Professional Documents
Culture Documents
doi: 10.1590/0037-8682-0465-2016
Major Article
[1]. Departamento de Fonoaudiologia, Hospital Universitário Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro,
Rio de Janeiro, RJ, Brasil. [2]. Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.
[3]. Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.
[4]. Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil.
Abstract
Introduction: A total of 771 cases of multidrug-resistant tuberculosis (MDR-TB) were reported in Brazil in 2014. Treatment of
MDR-TB with aminoglycosides can produce serious side effects such as permanent and irreversible hearing loss, which occurs in
5-64% of cases, and severely compromise patient quality of life. The goal of this research was to evaluate auditory and vestibular
side effects in patients treated for MDR-TB and to identify associations between these complaints and the type of aminoglycoside
used. Methods: We performed a retrospective review of 599 medical records from patients with MDR-TB who were treated at
the Hélio Fraga/Fiocruz Reference Center between 2006 and 2010. Cases without auditory or vestibular complaints and patients
who were not treated with aminoglycoside drugs were excluded from the study. Results: Of 164 eligible cases, 55 (33.5%)
reported an auditory or vestibular complaint and medication was subsequently suspended, although hearing damage was not
confirmed in all cases. Audiometric testing confirmed hearing loss in 11 (21.7%) of 12 cases submitted for evaluation. Hearing
loss related to ototoxicity was confirmed in 15 (62.5%) cases. Tinnitus was significantly associated with the use of amikacin and
streptomycin. Conclusions: Evaluations of ototoxicity symptoms were not usually reported in the routine care of patients with
MDR-TB. Complaints of tinnitus were associated with amikacin and streptomycin use. These results require confirmation in
future studies.
Keywords: Aminoglycoside. Hearing. Hearing loss. Tuberculosis.
METHODS
Corresponding author: Fga. Karla Anacleto de Vasconcelos.
e-mail: karla.fono@hotmail.com
We retrospectively enrolled patients with MDR-TB who
Received 15 November 2016 attended the outpatient clinic at Helio Fraga Reference Center/
Accepted 18 October 2017 FIOCRUZ between January 2006 and December 2010. Clinical
646
de Vasconcelos KA et. al - Hearing loss after MDR-TB treatment
647
Rev Soc Bras Med Trop 50(5):646-651, September-October, 2017
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FIGURE 1 - The study on the organization chart data colletion in CRPHF (2006-2010). CRPHF: Centro de Referência Professor Helio Fraga;
MDR-TB: multidrug-resistant tuberculosis.
648
TABLE 1
Statistical analysis between the type of aminoglycoside and hearing complaints in population evaluated.
amikacin 145 88,4 339 77,9 101 69,7 44 30,3 145 82 56,6 63 43,4 145 23 15,9 122 84,1 145
<0,01 0,40 0,04 0,24
streptomycin 19 11,6 86 19,8 15 78,9 4 21,1 19 6 31,6 13 68,4 19 5 26,3 14 73,7 19
Sex
male 87 53,0 273 62,8 70 80,5 17 19,5 87 43 49,4 44 50,6 87 10 11,5 77 88,5 87
0,04 <0,01 0,25 0,07
female 77 47,0 162 37,2 46 59,7 31 40,3 77 45 58,4 32 41,6 77 17 22,1 60 77,9 77
Age group
40 - 59 76 46,3 196 45,1 0,76 54 71,1 22 28,9 76 0,95 33 42,3 45 57,7 78 0,04 15 19,7 61 80,3 76 0,44
Education
elementary school 88 53,7 285 65,5 60 68,2 28 31,8 88 53 60,2 35 39,8 88 12 13,3 78 86,7 90
0,49 0,11 0,14
high school 49 29,9 72 16,6 0,04 37 75,5 12 24,5 49 23 46,9 26 53,1 49 10 20,0 40 80,0 50
higher education 8 4,9 18 4,1 5 62,5 3 37,5 8 3 37,5 5 62,5 8 3 37,5 5 62,5 8
Previous treatments
≥2 118 72,0 314 72,2 0,23 84 71,2 34 28,8 118 0,66 64 54,2 53 44,9 118 0,43 20 16,9 98 83,1 118 0,97
Previous aminoglycoside
yes 103 71,0 234 53,8 72 69,9 31 30,1 103 59 57,3 44 42,7 103 14 13,6 89 86,4 103
no 49 33,8 175 40,2 0,03 35 71,4 14 28,6 49 0,84 22 44,9 27 55,1 49 0,20 11 22,4 38 77,6 49 0,25
de Vasconcelos KA et. al - Hearing loss after MDR-TB treatment
649
Rev Soc Bras Med Trop 50(5):646-651, September-October, 2017
50
45
40
35
30
25
20
15
10
5
0
1 to 30 days 31 to 60 days 3 to 12 months after termination More than 18
of use (period months of use
indicated, Ministry (treatment failure )
of Health)
FIGURE 3 - Distribution of the relationship between the time of use and the reporting of auditory/vestibular complaints.
over time. Therefore, patients exposed to vestibulotoxic agents medical records/missing data. The attending medical specialists
may initially experience some imbalance or dizziness and at MDR-TB reference centers do not habitually document data on
recover thereafter. Vestibular rehabilitation or labyrinthine auditory or vestibular complaints. Proper auditory monitoring and
rehabilitation can accelerate the process of compensation in the careful assessment of hearing complaints should be routine
cases of dizziness resulting from the use of ototoxic drugs. procedures in treating patients with MDR-TB.
In the present study, approximately 70% of records analyzed The development of standard operating protocols for
were excluded because there were no reported adverse events monitoring hearing has not been a priority in medical practice;
of interest. Auditory and vestibular complaints should have a however, a systematic investigation into the hearing conditions
prominent place in the medical records of patients with MDR- of patients exposed to ototoxic drugs would: 1) support clinical
TB who are treated with aminoglycosides. When a complaint decisions; 2) provide an assessment of the overall effectiveness
was reported, physicians discontinued aminoglycoside treatment of current clinical methods for monitoring ototoxicity; and 3)
without laboratorial confirmation of hearing loss. Awareness of aid the development of programs for clinical application.
the consequences of a hearing loss and delays for diagnosis in
the public health system likely caused physicians and patients to
Acknowledgments
decide against the continuation of treatment. In our study, only
27% patients were referred for hearing assessment and of these, We thankful to the team members of the outpatient clinic at Hélio Fraga
91% of cases were confirmed to have hearing loss. The addition Reference Center/Fundação Oswaldo Cruz (FIOCRUZ), especially
Dr. Margareth Dalcolmo and nurse Suzanne Leite.
of an on-site or referral team of otolaryngologists and audiologists
to TB clinics can enable the proper testing and monitoring of
auditory and vestibular function in patients treated for MDR-TB. Conflicts of interest
The present study had some limitations. First, the effects or The authors declare that there is no conflict of interest.
contributions of confounding variables for hearing loss such as
smoking and noise exposure were not studied and are not currently
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