368 The International Journal of Tuberculosis and Lung Disease
compared regression predicted years of potential life
lost (YPLL) for a population of TB survivors
following cure and those for persons with latent
tuberculous infection (LTBI).
As Lalli et al. appropriately point out, adequate
control of potentially important population risk
differences is vital to understanding how TB can
impact health outcomes. Choosing the most similar
comparison group available or precise risk matching
among subjects may minimize the effects of unmea-
sured population differences. Risk adjustment during
analysis was made more challenging by our use of
administrative data, which can be limited by incon-
sistently ascertained or reported variables. Predicted
YLL was derived by using a regression model
adjusted for age, sex, and ethnicity, foreign birth,
incarceration and human immunodeficiency virus
status, with comparison to the LTBI group serving as
indirect control for other factors.
Our assumption that persons with a history of TB
are more similar to those with diagnosed LTBI in terms
of all-cause health risks than to the general US
population is well grounded. In the United States,
populations at greatest risk for prevalent TB or LTBI
are similar in important ways, and similarly are unlike
a more generalized population.1,2 These share envi-
ronmental, social, economic, demographic, and other
factors that may affect risks for increased morbidity
and mortality and decreased health-related quality of
life.1,2 Because of these commonalities, and where
more precise data is unavailable, LTBI is a common
proxy for broad population risks not directly related to
TB.3 We have found health outcomes for populations
with either a history of active TB or LTBI to be
consistently dissimilar to those of the general US
population in our other analyses as well.4,5 We are
confident that our adjusted model reliably captures the
burden of excess mortality associated with a history of
fully treated TB in the US. More importantly, we
believe that research to identify and explain causal
factors related to this phenomenon may lead to
strategies that can reduce this burden.
SALLY HOGER, DRPH*
KRISTINE LYKENS, PHD†
SUZANNE BEAVERS, MD CR‡
DOLLY KATZ, PHD‡
THADDEUS MILLER, DRPH†
*Tarleton State University
Fort Worth, TX
†University of North Texas Health Science Center
Fort Worth, TX
‡Centers for Disease Prevention and Control,
Atlanta, GA
USA
For the Tuberculosis Epidemiologic Studies
Consortium
e-mail: hoger@tarleton.edu
http://dx.doi.org/10.5588/ijtld.14.0852-2
References
1 Centers for Disease Control and Prevention (CDC). Reported
tuberculosis in the United States, 2012. Atlanta, GA, USA: US
Department of Health and Human Services, CDC, October 2013.
2 Linas B P, Wong A Y, Freedberg K A, Horsburgh C R Jr. Priorities
for screening and treatment of latent tuberculosis infection in the
United States. Am J Respir Crit Care Med 2011; 184: 590–601.
3 Bauer M, Leavens A, Schwartzman K. A systematic review and
meta-analysis of the impact of tuberculosis on health-related
quality of life. Qual Life Res 2013; 2: 2213–2235.
4 Pasipanodya J G, Miller T L, Vecino M, et al. Using the St.
George’s Respiratory Questionnaire to ascertain health quality in
persons with treated pulmonary tuberculosis. Chest 2007: 132:
1591–1598.
5 Miller T L, Wilson F E, Pang J W, et al. Mortality hazard and
survival after tuberculosis treatment. Am J Public Health (In press).
Dual infection with pulmonary tuberculosis
and Lophomonas blattarum in India
The protozoan Lophomonas blattarum, a commensal
inhabitant of cockroaches, is an unusual cause of
bronchopulmonary infections.1,2 Amoeboflagellates
found in airway samples help in diagnosis, although
their identical morphology to ciliated bronchial
epithelium is a hindrance in interpretation.
Since the emergence of lophomoniasis in 1993, 53
cases have been reported in China, six in Peru and
two in Spain, but none in India.2–5
House dust contaminated with cysts may be
inhaled, initiating infection. Infections are reported
mostly in adults; very few have been described in
children.2 Poor immunity and renal transplant
predispose to the infection.1 Asthma and coexistent
TB predispose to clinical manifestations, including
pneumonia, bronchiectasis and pulmonary abscess-
es.3,5 We report here the first case from India.
A 60-year-old man was hospitalised with fever,
mucopurulent expectoration, breathlessness and loss of
appetite for a month. Auscultation revealed crepita-
tions and bronchial breathing in the left supramam-
mary area. Haematology showed neutrophilia and
chest X-ray showed left upper lobe consolidation.
Empirical ceftriaxone for suspected pneumonia
showed no favourable response. Sputum Ziehl-Neelsen
staining did not demonstrate acid-fast bacilli, but
Xpertw MTB/RIF detected Mycobacterium tuberculo-
sis without rifampicin resistance. The patient improved
on anti-tuberculosis treatment consisting of daily oral
rifampicin 450 mg, isoniazid 300 mg, pyrazinamide
1000 mg, ethambutol 800 mg and pyridoxine 10 mg.
A month later, the patient was readmitted with
fever, worsening cough and dyspnoea. Computerised
tomography of the thorax revealed consolidation,
bronchiectasis, cavitation and nodular opacity within
the left upper lobe. Bronchial wall thickening, fibrosis
and mediastinal lympadenopathy suggested endo-
bronchial infection.
Fiberoptic broncoscopic examination revealed hy-
peraemic mucosa. Deposits obtained from bronchoal-
veolar lavage (BAL) after centrifugation at 2000 rpm
for 15 min demonstrated lymphocytes, red blood cells
 Correspondence 369

and actively motile flagellated amoebae. These were

translucent oval 25–35 lm with pseudopodia and a
polar tuft of flagellae lashing rhythmically 15 times/10
sec (Figure). Methylene blue staining differentiated
microorganisms from ciliated bronchial cells. A
definite history of contact with cockroaches was
admitted by our patient, who denied travel outside
India. The parasite was identified as Lophomonas
blattarum, and oral metronidazole 400 mg thrice daily
was initiated; steady improvement was noted, with
absence of protozoa from BAL after one month of
therapy. Anti-tuberculosis treatment was continued for
9 months and the patient attained clinical cure.
Lophomonas is classified under supergroup Ex-
cavata, rank Parabasalia. Trophozoites encyst in
adverse conditions and excyst in two motile forms
under proper conditions. Given suitable temperature,
humidity and oxygen concentration in the human
respiratory tract, excysted trophozoites affect prote-
ase receptors and interact with tight-junctions.2
The pyriform trophozoite is 20–60 3 12–20 lm in Figure Translucent, oval to pear-shaped amoeboflagellate,
size and bears a polar tuft of flagellae, the body being 25–35 lm in size, with pseudopodia and a polar tuft of flagellae
unstriated in L. blattarum. A trumpet-shaped calyx seen as a crown. Crenated red blood cells and necrotic material
visible (magnification x 400).
extends down the central axis and has a nucleus
inside. A specialised cytoplasmic collar, the parabasal Indira Gandhi Medical College
body, with numerous radiating tubules that support Shimla, India
the nucleus-endomembrane system and axial fila- e-mail: santwana1812@gmail.com
ment, are seen on electron microscopy. This endo- http://dx.doi.org/10.5588/ijtld.14.0513
membrane assembly probably synthesises enzymes,
lysosomes and peroxisomes.2 Conflict of interest: none declared.
Various authors have distinguished cells from
protozoans by absence of red granules, positivity to References
ultraviolet light or staining with Heidenham iron 1 Martinez-Giron R, Esteban J G, Ribas A, Doganci L. Protozoa in
hematoxylin, Papanicolaou or Wheatley’s tri- respiratory pathology: a review. Eur Respir J 2008; 32: 1354–
chome.2,3 We used methylene blue stain and differ- 1370.
2 Martinez-Giron R, Van Woerden H C. Lophomonas blattarum
entiated ciliated bronchial epithelial cells by
and bronchopulmonary disease. J Med Microbiol 2013; 63:
perceiving motility of trophozoites on rigorous 1641–1648.
screening of wet mounts within 2 h of sample 3 Ribas A, Mosquera J A. Amoeboflagellates in bronchial asthma.
collection. A segment of alveolar membrane illustrat- Acta Cytol 1998; 42: 685–690.
ed bronchial cells with static cilia and an embedded 4 Ribas A, Martinez-Giron R, Ponte-Mittelbrum C, Alonso-
trophozoite with motile flagellae. Cuervo R, Iglesias-Llaca F. Immunosuppression, flagellated
protozoa in the human airways and metronidazole:
Treatment consists of oral metronidazole 500 mg observations on the state of the art. [Letter]. Eur Soc Organ
8–12 hourly or 2 g daily in adults and 7.5–15 mg/kg Transplantation 2007; 20: 811–812.
every 8 h in children for a week. Severe cases may be 5 He Q, Chen X, Lin B, Qu L, Wu J, Chen J. Late onset pulmonary
treated with intravenous metronidazole 15 mg/kg/h Lophomonas blattarum infection in renal transplantation: a
followed by 7.5 mg/kg/6 h as maintenance.1,2,4,5 report of two cases. Intern Med 2011; 50: 1039–1043.

SANTWANA VERMA, MD* Cavitary tuberculosis and tracheal stenosis

GHANSHYAM VERMA, MD†
DIG VIJAY SINGH, MD*
JITENDER MOKTA, MD‡
RAMESHWAR SINGH NEGI, MD§
ANUPAMA JHOBTA, MD¶
ANIL KANGA, MD*
*Department of Microbiology,
†Department of Dermatology
‡Dept. of Internal Medicine
§Dept. of Pulmonary Medicine
¶ Department of Radiodiagnosis
simulating granulomatosis with polyangiitis
We describe a 38-year-old female who presented
tracheal stenosis with lung cavities, illustrating the
challenges of diagnostic differentiation between tuber-
culosis (TB) and granulomatosis with polyangiitis
(GPA). The patient’s condition began with productive
cough on May 2009, leading to progressive dysphonia.
Initial acid-fast bacilli (AFB) test was negative. Biopsy
of the larynx showed granulomatous laryngitis.
In September, the patient’s symptoms had pro-
gressed to include dyspnoea, haemoptysis, fever and