Correspondence
Primary nasopharyngeal tuberculosis
2. Sim T, Ong B H. Primary tuberculosis of nasopharynx. Singapore Med J 1972: 13: 39-43. 3. Prabhu S R, Daftary D K, Dholakia H M. Tuberculous ulcer of the tongue. J Oral Surg 1978: 36: 384-386. 4. Bennett .I DC. Primary nasopharyngeal tuberculosis, presenting as bilateral conductive deafness. Pak J Otolaryngol 1989: 5: 101-103.
Primary tuberculosis of adenoids is very rare, and even more so in adults as the adenoids usually regress at puberty. We report a case of tuberculosis primarily confined to adenoids in an adult female. A 25-year-old female presented with a slowly progressive left-sided deafness of 1 year’s duration. She did not smoke or drink. There was no family history of deafness or tuberculosis. Physical examination revealed retraction of the left tympanic membrane. Puretone audiometry revealed 35 dB conductive hearing loss and impedance audiometry showed Ad type curve on the left side. Lateral roentgenogram of the nasopharynx revealed a soft tissue mass. The ESR was 40 mm in the first hour by the Westergren method. The Mantoux test was strongly positive (25 mm at 72 h with 5TU). Chest X-ray was normal. Examination of the nasopharynx under general anaesthesia revealed a soft mass with no surrounding induration and no tendency to bleed on touch. This was excised and sent for histological examination, and was reported as tubercular adenoiditis. The patient was put on INH 300 mg, rifampicin 600 mg, ethambutol 800 mg and 50 mg pyridoxin daily. She was completely relieved of deafness after 2 months of treatment, which was continued for another 10 months. In the past nasopharyngeal tuberculosis, especially secondary to pulmonary involvement, has not been infrequent.’ Primary nasopharyngeal tuberculosis is however not common.2 In the normal course of events, the intact mucosa is relatively resistant to mycobacterial invasion; however repeated exposure to infected sputum may overwhelm this defence.3 In rare cases infection may be acquired by the haematogenous route. Also, even more rarely, the lymphoid tissue of the nasopharynx may be the primary site, as in the present case.’ A similar case has been reported earlier.”
Department
Nosocomial transmission of multidrug-resistant tuberculosis between AIDS patients Recent reports have demonstrated an increasing risk for tuberculosis in AIDS patients, and the importance of nosocomial transmission and drug resistance in the diffusion of the disease.‘-” We were recently confronted in our unit with nosocomial transmission of multidrugresistant tuberculosis between AIDS patients, and report here our experience. The 2 index cases were a French man who had lived in the USA for the past 10 years, and his American wife. They had been infected with HIV in 1985 and 1986 respectively, and had been treated in a New York hospital for the past 3 years. Neither had a past history of tuberculosis. They returned to France in November 1990 and were shortly hospitalized for fever and clinical deterioration. Bronchoalveolar fluid from the wife and sputum smear from her husband revealed numerous acid-fast bacilli, and standard therapy with rifampin, isoniazid, ethambutol and pyrazinamide was initiated. The antibiogram was the same in both cases, showing a BK strain resistant to rifampin, isoniazid and ethambutol, indeterminate for pyrazinamide, and sensitive to streptomycin, ofloxacin, clofazimine, PAS, cycloserine, ethionamide and thiacetazone. The initial therapy was then replaced by streptomycin, pyrazinamide and clofazimine, with ethionamide for the wife, and ofloxacin for the man. The wife died in March 199 1, from uncontrolled disseminated tuberculosis. Her husband had positive sputum smears up to February 1991, and died in June 1991 from HIV encephalitis. The secondary case was an AIDS patient who had been hospitalized in the same unit in December 1990 and January 1991. Sputum and blood samples at this time were sterile. In March 1991, he was rehospitalized for fever and died in April 1991 from disseminated tuberculosis with an antibiogram pattern similar to those of the above couple. These data are highly suggestive of the nosocomial transmission of multiresistant BK strain, despite standard isolation precautions. The rate of transmission of active tuberculosis in HIV patients is estimated to be as high as 37-44 %.I.’ Within the past 5 years, none of the
S.P.S. Yadav Ishwar Singh Jagat Singh T.S. Jaswal* of Otolaryngology and Pathology* Medical College and Hospital Rohtak India
References I. Hollender A R. The Nasopharynx: specimens.
Lqngoscope
a study of 140 autopsy 1946: 56: 286-292. 397
398
Tubercle and Lung Disease
BK strains isolated in our unit have had a similar antibiogram pattern. Chronological data supported the hypothesis that our 2 index cases had acquired tuberculosis in New York. An epidemiological report on nosocomial outbreaks of multidrug-resistant tuberculosis which occurred in New York at the same time further confirms the possibility of nosocomial contamination for them as we11.3 The 2 index cases were confined to their room as soon as the results of the search for acid-fast bacilli at direct examination were obtained. In view of the results of antibiograms, more strict precautions were adopted, including mask wearing for the index patients and nursing staff and strict limitation of visits. During the period over which any 1 of the 3 patients had positive sputum cultures, 53 AIDS patients were hospitalized in the same part of the unit. So far, no newly acquired tuberculosis has developed, either in these patients or among the 20 health care workers exposed. Tuberculin test was not systematically performed because BCG vaccine is universally used in France. Contact in overcrowded inpatient and outpatient facilities and the emergence of multiresistant BK may play an important role in the recent dramatic increase of tuberculosis.’ Tuberculosis is also the main infection that can be transmitted from immunocompromised hosts to health care workers.‘92 The only ways to prevent such a dissemination are early diagnosis, rapid antibiogram results and respiratory isolation precautions. Isoniazid preventive therapy should be promptly implemented among contact subjects, but its efficacy is limited by resistance and by the accelerated progression of newly acquired tuberculosis in immunocompromised patients. Prevention of multidrug-resistant tuberculosis dissemination in AIDS and non-AIDS patients should become a matter of utmost priority for the immediate future. L. Cotte Hepatology and AIDS unit H6pital de 1 ‘H&el-Dieu 1, place de 1 ‘H&pita1 69288 Lyon Cedex 02 France F. Fougerat Mycobacteria Laboratory IiastitutPasteur Lyon France C. Trepo Hepatology and AIDS unit H6pital de 1 ‘Hhel-Dleu and INSERM U 271 Lyon France
References 1. Daley C L, Small P M, Schecter G F et al. An outbreak of tuberculosis
with accelerated
progression
among persons infected
with the human immunodeficiency virus. N Engl. 3 Med 1991; 326: 231-235. 2. Di Perri G, Cruciani M, Danzi M C et al. Nosocomial epidemic of active tuberculosis among HIV-infected patients. Lancet 1989; ii: 1502-1504. 3. Centers for Disease Control. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons. Florida and New York, 1989-1991. MMWR 1991; 40: 585-591.
Epidemiological mess? Grzybowski’s comment on the treatment aspect of BCG trial in his article ‘Natural history of tuberculosis epidemiology’ as ‘epidemiological mess’, stimulates me to react.‘.’ Being associated with the study as a supervisor of field operations, it is my privilege to share with you my experience of the treatment activity in the study. As is well known, the objective of the study was to find the efficacy of BCG vaccination in prevention of pulmonary tuberculosis. For ethical reasons, it was also decided to put all cases diagnosed in the study on antituberculosis treatment. To provide treatment for the cases nearer to their doors, the existing health infrastructure in the form of the District Tuberculosis Programme (DTP) had to be the only machinery, since it would not have been possible for the BCG project to run parallel specialized centres throughout the area without substantially diluting its resources. Moreover, the exclusively set up project centres for treatment would also have been largely unknown units, not otherwise frequented by the patients. However, it was realized that the additional caseload on the DTP, as a consequence of the project operations, could throw the existing system out of gear, especially in terms of drug supply. Also, its ability to motivate such a large number of patients for treatment could only, in any case, be limited. The Project therefore formulated a special treatment advisory team consisting of a leader and three to four health workers. This team called on each of the diagnosed cases, initially motivated him and gave him a referral slip. He was advised to report to nearest health centre with the slip to receive treatment. A copy of the referral slip containing identification particulars and details of diagnosis was personally handed over by the team to the medical officer concerned, with a request to treat the case on his attending the centre. The project team had also established a good rapport with the community by paying repeated visits to villages. This enabled patients having difficulty in getting treatment to approach the project staff for redressal. Such cases were attended to in priority by the project treatment team. Thus, four important prerequisites for active casefinding and treatment were met under the project, as follows: 1. 2. 3.
Identifying cases at their doorsteps. Arranging treatment nearer their homes. Initial motivation by the project team.
Primary nasopharyngeal tuberculosis
2. Sim T, Ong B H. Primary tuberculosis of nasopharynx. Singapore Med J 1972: 13: 39-43. 3. Prabhu S R, Daftary D K, Dholakia H M. Tuberculous ulcer of the tongue. J Oral Surg 1978: 36: 384-386. 4. Bennett .I DC. Primary nasopharyngeal tuberculosis, presenting as bilateral conductive deafness. Pak J Otolaryngol 1989: 5: 101-103.
Primary tuberculosis of adenoids is very rare, and even more so in adults as the adenoids usually regress at puberty. We report a case of tuberculosis primarily confined to adenoids in an adult female. A 25-year-old female presented with a slowly progressive left-sided deafness of 1 year’s duration. She did not smoke or drink. There was no family history of deafness or tuberculosis. Physical examination revealed retraction of the left tympanic membrane. Puretone audiometry revealed 35 dB conductive hearing loss and impedance audiometry showed Ad type curve on the left side. Lateral roentgenogram of the nasopharynx revealed a soft tissue mass. The ESR was 40 mm in the first hour by the Westergren method. The Mantoux test was strongly positive (25 mm at 72 h with 5TU). Chest X-ray was normal. Examination of the nasopharynx under general anaesthesia revealed a soft mass with no surrounding induration and no tendency to bleed on touch. This was excised and sent for histological examination, and was reported as tubercular adenoiditis. The patient was put on INH 300 mg, rifampicin 600 mg, ethambutol 800 mg and 50 mg pyridoxin daily. She was completely relieved of deafness after 2 months of treatment, which was continued for another 10 months. In the past nasopharyngeal tuberculosis, especially secondary to pulmonary involvement, has not been infrequent.’ Primary nasopharyngeal tuberculosis is however not common.2 In the normal course of events, the intact mucosa is relatively resistant to mycobacterial invasion; however repeated exposure to infected sputum may overwhelm this defence.3 In rare cases infection may be acquired by the haematogenous route. Also, even more rarely, the lymphoid tissue of the nasopharynx may be the primary site, as in the present case.’ A similar case has been reported earlier.”
Department
Nosocomial transmission of multidrug-resistant tuberculosis between AIDS patients Recent reports have demonstrated an increasing risk for tuberculosis in AIDS patients, and the importance of nosocomial transmission and drug resistance in the diffusion of the disease.‘-” We were recently confronted in our unit with nosocomial transmission of multidrugresistant tuberculosis between AIDS patients, and report here our experience. The 2 index cases were a French man who had lived in the USA for the past 10 years, and his American wife. They had been infected with HIV in 1985 and 1986 respectively, and had been treated in a New York hospital for the past 3 years. Neither had a past history of tuberculosis. They returned to France in November 1990 and were shortly hospitalized for fever and clinical deterioration. Bronchoalveolar fluid from the wife and sputum smear from her husband revealed numerous acid-fast bacilli, and standard therapy with rifampin, isoniazid, ethambutol and pyrazinamide was initiated. The antibiogram was the same in both cases, showing a BK strain resistant to rifampin, isoniazid and ethambutol, indeterminate for pyrazinamide, and sensitive to streptomycin, ofloxacin, clofazimine, PAS, cycloserine, ethionamide and thiacetazone. The initial therapy was then replaced by streptomycin, pyrazinamide and clofazimine, with ethionamide for the wife, and ofloxacin for the man. The wife died in March 199 1, from uncontrolled disseminated tuberculosis. Her husband had positive sputum smears up to February 1991, and died in June 1991 from HIV encephalitis. The secondary case was an AIDS patient who had been hospitalized in the same unit in December 1990 and January 1991. Sputum and blood samples at this time were sterile. In March 1991, he was rehospitalized for fever and died in April 1991 from disseminated tuberculosis with an antibiogram pattern similar to those of the above couple. These data are highly suggestive of the nosocomial transmission of multiresistant BK strain, despite standard isolation precautions. The rate of transmission of active tuberculosis in HIV patients is estimated to be as high as 37-44 %.I.’ Within the past 5 years, none of the
S.P.S. Yadav Ishwar Singh Jagat Singh T.S. Jaswal* of Otolaryngology and Pathology* Medical College and Hospital Rohtak India
References I. Hollender A R. The Nasopharynx: specimens.
Lqngoscope
a study of 140 autopsy 1946: 56: 286-292. 397
398
Tubercle and Lung Disease
BK strains isolated in our unit have had a similar antibiogram pattern. Chronological data supported the hypothesis that our 2 index cases had acquired tuberculosis in New York. An epidemiological report on nosocomial outbreaks of multidrug-resistant tuberculosis which occurred in New York at the same time further confirms the possibility of nosocomial contamination for them as we11.3 The 2 index cases were confined to their room as soon as the results of the search for acid-fast bacilli at direct examination were obtained. In view of the results of antibiograms, more strict precautions were adopted, including mask wearing for the index patients and nursing staff and strict limitation of visits. During the period over which any 1 of the 3 patients had positive sputum cultures, 53 AIDS patients were hospitalized in the same part of the unit. So far, no newly acquired tuberculosis has developed, either in these patients or among the 20 health care workers exposed. Tuberculin test was not systematically performed because BCG vaccine is universally used in France. Contact in overcrowded inpatient and outpatient facilities and the emergence of multiresistant BK may play an important role in the recent dramatic increase of tuberculosis.’ Tuberculosis is also the main infection that can be transmitted from immunocompromised hosts to health care workers.‘92 The only ways to prevent such a dissemination are early diagnosis, rapid antibiogram results and respiratory isolation precautions. Isoniazid preventive therapy should be promptly implemented among contact subjects, but its efficacy is limited by resistance and by the accelerated progression of newly acquired tuberculosis in immunocompromised patients. Prevention of multidrug-resistant tuberculosis dissemination in AIDS and non-AIDS patients should become a matter of utmost priority for the immediate future. L. Cotte Hepatology and AIDS unit H6pital de 1 ‘H&el-Dieu 1, place de 1 ‘H&pita1 69288 Lyon Cedex 02 France F. Fougerat Mycobacteria Laboratory IiastitutPasteur Lyon France C. Trepo Hepatology and AIDS unit H6pital de 1 ‘Hhel-Dleu and INSERM U 271 Lyon France
References 1. Daley C L, Small P M, Schecter G F et al. An outbreak of tuberculosis
with accelerated
progression
among persons infected
with the human immunodeficiency virus. N Engl. 3 Med 1991; 326: 231-235. 2. Di Perri G, Cruciani M, Danzi M C et al. Nosocomial epidemic of active tuberculosis among HIV-infected patients. Lancet 1989; ii: 1502-1504. 3. Centers for Disease Control. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons. Florida and New York, 1989-1991. MMWR 1991; 40: 585-591.
Epidemiological mess? Grzybowski’s comment on the treatment aspect of BCG trial in his article ‘Natural history of tuberculosis epidemiology’ as ‘epidemiological mess’, stimulates me to react.‘.’ Being associated with the study as a supervisor of field operations, it is my privilege to share with you my experience of the treatment activity in the study. As is well known, the objective of the study was to find the efficacy of BCG vaccination in prevention of pulmonary tuberculosis. For ethical reasons, it was also decided to put all cases diagnosed in the study on antituberculosis treatment. To provide treatment for the cases nearer to their doors, the existing health infrastructure in the form of the District Tuberculosis Programme (DTP) had to be the only machinery, since it would not have been possible for the BCG project to run parallel specialized centres throughout the area without substantially diluting its resources. Moreover, the exclusively set up project centres for treatment would also have been largely unknown units, not otherwise frequented by the patients. However, it was realized that the additional caseload on the DTP, as a consequence of the project operations, could throw the existing system out of gear, especially in terms of drug supply. Also, its ability to motivate such a large number of patients for treatment could only, in any case, be limited. The Project therefore formulated a special treatment advisory team consisting of a leader and three to four health workers. This team called on each of the diagnosed cases, initially motivated him and gave him a referral slip. He was advised to report to nearest health centre with the slip to receive treatment. A copy of the referral slip containing identification particulars and details of diagnosis was personally handed over by the team to the medical officer concerned, with a request to treat the case on his attending the centre. The project team had also established a good rapport with the community by paying repeated visits to villages. This enabled patients having difficulty in getting treatment to approach the project staff for redressal. Such cases were attended to in priority by the project treatment team. Thus, four important prerequisites for active casefinding and treatment were met under the project, as follows: 1. 2. 3.
Identifying cases at their doorsteps. Arranging treatment nearer their homes. Initial motivation by the project team.
