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Jaundice is an alarm symptom that should always be treated urgently, regardless of whether the responsible doctor is in primary care or in the emergency room. The differential diagnoses can be significantly delimited (hepatocellular vs. cholestasis) and several clues to the etiology can be determined from a carefully performed anamnesis, clinical examination, and basic laboratory tests. Exclusion of cholestatic etiology is essential due to life-threatening differential diagnoses and complications, but acute medical conditions also occur, such as acute liver failure. Prompt processing at the correct instance can be crucial for the short-term and long-term prognosis of the patient., Ikterus, även kallat gulsot, är ett allvarligt symtom där korrekt handläggning är av stor betydelse [1]. Denna artikel syftar till att redogöra för några vanliga och viktiga bakomliggande orsaker till ikterus, ge förslag till handläggning och uppföljning samt översiktligt beskriva olika behandlingsalternativ.

The intracellular (IC) effect of drugs against Mycobacterium tuberculosis (Mtb) is not well established but increasingly important to consider when combining current and future multidrug regimens into the best possible treatment strategies. For this purpose, we developed an IC model based on a genetically modified Mtb H37Rv strain, expressing the Vibrio harvei luciferase (H37Rv-lux) infecting the human macrophage like cell line THP-1. Cells were infected at a low multiplicity of infection (1:1) and subsequently exposed to isoniazid (INH), ethambutol (EMB), amikacin (AMI) or levofloxacin (LEV) for 5 days in a 96-well format. Cell viability was evaluated by Calcein AM and was maintained throughout the experiment. The number of viable H37Rv-lux was determined by luminescence and verified by a colony forming unit analysis. The results were compared to the effects of the same drugs in broth cultures. AMI, EMB and LEV were significantly less effective intracellularly (MIC90: greater than4 mg/L, 8 mg/L and 2 mg/L, respectively) compared to extracellularly (MIC90: 0.5 mg/L for AMI and EMB; 0.25 mg/L for LEV). The reverse was the case for INH (IC: 0.064 mg/L vs EC: 0.25 mg/L). In conclusion, this luciferase based method, in which monitoring of cell viability is included, has the potential to become a useful tool while evaluating the intracellular effects of anti-mycobacterial drugs., Funding Agencies|Swedish Heart and Lung Foundation (Oscar II Jubilee Foundation); Marianne and Marcus Wallenberg Foundation; Research Council of Southeast Sweden (FORSS)

OBJECTIVES: To describe wild-type distributions of the MIC of fluoroquinolones for Mycobacterium tuberculosis in relation to current critical concentrations used for drug susceptibility testing and pharmacokinetic/pharmacodynamic (PK/PD) data. METHODS: A 96-stick replicator on Middlebrook 7H10 medium was used to define the MICs of ciprofloxacin, ofloxacin, moxifloxacin and levofloxacin for 90 consecutive clinical strains and 24 drug-resistant strains. The MICs were compared with routine BACTEC 460 susceptibility results and with MIC determinations in the BACTEC MGIT 960 system in a subset of strains using ofloxacin as a class representative. PK/PD data for each drug were reviewed in relation to the wild-type MIC distribution. RESULTS: The wild-type MICs of ciprofloxacin, ofloxacin, moxifloxacin and levofloxacin were distributed from 0.125 to 1, 0.25 to 1, 0.032 to 0.5 and 0.125 to 0.5 mg/L, respectively. The MIC data correlated well with the BACTEC 960 MGIT and BACTEC 460 results. PD indices were the most favourable for levofloxacin, followed by moxifloxacin, ofloxacin and ciprofloxacin. CONCLUSIONS: We propose S (susceptible)

Background: Tuberculosis remains a major global public health problem. Not surprisingly, most cases of this disease occur in poor countries and an increasing number of patients harbor drug - resistant bacteria. The cornerstone of bacteriological diagnosis of tuberculosis is direct sputum smear microscopy. This method is rapid, inexpensive and specific, however, sensitivity is discouragingly low. Regarding drug susceptibility testing, the methods available today are either cheap and slow or fast but too costly to be applicable in most high incidence areas. The aim of this investigation was to improve detection and drug susceptibility testing of Mycobacterium. tuberculosis with special emphasis on settings with scarce resources. Methods: We evaluated an improved method for sputum microscopy, which is based on liquefaction of the sample with household bleach, followed by its concentration by centrifugation prior to staining and microscopy. The bleach microscopy method was compared to standard direct microscopy in Honduras. Then, we performed a literature review in search for all studies that have compared the bleach method to the direct method in low- and middle-income countries. We further sent out questionnaires to key persons in national tuberculosis control programs in order to investigate the knowledge and opinions about this alternative method. We also developed and evaluated a new method for rapid and inexpensive drug susceptibility testing, which is based on the ability of M. tuberculosis to reduce nitrate to nitrite. The performance of this method, the Nitrate Reductase Assay, for drug susceptibility testing was compared to the standard BACTEC 460 liquid culture system. Moreover, we evaluated the performance of a commercial automatic culture system called BacT/ALERT 3D for primary detection of M. tuberculosis in clinical samples and for drug susceptibility testing. Results: We found that the bleach method could improve sensitivity with 3 7 %, Arith unchanged s

Background: Nitric oxide (NO) is produced in macrophages by the inducible NO synthase (iNOS) upon activation by pro-inflammatory cytokines. NO has been shown to be essential for the control of Mycobacterium tuberculosis infection in murine models whereas its importance in man is not as clear. There is a lack of studies regarding the susceptibility to reactive nitrogen species (RNS) in clinical strains of M. tuberculosis and the relation to first-line drug resistance, such as to isoniazid (INH). The aim of this study was to explore susceptibility to RNS and intracellular survival of clinical strains of M. tuberculosis, with or without INH resistance. Method: Seven clinical strains of M. tuberculosis were transformed with the pSMT1-plasmid encoding Vibrio harveyi luciferase. Survival was analysed by luminometry following exposure to the NO donor DETA/NO or peroxynitrite (SIN-1). Intracellular killing was studied in murine macrophages (RAW 264.7) activated with interferon gamma (IFN-γ) and lipopolysaccharide (LPS). Results: There was a significant effect on growth control of M. tuberculosis strains upon macrophage activation, which showed variability among clinical isolates. In the cell-free system, all strains showed a dose-dependent susceptibility to DETA/NO and SIN-1, and clinical strains were in general more resistant than H37Rv to DETA/NO. INH-resistant strains with an inhA mutation were significantly more tolerant to DETA/NO than inhA wild type. Conclusion: Reactive nitrogen species inhibited growth of clinical M. tuberculosis isolates both in an intra- and extracellular model with significant difference between strains. Increased tolerance to NO was associated with isoniazid resistance mediated by inhA.