Scrofula Revisited: An Update on the Diagnosis and Management of Tuberculosis of Superficial Lymphnodes

Lymphnode tuberculosis is a disease of great antiquity. It is the commonest form of extra-pulmonary tuberculosis, and is probably the commonest cause of chronic lymphadenitis in children. Even after the advent of effective chemotherapy for tuberculosis, it still poses considerable problems in diagnosis and management. The disease usually presents as a painless lymphadenopathy of the superficial lymphnodes of insidious onset, which may proceed to abscess and sinus formation if neglected. Cervical nodes are most commonly affected, but multiple node involvement is common. Differential diagnosis include other infections, neoplasia, congenital conditions in the head and neck and rarely, drug reactions. Diagnosis, whenever feasible, should be made on the basis of histological evidence after lymphnode biopsy. Diagnosis, made on clinical grounds has poor specificity and will result in a great degree of over diagnosis. Recently, the role of fine needle aspiration cytology as an initial screening procedure has been recognized. The Tuberculosis Research Centre carried out the first clinical trial which established the efficacy of short course chemotherapy in the treatment of childhood lymphnode tuberculosis. In 168 children with biopsy confirmed lymphnode tuberculosis treated with an intermittent six month regimen, the cure rate after five years was 95%. The Revised National Tuberculosis Control Programme recommends that patients with lymphnode tuberculosis (Category 3) should be treated with rifampicin and isoniazid three times a week for six months, with pyrazinamide for the first two months

Current trends in chemotherapy of tuberculosis

After treptomycin, which heralded the era of antibacterial chemotherapy for tuberculosis (TB), many important advances have made available treatment regimens that are almost 100 per cent curative. Randomised clinical trials by the Tuberculosis Research Centre, in Chennai and British Medical Research Council in East Africa and in the Far East have helped to establish many of the principles of antituberculosis chemotherapy. With successes have also come fresh challenges. Mycobacterium tuberculosis becomes rapidly resistant to the drugs used against it and in the last decade, the HIV epidemic has had an adverse impact on the global epidemiology of tuberculosis, with many countries in Sub-Saharan Africa experiencing a 2-3 fold increase in their TB burden. While the currently recommended treatment regimens are very effective, they have failed to control the burden of TB in the developing countries due to less than satisfactory implementation of the control programmes. Faced with the dual threat of multidrug resistant TB and the HIV/facilitated increase in TB, the WHO has instituted a Global TB Control Programme based on the directly observed treatment shortcourse (DOTS) strategy. Much of the principles of this strategy have come out of research in India. As part of this strategy, the Government of India is implementing a Revised National Tuberculosis Control Programme (RNTCP). Under the RNTCP standardized treatment regimens are prescribed for different treatment categories. Already more than 80 per cent of the population is covered by this Programme and full coverage is slated for 2005. Meanwhile, fresh research is ongoing to shorten treatment duration, a measure that should greatly aid TB control

Rifampicin-induced renal toxicity during retreatment of patients with pulmonary tuberculosis

Rifampicin is a crucial component of treatment regimens for tuberculosis and has been in use since the early 1970’s. It is usually considered safe. Rarely life-threatening complications like acute renal failure or acute thrombocytopaenia may manifest during treatment with rifampicin. In our experience at the Tuberculosis Research Centre of treating more than 8000 pulmonary and extrapulmonary tuberculosis patients with rifampicin-containing regimens over the last 30 years, we are reporting 3 cases of probably rifampicininduced acute renal failure. Despite extreme therapeutic safety of this drug the clinician must be aware of this rare complication, which if detected early is completely reversible

Role of Non-Governmental Organizations in Tuberculosis control

Our experience over the last 18 months has given us hope that NGOs have great potential as an effective task force in augmenting the efforts of the government in tuberculosis control activities. They have been successful in identifying and referring chest symptomatics to us. In the near future,we hope to test out strategies for utilising their services in case-holding and supervised administration of chemotherapy

Persistng alveolitis in miliary tuberculosis despite treatment with short-course chemotherapy

Bronchoalveolar lavages in two patients with miliary tuberculosis have shown lymphocytic alveolitis. A 6-month regimen with an initial intensive 2- month phase resulted in remarkable clinical and radiographic improvement in both. However, bronchoalveolar lavage following treatment has shown that there was a persistence of lymphocytic alveolitis, though with reduced intensity. The significance of the persisting alveolitis, despite treatment, is not known at present. There is also a suggestion that compartment-alisation of lymphocytes may occur in miliary tuberculosis of the lung

Evaluation of mycobacterium tuberculosis antigen 6 by enzyme linked immunosorbent assay (ELISA)

Mycobacterium tuberculosis Antigen 6, which is a 30 KDa protein purified by DEAE-Cellulose chromatography, was evaluated by enzyme linked immunosorbent assay (ELISA) for its sensitivity and specificity for antibody detection in sera from patients with pulmonary tuberculosis. Purified Protein Derivative (PPD) was used for comparison. Antigen 6 could detect 89% of bacteriologically confirmed cases and 32% of bacteriologically negative cases. However, 25% of the healthy volunteers also had positive antibody levels. Among the treated, inactive cases of tuberculosis 44% had higher antibodies. Thus, because of the low specificity and persisting antibody titres, Antigen 6 cannot be used in diagnostic or prognostic tests

Phase Change Material on Augmentation of Fresh Water Production Using Pyramid Solar Still

The augmentation of fresh water and increase in the solar still efficiency of a triangular pyramid is added with phase change material (PCM) on the basin. Experimental studies were conducted and the effects of production of fresh water with and without PCM were investigated. Using paraffin as the PCM material, performance of the solar still were conducted on a hot, humid climate of Chennai (13°5′ 2" North, 80°16′ 12"East), India. The use of paraffin wax increases the latent heat storage so that the energy is stored in the PCM and in the absence of solar radiation it rejects its stored heat into the basin for further evaporation of water from the basin. Temperatures of water, Tw, Temperature of phase change material, TPCM, Temperature of cover, Tc were measured using thermocouple. Results show that there is an increase of maximum 20%, in productivity of fresh water with PCM

Liver function tests during treatment of tuberculosis with short-course regimens containing isoniazid, rifampicin & pyrazinamide

Serial liver function tests (aspartate amino transferase–AST, alanine amino transferase– ALT and total bilirubin) were undertaken in patients admitted to controlled clinical trials for the treatment of tuberculous meningitis and pulmonary tuberculosis. In patients with tuberculous meningitis, daily treatment with isoniazid 20 mg/kg in addition to rifampicin 12 mg/kg resulted in a significant increase in the activities of both AST and ALT; there was no appreciable change with regimens containing isoniazid 12 mg/kg. In two studies on pulmonary tuberculosis, there was a significant increase in the activities of both enzymes following 2 or 3 months of treatment with daily streptomycin, isoniazid and pyrazinamide with or without rifampicin. No appreciable differences were observed between patients who received rifampicin and those who did not and also between slow and rapid acetylators of isoniazid. Serum total bilirubin showed a significant decrease following treatment for 2 months with a daily regimen containing rifampicin in patients with tuberculous meningitis and also in those with pulmonary tuberculosis. A comparison of patients who developed jaundice during treatment with anti-tuberculosis drugs and others who had jaundice presumably due to infective hepatitis revealed lower mean values for total bilirubin, AST and ALT in the former group (by 48–64%) than in the latter (P < 0.02). There was, however, considerable overlap between the two groups in the distributions of all parameters

Rifampicin-induced acute thrombocytopenia.

Rifampicin is an essential component of the treatment regimen for tuberculosis. Extensive clinical experience has shown that the drug is well tolerated, but on rare occasions it can cause life threatening adverse reactions like acute renal failure and thrombocytopenia. At the Tuberculosis Research Centre, we have treated more than 8000 patients with pulmonary and extra-pulmonary tuberculosis with rifampicin-containing regimens over the past 30 years and we are reporting a case of acute thrombocytopenia probably rifampicin induced, in a patient who was retreated for tuberculosis. The physician treating tuberculosis patients must be aware of this rare life threatening complication, which if detected early, is completely reversible