Changes in glycosylated haemoglobin and treatment outcomes in patients with tuberculosis in Iran: a cohort study.

BACKGROUND: Diabetes mellitus (DM) affects tuberculosis (TB) treatment outcomes, mostly by increasing recurrence, mortality and treatment failure. The objectives were to determine the pattern of change in glycosylated haemoglobin (HbA1c) level in new TB patients admitted to hospital at the start and 3-months after TB treatment, and to relate the measurements at these two time intervals to whether patients successfully completed treatment. METHODS: A prospective cohort study was conducted on hospitalized new TB patients at Masih Daneshvari Hospital from 2012 to 2013. All patients were tested for HbA1c at the beginning and 3 months after initiation of TB treatment. Changes in HbA1c were compared to TB treatment outcome. RESULTS: There were 317 new TB cases admitted to hospital of which 158 had HbA1c at baseline and 3-months. Of these, 67 (42%) had normal values, 54 had an elevated HbA1c at either base-line or 3-months (uncertain diabetes status) and 37 (24%) had elevated HbA1c (≥6.5%) at both time points (DM). There were differences between the groups: those with DM were older, had a known history of DM and a higher prevalence of cavities on chest x-ray. There were 150 (95%) patients who successfully completed treatment with no significant differences between the groups. CONCLUSION: There were changes in HbA1c during the first three-months of anti-TB treatment, but these were not associated with differences in TB treatment outcomes. Transient hyperglycemia should be considered in TB patients and needs to be taken into account in planning care and management

HIV and tuberculosis trends and survival of coinfection in a referral center in Tehran: A 12-year study

AbstractObjective/backgroundThe risk of mortality and morbidity among tuberculosis (TB) and human immunodeficiency virus (HIV) coinfected patients is significantly higher than that of patients infected with TB alone. The aim of this study was to evaluate the survival of TB-HIV patients in a TB-referral center during a 10-year follow-up.MethodsAll TB-HIV patients in our referral center were enrolled in the study from 2003 to 2014, and patients were divided into two groups: HIV-TB patients without a history of TB treatment (new cases of TB) and HIV-TB patients with a history of TB treatment. Both groups were treated based on World Health Organization TB-treatment guidelines, and multivariate analysis was performed to evaluate risk factors of all-cause mortality.ResultsDuring the study, 22 HIV-TB patients with a history of TB treatment and 263 HIV-TB patients with newly diagnosed TB were included. Baseline demographic and clinical characteristics were similar, except that miliary TB (98% vs. 2%) and mortality (97% vs. 3%; p=0.06) were more likely in HIV patients with newly diagnosed TB. During TB treatment and subsequent follow-up, two patients did not respond to treatment and 92 (32.3%) patients died, whereas the cure rate was 60%. Pneumothorax [hazard ratio (HR): 3.17], coinfection (herpes zoster, toxoplasmosis, cytomegalovirus infection, Pneumocystis jiroveci, candidiasis, and other opportunistic infection; HR: 1.75), CD4<100cells/mL (HR: 1.96), thrombocytopenia (HR: 2.29), and lack of treatment with antiretroviral agents (ART; HR: 2.82) were significantly associated with all-cause mortality according to multivariate analysis.ConclusionOur retrospective review of coinfected TB-HIV patients hospitalized in Tehran showed that the management and monitoring of coinfection, pneumothorax and other adverse effects, as well as early initiation of ART, improved patient survival

Evaluation of Hepatoprotective Effect of Silymarin Among Under Treatment Tuberculosis Patients: A Randomized Clinical Trial

Abstract Hepatic toxicity is the most serious adverse effect of anti tuberculosis drugs. This study was performed to evaluate the efficacy of silymarin as a hepatoprotective herbal agent. In a randomized double blind clinical trial, 70 new cases of pulmonary tuberculosis were divided into two groups. The intervention group was assigned to receive silymarin and the control group received placebo. Tuberculosis was treated by classic regimen consisting isoniazid, rifampin, pyrazinamide and ethambutol. No statistically significant difference was found between the two groups concerning the frequency of drug induced liver injury or mild elevation of liver enzymes. Silymarin was safe without any major side effect. Our results showed no significant hepatoprotective effect of silymarin among patients on tuberculosis treatment

Effect of pulmonary hypertension on outcome of pulmonary tuberculosis

Objectives: Pulmonary hypertension is a serious disorder with catastrophic outcomes. This study aimed to evaluate the effect of pulmonary arterial hypertension on the outcome among new cases of pulmonary tuberculosis. Novel modalities are available as therapeutic options, so early diagnosis of pulmonary arterial hypertension may be important. Methods: In a cross-sectional study, 777 new cases of pulmonary tuberculosis were recruited in the National Research Institute of Tuberculosis and Lung Disease, Tehran, Iran. Pulmonary arterial pressure was measured by resting transthoracic echocardiography on the beginning of tuberculosis treatment. Echocardiography was performed by a cardiologist expert in the field. Patients with systolic pulmonary arterial pressure more than 35 mmHg were defined as pulmonary hypertensive. The relationship between pulmonary arterial hypertension and mortality was assessed during six months of tuberculosis treatment. Results: Seventy-four (9.5%) of 777 new cases of pulmonary tuberculosis had pulmonary arterial hypertension. Among them, 10 (13.5%) died during the treatment period. In comparison with 5% mortality among cases without pulmonary arterial hypertension, death was significantly associated with pulmonary hypertension (p = 0.007). Logistic regression analysis showed that pulmonary arterial pressure more than 35 mmHg is an independent predictor of death among tuberculosis patients. Conclusion: Among new cases of pulmonary tuberculosis, a significant association between mortality and pulmonary arterial pressure >35 mmHg was found. Therapeutic intervention may change the outcome of these patients

Outcome of drug-resistant tuberculosis treatment among HIV-positive patients at the tertiary center in Tehran

Objectives: Drug-resistant tuberculosis (TB) is a major challenge in controlling TB. HIV-positive patients are vulnerable to TB 100 times more than the general population. Drug-resistant TB leads to high morbidity and mortality in this population. In this study, the outcome of treatment of drug-resistant TB among HIV positive patients from 2003 to 2013 in a tertiary center in Iran will be reviewed. Materials and Methods: All HIV-positive patients with any drug-resistant TB from 2003 to 2013 were selected. The outcome of treatment was extracted from patients’ charts. Results: Out of 269 TB-HIV patients, 34 patients were recruited. All patients were male and the mean age was 37.38±7.03. Isoniazid (INH) resistant, rifampin (RIF) resistant and multi-drug resistant (MDR) was diagnosed in 11 (32.4%), 7 (20.6%) and 16 (47.1%), respectively. Mean CD4 count was 91.61±23.55. Outcome of treatment in the INH-resistant cases was cured in 5 (45.5%), failure in 2 (18.2%) and death in 4 (36.4%). In the RIF-resistant group, outcome was as follows: cured 5 (71.4%) and failure in 2 (28.6%). In the MDR-TB patients’ group, cured, failure and death were 12 (75%), 2 (12.5%) and 2 (12.5%), respectively. Conclusion: Treatment of drug-resistant TB can be achieved despite considerable mortality

Detection of latent and active tuberculosis among HIV-positive patients at the North of Tehran

Objectives: HIV patients are prone to tuberculosis (TB) disease, and screening these patients for TB is important. The aim of this study is to analyze the prevalence of active and latent TB and the sensitivity, specificity, negative (NPV) and positive predictive value (PPV) of clinical signs and symptoms for the diagnosis of active TB in HIV-infected subjects. Method: From April 2008 to March 2011, 154 consecutive HIV-infected patients attending the HIV clinic at Masih Daneshvari Hospital were enrolled in the study. For the diagnosis of active TB, two sputum samples (one on presentation and another early morning) were collected from each subject and examined by Ziehl–Neelsen (ZN) microscopy for identification of acid-fast bacilli (AFB). Mycobacterial culture sputum specimens were inoculated on Lowenstein–Jensen (LJ) slants for 4–8 weeks to detect colonies. In those patients with a negative sputum sample for AFB, a polymerase chain reaction (PCR) was performed. Active TB was defined as positive sputum smear or culture for mycobacterium TB or positive polymerase chain reaction (PCR). Also, patients with signs and symptoms compatible with TB who responded to anti-tuberculous medications were classified as having active TB. Results: The mean of age was 36±8 (ranged, 22–62) and 127 (82%) were male. The antiretroviral therapy (ART) had been started in 40 (26%) patients, with 15 (10%) receiving trimethoprim/sulfamethoxazole as a prophylaxis; 119 (77%) were intravenous drug users. Among these patients, 58 (38%) individuals were diagnosed with active TB, of which 48 (83%) had smear-positive pulmonary TB. The mean of the baseline CD4 cell count in HIV patients with and without active TB was 67cells/ μl and 180cells/ μl, respectively (P-value=0.018). The multivariable regression analyses found that CD4<100cells/ μl (OR=2.67; 95% CI 1.23–5.78; P-value=0.013) and smoking (OR=13.4; 95% CI 3.03–59.4; P-value=0.001) were the only significant variables associated with TB in this study. Among the 96 patients who were not diagnosed with active TB, 8 (8%) had a positive tuberculin skin test (TST) and isoniazid prophylaxis was initiated. The presence of any one of six clinical features (cough, sputum, fever, night sweating, weight loss and loss of appetite) had sensitivity (89.6%) and specificity (45.8%) with a PPV of 50% and a NPV of 88%. Conclusion: Due to the high rate of active TB, careful screening of patients with signs and symptoms, X-ray and sputum examination must be performed

Nontuberculous mycobacterium in a tertiary tuberculosis center in Iran: Dispensation and outcome of treatment

Introduction: Nontuberculous mycobacterium (NTM) has clinical and radiological manifestations that are indistinguishable from Mycobacterium tuberculosis (MTB). In an endemic area for tuberculosis (TB), limited data about prevalence and outcome of treatment of these patients is available. In this study the prevalence of different types of mycobacterium and response to treatment in a tertiary referral center in Iran will be evaluated. Materials and method: All NTM cases from 2004 to 2013 at the National Research Institute of Tuberculosis and Lung Diseases (NRITLD) in Iran were extracted from the database. All NTM patients who were treated for NTM diseases entered this study, and the outcome of treatment was evaluated. Results: A total of 104 cases were detected. The mean age was 56.34±15.77 years. Half of the patients were male. Most of the patients had a history of prior TB treatment. The most common types of NTM were Mycobacterium simiae (44 [42.3%]), Mycobacterium kansasii (18 [17.3%]), Mycobacterium abcessus (15 [14.4%]), and Mycobacterium chelonea (14 [13.5%]), respectively. The outcome of treatment was as follows: cure 61 (58.7%), failure 17 (16.3%), relapse 3 (2.9%), default 13 (12.5%) and death in 10 (9.6%) patients. Conclusion: Treatment of NTM had a low cure rate despite low mortality

Impact of diabetes mellitus on tuberculosis drug resistance in new cases of tuberculosis

AbstractBackground and objectiveDiabetes mellitus (DM) has an effect on many aspects of tuberculosis (TB). The aim of this study is to determine the impact of DM on anti-tuberculosis drug resistance in new cases of TB patients.Materials and methodsA case-control study was conducted on all newly diagnosed pulmonary TB adult patients with DM as cases and without DM as controls who were hospitalized and treated at the National Research Institute of Tuberculosis and Lung Disease (NRITLD) from May 2013 to October 2013. A molecular resistance test for rapid detection of resistance to isoniazid and rifampin was done for all smear-positive TB patients. A multivariate analysis was performed to determine the impact of DM on any anti-TB drug resistance.Results45TB cases with DM and 45TB cases without DM were included. TB cases with DM were more likely to be older (61 vs. 47years, p=0.001). Two TB–DM patients had multidrug-resistant TB (MDR-TB) (4.4%) compared with zero cases of MDR-TB in the control group, and TB–DM cases were resistant to at least one drug (11.1% vs. 4.4%, p=0.43). DM remained significantly associated with any drug resistance (OR: 6.32, 95% CI: 1–40.72) in multivariate analysis.ConclusionNew TB patients with DM are at increased risk of anti-TB drug resistance. More studies are needed to confirm these results

Treatment outcome and mortality: Their predictors among HIV/TB co-infected patients from Iran

Background: The risk of death is significantly higher in TB/HIV-infected patients than in those patients with just one disease or the other. This study aims to evaluate the impact of demographic, clinical and laboratory characteristics on the treatment outcome and mortality of TB/HIV co-infected patients in a TB tertiary center in Iran. Materials and methods: The study was conducted at Iran's National Referral Center for Tuberculosis. In total, 111 patients were recruited between 2004 and 2007. Mycobacteriology studies were performed for all patients. Demographic, clinical, and lab data of all patients were analyzed, and predictors of unsuccessful outcomes, as well as mortality, were determined. Results: The mean age for all 111 TB/HIV patients was 38±9 years (range 22–70) and 107 patients (96.3%) were male; 104 patients (93.7%) had a history of drug abuse, and 96 patients (86.4%) had a history of imprisonment. The route of transmission of HIV was intravenous drug use in 88 of the patients (79.3%); 23 patients (20.7%) had a history of Category 1 (CAT-1) (5.4%) and CAT-2 treatment. Highly Active Antiretroviral Therapy (HAART) was given to 48 patients (43.2%). There was no significant association found between treatment outcome or mortality with sex, smoking, drug and alcohol abuse, imprisonment, route of transmission, history of CAT-1 and CAT-2, cluster of differentiation 4 (CD4), and adverse effects (p > 0.05). Administration of HAART led to a significantly higher rate of good outcome (p < 0.001). Lower Albumin levels and body weight were significantly associated with mortality. Conclusion: Albumin levels and weight can be predictors of mortality and an unsuccessful outcome. Administration of HAART led to a better outcome

Recurrent Drug-Induced Hepatitis in Tuberculosis-Comparison of Two Drug Regimens

Drug-induced hepatitis (DIH) is one of the major complications among the treatment of patients with tuberculosis (TB); it might even be fatal. This study tries to address the recurrence of DIH with 2 anti-TB regimens. In the retrospective study from 2007 to 2010, 135 TB patients with DIH who were older than 16 years were entered to study. The patients with DIH were randomly treated with a regimen, including isoniazid, rifampin, and ethambutol, plus either ofloxacin or pyrazinamide. The patients were reviewed for occurrence of recurrent DIH. Cure and completed treatment were considered as acceptable treatment outcomes, whereas default of treatment, treatment failure, and death were considered to be unacceptable outcomes. Therefore, 135 subjects with DIH were reviewed, and 23 patients (17%) experienced recurrence of hepatitis (19 cases in the ofloxacin group and 4 cases in the pyrazinamide group). There is no significant difference in recurrence of hepatitis between these 2 groups (P = 0.803). An acceptable outcome was observed in 95 patients (70.4%), and an unacceptable outcome was seen in 14 cases (10.3%). There was no significant difference in outcomes between these 2 regimens (P = 0.400, odds ratio = 1.62, 95% confidence interval, 0.524-4.98). The results of our study suggest that ofloxacin-based anti-TB regimen does not decrease the risk of recurrent DIH. Therefore, adding ofloxacin in the case of DIH is not recommended