European Respiratory Monograph: Tuberculosis

European Respiratory Monograph is published quarterly by the European Respiratory Society (which also publishes the monthly European Respiratory Journal), with each issue devoted to “a specific clinical area of respiratory health.” These monographs—free for all members of the Society—can also be purchased individually, and fall into a category between journal supplement and textbook. The recent issue devoted to tuberculosis is more the former than the latter, although the text is longer than a typical supplement and the volume itself is closer in physical size to a tall paperback book (17 × 25 cm). With 18 chapters by 55 authors—each 4000 to 8000 words in length—the book reads more like an anthology of related articles rather than an integrated and unified whole. Each chapter has a brief abstract, and redundancy occurs between some chapters. This is not necessarily a bad thing, as not every reader will want to read the book in its entirety. Tuberculosis also falls in the middle ground between being an elementary text for beginners and an update for experts. Several chapters review basic concepts familiar to most tuberculosis specialists, whereas others describe cutting-edge research and provide advanced management guidelines for extensively drug-resistant tuberculosis. The first chapter, “Microbiology of M. tuberculosis and a new diagnostic test for TB” provides an excellent, concise, and current review of tuberculosis pathogenesis and a brief overview of diagnostics. Chapter 10, devoted entirely to diagnostics, covers the topic in detail. Chapter 4, titled “Human genetic variability and susceptibility to pulmonary TB,” effectively describes laboratory techniques and scientific rationale. However, a detailed listing of negative or inconclusive studies, organized by each receptor or cytokine, will be slow going for all but the most dedicated geneticist or immunologist. Additional chapters cover “Epidemiology of TB” (including mechanisms of transmission), “TB in children” (largely understudied to date), “TB as an occupational disease” (particularly health care and mining), and “TB in the immunocompromised host” (including patients with solid organ transplants and hematologic malignancies). There are paired chapters on prevention of tuberculosis and drug resistance in both high- and low-incidence countries. The chapter on drug resistance in high-incidence countries includes a brief but clear-eyed examination of the ethical dilemmas raised by patients who fail treatment for drug-resistant tuberculosis and are deemed “incurable,” but who remain a threat to society. The chapter on tuberculosis vaccine development is inspiring and should generate optimism in those who wonder why there has not been a new tuberculosis vaccine in nearly a century. Chapters on “Treatment of TB” and “Management of adverse drug events in TB therapy” are well-written for the nontuberculosis specialist. They provide guiding principles of tuberculosis therapy and specific examples of regimens. The chapter on tuberculosis in migrants highlights an important issue, as such patients are responsible for much of the tuberculosis incidence in the developed world. As expected in a multiauthored anthology format, writing styles and quality vary from chapter to chapter. Some authors hew closely to published evidence. whereas others either openly offer recommendations that contradict existing guidelines or provide opinion where existing guidelines are silent. Admittedly, the evidence base for much of tuberculosis management—especially drug-resistant tuberculosis—is weak, but I would like to have seen these authors acknowledge that they were making an anecdotal recommendation rather than presenting their advice with the same vigor as that for which the evidence is strong. Not surprisingly, the book focuses heavily on Europe, although 2 chapters devoted to high- incidence countries are written by non-European authors and deal primarily with South Africa. Only passing mention is given to India and China, which together account for a third of all tuberculosis cases and half of drug-resistant tuberculosis cases worldwide. The chapter on nontuberculous mycobacteria addresses the most prevalent and clinically significant species in Europe (which differ from other areas of the world). Tuberculosis provides virtually no history of the disease, nor much description of molecular epidemiologic techniques. This is not a text for someone starting from scratch, and trainees as well as general internists seeking a core text would find more suitable alternatives. Still, the editors and authors have done a commendable job identifying and describing major recent advances in the field and providing the context into which these advances fit. In addition, each chapter provides a robust set of current references that will be useful to those seeking more information on a given topic. Tuberculosis will likely appeal most to pulmonary and infectious diseases specialists with some clinical or research experience in tuberculosis who are looking for an update on this broad and rapidly expanding field. To that end, the middle ground between textbook and supplement may be a useful niche of its own.