The Indian Journal of Tuberculosis - LRS Institute of Tuberculosis ...

The
Indian Journal of Tuberculosis
Vol. 47 New Delhi, April, 2000 No. 2
Editorial
REVIEWING THE NTP
From 4th to 16th February, 2000, India’s National Tuberculosis Programme was reviewed by a Joint
Tuberculosis Programme Review Group. The review was proposed by the Government of India on the eve
of a major push to cover a much larger chunk of the population than before by RNTCP by the year 2001
and was facilitated by the WHO.
The Group comprised 7 international experts from the WHO, the Royal Netherlands Tuberculosis
Association (KNCV), Centres for Disease Control and Prevention (CDC-USA), the Danish International
Development Agency (Danida), the World Bank and the Department for International Development
(DFID-UK). Besides, there were 16 Indian participants from the Ministry of Health and Family Welfare,
Directorate General of Health Services, Indian Medical Association, Tuberculosis Association of India,
Employee’s State Insurance Corporation, Medical colleges, the ICMR, Railways and state as well as district
tuberculosis control officers in the Group. The experts formed a varied group and not tuberculosis specialists
alone.
The RNTCP implementation had begun in October 1993. It had first covered a population of 2.4
million, as a pilot project, Later, it was extended to cover 14 million population in 1995, and 20 million in
1996. More rapid expansion was started in late 1998 aiming to cover 120 million people 1 , that is just 12 per
cent of the total population, compared with NTP’s coverage of about 85% of the districts and over 90% of
the population. In addition, Government had the pressing need for better utilization of the $ 176 million
soft IDA loan extended by the World Bank coupled with a significant fall in the international prices of antituberculosis
drugs and binocular microscopes, etc. Under the circumstances, it had become imperative for
the Government to speed up RNTCP coverage to 400 million people by the year 2001, The Government of
India needed expert opinion regarding the operational feasibhityof the proposal. The Group was given a
threefold brief: to judge the programme status in the present RNTCP areas; to recommend if and which of
the NIP districts could be made ready for the switch over to RNTCP, and whether the RNTCP policies and
practices had proven their worth and become generally acceptable.
The Joint review was planned on the lines of a similar international exercise undertaken in 1992 by
GOI/WHO/SIDA/(Swedish International Development Agency) prior to the introduction of RNTCP in the
country 3 . The international review was unlike the several earlier reviews of the NIP undertaken
nationally 3-4 , prior to 1992. In a nutshell, the joint reviews were meant to be a vision of the “woods”,
complete with epidemiology of the disease, theoretical models and the like, compared with the national
reviews which were “trees” oriented and focused on the load of symptomatics in the NTP institutional
network, quality and quantity of case-finding, case-holding, treatment and the like. Obviously, each kind
of review has both positive and negative aspects. In fact, WHO have recently prescribed written guidelines
for reviewing National Tuberculosis Programmes 5 .
Accordingly, the Group were given 5 themes for making their Observations and giving recommendations
: national policy and organisational structure, diagnostic and treatment considerations, procurement

72 EDITORIAL
procedures and status of supplies, supervision and monitoring, education, traning as well as advocacy.
Field visits were arranged to Delhi, U.P., West Bengal, Maharashtra and Tamil Nadu. The sample of
districts to be observed in each state was purposive - one good performing and the other not so good- and
the RNTCP formats, were to be used for observing and not specially prepared evaulation protocols.
Participants were expected to interview medical officers, paramedical programme workers, patients and
their family members, administrators, social leaders and even politicians and the public, but no schedule
was laid down. A fajjfly exhaustive compendium of background literature was made available to each
member for familiarization. The group divided into five teams, each taking one theme for specific
responsibility, while passing their other relevent observations to different teams, as appropriate. There
were endless discussions before, during and after field visits to arrive at a consensus. By the scheme of
things, opinions more than hard data dominated the scene.
Admittedly, the canvas was large for the Group to paint on, and the time to do so somewhat limited.
The Group’s recommendations should be of interest to many quarters besides the Government and agencies
supporting the programme. When abstruse subjects like the impact on RNTCP of HIV/AIDS epidemic, the
co-operation to be enlisted from private practitioners who have to keep profit in the forefront, and involvement
of NGOs, long set in their “age-old” ways are included in the ambit of field observations, it would be
unrealistic to expect far reaching recommendations. Apart from these kinds, of considerations, there is the
mundane aspect of practicability of such high cost, high visibility programme reviews. Perhaps, in future,
the inevitable follow up reviews of NTP/RNTCP mary have to be more modest, less expensive and
quantitatively more informative.
D.R. Nagpaul
REFERENCES
1. Khatri G.R., Revised National Tuberculosis Control Programme, ind, J. Tub,. 1999, 46, 157
2. World Health Organisation, 1992. WHO/TB/95.186 (limited distribution)
3. Institute of Communication, Operations Research and Community Development. In depth Study on NTP- An Overview,
1988 (limited distrtbution)
4. Nagpaul D.R., India’s National Tuberculosis Prgrammeran Overview. Ind. J. Tub. 1989, 36, 205
5. World Health Organisations. Guidelines for Conducting Review of National Tuberculosis Programmes. 1998, WHO/
TB/98. 240

Oration Ind. J. Tub. 2000, 47, 73
ROLE OF BAL IN THE DIAGNOSIS AND IMMUNOLOGICAL EVALUATION
OF PATIENTS WITH PULMONARY TUBERCULOSIS*
V.K, Vijayan 1
INTRODUCTION
Mycobacterium tuberculosis discovered by
Robert Koch in 1882 is the leading killer of adults 1 .
The World Health Organisation (WHO) has
estimated that there are nearly 1.7 billion indiviuals
infected with Mycobacterium tuberculosis
throughout the world, approximately20 million are
active cases, three million die each year, and eight
million new cases occur each year, of which three
million are infectiousMhe WHO had estimated that
if worldwide tuberculosis (TB) control programmes
are not improved, 90 million new cases and 30
million deaths could be expected during the decade
1990-19993-4. of the 1 billion Inhabitants in India,
approximately 300 million are infected with
M. tuberculosis, 12-14 million have active
tuberculosis, three to four million are infectious cases
and around half a million die each year 5 . Two
decades ago, the goal of industrialized countries with
low prevalence of tuberculosis was eradication or
elimination of tuberculosis. Elimination is possible,
if the rate of infection is less than 1% in the general
population or there is only one smear-positive case
per million inhabitants. In countries like India, It has
not been possible to make even a dent in the problem
of tuberculosis despite a well defined National
Tuberculosis Prgramme which has been in operation
for more than three decades. However, in many
industrialized countries, the downward trend in
tuberculosis has either been stabilized or even
slightly reversed. Serveral factors including closing
down of TB clinics, economic recession,
demographic reasons, HIV/AIDS epidemic and
population migration have contributed to this
phenomenon. Since Robert Koch’s discovery of
tubercle bacilli in 1882, at least 200 million people,
especially those in the most economically productive
years of life, have died of tuberculosis 6 . Realizing
the gravity of the problem, the WHO, in 1993,
declared tuberculosis to be a global emergency. This
has led to renewed worldwide interest in research in
tuberculosis.
Even though potent chemotherapeutic regimens
are currently available to treat patients with
pulmonary tuberculosis, radiographic and
pulmonary function abnormalities persist in a
proportion of tuberculosis patients despite
treatment 7 .Thus, in order to “treat” all pulmonary
tuberculosis patients successfully, we should be able
to prevent lung damage and subsequent fibrosis.
However, the pathogenesis and mechanism of lung
injury and fibrosis in pulmonary tuberculosis are not
well understood to enable formulation of modalities
of treatment that may prevent fibrosis.
Bronchoalveolar lavage (BAL) studies have been
found to be useful for assessing the lower respiratory
tract inflammation and studying the pathogenesis of
various lung diseases 8 . Evaluation of lung immune
processes in pulmonary tuberculosis, using BAL,
may aid in understanding the mechanism of lung
injury and fibrosis which, in turn, may help in the
formulation of modalities of treatment that prevent
fibrosis. In addition, since BAL samples the
epithelial lining fluid of the alveoli, it is likely to
facilitate early diagnosis of sputum smear negative
pulmonary tuberculosis.
Studies on Pathogensis
BAL studies in 27 sputum smear negative
patients radiographically suspected to be pulmonary
tuberculosis, later confirmed as active pulmonary
tuberculosis by the isolation of Mycobacterium
tuberculosis in culture from sputum and/or lavage
specimens, identified the presence of two distinct
cell profiles 9 . One group (macrophage predominant)
had significiantly elevated total cells and alveolar
* Ranbaxy-Robert Koch Oration delivered at the 54th National Conference on Tuberculosis and Chest Diseases, held at
Patna, 26-29, December, 1999.
1. Director, VP Chest Institute, University of Delhi, Delhi-110007

74 VK VIJAYAN
macrophages in both the radiologically normal as
well as abnormal lobes. The other group
(lymphocyte predominant) had elevated numbers of
total cells, lymphocytes and granulocytes
(neutrophils and eosinophils) in the radiologically
abnormal lobe only. As patients’ age, smoking habit,
fluid recovery during BAL, the reaction to PPD skin
test, the nutritional status (as assessed by body
weight) and radiological abnormalities were similar
in both the groups, the reason for the observed
difference in cell profiles in the two groups could
not be explained, except for the suggestion that the
duration of illness (1.5±0.26 Vs 2.1±0.5 months)
was longer in the lymphocyte predominant group.
Even though the human immunodeficiency virus
(HIV) status was not assessed in all the subjects,
there was no difference in HIV status between the
two groups, among those in whom it was evaluated.
Sputum smear positive pulmonary tuberculosis
patients have been shown to have lymphocytosis in
BAL fluid 10-13 . In addition, eosinophilic pneumonia
was demonstrated in 3 cases of radiologically and
bacteriologically confirmed pulmonary
tuberculosis 14 . In 2 patients, pulmonary eosinophilia
was present only at the site of lesion and the third
had eosinophilia both in peripheral blood and lung.
There was complete elimination of eosinophilic
inflammatory process in 2 patients who had
successfully completed anti-Tuberculosis treatment 14 .
BAL studies in miliary tuberculosis show
lymphocytic alveolitis 15-16 . Elevated levels of
immunoglobulins (IgG, IgA, IgM) and fibronectin
were demonstrated in BAL fluid from patients with
miliary tuberculosis 16 . Lymphocytic alveolitis 15-16
and raised immunoglo-bulins (IgG and IgA)
persisted in BAL fluid despite treatment and this
was associated with a reduction in carbon monoxide
diffusing capacity 16 .
Lymphocytes, which arc building blocks of
grariuloma are brought to the site of lesion and
activated by interleukin-I and gamma-interferon
released by activated macrophages 17 .Thus,
lymphocytosis in the radiologically abnormal but not
in the --adiologically normal lobe 9 may represent
localization of granuloma at the site of lesion. Other
cell types, such as neutrophils and eosinophils also
contribute to granuloma formation 18 and in
conformity with this, there is a significant elevation
of neutrophils and eosinophils in the radiologically
abnormal lobe 9 as well. The main type of
lymphocytes in tuberculous granutoma is T cells 10-19
and an increase in CD 4+ T cells is also demonstrated
in tuberculous pleural effusion 20 . Activated T cells
are capable of spontaneously releasing lymphokines,
such as interleukin-2, gamma interferon and tumor
necrosis factor and play an important role in immune
response in tuberculosis 17-18 . The demonstration of
expanded numbers of alveolar macrophages in both
radiologically normal and abnormal lobes of patients
with shorter duration of symptoms may suggest the
possibility that monocyte macrophage collection in
the lung precedes lymphocyte collection and
granuloma formation at the site of lesion following
tuberculous disease. This is suggested by the fact
that abnormal accumulation of lymphocytes and
granulocytes was seen only in radiographically
abnormal lung segments of patients with longer
duration of symptoms. However, there was no
significant difference in duration of symptoms
between the two groups for coming to a definite
conclusion.
A dissociation of cell mediated immunity (CMI)
and delayed type hypersensitivity (DTH) was
described in tuberculosis and it had been suggested
that cellular types of immune responses were
involved in both 21 . The CMI was seen as beneficial
host response and DTH as the iminunological
reaction that caused caseous necrosis 22 . Although
tuberculin positive hosts with good CMI as well as
poor CMI could arrest bacillary multiplication, the
host with poor good CMI might recover whereas
the host witja poor CMI might suffer excessive tissue
destruction-. All the patients in the cited study 9 in
which two cell profiles were observed had strong
tuberculin reaction (>10 mm). The observation of
two types of cell profile may, therefore, suggest the
possibility that one group may have tuberculin
reactive good CMI and the other tuberculin-reactive
poor CMI. It had also been suggested that two
mechanisms of cell mediated responses, referred to
as the Listeria-type and the Koch-type could occur
in infections with mycobacteria. The Listeria-type
response is thought to provide protective
immunity 23-24 . It had also been described previously
that healing could occur in a proportion of
tuberculous patients without treatment 25-26 which
might be due to the development of good CMI in

ROLE OF BAL IN DIAGNOSIS OF PULMONARY TUBERCULOSIS 75
some of these patients. Alveolar macrophages from
patients with active pulmonary tuberculosis
produced significantly higher hydrogen peroxide 27 ,
indicating that these cell are activated. Alveolar
macrophages that were resistant to OK la (anti-DR
monoclonal antibody and complement treated) in
fact produced increased levels of hydrogen
peroxide 28 . It may also be possible that the finding
of generalised collection of macrophages in the lung
in one group may suggest the inability of the host to
localise the immune response as observed in
lymphocyte predominant group. Further studies are
required to unravel the importance of finding two
distinct cell profiles in lavage fluid in pulmonary
tuberculosis 9 .
Pulmonary surfactant has been known to have
immunoregulatory functions 29 . And, bactericidal
activity has been shown in crude preparations of lung
lavage material 30-31 . Bacterial infection is associated
with chronic respiratory diseases 32 . To understand
the pulmonary defense mechanisms against common
bacterial infections, such as Staphylococcus aureus,
in patients with pulmonary tuberculosis, bactericidal
activity in lavage samples from patients with active
and inactive pulmonary tuberculosis and healthy
subjects was studied 33 . Alveolar lining material of
patients with active pulmonary tuberculosis had less
bactericidal activity against bacterial infetions such
as Staphylococcus aureus 33 . The lavage fluids of
normal and inactive tuberculosis patients were more
efficient in their killing activity against
Staphylococcus aureus than were active tuberculosis
patients. It had also been observed that lymphocytic
alveolitis in tuberculosis patients was associated with
increased bactericidal activity against
Staphylococcus aureus, whereas no lymphocytic
alveolitis was associated with reduced activity 33 . As
bactericidal activity gets restored in inactive
pulmonary tuberculosis patients, following antituberculosis
treatment, there is no need for treating
active tuberculosis patients with antibiotics. It had
also been demonstrated that there was increased
production of pro-coagulant activity by alveolar
macrophages, in collaboration with lymphocytes and
other cells at the site of tuberculosis lesions and this
may lead to fibrin formation 34 . The fibrin deposition
in the alveolar space and interstitial tissue may lead
to further lung injury.
It had been demonstrated that lung epithelial
lining fluid levels of tumor necrosis factor-alpha,
interleukin-6 and interleukin-I beta were increased
in tuberculosis patients and these had a significant
correlation with disease, status 35-36 . These cytokines
are likely to be involved in directing granuloma
formation and control of M. tuberculosis infection.
The predominance of CD4(+) T cells producing both
pro-inflammatory cytokine interferon-gamma and
the anti-inflammatory cytokine interleukin-10 in
BAL fluid of patients with active tuberculosis was
also observed”. Active pulmonary tuberculosis had
also been found associated with increased numbers
of CD8+celIs and marked increase in the expression
of IL-12 and IFN-gamma mRNA in the BAL fluid,
both of which might be useful markers of disease
activity 38 . In HIV positive tuberculosis patients, it
had been shown that there was a markedly reduced
percentage of CD4+ lymphocytes and an increase
in the percentage of CD8+ lymphocytes 39 . Thus, in
HIV positive tuberculosis patients, failure of CD4+
alveolitis may limit an effective immune response.
In patients with active pulmonary tuberculosis
without HIV infection, it had been demonstrated that
a decreased CD4/CD8 ratio with an increase in CDS
eel Is in the alveolar spaces was associated with slow
disease regresssion, suggesting that the balance of
T-lymphocyte subsets might play a central part in
the modulation of host defense against mycobacterial
infection 40 .
Studies on Diagnostic Utility
Microscopic examination of sputum smears for
AFB, developed by Robert Koch more than a century
ago, continues to be the most important diagnostic
test for tuberculosis 41 . Even though M, tuberculosis
culture is the gold standard for diagnosis, it is time
consuming, expensive and not practicable for routine
management of patients. Radiometric method, such
as BACTEC system, although provides rapid results
(average, 9 days) yet is also expensive and cannot
be applicable in our country, except in a few referral
centres 42 . The new diagnostic tests 43 that are being
evaluated include improved AFB detection by
immunomagnetic separation strategy, detection of
mycobacterial components (tuberculo-stearic acid,
2-eicosanol etc.), signal amplification methods
(branched DNA signal amplification, QB signal

76 VK VUAYAN
amplification and reporter phage systems) and target
amplification methods such as polymerase chain
reaction (PCR) amplification, RNA amplification,
strand displacement amplification and ligase chain
reaction amplification. A serological test that aids
in the diagnosis of smear negative and
extrapulmonary tuberculosis is not currently
available 44 . Childhood pulmonary tuberculosis is
managed largely clinically because of the absence
of a reliable diagnostic test. Patients with positive
tuberculin skin test and abnormal chest radiographs
compatible with tuberculosis pose diagnostic
problems and therapeutic dilemma (to treat or not
to treat for tuberculosis) to chest physicians.
Fibreoptic bronchoscopic studies provide various
types of specimens (aspirates, brushes, lavage fluids
and biopsies) which may be useful for early
diagnosis of sputum smear negative pulmonary
tuberculosis 44-45
In a retrospective review of patients over a sixyear
period, Baughman et al 52 observed that
bronchoscopy with BAL was useful in the diagnosis
of pulmonary tuberculosis. In their study, there were
30 patients whose pre-bronchoscopy expectorated
sputum specimens were negative for AFB. Of these,
bronchoscopy specimens were smear positive in 26
(87%). Only 9 (30%) had sputum culture positivity.
In another study 53 , out of a total of 71 suspected
patients, sputum culture was positive in 33 (46.5%)
while BAL culture was positive only in 24(34%)
patients in whom sputum cultures were also positive.
In none of the patients was tuberculosis diagnosed
by BAL culture alone, despite BAL being cultured
in several different media. Lavage smear positivity
enabling a rapid diagnosis was possible in 3 (9%)
of 33 patients proved to be tuberculous by sputum
culture examination 53 . Thus, a single bronchoscopic
procedure, such as BAL fluid obtained by instillation
of normal saline and cultured for M.tuberculosis was
not superior to sputum culture examination for the
diagnosis of sputum smear negative, X-ray positive
pulmonary tuberculosis. Kennedy et al had reported
in a retrospective analysis of 112 patients that 91%
of prebronchoscopy sputum specimens (all smear
negative) had positive culture results, but only 63%
of BAL specimens were positive for
M.tuberculosis 5 *. Sputum smear negative pulmonary
tuberculosis is a paucibacillary condition and the
dilution of epithelial lining fluid by the instilled
saline might be responsible for the low yield from
BAL specimens. In addition, the local anesthetic
used for bronchoscopy also might have suppressed
the growth of M.tuberculosis 55 . In childhood
pulmonary tuberculosis, Somu et al found that gastric
lavage was superior to BAL fluid for isolation of
M.tuberculosis in culture 56 .
Kennedy et al 54 had further observed that early
diagnosis of sputum smear negative pulmonary
tuberculosis was possible in 38% of patients if
different bronchoscopy procedures such as
transbronchial biopsy (TBB) and post-bronchoscopy
sputum, in addition to BAL were studied. Panda et
al reported that immediate diagnosis was possible
in 35% of patients using TBB and bronchoscopy
lavage 57 . Charoenatankul et al also found that the
diagnostic yield of overall bronchoscopic procedures
(BAL smear and culture and TBB) was 32.5% in
patients with suspected smear negative pulmonary
tuberculosis 58 . Thus, an early diagnosis of
tuberculosis is possible in nearly 1/3 of sputum smear
negative pulmonary tuberculosis if different
bronchoscopic procedures are employed instead of
a single procedure during bronchoscopy. In a
decision analysis model, to assess the overall utility
of BAL in clinically suspected sputum smear
negative pulmonary tuberculosis, it has been
suggested that in a region of high tuberculosis
prevalence, empirical treatment is the best course
of action. BAL in such circumstances can be
reserved for further investigation of patients not
responding to empirical anti-tuberculosis treatment 59 .
In a study that determined the clinical utility of
rapid tuberculosis detection in BAL samples by
polymerase chain reaction (PCR), it was observed
that BAL PCR gave sensitivity, specificity, positive
and negative predictive values of 66.7%, 100%,
100% and 88% respectively 60 . These investigators
had also demonstrated that BAL PCR had a good
concordance with the final diagnosis of active
tuberculosis 60 . In another study, the PCR assay gave
a positivity rate of 80.9% compared with 8.8% for
smear examination and 7.4% for culture for
M.tuberculosis in BAL specimens 61 . Thus, PCR
assay was found to be more sensitive than smear
and culture in detecting M.tuberculosis in BAL
specimens of patients with sputum smear-negative
pulmonary tuberculosis.

ROLE OF BAL IN DIAGNOSIS OF PULMONARY TUBERCULOSIS 77
Further immunoiogical studies of the
cytokines 62-63 released from lung immune and
inflammatory cells are required to assess for
immunologicai competence of the host thai may aid
in understanding the pathogenesis of tissue
destruction and healing in pulmonary tuberculosis.
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Leading Article Ind. J Tub. 2000, 47. 79
PCR FOR DIAGNOSIS OF TUBERCULOSIS : WHERE ARE WE NOW ?
INTRODUCTION
During the past decade, the advantages of
diagnostic molecular techniques have been so widely
publicized that there is increased pressure on clinical
microbiology laboratories to either include them in
their “research” activities or risk being left behind in
the quality of service that they provide to their
clinicians and patients.The Polymerase Chain Reaction
(PCR) is one such technique.
Before introducing any molecular technique in
a diagnostic laboratory, several strategic questions
must be addressed. Some of these are :
(i) Which organism to target? (ii) Which clinical
specimen to test? (iii) Do molecular tests fulfil the
required criteria of high sensitivity and specificity,
speed, simplicity and clinical relevance?
In general, molecular diagnostic techniques are
indicated for:
*Detection of organisms that cannot be grown
in vitro or for which current culture techniques are
too insensitive,
*Detection of organisms requiring complex
media and/or prolonged incubation time.
Since arriving at a correct diagnosis of
tuberculosis meets both the criteria listed above,
nucleic acid amplification techniques for diagnosis
of tuberculosis have attracted considerable interest
with the hope of shortening the time required to
detect and identify Mycobacterium tuberculosis in
respiratory specimens such as sputum or BAL. It is
in this field of clinical microbiology that most
amplification procedures, developed either in house
or in commercial formats, have been evaluated.
Technical Aspects
The basic principle of any molecular diagnostic
test is the detection of a specific sequence in clinical
sample by hybridizing the nucleic acid it contains
with a complementary sequence (probe) followed
by detection of the hybrid. However, the sensitivity
of this procedure for tuberculosis is below that
of AFB smear examination after ZN staining’.
Therefore, there is a need to amplify the target
sequences present in clinical specimen before
hybridization. Any stretch of nucleic acid can be
amplified by using DNA polymerase, provided that
some sequence data are known to allow the
designing of appropriate primers. For diagnosis of
tuberculosis, many different DNA amplification
targets have been used, such as : genes encoding
the 32 kDa, 38 kDa or 65 kDa antigens; or the dnaJ,
groE 1 or mtb-4genes; some of these genes are group
specific, with species identification requiring
subsequent restriction enzyme treatment or
hybridization. 2
However, the target most frequently amplified
is the IS 986 or IS 6110 repetitive element, which is
present in multiple copies (upto 20) in most strains
of M.tuberculosis complex. DNA from the bacteria
present in clinical specimens has been extracted by
numerous methods ranging from simple boiling or
shaking with glass beads to more complex extraction
procedures. Due to the risk of cross contamination,
some scientists have performed PCR with d DTP
instead of d TTP allowing for decontamination with
uracil-N’-glycosylase. Upto one fifth of clinical
specimens have been reported to contain inhibitors
of Taq polymerase and prudent scientists have
devised internal quality control strategies to identify
the presence of inhibitors to prevent false negative
reporting.
Results From Sputum Specimens with in House
PCR Tests
None of the studies summarized in Table 1
found a statistically significant difference between
culture results and amplification techniques.
Therefore, the heightened sensitivity of PCR
reported by most Indian scientists would suggest
inadequate mycobacterial isolation procedures
used in different clinical laboratories in India,
besides the ever present risk of false positive
results. It has been recommended that for each
sample, decontamination should be performed by
the gentler n-acetyl 1-cystein method with close
attention paid to total time of exposure rather than
by the harsh sodium hydroxide method and that two
media - one egg based and another agar based -
should be used to maximize chances of isolation of
mycobacteria.

80 ASHOK RATTAN
Table 1. Sensitivity and specificity of PCR according to some international studies
Study
No. of
Specimens
Prevalence
%
Sensitivity
%
Specificity
%
PPV
%
C R C R C R
Abe 3 135 28 81.3 84.2 94.2 300 81.3 84.0
Beige 4 103 47 98.0 70.0 75.0
Clarridge 5 >5000 4.4 83.6 86.1 98.7 100 94.2 98.4
Miller 6 750 21 78.2 92,3 100.0
Nolle 7 3J3 40 91.0 100.0 100.0
Shawar 8 384 18 74.0 80.0 95.0 97 77.0 86.0
Yuen 9 519 8 96.0 85.0 100
Prevalence of positive specimens based on culture results PPV=positive predictive value
C=crude results R=revised results after discrepancy analysis
When the results are analyzed separately for
smear positive and smear negative cases (Table 2),
PCR appears to suffer from lack of sensitivity in
smear negative but culture positive cases.
Table 2. PCR sensitivity in different studies
according to smear and culture positivity
Study
PCR Sensitivity (%) in different studies
Overall
Smear+
Culture +
Smear-
Culture +
Abe 3 84 96 50
Clarridge 5 86 94 62
Miller 6 92 98 78
Nolte 7 91 95 57
Yuen 9 96 100 92
The effectiveness of PCR for tuberculosis is
related to experience and accuracy of the personnel
conducting the assay. This was illustrated by an
external quality control study of seven laboratories
from different parts of the world (no laboratory from
India participated) which received and tested 200
spiked sputum specimens. Each laboratory used its
own protocol for the test, all targeted IS 6110 for
amplification. False positives varied from 0 to 20%,
but one laboratory reported as many as 77% of
negative control specimens as positive. None of the
laboratories could reliably and consistently pick up
samples with 103 AFB/ml (sensitivity of AFB
smear examination by ZN method is 104 AFB/ml) 10 .
A second external quality control study of 30
laboratories showed no improvement, with 56% of
participating laboratories reporting false positive
results in 5 to >50% of the samples tested”.
Results With Commercially Available
Amplification Tests
The commercially available PCR (Amplicor,
Roche) and TMA (Gene Probe) test gave results
comparable to those obtained with in house PCR
tests in the hands of many scientists. Surprisingly,
more specimens appeared to have Taq
polymerase inhibitors when using the commercial
kits (Table 3).
Results of M Tuberculosis Direct Test (MTDT) In Smear
Positive And Smear Negative Specimens
Table 4 gives the results of MTDT test done in
specimens obtained from AFB smear positives and
smear negatives in the cited studies

PCR IN PULMONARY TUBERCULOSIS 81
Table 3. Evaluation of commercially available PCR (Amplicor) test for M. tuberculosis in different studies
Study
No. of
Specimens
Prevalence
%
Sensitivity
%
Specificity
%
PPV
%
C R C R C R
Carpentier 12 2,073 9 86 98 94.5
D’Amato 13 985 66.7 99.7 91.7
Gleason 14 532 95 96
Ichiyama 15 422 29 97.8 96 98.7
Schirm 16 504 6 70.4 98
Vuorinen 17 256 84.6 82.8 99.1 100 100
Wobeser 18 1,480 9.5 79 99 93
C=Crude resultsU- Revised results after discrepancy analysis
Table 4. MTDT Sensitivity according to quality of
AFB positivity in different studies
Study
PCR Sensitivity (%) in different studies
Overall
S mean+
On Iture +
Smear-
Culture +
Abe 3 92 100 70
Bodmer 19 71 100 14
Jonas 20 82 100 54
Miller 6 91 94 63
Pfyffer 21
Portaels 32 95
86
Conclusions
100
89
80
85
PCR is an efficient technique with the’theoretical
possibility of amplifing one DNA sequence of
interest to 106 copies in the course of one working
day. However, there appears to be considerable
confusion regarding its place in the diagnostic
laboratory. While research activity must continue
if we are to refine the test, remove the numerous
drawbacks and reap the benefit of its potential,
at present in view of the available data, the test
should not be used for diagnostic decision
making 10,11,23 . In 1996, USA FDA recommended
that MTDT should be restricted to smear positive
specimens from untreated patients of
tuberculosis and used only in conjunction with
traditional sputum examination 24 . It should not
be used for smear negative sputum or other
specimens such as pleural or cerebrospinal fluids.
In the last few years, although numerous papers have
been published from various laboratories of the
world, including India, there appears to have been
no quantum jump in the state of the art knowledge
in as far as use of PCR for diagnosing tuberculosis
is concerned to warrant any change in USA FDA’s
recommendations. It needs to be stressed that
based solely on PCR results, clinicians should
neither start treatment nor stop treatment 25 . It
would be prudent for clinical laboratories to allocate
additional resource to techniques which have been
shown to be highly reliable (although not adequately
sensitive) so as to optimize their diagnostic potential,
while research laboratories must address themselves
to overcoming the numerous problems and variables
identified, while performing PCR, before they offer
this test.
Molecular diagnostic techniques, although
found promising, have not yet delivered their
promise. They are currently at a stage analogous to
that of clinical bacteriological techniques in the
1960s, before they were improved by using
standardized protocols which stressed on
appropriate quality, assured reagents, meticulous
attention to detail, adequate internal quality control
and participation in external proficiency testing
programmes.
Ashok Rattan
Director, Microbiology New Drug Discovery Reseach,
Ranbaxy Research Laboratories, New Delhi-110 020

82 ASHOK RATTAN
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Original Article Ind J. Tub. 2000, 47, 83
PLEURAL FLUIC/SERUM CHOLINESTERASE RATIO FOR EXUCATIVE PLEURAL EFFUSIONS
A.K. Janmeja 1, K.M. Goyal 2 and Manju Sharma 3
(Received on 3.8.99; Accepted on 15.11.99)
Summary: Several studies have revealed that the widely used Light et al criteria misclassify an unacceptably high
proportion of pleural effusions as being exudates or transudates. The pleural fluid/serum cholinesterase ratio has been
considered to be more promising differentiator. A study was conducted to judge the efficacy of this criterion, in
comparison with the Light et al criteria.
In all, 50 pleural effusions comprising 30 exudative types (10 each of malignant, tuberculous and parapneumonic
etiologies and 20 transudative types (10 each of congestive heart failure and nephritic syndrome) were evaluated.
Various other investigations to classify pleural fluids according to Light et al criteria, viz. pleural fluid total proteins,
serum proteins, pleural fluid LDH and serum LDH estimation also were done for every patient along with pleural fluid
cholinesterase level and pleural fluid/serumk cholinesterase ratio. The estimation of cholinesterase was done by kinetic
colorimetry method using Autopak cholinesterase commercial kit.
By using Light et al criteria, 2 exudative and 3 transudatie cases were misclassified i.e. 10% of the toal cases. Using
pleural fuluid cholinesterase level alone (cut off value; 1600 I.U.), 3 (6%) cases were misclassified but with pleural
fluid/serum cholinesterase ratio criterion (cut off value; 0.5), only 1 (2%) case was misclassified.
The pleural fluid/serum cholinesterase ratio was found to be the most sensitive crierion to the most sensitive criterion to
differentiate between exudative and transudative pleural effusions. The cholinesterase ratio criterion is simpler to
perform and is economical.
Key Words: Cholinesterase ratio, Pleural effusion, Exudative effusion. Transudative effusion.
INTRODUCTION
Pleural effusion occurs in a large variety of
pathological conditions, but determination of the

cause of pleural effusion is not always easy
Invasive loca procedures such as pleural biopsy,
thoracoscopy etc. are indicated in patients with
pleural abnormalities, in which case the effusion is
exudative. In 1972, Light et al 1 developed criteria
for differentiating between transudates and
exudates, which have been widely accepted.
However, several reports 2-5 have shown that the
Light et al criteria misclassify a large number of
effusions: even upto 20% to 30% of transudates.
Therefore, several alternative parameters have been
proposed e.g., pleural fluid cholestrol level
and pleural fluid/serum cholestrol ratio; pleural
fluid/serum bilirubin ratio; serum-pleural effusion
albumin gradient’ alkaline phosphate value and
modified Light et al criteria, But their superiority with
respect to the criteria of Light et al remains doubtful.
In 1978, Cabrer et al 6 and recently, in 1996, Eduardo
et al 5 have estimated pleural fluid cholinesterase and
pleural fluid/serum cholinesterase ratio and found
these to be more efficient for seperatimg pleural
transudates from exudates.
This study was planned to evaluate the usefulness
of estimating the cholinesterase level in pleural fluid
and pleural fluid/serum cholinesterase ratio for
differentiating pleural transudates from exudates.
1. Professor 2. Senior Resident 3. Associate Professor
Department of Tuberculosis & Chest Diseases, Government Medical College, Chandigarh
Correspondence: Prof. A.K. Janmeja, 1117, Sector 32-B, Chandigarh-160 044 Fax: 0172-609360, 608488

84 AK.JANMEJAETAL
MATERIAL AND METHODS
The study was conducted in the Department
of Respiratory Medicine at postgraduate Institute of
Medical Sciences, Rohtak. Patients with pleura!
effusion were selected for the study between January
and September, 1998, comprising the following two
groups, on the basis of clinically confirmed
etiological diagnosis.
Group A: comprised 10 cases each of tuberculosis,
malignant and parapneumonic pleural effusions.
Group B: comprised 10 pleural effusions due to
congestive heart failure (CHF) and 10 of nephrotic
syndrome, as a result of systemic factors which
caused movement of fluid in and out of pleural space
without a direct pathological involvement of pleura.
Cases of pleural effusion which had more than,
one possible cause e.g., patients of heart failure with
pneumonia or malignancy; persons with liver
cirrohsis or with hepatocellular disease and persons
with history of exposure to pesticides were excluded.
Tuberculous pleural effusion was confirmed by
demonstrating caseating epithelioid granuloma by
pleural biopsy, or isolation of tubercle bacilli in
pleural fluid/biopsy specimen. Malignant pleural
effusion was confirmed by demonstration of
malignant cells in pleural fluid or in pleural biopsy,
with or without histolotgical evidence. An effusion
was considered parapneumonic when seen along
with typical clinico-radiological profile of
pneumonia and response to antibiotics. CHF was
diagnosed by cardiomegaly on roentgenogram and
ediocardiography, presence of pulmonary
congestion, absence of lesion in Chest X-ray and
response to CHF therapy. Nephrotic syndrome was
diagnosed by establishing proteinurea of more than
3.5 g/24 hours’ oedema, hypoalbuminemia of less
than 3.5 g per decilitre and hypercholestrolemia.
Thoracentesis was performed in each case and
great care was taken not to let the fluid mix with
blood. About 0.2 ml of pleural fluid specimen was
stored in a clean and dry test tube between 2-8°
Celsius for estimation of cholinesterase, lactic
dehydrogenase (LDH) and proteins. Heparin was
used as anticoagulant. The pleural fluid and serum
specimens were obtained within an hour of each
other. In CHF patients pleural fluid specimens were
col lected not later than 48 hours after startkig diuretic
therapy. The cholinesterase activity in pleural fluids
and sera was assayed according to Dietz et al by
kinetic colorimetry using Autopak cholinesterase
commercial kit.
To classify pleural effusions according to the
Light et al criteria 1 , each case was subjected to
pleural fluid total proteins, total serum proteins,
pleural fluid LDH and serum LDHestimations. Total
proteins were estimated by Biurete method and LDH
by Kinetic U.V. optimized standard method using a
kit. Statistical analysis of differences was by
Student’s test.
RESULTS
A total of 66 pleural effusion patients were
evaluated. Thirteen (24.2%) patients were excluded,
either because aetiology could not be ascertained or
more than one cause was found, one patient had
chylothorax and one had frank haemorrhagic fluid.
In all, 50 patients satisfied the established criteria
and were included in the study. A majority of the
cases (99%) belonged to 3rd to 6th decades of life
and male to female ratio was 4:1.
Table I: Extent of misclassification of pleural fluids
according to different parameters
Criterion Exudates Transudates
Light et al
PI. fluid cholinesterare
PI. fluid to serum
Ca Tb Pn Che Ns Total
n=10 n=10 n=10 n=10 n=10 n=50
%
1
1
1
0
0
1
2
1
1
0
5(10)
3(6)
Cholinesterase ratio 0 0 - 0 1 0 1(2)
Ca = Cancer Tb = Tuberculous
Che = Congestive heart failure
Pn = Parapneumonic
Ns = Nephrotic syndrome
Table 1 gives the number of pleural effusion
cases misclassified by various parameters in the
present study: 5 pleural effusion cases (2 from exu-.
dative and 3 from transudative group) were
misclassified by the Light et al criteria. The mean
pleural fluid cholinesterase level in malignant, tuberculous
and parapneumonic pleural effusion cases
was 2357.5 (SD 480.1), 2599.0 (SD 589.2) and
2413.4 (SD 458.0) I.U. respectively. In Group B
Patients, it was 943.6 (194.2) and 959.6 (274.5) in

PLEURAL FLUID DIFFERENTIATION 85
CHF and nephrotic syndrome cases respectively.
The mean pleural fluid cholinesterase level for
Group B i.e. transudative pleural effusion cases was
951.6 (216.7), mean pleural fluid cholinesterase
level for Group A i.e. exudative pleural effusion
cases was 2440.96 (493.55) and the difference between
the two was statistically highly significant
(p

86 A.K.JANMEJAETAL
according to concent: dtion gradient. Thus, the
exudative fluids contain increased concentration of
LDH & proteins which are similar in their
biophysical behaviour. Transudation of plasma
through intact serous membrane results in the
transport of water and low molecular weight ions or
molecules (eg. sodium,,glucose, urea etc.) but
prevents permeation of protein molecules through
intercellular pores of r/ormal endothelium and
mesothelium. As cholinesterase is a high weight
molecule, its concentration is expected to be low in
transudative pleural effusion as against exudative
pleural effusion. In 1978, Cabrer et al 6 analysed the
cholinesterase activity in pleura! effusions of diverse
causes and found a significant difference in the
average level of cholinesterase between transudates
and exudates. The fact later became the basis for
using cholinesterase levels for differentiating two
types of effusions by using pleural to serum
cholinesterase ratio. In the present study, by using
pleural to serum cholinesterase ratio, we have
accurately classified 98,% of pleural effusion cases.
One case of transudative effusion which belonged
to CHF group was miscfassifled as an exudate. The
cholinesterase ratio in this case was 0.6 (the cut off
value between exudate and transudate was 0.5). The
misclassified case was further investigated and no
evidence of any hepatic derangement either at
present or in past was found. Eduardo et al 5 , while
comparing the cholinesterase criteria with that of
Light et al and cholesterol criterion, also observed
that pleural fluid to serum cholinesterase ratio
criterion was able to correctly classify 98.7% of the
153 pleural effusion patients. Their two cases which
were falsely classified as exudates were having
hepatic cirrhosis. Misclassification rates by Light et
al criteria, Cholestrol & Cholinesterase ratio were
7.8%, 6.5% and 1.3% respectively. In our study,
misclassification with Light et al criteria was 10%.
That transudative pleural effusion gets misclassifed
as exudate more often by Light’s criteria has been
observed by various workers 2-5 . In the present study,
15% transudates were misclassified as exudates
compared with 6.6% exudates as transudates, while
in Eduardo et al’s study misclassification rate was
25% for transudates and 2.5% for exudates. Pleura!
fluid cholinesterase level estimation alone
misclassified 6% cases in the present study compared
with 8% in Eduardo’s, suggesting that pleural fluid
cholinesterase level measurement alone is not
satisfactory.
The most analysed parameters in the recent past
have been pleural fluid cholesterol level and pleural
fluid to serum cholesterol ratio. The misclassification
rates were 6.8-7.8% by pleural fluid cholesterol
level 3 ’ 8 , while pieural fluid to serum cholesterol ratio
misclassified 6.6-8.6% cases 3 - 9 . Meise! 4 et al found
pieural fluid to serum bilirubin ratio estimation also
far from satisfactory as misc I ass ifi cation ranged from
lOto 19%. Roth etal’°analysed the serum - albumin
in gradient in their 59 patients and correctly classified
all the transudates and 39 of the 41 exudates but
other authors could not reproduce similar satisfactory
results. Tahaoglou et al” found the level of alkaline
phosphatase Tower in transudates compared to
exudates but misc lass ifi cation rate was 6.5%.
The results of our study compared with the
parameters used by others suggest that the
pieural fluid to serum cholinesterase ratio
criterion is the most sensitive parameter for
differentiating transudative and exudative
pieural effusions. Besides, cholinesterase ratio
criterion is simpler to perform and economical
compared with the criteria of Light et al.
REFERENCES
1. Light RW, McGregor MI, Luchsinger PC. Pleural
Effusions: The diagnostic separation of transudates and
exudales. Ann Intern Med 1972; 77: 507
2. Hamm H, Brohan U, Bohmer R, Missamahl HP.
Cholesterol in Pleural Effusions: adiagnostic aid. Chest
1987:92:296
3. Valdes L, Pose A, Suarez J, Gonzalez JR, Sarandeses
A, Sanjose E. Cholesterol: a useful parameter for
distinguishing between pleural exudates and transudates.
Chest 1991; 99: 1097
4. Meiscl S, Shamis A, Thaler M, Nussinovioht N,
Rosenthal T. Pleural fluid to serum bilirubin
concentration ratio for the separation of transudates from
exudates. Chest 1990; 98:141
5. Eduardo GP, Isabel PN, Jose FS, Benedicto J, Juan C.
Pleural fluid to serum cholinesterase ratio for separation
of transudates and exudates. Chest 1996; 110:97
6. Cabrer B, Bofill D, Gran A. Valor de la cholinesteresa
en liquido pjeural para su diagnostico etiologico. Rev
ClinEsp1978; 150: 183
7. Dietz AA, Rubinstein H, Lubrano T. Colorimetric
determination of serum cholinesterase and its genetic
variants by the propionylthio-choline -dithiobis
(nitrobenzoic acid) procedure, CUnChem 1973; 19:1309
8. Romero S. Candela A, Mertin C. Evaluation of different
criteria for the separation of pleural transudates from
exudates. Chest 1993; 104: 339
9. Gil Suay V, Martinez Morgon E, Cases Viedma E et ai.
Pleural cholesterol in differentiating transudates and
exudates: a prospective study of 232 cases. Respiration
1995; 62:57
10. RothBJ,O’MearaTF,CragunWH. The serum effusion
albumin gradient in the evaluation of pleural effusions.
Chest 1990; 98: 546
11. Tahaoglu K, Kizkin O.Alkaline phosphatase:
distinguishing between exudates and transudates (letter).
ches 1994; 105:1912

Original Article Ind. J. Tub. 2000, 47, 87
ROLE OF SILICON IN MODULATING THE INTERNAL MORPHOLOGY
AND GROWTH OF MYCOBACTERIVM TUBERCULOSIS
Satadal Das 1 and U.K. Chattopadhyay 2
(Received on 12.7.99, Accepted on 4.12.99)
Summary: Silicon is known to enhance the growth and pathogenicity of Mycobactenum tuberculosis. In this study the pattern
of growth of different strains of M.tuberculosis was studied on a carbon free silicon based culture medium and compared with that
on conventional media. Thirty-two strains of M.tuberculosis from mostly clinical isolates were serially propagated on a carbon free
silicate medium and on different conventional media using standard inocula
There was initial good growth on the silicon based medium in comparison with the conventional media. However, the growth
was considerably reduced after early serial transfers but improved again in late serial cultures.
The initial good growth appears to be due to increased activity of silicon induced fatty acid synthase and the late improvement
due to slow adaptation of M.tuberculosis to the carbon free metaboiism by the formation of silicic acid esterified cell wall and
silicon induced genetic alteration. All these changes were probably responsible for the formation of fibrous, ropelike structures and
dense granules seen under electron microscope.
Since the silicon content of the lung tissue is comparatively higher than many other tissues of the human body, it could play a
role in the pathogenicity of tuberculosis in the lungs
Key words :- Silicon, morphology; growth; M tuberculosis
INTRODUCTION
Many organisms are known to be able to utilise
silicon (Si) which is present in plenty in nature
(Fig. 1). There are distinct Si accumulator plants like
Cyperaceae,Graminae, Juncaceae and Moquiles
Spp.;organisms like marine phytoplankton, marine
brown algae, ‘horsetails’, foraminifera and porifera
contain enough Si, in the range of 60,000-4,37,000
mg per kg dry matter (DM). Bacteria contain about
180 mg per Kg DM of Si 1-2 . Addition of Si in culture
media showed a remarkable growth accelerating
effect on Staphylococcus aureus 3 ; its utilisation 4 and
in Nocardioform organisms 5 .
There is considerable indirect evidence of Si
utilisation by bacteria. Thus, ‘non-typhoidal
Salmonella’, Enterobacter, Klebsiella and
Citrobacter can survive better in Si-riched sandy-
loam soil than in the plain loam soil 6 . Si is known to
enhance the growth of Mycobactenum tuberculosis
in the lungs where Si is present to a high degree.
Experimentally, Si was found to increase
pathogenicity of BCG, a typical mycobacterium,
M.tuberculosis and M. Leprae 7-11 .
There is a profound similarity of Si chemistry
and carbon (C) chemistry 12 . The silicon compounds
have kinetic parameters identical to those of their
carbon analogues 13 . It is possible that an organism
can utilise Si in a C-deficient environment. In the
present study, a possible role of Si in in vitro growth
ofM.tuberculosis even in the absence of a C source
was studied. As lung is the most important Si
accumulator in the body of man’ and because
mycobacteria can utilise Si 4 , a possible role of Si in
the pathogenicity of M.tuberculosis was sutdied.
1. In-Charge Department of Laboratory Medicine, Peerless Hospital & B.K. Roy Reseaich Centre, Calcutta
2. Associate Professor, Department of Micorbiology All India Institute of Hygiene and Public Health, Calcutta
Conesspondence. Dr. U.K Chattopadhyay, Deplt. of Microbiolog) All India Institute of Hygiene and Public Health 110, Chittaranjan
Avenue, Calcutta-700 073

88 SATADAL DAS AND U.K. CHATTOPADHYAY
MATERIAL AND METHODS
M.tuberculosis strains - The strains used were
H 37 R v .H 37 ,R a and 30 clinical isolates. Pure
cultures
were maintained on Lowenstein-Jensen Medium
(LJM) and were checked for purity 4 .
Culture Media - Lowenstein Jensen Medium
was prepared by usual procedure 14 . The Kirschner
silicate medium (KSM), in each MacCartney bottle,
comprised 3 ml of Kirschner Medium 15 concentrated
2.5x, plus 3 ml Na 2 Sio 3 (Fluka, Switzerland)
11.8 g/dl used as a solidifying base, with addition
of H 3 PO 4 (1.5 ml. of 16% V/V aqueous solution).
The system of preparation of media utilising Na 2
Sio 3 and H 3 PO 4 was described previously by many
workers 4,5,16 but the ratio of the chemicals and technique
used in this experiment were thoroughtly altered.
As a result, the medium became transparent
like glass; adjustment of pH was easier, release of
water from the medium was very little and stability
was longer (6 months). The silicate minimal medium
(SMM) comprising Na 2 HPO 4 ,0.750g;KH2PO 4
1 .0g; MgSO 4 ,0.150g, NH 4 NO 3 , -1.250g and distilled
water 100 ml was sterilised by passing through
sintered glass filter lacking any C source, and solidified
with a mixture of Na 2 SiO 3 and H 3 PO 4 ,as
described for KSM above. All the chemicals were
of the Analar or equivalent grade and only double
distilled water was used.
Cultivation Proceduers - The inocula were
prepared by transferring 6-7 colonies from the stock
culture media to glass homogenisers followed by
grinding and suspension in 5 ml phosphate buffer
(pH 7.4) saline and homogenising by shaking with
glass beads. The step was followed by low speed
centrifugation (10 min) to give a uniform
homogeneous suspension. These suspensions were
then matched and standardised with reference to
Macfarland’s standard (1%) and 0.02 ml of these
standardised suspensions was used as inoculum. In
our previous experiment 4 , we had estimated viable
counts of these inocula; each produced 100-200
isolated colonies on LJM. Repeated subculture was
done simultaneously on LJM, KSM and SMM. The
time taken for growth on a particular medium at
37°C, its increase with the duration of incubation,
colonial morphology, effect’of serial transfers on
growth, microscopic morphology with different
types of strains and acid fastness were noted. The
growth characteristics were also examined with
respect to the capacity for reversion to the original
colonial and morphological (microscopic)
characters, when returned to the LJM. The original,
as well as the KSM and the SMM propagated
cultures were checked for authenticity and purity
by requisite tests 4 and for their mycobacterial
characters at different stages of the study.
Electron Microscopy (EM) Study -Electron
microscopy observations of the mycobacteria grown

SILICON MODULATION OF GROWTH OF M. TUBERCULOSIS 89
on silicate and conventional media were done with
the help of Jeol JEM-200 CX electron microscope
(Jeol Ltd. Tokyo, Japan) after staining with 1%
solution of uranyl acetate on a carbon coated copper grid.
FINDINGS AND DISCUSSION
Two types of media in which Si was an
important elemental part, with or without any evident
source of C (in KSM and SMM media respectively),
were used to detect if M. tuberculosis could use Si,
at least partially, in exchange for carbon. The results
of the study [Graph 1] showed that colonies of M
tuberculosis (H 37 R V ,H 137 R a , 30 clinical isolates)
appeared earlier on KSM as compared with LJM.
But on KSM, the growths remained uniform for
about 25 days after which they increased in a
significant way till they became confluent. On
subsequent passages, the growth of all the strains
on KSM showed a relative diminution in the final
amount and their maximum attainable growths were
no more than those on the LJM.
A significant observation seems to be that
growth of different strains of M. tuberculosis did
not improve on the C-free, inorganic salt-based
minimal medium (SMM) as compared with C-
containing KSM medium; all the cultures which
could grow on the KSM were also able to grow on
the SMM and they grew in a more satisfactory
manner after repeated (4-6) serial passages on this
medium. The ‘carry over’ of C from the original
medium via the inoculum and the very small amount
of impurities in the chemicals of Analar grade
reagents could provide very little C for growth. That
probably resulted in considerably reduced growth
after initial improvement which could improve again
after slow adaptation to the C-free metabolism, after
repeated passages. These findings suggest that M
tuberculosis strains are able to utilise Si facultatively
in the absence of C, either partly or wholly. In one
of our previous experiments, mycobacterial strain
(H 37 R a ) was shown to contain more silicon by
electron microanalyser when grown on SMM
(24.90%) than when grown on LJM (0.84%) 5 .
Additional characteristics noted in the present
experiment were the penetration of SMM,
development of branching of the bacillary bodies,
increased beading, presence of coccoid bodies and
minimised acid fastness. One important finding was
that the addition of 0.04 g/d 1 ferric citrate and 0.002
g/dl pyridoxine in the final stage of SMM produced
mycelial forms of mycobactejia. Electron
microscopy observations showed plentiful fibrous
rope like structures and dense granules in the
mycobacteria grown on silicate media. Additional
findings were the decreased size and less lipoidal
bodies in comparison with the mycobacteria grown
on conventional media.
The findings of this study, thus, indicate that Si
utilisation is probably an important marker of M.
tuberculosis pathogen!city. There is plenty of Si in
the lung tissue. Si can, thus, promote growth of M
Tuberculosis in the lungs, either by local action or
by systemic effect. The local action of Si on
M.tuberculosis is either a direct one or via indirect
means [Fig.2], Indirectly, Si can help in the
Graph 1
GROWTH PATTERNS OF H R ON DIFFERENT MEDIA

90 SATADAL DAS AND U.K. CHATTOPADHYAY
Fig. 2
ROLE OF Si IN TUBERCULOSIS
multiplication of M. tuberculosis in monocytes and
macrophages by increasing the permeability of
phagolysosomal membrane leading to diffusion of
enzymes, release of tumour necrosis factor, increased
prostaglandins, decreased succinic dehydrogenase 17
and complement fractions 18 . Si, as a hapten, also
causes immunogenic cell proliferation leading to
formation of antigen/antibody complexes.
Systemically, Si level of more than 3.9 mg/d 1 in
whole blood causes decrease of superoxide
dismutase, catalase and glutathione 19 which are more
prbminent in tropical countries due to 50 times more
(about 1000 mg/day) intake of Si than elsewhere.
All these alterations become prominent in silkosis
and lead to peribronchial and perivascular
flbroblastic reaction in the lungs with formation
of fibrous silicose nodules proceeding to
conglomerate silicosis, which always are conclusive
evidence of tuberculosis. However, in this paper,
our main point of discussion is the direct effect
of Si on M. tuberculosis. The uniform early
appearance of colonies of M.tuberculosis on the
silicate media, on the 3rd day of culture occurs
simultaneously with the increased fatty acid
synthase activity which also becomes maximum
on the 3rd day in Si activated cells 20 . This increased
enzymatic activity probably causes rapid
multiplication of cells leading to the early formation
of colonies on KSM and SMM media in comparison
with the LJM. In this early phase, there was also no
significant alteration of the bacterial morphology.
After the initial rapid multiplication phase, there is
a ‘stationary’ phase, with absent fatty acid synthase
activity, which diminishes after 5 days. Multiplication
of M. tuberculosis then comes to a halt, but after about
20 days or after repeated subcultures, there is
improvement in growth again, probably due to Si
utilisation as indicated by the formation of silicic acid
esterified cell wall 21 , also known as’wall bound silicate’
which is very difficult to remove from the bacteria 22 .
The cell multiplication is helped by Si-induced genetic
alterations e.g., by Si-guided nucleic acid synthase 23-24 ,
Si-induced gene expression before translation 25 and by
transformation 26 . Peculiarly, in this late phase, many
bacteria become branched, and after the addition of
small quantities of ferric citrate and pyridoxine, a
typical conversion to mycelial forms occurs due to
some unknown mechanisms. The Si-induced growth
of M. tuberculosis, therefore, may signify a new
aspect of mycobacterial metabolism with, perhaps,
its pathogenicity linked to it.

SILICON MODULA I ION OF GROWTH OF M. TUBERCULOSIS 91
REFERENCES
1. Bowen HJM. Environmental chemislr> of the Elements.
Academic Press, London, 1979.7.147
2. Lapo. A.V. Traces of Bygone Biospheres. Mir
Publishers. Moscow, 1979.92 and 168
3. Tajirna M. The effect of silicon on the growth of
btapny’ococcus aureus. Nippon Jibiinkoka Gakkai
Kaiho. 1990. 93(4); 630
4. Das S. Mandal S. Chakraborty A N. Dastidar S G.
Metabolism of silicon as a probable pathogenicily factor
for Mycobacterium & Nocardiasupp Indian.1 MedRes
199295(A). 59
5. Chakraborty A N. Das S. Mukherjee K. Dastidar S G
Sen D K. Silicon (Si) Utilisation by Chemoautolrophic
Nocardio form bacteria isolated from human and animal
tissue infected with Lprosy Bacillus. Indian Journal of
Expi Biology 1988. 26(1!)! 839
6. Papavassiliou, J.;Leonardopoulos, .1 Survival of
Enterobacteria in two different types of sterile soil. In
proceedings in Life Sciences. Microbial Ecology. Edited
by M.W.Loutit and J.A.R. Miles. Springer-Verlag.
Berlin. 1978. pags 206 to 209
7. Allison A C. Hart D A. Potenliation by silica of the
growth of Mycobactemtm tuberculosis in macrophage
culture. BrJExp Pathol 1968. 49. 465
8 Heppieston. A.G. The flbrogenic action of silica, fir.
Med Bull 1969.25 : 282
9. Guerra. E.G. Encyclopaedia of occupational health and
safety Vol. II (International Labour Office. Geneva),
1974
10. Baily W C . Brown M, Buechner H A. SIlico-
M>cohacterial disease in sandblasters Am Rev Resp Dix
1974. !IO. 115
11. Shell} V P. Animal Modei to study the mechanism of
nerve damage in leprosy-a preliminary report.
International Journal ofLeprosvA other Wycobacterial
Diseases 1993, 61(1). 70
12. Prakash. S. Advanced chemistr) of Rare Elements. S.
Chand& Co. New Delhi. 1975
13 Aberman A Segal D. Shalitin Y, Gutman A L. silicon
compounds as substrate and inhibitors of acetylcholineesterase.
Biochemicalet Biophysica Acta, 1984; 791
(2); 278
14. Das, S. Handbook ol Microbiology. Current Books
International, Bombay, 1995, 48
15 Kirschner, O.:bl Baki. Abt. I Orig 1932.125.225
16. Das S- Studies on the biological characteristics of
mycobacteria and related species on silicate and some
conventional media. Thesis : MD (Microbiology).
Calcutta University, 1983
17. Shen FZ. the effect of silicon on tuberculosis infection
and immune system. Chinese Journal of Tuberculosis
& Respiratory Diseases. 1991; 14(5), 292 and 320
18. Rothman B L. Contmo J, Mcrrow M, Despuis A.
Kennedy T Kreutzef D L. Silica induced suppression
of the production of third and fifth components of the
complement system by human lung ceils invitro
Immunopharmacology & Imunotoxicology. 1994; 16(4),
525
19. Najda. J.; Goss. M; Gminski, J; Weglarz. L;. Siemianowicz.
K; Olszowy. Z the antioxidant enzymes
activity in the conditions of the systemic hypcrsiliccmia.
Biological Trace Element Research. 1994; 42(1). 63
20. RamiJ.SteiuelW. SasicSM Puel-m; Rini C. besombes
J P. E!ias J A. Rooncy S A. Fatty acid synthase activity
andmRNA level in hjpertrophictype II cells from silica
treated rats. American Journal of Physiology. 1994:267;
128
21. Beinen. W. Silicon metabolism in micro-organisms VII.
Distribution of silicic acid in cell fractions of Proteus
nnrabilis, and the demonstration of carbohydrate silicic
acid esters. Archivjur Mikrobiologie. 1965:52(1) 69
22. Urrulia M M, Reveridge T J. Remobihzalion of heavy
metals retained as oxyhydroxide or silicates by bacillus
subtiiis cells Appt. Environ. Mtcrobiol. 1993; 59(12)
4323
23 Dariey W M. Volcani B E. Role of silicon in
diatommetabolism. A silicon requirement for
deoxyribonucieic acid synthesis in the diatom
Cylindrotheca fust/ormif Retmann and iewin
Experimental Cell Research 1969; 58(2). 334
24. Vornokov M G. Skorobogalova V I. Vugmeister E K
Makarskii V V. Silicon in nucleic acids. Doklady
Akademii Nauk SSSR 1975; 220(3), 723
25. Reeves C D. Volcani B E, Role of silicon in diatom
metabolism, Messenger RNA and Polypeptide
accumulation patterns in synchronized cultures of
Cylindrotheca fusiformis Journal General
Microbiology. 1985; 131 (Pt 7), 1735
26. Malcov. S.V.; Barabanshchikov Bl. The effectof silicon
metabolism on genetic transformation in Bacillus
subttiis. Molekitlmrnaia Genetika. Mikrobielogia i
vintsohga. 1991. (2). 9

LEAVES FROM HISTORY - 4
Born in Scotland in December 1857, Robert Philip received his medical education in
Europe. In the winter of 1882, while working in a Viennese laboratory, he had his first
glimpse of the Tubercle Bacillus, just then discovered by Robert Koch, which made a profound
impression on his mind. He decided to put his energies to bring tuberculosis under control.
In 1887, he returned to Edinburgh in Scotland, where he established a dispensary for
the diagnosis and treatment of tuberculosis, free of charge to the patients. His idea in starting
a free dispensary was to establish a system for dealing with an infectious disease on the lines
of prevention of infection, away from the then prevailing practice of “Fresh air, Fresh milk,
Fresh eggs and Rest”. His dispensary provided for clinical examination of patients, dispensing
of medicines as well as disinfectants, visiting all the registered patients in their homes for
giving instructions to patients on how to conduct themselves in society. Also, for the selection
of some patients for sending them to sanatoria in the hills. x New cases were discovered by
staging “March Past” in different areas, looking for patients likely to be suffering from
Tuberculosis. This, perhaps, was the start of Social Medicine as the system covered a large
number of patients and took care of their social and preventive needs.
His well-coordinated system came to be known as the “Edinburgh System” and was
later christened as the “Chest Clinic” to become a most important unit in the control of
tuberculosis.
In 1914, Robert Philip was honoured with a knighthood and he donated his dispensary
as a gift to the city of Edinburgh. In 1922, he was elected President of the British Medical
Association.

Original Article Ind. J Tub. 2000, 47, 93
CLINICAL PROFILE OF PNEUMOCYSTIS CARINII PNEUMONIA
IN HIV INFECTED PERSONS*
N. Usha Rani 1 , V.V.R. Reddy 2 , A.Prem Kumar 1 , K.V.V. Vijay Kumar 2 ,
G.Ravindra Babu 3 and D.Babu Rao 4
Summary : Between Dec’97 and Nov’98, out of 120 patients injected with HIV, 23 cases of Pneumocystis carinu
pneumonia (PCP) were found and their clinical profiles were studied at the department of TB and Chest Diseases. Andhra
Medical College, Visakhapatnam. The diagnosis of PCP was made using CDC criteria based on chest X-ray. It is coacltided
that PCP is not an uncommon complication in HIV infected individuals in this country. As many as 65% of PCP
cases belonged to the economically productive age group of 21-30 years; 40% were truckers or manual labourers: dry
cough, dyspnoea on exertion, low-grade lever were the most common presenting symptoms In patients with initial SP0 2
less than 90%. the degree of exercise induced oxygen desaluration was more. The yield from induced sputum specimens
stained by CMS was 50%. Almost 92% ot the cases showed raised LDH level. Response rate to Cotrimoxazole therapy
was 74% and good drug tolerance was observed Nearly 43% of the cases bad coexistent tuberculosis, out of which 90%
were having extra-pulmonary tuberculosis.
Key words :- Pneumocyslis carinii pneumonia, HIV infection, HIV A tuberculosis
INTRODUCTION
Prior to 1980s, Pnewnocysfis carimi pneumonia
(PCP) was a sporadic cause of pneumonia occurring
mainly in a few immune-compromised patients. In
1981, the outbreak of PCP among homosexuals in
Los Angeles (USA) led to the recognition of AIDS’ 2
as a clinical entity. In the West, 75% of individuals
infected with HIV developed PCP, sooner or later.
The widespread use of primary and secondary
prophylaxis led to a decline in the occurrence of
PCP, after 1988. In India, although the incidence of
HIV infection is rapidly increasing, yet case reports
of PCP are scarce in the Indian literature.
The increasing numbers of extrapufmonary and
atypical forms of pulmonary tuberculosis in our
patients led to the suspicion and later confirmation
of the co-existing HIV infection in them. The fact
that PCP is the most common opportunistic infection
in AIDS cases in the West 1 prompted us to study
the occurrence and clinical profile of PCP cases in
southern India.
MATERIAL AND METHODS
The study was undertaken during a period of
one year, from Dec’97 to Nov’98 and 120
patients
with HIV infection were recognized among those
reporting with various respiratory ailments at the
Govt. Hospital for Chest and Communicable
Diseases, Visakhapatnam.
Out of the 120 cases with HIV infection, 23
cases were presumed to be of PCP, using CDC/
CDSC (Centres for Disease Control/Communiable
Disease Surveillance Centre) Criteria.
The CDC/CDSC 4,5 criteria allow presumptive
diagnosis of PCP being made in a HIV infected
person with-
1. Dyspnoea on exertion/non-productive cough of
recent onset
2. Chest X-ray showing diffuse bilateral interstitial
infiltrates
3. Arterial hypoxaemia
4. No evidence of bacterial pneumonia.
All the 23 cases were proved to be HIV positive.
The initial positive ELISA test was confirmed by
repeat ELISA using different Ag or by
Immunocomb/ Immunoblot / Capillus method, after
taking informed consent. The study of clinical profile
included recording of bio-data, history of risk factors,
*Paper presented at the 53rd National Conference on Tuberculosis and Chest Diseases, Bhubaneshwar. Dccemebr 27 th To 30 th 1998
1 post graduate Student 2. Asst Professor. 3. Professor, 4 Professor and Head of Deapartment
Correspondence : Dr. G. Ravindra Babn. Professor in Deptt. ol TB and Chest Diseases. Andhra Medical College, Visakhapatnam

94 N. USHARANIETAL
presenting symptoms and clinical examination.
Sputum direct smear examination for AFB by Ziehl-
Neelsen’s staining was done in all the cases. Sputum
speciments were obtained by collecting induced
sputum using 5% hypertonic saline inhalations by
nebuliser and specimens were stained by Giemsa/
Gomori Methenamine Silver (QMS) staining
procedure at the Department of Microbiology,
Andhra Medical College, Visakhapatnam. Routine
blood and urine examinations were done. Serum
lacto dehydrogenase (LDH) levels were estimated.
Mantoux test was done with 5 TU of P.P.D. Exercise
oxygen saturation (EOS) measurements were done
in all the cases with Ohmeda Pulse Oximeter using
Ohmeda finger probes.
A 10-min exercise which causes a fall of oxygen
saturation pressure (SPO 2 ) to 90% or less or a 2-min
exercise which causes a fall of SPO 2 by 3% was
taken as positive desaturation test 6-9 . ECG
echocardigraphy high resolution CT were done in
selected cases. All the 23 patients were treated with
Cotrimoxazole for 3 weeks. Patients who had initial
SP0 2 of less than 90% and respiratory rate of more
than 25 per minute were started on a 3 week course
of Prednisolone.
FINDINGS
Of the 23 cases of PCP, diagnosis was confirmed
by the demonstrtion of cysts (Fig. 1) by GMS/Giemsa
stain in 6 cases (26%).
Of the 23 cases, 18 (78%) were males, 11 (47%)
belonged to the age group of 21-30 years and 40%
were truckers or manual labourers. All males gave
a history of promiscuous behaviour and casual sex.
One female had undergone blood transfusion.
Table 1. Exercise oxygen saturation measurement.
10 mts exercise90%
with drop
Initial SPO 2

PCP IN HIV INFECTED PERSONS 95
Fig. 3 HRCT showing bilateral ground gloss opacities
Additional treatment with corticosteroids was given
toll patients (48%). No adverse effects were
observed in 70% of them. Adverse effects like minor
rashes, jaundice and methaemoglobinaemia were
chest seen in the remaining cases.
In all, 43% of the total 23 cases of PCP
developed tuberculosis before or after the PCP
episode, of which 90% were extrapulmonary,
tuberculosis lymphadenitis being the commonest.
DISCUSSION
Fig, 2 X-Ray showing bilateral mid & lower zone
interstitial shadows
Clinical response (Table 3) to 3 weeks’ treatment
with Cotrimoxazole (CTM) (15/75 mg/kg.bd.wt.)
was good. CTM was well-tolerated by 74% of the
cases, whether on treatment or prophylaxis.
Table 3. Therapeutic profile in PCP
Treatment n %
3 Weeks of CTM treatment 7 30%
3 Weeks of CTM prophylaxis 8 35%
Relapses 2 9%
Deaths 2 9%
Absconded 4 17%
Total 23 100%
+ Prednisolone 3 Weeks 11 47%
HIV infection has become a global pandemic.
Approximately 60% of HIV positive persons
develop AIDS within 12-13 years after infection.
India has been categorized as a pattern II country,
with the estimated cases of AIDS rising rapidly.
The present study was aimed at studying the
clinical profile of PCP in HIV infected persons.
During the study period, 120 HIV infected persons
were presumptively recognised. The proportion of
PCP cases in the group was 19%; the observed
higher percentage compared to other Indian studies 10
may be due to the CDC criteria used for making the
diagnosis of PCP. In a HIV infected person, when
chest X-ray shows an interstitial pattern, a high index
of suspicion is required to work out the case in the
PCP direction. Inter-observer variations might have
contributed to reporting of a lower incidence of PCP
in the Indian studies.
A majority of our cases belonged to the age
group 21-30 years, similar to that of Mohanty et al 10 .
In the present study, the mean duration of PCP illness
was 1.5 months, compared with 28 days and 25 days
reported in western studies.

96 N. USHA RANI ET AL
In the early stage of PCP, the chest
radiograph shows fine bilateral perihiliar diffuse
infiltrates which progress to the interstitial
alveolar butterfly pattern 11 . From the hilar
region, the infiltrates spread to apices or bases.
However, normal X-ray may be seen in 2-34%
of the cases. In the present study, all the cases, on
account of the method of selection, had bilateral
interstitial shadows with perihilar and basilar
distribution. The HRCT helps to detect interstitial
disease not visible on routine chest radiographs 12 .
Therefore, HRCT is a useful diagnostic tool in the
clinical setting of PCP when the chest X-ray is
normal.
In the present study, P.C. cysts were
demonstrated by GMS in 5 out of 10 (50%) cases.
The GMS staining is the gold standard for
morphological identification of P.C. cysts 13 . A wide
range of variability in the yield of GMS is noted in
various studies 13-15 . Visualisation of clusters of cysts
within foamy material clinches the diagnosis. Cup
shaped, creascent shaped, banana shaped cysts with
capsular thickening are characteristic. Presently,
immunofluorescent staining with monoclonal
antibodies has replaced GMS and other techniques
in western countries.
Exercise oxygen saturation measurements
(EOS) showed that all the 23 cases had fall of SPO 2
with exercise. Six patients had initial SPO,, less than
90%, whose mean drop with exercise was 11 %. EOS
results may vary depending upon the extent or the
timing of occurrence of PCP.
Serum LDH level estimation in a useful
screening test 2 u . Increased levels were observed in
92% of the cases in the present series. It is also useful
to monitor the response to theaphy.
Co-existent tuberculosis was seen in 10 out of
23 cases of PCP. Some cases of extrapulmonary
tuberculosis developed PCP while on antituberculosis
theraphy, within 2-10 months. Three
cases of PCP developed tuberculous lymphadenitis
after 3 months of the PCP and 2 cases of pulmonary
tuberculosis developed PCP while on treatment for
3 months. Since 20% of HIV infected persons can
progress to AIDS in 5 years, not only can cases of
extra-pulmonary tuberculosis but even pulmonary
forms of tuberculosis develop PCP, sooner or later.
Response rate to 3 weeks of Cotrimoxazole in
our cases was 73% i.e. almost the same as 75% and
60% in other studies 2 . Only 8% in the present study
had major adverse reactions.
Any HIV infected person with interstitial pattern
on chest X-ray and or dry cough should be suspected
of having PCP and should be further investigated.
Diseases like interstitial fibrosis, interstitial edema,
lymphangitis and carcinomatosis may mimic PCP
on X-ray, but they are rare in the younger age groups.
Absolute eosinophilic count helps to rule our tropical
pulmonary eosinophilia which also may mimic PCP.
The CDC criteria can be used for making a
presumptive diagnosis of PCP. Diagnostic
techniques like Bronchoalveolar Lavage/Trans
bronchial Lung Biopsy 16,17 may be used in cases who
do not respond to Cotrimoxazole theraphy in 5-7
days. In fact, extrapulmonary tuberculosis cases may
receive primary prophylaxis with Cotrimoxazole
since the drug is well tolerated.
REFERENCES
1. John. F.Murray and John Mills pulmonary infectious
complications of HIV infection part-I and II; State of
Art.AmRev.Respir.Dis. 1990,141.1356 and 1582
2. StewartJ. Levine, Pneumocystis carinii, Clinics in Chest
Medicine, 1996, 17,665
3. Wallace J.M. Rao, A.V.Glassroth, J et al : Respiratory
illness in persons with AIDS, Am.Rev Resp.Diseases,
1993, 148; 1523
4. Centres for Disease Control, Pneumocystis carinii
Pneumonia- Los Angeles MM. W.R. 1980, 30; 250
5. Centres for Disease Control, Update on AIDS • United
States, MM.W.R 1982. 31; 507
6. Christos Chouaid, Dominique, Maillard : Cost
effectiveness of non-invasive 0 2 saturation, measurement
during exercise for the diagnosis of PCP, Am.Rev.
RespirDis 1993. 147, 1360
7. G.Faetkenheurer et al : Exercise Oximetry for early
diagnosis of PCP, Lancet, 1989.222.
8 Jaume Sauleda, Joaquim, GEA et al. Simplified exercise
test for differential diagnosis of PCP in HIV, Thorax
1994;49; 112
9. D.E.Smith, J.Wyatt, AMc.Lucky el al: severe exercise
hypoxaemia with normal or near normal X-rays in PCP.
Lancet, 19S8. 5, 1049
10. K.C.Mohanty, Sudhir Nair: Changing trend of HIV
infection in patients with respiratory diseases in Bombay
since 1988. Ind.J.Tub. 1994,41,147.
11. Fishman’s pulmonary disease and Disorders III edition,
IIvolume, section 20, Chapter 150-2313.
12. Laurence, Huang and John D.: AIDS and Lung, Medical
clinics of North America, No.4, July 1986. 80, 775
13. Kirsch C.M. Jenes. W.A.: Analysis of induced sputum
for the diagnosis of recurrent PCP, Chest 1992. 102,
1152
14. Zaman.M.K. White D.A. Serum LDH levels and PCP -
Diagnostic and prognostic significance. Am. Rev. Resp.
As 1988. 137; 769
15. Robert F.Miller, David.M.Mitchell, Pneumocystis
carinii Pneumonia, AIDS and lung update 1995, Thorax;
1995.50: 191
16. Tin. J.V. Bien. H. J, Detsky A.S- Bronchoscopy Vs
empirical therapy in HIV patients with presumptive PCP
Am.Rev.Resp.Dis,.1993. 148.370

Original Article Ind, J. Tub. 2000, 47, 97
RADIOIMMUNOASSAY ANTIBODY DETECTION IN PULMONARY
TUBERCULOSIS*
G.V Kadival, M.Kameswaran and M.K. Ray**
Summary : Diagnosis of tuberculosis continues to pose serious problems mainly because of difficulty in differentiating
between patients with active tuberculosis, those who have healed lesions and normal BCG vaccinated individuals.
A simple, rapid radioimmunoassay (RIA) for the detection of anti-tuberculosis antibody has been developed by modification
of an earlier RIA test for M. tuberculosis antibody. The assay uses S. aureus as the solid phase to capture the antibody from clinical
samples and 125 I labelled M. tuberculosis antigen as a “tracer” for binding to the captured antibody.
Clinical evaluation of the modified RIA test was done with 286 serum specimens obtained from patients with pulmonary
tuberculosis and from individuals who were normal and BCG vaccinated. Sensitivity of 81% and specificity of 96% were observed.
Clear differentiation between the patients and control population was found possible. The assay is not only simple and user friendly
but is also rapid and enables early diagnosis and early institution of treatment.
Key words :- Radioimmunoassay, Tuberculosis antibodies, Early diagnosis of Tuberculosis
INTRODUCTION
Despite world-wide efforts made to cure the
disease by treatment with antituberculosis drugs, 10
million new cases and 3 million deaths still occur
every year, mainly in developing countries 1 .
The success of tuberculosis control
programmes depends not only on successful
completion of treatment but also on sound
backing from diagnostic tests for early diagnosis
for treatment and constant monitioring of the
disease status and response to treatment.
Radioimmunoassay (RIA) and Enzyme Linked
Immunosorbent Assay (EL1SA) tehniques have
been developed for the detection 01 M. tuberculosis
antigen and M. tuberculosis antibody in clinical
specimens, from mid-seventies onwards with
varying degrees of sensitivity and specificity 2-13 .
Almost all the assays developed at our Centre
require the detection of both tuberculosis
antigen and antibody from clinical samples 9-13 .
The persistence of antibodies in serum after
effective chemotherapeutic treatment could
hinder serodiagnostic assays but could serve
as an indicator of prognosis of the illness’ 4 . The
need at the present juncture is for a test with
good sensitivity and specificity for early
diagnosis. With this aim, we have modified the
antibody test and describe below a single test
which is simple, rapid and user friendly for early
diagnosis of tuberculosis.
MATERIAL & METHODS
Antigen - M. tuberculosis H37RV strain was
grown in Youman’s medium for 4-6 weeks. Cultures
were heat inactivated by autoclaving at 120°C
for 20 min followed by sonication for extraction
of antigen from cells. The suspension was
ultracentrifuged at 1,05,000 x g for 90 min and
the supernatant was used as the source of
antigen.
The sonicate antigen was iodinated with 125 1 by
*Paper presented at the 53rd National Conference on Tuberculosis and Chest Diseases, Bhubaneshwar, Decemebr 27 - 30 1998
**Radiation Medicine Centre (B.A.R.C.J, Mumbai
Correspondence : Dr. G. V. Kadival, Radiation Medicine Centre (B.A.R.C.) C/o Tata Memorial Annexe, Jerbai Wadia Road, Parel.
Mumbai-400012

98 G. V. KAD1VAL ET AL
the iodogen method 15 . The iodinated antigen was
purified from free iodide by separation on a
Sepharose 6B column. The immunoreactive peak
was used as the radioactive antigen or “tracer”.
Antibody - Rabbit anti-BCG antibody (M/s
Dakopatts, Copenhagen) was obtained and used for
the standard curve technique.
Solid Phase - Staphylococcus aureus (Cowan
I) was used as the solid phase. S. aureus has Protein
A on its surface and can bind immunoglobulins (Ig)
efficiently through the Fc region. The S. Aureus
cultures were grown in nutrient medium for 3-4 days.
After harvesting, the cells were heat inactivated at
80”C for 40 min. A 10% suspension was made and
used as the solid phase.
Study Population - A total of 286 blood
specimens were collected from patients of
pulmonary tuberculosis who were at various stages
of the disease and at various stages of treatment.
These patients were classified as follows:
Group I - 54 patients, who were AFB positive
both by smear and culture
Group II - 95 patients who were AFB negative
by smear but positive by culture
Group III - 80 patients who were negative both
by smear and culture
Group IV - 57 patients who were clinically
considered as tuberculous but their smear and culture
status was not available
Control Group - 70 individuals who had no
history of tuberculosis but were all BGC vaccinated
Assay Procedure - Standard anti-BCG antibody
at various concentrations of the diluted serum
samples, in which the antibody levels were to be
determined, were incubated with S. aureus at 1:3
dilution and l25 1 - M. tuberculosis antigen. The
reaction mixture was incubated for 4 h at room
temperature with constant shaking. Subsequently, 2
ml of 0.02M veronal buffer (pH 7.6) was added and
the entire mixture centrifuged at 300 rpm for 40 min.
The pellet was counted in a gamma counter and the
antibody concentration was determined from the
standard curve and expressed as ug% of IgG as
compared with anti-BCG IgG.
RESULTS
The control group showed low levels of
antibody. Using the upper cut off limit of negativity
as mean ±2SD, the specimens which showed values
above 25ug% of IgG were considered as positive, it
was found that 3 of the 70 control samples (94.3%)
were false positives. Table I shows the % positivity
in the different groups of patients. Group I, which
comprised patients positive by both smear and
culture, showed a positivity rate of 81%, Group II
patients who were negative by smear but positive
by culture had positivity of 69.5%, Group HI
patients, who were negative both by smear and
culture, had positivity of 63.5% and Group IV,
clinically diagnosed as tuberculous, showed
positivity of 61.4%. The overall sensitivity and
specificity of the assay were 81% and 95.7%
respectively.
Table I Determination of Specificity and Sensitivity
of the RIA Test
SPECIFICITY
Group
No.
Tested
True
Negative
False
Positive
%
Specificity
Non-TB Controls 70 67 3 957
SENSITIVITY
Group
No.
Tested
True
Negath e
False
Positive
%
Specificity
Smear & Cults Pos(Gr.I) 54 44 10 81.0
Smear Neg& Cull PoslGr 11) 95 66 29 69.5
Smear & Cult Neg {Grill) 80 50 30 93.5
Clinically luherculous (Gr.IV) 57 35 22 61.4
The antibody levels in the patient population
are much higher than the cut off limit.
DISCUSSION
The clinical need for a serological test for
tuberculosis which is rapid as well as simple is felt
for differential diagnosis, particularly in culture and/
or smear negative patients. In tuberculosis, the
immune response leads to a rise in the titre of
antibodies against different antigenic determinants
of M tuberculosis. Hence, the antibody specificity
may range from the species specific to that
specific for the causative organism.

ANTIBODY DETECTION IN PULMONARY TUBERCULOSIS 99
The antibody response in tuberculosis has
been studied for a long time 2-4,9-14, 16-18 . Although
one of the major drawbacks of serological tests
is the persistence of antibodies even after
effective treatment, it has been found to be
useful in assessing the effectiveness of
treatment ( i n patients with tuberculous
meningitis 14 ).
The RJA test for the detection of M.
tuberculosis antigen and M. tuberculosis
antibodies developed at our centre has been
tested in various clinical manifestations of
tuberculosis 9,10,16 . These studies showed that
detection of antibodies alone had poor
sensitivity, and it required a combination of both
antigen and antibody detection to enable more
reliable diagnosis. Also, the test per se was time
consuming, involving longer incubation time
and centrifugation steps.
The test described now is a modified
antibody assay, which is simple (involving the
addition and incubation of all the reagents
together) as well as rapid, Further, specimens
are analysed directly without any pre-treatment,
making it user friendly.
Evaluation of the assay in 286 clinical
samples showed that 81% of the patients who
were positive by smear and culture were also
positive by this test which is not very high.
However, the more important group of patients
is of those who are smear negative but culture
positive. It is this group that requires early
diagnosis and treatment. Our test could detect
antibodies in 70% of the cases within 4-5 hours
whereas culture results would take 6-8 weeks.
The group which is smear and culture negative
but clinically and radiologically tuberculosis had
positivity of 63.5%. A false positivily of 4% in
the control group is, perhaps, acceptable as
these individuals are all BCG vaccinated and
exposed to other environmental mycobacteria,
which could give rise to antibodies, thereby
contributing to the false positivity.
An overall sensitivity of 81% and specificity
of 96% is acceptable and is comparable with
the results from other laboratories including
those from countries where the prevalence of
tuberculosis is low and hence the control
population can be clearly distinguished from the
patients’ population 19 . Moreover, the antigen
used in their test was the 38 kDa antigen, which
is specific to the M.tuberculosis complex,
whereas the antigen used in our test is a partially
purified antigen.
REFERENCES
1. Kochi, A; The global tuberculosis situation and the new
control strategies of the World Health Organisation,
Tubercle; 1991,72.1
2. Benjamin, R.G. Daniel, T.M.; Serodiagnosis of
tuberculosis using Enzyme Linked Immunosorbenl
Assay of antibody to Mycobactenum tuberculosis
antigen 5; Am. Rev Res. Dis., 1982, 126, 1013
3. Daniel, T.M., Benjamin, R.G., Dabane, S.M., Ma,Y.,
Balestino, E.A.; ELISA of IgG antibody to
M.tuberculosis antigen 5 for serodiagnosis of
tuberculosis, Ind J Pae.; 1985, 52, 349
4. Ma, Y., Wang, Y., Daniel, T.M.; Enzyme Linked
Immunosorbent Assay using Mycobactenum
tuberculosis antigen for the diagnosis of pulmonary
tuberculosis in China; A me Rev. Res. Dis.; 1986, 134,
1273
5. Chandramukhi. A Bothamley, G.H., Brennan, P.J
Ivanyi, J.; Levels of antibody to defined antigens of
Mycobactenum tuberculosis in tubercular meningitis;
J.Clm Microbiol, 1989, 27(5), 821
6. Strauss, E.. Wu. N.:Radioimmunoassay of
tuberculoprotein derived from Mycobacterium
tuberculosis, Proc. Nat!. Acad Sci USA, 1980.
77(7),4301
7. Kadival, G.V., Samuel, A.M., Virdi, S.S., Kale, R.N ,
Ganatra, R.D., Radioimmunoassay of tubercular antigen;
Ind J Med Res, 1982,75,765.
8. Kadivai. G V. Samuel, A.M., Mazerallo, T.B.M.S.
Chaparas, S.D. ; RAdioimmunoassay for detecting
Mycobacterium tuberculosis antigen in cerebrospinal
fluids of patients with tubercular meningitis; J. infec
Dis, 1987, 155(4), 608
9. Samuel, AM. Kadival, G.V., Irani, S., Pandya, S.K.
Ganatra, R.D.: A sensitive and specific method for
diagnosis of tubercular meningitis; Ind. J.Med.
1983,77,752
10. Samuel A.M., Kadival G.V., Ashtekar M.D., Ganatra
R.D.; Evaluation of tubercular antigen and antitubercular
antibodies in pleural and ascilic effusions, Ind J. Med.
Res. 1984,80,563
11. Ashtekar. M D. Dhalla, A.S. Mazerallo,
T B.M S Samuel, A.M., A study of Mycobactenum
tuberculosis antigen and anlibodj in cerebrospinal fluid

100 G. V. KADIVAL ET AL
and blood in tubercular meningitis; Cli. Immunol.
ImmunopathoL; 1987, 45, 29
12. Kadival, G.V., Kameswaran, M., Ashtekar, M.D.,
Samuel, A.M., Immunodiagnosis of tuberculosis using
polyclonal and monoclonal antibodies; Trop. Med.
Parasitoi; 1990,41,363
13. Ashtekar, M.D., Samuel, A.M. Kameswaran, M.,
Kadival, G.V., Shahalkar, V., Rakadjualsja, S.; A study
of tubercular antigen and antibody in childhood
tuberculosis; J. Trop. Pediatrics; 1992,38,22
14. Kadival, G.V., Kameswaran, M., Doshi, R. Todiwala,
S.S., Samuel, A.M.; Detection of antibodies to defined
M.tuberculosis antigen (38 KDa) in CSF of patients with
tubercular meningitis; Zbl. Bakt; 1994 281, 95
15. Fraker, P.J., Speck, J.C.; Protein and Cell Membrane
lonisation with sparingly soluble Chloramind 1.3.4.6
tetrachloro-3?, 6? Diphenyl glycouril; Biochem. Biophys.
Res.Comm.; 1978,80,849
16. Samuel, A.M. Ashtekar, M.D- Ganatra, R.D.;
Significance of circulating immune complexes in
pulmonary tuberculosis; Clin. Exp. Immunol,; 1984,
58,317.
17. Kaplan, M.H., Chase, M. W.; Antibodies to Mycobacteria
in human tuberculosis: Development of antibodies before
and after antimicrobial therapy; J Infec. Dis.; 1980,142
(6), 825
18. Grange J.M.; The humoral immune response in
tuberculosis-its nature, biological role and diagnostic
usefulness; Adv. Tubefc Res.; 1984, 21.1
19. Jackett, P.S. Bothamley, G.H., Batra, H.V., Mistry, A.
Young, D.b. Ivanyi, J.;Specificity of antibodies to
immunodominant mycobacterial antigens in pulmonary
tuberculosis; J. Clin Microbiol.; 1998, 26( 11), 2313

Case Report Ind. J. Tub. 2000, 47, 101
ISOLATED TUBERCULOUS MESENTERIC ABSCESS
-A CASE REPORT
D. Vijaya 1 , T.K. Lakshmi Kanth 1 *, S.I.S. Khadri 1 *, H.C. Suresh Chandru 3 * and A. Malini 4
(Received on 28.9.99, Accepted on 25.10.99)
Summary: A 25 year old male, who was clinically and radiologically diagnosed as a case of appendicular abscess, was found
on abdominal exploration to have a mesenteric abscess which was proved to be tuberculous on microbiological studies. The rarity
of this condition prompted its reporting.
INTRODUCTION
The common forms of extra-pulmonary
tuberculosis seen in clinical practice are
lymphadenopathy, meningitis, osteoarthritis and
urogenitai tuberculosis’. The incidence of
extrapuimonary tuberculosis is getting more
common as a result of the growing numbers of HIV
positive patients 2 . Abdominal tuberculosis is fairly
common in India. It can affect any abdominal organ
but particularly involves small intestine and caecum.
Here we report a unique case of an isolated
mesenteric tuberculous abscess caused by
Mycobacterium tuberculosis.
CASE REPORT
A 25 year old male medical student, previously
in good health, presented with throbbing pain, in
the central abdomen in the beginning, which had
localised in right lower abdomen for one month,
fever and chills for 3 days relieved by sweating. No
history of vomiting, diarrhoea, cough or haemoptysis
was present.
On examination, he was a moderately built,
poorly nourished male. Cardiovascular and
respiratory systems were normal. Local examination
revealed a firm mobile mass measuring 7x5 cms with
defined margin in the right iliac and lu.nbar regions.
Routine urine and blood examinations were within
normal limits except for ESR which was 62mm/hr
Westergren. HIV serology was negative. Barium
enema was normal. CT scan diagnosis was
appendicular abscess. Chest X-ray showed
fibrocavitation in the right upper zone of the lung.
Sputum and urine were negative for acid fast bacilli.
Mantoux test was positive. Clinical diagnosis of
appendicular abscess/ileocaecal tuberculosis was
made. Laparotomy showed a spherical 8 cm isolated
mass medial to the caecum, in the root of mesentry.
All other organs were normal. There was no
mesenteric lymphadenitis. Pus aspirated from the
abscess cavity was sent to the Microbiology
Department for microscopy and culture and the
content of the abscess was scooped out and sent for
histopathological examination. Gram’s staining and
routine culture did not reveal any organisms. ZN
staining and culture on LJ medium yielded
Mycobacterium tuberculosis. The isolate was
sensitive to Rifampicin, Streptomycin, INH and
Ethambutol. Histopathological examination showed
a pattern consistent with tuberculous granuloma.
Patient was put on anti-tuberculosis therapy and on
follow up showed good response.
DISCUSSION
The diverse clinical features of abdominal
tuberculosis are fairly varied and non-specific and
often present a diagnostic challenge. 3 Most of the
patients can be diagnosed only after laparotomy.
Inove reported a case of tuberculous mesenteric
lymph node abscess with caseous granuloma
diagnosed after laparotomy. 4 In our case, the

102 D. VIJAYA ET AL
mesenteric cold abscess might be secondary to
symptomless pulmonary tuberculosis which
probably spread to the mesentry after swallowing
sputum. This report emphasizes the diverse clinical
features of abdominal tuberculosis and the need for
a high index of suspicion for the proper management
of such cases.
ACKNOWLEDGEMENTS
Authors are grateful to Dr. L. Chandramma,
Superintendent, and the staff of Microbiology
Department, Bowring and L.C. Hospital for their
encouragement and cooperation. They also thank the
staff of NTI Bangalore for performing the
antibiogram of the isolate.
REFERENCES:
1. Jayaprakash B, Rajeev Ram,Rajani M, Geener KJ,
Tuberculosis of breastJAPI, 1999,47,449
2. Gilliam Dean, Peter Alderman. An unusual presentation
of tuberculosis. Tropical Doctor, 1997,27,185
3. Ezzeldin M. Ibrahim, Mohamed O AL Sohaibani
Suleman A.AI Suleiman, Mohamed B Satti Fatma A A!
Mulhim, Fatma Qaddara. Tuberculosis of the pancreas:
a rare cause of obstructive jaundice and portal
hypertension. Tropical Gastroenterology, 1987,8,167
4. Inove Y, Kanamori Y, MiuraN, Watanabe T, Watanabe
K, NakamuraN, Tutumi T, Murata I, Kouno S, Hirano
T et al.A case of tuberculous mesenteric lymphadenitis
detected by abdominal symptoms after 4 months’
antitubcrculosis therapy against pulmonary tuberculosis.
Kekkaku. 1991,66,543

Case Report Ind J Tub. 2000, 47, 103
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
WITH ASPERGILLOMA MIMICKING
PULMONARY TUBERCULOSIS
Raj Kumar*
(Received on 8.6.99; Accepted on 11.11.99)
1
Summary ; A 45 year old male having cough, haemoptysis and dyspnoea for three years, who had received two courses of
anti-tuberculosis therapy without any relief was found to have allergic broncho-pulmonary aspergillosis, with coexistent aspergilloma
lying in a cavity with fluid: a rare association.
INTRODUCTION
After the first description of allergic
bronchopulmonary aspergillosis (ABPA) by Hinson
and colleagues 1 , in 1952, several reports have been
published about this entity. ABPA is fairly common
in our country and could be seen as an important
emerging disease 2 . The spectrum of aspergillus
associated respiratory disorders can broadly be
classified into three clinical categories, viz, allergic
aspergillosis, aspergilloma and invasive
aspergillosis. Saprobic colonization of bronchial tree
leads to the formation of aspergilloma in cavities.
Cavitation is known to occur in ABPA, but
coexistent afepergilloma is rather uncommon 3-5 .
ABPA consequent to aspergilloma formation
is a rarity 6 . Reported hereunder is a case of ABPA
with aspergilloma, in a cavity filled with
fluid.
malaise without any weight loss, and passage of
brownish plugs with sputum. Patient had smoked
20 cigarettes per day for 20 years before he ceased
smoking three years ago. There was no family
history of hypertension, diabetes, immunodeficiency
disease or neoplasm. The patient also gave history
of taking anti-tuberculosis treatment (RHZE) for one
year, in 1995, on the basis of chest x-ray and
symptomatology, which was repeated in 1997
(SHRZ) for 6 months on a similar basis. He was
referred to VPCI because he did not benefit from
the anti-tuberculosis treatment.
CASE REPORT
A 45 year old male, non-smoker,
was referred to the Vallabhbhai Patel
Chest Institute (VPCI) with chief
complaints of cough, haemoptysis
and dyspnoea for the preceding three
years. He also gave history of recurrent lowgrade
febrile episodes associated with Fig. la Chest roentgenogram PA view showing fungal ball in
a cavity in right upper lobe
*Department of Respiratory Medicine, V,P Chest Institute, University of Delhi, Delhi.
Correspondence : Dr. Raj Kumar, Lecturer, Department of Respiratory Medicine, V.P. Chest Instute, University of Delhi, Delhi-7

104 RAJ KUMAR
Fig. Ib Chest roentgenogram lateral view showing fungal
ball in a cavity in right lobe
Physical examination revealed a well built, well
nourished, middle aged man in no acute distress.
There was no cynosis or clubbing. Trachea was
shifted to the right side and coarse crackles were
audible in the right anterior chest along with bilateral
ronchi.
Total leucocyte count was 9200/mm 3 with 10%
eosinophils. Pulmonary function test showed mild
to moderate obstruction. Several sputum specimens
examined and cultures for Mycobacterium
tuberculosis were negative. Mycological
investigations including culture of the sputum
yielded Aspergillus fumigatus. Gel diffusion studies
detected strong bands of serum precipitance against
Aspergillits fumigatus. Intradermal challenge with
extract of Aspergillus fumigatus (1:50) gave strong
type I reaction but not type III reaction. The total
IgE counts were raised (2831.55 IU/ml). Specific
IgG and IgE against As. fumigatus were positive.
CT guided fine needle aspiration cytology from the
cavity revealed fungal hyphae on microscopic
examination. A diagnosis of ABPA with
concomitant aspergilloma was established.
The anti-tuberculosis treatment was stopped and
the patient was initiated on oral prednisotone with a
dose of 40 mg once daily along with bronchodilators
and other symptomatic therapy. The patient
improved remarkably symptomatically in four
weeks,
DISCUSSION
Fig. 2 C T Scan showing presence of fungal ball in
the cavity with fluid
Chest foentgenograms (PA and lateral) revealed
a pulmonary opacity with central cavity formation
and external fibrosis, in the right upper lobe. There
was a well defined rounded opacity (Fig. la,b) inside
the cavity. The mass within the cavity also
demonstrated positional change.The linear
tomogram of the chest confirmed the presence of
fungal ball and presence of fluid in the cavity (Fig. 2).
The existence of ABPA is being increasingly
recognised in India. Chronic lung damage associated
with ABPA appears to provide a favourable
condition for the formation of aspergilloma though
aspergilloma is not always seen in patients with
ABPA 6 ’ 7 . Cavitation is not a common feature of
ABPA but may occur in 3% of cases 8 - 9 . Pulmonary
tuberculosis cavitation may be associated with the
developjment of aspergilloma more commonly. Yet,
only a few cases of pulmonary tuberculosis
associated with aspergilloma have been reported
from India 10 . Ein et al 7 reported two patients who
developed ABPA consequent to aspergilloma
formation in lungs previously damaged by
tuberculosis.
A cavity containing fluid with aspergilloma is
an extremely rare event and may occur due to
lignification of fungal mass”. Failure to diagnose
ABPA may cause confusion in reaching correct
diagnosis thus delaying the initiation of proper
therapy. Frequently, symptoms like haemoptysis,
cough, fever etc. caused by ABPA/aspergilloma are

105
attributed to active tuberculosis and managed
incorrectly, as happened in our case.
REFERENCES
1. Hinson KFW, Moon AJ, Plummer. NS
Bronchopulmonary aspergillosis: A review and report
of eight new cases. Thorax 1952; 7:317
2. Shah A. Allergic bronchopulmonary aspergillosis: An
emerging disease in India (editorial). Indian J Chest Dis
Allied Set 1994;36:169
3. Safirstein BH, D’Souza MF, Simon G, Tai EHC, Pepys
J. Five year follow up of allergic bronchopulmonary
aspergillosis. Am Rev. Respir Dis 1973;108.450
4. McCarthy DS, Pepys J. Allergic bronchopulmonary
aspergillosis (clinical features), din Allergy 1970; 1:26
5. Shah A. Khan ZU, Chaturvedi S, Ramachandran S,
Randhawa HS, Jaggi OP. Allergic bronchopulmonary
aspergillosis with co-existent aspergilloma. A long term
follow up. J. Asthma 1989; 26:5
6. Rosenberg HL, Greenberger PA. Allergic
bronchopulmonary aspergillosis and aspergilloma: Long
term follow up without enlargement of large
multiloculated cavity. Chest 1980:85:123
7. Bin ME, Wallace RJ Williams TW. Allergic
bronchopulmonary aspergillosis-like syndrome
consequent to aspergilloma. Am Rev. Respir Dis
I979;119:8II
8. Phelan MS, Kerr 1H. Allergic bronchopulmonary
aspergillosis: The radiological appearance during long
term follow up. Clin Radian 1984; 35:385
9. Me Carthy DS, Simon G, Hargreave FE. The radiological
appearance in allergic bronchopulmonary aspergillosis.
Clin Radiol 1910;21 :366
10. Menon, M.P.S. Das A.K.; Allergic bronchopulmonary
aspergillosis (radiological aspects), Ind. J. Chest Dis.:
1997, 19, 157
11. Goldberg B. Radiological appearance in pulmonary
aspergillosis. Clin Radiol 1962; 13:106

106
What To Do For Quitting
Smoking
After making a firm resolve to quit smoking, you may take the
following steps:
1. Consult your doctor. He is best placed to show you the way and
help you medically at crucial junctures.
2. Join or form a group/an association of smokers who have successfully
quitted, like the Alcoholics Anonymous for drinkers.
3. Read guide-book about quitting smoking,
4. Keep trying instead of thinking how difficult it is to quit or the
pleasure you might get from just a single cigarette.
5. Talk freely to other smokers about how you are already succeeding.
And advise the vulnerable non-smokers why they should never start
the habit. This activity will help boost your own morale.
6. Finally, have full faith in your own self. You are the one who is
going to succeed. Do not deprive yourself of some therapies that are
available for ‘nicotine replacement’, if your doctor so advises.
YOU HAVE TO QUIT
Published by thv Tuberculosis Association of India m the interest of public health

Case Report
Ind. J. Tub. 2000, 47, 107
LYMPHOMA OF SPINE PRESENTING AS POTT’S
DISEASE : A CASE REPORT
Veena Maheshwari 1 , Kiran Alam 2 , Shah Aiam Khan 3 *, Ghazala Mehdi 2 and A.A. Iraqi 4 *
(Original version received on 16.9.99; Revised version received on 15.1.2000; Accepted on 29.2.2000)
Summary: A rare case of primary non-Hodgkin’s lymphoma of spine in a 40 year old female, initially diagnosed and treated
as Pott’s disease is presented.
INTRODUCTION
Lymphomas and leukemias rarely involve the
vertebral column. The clinical manifestations of
lymphoma can closely mimic tuberculous
spondylitis 1 . Lymphoma of bone is usually
secondary to lymphoma of lymphoid tissue.
CASE REPORT
A 40 year old female presented with pain in
tower back, continuous low grade fever and loss of
appetite for four months. Clinical examination
revealed “twist tenderness” at twelfth thoracic and
first lumbar vertebrae along with para-vertebral
spasm and limitation of all spinal movements. There
was no lymphadenopathy, organomegaly or
neurological weakness.
Investigations revealed hemoglobin of I0.8g%,
total leucocyte count: ll,000/-cu mm, differential
leucocyte count : neutrophils 38%, lymphocytes
51 %, eosinophils 11 %, and ESR 40 mm in 1st hour
(Wintrobe’s method); blood sugar 90 mg% and blood
urea 30 mg%. The X-ray chest was within normal
limits. Mantoux test was positive (15x10 mm).
Radiograph of dorso-lumbar spine (Fig.l)
revealed destruction of the T-12 vertebral body with
osteoporosis and minimal reduction of disc space
between twelfth thoracic and first lumbar vertebrae
and a suggestive paravertebral shadow. The CT scan
Fig. 1 X-ray dorso-lumbar spine showing destruction of
T-12 vertebral body with reduction of disc space between
T-12 and L-1 vertebrae
revealed widespread destruction of the body of
twelfth thoracic vertebra and the underlying disc
along with a paravertebral mass (Fig. 2). Correlating
the clinical, laboratory and radiologica! findings and
Fig. 2 CT scan shows widespread destruction of T-12
vertebra and disc with paravertebral mass
1. Reader, 2. Lecturer, 3. Senior Resident, 4. Professor
Departments of Pathology & Orthopaedies*, J.N. Medical College, Aligarh Muslim University, Aligarh
Correspondence : Dr. Veena Maheshwari, 2/82, Arya Nagar, Avantika Part-2, Ramghat Road, AIigarh-202001

108 VEENA MAHESHWARIET AL
keeping in view the high prevalence of tuberculosis
in our country, a diagnosis of Pott’s spine was made.
The patient was advised absolute bed rest and antituberculosis
therapy consisting of four drugs
Rifampicin, Ethambutol, Isoniazid and
Pyrazinamide for 2 months, followed by Rifampicin
and Isoniazid for 4 months. However, the patient
showed no improvement and, subsequently,
developed features of upper motor neuron disease
involving the lower trunk and both legs. The motor
power was grade II/V with exaggerated deep tendon
reflexes and an extensor plantar response. The
sensory diminution was confined to pain and touch
below the T 12 dermatome. Posterior column
modalities were intact. Since the patient failed to
respond to treatment, an antero-lateral
decompression was done through right lateral
approach and the obtained specimen was submitted
for histopathological examination. Gross
examination of the tissue revealed a greyish white,
friable mass. Microscopic examination showed
round cells with areas of necrosis and hemorrhage.
The cells were monotonous with convoluted nuclei,
open chromatin, prominent nucleoli and mitotic
figures (Fig. 3). A diagnosis of non-Hodgkin’s
Fig. 3 Photomicrograph showing monotonous cells with
scanty cytoplasm. Bony trabeculae seen in lower right
hand corner (H & E x 250)
lymphoma (Histiocytic type) according to
Rappaport’s classification was made. Wide field
radiotherapy was given and patient was discharged
with advice for regular follow up. The patient died
a year later, following disseminated disease.
DISCUSSION
Primary malignant lymphoma of spine is a
distinct clinicopathological entity. Lymphomas and
teukemias rarely involve the vertebral column,
closely mimicking Pott’s spine when they do 1 .
Lymphoma of spine has a variable clinical
presentation and patients present late in the course
of the disease. Roentgenographically, a combination
of bone production and bone destruction is seen
involving a wide area 3 . Frequent occurrences of
osteoporosis and bone destruction can make it
difficult to differentiate lymphoma from Pott’s spine,
the hallmark of which is reduced disc space with
osteoporosis. Histiocytic type of non-Hodgkin’s
lymphoma is known to involve bone besides the
lymphoid system 4 but the involvement of vertebral
column is rare. Such lymphomas have a more
pleomorphic origin than the large cell lymphomas
of lymphoid origin and are less aggressive as
compared to their lymphoid origin counterparts 5 .
Although bone is rarely involved in Hodgkin’s
disease, the involvement of vertebral column is more
common. The osseous lesions of Hodgkin’s disease
are often asymptomatic and not easily detected by
conventional radiography 6 . Thus, lymphomas of
spine, although rare, cause considerable differential
diagnostic difficulty from tuberculous spondylitis
which is common in our country. The ultimate
answer to diagnostic dilemma lies in histopathological
examination.
REFERENCES
1. Tuli SM; In Tuberculosis of the skeletal system (Bones,
Joints, Spine and Bursal Sheaths). 1st Edn, Jaypee
Brothers Medical Publishers (P) Ltd., New Delhi, 1993
2. Boston HC and Dahlin DC: Malignant lymphoma (so
called Reticulum cell sarcoma) of bone. Cancer 1974;
34;1131
3. Clayton F, Butlers JJ and Ayala AG : Non-Hodgkin’s
lymphoma in bone: pathological and radiological
features with clinical correlates. Cancer 1987; 60:2494
4. Issacson P. Wright DH and Jones DB: Malignant
lymphoma of true histiocytic (monocyte/macrophage)
origin. Cancer 1983; 51: 80
5. VanderValkP,MeijerILM,WillernzeR,VanOosterom
AT, Spaander PJ, de Velde J : Histiocytic sarcoma (true
histiocytic lymphoma). A clinicopathological study of
20 cases. Histopathology 1984; 8: 105
6. Horan FT: Bone involvement in Hodgkin’s disease. Br
JSurg 1969; 56: 277

Case Report Ind J. Tub. 2000, 47, 109
‘FLU’ LIKE SYNDROME DUE TO ETHAMBUTOL
Rajinder Singh Bedi
(Receivedon 17.5.99, Accepted on 6.8.99)
Summary : A patient who developed severe ‘flu’ tike symptoms due to ethambutol is reported as no similar case has been
documented in medical literature so far.
INTRODUCTION
Ethambutol (EMB), an effective antituberculosis
drug, is generally well tolerated, its main
adverse reaction being optic neuritis. Other
uncommon adverse effects include arthralgia, skin
rash, peripheral neuropathy, hepatitis, malaise,
gastrointestinal upset, mental confusion, headache,
dizziness and fever etc. 1
A case is being reported in which the patient
developed ‘flu’ like syndrome due to EMB.
Review
of literature did not give any report on EMB-induced
‘flu’ like syndrome.
CASE REPORT
A 65 year old male presented with 2 months’
history of right side chest pain, low grade fever and
dry cough. Chest examination revealed signs
suggestive of right basal effusion, confirmed on a
chest radiograph. About 500 ml. of straw coloured
fluid (proteins 5.2 g%, with 94% lymphocytes and
no malignant cells) was aspirated. Except for
elevated ESR of 56 mm 1st hr. Westergren, routine
haematologic investigations were non-contributory.
Patient was non-diabetic. Mantoux test with PPD 5
T.U. was positive (12x12 mm) after 48 hrs.
Treatment was started with Rifampicin, Isoniazid,
Ethambutol and Pyrazinamide in conventional
dosages.
One week after the start of therapy, patient
developed high grade fever with rigors, malaise,
severe body aches and confusion, nearly three-hours
after the ingestion of all the four drugs on empty
stomach. Total and differential white cell counts
were normal and blood smears were negative for
malarial parasite. The fever subsided with
Paracetamol. Therefore, anti-tuberculosis regimen
was continued the following day, but he again
developed fever with rigors, chills and body pains
by noon. All the drugs were then stopped. The patient
remained afebrile for the next two days.
A provisional diagnosis of ‘flu ’ syndrome due
to Rifampicin was made. A regimen of reintroducing
each drug in turn, starting with a low dose was
commenced. Starting with 25 mg of Isoniazid on
the first day and reaching full dose of 300 mg by the
third day produced no untoward reaction. On the
fourth day, 200 mg of Ethambutol was given as the
starting dose, but patient developed high grade fever
(101 °F) with rigors, chills and mental confusion after
two hours. Ethambutol was discontinued and the
patient recovered. Over the next one week, the
patient was given gradually increasing doses of
Rifampicin and Pyrazinamide, one after the other,
and both drugs were tolerated well.
The patient was managed with Rifampicin,
Isoniazid and Pyrazinamide with no further episodes
of fever. At the four-month follow up, patient’s
progress was uneventful and he is now receiving
Rifampicin and Isoniazid.
In order to confirm the presence of EMB
antibodies in patient’s serum, contact was made with
several laboratories of repute. However, requisite
technology to do the testing could not be made
available.
Correspondence : Dr. R.S. Bedi Nursing Home, Sher-e-Punjab Market, Patiala

110 RAJINDER SINGH BEDI
DISCUSSION
To the best of our knowledge, based on a thorough
review of medical literature, the present case
is the first case of ‘flu’ like syndrome due to EMB.
The ‘flu’ syndrome has usually been associated with
intermittent (rarely daily) use of Rifampicin, though
a report on 3 cases of ‘flu’ like symptoms due to
Isoniazid was published in 1989 2 .
Though fever has been described as an infrequent
adverse reaction with EMB, typical ‘flu’ like
syndrome consisting of fever, chills, malaise, shivering,
dizziness, headache and bone pains occurring
within a few hours (2-4) of drug intake is not on
record. In a review of nearly 2,000 patients on EMB
(15 mg/kg), less than 2% had adverse reactions, 0.8%
experienced diminished visual acuity, 0.5% had a
rash and 0.3% developed drug fever 3 .
Rifampicin-induced “flu” syndrome typically
begins 2-3 hours after drug ingestion, lasts for upto
8 hours and usually requires no treatment. When it
persists, reduction of dose, a change to daily administration
and rarely interruption or termination of
Rifampicin has been advocated. EMB induced ‘flu’
syndrome in the present case followed similar time
course as has been reported with Rifampicin, but
was more severe in nature, even with 200 mg dose.
EMB was totally withdrawn and the case was managed
successfully with the other anti-tuberculosis
drugs.
The underlying mechanism of EMB- induced
‘flu’ syndrome cannot be postulated, though, like
Rifampicin, it may have an immunological origin 4 .
REFERENCES
1. Mandel! GL, SAnde MA. Antimicrobial agents. In
Goodman & Oilman’s Pharmacological Basis of
Therapeutics. 8th ed. Me Graw-HMI Int. edition. 1992,
1152
2. Motion S, Humphries MJ, Gabriel M. Severe ‘flu’ like
symptoms due to Isoniazid - A report of 3 cases. Tubercle
1989,70:57
3. Pitts FW. Tuberculosis : Prevention and therapy. In :
current concepts of infectious diseases. John Wiley &
Sons. Inc. New York 1977, 181
4. O’Mohoney G, Chew WK., Relationship between
Rifampicin-dependent antibody scores, serum
Rifampicin concentrations and symptoms in patients
with adverse reactions to intermittent Rifampicin. Clin
Allergy 1973;3:353

Ind J. Tub, 2000, 47, 111
THE FIFTY FOURTH NATIONAL CONFERENCE ON TUBERCULOSIS AND
CHEST DISEASES: A BRIEF REPORT
M.M. Singh*
The 54 th National Conference on Tuberculosis
and Chest Diseases was held in the L.N. Mishra
Institute Auditorium, Patna from 26 th to 29 th
December, 1999, under the joint auspices of the
Tuberculosis Association of India and the Bihar
Tuberculosis Association. The annual national event
had come to Patna after a lapse of 27 years when
the 27 th National Conference was held in November
1972. The Reception Committee and the Organising
Committee appointed by the State Association,
undertheoverallleadershipofShri U.N. Vidyarthi,
Chairman, Bihar Tuberculosis Association and the
Organising Chairman and his dedicated workers,
had made elaborate arrangements for making the
Conference a success. Nearly 300 delegates attended
the Conference. The response from the delegates
from other States was not encouraging.
Preceding the Conference, there was an
interesting and highly educative programme of
CME, on 26 th December, 1999 morning which was
inaugurated by Dr. Kalyan Hazari, former President
of IMA. The CME programme covered varied
subjects ranging from diagnosis of tuberculosis,
immunology of tuberculosis to DOTS and
Intermittent Chemotherapy. Dr. G.R. Khatri
presented his key-note address on RNTCP.
The afternoon of the first day also marked
the inauguration of the main conference with great
fanfare, in the presence of all the delegates, by Dr.
G.R. Khatri, DDG (TB), Government of India, and
Chairman, Management Committee, Tuberculosis
Association of India. Dr. Akhileshwar Prasad Sinha
welcomed the delegates. Shri U.N. Vidyarthi also
addressed the gathering. As the Chairman.
Tuberculosis Association of India, Dr. S.P.
Aggarwal could not attend the Conference because
of certain unavoidable circumstances, his address
was read out by Dr. Khatri. The salient points made
in the DGHS’s address related to the status report
on the RNTCP’s 1 lakh cases treated so for. The
fact that about 80% of the tuberculosis patients were
treated successfully in 48 districts of 16 states and
union territories of the country was highlighted. He
expressed concern over the emergence of drug
resistance and the spread of HIV which are
thre?tening to further complicate the situation.
During the inauguration of the Conference, Dr.
M.M. Singh, Vice-Chairman of the Tuberculosis
Association of India, also addressed the delegates
and gave good wishes on behalf of the Tuberculosis
Association of India. Then followed the colourful
Awards Giving Ceremony. Dr. R.P. Bhgi read out
the citations. The Dr. P.K. Sen TAI Gold Medal
Oration Award went to Dr. M.M. Singh, Vice-
President of the Delhi TB Association and currently
the Vice-Chairman of the Tuberculosis Association
of India; the Ranbaxy-Robert Koch Oration Award
was given to Dr. V.K. Vijayan, Director, VP Chest
Institute Delhi; and the Lupin-TAI Oration Award
was bagged by Dr. K. Jagannath, Director, Institute
of Thoracic Medicine, Chennai.
In his presidential address, Dr. Agnihotri
highlighted the problems created by tubercle
bacillus which he said will be more serious in the
new millennium. He mentioned the role of lungs in
disease and health. He said that the lungs play a
vital role in the maintenance of health and stressed
the need for the maintenance of clean environment
such as parks, greenery, etc. in the heart of the cities.
He also stressed the need for regular breathing
exercise such as Pranayam by all. He also underlined
the fact that because of deficient immunity, tubercle
bacillus spreads in the body. He also said that
tuberculosis develops in the under-nourished,
diabetics, starving and HIV infected persons due to
immune depression. He stressed that the defence
mechanism of the body should always be on alert.
* Vice-Chairman, Tuberculosis Association of India

112 M.M. SINGH
so that tuberculosis does not develop. He said that
immuno-modulator drugs were not available till
today. Also that in our ancient medicine, Rasayanas
were used as immuno-modulators to increase the
body immunity. He advised that Rasayanas may be
used with the present day anti-tuberculosis therapy
which will definitely be a step forward in the
management of tuberculosis.
Dr. Agnihotri stressed the need for raising the
level of nutrition and the standard of living in order
to improve public health in general.
Ayurveda had a well-documented holistic
concept of immunity. He said that we had only to
understand Sanskrit language : a combination of
western medicine and Ayurveda will provide the
answer to most of our health problems. He said that
Rasayans used with chemotherapy will be more
effective in controlling tuberculosis.
He stressed that interaction between man and
tubercle bacilli leads to tuberculosis, therefore both
bacilli and host should be the objects of our concern
in controlling tuberculosis.
After the inauguration, there was a cultural
programme followed by dinner hosted by the Bihar
Tuberculosis Association. On the 27th December,
1999, the scientific programme of the Conference
started. The first session consisted of 6 papers
mainly on RNTCP and DOTS, presented by various
workers. The second session was chaired by Dr.
K..C. Mohanty and Lt. General. Jayaswal. The next
session started with an address by the President of
the Conference on his favourite subject of holistic
fight against tuberculosis. This was followed by Dr.
P.K. Sen TAI Gold Medal Oration by Dr. M.M.
Singh. This session was chaired by Dr. G.R. Khatri.
This was followed by a session on the sociological
aspects of tuberculosis with impact of the disease
on people and perceptions and attitudes of
tuberculosis patients under treatment in private and
public health institutions. The paper on role of
counselling and education on treatment adherence
of tuberculosis patients was highly appreciated.
After lunch, there was a session on management of
MDR tuberculosis. In this session, five papers were
presented. The last session of the day dealt with
HIV and tuberculosis. In this session, trend of HIV
infection in various categories of tuberculosis
patients in rural India was discussed. Earlier in the
day, there was a guest lecture by Dr. C.N.
Paramasivan, Tuberculosis Research Centre,
Chennai on the subject: “An Overview on Drug
Resistant Tuberculosis in India”. The day’s
programme ended with a nice cultural programme
followed by dinner.
On 28th December, 1999, after breakfast, there
was a session on management of tuberculosis in
which four interesting papers were presented. After
this session, there was a symposium on Immunomodulation
in which immuno-modulators for use
in chest diseases, clinical medicine and Ayurvedic
immuno-modulators available were discussed. This
was followed by Robert Koch-Ranbaxy Oration by
Dr. V.K. Vijayan, Director, V.P. Chest Institute,
Delhi. The subject of his oration was “Role of
Bronchoalveolar Lavage in the Diagnosis and
Immunological Evaluation of Patients of Pulmonary
Tuberculosis”. This was followed by Lupin-TAI
Oration by Prof. K. Jagannath on the subject of
“MDR TB-Current Status and Treatment. In the
evening, there was a session on extra-pulmonary
tuberculosis and varied papers on tuberculosis of
central nervous system, bones and joints and genital
system, etc. were discussed.
On 28 lh December, 1999, the meeting of the
Secretaries of State Association was held. It was
stressed at the meeting that the sale of TB seals
should be intensified through State Associations,
States and districts should get regular and
uninterrupted supply of anti-tuberculosis drugs
without any discrimination. A suggestion was also
made that efforts should be made to get 100%
income-tax exemption on donations, instead of 50%
presently available.
A noteworthy feature of the Conference was that
a number of papers were presented by young
workers who showed keen interest in presenting
papers of good quality.
The meeting of the Standing Technical
Committee was also held the same day. It reviewed
the papers presented at the Conference and
commented that the orations as well as guest lecture
were outstanding and the quality of papers presented
at the scientific sessions was generally good. The
committee highly appreciated the hospitality

54 TH NATIONAL CONFERENCE 113
extended by the Bihar Tuberculosis Association
which had made the Conference highly successful
despite certain constraints. The invitation extended
by the Bengal Tuberculosis Association for hosting
the next National Conference in Calcutta was noted
with satisfaction. It was suggested that the dates of
the Conference should not clash with other
important conferences. The evening was devoted
to the management of extra-pulmonary tuberculosis.
After the conclusion of the day’s business there was
a cultural programme, followed by dinner.
On 29-12-1999, after breakfast, a session on
childhood tuberculosis was scheduled but the same
could not be held because Dr. Kamlesh Chopra
could not attend the conference. In its place, papers
on chest diseases were presented. Besides, there
were papers on evaluation of direct sensitivity test
for M. tuberculosis and also polymerase chain
reaction as a definitive diagnostic tool.
The concluding session was held on the 29 th
December, 1999 and the valedictory address was
delivered by Dr. Lala Surajnand Prasad. The address
covered tuberculosis in children. This was followed
by a brief resume of the Conference by Dr. M.M.
Singh, Vice-Chairman of the Tuberculosis
Association who profusely thanked the organisers
of the Conference for making it a grand success.
As-required under Rule 3 (xiii) of the Rules and
Regulations of the Tuberculosis Association of
India, four representatives, viz. Drs. Rajendra
Prasad, A.K. Janmeja, A.K. Jha Amar and K.B.
Gupta were elected to be members of the Central
Committee.
Chairman of the Bihar Tuberculosis
Association, Shri Vidyarthi presented mementoes
to all his workers and praised their work in the
organisation of the Conference. On behalf of the
delegates, Dr. R.P. Bhagi, Dr. V.K. Challu, and Mrs.
Pushpa Phalgunan, thanked the Tuberculosis
Association of India for organising a successful
conference. At the end of the Conference, Prof. S.B.
Lai, General Secretary, Bihar Tuberculosis
Association proposed a vote of thanks.

Ind. J Tub 2000, 47, 114
CONTEMPORARY ISSUES
AIDS CHEMOPROPHYLXIS
Dr. Eric Rosenberg of the Massachusetts General
Hospital and the Harvard Medical School, USA
has reported on what appears to be the forerunner
of chemoprophylaxis for AIDS.
If persons are given highly active anti-retroviral
therapy (HAART) during the “prodromal” phase of
HIV infection i.e., just after exposure but before
anti-bodies appear in serum and the ELISA test
shows seropositivity, such persons may never develop
frank AIDS. There appears to be a latent period,
soon after HIV infection, lasting for several
weeks, during which the recently infected person
may have vague symptoms, especially mild flu-like
symptoms but the ELISA test would still be negative.
If there is known contact with an HIV positive
person, HAART could be started by him/her on presumptive
basis.
Reporting on 21 such patients with HIV-I
infection, who were given HAART before they became
seropositive but who had a heavy viral load
in the blood on culture, Dr. Rosenberg found after
one year of follow up that only 2 patients who had
interrupted their treatment prematurely still had the
virus in blood while the rest were just ELISA positive.
Other workers have reported that HAART may
also have a limited role to play in suppressing viral
multiplication long after seroconversion.
TUBERCULOSIS : a RAY OF HOPE
It is common to come across all round
pessimism when public health administrators prefer
to quote the likely number of deaths in a year or the
number of persons suffering from tuberculosis in
the country instead of giving the mortality and
morbidity rates. They have reasons to do so:
numbers tell better how gigantic the problem is for
which the efforts being made may not be adequate.
And numbers illustrate the overall effect of the
ongoing population explosion under which the
numbers keep going up, even when the rates may
be slowly decldining.
The conventional wisdom about the population
explosion too is of the inadequate kind. That
uncontrolled population growth does away with the
fruits of development, technological advances and
capital formation, and increases the load of diseases
like tuberculosis, resulting in little or nil prosperity
and more disease, may not be entirely true as well.
Recent studies have put a doubt on the nature
of the relationship between growth, prosperity and
sickness in the community. A statistically significant
relationship has yet to be established between the
population growth rate and the per capita output rate.
Bloom and Williamson (World Bank study) have
related the recently observed ‘Asian Economic
Miracle 1 with ‘Demographic Transition’: the
prosperity observed was because of population
growth which had put in more people in the ‘workage
group 1 as compared with the economically
dependent population. The phenomenon of
demographic transition had earlier worked
differently in Europe, where it took nearly a century
to put in a sufficient number of people in work-age
group because of lack of medical armamentarium,
then, compared with what is available today.
Demographic transition that occurred in the midsixties
in East Asia was quicker and far more
favourable, leading to very rapid prosperity. This
favourable demographic transition is expected to
peak by 2010, and decline thereafter. There are
many other factors which also play a part in
prosperity and the situation is complex.
India appears to be placed in a very favourable
situation, compared to China, in respect of the
demographic transition phenomenon. The
favourable shift towards producing a bulge in the
work-age group in India began gradually in 1970.
The ratio between working and dependent
population then was 1.2: 1 and is now 1.5:1; it might
peak at 2.4:1 around 2030, when the overall
population growth is expected to either keep
declining or stabilise around 2015. We have,
therefore, an opportunity to let economic prosperity
catch up with tuberculosis morbidity and mortality

CONTEMPORARY ISSUES 115
to an extent which our control programme may not
be able to do for a long time.
A NEW DRUG FOR ASTHMA
Dr. Henry Milgrom of the National Jewish
Medical Research Centre in Denver (USA) has
reported in the New England Journal of Medicine
his discovery of a new class of anti-allergic/antibody
drug to fight steroid dependent chronic
asthma. The drug, “anti-ige” reins body’s immune
system to produce antibodies against allergens to
which the patient is sensitive. During experimental
trials, not only were symptoms greatly relieved by
the drug but it was possible to wean patients away
from steroids which they had been taking for years,
exposing them to the serious side effects of
osteoporosis, cataract and high blood pressure.
According to Dr. Milgrom, it is a completely new
approach, to asthma therapy which may
revolutionise current practices to deal with allergic
asthma.
LEPROSY ABOUT TO GO
Leprosy is nearing elimination as a world wide
public health problem. In all, there are just 10 countries
where the number of leprosy cases is more
than the WHO target of less than I case per 10,000
population. When the use of multi-drug therapy
(MDT) for leprosy was introduced in the early
1980s, 122 countries were having an unacceptable
number of leprosy patients. Since then; the global
prevalence of the disease has been reduced by 85%.
According to WHO estimates, nearly 200 million
patients will have to be detected over the next 2-3
years, 90% of whom live in 13 countries in Africa,
Americas and Asia (including India) in order to
eliminate leprosy worldwide.
The scenario in respect of tuberculosis continues
to be grim. India is estimated to have l/4th of
the global tuberculosis cases.
THE SIXTH LARGEST KILLER
The World Health Organisation has estimated
that 11 million work-age adults and children died
from just six infectious diseases in 1998. These are:
Acute Respiratory Infections (ARI), Tuberculosis,
Malaria, Diarrhoea! diseases, Measles and AIDS.
The six diseases account for 90% of all deaths
that occur due to infectious diseases among people
under 44 years of age. Of the 11 million deaths
caused by infectious diseases, ARI took the biggest
toll (35 million) mostly among children in developing
countries. Diarrhoeal diseases, which rival
ARI as the biggest killer of children, destroyed 2.2
million lives. Tuberculosis killed 1.5 million people
and emerged as the biggest single killer of adults,
surpassing Malaria. AIDS beat Tuberculosis and
accounted for 2.3 million deaths among whom 1.5
million were young adults in developing countries.
Malaria accounted for 1.5 million deaths, about two
thirds being children.

Ind. J. Tub. 2000, 47, 116
FORUM
Revised National Tuberculosis Control Programme
I have read with interest the article-’The Revised
National Tuberculosis Control Programme: A Status
Report on First 1,00,000 patients”, published in the
Indian Journal of Tuberculosis (1999, 46, 157). I
convey my sincere thanks to the Government of
India’and the personnel involved in successful
implementation of the programme.
Further, I also appreciate the author for inviting
suggestions to improve the implementation of the
programme. My observations/queries regarding the
article are as follows :
1. The author has mentioned that 15 percent of
chest symptomatics were found to have positive
smear for acid fast bacilli. But, it is not clearly stated
whether these patients were diagnosed for the first
time or also included chronic excretors of tubercle
bacilli in sputum. Further, many of the patients were
diagnosed outside the purview of RNTCP but were
included for treatment with DOTS. In such a
situation, it becomes really difficult to draw any
conclusion about the proportion of chest
symptomatics having smear positive tuberculosis.
2. In the ‘Discussion’, the author has mentioned
that those unwillingto participate in DOT are offered
Streptomycin, Isoniazid and Ethambutol. Why not
give them daily Rifampicin, Isoniazid, Ethambutol
and Pyrazinamide followed by Isoniazid/
Rifampicin? I believe that the cost factor may be
the reason for recommending SHE instead of
RHEZ/RH. But, if one calculates the total cost of
treatment with SHE/HE, including the cost of
disposable syringes and, many a time, the money
paid by patient to get injection or conveyance
charges to the facility, the cost of SHE is higher
than daily self administration of RHEZ/RH. RHEZ/
RH should be the standard treatment for newly
diagnosed smear positive pulmonary tuberculosis
patients. Such/effective and patient friendly
treatment will Jabost the confidence of other patients
to accept treatment under the state owned control
programme.
3. The author has mentioned that 2/3 rd of the
patients in Category II had a successful outcome.
Category II under RNTCP includes heterogeneous
re-treatment patients e.g. relapses in those with
inadequate duration of treatment, resumption of
treatment after interruption and treatment failures.
The first two types (relapses, resumption after
interruption/default) are likely to have sensitive
bacilli but treatment failures are not likely to have
the same. Therefore, Category II treatment will yield
favourable result in those with relapse or resumption
of treatment after default but not in treatment failures.
To analyze this aspect, the author is requested to
break up the results in different subsets of patients
of Category II.
4. It will also be of interest if the author can
give the following details:
(i)What proportion of the patients remained
persistently sputum positive at the end of 3 months,
in Category I and how many of them converted by 5
months on the same treatment? Does the author have
the culture sensitivity pattern of those who remained
positive at 3 month period?
(ii) RNTCP programme has been in operation
for the last 5-6 years in many of the cities. Do we
have data about relapses among those who
completed the stipulated duration of treatment?
M.L. Gupta
Jaipur
The author replies:
The interest and questions of Dr. Gupta are
appreciated.
In the RNTCP, 25-33% of smear-positive
patients diagnosed are re-treatment cases. Hence, of
the 15% of patients examined for diagnosis who have
positive smears, at least 10-12% are new patients.
Only patients diagnosed in the RNTCP are treated
in the RNTCP.
Use of daily unsupervised Rifampicincontaining
regimens in the RNTCP would be a
terrible’disservice to patients and to the community.
It is well documented in India and internationally
that the success rate of such a regimen would not
exceed 60% 1 . In the name of being “patient friendly,”

FORUM 117
such a strategy would ‘m fact’ expose patients to
substantially increased risk of drug resistance and
death, as well as increasing the spread of
tuberculosis, including multi-drug-resistant
tuberculosis, in the community. Rather, the effort
must be to ensure that treatment observation is
accessible and acceptable to patients by involving
community resources such as Anganwadi workers,
Dais, volunteers, NGOs, neighbours, cured patients,
etc. The importance of establishing convenient
treatment observation which draws on the strengths
of the community cannot be overemphasized.
Until 1998, the recording system for re-treatment
patients did not allow reliable differentation of
outcomes among different categories of patients.
Data on treatment outcomes for the first three
quarters of 1998 are given below (excluding one
district which has not reported for the 3rd quarter of
1998).
Treatment success was slightly less frequent
among patients who had failed previous treatment
compared with re-treatment patients who had a
relapse or treatment after default (62% vs 75% vs
71%). However, among each category of retreatment
patients, by far the most common reason
for an unsuccessful outcome was default. The most
common reason for failure of treatment is failure to
take the treatment, rather than failure of the treatment
to cure the patient
To put this in perspective, the 23 patients who
remained smear positive after 5 months or more of
re-treatment regimen, and who had failed a .previous
course of treatment, represent 0.1% (about one out
of a thousand) of the 19,198 patients placed on
RNTCP treatment in this time period.
Concerning sputum conversion, among
Category I patients, 10.9% have remained smearpositive
at the end of 2 months and 2.7% at the end
of 3 months. The separate outcomes of these patients
are not available from programme reports, nor are
drug susceptibility tests or relapses.
Concerning relapse and failure, one experience
is quite notable. The project officer of Pathanamthitta
district of Kerala evaluated 200 consecutive patients,
with the primary aim of determining which patients
had actually received treatment under observation.
He found that 53 (27%) had not been directly
observed. The rate of relapse and failure among these
53 patients was 45% compared with only 3% of the
147 patients who had received observed treatment
(Pathanamthitta District Tuberculosis Centre,
unpublished observation). Hence, the primary
determinant of both relapse and failure was the
failure to ensure direct observation of treatment at
time and place convenient to patients.
The programme welcomes operational research
to identify practical, operationally feasible means to
continue to improve the programme. Any alternative
strategy should be evaluated in the same manner as
the RNTCP has been evaluated - by systematic,
standardized evaluation and reporting of each and
every patient started on treatment. It will be
recognized that one of the greatest strengths of the
RNTCP is a rigorous recording and reporting system
which permits open and fair evaluation of policies.
REFERENCE
1. C.P. Chaulk and V.A. Kazandijan; Directly Observed
Therapy for treatment completion of pulmonary
tuberculosis:Consensus Statement of the Public Health
Tuberculosis Guidelines Panel (pubHshed erratum
appears in JAMA 1998.280.134) JAMA : 1998,279,943)
Priority in Tubercdlosis Programme Reserach
For more tharra decade, tuberculosis programme
research has been receiving only step-motherly
attention. It is encouraging that a strong plea has now
been made to overcome this lacuna by suggesting
“an agenda for research in tuberculosis control” 1 .
This, it is hoped, will lead to a proper plan of action
for tuberculosis programme research and its
implementation. While agreeing to the suggested
“agenda”, it is essential to keep in mind some basic
facts, which ought to be discussed in detail before
setting up priorities for tuberculosis programme
research. A healthy debate on these basic facts also
would be very rewarding.
Government Health Service System
An evaluation of the National Tuberculosis
Programme (carried out with emphasis on a system
approach) by the Institute of Communication,
Operations Research and Community Involvement
(ICORCI) in 1988, at the instance of Government
of India and WHO had clearly pointed out that the
efficiency of NTP cannot be improved unless and

]]8 FORUM
until serious efforts were made to improve the
government health service system with which NTP
is integrated 2 . Attempts have been made to revise
NTP without paying adequate attention to improving
health service system, which is basic and crucial.
Any attempt at revising NTP without improving the
system with which it is integrated is bound to fail,
even though it may show encouraging results in
initial periods (i.e., it is not sustainable). How can
one get anywhere fast by using a car with loose and
shaky connections, which has not been oiled and
greased properly to ensure smooth functioning of
its parts? It is important to realise that NTP is not
the only programme which has suffered from the
inefficiency of the health service system. Even the
high priority Family Welfare Programme was such
a victim, for years together! It is a matter for serious
concern that repeated recommendations emphasising
the need, and some steps for improving the efficiency
of the health service system have been ignored, even
though implementing these would have led to
definite improvement in the provision of total health
care including the tuberculosis programme. Further,
adequate attention has not been paid to understand
the manner and extent to which:
(a) staff problems such as role conflicts, ego
conflicts, promotion prospects and economic considerations
relating to the staff,
(b) the general work ethos prevalent in the
health care system as well as other sister systems
within the government,
(c) socio-economic and cultural factors within
and outside the system which affect the system, and
(d) the substantial involvement of nongovernmental
providers of health care, influence the
efficiency of the health service system in general
and the tuberculosis programme in particular. It is
essential to try out alternative solutions, which take
these factors into account and select one of them
which balances these factors to the largest extent
possible and puts forth realistic strategies to reduce
the remaining imbalances. Such an operations
research study, using a contextual approach, deserves
the highest priority because it will improve the entire
health service system^ including the tuberculosis
programme, in all parts ofthe country. If the need is
generally agreed to, a multi-disciplinary expert group
with representatives from all components of the
health service system (including health
administration and policy formulation) could
formulate further details and steps required.
Private Providers of Health Care
Various studies have shown that health services
provided by private/non-governmental organisations
are quite substantial. For first contact by the patients,
this proportion may be even more than 75% 3 .
Attempts made so far to involve them in tuberculosis
programme have not been rewarding enough. May
be, the approach itself needs to be changed.
Programme personnel have been telling these outfits
about what they should do and how some crucial
programme requirements have to be met by them. It
seems that enough attention has not been paid to
understand their problems and seek their
suggestions. For example, their financial
requirements for this purpose have to be met and
they and their staff need to be trained or properly
oriented. Considering their already’predominant
share in health services, it is high time that priority
is given to research on involving private providers,
in different parts of the country, based on fresh and
innovative thinking.
Appropriate Duration of Treatment
The assumption that all cases require the same
duration of treatment is questionable. Longitudinal
surveys by National Tuberculosis Institute,
Bangalore (NTI) have shown that one-third of sputum
positive cases were cured without any proper
treatment 4 . This rate may be even higher for better
socio-economic classes. Follow-up of untreated sputum
positive cases after shorter invervals had shown
that about 22% had sputum conversion after three
months which further increased to 25% at the time
of a second follow-up after 2-12 weeks 5 . Even
among NTP cases not completing full treatment,
substantial percentages had shown sputum conversion
With different duration of treatment 6 . It is relevant
that many countries had achieved very substantial
reduction in tuberculosis infection and prevalence
before the advent of chemotherapy! During
the period 1920 - 1940, tuberculosis mortality rates
in Netherlands had declined by 5.4% per year and
risk of infection had decreased by 3.8% per year in

FORUM 119
Vienna and 4.7% per year in Prague 7 . “Tuberculosis
had been in profound decline for many decades
before technological advances such as vaccines and
drugs became available 8 ”. Declining trend in annual
risk of infection despite a large proportion of cases
not being diagnosed and “so-called inadequate treatment”
of diagnosed cases also supports this view 9 .
Another important question is: “Is it ethical to advise
and even compel some tuberculosis patients to
continue to take drugs, when it is no longer necessary
for them, only because we have not made any
attempts to discriminate between patients requiring
different durations of treatment despite the clear indications
that substantial proportions of cases have
been cured with either no specific treatment or “so
called inadequate specific treatment?” It is possible
that some of the “so-called defaulters” of treatment
may have been wiser in stopping treatment when
they no longer required it. And a discriminant analysis
of data to provide indicators for classification of
patients requiring different durations of treatment
could help to substantially reduce the present nonethical
treatment practices. This could also lead to a
better utilisation of the available drugs and the money
spent on it. Further research has to be carried out as
to why a substantial proportion of tuberculosis cases
get cured without proper treatment or with so-called
inadequate treatment.
Providing Care for Other Chest Diseases
Even if passive case finding is highly successful,
only about 10% of the chest symptomatics seeking
relief who are suffering from tuberculosis can
be taken care of. The programme has nothing specific
to offer to the remaining 90% (i.e., to the vast
majority of chest symptomatics) and probably does
not seem to care about what happens to them. How
far is it ethical to do so on the ground that the programme
planners are tuberculosis specialists and are
not expected to provide relief to chest symptomatics
who are not suffering from tuberculosis? Further, is
it not naive to expect that the chest symptomatics
who came seeking relief for their suffering would
continue to come to these centres despite about 90%
of them not being offered any specific treatment and
that the news will not spread to other chest
symptomatics in the community? It need hardly be
emphasised that such non-holistic approaches by
different specialised programmes have virtually
driven those needing health care to the private sector.
Both for ethical considerations and the need of
the tuberculosis programme to encourage chest
symptomatics to seek relief for their suffering, as
early as possible, from the programme centres, it is
high time that serious’attention is given to undertaking
research for providing care for other chest
diseases, by involving alternative systems of health
care, if necessary, in such research efforts. More than
10 years back, ICORCI had brought out these aspects
and recommended that National Tuberculosis
Institute and similar institutes should be converted
into Institutes of Tuberculosis and Chest Diseases 2 .
Mid-Term Evaluation of RNTCP
RNTCP was implemented in 1993 and is functioning
in a number of districts. It is high time that
an objective and in-depth “mid-term evaluation” is
carried out to understand the strengths and weaknesses
of RNTCP in different parts of the country.
Research Evaluation and Public Interest
Large sums of money are spent on research and
evaluation. Of particular interest are studies relating
to the health service system and its improvement.
Over the years, the health service system has often
been criticised by many individuals, journalists and
research organisations and its image has been
steadily going down among the people who have
been forced to seek help from private practitioners,
clinics and hospitals and incurring avoidable cost to
themselves. Objective studies have made important
recommendations for effecting improvements which
have mostly been overlooked! Why should the
country spend large sums of money on research and
evaluation if no one is interested in utilising the
findings? This question does not imply that we
should automatically accept all the recommendations
from research and evaluation studies. But, it does
strongly urge that the findings from research and
evaluation studies are widely debated with an open
mind in different fora (including, invariably, the
authors of the recommendations and nongovernment
organisations also) and that the reasons
for rejection of recommendations, substantiated by
a healthy debate should be made known to all
concerned. In this manner, research workers and

120 FORUM
organisations can be convinced not to waste their
efforts on impracticable solutions. Or, if not
convinced, they can start a fresh dialogue to remove
any communication blocks or to modify the
recommendations suitably. Absence of such healthy
debates and dialogues is not in public interest. One
suggestion is that a committee of experts consisting
of research workers, administrators and policy
makers, representing both government and nongovernment
organisations should periodically
review the findings from research and evaluation
studies to ensure maximum utilisation of research
and evaluation findings, in public interest.
S.S. Nair
Retd Director (Evaluation), Ministry of Health and
Family Welfare, Government of India & presently,
Chairman, Forum for Research, Training and
Evaluation, Bangalore
REFERENCES
1. Nagpaul DR: An Agenda for Research in Tuberculosis
Control:Ind. J. Tub., 1999, 46, 141
2. Institute of Communication, Operations Research and
Community Involvement, Bangalore. An In-depth Study
on National Tuberculosis Programme of India:
Unpublished: Abstracted in Summaries of NTI Studies
by National Tuberculosis Institute, Bangalore, 1997,100
3. Institute of Communication, Operations Research and
Community Involvement, Bangalore; Behaviour Pattern
of Chest Symptomatics in Rural and Urban Populations
in Karnataka: Unpublished (1998)
4. National Tuberculosis Institute, Bangalore; Tuberculosis
in a Rural Population of south India; A Five Year
Epidemiological Study: Bull. WHO 1974, 51, 473
5. Gothi GD, Chakraborthy AK, Parthasarathy K and
Krishnamurthy VVK: Incidence of pulmonary
tuberculosis and change in bacteriological status of cases
at shorter intervals; Ind. J. Med. Res., 1978, 68, 564
6. Baily GVJ, Samuel GER and Nagpaul DR : A
Concurrent comparison of an Unsupervised Selfadministered
Daily Regimen and a Fully Supervised
Twice Weekly Regimen of Chemotherapy in a Routine
Out-patient Treatment Programme : Ind J. Tub., 1974,
21, 152
7. Royal Netherlands Tuberculosis Association, Selected
Papers, 1980,20,20
8. Ian Smith: Stop TB - Is DOTS the Answer?:Ind J. Tub.,
1999,46,81
9. Chakraborty AK. Choudhary K. Sreenivas TR.
Krishnamurthy MS, Shashidara AN. Channabasavaiah
R: Tuberculosis Infection in a Rural Population of south
India; 23-year trend : Tubercle and Lung Dis., 1992,
73,213

Ind. J. Tub. 2000, 47, 121
NEWS & NOTES
21ST EASTERN REGION CONFERENCE OF
THE 1UAT-LD
The 21st Eastern Region Conference of the International
Union Against Tuberculosis and Lung
Disease would be held in the Philippines in 2001.
Overall chairperson is Dr. Camilo C.Roa. Further
details can be had from Dr. Camilo C. Roa, The Philippine
Tuberculosis Society Inc., 84l6 NacioStreet,
North Susana Execo V.L., Division, Quezon City,
Philippines. (Fax:(632)932-9269; E-mail:croa@inext.net),
6 th CME IN HAEMATOLOGY AND
HAEMATO-ONCOLOGY
The 6 lh Continuing Medical Education session
in Haematology and Haemato-oncology would be
held at the Bombay Hospital Institute of Medical
Sciences, Marine Lines, Mumbai, from 1 l th to I4 th
May, 2000. It would be oriented towards
postgraduate students and senior staff members from
Pathology, Paediatrics and Medicine Departments
and will cover both diagnostic and therapeutic aspects.
Further details can be had from: Dr. M.B.
Agarwal, MD, Programme Director-6 th CME in Haematology,
Haemato-oncology Centre, Vijay Sadan,
168B, Dr. B. Ambedkar Road, Dadar TT; Mumbai-
400 014; Tel:022-4144453,022-4142272; Fax;Q22-
4140058; E-mail: mbagarwal-@hotmail.com.
55 th NATIONAL CONFERENCE ON TUBER-
CULOSIS & CHEST DISEASES
The 55 th National Conference on Tuberculosis
and Chest Diseases will be held in Calcutta from 7 th
to 10 th December, 2000. Those who wish to present
papers on any subject related to tuberculosis may
kindly forward three copies of the abstracts of the
papers to the Secretary-General, Tuberculosis
Association of India, 3, Red Cross Road, New Delhi-
110 001, latest by 31 st July, 2000.
The subjects chosen for presentation are : prevention
of tuberculosis, imiiiunologyand Ayurveda
including Yoga, lung cancer, non-tuberculosis chest
diseases, bronchial asthma, HIV and TB, MDR-TB,
childhood tuberculosis, environmental pollution and
health, extra-pulmonary tuberculosis and tubercu-
losis control programme. In addition, as usual, assorted
papers/free communications on any subject
relating to tuberculosis and chest diseases are also
welcome.
TBSEAL DESIGN
The Association has selected Gardens of India
and Cactus Flowers as designs for the 51 th TB Seal
campaign which will be launched on 2nd October,
2000. There will be a total of 10 designs for this
campaign.
WORLD CONGRESS ON LUNG HEALTH
FLORENCE-2000
The first World Congress on Lung Health organised
by the European Respiratory Society, in
collaboration with American Thoracic Society,
Internationa! Union Against Tuberculosis and Lung
Disease and the Asian Pacific Society of
Respiratology will be held in Florence (Italy) from
30 th August to 3 rd September, 2000. The Congress
coincides with the 10th Annual Congress of the
European Respiratory Society. For further details,
please contact Dr. Dario Olivien, Department of
Respiratory Diseases, University of Parma, Via
Resori, 10, I-43100 Parma, Italy (Fax : 39 0 521
292615; E-mail : olivieri@unipr.it).
13 TH AFRICA REGION CONFERENCE OF
THE IUATLD
The 13 th Conference of the Africa Region of the
International Union Against Tuberculosis and Lung
Disease, organised by the Africa Region of the
IUATLD, will be held in Conakry (Guinea) from
24 th to 27 th May, 2000 under the patronage of the
Ministry of Public Health of the Republic of Guinea.
The Conference is designated as a NO SMOKING
CONFERENCE and the subject is promotion of lung
health in Africa. For further details, please contact
the General Secretariat of the Conference -
International Union Against Tuberculosis and Lung
Disease, 68, Boulevard Saint-Michel, 75006 Paris
(France). Fax : +33-143 29 90 87; E-mail:
mailto:union@iuatle.org union@iuatld.org; Local

122 NEWS & NOTES
Secretariat of the Conference: Conakry, Guinea Fax:
+224 41 20 58; E-mail: prsow@leland-gn.org.
ANTI-TB WEEK
The Tuberculosis Association of India observed
Anti-TB Week from 17 th to 23rd February, 2000.
During the week, health education materials on
tuberculosis were displayed for creating awareness
among the general public. The State affiliates also
observed the Anti-TB Week.
The Tuberculosis Association of Goa sent out a
circular letter to TB authorities in the State regarding
observance of Anti-TB week. All concerned were
requested to create awareness among the general
public about the problem of tuberculosis and seek
their cooperation in the implementation of the
National Tuberculosis Programme in Goa as well
as observance of the Anti-TB Week. Suggestions
were made in the circular letter with regard to how
the health education drive could be conducted.
SCIENTIFIC MEETING OF THE DELHI
TUBERCULOSIS ASSOCIATION
A scientific meeting was arranged by the Delhi
Tuberculosis Association on 3rd March, 2000 in the
premises of the Association . Emeritus Prof. Vaidya
M.S. Agnihotri was the speaker on the subject of
“Holistic Approach Towards Treatment of
Tuberculosis”. Dr. M.M. Singh, Vice-Chairman of
the Tuberculosis Association of India, presided over
the function.
JOINT TUBERCULOSIS PROGRAMME
REVIEW
The Government of India along with the WHO
undertook a comprehensive joint review of the
tuberculosis programme of the country from 4 th to
16 ih February, 2000. The objective of the review was
threefold: definition of the status of RNTCP, which
is presently covering a population of 150 million, in
terms of the technical policies followed and the
actual performance; evaluation of the status of NTP
operating in rest of the districts leading to the
formulation of an outline plan for the expansion of
RNTCP to those districts and recommendations for
promoting effective political commitment and
improving sustainability of RNTCP.
The Review Team comprised 25 members:
seven were international experts from WHO, Royal
Netherlands Tuberculosis Association, Danish
International Development Agency (DANIDA),
Department of International Development (DFID)
of U.K., World Bank, and Centres for Disease
Control and Prevention (CDC). Eighteen Indian
experts were from the Ministry of Health and Family
Welfare, Central Tuberculosis Division of the
DGHS, Railways Employees State Insurance
Corporation (ESIC), Medical Colleges, Indian
Medical Association, Tuberculosis Association of
India, eminent tuberculosis workers and district and
state level tuberculosis control officers. These
experts formed themselves into five teams, one of
which, on visit to West Bengal, branched off to visit
Assam as well. Rest of the four teams visited Delhi.
U.P., Tamil Nadu and Maharashtra.
The joint review was done’on the lines of the
earlier review done in 1992 by the Government of
India and Swedish International Development
Agency (SIDA) before RNTCP strategy was
developed, in 1993

Ind. J Tub. 2000, 47, 123
ABSTRACTS
Outcome of multi-drug-resistant tuberculosis in
human immunodeficiency virus-infected patients
Franzetti et al; Cli.Inf Dis.; 1999, 29, 553
From 1998 to 1996,324 cases of culture positive
tuberculosis, of whom 90 (27.8%) were drug
resistant were studied. In all, 61 of the 69 isolates
tested had identical restriction fragment length
polymorphism patterns. The strains were susceptible
only to Ethionamide and resistant to Ethambutol,
Streptomycin, Cycloserine, Amikacin, Kanamycin,
Terizodone, Ofloxacin, Rifabutin and Rifapentin.
The median survival time of the patients was 94
days. Multivariate analysis showed a trend towards
better outcome during 1994-96 and in extrapulmonary
tuberculosis. The delay between
appearance of symptoms and start of therapy was
not a determining factor in survival time. The four
drug anti-tuberculosis treatment had higher efficacy
compared to regimens with fewer drugs.
How much Isoniazid is needed for prevention of
tuberculosis among immunocompetent adults?
G.W. Comstock; Int. J. Tub. Lung Dis.: 1999, 847
The tendency to reduce the period of INH
chemoprophylaxis from 12 months to 6 months was
studied. This recommendation and the relevant
outcomes observed in controlled trials were
reviewed. It was found that in immunocompetent
persons, 6 months of preventive therapy does not
give optimal results. In less than 12 months of
preventive treatment, 9-10 months appear to give
optimal results. The total duration of preventive
treatment may be more important than its continuity.
Does aging modify pulmonary tuberculosis?
C.Perez-Guzman et al; Chest; 116, 961
Clinical, radiological and laboratory features of
pulmonary tuberculosis in the elderly were
compared with those in the younger cases. A meta
analysis of 12 published studies was done in respect
of each variable. No differences were found with
respect to male predominance, evolution time before
diagnosis, prevalence of cough, amount of sputum,
weight loss, fatigue/malaise, radiographic lesions,
AFB sputum positivity, anaemia and
aminotransferases. There was low occurrence of
fever, sweating, haemoptysis-, cavitary disease and
Mantoux positivity as well as serum albumin and
blood leucocyte counts in the older cases. In
addition, aged cases had more of dyspnoea and
associated conditions like COPD, diabetes and
malignancies. The meta analysis identified that the
main difference in older TB patients is due to old
age and not necessarily due to tuberculosis.
Unrecognized Transmission of Tuberculosis in
Prisons
C.R. Macintyre et al; Eur. J. Epi; 1999, 15, 705
In the Maryland Prison in USA, the prisoners
with recently observed Mantoux conversion who
had identifiable exposure to confirmed cases of
tuberculosis within the prison system were studied.
The hypothesis was that infection had occurred
during the perod of incarceration. All cases
diagnosed in the prison during the period of the study
were studied from records, retrospectively. Skin test
conversion and the potential sources of infection
within the prisons were matched. All inmates
discharged from the prison were then matched with
cases of tuberculosis notified to the Maryland
Department of Health. The inmate turnover was 21 %
per annum. Probable exposure to a known source
was found in 13% of converters, possible exposure
in 10% and no exposure in 72% of the inmates. In
5%, the status could not be determined. Four cases
of pulmonary tuberculosis notified were identified
within 3 months of their discharge from prisons. It
is concluded that significant transmission of
tuberculosis due to undiagnosed index cases in the
prisons may occur. Therefore, it is suggested that
tuberculin skin test should be done routinely to
identify tre h infection.
Extensive Transmission of Mycobacterium
Tuberculosis from a child
A.B. Curtis el al; New England Journal of Medicine;
1999, 341, 1491
An infectious case of tuberculosis, a 9 year old

124 ABSTRACTS
boy, was discovered in North Dakota in USA
because his guardian was found to have extrapulmonary
tuberculosis. The child had bilateral
cavitary disease and was perhaps the only known
possible source of infection for his guardian. Of the
276 contacts of the child who were skin-tested, 56
(30%) gave positive results, more than 10 mm. The
contacts were in the household, besides class room
contacts, bus riding contacts and day care contacts.
In all, 118 of the tuberculin positive contacts were
given preventive therapy. An additional case found
was the twin brother of the 9 year old patient. This
case was non-infectious. It is concluded that children
with tuberculosis, especially cavitary or laryngeal
tuberculosis, should be considered highly infectious
and screening of all the possible contacts should be
undertaken systematically.
Ecological Analysis of ethnic differences in
relation between tuberculosis and poverty
J.I. Hawker et al; British Medical Journal; 1999.
319, 1031
The paper reports on a retrospective analysis of
1516 notified cases of tuberculosis found in
Birmingham (UK) during 1989-1993- The ethnic
origin of the patients was analysed in relation of
indices of poverty. Univariate analysis showed that
disease rates were significantly associated with
several indices of poverty and with the proportion
of population of South Asian origin. On multiple
regression, it was found that higher level of overcrowing
was independently associated with
tuberculosis rates. For the white population,
overcrowding was associated with disease rates
independently of other variables but no such
relationship was founU for the South Asian
population, either in single or multivariate analysis.
The authors conclude that poverty is significantly
associated with tuberculosis in the white population
but not in patients of South Asian origin. It is also
suggested that etiological factors and, therefore,
perhaps interventional procedures may also differ
in different ethnic groups.
Global burden of Tuberculosis : Estimated
incidence, prevalence and mortality by country
C. Dye et al: JAMA; 1999, 282 677
This WHO publication reports on the risk and
prevalence of M tuberculosis (MTB) infection and
tuberculosis incidence, prevalence, mortality and
disease rates, attributable to HIV for 212 countries,
in 1997. The sources of the information were
notifications of the WHO, annual risk of infection
from tuberculin surveys and data obtained from
prevalence surveys. Where more reliable sources
were not available, the rates were strongly influenced
by the panel members’ opinion. Where high quality
data were available, the estimates were more
objective. In 1997, new cases oftuberculosis totalled
an estimated 7.96 million (range : 6.3-11.1 million),
of which 3.52 million (2.8-4.9 million) i.e. 44% were
smear positive infectious pulmonary tuberculosis.
In addition, there were 16.2 million (12.1-22.5
million) existing cases of disease. Mortality was
estimated at 1.87 million (1.4-2.8 million). Overall
case fatality rate was estimated at 23% but exceeded
50% in some African countries where HIV
prevalence rates are know to be high. Global
prevalence of MTB infection was 32%, 80% of all
incident cases were found in 22 countries, more than
half being found in 5 South East Asian countries.
Prevalence of MTB/HIV co-infection worldwide
was 0.18% and 64,000 incident tuberculosis cases
(8%) had HIV infection. The main burden of
tuberculosis was concentrated in South East Asia,
Sub-Saharan Africa and Eastern Europe because of
poor control measures and HIV co-infection,
especially in African countries.
Increased absolute number but not proportion
of γ/δ T-lymphocytes in the bronchoalveolar
lavage fluid of patients with active pulmonary
tuberculosis
T.C. Tsao et al; Tubercle and Lung Disease; 1999,
79, 215
The proportions and absolute cell count of γ/δ
T-lymphocytes in the peripheral blood of patients
with pulmonary tuberculosis (PTB) remains
controversial. Since PTB is an infectious airway
disease, bronchoalveolar T-lymphocytes should be
a better indicator of local immune T-cell reaction
after TB infection than peripheral blood
T-lymphocytes. A study was conducted to quantitate
the absolute cell count and proportions of γ/δ
T-lymphocytes in the bronchoalveolar lavage fluid,
(BALF) of patients with active pulmonary
tuberculosis. Analysis of lymphocytes in the

ABSTRACTS 125
bronchoalveolar iavage fluid was performed in 25
patients with active PTB and 16 normal controls (in
Taiwan). All of the patients were negative for HIV
infection and none was immunocompromised.
BALE and blood were prepated for cell differentia!
count and flow cytometry analysis using monoclonal
antibodies CD3, CD4, CDS, CD25, HLA-DR and
γ/δ as well as α/β T-lymphocyte receptors. The
number of cells per volume of recovered BALF was
significantly higher in the patients with active PTB
than in normal controls. BALF from PTB patients
also showed increased percentage of lymphocytes
CD3+ lymphocytes and CD3- γ/δ T-lymphocytes
were significantlty higher in the BALF, but not in
the blood of patients with TB. However, the
proportions of CD3+ γ/δ T-lymphocytes in BALF
of patients with TB was comparable to that of normal
controls. The γ/δ T-lymphocytes in the BALF rarely
expressed CD4, CD25 and HLA-DR in both groups.
It is concluded that γ/δ T-lymphocytes are not the
major subpopulation of CD-3 lymphocytes in the
BALF that react to mycobacterial infection in the
patients with clinically established active
tuberculosis.
Hypodense alveolar macrophages in patients with
Diabetes Mellitus and Active Pulmonary
Tuberculosis
C.H. Wangetal; Tubercle and Lung Disease; 1999,
79, 235
A study was conducted in Taiwan to determine
the difference in activation status of alveolar
macrophages (AM) and T cells between patients
with TB plus diabetes mellitus (DM) anclTB alone.
The heterogeneity of AM from 14 patients with
TB+DM, 9 with TB alone, 10 normal subjects and
8 DM alone patients, was studied using Percoll
density fractionation. The intracelkilar H 2 O.,
production of AM before and after stimulation with
phorbol myristate acetate (PMA) or F-Met-Leu Phen
(FMLP) was assayed with loading cells with 2’,7’ ..
dichlorofluorescin (DCFH) and analysed by flow
cytometry. Lymphocytes subsets (CD3, CD4, CDS)
and their activation status (CD25) in bronchoalveolar
AM (1.030 g/ml) and the magnitude of DCFH
oxidation of AM was higher in TB patients than in
normal subjects, regardless of DM. Patients with
TB+DM had a significantly lower proportion of the
least density AM fraction than TB alone patients,
regardless of disease extent. Among TB patients,
the proportion of the least dense AM was inversely
correlated with bacterial load in sputum and the
disease extent in chest radiograph. Stimulation of
AM with PMA or FMLP induced an increase in the
hypodense AM subopulations and enhanced
intracelkilar H 2 O 2 generation in patients with
TB+DM and to a similar extent in normal subjects,
but not in patients with TB alone. There was no
significant difference in CD3 numbers, CD4/CD8
ratio, and CD25+ cells between patients with TB
alone and TB+DM. The activation status of AM or
T-lymphocytes from DM alone patients was not
sigificantly different from that from normal subjects.
It is concluded that hypodense subpopulatlons of
AM increase in active TB patients and are related to
the disease severity as well as activation status of
AM. AM in TB patients complicated with DM was
less activated and may be contributory to the
susceptibility to mycobacterial infection.
Evaluation of a Serologic Test for the Diagnosis
of Tuberculosis
M.L. Mathurelal; Int. J. Tub LungDis.; 1999, 3 732
The ICI TB test, a new, simple serological
diagnostic test for tuberculosis (TB), was performed
on serum samples from individuals seen at an urban
teaching hospital and a local health department clinic
in California, USA. The study population included
cases of TB, diseases with mycobacteria other than
tuberculosis (MOTT), no n-mycobacterial
pulmonary diseases and healthy controls. In contrast
to prior studies, the ICT TB test had little value in
detection of new cases of TB (overall sensitivity was
20%). It had very low sensitivity (4%) in the first
month of disease. The sensitivity improved in
patients tested at least 3 months after clinical
presentation, but still remained fairly low. The test
was also positive in 30% cases of disease caused by
MOTT demonstrating cross-reactivity. It was
negative in all HIV-positive cases of TB or MOTT.
The overall specificity was 89%. It is suggested that
at least part of the discrepancy between these results
and those of previous investigators may be
attributable to differences in the respective study
populations, including incidence of HIV disease and
duration of tuberculous illness prior to testing.

126 ABSTRACTS
Evolution of serum β 2 -microglobulin
concentrations during treatment of tuberculosis
patients
J. Callazos et al; Scandinavian Journal of Infectious
Diseases; 1999, 31, 265.
Thirty six human immunodeficiency virusseronegative
patients were studied in order to evaluate
serum β 2 -microglobulin (β 2 -M) levels in
immunocompetent patients with tuberculosis who
were receiving treatment (Isoniazid and Rifampicin
for 6 months with Pyrazinamide for the first 2
months). Six measurements of several clinical and
laboratory parameters were carried out at different
intervals during the 6 months of treatment. The
mean serum β 2 -M at presentation was 149 nmol/
litre and 4 patients had values above the upper normal
limit. Significant decreases in the mean β 2 -M
concentration were observed in the follow-up
determinations in the patients as a whole (P=0.002),
in the patients with normal (P=0.039) and in the
patients with increased β 2 -M at presentation
(P=0.037). β 2 -M significantly correlated with erythrocyte
sedimentation rate (P=0.002). The statistically
significant decrease observed in patients with both
normal and increased β 2 -M values at presentation
suggests that the immunological dysfunction responsible
for the increase in β 2 -M involves most, if not
all, patients with tuberculosis. The measurements
of β 2 -M in conjunction with other clinical and laboratory
parameters could be helpful in evaluating the
response to therapy, particularly in those patients
with increased β 2 -M at presentation.