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Issue. Articles

3(14) // 2013

 

 

1. Original research

 

Influence of antiretroviral therapy on the course of tuberculosis in patients with tuberculosis/HIV co-infection depending on the severity of immunosuppression and period of application during the main course of treatment

S.. Cherenko, N.A. Marchenko, L.Ya. Maniv

Objective — to study the frequency and severity of immune reconstitution syndrome under the influence of antiretroviral therapy (ART) in patients with TB/HIV co-infection.
Materials and methods. A prospective, controlled study included 128 patients with new cases of TB/HIV co-infection, 64 patients of them were receiving ART. The method of selection of a pair according to sex, age, nature of tuberculosis and the degree of immunedeficiency, the presence of opportunistic infections was used to form control group of patients not receiving antiretroviral therapy. Each group had 44 (68.7 %) pulmonary tuberculosis cases. 20 (31.3 %) patients with extrapulmonary tuberculosis had miliary tuberculosis involving abdominal and intrathoracic lymph nodes, tuberculosis of peripheral lymph nodes. Opportunistic diseases were revealed in 51 patients of each group — oropharyngeal candidosis, viral hepatitis B and/or C. 32 patients of each group presented severe immunodeficiency — CD4 count was less than 50 cells/mcl, in the rest of the patients — > 50 < 200 cell/mcl.
Results and discussion. Following the appointment of ART 33 (51.6 %) of 64 patients had worsening of tuberculosis course or had developed TB, which was defined as immune reconstitution syndrome (IRS).
5 (7.8 %) of them died of the generalization of tuberculosis and other opportunistic diseases. 45.3 % of patients of the control group had worsening of TB course (p > 0.05), 29.7% of them died during the chemotherapy of generalized tuberculosis (p < 0.05). IRS was observed starting from the 2nd week till the 3rd month of ART— in average (5.1 ± 0.5) weeks. IRS commonly develops in 2—4 weeks, when the number of CD4 lymphocytes is 1—20 cells/mcl (in 76.5 % of patients versus 9.1 % of cases when the CD4 cell count was higher than 50 cells/mcl, p < 0.05).
Conclusions. Patients with severe immunodeficiency who undergo ART develop IRS in any time of antituberculosis therapy. Severity of its manifestations with the risk of lethal outcome is determined by the low level of CD4 lymphocytes (less than 50 cells/mcl).

Keywords: TB/HIV co-infection, immune reconstitution syndrome.

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2. Original research

 

Continuous infusion of carbapenems as alternative method of treatment of nosocomial pneumonia caused by multidrug-resistant infection

S.. Dubrov, O.. Gavrylenko, E.. Buhaieva, T.A. Lubitskaya

The article provides the review on the prolonged infusion of antibacterial drugs for the treatment of nosocomial infection caused by multidrug-resistant pathogens and also presents the results of own study on evaluation of the effecacy of the continuous infusion of imipenem/cilastatin for the antimicrobial treatment of nosocomial pneumonia in ICU patients.
Materials and methods. The study included 39 patients with combined trauma, complicated by ventilator associated pneumonia caused by multidrug-resistant strains of Pseudomonas aeruginosa or microbial associations.
Results and discussion. The study showed high clinical and microbiological efficacy of continuous infusion of imipenem/cilastatin for the treatment of ventilator-associated pneumonia caused by multidrug-resistant strains of Pseudomonas aeruginosa or microbial associations. Eradication of pathogen was present in 12 patients (30.8 %) in 8—10 days after the beginning of antibiotic therapy. Mortality of patients during their stay in the ICU was 12.8 %. Pneumonia was not the principal cause of death in these patients.
Conclusions. Application of continuous infusion of carbapenems in patients with the ventilator associated pneumonia caused by multidrug-resistant strains of Pseudomonas aeruginosa or microbial associations can improve the results of treatment of severe nosocomial infection.

Keywords: multidrug-resistant infection, ventilator associated pneumonia, continuous infusion of antibiotics, carbapenems, imipenem/cilastatin.

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3. Original research

 

Dynamics of immunological acute phase parameters of blood in patients with pulmonary tuberculosis relapses during treatment

D.O. Butov

Objective — to study changes in the dynamics of immunological acute phase parameters of blood in patients with pulmonary tuberculosis relapses (RTBL) during treatment.
Materials and methods. A study of the dynamics of C-reactive protein (CRP), sialic acid (SA), interleukin-2 (IL-2), interleukin-8 (IL-8) and interferon-γ (IFN-γ) serum levels in 250 relapse cases and newly diagnosed pulmonary tuberculosis (NDTBL) cases and 30 relatively healthy donors were conducted. All patients experienced infiltrative pulmonary tuberculosis. The study was conducted before treatment and after two months of therapy.
Results and discussion. The study revealed a significant increase in studied indices in comparison to the healthy donors that were observed to significantly decrease after the two-month treatment. There was a significant difference in CRP, SA, IL-2, IL-8 and IFN-γ serum levels, both before treatment and after two months of ongoing therapy between patients with RTBL and NDTBL, being higher in patients with RTBL. The presence of destruction didn’t influence CRP, SA, IL-2, IL-8 and IFN-γ both before the treatment and after two months of therapy.
Conclusions. Studied indices appeared to be significantly higher in patients with RTBL and NDTBL than in healthy donors. Significant difference in CRP, SA, IL-2, IL-8 and IFN-γ was observed being higher at relapse of pulmonary tuberculosis than in patients with NDTBL both before treatment and after two months of antituberculosis therapy. The possibility of use of indicators to assess the effectiveness of therapy was considered.

Keywords: pulmonary tuberculosis, pulmonary tuberculosis relapse, newly diagnosed pulmonary tuberculosis, immune system, acute phase parameters, cytokines.

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4. Original research

 

The evaluation of cardio- and haemodynamics according to direct methods of investigation in clinically cured pulmonary tuberculosis patients

R.N. Shevchenko

Objective — to study the condition of cardiovascular haemodynamics and pulmonary circulation in clinically cured pulmonary tuberculosis patients.
Materials and methods. he investigation of cardiovascular haemodynamics and pulmonary circulation was conducted using the method of probing the pulmonary artery and right heart cavities in 11 clinically cured patients from MDR-TB with metatuberculosis pulmonary fibrosis and pulmonary clinical signs of heart failure A phase II.
Results and discussion. The investigation showed a significant increase in both systolic and diastolic blood pressure in the pulmonary artery, the right ventricle and atrium in these patients. Pulmonary hypertension in these patients has predominantly pulmonary-vascular genesis. The established changes at the Valsalva probe and after physical activity indicate to significant disorder of cardio- and haemodynamics of the pulmonary circulation and reduction of its compensatory reserves.
Conclusions. There is a need for early diagnosis of pulmonary hypertension and its timely treatment in clinically cured multidrug-resistant pulmonary tuberculosis patients in order to prevent the early cardiopulmonary diseases.

Keywords: cardiohemodynamics, hemodynamics of the pulmonary circulation, clinically cured pulmonary tuberculosis.

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5. Original research

 

Results of high-dose isoniazid therapy in multidrug-resistant destructive pulmonary tuberculosis patients with extensive drug resistance of Mycobacterium tuberculosis

I.B. Bialyk

Objective — to study the results of high-dose isoniazid therapy in patients with multidrug-resistant destructive pulmonary tuberculosis with extensive drug resistance of Mycobacterium tuberculosis.
Materials and methods. Isoniazid (0.45—0.9 g/day during 6—12 months) was included into drug regimens (containing 4—7 mainly the 2-nd line and reserve drugs) of 63 patients with multidrug-resistant destructive pulmonary tuberculosis with extensive drug resistance of Mycobacterium tuberculosis. The studied group was compared with the control group with the same kind of process, intensity and terms of therapy, without isoniazide.
Results and discussion. Inclusion of high-dose isoniazid in the regimens of therapy in patients with multidrug-resistant destructive pulmonary tuberculosis with extensive drug resistance of Mycobacterium tuberculosis increased sputum conversion by 9.5 % (to 50.8 %) and partial and full cavern regression – by 15.7 % (to 73.0 %). Average terms of smear conversion were reduced by 0.95 month and terms of cavern healing – by 1.03 month. Tolerance of isoniazide in daily dose 0.45—0.9 g was good or sufficient.
Conclusions. Isoniazide in daily dose 0.45—0.9 g can be applied as a reserve antituberculosis drug of choice in long term treatment in patients with multidrug-resistant pulmonary tuberculosis with extensive drug resistance of Mycobacterium tuberculosis.

Keywords: multidrug-resistant destructive pulmonary tuberculosis, extensive drug resistance, isoniazid in doses 0,450,9 g, sputum conversion, cavern healing.

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6. Original research

 

The effectiveness of early complex therapy of endogenic emaciation in patients with destructive pulmonary tuberculosis

V.P. Dubrov, P.V. Herasymenko, V.S. Zub

Objective — to study the effectiveness of early complex therapy of endogenous emaciation in patients with destructive pulmonary tuberculosis during the intensive phase of treatment.
Materials and methods. 10 patients with destructive pulmonary tuberculosis and endogenic emaciation were examined. The level of endotoxicosis markers, protein status and body mass index were monitored during the study. Enterosorption, plasmaphairesis, substitutive infusion, nutritional supplementation were fulfilled.
Results and discussion. High concentration of endotoxins, hypoproteinemia with hypoalbuminemia and decreased body mass index were detected before treatment. Therapy has helped to stabilize the somatic status. The dynamics of the endotoxicosis markers showed its significant reduction after the course of intensive combined detoxification. Leukocyte intoxication index and the average mass molecules count decreased more than 2 times. Substitutive infusion of 5 % albumin during plasma effusion allowed to avoid protein loss and resulted in the albumin growth by 8.8 %, and total protein growth by 10.7 % ( > 0.05). Further follow-up revealed the average increase in body weight by (2.4 ± 0.16) kg with an increase in body mass index by 4.6 % (p > 0.05).
Conclusions. An early start of intensive combined detoxification provides the reduction in levels of endotoxicosis markers more than two times, that helps to improve physical status of patients. Substitu­tion infusion and nutritional supplementation during detoxification prevent worsening protein-energy malnutrition and are accompanied with positive dynamics of body mass index. Treatment has been increasing the indexes of total protein and albumin, what is an optimistic prognostic sign of disease course and treatment.

Keywords: endogenous emaciation, tuberculosis, detoxification, hypoproteinemia.

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7. Original research

 

Thyroid activity at specific and nonspecific infiltrative changes in the lungs

L.D. Todoriko, L.D. Migailuk

Objective — to study the functional activity of the thyroid gland in patients with community-acquired pneumonia, pneumonia with HIV infection and infiltrative pulmonary tuberculosis.
Materials and methods. A complex study and follow-up of 18 patients with community-acquired pneumonia, 19 patients with newly diagnosed infiltrative pulmonary tuberculosis and 9 HIV positive pneumonia patients were conducted. A comprehensive study of the functional activity of the pituitary gland, thyroid function of the thyroid gland using enzyme immunoassay was conducted in all patients on admission to hospital.
Results and discussion. The study results showed that thyroid dysfunction in patients with infiltrative changes in the lungs depends on: the nature of the causative agent, the size of infiltration spreading and the degree of metabolic immunosuppression in general. The level of thyroid activity in development of community acquired pneumonia, pneumonia in HIV positive patients and in patients with newly diagnosed infiltrative pulmonary tuberculosis testifies to the revealed data.
Conclusions. In the presence of infiltrative processes in the lungs significant multiple changes in thyroid homeostasis take place, being variable, depending on the etiology of the inflammatory process and showing hidden disorders of the thyroid gland. Thyroid dysadaptation syndrome in all study groups of patients is accompanied by significant increase in the peripheral conversion of iodothyronines against impairment of the thyrotropic function of the hypophysis (almost 99.1 % of cases).

Keywords: community acquired pneumonia, newly diagnosed infiltrative pulmonary tuberculosis, HIV infection, thyroid activity, infiltration.

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8. Original research

 

Peculiarities of the tuberculous meningoencephalitis clinical picture in HIV-infected patients

O.V. Korzh, T.V. Tlustova

Objective — to define the peculiarities of the tuberculous meningoencephalitis clinical picture in HIV-infected patients. 
Materials and methods. The 78 HIV-positive persons with tuberculous meningoencephalitis (TM) were divided in to groups depending on the state of immunity: 52 patients with CD4 count less than 100 cells/mcl (1-st group), and 26 persons with CD4 count more than 100 cells/mcl (2-nd group). Complaints, the state of consciousness, CD4-lymphocytes count, meningeal symptoms and cranial-cerebral nerves symptoms were examined.
Results and discussion. More than half of the HIV-positive persons (56.4 %) had CD4 level below 50 cells/mcl, CD4 count did not exceed 100 cells/mcl in 66.7 % of patients. There were no significant differen­ce between studied groups on frequency of pulmonary tuberculosis, tuberculosis of other internal organs and clinical symptoms of disease excepting vomiting that was revealed significantly less often in the 1-st group (p < 0.03). Pulmonary tuberculosis was diagnosed in 92.3 and 84.6 % of patients respectively. The most frequent clinical symptoms regardless of immune status were protracted head pain, fever and impairment of consciousness. A majority of patients of the 1-st and 2-nd groups had classic neurological signs of meningoencephalitis, however TM without cranial-cerebral nerves irritation was registered 3.5  times more often among persons with advanced immunosupression (p < 0.03), and a tendency to more frequent absence of meningeal symptoms was determined. Generally, atypical course of TM with different combinations of neurological picture against the background of the advanced immunosupression was observed in 40.4 % of cases.
Conclusions. TM in HIV-infected persons is practically always accompanied with pulmonary tuber­culosis and tuberculosis of other internal organs, especially intrathoracic lymphatic nodes, progressing according to the degree of immunosupression. The basic TM symptoms in the HIV-infected patients regardless of immunity status were the protracted head pain, fever and impairment of consciousness. Majority of the patients had characteristic neurological symptoms of meningoencephalitis, however quantity of patients not experiencing vomiting and irritation of cranial-cerebral nerves increased at the decline of CD4 count below 100 cell/mcl.

Keywords: tuberculous meningoenephalitis, HIV-infected patients, immunity state.

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9. Original research

 

State of blood glutathione-dependent enzyme system in experimental pulmonary edema

V.M. Zhadan, V.I. Korzhov

Objective — to study the enzyme activity of erythrocytes glutathione system in experimental adrenaline (hemodynamic) pulmonary edema when administered different doses of adrenaline.
Materials and methods. The study included 52 white mongrel rats of both sexes. Pulmonary edema in rats was simulated by a single intramuscular injection of 0.18 % adrenaline tartrate at doses of 2.5 mg / kg, 1.5 mg / kg, 1.0 mg / kg and 0.5 mg / kg. State of glutathione-dependent enzyme system was studied by the analysis of enzymes activity — glutathione peroxidase (GP), glutathione reductase (GR), glutathione transferase (GT).
Results and discussion. The paper investigates and evaluates parameters of blood glutathione-dependent enzyme system in experimental pulmonary edema depending on the applied dose of adrenaline. The use of relatively low doses of epinephrine (1.0, 0.5 mg/kg) was revealed to lead to the significant increase in GP activity only. The activity of GR and GT at these doses remains at control values. The administration of higher doses of epinephrine (2.5, 1.5 mg/kg) leads to more significant changes in the studied parameters: significant decrease of GR and GT, increase of activity of GA. The changes were the most prominent at the dose of 1.5 mg/kg: the activity of GR and GT reduced by 17.8% and 44.6% respectively, the activity of GP increased by 57.4%.
Conclusions. Experimental pulmonary edema leads to disorder of homeostasis in the glutathione-dependent enzyme system. The use of high-dose epinephrine is accompanied not only by a compensatory shift in enzymatic antiperoxidant protection level in the blood (increased activity of GA) but also by decompensatory changes in enzyme activity (decreased activity of GR and GT), what indirectly may indicate the beginning of the breakdown of compensatory mechanisms in the glutathione system.

Keywords: pulmonary edema, glutathione metabolism enzymes: glutathione reductase, glutathione transferase, glutathione peroxidase.

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10. Original research

 

Tuberculosis incidence among health care professionals in Vinnitsa region during 20072012

O.P. Litvinyuk, S.V. Zaikov, M.A. Tkhorovskyy, N.M. Gonchar

Objective — to study tuberculosis incidence among health care professionals of Vinnitsa region in the period 2007—2012.
Materials and methods. The study presents the analysis of the tuberculosis incidence among health care professionals of general practice and TB institutions in Vinnitsa region, according to official TB service data for a six-year period.
Results and discussion. Tuberculosis incidence among health care professionals in Vinnitsa region has a negative trend. Over the past 6 years it has increased from 50.5 to 51.5 per 100 000 health care professionals. Compared with decreasing trend of TB incidence among the population of Vinnitsa region (from 60 to 55.3 per 100 000 population) studied incidence among hospital staff of general practice and TB facilities shows to be very important and requiring further study. A large number of TB relapse cases in health care professionals indicate the inadequate quality of treatment and follow-up. Low protection against infection caused growth of incidence among health care professionals of TB facilities, which made up fifth of all TB cases among health care professionals for the past 6 years. In the gender structure of the TB incidence among health care workers women made up four-fifths of cases, that is associated with high incidence among nurses. More than a half of physicians being TB patients are men.
Conclusions. Against the background of reducing of TB incidence in Ukraine and Vinnitsa region for the last 6 years we observe the growth of the TB incidence among health care professionals. The highest number of TB cases is among nurses. TB relapses are also quite often among medical workers. One-fifth of all health care professionals, who developed TB during 6 years, are workers of TB facilities. Women develop TB more often among health care workers.

Keywords: tuberculosis, incidence, health care professional, Vinnitsa region.

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11. Original research

 

HIV-associated tuberculosis in Poltava region

V.G. Bondarenko, A.. Vorodyuhina, M.V. ulish, .V. schenko, .M. Bondarenko, D.V. Bezruchko

Objective — to study morbidity, mortality, clinical and radiological manifestations and efficacy of the treatment of HIV-associated tuberculosis in Poltava region.
Materials and methods. Analysis of HIV-associated TB morbidity and mortality in Poltava region, and analysis of case histories of 116 HIV-associated tuberculosis patients.
Results and discussion. Poltava region shows continuous increase in HIV-associated tuberculosis morbidity and mortality over the last few years. HIV-associated tuberculosis patients more often have lung tuberculosis (86 %) and 21 % of patients along with pulmonary localization have also extrapulmonary tuberculosis. 93.5 % of HIV-associated tuberculosis cases were diagnosed under patient-initiated seeking of medical care and only 6.5 % of cases were revealed under the routine screening. Timely administration of anti-TB and antiretroviral therapy for HIV-associated tuberculosis leads to a more benign course of the disease and slows the progression of AIDS.
Conclusions. Interventions on the timely prevention, diagnosis and treatment of this disease should be tuned up in order to prevent the spread of HIV-associated tuberculosis.

Keywords: HIV-associated tuberculosis, Poltava region, morbidity, mortality, treatment.

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12. Lectures

 

Hemoptysis and pulmonary hemorrhage in tuberculosis of the respiratory system: athogenesis, pathological changes, clinical manifestations, diagnosis and emergency treatment

N.I. Fomichova, N.A. Gritsova, .. Raznatovska, T.Yu. Klepikova

The article presents the pathogenesis and pathological changes, clinical manifestations, diagnosis and emergency care for hemoptysis and pulmonary hemorrhage with pulmonary tuberculosis. Algorithms for step by step diagnostic and emergency care for pulmonary hemorrhage are described in detail.

Keywords: hemoptysis, pulmonary hemorrhage, pulmonary tuberculosis.

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13. Lectures

 

Current issues of diagnostics and treatment of extrapulmonary tuberculosis

V.I. Petrenko, L.D. Todoriko, A.V. Boiko

While pulmonary tuberculosis in Ukraine is under control diagnostics of extrapulmonary tuberculosis is now the issue of the day. Extrapulmonary TB of respiratory system presents 58 % in the structure of TB incidence in Ukraine. Bone and joint TB occupies the leading place, then go tuberculosis of periphe­ral lymph nodes, urogenital system, eyes, nervous system and other localizations. The complex diagnos­tics of extrapulmonary TB is presented with modern radiological methods, contact and non-invasive research, bacteriological, genetic, immunological, biochemical, and other methods. Complicated modern epidemiological situation on tuberculosis in the country highlights the need for high-speed diagnostics. Treatment of patients with extrapulmonary tuberculosis should be conducted according to the Annex to the MOH of Ukraine Order 1091 dated 21.12.2012.

Keywords: extrapulmonary tuberculosis, incidence, diagnostics, polimerase chain reaction.

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14. Lectures

 

Lungs immune system Lecture 1. The physiological aspect

B.V. Noreyko, S.B. Noreyko, Yu.A. Grishun

The lecture is aimed to identify and characterize bronchopulmonary immune and physiological features which provide alveolar homeostasis maintenance and lungs diseases prevention.
The authors pointed out that this is impossible for the lungs immune system to be taken out from the other important functions of the respiratory apparatus such as condition function of the lungs, and different functional of the mucociliary system and surfactant.
The authors are discussing the neuromediators and immunological mechanism of the bronchial hyporeaction that is of great importance in pulmonology and phthisiology.
The broncho-assossiated lymphatic tissue is the subject of discussion of another part of the lecture. The broncho-assossiated clusters are located in the mucous membrane in the zone of bifurcation of large bronchus. They are being a kind of terminals for lungs immune system, that provide fast mobilisation of protection mechanisms when affected by distractive factors on the bronchial memrane.

Keywords: immune system, physiology of the lungs.

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15. Reviews

 

Place and prospects for the introduction of the syndrome approach for the treatment of STI in Ukraine as an effective mechanism to counter HIV infection/AIDS

I.S. Myronyuk, I.B. Pereginec

The article emphasizes the urgent need of the syndrome approach the diagnosis and treatment of STI in Ukraine based on the analysis of the features of the development of the situation with the epidemic of HIV/AIDS in Ukraine, review of the international experience with the aim of combating the sexually spread of HIV infection/AIDS.

Keywords: syndromic management, STI, HIV/AIDS, Ukraine.

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16. Clinical case

 

Case of tuberculosis in female patient undergoing long-term hemodialysis

M.M. Savula, N.M. Lopushanska, H.M. Baburnych

The case study presents the course of pulmonary tuberculosis in female patient with chronic renal failure undergoing long-term hemodialysis. Antituberculosis therapy was successful but in 3 month different complications have occurred. Tuberculosis was the reason for not undergoing kidney transplantation.

Keywords: chronic renal failure, hemodialysis, tuberculosis.

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17. Clinical case

 

Lymphangioleiomyomatosis: a modern view of disease and radiological presentation of clinical case

L.A. Hryshchuk, N.V. Deresh, V.O. Beskyy, V.Ye. Cybulyak

The article presents the literature data and radiological presentation of a clinical case of lymphangioleiomyomatosis in 46-years old woman with complaints of shortness of breath and pain in the chest. At admission to the hospital plain x-ray revealed a large right pleural effusion with increased transparency lung fields. The pleural puncture obtained hilous in amount of about 2.5 liters. Videothoracos­copy with further biopsy and computed tomography of the chest and abdomen with intravenous contrast enhancement were condacted and revealed lymphangioleiomyomatosis indicative changes. Associated findings were: a large cavernous hemangioma of the right lobe of the liver, nodular hyperplasia of the right lobe of the thyroid gland and the doubling of both kidneys as a development option. The cytological investigation of pleural effusion confirmed diagnosis of lymphangioleiomyomatosis.

Keywords: Lymphangioleiomyomatosis, pulmonary cysts, radiological changes.

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