Tuberculosis treatment remains a challenge due to the need to consider, when approaching it, the context of individual and collective health. In addition, social and economic issues have been shown to be variables that need to be considered when it comes to treatment effectiveness. We conducted a critical review of the national and international literature on the treatment of tuberculosis in recent years with the aims of presenting health care workers with recommendations based on the situation in Brazil and better informing decision-making regarding tuberculosis patients so as to minimize morbidity and interrupt disease transmission.

Keywords: Tuberculosis/drug therapy; Tuberculosis/prevention & control; Tuberculosis/surgery; Tuberculosis/classification.

Objective: To analyze the treatment strategies that influence the effectiveness of tuberculosis treatment at primary care clinics (PCCs) in Brazil. Methods: This was a descriptive, retrospective epidemiological survey based on the medical records of 588 tuberculosis patients enrolled in the tuberculosis control programs at two PCCs located in the city of Belém, Brazil: Centro de Saúde Escola do Marco (CSEM) and Unidade Básica de Saúde da Pedreira (UBSP). The survey was limited to patients enrolled between January of 2004 and December of 2008. We included only patients between 18 and 59 years of age, and we excluded those who were transferred or were found to have been misdiagnosed. We collected data regarding age, gender, type of treatment (self-administered or supervised), co-infection with HIV, and treatment outcome. The health professionals involved in the tuberculosis control program at the two PCCs were interviewed regarding the strategies used for tuberculosis control and regarding routine clinical care for tuberculosis patients. Results: There were no significant differences between the CSEM and UBSP patients regarding age, gender, or co-infection with HIV. Supervised treatment was used significantly more frequently and the rate of cure was higher at the CSEM than at the UBSP, whereas the rate of treatment noncompliance was higher at the UBSP than at the CSEM. Conclusions: For patients enrolled in tuberculosis control programs at PCCs in Brazil, supervised treatment appears to be an extremely important strategy for reducing the rate of treatment noncompliance.

Keywords: Tuberculosis; Patient dropouts; Patient care planning; Treatment outcome.

A case of exuberant endobronchial tuberculosis is presented in a 29-year-old male patient, HIV negative, under endoscopic aspects before and after the institution of a specific therapy. Considering the high tuberculosis infection/disease prevalence in our environment and the potential sequelae of this kind of tuberculosis, the authors emphasize the importance of the respiratory endoscopic examination for the diagnosis, treatment, and follow-up of endobronchial lesions.

Keywords: Bacilo álcool-acidorresistente

Tuberculosis is a disease of high incidence and prevalence in Brazil. Imaging methods can reveal signs suggestive of tuberculosis activity or sequelae. Chest radiographs can reveal active lung tuberculosis through consolidations, cavitations, interstitial patterns (nodular and reticulo-nodular), mediastinal or hilar lymphadenopathy and pleural effusions. Images compatible with the active disease, such as centrilobular nodules segmentarily distributed, thick-walled cavities, thickened bronchial or bronchiolar walls, bronchiectasis and lymphadenopathy can be observed by computerized tomography. Thin-walled cavities, traction bronchiectasis, parenchymal bands, emphysema and mosaic pattern are signs suggestive of inactive disease. Gallium-67 citrate scyntigraphy is a complementary method useful in the detection of infectious diseases, including tuberculosis, especially in immunocompromised patients. Inhalation / perfusion analyses are used in the pre-operative assessment of patients carrying tuberculosis sequelaes and multiresistant tuberculosis. Positron emission tomography with fluorine-18 labeled deoxyglucose allows the detection of the inflammatory process that takes place during the active stage of tuberculosis and may persist, not so intense, after specific treatment is over. Imaging methods are valuable tools to be used in the diagnosis and follow up of pulmonary tuberculosis.

Keywords: Tuberculosis. Radiography. Computed tomography. Scintigraphy. Emission-computed tomography.

Tumors of the anterior mediastinum include several entities with different radiological and clinical manifestations, constituting a heterogeneous group of congenital, inflammatory, and neoplastic conditions. Among these lesions, the most common primary tumor of the mediastinum is thymoma, nearly followed by germ cell tumors and lymphomas. Tuberculosis of the thymus, an extremely rare condition, typically involves the mediastinal lymph nodes. We present, in this study, pathological, radiological, and clinical findings of one case of tuberculosis of the thymus in an 18-year-old patient who presented thoracic pain, dyspnea upon minimal effort, and progressive worsening of the symptoms in one week. The chest X-ray showed a large mass in the mediastinum, and computed tomography scans indicated that it was located anteriorly. The patient was submitted to surgery in order to excise the mass. Microscopy revealed a massive inflammatory response and granulomas in the thymic tissue. Ziehl-Neelsen staining for acid-fast bacilli yielded positive results, and a diagnosis of tuberculosis was made. Surgeons and pathologists should remain alert for this condition and should include it in the differential diagnosis of mediastinal masses.

Keywords: Thymus; Tuberculosis; Thoracic surgery; Pathology.

Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.

Keywords: Tuberculosis; Respiratory insufficiency; Respiration, artificial; Hospitalization.

Objective: To evaluate cases of chronic pulmonary histoplasmosis diagnosed in recent years at the Complexo Hospitalar Santa Casa in Porto Alegre, in the state of Rio Grande do Sul, Brazil. Methods: Cases diagnosed at the Santa Casa Hospital Complex within the last 25 years were reviewed. Four cases in which the diagnosis was made through histopathological analysis or culture and confirmed by with serologic testing are described. Cases from the Brazilian literature are also discussed. Results: The principal clinical manifestations were cough, dyspnea, fever, anorexia and weight loss. Among the radiological findings were emphysema, cystic cavities, bronchiectasis and pleural thickening. All patients had an epidemiological history of contact with chicken feces. One of the patients presented Aspergillus fumigatus colonization of cavities. Conclusion: Chronic pulmonary histoplasmosis must be considered in patients with chronic obstructive pulmonary disease presenting cavitary lesions of the lung, sputum smear microscopy negative for acid-fast bacilli and negative tuberculin skin test. Hemoptysis occurring in the presence of cured or fading pulmonary lesions is suggestive of Aspergillus colonization.

Keywords: Histoplasmosis/diagnosis; Histoplasmosis/drug therapy; Histoplasma/isolation & purification; Tuberculosis, pulmonary/diagnosis; Itraconazole/drug therapy; Sputum/microbiology; Diagnosis, Differential

Objective: To analyze tuberculosis treatment outcomes and their predictors. Methods: This was a retrospective longitudinal cohort study involving tuberculosis patients treated between 2004 and 2006 at the Instituto de Pesquisa Evandro Chagas, in the city of Rio de Janeiro. We estimated adjusted risk ratios (ARRs) for the predictors of treatment outcomes. Results: Among 311 patients evaluated, the rates of cure, treatment abandonment, treatment failure, and mortality were 72%, 19%, 2%, and 6%, respectively. Changes in the treatment regimen due to adverse events occurred in 8%. The factors found to reduce the probability of cure were alcoholism (ARR, 0.30), use of the streptomycin+ethambutol+ofloxacin (SEO) regimen (ARR, 0.32), HIV infection without the use of antiretroviral therapy (ART; ARR, 0.36), and use of the rifampin+isoniazid+pyrazinamide+ethambutol regimen (ARR, 0.58). Being younger and being alcoholic both increased the probability of abandonment (ARR, 3.84 and 1.76, respectively). It was impossible to determine the ARR for the remaining outcomes due to their low prevalence. However, using the relative risk (RR), we identified the following potential predictors of mortality: use of the SEO regimen (RR, 11.43); HIV infection without ART (RR, 9.64); disseminated tuberculosis (RR, 9.09); lack of bacteriological confirmation (RR, 4.00); diabetes mellitus (RR, 3.94); and homosexual/bisexual behavior (RR, 2.97). Low income was a potential predictor of treatment failure (RR, 11.70), whereas disseminated tuberculosis and HIV infection with ART were potential predictors of changes in the regimen due to adverse events (RR, 3.57 and 2.46, respectively). Conclusions: The SEO regimen should not be used for extended periods. The data confirm the importance of ART and suggest the need to use it early.

Keywords: Tuberculosis; HIV; Rifampin; Drug toxicity; Risk factors; Medication adherence.

Objective: To identify risk factors for recurrence of tuberculosis. Methods: We studied a cohort of 610 patients with active pulmonary tuberculosis who were enrolled for treatment between 1989 and 1994 and cured using a three-drug treatment regimen of rifampin, isoniazid and pyrazinamide (RHZ). The risk factors studied were age, gender, race, duration of symptoms, lesion cavitation, extent of disease, diabetes mellitus, alcoholism, HIV infection, delayed negative sputum conversion, treatment compliance, and medication doses. In order to detect recurrence, the patients were monitored through the Rio Grande do Sul State Healt Department Information System for 7.7 ± 2.0 years after cure. Data were analyzed using the Student's t-test, the chi-square test or Fisher's exact test, and Cox regression models. Results: There were 26 cases of recurrence (4.3%), which corresponds to 0.55/100 patients-year. The recurrence rate was 5.95 and 0.48/100 patients-year in HIV-positive and HIV-negative patients, respectively (p < 0.0001). In the multivariate analysis, HIV infection [RR = 8.04 (95% CI: 2.35-27.50); p = 0.001] and noncompliance [RR = 6.43 (95% CI: 2.02-20.44); p = 0.002] proved to be independently associated with recurrence of tuberculosis. Conclusions: Recurrence of tuberculosis was more common in HIV-positive patients and in patients who did not comply with the self-administered treatment (RHZ regimen). Patients presenting at least one of these risk factors can benefit from the implementation of a post-treatment surveillance system for early detection of recurrence. An alternative to prevent noncompliance with tuberculosis treatment would be the use of supervised treatment.

Keywords: Tuberculosis; Recurrence; Risk factors.

We report the case of a 50-year-old male with a rare combination: pulmonary tuberculosis and cutaneous leukocytoclastic vasculitis. The patient sought emergency treatment presenting with headache, arthralgia, cutaneous rash, and weight loss (4 kg) in the last 20 days. A chest X-ray, performed in a previous outpatient visit, revealed cavitation in the middle and upper lobes of the right lung, as confirmed by computed tomography. Sputum smear microscopy (Ziehl-Neelsen staining) was positive in three consecutive samples, and the result of the skin lesion biopsy was consistent with cutaneous leukocytoclastic vasculitis. The patient was therefore diagnosed with cutaneous leukocytoclastic vasculitis accompanied by pulmonary tuberculosis. Our objective was to describe a combination rarely reported in the medical literature and to discuss the possible pathogenic mechanisms of this combination.

Keywords: Vasculitis, hypersensitivity; Tuberculosis; Hypersensitivity.

Two quite dyspneic HIV positive patients were admitted to the Emergency Room; they presented with aspects and images suggesting pericardial effusion. The analysis of an initial liquid puncture did not show any specificity and the patients did not register any clinical improvement. Both patients were submitted to a subxiphoid pericardial window, all the effusion liquid was drained, and a biopsy of the pericardium tissue was completed revealing a granulomatous process. Good evolution was the result of specific treatment. Such findings draw attention to a high possibility of pericardial suffusion in AIDS patients being tuberculosis, in particular if one considers the high prevalence of this disease in Brazil. The results also showed that the opening of a subxiphoid pericardial window and the specific triple scheme is a procedure that leads to good therapeutic evolution in this kind of patients.

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration ≥ 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.

Keywords: Silicosis; Tuberculosis; Diagnostic techniques and procedures; Chemoprevention.