolent patient showed by now clear signs of meningism and acid-fast bacilli were found in the cerebrospinal fluid . NMR showed a finding consistent with bacterial meningoencephalitis . During therapy with INH, Rifa and EMB, the clinical course and the CSF findings showed rapid improvement . Nevertheless, spontaneous abortion occurred in the 23rd week of pregnancy . Previous history revealed, that granulomatous salpingitis had been diagnosed several years earlier as the reason for infertility. Kekkaku, 1994 Sep, 69(9), 575 - 9 {Commemorative lecture of receiving Imamura Memorial Prize . III . Estimating the year of eradication of tuberculosis in Japan}; Ohmori M; The year by which tuberculosis could be eradicated, has been discussed for several foreign countries, and based on those results, new strategic plans and goals have been elaborated . Therefore, in Japan too, it was desired to estimate the point at which eradication of tuberculosis would be achieved . The author estimated the year of eradication of tuberculosis, according to the criterion proposed by Dr . Styblo that "tuberculosis is eradicated when the prevalence of tuberculosis infection in the general population has fallen below 1% and continues to decrease" . If the risk of infection is changing at a regular rate, it is possible to estimate the risk of infection at any particular time . Once the risk of infection is determined, it is also possible to calculate the age-specific prevalence of infection and the proportion of the population infected with tubercle bacilli at any given time . In Japan, the risk of infection before World War II was assumed to be around 4%; since then, it has declined on average, by 10 to 11% annually . The incidence rate in Japan also has declined, on average, by 10 to 11% annually . However, since late 1970s, the annual speed of decline of the incidence rate has slowed down . Therefore, I assumed that the recent trend of the infection risk is the same as the trend of the recent incidence rate among the 0-29 year age-group . The size of the effect of age on the risk of infection has been discussed . The author also considered age-effects in the model.(ABSTRACT TRUNCATED AT 250 WORDS) Kekkaku, 1994 Sep, 69(9), 555 - 8 {A comparison of pathohistological findings of transbronchial lung biopsy specimens between Mycobacterium tuberculosis and mycobacteria other than Mycobacterium tuberculosis infections}; Maesaki S et al.; The pathohistological findings of transbronchial lung biopsy (TBLB) were compared between Mycobacterium tuberculosis infection (group A) and Mycobacteria other than Mycobacterium tuberculosis (MOTT) infections (group B) . The number of positive pathological findings in TBLB were 14 (70%) in group A and 2 (16%) in group B, respectively . Eleven cases (55%) in group A were positive for acid-fast bacilli in TBLB by Ziehl-Neelsen stain, and 3 cases of group A showed granulomatous lesion in TBLB . In pathohistological findings of group B, 2 cases (16%) were granulomatous lesion, 4 cases (33%) were fibrosis, and 3 cases (25%) were inflammatory changes . The pathohistological examination of TBLB was more useful for the diagnosis of pulmonary tuberculosis than for MOTT infection. Kekkaku, 1994 Sep, 69(9), 549 - 53 {Investigation of tuberculosis among the necropsy staff and environment in necropsy rooms}; Shishido S et al.; We examined the incidence of tuberculosis among necropsy staff and the environment in the necropsy rooms at five medical institutions carrying out a large number of necropsy annually in the metropolis of Tokyo . The following results were obtained: 1) Incidence of tuberculosis was high among necropsy workers . 2) The method of wearing face masks was inadequate . 3) Tubercle bacilli were detected from the necropsy workers' aprons and the air-conditioning equipment of the necropsy room . 4) Formalin treatment of resected organs, especially the lungs, was inadequate . 5) The air conditioners in necropsy rooms were not effective . Considering these findings, improvement of the working conditions and environment of the necropsy rooms is needed. Kekkaku, 1994 Sep, 69(9), 543 - 7 {Experimental tuberculosis infection of guinea pigs in the necropsy room and examination of infection risk using guinea pigs with tuberculosis}; Shishido S et al.; The high incidence of tuberculosis among necropsy workers is well known and several problems related to their working conditions have been pointed out . We investigated the possibility of infection with tubercle bacilli under necropsy working conditions using guinea pigs housed in a necropsy room in which about 2,000 necropsies per year were carried out . Tuberculosis infection developed in one out of five guinea pigs . In addition, we exposed five guinea pigs to tubercle bacilli and sacrificed them in a safety cabinet . The lungs, livers, and spleens were resected, flattened, and sliced finely on a cutting board . Detection of tubercle bacilli from filtered air and the surfaces of the room was attempted, however, no bacilli were cultured . The resected tuberculous lungs were intra-tracheally treated with formalin or physiological saline and the viability of the bacilli in the lung was assessed . Bacilli survived up to two hours after physiological saline injection but no viable organisms were detected after 15 minutes of formalin treatment . These findings indicate that the necropsy room workers were exposed to tuberculosis infection . As a preventive control measure, we recommend to treat tuberculous organs in the safety cabinet and to slice lungs after formalin treatment. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi, 1994 Sep-Oct, 35(5), 455 - 9 Tuberculous peritonitis in a child undergoing continuous ambulatory peritoneal dialysis; Tsai TC et al.; We present a 13-year-old girl with Arnold-Chiari syndrome and uremia secondary to neurogenic bladder . She had been treated with continuous ambulatory peritoneal dialysis (CAPD) for 13 months prior to the development of peritonitis . The patient demonstrated no improvement with a 3-day therapy of intraperitoneal vancomycin and netilmicin . Meanwhile, smear of centrifuged dialysate revealed acid fast bacilli on two occasions . We, then, started anti-TB therapy with oral isoniazid (INAH), rifampin and ethambutal . The symptoms subsided within three days . In the first week, the patient lost her peritoneal ultrafiltration and needed daytime automatic peritoneal dialysis . At the last follow-up examination, 12 months after treatment, she remained well on standard CAPD. Pathol Res Pract, 1994 Sep, 190(8), 782 - 5 Demonstration of mycobacterial antigens in skin biopsies fron suspected leprosy cases in the absence of bacilli; Barbosa Junior Ade A et al.; Skin-biopsies from fifty-six patients suspected of early leprosy from Bahia State, Brazil, were examined histopathologically . The Fite-Faraco staining failed to demonstrate acid-fast bacilli in this material . The prominent features of the lesions were inflammation of the neurovascular bundles and sometimes inflammation of the skin appendages . The non-specific infiltrate was predominantly composed of histiocytes and lymphocytes . In 41 cases (73.2%) epidermal atrophy was also present . The avidin-biotin peroxidase technique was used with primary antibodies to detect bacillary antigens (anti-BCG serum) and nerve branches (anti-S-100 protein serum) . Immunohistochemical detection of bacillary antigens using the anti-BCG serum was positive in 28 cases (50%) . A positive staining for S-100 protein was observed in 40 cases (71.4%) in dendritic antigen-presenting cells of the skin . The detection of bacillary antigens, together with the clear demonstration of nerve bundles enhanced our capacity to fulfill morphologic criteria for the diagnosis of early leprosy . Our observations indicate that the use of immunohistochemical methods represent a useful tool for the early diagnosis of leprosy. Antimicrob Agents Chemother, 1994 Sep, 38(9), 2054 - 8 Metronidazole is bactericidal to dormant cells of Mycobacterium tuberculosis; Wayne LG et al.; Very abrupt exposure to anaerobic conditions has a lethal effect on actively growing cultures of Mycobacterium tuberculosis . However, incubation under conditions in which oxygen is depleted gradually causes M . tuberculosis to shift down from active replication to dormancy . The dormant bacilli are resistant to the bactericidal effects of anaerobiosis and also exhibit partial or complete resistance to the bactericidal effects of isoniazid and rifampin . On the other hand, metronidazole, a drug specific for anaerobes, kills dormant tubercle bacilli under anaerobic conditions, but it has no effect on actively growing aerobic cultures . The lethal effect of metronidazole under anaerobic conditions is enhanced by rifampin . The possible implications of these findings on the phenomenon of latency in tuberculosis are discussed. J Gastroenterol Hepatol, 1994 Sep-Oct, 9(5), 512 - 3 The Loeffler's methylene blue stain: an inexpensive and rapid method for detection of Helicobacter pylori; Misra V et al.; Loeffler's methylene blue, commonly used as a counter-stain for acid fast bacilli, was used to detect Helicobacter pylori in paraffin sections and touch smears of gastric mucosal biopsies from 15 patients with duodenal ulcer and 35 with non-ulcer dyspepsia, and the results were compared with the modified Giemsa stain . The time taken to stain smears by Loeffler's methylene blue was approximately 10 min and the results correlated well with those stained by the modified Giemsa stain . However, the Loeffler's methylene blue method was found to be simpler, quicker and cheaper than the modified Giemsa stain. Can J Surg, 1994 Aug, 37(4), 300 - 6 Unusual presentations of abdominal tuberculosis; Walia HS et al.; OBJECTIVE: To review unusual presenting features and diagnostic difficulties of abdominal tuberculosis in an endemic region . DESIGN: Retrospective clinical study from 1984 to 1989, illustrated by case reports . SETTING: A single hospital in Kuwait . PATIENTS: Fifty patients with abdominal tuberculosis established by the standard histologic and bacteriologic demonstration of acid-fast bacilli or tuberculous granulomas . MAIN OUTCOME MEASURES: Site of disease and unusual features at presentation . RESULTS: Tubercular lesions are most commonly seen in the ileocecal region . They are also common in the ileum but are less common in the appendix and jejunum . Involvement of the ascending colon, rectum and upper gastrointestinal tract is rare . Abdominal tuberculosis presents in many ways depending on the degrees of ulceration, fibrous healing, infection and caseating abscess formation . CONCLUSIONS: Abdominal tuberculosis should be considered in immigrants from regions where this disease is endemic who present with abdominal signs and symptoms . Imaging studies, endoscopy and laparoscopy may preclude laparotomy for the diagnosis of abdominal tuberculosis . Antituberculosis chemotherapy is the mainstay of treatment. Infect Control Hosp Epidemiol, 1994 Aug, 15(8), 536 - 9 Utility of the hospital tuberculosis registry; Bryan CS et al.; Emerging guidelines suggest that the management of tuberculosis and suspected tuberculosis in the hospital will become an increasingly costly enterprise . The local hospital registry can be a focal point for determining the extent to which such measures are necessary at individual institutions, that existing infection control recommendations are being carried out, and that patients released from the hospital are not lost to follow-up . Consideration might be given to inclusion of all patients begun on antituberculous therapy, regardless of the results of acid-fast bacilli cultures, in view of renewed concern about patient compliance. Infect Control Hosp Epidemiol, 1994 Aug, 15(8), 513 - 5 Changing patterns of mycobacterial disease at a teaching community hospital; Cox JN et al.; OBJECTIVES: To evaluate trends in the occurrence and diagnosis of mycobacterial disease . DESIGN: Prospective surveillance study using a central tuberculosis registry at a 611-bed teaching community hospital . RESULTS: Data pertaining to 715 patients were entered into the registry between 1976 and 1991 on the basis of positive smears or cultures for acid-fast bacilli (AFB) . Over time, the ratio of isolates of Mycobacterium tuberculosis to isolates of nontuberculous mycobacteria reversed (from 3.2 to 1 between 1976 and 1981 to 1 to 1.6 between 1986 and 1991) . The sensitivity of the sputum AFB smear for diagnosis of pulmonary tuberculosis increased (from 0.73 to 0.96), but the positive predictive value of the sputum AFB smear declined (from 0.72 to 0.59) . The acquired immunodeficiency syndrome epidemic accounted for these changes only to a small extent . CONCLUSIONS: The increasing occurrence of non-tuberculous mycobacterial disease and the declining positive predictive value of the sputum AFB smear at this hospital imply that respiratory isolation and antituberculous therapy will be used inappropriately for many patients . The development and use of newer tests for early isolation and specific identification of M tuberculosis should be accelerated. Tuber Lung Dis, 1994 Aug, 75(4), 286 - 90 Single and double drug susceptibility testing of Mycobacterium avium complex and mycobacteria other than the tubercle (MOTT) bacilli by a micro-dilution broth minimum inhibitory concentration (MIC) method; Telles MA et al.; SETTING: The incidence of Mycobacterioses is increasing annually, especially in patients with AIDS . There is no clear correlation between in vitro drug susceptibility testing of mycobacteria other than the tubercle (MOTT) bacilli and the in vivo response . Although in vitro, MOTT bacilli appear resistant, some patients respond to treatment possibly as a result of a synergistic action between the drugs being used . OBJECTIVE: To produce a simple method to determine which individual drugs or combinations of drugs will be effective in killing the causative organism . DESIGN: A broth microdilution method, using microtitre plates, was used to determine the minimum inhibitory concentration (MIC) of the drugs alone and then in combination . RESULTS: It was found that the MIC values of the test drugs varied between but were constant within each of the species . Mycobacterium xenopi, M . malmoense and M . kansasii showed a large amount of susceptibility while M . avium complex, M . fortuitum and M . chelonae were limited in their response . These results were reproducible . The test was also easy to perform . The drug combination studies showed that each strain of the M . avium complex tested exhibited synergy between different combinations of drugs . CONCLUSION: This method, therefore, can be used to indicate individual or combinations of drugs that will or will not act upon the Mycobacterium species isolated . The method was also very rapid, giving a result within 7 days. Tuber Lung Dis, 1994 Aug, 75(4), 266 - 70 Six years' experience with the discontinuation of BCG vaccination . 3 . Transmission of tubercle bacilli in an unvaccinated population; Dankova D et al.; SETTING: Mass BCG vaccination of newborns has been discontinued since 1986 in one third of the Czech Republic (30,000 newborns annually) except for babies with a high risk of tuberculosis . OBJECTIVE: The transmission and risk of tuberculosis infection were evaluated in non-BCG-vaccinated children representing a population living in satisfactory socio-economic conditions . DESIGN: In 1986-92, of 184,648 children tuberculin tested at 2-year intervals, 283 were infected . RESULTS: The risk of infection was low (0.04%) . Infections very rarely occurred in children below the age of 1 year and the highest rate was in children 2-3 years old . The sources of infection were found in the families of only one half of the youngest children and in 10% of the older ones . In the remaining children occasional contacts with sources outside the family must be taken into account, but the mode of contact and transmission of infection were not identified . The only factor contributing to tuberculosis transmission was the high population density . CONCLUSION: The risk of infection was low and identified sources of tuberculosis were rare in a stable population of children without evident risk factors . Children were infected by occasional contact with tuberculous cases outside of their families . The unfavourable factors associated with living in overcrowded industrialised settlements contributed to the risk of infection of non-BCG-vaccinated children. Kekkaku, 1994 Aug, 69(8), 503 - 11 {An investigation on risk factors relating to the treatment difficulty in originally treated pulmonary tuberculosis cases}; Kitahara Y et al.; In order to investigate whether so-called risk factors relating to treatment difficulty are true risk or not, treatment results of 520 in-patients originally treated for pulmonary tuberculosis during 12 years' period from 1980 to 1991 in our hospital were analyzed . The proportion of cases with so-called risk factors among total 520 cases was as follows: Aged patients (70 years of age and over) 31.5% . Cases discharging abundant bacilli in sputum (Gaffky scale VII or above or culture, +3 positive) 29.4% . Adverse reactions to drugs 18.1% . Far advanced cavitary lesions (GAKKAI Classification I or II3) 15.6% . Relative risk of various risk factors in cases of group A (died of tuberculosis), group B (showed delay in the negative conversion of bacilli; namely, cases converted to negative only 4th month of treatment or later) and group C (cases of groups A and B) were calculated comparing with cases of the control group (pretreatment negative bacilli cases or cases converted to negative within 3 months) . In cases of group A died of tuberculosis, the results were as follows; pretreatment abundant bacilli discharge 3.1, far advanced cavitary lesions 4.6, emaciation and/or malnutrition 5.1 . Other risk factors identified were the following; unhealthy life style 4.0, severe gastrointestinal tract disease 3.9, impaired pulmonary function 3.3, complicated infections 3.2, cerebrovascular injuries including psychosis and nervous system diseases 2.3, diabetes mellitus 2.0, and the adverse reactions to drugs 1.9 . In cases of group B showing delay in the negative conversion of bacilli, significant risk factors were pretreatment abundant bacilli discharge, far advanced cavitary lesions, emaciation and/or malnutrition and diabetes mellitus.(ABSTRACT TRUNCATED AT 250 WORDS) Masui, 1994 Aug, 43(8), 1243 - 7 {The effects of H2 blockers on gastric flora and sputum culture}; Noguchi J et al.; Gastric juice and sputum of 12 patients, who had entered the intensive care unit postoperatively and received respiratory management, were examined for bacteria and their relationship with gastric pH was investigated . Gastric bacteria were detected in only 3 specimens out of 14 (21.4%) when the pH was under 3.5, and when the pH was above 3.5, gastric bacteria were detected in 33 specimens out of 35 (94.3%) . Proliferation of gastric flora was observed as the pH increased . In 7 cases, Gram-negative bacilli (important etiologically as a cause of pneumonia) were detected . Gram-negative bacilli were also detected in sputum culture and these were found to be of the same bacteria type as those found in the gastric juice . However, no evident cases of pneumonia were observed, and proliferation of gastric bacteria did not increase the incidence of postoperative pneumonia. Kansenshogaku Zasshi, 1994 Aug, 68(8), 982 - 5 {A case report of atypical tuberculous spondylitis}; Uno M et al.; A 22-year-old male was admitted to our hospital because of progressive weakness of bilateral lower limbs on October 29, 1992 . He also complained of cough, sputum and back pain for 6 months . He had no history of underlying disease . His family history disclosed that his elder brother had tuberculous peritonitis . Chest radiogram on admission showed an abnormal shadow around the right first arch . Computerized tomogram revealed osteolytic lesions of the vertebral corpus and posterior elements at the level of C3, Th5, and Th11 . Metastatic bone tumor was strongly suspected and surgical decompression was done on November 12 . Histologic findings of the bone showed caseation and Langhans's giant cells, and acid fast bacilli were isolated . He was treated with anti-tubercular chemotherapy and showed remarkable relief of his symptoms over a period of 6 months therapy . This was a case of atypical tuberculous spondylitis . The main locus existed at the posterior elements of the vertebra and the distribution of vertebral lesions was multiple including cervical spine. East Afr Med J, 1994 Aug, 71(8), 496 - 500 Endoscopic study of African AIDS patients with upper gastrointestinal symptoms; Elshazly MA et al.; This study was carried out to investigate the endoscopic and histopathological findings in AIDS patients in Mulago Hospital, in Uganda who present with upper gastrointestinal symptoms . Any observed morphological changes were biopsied . Duodenal contents were aspirated in each case for microscopic examination . Vomiting was reported in 100% of the patients, dysphagia and epigastric pain were reported in 89% . Other symptoms reported in decreasing frequency were odynophagia 46%, retrosternal chest pain 40%, haematemesis 10%, and hiccough 3% . Up to 74% of the patients had morphological changes in the oesophagus, while 28% showed changes in the stomach . Only 15% demonstrated changes in the duodenum . Duodenal aspirate revealed giardia lamblia 22%, Acid fast bacilli 7% and cryptosporidium 5% . Endoscopic findings were mostly observed in the oesophagus . Candida was the main pathogen detected . Also atrophic gastritis is a recognizable finding in these patientsPIP: 50-90% of people with AIDS experience disease of the upper gastrointestinal tract during the course of their illness, such as opportunistic infections, cytomegalovirus, Herpes simplex virus, and malignant neoplasms . This paper reports the endoscopic and histopathological findings among 100 AIDS patients in Mulago Hospital, Kampala, Uganda, who presented with upper gastrointestinal symptoms . The diagnosis of AIDS was based upon the World Health Organization clinical definition for AIDS . Observed morphological changes were biopsied, while duodenal contents were aspirated in each case for microscopic examination . Vomiting was reported among all patients, dysphagia and epigastric pain in 89%, odynophagia in 46%, retrosternal chest pain in 40%, haematemesis in 10%, and hiccough in 3% . Up to 74% of the patients had morphological changes in the esophagus, while 28% showed changes in the stomach . Only 15% demonstrated changes in the duodenum . Duodenal aspirate revealed giardia lamblia among 22%, acid fast bacilli in 7%, and cryptosporidium in 5% . Endoscopic findings were mostly observed in the esophagus . Candida was the main pathogen detected . Atrophic gastritis was also a recognizable finding among these patients . QJM, 1994 Aug, 87(8), 511 - 8 Relapsing bacterial meningitis in adults; Tang LM et al.; Relapsing bacterial meningitis is a rare condition, diagnosed in eight patients between 1981 and 1993 at our institution . These accounted for 3.4% of 234 adult patients with blood and/or cerebrospinal fluid culture-proven bacterial meningitis . A review of the English-language literature from 1966 to the present revealed only five further adult cases of relapsing bacterial meningitis with in-depth case histories . Of these 13 total patients, nine were female and four male, aged 17-61 years . Ten were neurosurgical patients . Gram-negative bacilli, especially Klebsiella species, were the commonest micro-organisms identified for both the initial episode and the relapse of infection . Three patients died in the course of relapse . Four or more weeks of antibiotic therapy may be needed to treat post-surgical patients with Gram-negative bacillary meningitis . Even a normal cerebrospinal fluid study at the end of treatment of bacterial meningitis is not a guarantee of freedom from relapse. Clin Infect Dis, 1994 Aug, 19(2), 334 - 6 High predictive value of the acid-fast smear for Mycobacterium tuberculosis despite the high prevalence of Mycobacterium avium complex in respiratory specimens; Yajko DM et al.; The value of the smear for acid-fast bacilli in predicting pulmonary tuberculosis is unclear in a setting where there is a high prevalence of Mycobacterium avium complex in respiratory specimens . To evaluate the impact of a high prevalence of M . avium complex on the predictive value of the acid-fast bacilli smear for tuberculosis, we reviewed findings on smears and results of cultures over a 3-year period at a hospital where M . avium complex is the predominant mycobacterial isolate . In this setting, the predictive value of the acid-fast bacilli smear for Mycobacterium tuberculosis was 92% for expectorated sputum specimens, 71% for induced sputum specimens, and 71% for bronchoalveolar lavage specimens . When multiple specimens collected from the same patient were excluded from the data base, the predictive values were 87%, 70%, and 71%, respectively . Smears of sputum samples were positive at the same rate for patients with tuberculosis who had AIDS and for patients with tuberculosis who did not have AIDS. Vet Rec, 1994 Jul 23, 135(4), 82 - 5 Serodiagnosis of Mycobacterium bovis infection in badgers: development of an indirect ELISA using a 25 kDa antigen; Goodger J et al.; A 25 kDa antigen of Mycobacterium bovis has previously been identified as immunodominant during badger infections . This 25 kDa antigen was partially purified from sonicated M bovis bacilli by using water precipitation and ion exchange chromatography, and its purification was monitored with a mouse monoclonal antibody, MBS43, which was specific for the antigen . The partly purified antigen was used to develop an ELISA for the assay of badger sera for the presence of specific antibodies . A presumed negative badger population was used to calculate the assay's threshold of seropositivity and using this value, its sensitivity (37 percent) and specificity (98 percent) were determined in a second population of known culture status . The results indicate that it may be possible to develop a specific and cost effective serological field assay for the diagnosis of M bovis infection in living badgers. Kansenshogaku Zasshi, 1994 Jul, 68(7), 932 - 6 {A case report of miliary tuberculosis with acute respiratory failure diagnosed by polymerase chain reaction method}; Kohagura N et al.; A 51-year-old male was admitted because of cough and high fever . His chest X-ray and CT revealed miliary shadows, he was administered some antibiotics . But on the 8th day, his chest X-ray revealed ground glass shadows and he was under severe hypoxemia . We suspected miliary tuberculosis with acute respiratory failure due to his clinical course . The intensive therapy with antituberculosis drugs, hydrocortisone (1 g/day) was started and intubation was performed . The smear of the clinical samples did not show acid-fast bacilli on admission . However, by the polymerase chain reaction amplification method specific DNA fragments of Mycobacterium tuberculosis complex were detected from BALF and bone marrow . He was extubated after the 13th day and he recovered . It is difficult to separate and identify tubercle bacilli rapidly, but PCR is available for early diagnosis. Kekkaku, 1994 Jul, 69(7), 463 - 9 {A nutritional and immunological investigation of patients with tuberculosis}; Handa M; In recent years, the rate of decrease of the number of new patients with tuberculosis has slowed down . The aging of the Japanese population partially accounts for the increase in the number of patients with tuberculosis . The disease is often transmitted from these aged patients to those who were uninfected . Since it is well-known that a poor nutritional condition lowers the immunological resistance to tuberculosis, we used Onodera's PNI (Prognostic Nutritional Index; 10 x serum albumin concentration + 0.005 x peripheral lymphocyte count) as a parameter to check the nutritional condition and immunological deficiency in patients suffering from tuberculosis . We examined a total of 451 patients with tuberculosis who were admitted to our hospital from 1987 to 1991 . The PNI value decreased with age and was low in patients with extensive lesions on chest X-ray as well as in those with complications, PNI was also low in patients showing negative tuberculin skin reaction, and increased with the intensification of the positive reaction . In patients showing negative conversion of bacilli during treatment, PNI value on admission increased significantly immediately before discharge . Patients with percent ideal body weight (IBW, calculated by the Broca's method modified by Katsura) on admission less than 90% accounted for 48.6% of all patients . There was a positive correlation between PNI and an obesity index (P < 0.01, r = 0.24) . After admission, in patients showing negative conversion of bacilli, there was a positive correlation between the increase in PNI and the gain of body weight (P < 0.01, r = 0.30).(ABSTRACT TRUNCATED AT 250 WORDS) Gut, 1994 Jul, 35(7), 1001 - 3 Interrelation of strongyloidiasis and tuberculosis; Dwarakanath AD et al.; A 31 year old man from Gambia, resident in the United Kingdom for two years, presented with a two month history of unproductive cough, malaise, weight loss, non-specific abdominal pain, and episodic diarrhoea . Acid alcohol fast bacilli were identified in his sputum, together with Strongyloides stercoralis larvae and Giardia lamblia cysts in his stools . This case illustrates that latent strongyloidiasis can become overt in the presence of tuberculosis, and the diagnosis of strongyloidiasis must be borne in mind in patients who have previously resided in endemic regions. Infection, 1994 Jul-Aug, 22(4), 287 - 9 Pancreatic tuberculosis mimicking pancreatic head carcinoma: a case report and review of the literature; Wu CS et al.; A 24-year-old man presented with vague abdominal fullness and a mild epigastric dull pain for about 3 months was found to have a pancreatic head tumor at a medical center 2 months ago . He came to our hospital for further treatment . Ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP) and abdominal computed tomography (CT) all revealede a pancreatic head tumor . Laparotomy was performed because pancreatic head carcinoma was highly suspected . Indurated mass in the pancreatic head, enlarged lymph nodes and white tubercles on the intestine proved to be tuberculosis on histological examination of a frozen section . Acid fast bacilli were also found . The patient was given antituberculous therapy and is now doing well . To avoid unnecessary laparotomy, CT, echo-guided percutaneous aspiration cytology or biopsy and culture of the tissue for mycobacteria should be done in a patient with pancreatic mass, especially in a region where pulmonary and abdominal tuberculosis are common. Proc Natl Sci Counc Repub China B, 1994 Jul, 18(3), 95 - 100 Improvement of penicillin G acylase production by using pac gene clone; Liu YT et al.; The penicillin G acylase gene (pac gene) from Escherichia coli ATCC 9637 has been isolated . It conferred the production of penicillin G acylase upon E . coli HB101 and other enteric bacilli . Restriction enzyme analysis and subcloning studies reveal that the gene is contained within a 2.3 kb HindIII-SmaI DNA fragment . In vitro protein synthesis study suggests a gene product of approximately 90 kDa . By using the genetically engineered bacteria which harbor a novel recombinant plasmid (pGL5) bearing a constitutively expressible pac gene, a 20-fold increased production yield of penicillin G acylase activity was obtained as compared with that produced by the original strain, E . coli ATCC 9637. J Indian Med Assoc, 1994 Jul, 92(7), 219 - 20 Microflora in postirradiated cancer cervix; Chatterjee BD et al.; Cases of cancer cervix receiving radiation therapy revealed more anaerobes (50%) in comparison to normal controls (44.6%) . The aerobic organisms were suppressed in the former cases (63.6%) in contrast to the latter group (90.7%) . Of the anaerobes, the Gram-negative bacilli were more notable (18.1%) in cancer cervix than the normal controls (4.6%) . The anaerobes like Peptococcus prevotii (18.1%) and Bacteroides oralis (9%) and the aerobes, Staph aureus (13.6%) and klebsiella (13.6%) were prevalent in cancer cervix . The higher incidence of aerobic and anaerobic organisms in stage III elderly (> 45 years) patients of cancer cervix may necessitate antibacterial therapy. Ultrastruct Pathol, 1994 Jul-Aug, 18(4), 423 - 32 Ultrastructural study across the leprosy spectrum; Ortega VV et al.; We have carried out a systematic ultrastructural study of the bacilli, the cell-mediated response in the host, and the dermal microvasculature in lepromatous (LL), borderline lepromatous (BL), and borderline tuberculoid (BT) types of active leprosy (eight cases) . In the types of least resistance (LL and BL), macrophages with large cytoplasmic processes were observed; in addition, numerous peripheral vacuoles were found in BL . Mast cells were abundant and vascular alterations constant . BT macrophages showed more regular outlines and multivacuolated cytoplasms with plentiful rough endoplasmic reticulum . Giant cells were scarce . Bacilli, both isolated and in globi, were contained within the vacuoles and appeared constantly in macrophages and endothelial and Schwann cells in LL and BL . Conversely, in BT they were found singly, infrequently in the endothelial cells, and not at all in Schwann cells . Forms in the process of destruction or degradation were more common than intact forms, in which the symmetric outline of the membrane could be seen clearly. Nippon Rai Gakkai Zasshi, 1994 Jul, 63(2), 35 - 46 On the beta-glucuronidase binding protein (BGBP) of microorganisms . Its purification, the antiserum preparation against that and its localization in leproma and the other infectious lesions shown by immunohistologic method; Matsuo E et al.; Our previous studies suggested that M . leprae (ML) grow in peripheral nerves and lepra cells because ML metabolize hyaluronic acid (HA), and use its component for their growth by the aid of host enzyme combined to the bacilli derived beta-glucuronidase binding protein (BGBP) . In this study, therefore, we examined the method to purify BGBP from a mycobacterium HI-75 originally separated from a leproma and cultured by modified Ogawa's medium containing split products of HA (glucuronic acid and N-acetylglucosamine) . The distribution of BGBP in leproma and the other lesions consisting of hepatitis B virus infected liver and M . avium-intracellulare infected lung tissue were also immunohistologically examined . As the result, the best method to get BGBP was preparatory electrophoresis in the final step of the purification and not the molecular sieving . The BGBP was actually proven in leproma and the other infected tissues as described, indicating the abilities of these microorganisms to utilize the metabolic machinery of the host with the similar ways to that of ML. Indian J Chest Dis Allied Sci, 1994 Jul-Sep, 36(3), 125 - 31 Evaluation of a cold staining method for acid-fast bacilli in sputum; Mathew S et al.; Comparison between the Ziehl-Neelsen staining method for acid-fast bacilli, applied with and without heating, was carried out in a controlled investigation using smears prepared from 306 sputum samples collected prior to treatment from suspected cases of pulmonary tuberculosis . Smear and culture positivity were graded and the colour intensity of bacilli recorded . Results showed that the chance corrected agreement (Kappa) between Z-N and cold methods was only 78% . The sensitivity of the Z-N and cold methods were 84% and 77% respectively when compared with culture results . Assuming 10% smear positivity among symptomatics reporting to Peripheral Health Institutions (PHIs), the positive predictive value of the cold method was very low (53%) . When compared to culture, the positive predictive value is 71% for the Z-N method and 57% for the cold method for a symptomatic population with 15% culture positivity