Goodpasture’s syndrome is a rare vasculitis associated with anti-glomerular basement membrane (anti-GBM) autoantibodies that target type IV collagen found in the basement membranes of glomeruli and alveoli. We present a case of a 79-year-old man with seronegative Goodpasture’s syndrome with predominant respiratory symptoms and mild acute kidney injury that initially improved. Final diagnosis was made by immunofluorescent staining on open lung biopsy which also revealed concomitant organising pneumonia. The patient underwent treatment with corticosteroids, cyclophosphamide, haemodialysis and plasmapheresis. This was an atypical presentation wherein the patient only exhibited pulmonary symptoms early in the course of illness in the setting of negative anti-GBM antibody serum testing, which made diagnosis challenging. With this case, we emphasise that clinicians should have a high suspicion for Goodpasture’s syndrome in the setting of unexplained severe pulmonary or renal disease despite negative anti-GBM antibody testing.
Studies report variability in the rates and causes of isolation errors among in-patients with active tuberculosis (TB). We reviewed our experience with delays or premature discontinuation of airborne infection isolation (AII).Medical records of patients admitted to the Bellevue Hospital Center, New York City Health & Hospitals, New York, NY, USA, between January 2006 and July 2012 with a positive respiratory culture for Mycobacterium tuberculosis were reviewed. Patients who were out of AII despite being infectious were identified, as the episodes had prompted a contact investigation.Of 246 admissions with positive respiratory cultures, 35 AII errors were identified among 27 patients. Most patients had signs or symptoms of TB on admission. Only four patients had positive sputum smears. In 16 (46%) episodes, the patients had never been isolated, 11 (31%) had delayed isolation, and 8 (23%) were prematurely taken off AII. The most common reasons for patients being off AII while infectious were an incorrect alternative diagnosis (15/35, 43%) or a dual diagnosis (9/35, 26%).Particularly in smear-negative cases, AII errors due to TB may occur when providers conclude that another diagnosis explains their findings. In many cases, that diagnosis is correct, but TB is also present. This error rate might be a useful quality indicator.
ABSTRACT The immunodominance of Mycobacterium tuberculosis proteins malate synthase (MS) and MPT51 has been demonstrated in case-control studies with patients from countries in which tuberculosis (TB) is endemic. The value of these antigens for the serodiagnosis of TB now is evaluated in a cross-sectional study of pulmonary TB suspects in the United States diagnosed to have TB, HIV-associated TB, or other respiratory diseases (ORD). Serum antibody reactivity to recombinant purified MS and MPT51 was determined by enzyme-linked immunosorbent assays (ELISAs) of samples from TB suspects and well-characterized control groups. TB suspects were diagnosed with TB ( n = 87; 49% sputum microscopy negative, 20% HIV + ) or ORD ( n = 63; 58% HIV + ). Antibody reactivity to MS and MPT51 was significantly higher in U.S. HIV + /TB samples than in HIV − /TB samples ( P < 0.001), and it was significantly higher in both TB groups than in control groups with latent TB infection ( P < 0.001). Antibody reactivity to both antigens was higher in U.S. HIV + /TB samples than in HIV + /ORD samples ( P = 0.052 for MS, P = 0.001 for MPT51) but not significantly different between HIV − /TB and HIV − /ORD. Among U.S. HIV + TB suspects, a positive anti-MPT51 antibody response was strongly and significantly associated with TB (odds ratio, 11.0; 95% confidence interval, 2.3 to 51.2; P = 0.002). These findings have implications for the adjunctive use of TB serodiagnosis with these antigens in HIV + subjects.
Abstract: Mycobacterium tuberculosis develops spontaneous resistance mutants to virtually every drug in use. Courses of therapy select for these mutants and drug-resistant organisms emerge. The development of drug-resistant organisms has reached the point that drug resistance now threatens to undermine global success against tuberculosis (TB). New drugs are needed. The last new class of drugs specifically developed for treatment of TB was the rifamycins over 40 years ago. New funding sources and the development of product development partnerships have energized the TB drug development effort. There are now more TB drugs in development than at any time in the past. The first of these drugs to be developed and marketed was bedaquiline. Bedaquiline has an entirely novel mechanism of action and so should be active against otherwise highly resistant organisms. It acts on the transmembrane component of adenosine triphosphate synthase and acts by preventing electron transport. This raises the exciting possibility that bedaquiline may be active against less metabolically active organisms. Drug–drug interactions between rifamycins and the cytochrome P450-3A system will limit bedaquiline's utility and create complexity in treatment regimens. In clinical trials, treatment with bedaquiline added to a background multidrug-resistant TB regimen was associated with earlier culture conversion and higher cure rates, but there were unexplained excess deaths in the bedaquiline arms of these trials. Food and Drug Administration approved bedaquiline for the treatment of multidrug-resistant TB when an effective treatment regimen cannot otherwise be provided. They required a black box warning about excess deaths and require that a phase III trial be completed. A planned Phase III trial is being reorganized. While bedaquiline is an exciting drug and marks a dramatic moment in the history of TB treatment, its ultimate place in the anti-TB drug armamentarium is unclear pending the Phase III trial and the development of other new drugs that are in the pipeline. Keywords: bedaquiline, multidrug-resistant tuberculosis, Sirturo
Bellevue Hospital, a large public hospital in New York City.To discern the clinical characteristics of spinal tuberculosis (Pott's disease) in patients with the human immunodeficiency virus (HIV).Review of all cases of spinal tuberculosis seen at the hospital from 1988 to 1995, with comparison of HIV-positive and HIV-negative cases. Chart reviews for all cases were performed and information regarding signs and symptoms, neurological findings, laboratory and radiographic data, medical and surgical treatment and eventual outcome were recorded.We collected 26 cases of tuberculosis of the spine between July 1988 and June 1995. Seven of our 26 patients (27%) were HIV seropositive. Six of these were PPD+ on presentation. When compared with HIV-negative patients, those with HIV and spinal tuberculosis had similar clinical presentations; most patients had a diagnosis made with percutaneous needle aspiration biopsy of clinically involved areas, and open procedures added little diagnostic information. Most were treated without surgery, and response to antituberculosis therapy was uniformly good.We conclude that clinical presentations of spinal tuberculosis are similar in HIV-positive and -negative patients, and good outcomes can be expected with regard to mycobacterial disease.
