A 61-year-old man presents to the emergency department (ED) complaining of pain in his right eye that has persisted for 5 days, with associated redness and swelling.

The patient had been examined at another ED a few days before this presentation and was diagnosed with herpes zoster, for which he was given a prescription for acyclovir and hydrocodone and discharged home.

Since he started taking acyclovir, the patient has noticed that the pain and swelling in his eye has increased. He also reports binocular diplopia and decreased visual acuity. On the day of presentation, he is nauseous and vomiting, and he cannot open the affected eye.

On physical examination, the patient has normal and stable vital signs. Visual acuity in the unaffected left eye is normal at 20/25. In the right eye, he can only perceive bright light. In addition, the affected eye demonstrates ptosis of the upper eyelid, generalized proptosis, and mild periorbital erythema with associated edema (see Figure 1). Extraocular movements of the affected eye are as shown (see video clip). The right pupil is 8 mm in diameter and nonreactive to direct and indirect light. Intraocular pressure in both eyes, as measured by a handheld tonometer (Tono-Pen), is normal at 12 mm Hg.

Discussion

Diagnosis: Cerebro-rhino-orbital phycomycosis (CROP)/mucormycosis

Figure 2. (Click to enlarge)

CROP is an aggressive, invasive infection that is caused by broad, nonseptate fungi with irregularly shaped hyphae from the class Phycomycetes. The genera that typically cause infection are Rhizopus, Rhizomucor, Absidia, and Basidiobolus. The spores of these fungi are ubiquitous and gain entrance to the human body through the mouth and the nose. Individuals who are immunocompetent will phagocytize these spores; therefore, they do not develop the disease.

Infection is most common in immunosuppressed persons, specifically in patients with poorly controlled diabetes mellitus (often in the setting of metabolic acidosis), and in patients receiving the iron-chelating drug deferoxamine.^[1] Unlike immunocompetent individuals, whose bodies phagocytize the spores, immunocompromised patients have massive spore proliferation. Mucormycosis is described almost exclusively in patients with compromised immune systems or metabolic abnormalities. The spores attach to the nasal or oral mucosa, where massive germination and hyphae formation occur, allowing the fungus to directly invade the blood vessels. Areas of ischemic infarction and necrosis are seen in the infected tissue. The fungi invade the blood vessel lumina and cause thrombosis through inflammatory occlusion. Infection usually begins in the nasal cavity and the maxillary sinuses, followed by direct invasion of contiguous structures, such as the palate, the orbits, the ethmoid sinuses, and the brain. Orbital involvement occurs when the ethmoid sinuses are affected. Intracranial spread can occur through the ophthalmic artery, superior fissure, or cribriform plate.

Rhinocerebral infections are usually fulminant and have high morbidity and mortality rates, despite improved diagnostic and therapeutic interventions. Mortality rates of 30-70% are quoted in the literature, with higher mortality rates seen in older series. The mortality rate in diabetic patients appears to be lower than it is in nondiabetic patients and in patients with intracerebral involvement. Death may occur within 2 weeks if CROP is left untreated or is unsuccessfully treated. Additionally, until the 1950s, this disease was almost always fatal. Even with recovery, permanent residual effects, such as blindness and cranial nerve defects, occur in up to 70% of cases.

The clinical manifestations of CROP may include orbital and facial pain, fever, periorbital and orbital cellulitis, proptosis, purulent nasal discharge, and mucosal necrosis that appears as black eschars in the nasopharynx, the oropharynx, and the tissues surrounding the orbits and sinuses. These clinical features are not universally seen; therefore, a high index of suspicion is required. Ocular involvement leads to afferent papillary defects and loss of visual acuity. Progressive extension of necrosis into the brain can lead to cavernous sinus thrombosis and abscess formation. The patient may demonstrate an altered mental status, convulsions, aphasia, or hemiplegia.

Patients with diabetic ketoacidosis are most often affected, but opportunistic infections may also develop in association with renal deferoxamine therapy (eg, in patients with chronic renal disease) or with immunosuppression (particularly in patients with neutropenia or those receiving high-dose corticosteroid therapy).^[1,3]

The diagnostic study of choice is computed tomography (CT) scanning of the orbits and sinuses. In affected patients, CT scans demonstrate soft-tissue swelling, sinus mucosal thickening, and bone erosion. Intracranial and cavernous sinus involvement may also be present. Magnetic resonance imaging (MRI), if available, can show extension of the infection into the surrounding blood vessels, orbital fat, and intracranial areas. Urgent biopsy is usually indicated. Necrotic and edematous tissue with neutrophilic infiltrate is frequently seen with fungal elements (which are broad, nonseptate hyphae with branching at 90°).^[3,4]

The cornerstone of medical treatment for CROP is the administration of systemic amphotericin B at the highest patient-tolerable dose. Local packing of the involved mucosal membranes with an amphotericin B solution is effective for minimizing local disfigurement. When on the medication, the patient should be assessed for nephrotoxicity, as well as other systemic symptoms of toxicity, including fever, nausea and vomiting, phlebitis, anemia, and electrolyte abnormalities. Liposomal amphotericin B may be more efficacious; it is less toxic, thus allowing higher doses of the medication to be given. Additionally, local irrigation and packing of the areas to aid delivery of amphotericin to necrotic and poorly perfused tissues is recommended, because poor vascular supply may prevent systemic therapy from reaching the fungus and because local irrigation of infected tissue has been reported to be an important adjunct to treatment that may even help prevent disfiguring surgery. Treatment of the underlying disease (eg, hypoxia, acidosis, hyperglycemia, electrolyte abnormalities) and discontinuation of any immunosuppressants are also important. The physician should evaluate any steroid medication, antimetabolites, or immunosuppressants that the patient is taking, and such agents should be discontinued if appropriate. It is encouraged that the advice of an infectious disease specialist be obtained.

Aggressive, emergency surgical debridement of all necrotic tissue is necessary; sometimes, multiple procedures are needed to clear all necrotic tissue. The vaso-occlusive effect of mucormycosis leads to infrequent bleeding of the involved tissue; therefore, debridement of affected tissue until normal, well-perfused, bleeding tissue is encountered is ideal. Intraorbital irrigation of amphotericin B may be considered as an adjunct treatment. Surgery may often be disfiguring. Orbital exenteration, as well as removal of the sinuses, may be necessary. Some authors have suggested hyperbaric oxygen as an adjunctive treatment. Reconstructive surgery after complete resolution of infection should be considered.

Indeed, a multidisciplinary approach is best for the treatment of this condition. An ophthalmologist is required to evaluate for ophthalmoplegia and optic neuropathy. An oculoplastic surgeon can provide an orbital evaluation, as well as perform debridement and reconstruction. An otolaryngologist is required for biopsy or debridement of the nasal and sinus cavities. An infectious disease specialist can provide guidance for appropriate medical treatment with antifungal agents. Internal medicine specialists and endocrinologists are useful for the medical management of underlying systemic etiologies. Neurosurgery may be necessary if intracranial involvement is present. Finally, a pharmacotherapy specialist can assist with dosing of amphotericin B.

The complications of CROP include intracranial invasion, cavernous sinus thrombosis, blindness, occlusion of the central retinal artery, and airway obstruction caused by infections of the head and neck (with spread to the carotid sheath or the mediastinum through the fascial planes). The prognosis of CROP is guarded, with reported mortality rates of 30-70% (as stated earlier).^[4]

In this patient, treatment with amphotericin B was promptly initiated. CT scans of the orbits and sinuses demonstrated an air-fluid level in the right maxillary sinus, mucosal thickening of the right anterior ethmoid sinus, and preseptal cellulitis (see Figure 2A). An MRI of the head showed enhancement of the intraconal fat and rectus muscles of the right eye (see Figure 2B). The patient received emergency sinus debridement, and a biopsy was performed. Pathology demonstrated fungal angiitis and orbital inflammation that was consistent with mucormycosis. The patient underwent 3 additional operations, including exenteration of the right eye, and received hyperbaric oxygen treatments. After hospitalization for 3 weeks, he was discharged to home in good condition.

REFERENCES

1. Systemic fungal diseases. In: Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. New York, NY: John Wiley & Sons; 1999.
2. Earhart KC, Baugh WP. Rhinocerebral mucormycosis. eMedicine journal [serial online]. Last Updated: June 26, 2006. Available at: www.emedicine.com/med/topic2026.htm. Date accessed: April 15, 2005.
3. Nithyanandam S, Jacob MS, Battu RR, Thomas RK, Correa MA, D’Souza O. Rhino-orbito-cerebral mucormycosis. A retrospective analysis of clinical features and treatment outcomes. Indian J Ophthalmol. 2003;51:231-6. Abstract
4. Yen KG, Yen MT. Mucormycosis. eMedicine journal [serial online]. Last updated: August 22, 2006. Available at: www.emedicine.com/oph/topic225.htm. Date accessed: December 20, 2004.

In 2007, a total of 13,293 tuberculosis (TB) cases were reported in the United States; the TB rate declined 4.2% from 2006 to 4.4 cases per 100,000 population. This report summarizes provisional 2007 data from the National TB Surveillance System and describes trends since 1993. The TB incidence rate in 2007 was the lowest recorded since national reporting began in 1953. Despite this overall improvement, progress has slowed in recent years; the average annual percentage decline in the TB rate slowed from 7.3% per year during 1993–2000 to 3.8% during 2000–2007.* Foreign-born persons and racial/ethnic minorities continued to bear a disproportionate burden of TB disease in the United States. In 2007, the TB rate in foreign-born persons in the United States was 9.7 times higher than in U.S.-born persons.^† TB rates among Hispanics,^§ blacks, and Asians were 7.4, 8.3, and 22.9 times higher than among non-Hispanic whites, respectively. In 2007, foreign-born persons accounted for a majority of TB cases among Hispanics (77.2% [2,942 of 3,812]) and among Asians (96.1% [3,261 of 3,393]), whereas U.S.-born persons accounted for a majority of TB cases among blacks (71.2% [2,439 of 3,427]). Among U.S.-born racial and ethnic groups, the greatest disparity in TB rates was for U.S.-born blacks, whose rate remained nearly eight times that of U.S.-born whites.^¶ The slowing decline in TB incidence and persistent disparities between U.S.-born and foreign-born persons and between whites and minorities threaten progress toward TB elimination in the United States. The strategic plan for the elimination of TB issued in 1989 by CDC and the Advisory Committee for the Elimination of Tuberculosis set a goal of TB elimination (i.e., less than one case per 1 million population) by 2010 and an interim target case rate of 3.5 per 100,000 population by 2000 (1).

Health departments in the 50 states and the District of Columbia (DC) electronically report to CDC verified TB cases that meet the CDC/Council of State and Territorial Epidemiologists case definition.** Reports include the patient’s race, ethnicity (i.e., Hispanic or non-Hispanic), treatment information, and, whenever available, drug-susceptibility test results. CDC calculates national and state TB rates overall, by country of origin, and by racial/ethnic group by using current U.S. census population estimates (2–4).

In 2007, TB rates in reporting areas ranged from 0.4 (Wyoming) to 10.2 (DC) cases per 100,000 population (median: 3.5 cases). Twenty-nine states and DC had lower rates in 2007 than 2006; 21 states had higher rates. In 2007, for the third consecutive year and the third time since national reporting began, more than half of states (52.0% [26 of 50]) had TB rates less than or equal to the 2000 interim target case rate of 3.5 per 100,000 population; however, 12 (46.2%) of those 26 had higher rates of TB in 2007 than in 2006. Five states (California, Florida, Illinois, New York, and Texas) reported more than 500 cases each for 2007; combined, these five states accounted for more than half (52.0% [6,912]) of all TB cases.

Among U.S.-born persons, the number and rate of TB cases continued to decline in 2007. The number of TB cases in U.S.-born persons (5,464 [or 41.5% of all cases in persons with known origin]) declined 7.4% compared with 2006 and 68.6% compared with 1993. In 2007, the TB rate among U.S.-born persons was 2.1 per 100,000 population, representing a 7.8% decline since 2006 and a 71.4% decline since 1993.^††

Among foreign-born persons in the United States, both the number and rate of TB cases declined in 2007. A total of 7,690 TB cases were reported among foreign-born persons (58.5% of all cases in persons with known origin), a 1.6% decrease from the 7,814 cases reported in 2006. The TB rate among foreign-born persons in 2007 was 20.6 per 100,000 population, which was a 6.5% decline since 2006 and a 39.5% decline since 1993. In 2007, more than half (51.8%) of foreign-born TB cases were reported in persons from four countries: Mexico (1,846), the Philippines (952), India (619), and Vietnam (568).

For the fourth consecutive year, more TB cases were reported among Hispanics than any other racial/ethnic group in 2007. From 2006 to 2007, TB rates declined for all racial/ethnic minorities except for Asians (+0.8%) and Native Hawaiian or other Pacific Islanders (+42.9%)^§§.

In 2007, among persons with TB with a known human immunodeficiency virus (HIV) test result, 11.3% (869 of 7,708) were coinfected with HIV. California data were not included in this calculation.

A total of 116 cases of multidrug-resistant TB (MDR TB) were reported in 2006, the most recent year for which complete drug-susceptibility data are available. The proportion of MDR TB cases was 1.1% in 2006 (116 of 10,306), compared with 1.2% in 2005 (124 of 10,633). The proportion of MDR TB cases among persons without a previous history of TB has remained stable at approximately 1.0% since 1997, but has been approximately four to five times higher for persons with a previous history of TB. In 2006, MDR TB continued to disproportionately impact foreign-born persons, who accounted for 84.5% of MDR TB cases. Foreign-born persons had higher percentages of MDR TB, both among persons with (7.0%) and without (1.4%) a previous history of TB. Since drug-susceptibility reporting began in 1993, cases of extensively drug-resistant TB (XDR TB)^§§§ have been reported every year in the United States except 2003. Two XDR TB cases were reported in 2005 and four in 2006. As of February 13, 2008, two XDR TB cases had been reported for 2007.

The recommended length of drug therapy for most types of TB is 6–9 months. In 2004, the latest year for which end-of-treatment data are complete, 82.1% of patients for whom <1 year of treatment was indicated completed therapy within 1 year, which is below the Healthy People 2010 target of 90% (objective 14-12).

Editorial Note:

After the resurgence of TB in the United States during 1985–1992, the annual TB rate decreased steadily. However, that decrease has now slowed. Furthermore, the proportion of TB cases contributed by foreign-born persons has increased each year since 1993. To achieve the goal of TB elimination in the United States (1), intensified efforts are required to strengthen domestic TB control and to address the global TB pandemic.

CDC is pursuing several strategies to address the higher rate of TB among foreign-born persons in the United States and the increasing proportion of cases they represent. In 2007, CDC published revised requirements for overseas medical screening of applicants for U.S. immigration (6,7). These revised technical instructions include 1) expanding TB screening by adding targeted tuberculin skin testing of children aged 2–14 years who live in countries with high TB incidence (i.e., WHO-estimated rates of >20 cases per 100,000 population) and all contacts of persons known to have TB, and 2) adding cultures and drug-susceptibility testing for persons with suspected TB.^¶¶¶ Implementation of these new guidelines began in 2007 in Mexico, Nepal, the Philippines, and Thailand, and is scheduled to start in 2008 in Kenya, Tanzania, Turkey, Vietnam, and several countries in Southern Africa. Also, CDC continues to work with international partners, including the Stop TB Partnership,**** to strengthen TB control in countries with high TB incidence.

To address the disproportionately high rate of TB among U.S.-born blacks, CDC is working with its state and local partners to focus attention on the problem of TB in the black community.^†††† To better understand how to reduce these disparities, CDC’s TB Epidemiologic Studies Consortium is conducting the National Study of Determinants of Early Diagnosis, Prevention, and Treatment of TB in the African-American Community.

HIV is the most important known risk factor for progression from latent TB infection (LTBI) to TB disease. CDC recommends routine screening for HIV for all persons with TB or LTBI at the initiation of TB or LTBI treatment.^§§§§ CDC continues to work with domestic and international partners to increase awareness of TB/HIV coinfection and improve the integration of TB/HIV health-care services (8).

In February 2008, the World Health Organization released its fourth global report on anti-TB drug resistance, which indicated that the number of MDR TB cases worldwide was the highest ever reported (489,139 cases in 2006) and that XDR TB had been reported in 45 countries (4). A critical need exists for new drugs and new drug regimens to address this growing challenge. The Global Alliance for TB Drug Development, of which CDC is a member, continued to make progress in this area in 2007, with new candidate drugs moving forward in clinical trials (9,10).

The findings in this report are subject to at least two limitations. First, the analysis was based on provisional data that are subject to change. This applies to TB case counts and HIV data, both of which are incomplete at this point in the reporting cycle. Second, population denominator data are drawn from multiple U.S. Census sources and also are subject to periodic adjustment in the estimates. CDC’s annual TB surveillance summary, scheduled to be published in fall 2008, will provide updated data.

Despite targeted measures to control TB, the slowing decline of TB in the United States indicates a need for improved case management and contact investigation, intensified outreach and testing of populations at high risk, better treatments and diagnostic tools, improved understanding of TB transmission, and continued collaboration with other nations to reduce TB globally. These measures are required to reach the goal of TB elimination in the United States.

References

1. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(No. S-3).
2. US Census Bureau. Annual estimates of the population for the United States, regions, states, and Puerto Rico: April 1, 2000 to July 1, 2007. Washington, DC: US Census Bureau; 2008. Available at http://www.census.gov/popest/states/NST-ann-est.html.
3. US Census Bureau. National population estimates for the 2000s: monthly postcensal resident population, by single year of age, sex, race, and Hispanic origin. Washington, DC: US Census Bureau; 2008. Available at http://www.census.gov/popest/national/asrh/2006_nat_res.html.
4. US Census Bureau. Current population survey. Annual estimates of the United States foreign-born and native resident populations. Washington, DC: US Census Bureau; 2008. Available at http://dataferrett.census.gov.
5. World Health Organization. Anti-tuberculosis drug resistance in the world. Fourth global report. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/tb/publications/2008/drs_report4_26feb08.pdf.
6. CDC. CDC immigration requirements: technical instructions for tuberculosis screening and treatment. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/ncidod/dq/panel_2007.htm.
7. CDC. Revised technical instructions for tuberculosis screening and treatment for panel physicians. MMWR 2008;57:292–3.
8. CDC. Provider-initiated HIV testing and counseling of TB patients—Livingstone District, Zambia, September 2004–December 2006. MMWR 2008;57:285–9.
9. Andries K, Verhasselt P, Guillemont J, et al. A diarylquinoline drug active on the ATP synthatase of Mycobacterium tuberculosis. Science 2005;307:223–7.
10. Matsumoto M, Hashizume H, Tomishige T, et al. OPC-67683, a nitro-dihydro-imidazooxaxole derivative with promising action against tuberculosis in vitro and in mice. PLoS Med 2006;3:e466.
    

    Trends in Tuberculosis — United States, 2007

     

    In 2007, a total of 13,293 tuberculosis (TB) cases were reported in the United States; the TB rate declined 4.2% from 2006 to 4.4 cases per 100,000 population. This report summarizes provisional 2007 data from the National TB Surveillance System and describes trends since 1993. The TB incidence rate in 2007 was the lowest recorded since national reporting began in 1953. Despite this overall improvement, progress has slowed in recent years; the average annual percentage decline in the TB rate slowed from 7.3% per year during 1993–2000 to 3.8% during 2000–2007.* Foreign-born persons and racial/ethnic minorities continued to bear a disproportionate burden of TB disease in the United States. In 2007, the TB rate in foreign-born persons in the United States was 9.7 times higher than in U.S.-born persons.^† TB rates among Hispanics,^§ blacks, and Asians were 7.4, 8.3, and 22.9 times higher than among non-Hispanic whites, respectively. In 2007, foreign-born persons accounted for a majority of TB cases among Hispanics (77.2% [2,942 of 3,812]) and among Asians (96.1% [3,261 of 3,393]), whereas U.S.-born persons accounted for a majority of TB cases among blacks (71.2% [2,439 of 3,427]). Among U.S.-born racial and ethnic groups, the greatest disparity in TB rates was for U.S.-born blacks, whose rate remained nearly eight times that of U.S.-born whites.^¶ The slowing decline in TB incidence and persistent disparities between U.S.-born and foreign-born persons and between whites and minorities threaten progress toward TB elimination in the United States. The strategic plan for the elimination of TB issued in 1989 by CDC and the Advisory Committee for the Elimination of Tuberculosis set a goal of TB elimination (i.e., less than one case per 1 million population) by 2010 and an interim target case rate of 3.5 per 100,000 population by 2000 (1).

    Health departments in the 50 states and the District of Columbia (DC) electronically report to CDC verified TB cases that meet the CDC/Council of State and Territorial Epidemiologists case definition.** Reports include the patient’s race, ethnicity (i.e., Hispanic or non-Hispanic), treatment information, and, whenever available, drug-susceptibility test results. CDC calculates national and state TB rates overall, by country of origin, and by racial/ethnic group by using current U.S. census population estimates (2–4).

    In 2007, TB rates in reporting areas ranged from 0.4 (Wyoming) to 10.2 (DC) cases per 100,000 population (median: 3.5 cases). Twenty-nine states and DC had lower rates in 2007 than 2006; 21 states had higher rates. In 2007, for the third consecutive year and the third time since national reporting began, more than half of states (52.0% [26 of 50]) had TB rates less than or equal to the 2000 interim target case rate of 3.5 per 100,000 population (Figure 1); however, 12 (46.2%) of those 26 had higher rates of TB in 2007 than in 2006. Five states (California, Florida, Illinois, New York, and Texas) reported more than 500 cases each for 2007; combined, these five states accounted for more than half (52.0% [6,912]) of all TB cases.

    Among U.S.-born persons, the number and rate of TB cases continued to decline in 2007. The number of TB cases in U.S.-born persons (5,464 [or 41.5% of all cases in persons with known origin]) declined 7.4% compared with 2006 and 68.6% compared with 1993 (Figure 2). In 2007, the TB rate among U.S.-born persons was 2.1 per 100,000 population, representing a 7.8% decline since 2006 and a 71.4% decline since 1993.^††

    Among foreign-born persons in the United States, both the number and rate of TB cases declined in 2007. A total of 7,690 TB cases were reported among foreign-born persons (58.5% of all cases in persons with known origin), a 1.6% decrease from the 7,814 cases reported in 2006. The TB rate among foreign-born persons in 2007 was 20.6 per 100,000 population, which was a 6.5% decline since 2006 and a 39.5% decline since 1993. In 2007, more than half (51.8%) of foreign-born TB cases were reported in persons from four countries: Mexico (1,846), the Philippines (952), India (619), and Vietnam (568).

    For the fourth consecutive year, more TB cases were reported among Hispanics than any other racial/ethnic group in 2007. From 2006 to 2007, TB rates declined for all racial/ethnic minorities except for Asians (+0.8%) and Native Hawaiian or other Pacific Islanders (+42.9%)^§§ (Table).

    In 2007, among persons with TB with a known human immunodeficiency virus (HIV) test result, 11.3% (869 of 7,708) were coinfected with HIV. California data were not included in this calculation.^¶¶

    A total of 116 cases of multidrug-resistant TB (MDR TB)*** were reported in 2006, the most recent year for which complete drug-susceptibility^††† data are available. The proportion of MDR TB cases was 1.1% in 2006 (116 of 10,306), compared with 1.2% in 2005 (124 of 10,633). The proportion of MDR TB cases among persons without a previous history of TB has remained stable at approximately 1.0% since 1997, but has been approximately four to five times higher for persons with a previous history of TB. In 2006, MDR TB continued to disproportionately impact foreign-born persons, who accounted for 84.5% of MDR TB cases. Foreign-born persons had higher percentages of MDR TB, both among persons with (7.0%) and without (1.4%) a previous history of TB. Since drug-susceptibility reporting began in 1993, cases of extensively drug-resistant TB (XDR TB)^§§§ have been reported every year in the United States except 2003. Two XDR TB cases were reported in 2005 and four in 2006. As of February 13, 2008, two XDR TB cases had been reported for 2007.

    The recommended length of drug therapy for most types of TB is 6–9 months. In 2004, the latest year for which end-of-treatment data are complete, 82.1% of patients for whom <1 year of treatment was indicated completed therapy within 1 year, which is below the Healthy People 2010 target of 90% (objective 14-12).

    Reported by: R Pratt, V Robison, T Navin, Div of TB Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; H Menzies, EIS Officer, CDC.

    Editorial Note:

     

    After the resurgence of TB in the United States during 1985–1992, the annual TB rate decreased steadily. However, that decrease has now slowed. Furthermore, the proportion of TB cases contributed by foreign-born persons has increased each year since 1993. To achieve the goal of TB elimination in the United States (1), intensified efforts are required to strengthen domestic TB control and to address the global TB pandemic.

    CDC is pursuing several strategies to address the higher rate of TB among foreign-born persons in the United States and the increasing proportion of cases they represent. In 2007, CDC published revised requirements for overseas medical screening of applicants for U.S. immigration (6,7). These revised technical instructions include 1) expanding TB screening by adding targeted tuberculin skin testing of children aged 2–14 years who live in countries with high TB incidence (i.e., WHO-estimated rates of >20 cases per 100,000 population) and all contacts of persons known to have TB, and 2) adding cultures and drug-susceptibility testing for persons with suspected TB.^¶¶¶ Implementation of these new guidelines began in 2007 in Mexico, Nepal, the Philippines, and Thailand, and is scheduled to start in 2008 in Kenya, Tanzania, Turkey, Vietnam, and several countries in Southern Africa. Also, CDC continues to work with international partners, including the Stop TB Partnership,**** to strengthen TB control in countries with high TB incidence.

    To address the disproportionately high rate of TB among U.S.-born blacks, CDC is working with its state and local partners to focus attention on the problem of TB in the black community.^†††† To better understand how to reduce these disparities, CDC’s TB Epidemiologic Studies Consortium is conducting the National Study of Determinants of Early Diagnosis, Prevention, and Treatment of TB in the African-American Community.

    HIV is the most important known risk factor for progression from latent TB infection (LTBI) to TB disease. CDC recommends routine screening for HIV for all persons with TB or LTBI at the initiation of TB or LTBI treatment.^§§§§ CDC continues to work with domestic and international partners to increase awareness of TB/HIV coinfection and improve the integration of TB/HIV health-care services (8).

    In February 2008, the World Health Organization released its fourth global report on anti-TB drug resistance, which indicated that the number of MDR TB cases worldwide was the highest ever reported (489,139 cases in 2006) and that XDR TB had been reported in 45 countries (4). A critical need exists for new drugs and new drug regimens to address this growing challenge. The Global Alliance for TB Drug Development, of which CDC is a member, continued to make progress in this area in 2007, with new candidate drugs moving forward in clinical trials (9,10).

    The findings in this report are subject to at least two limitations. First, the analysis was based on provisional data that are subject to change. This applies to TB case counts and HIV data, both of which are incomplete at this point in the reporting cycle. Second, population denominator data are drawn from multiple U.S. Census sources and also are subject to periodic adjustment in the estimates. CDC’s annual TB surveillance summary, scheduled to be published in fall 2008, will provide updated data.

    Despite targeted measures to control TB, the slowing decline of TB in the United States indicates a need for improved case management and contact investigation, intensified outreach and testing of populations at high risk, better treatments and diagnostic tools, improved understanding of TB transmission, and continued collaboration with other nations to reduce TB globally. These measures are required to reach the goal of TB elimination in the United States.

    Acknowledgments

    The findings in this report are based, in part, on data contributed by state and local TB-control officials.

    References

     

    1. CDC. A strategic plan for the elimination of tuberculosis in the United States. MMWR 1989;38(No. S-3).
    2. US Census Bureau. Annual estimates of the population for the United States, regions, states, and Puerto Rico: April 1, 2000 to July 1, 2007. Washington, DC: US Census Bureau; 2008. Available at http://www.census.gov/popest/states/NST-ann-est.html.
    3. US Census Bureau. National population estimates for the 2000s: monthly postcensal resident population, by single year of age, sex, race, and Hispanic origin. Washington, DC: US Census Bureau; 2008. Available at http://www.census.gov/popest/national/asrh/2006_nat_res.html.
    4. US Census Bureau. Current population survey. Annual estimates of the United States foreign-born and native resident populations. Washington, DC: US Census Bureau; 2008. Available at http://dataferrett.census.gov.
    5. World Health Organization. Anti-tuberculosis drug resistance in the world. Fourth global report. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/tb/publications/2008/drs_report4_26feb08.pdf.
    6. CDC. CDC immigration requirements: technical instructions for tuberculosis screening and treatment. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/ncidod/dq/panel_2007.htm.
    7. CDC. Revised technical instructions for tuberculosis screening and treatment for panel physicians. MMWR 2008;57:292–3.
    8. CDC. Provider-initiated HIV testing and counseling of TB patients—Livingstone District, Zambia, September 2004–December 2006. MMWR 2008;57:285–9.
    9. Andries K, Verhasselt P, Guillemont J, et al. A diarylquinoline drug active on the ATP synthatase of Mycobacterium tuberculosis. Science 2005;307:223–7.
    10. Matsumoto M, Hashizume H, Tomishige T, et al. OPC-67683, a nitro-dihydro-imidazooxaxole derivative with promising action against tuberculosis in vitro and in mice. PLoS Med 2006;

Intro:  March 24 is World TB Day.  Cough on a stranger.

MMWR, March 21, 2008 / 57(11);281:  World TB Day is observed each year on March 24 to commemorate the date in 1882 when Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). Worldwide, TB remains one of the leading causes of death from infectious disease. An estimated 2 billion persons (i.e., one third of the world’s population) are infected with M. tuberculosis. In 2005, approximately 8.8 million persons became ill from TB, and 1.6 million died from the disease. World TB Day provides an opportunity for TB programs, nongovernmental organizations, and other partners to describe problems and solutions related to the TB pandemic and to support worldwide TB-control efforts. The U.S. theme for this year’s observance is Partnerships for TB Elimination.

After approximately 30 years of decline, the number of TB cases reported in the United States increased 20% during 1985–1992. This led to a renewed emphasis on TB control and prevention during the 1990s and actions that reversed the increase in cases. Although the 2007 TB rate (4.4 cases per 100,000 population) was the lowest recorded in the United States since national reporting began in 1953, the average annual decline has slowed since 2000. In addition, multidrug-resistant TB remains a threat, extensively drug-resistant TB has become an emerging threat, and racial/ethnic minorities and foreign-born persons continue to account for a disproportionate number of TB cases.on porn detect computersex deutchland porndeutsche teen porndevaun porndeviant porn videos freedevice porn boundporn devilporn free devilfilms Map

The FDA has announced that the heparin product from China is not really heparin but hypersulfated chondroitin sulfate.  This substitution may be intentional.  Given the  recent tampering activities of the Chinese, I wouldn’t be a bit surprised. 
http://omniphysicians.com/2008/03/20/hypersulfated-chondroitin-sulfate/
This is a case report of pneumocephalus found in a recent issue of NEJM.  No, it’s not President Bush’s CT-scan.  It’s Jessica Simpson’s.
http://omniphysicians.com/2008/03/19/case-report-airheadus-curiosa/

The FDA allows blood to be stored for up to 6 weeks.   However a NEJM study says: “[p]atients receiving older blood (> 2 weeks) were also more likely to need prolonged ventilator support to help them breathe — 9.7 percent, compared with 5.6 percent — and suffered multiple organ failures at about three times the number of those receiving new blood.”   They also have a greater incidence of infections and death.  The National Association of Mosquitoes and Vampires have come out with a press release vowing they will only suck on transfused patients whose packed cells were less than 10 days old.
http://omniphysicians.com/2008/03/20/old-blood-dangerous-blood/
 

Use of standing orders for stroke victims resulted in a 4.3-fold increase in adherence to door-to-thrombolysis time of 1 hour or less, a 7.6-fold increase in dysphagia screening, and a 3.0-fold increase in prophylaxis for deep vein thrombosis.The other required measure was use of warfarin in patients with atrial fibrillation, for which the average adherence rate was 87%.
http://omniphysicians.com/2008/03/20/standing-orders-help-stroke-victims/
Kids with pneumonia.  An Atlanta study concluded that there’s a good possibility that it is MRSA-related.  There’s a lot we don’t know, however.  Is it only a local phenomenon or the tip of the proverbial iceberg?  Would you empirically add a MRSA antibiotic to the course of therapy? 
http://omniphysicians.com/2008/03/20/mrsa-in-kiddie-pnemonia/
Patients with suspected CAD and normal troponins, but with elevated NT-proBNP levels have a poorer prognosis by the 6-month cut-off period.  The researchers calculated that the optimal cut-off value of NT-proBNP was 474 pg/ml; mortality rates were 12.3% versus 1.3% in patients with NT-proBNP levels above versus below this cut-off, respectively.  Can using these tests in tandem help in deciding whether a patient should have an out-patient vs. an in-patient workup?
http://omniphysicians.com/2008/03/20/troponin-bnp-cad/
A study published in the Archives of Plastic Surgery concluded that young women with burns had the worst scarring.  The study came from Italy.  It’s only a rumor that their next study will be to see if massaging marinara sauce into the scars will ameliorate the scarring.
http://omniphysicians.com/2008/03/20/young-women-and-burn-scars/

Post #: 678, 681, 682, 684, 685, 686, 687.

Reuters (3/20) reports that on Wednesday, the Food and Drug Administration (FDA) granted “a priority review for” Merck & Co.’s application to market “its Gardasil cervical cancer vaccine to women aged 27 through 45.” This suggests that the FDA may “make its decision on the marketing application within six months, rather than within the agency’s typical 10-month review period.”

        Currently, the vaccine “is approved for use in girls and women between the ages of nine and 26 to block four types of human papillomavirus (HPV), which can cause cervical cancer and genital warts,” the Wall Street Journal /AP (3/20, D5) adds.