Management of emerging multidrug-resistant tuberculosis in a low-prevalence setting

AbstractMultidrug-resistant (MDR) tuberculosis (TB) is an emerging concern in communities with a low TB prevalence and a high standard of public health. Twenty-three consecutive adult MDR TB patients who were treated at our institution between 2007 and 2013 were reviewed for demographic characteristics and anti-TB treatment management, which included surgical procedures and long-term patient follow-up. This report of our experience emphasizes the need for an individualized approach as MDR TB brings mycobacterial disease management to a higher level of expertise, and for a balance to be found between international current guidelines and patient-tailored treatment strategies

Asymptomatic prostatic tuberculous abscess in an immunocompetent 54-year-old man with peritoneal tuberculosis

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Severe laryngeal and pulmonary tuberculosis under anti-TNF-α therapy

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Clinical Presentation, Diagnosis, and Bacterial Epidemiology of Peritoneal Tuberculosis in Two University Hospitals in France

International audienceINTRODUCTION: Diagnosis of peritoneal tuberculosis (pTB) is difficult, even in developed countries, where data are lacking. The aim of the present study was to describe the clinical presentation, diagnosis, and bacterial epidemiology of pTB in France over a 10-year period. METHODS: A retrospective study was conducted on pTB in two university hospitals in France, between January 2004 and December 2014. RESULTS: Among the 34 patients, 76.5% were migrants from areas of endemic tuberculosis (TB), mainly Africa. The main presentation (85.3%) was a checkup of ascites or suspicion of peritoneal carcinomatosis. On abdominal computed tomography, ascites was found in 90.6% and peritoneal thickening in 75%. Surgery was required for diagnosis in 58.8% of patients. Six of the patients who did not undergo surgery had ultrasound-guided peritoneal biopsy. Bacteriology was positive for ascites in only 58.1% of cases, for peritoneal biopsy in 73.3%, while granuloma was found in 95.5%. TB polymerase chain reaction (PCR) was positive in 25% of peritoneal biopsy. Mycobacterium bovis was isolated in 23.1% of cases and Mycobacterium tuberculosis in 76.9%. Isolates were fully susceptible (except M.~bovis naturally resistant to pyrazinamide). Many (38%) belonged to the lineage T (genetic analysis by spoligotyping). Cure rate was high (76.5%), after a 6-9~months of anti-tuberculous therapy. CONCLUSION: In developed countries, early diagnosis of pTB is still a challenge. Ultrasound-guided peritoneal biopsy may facilitate diagnosis. TB PCR can be useful on peritoneal biopsy. The lineage T was the most prevalent lineage, but more data are required to directly incriminate this lineage in the pathophysiology of pTB

Enfants au contact d’individus atteints d’une tuberculose multi-résistante : quelles stratégies adopter ? Analyse de 46 enfants contacts et revue de la littérature

International audienceINTRODUCTION: Tuberculosis-related morbidity and mortality remain important. Emergence and diffusion of multidrug-resistance tuberculosis (MDR-TB) is a global public health concern. Cases of MDR-TB in children are a sentinel event indicating the spread of a mycobacterial strain within a community. Latent TB precedes MDR-TB and screening and follow-up of contact individuals are key points of TB infection control. METHODS: We performed the case-investigation of 20 adult cases of MDR-TB managed in our institution. RESULTS: Forty-six pediatric contact individuals were identified. A high proportion of these children were lost to follow-up (80% at 12 months), showing that monitoring this reservoir population with migrant history is challenging. Five (11%) children presented a secondary infection: one child was diagnosed with active TB infection (positive tuberculin skin test associated with abnormalities on chest computer tomography [CT] scan). Four children were diagnosed with latent TB infection (isolated positive tuberculin skin test with normal CT scan). Two of these children received a treatment adjusted to the strain of the index case. DISCUSSION: In the setting of emerging MDR-TB, tuberculin skin test may be likely replaced by specific interferon-gamma release assays (IGRA), independent of prior BCG vaccination. In addition, chest CT scan is preferred to chest X-ray to detect TB lesions. The management of latent TB infection is controversial: immediate treatment with second-line anti-TB drugs adapted to the index case strain or, consistently with WHO guidelines, a simple follow-up with subsequent treatment in case of active TB.IntroductionMalgré une incidence en lente décroissance, la morbi-mortalité de la tuberculose (TB) reste importante. L’émergence et la diffusion de souches multi-résistantes (MR) constituent actuellement un problème mondial majeur de santé publique. Les cas pédiatriques de TB-MR sont un évènement sentinelle indiquant une circulation de souches au sein d’une communauté. L’infection tuberculeuse latente (ITL) précède les cas de TB-MR. La détection et le suivi des sujets contacts sont des axes clés de la lutte anti-TB.MéthodesAutour de 20 cas adultes atteints de TB-MR pris en charge dans notre institution 46 enfants contacts ont été recensés.RésultatsDurant le suivi, le nombre d’enfants perdus de vue était élevé (80 % à 1 an) attestant de la difficulté de suivre une jeune population « réservoir » issue de l’immigration. Le taux d’incidence d’une infection tuberculeuse secondaire était de 11 % : un enfant a développé une TB-maladie (virage tuberculinique associé à des anomalies tomodensitométriques thoraciques) ; quatre enfants ont développé une ITL (virage tuberculinique à tomodensitométrie thoracique normale). Deux enfants ont reçu un traitement adapté à la souche du cas index (préventif ou curatif).DiscussionDans ce contexte d’émergence de la TB-MR, la substitution de l’IDR par les tests de libération d’interféron (TLI), aussi sensibles et plus spécifiques (indépendants du BCG), semble pertinente. De même, la TDM thoracique optimise la détection de lésions infra-radiographiques. La stratégie de traitement de l’ITL en post-exposition d’une TB-MR avec une combinaison adaptée à la souche du cas index est débattue au profit d’une stratégie proposée par l’OMS de surveillance prolongée avec traitement curatif d’une TB active le cas échéant

Clinical Presentation, Diagnosis, and Bacterial Epidemiology of Peritoneal Tuberculosis in Two University Hospitals in France

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Linezolid in the Starter Combination for Multidrug-Resistant Tuberculosis: Time to Move on to Group Four?

International audienceLinezolid (LNZ), a group 5 antituberculous drug (unclear efficacy), was used in the starter regimens of 23 adults with multidrug-resistant tuberculosis. The LNZ-containing regimens were effective in achieving culture conversions and relapse-free outcomes. The most frequent LNZ-related side effect was neuropathy. We propose that LNZ should be reclassified among bactericidal second-line drugs