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1. Is Alcohol Use Associated With Cavitary Disease
in Tuberculosis?
Ana Moran, Deborah V. Harbour, Larry D. Teeter, James M. Musser, and Edward A. Graviss
Background: Alcohol mediates detrimental alterations in the immune response to Mycobacterium
tuberculosis. The association between quantity and frequency of alcohol use and the prevalence of
cavitary disease in tuberculosis (TB) has not been analyzed. To investigate the relationship of alcohol
use and the prevalence of cavitary disease in a 6-year population-based data set of individuals
with TB.
Methods: We assessed quantity and frequency of alcohol use (daily alcohol use, years of alcohol
use, and lifetime alcohol use) with a standardized questionnaire. The study group consisted of 1,250
patients analyzed for cavitary disease (HIV sero-negative subjects that were 18 years or older).
Significant covariates for cavitary disease were entered into multiple logistic regression models.
Results: Although daily alcohol use, years of alcohol use, and alcohol use 30 days or 6 months
before symptom onset were significant predictors of cavitary disease in univariate analysis, no
independent associations were found between alcohol use and cavitary disease in the multivariate
analysis. Only diabetes mellitus was independently associated with cavitary disease at any level or
frequency of alcohol use.
Conclusion: Alcohol use is not independently associated with increased prevalence of cavitary
disease in adult patients with TB.
Key Words: Tuberculosis, Alcohol, Epidemiology, Cavitation.
MYCOBACTERIUM TUBERCULOSIS (MTB) is
the major etiologic agent of tuberculosis (TB),
which is one of the most significant public health prob-
lems the world has experienced (Lauzardo and Ashkin,
2000; Malin and McAdam, 1995; Tiruviluamala and
Reichman, 2002). Tuberculosis is a complicated, multifac-
torial disease manifesting itself in several stages including
primary pulmonary disease, progression, and dissemin-
ation. Factors reported to be responsible for increased
worldwide rates of TB in recent years are human
immunodeficiency virus (HIV) infection and increases in
population rates, most particularly in the impoverished,
homeless, and malnourished, those living in crowded con-
ditions (such as prisons, nursing homes, mental facilities,
and shelters), injection drug users and other substance
abusers, those with extremes of age, and in the United
States, those who are foreign born (Lauzardo and Ashkin,
2000; Malin and McAdam, 1995; Tiruviluamala and
Reichman, 2002).
Acute and chronic alcohol use can predispose individu-
als to TB disease development through alterations of the
specific and nonspecific immune responses to MTB
(Jacobson, 1992; MacGregor, 1986; Nelson et al., 1995;
Roselle, 1992; Szabo, 1999). Alcohol has detrimental
effects on the T-lymphocyte compartment, which directs
and controls the specific cell-mediated immune (CMI)
response and is the major protective pathway in TB.
Molecular epidemiology and cluster analysis have
shown alcohol to be a risk factor associated with transmis-
sion of TB and development of TB disease (Buskin et al.,
1994; Friedman et al., 1987; Moss et al., 2000; Tekkel
et al., 2002; Yaganehdoost et al., 1999; Zafran et al., 1994).
In addition to an increased frequency of TB, previous
studies suggest that alcohol use predisposes individuals
to more severe forms of the disease (Jacobson, 1992;
Milne, 1970). Only 1 study has evaluated the role of
alcohol use in a dose–response fashion, finding that heavy
alcohol use (defined as 3 or more drinks daily) was
associated with an increased risk of all forms of TB
disease. However, the dose–response relationship between
From the Departments of Medicine (AM, EAG) and Pathology,
Center for Human Bacterial Pathogenesis Research, Baylor College of
Medicine, Houston, Texas (LDT, EAG); the School of Public Health,
University of Texas Health Center at Houston, Houston, Texas
(DVH); and the Center for Molecular and Translational Human Infec-
tious Diseases Research, The Methodist Hospital Research Institute,
Houston, Texas (JMM).
Received for publication March 31, 2006; accepted September 6,
2006.
None of the authors has a commercial or other conflict of interest to re-
port with regard to this article. This project has been funded in part with
federal funds, from the National Institute of Allergy and Infectious Diseas-
es, National Institute of Health, under contract N01-AO-02738 and
DA09238.
Reprint requests: Edward A. Graviss, PhD, MPH, Department of
Pathology (209E), Houston Tuberculosis Initiative, Baylor College of
Medicine, 1, Baylor Plaza, Houston, TX 77030; Fax: 713-798-8895;
E-mail: egraviss@bcm.tmc.edu
Copyright r 2006 by the Research Society on Alcoholism.
DOI: 10.1111/j.1530-0277.2006.00262.x
Alcohol Clin Exp Res, Vol 31, No 1, 2007: pp 33–38 33
ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH Vol. 31, No. 1
January 2007

2. chronic alcohol use and the severity of active pulmonary
TB, defined as cavitary disease, has not been previously
studied. Moreover, the relative effects of gender and other
risk factors such as history of incarceration, homelessness,
and ethnicity in combination with alcohol use have not
been evaluated in previous studies (Carpenter and Huang,
1991; Holmdahl, 1967; Milne, 1970). In a population-
based cohort of individuals, we evaluated the association
between chronic alcohol use and the prevalence of cavitary
disease among HIV sero-negative adult patients with
culture positive pulmonary TB.
MATERIALS AND METHODS
Study Population
The Houston Tuberculosis Initiative (HTI) is a prospective popu-
lation-based, active surveillance and molecular epidemiology study
of TB cases reported to the City of Houston Tuberculosis Control
Office and the Harris County Public Health and Environmental Ser-
vices. Since 1995, 93% of all reported TB patients have been enrolled
in this study. Personal identifiers were removed and the data set for
the current study consisted of 3,082 individuals with TB, identified
from October 1, 1995 through September 30, 2001. The HTI data set
excludes patients who lived in Harris County, Texas, for less than 3
months, because they are considered prevalent Houston transmis-
sible cases. Of the original 3,082 individuals, the final study group
included 1,250 adults with culture-positive pulmonary disease. We
excluded cases that were considered prevalent by virtue of residing
for less than 3 months in Houston (n 5 154); cases deemed due to
contamination or whose TB diagnosis was later rescinded (n 5 37);
patients who were not located by the study personnel or who declined
participation in the study (n 5 298); and patients who had any extra-
pulmonary TB disease (n 5 761) or negative MTB culture from
pulmonary specimen(s) (n 5 204), because the focus of this study was
to access the effect of alcohol in the development of pulmonary dis-
ease with cavitation in patients with culture-positive pulmonary TB.
Human immunodeficiency virus sero-positive individuals (n 5 229)
were also excluded from the study because these patients are prone to
present with more severe disease irrespective of alcohol consump-
tion. Additional excluded individuals included patients below the age
of 18 (n 5 41), because we found a very low prevalence of alcohol use
in this age group, and subjects with missing data (n 5 108). The
patients were interviewed by trained project personnel, using a stand-
ardized questionnaire designed to gather basic demographic and
socioeconomic information, as well as clinical data regarding the
patient’s TB nd HIV status.
The diagnoses of HIV, TB disease, and the presence of cavitation
were confirmed by medical record review for all patients. Demo-
graphic (ethnicity, foreign-born status, gender, and age), social
(history of incarceration or homelessness, and level of education),
behavioral (amount and use of alcohol, drugs, and smoking), and
medical history variables (diabetes, chronic obstructive pulmonary
disease, cancer, renal failure, and hypertension) were included in the
analysis.
Alcohol Quantification
Alcohol use was quantified using quantity frequency measures of
alcohol use (Rehm et al., 1999), which were included in a standard-
ized questionnaire. Frequency (drinking days per week) was assessed
by the following question: ‘‘During the past 6 months, how often did
you drink alcohol?’’ Response categories included daily, nearly daily,
3 to 4 times/wk, 1 to 2 times/wk, occasionally, once, never. Quantity
(drinks per day) was assessed by the following question ‘‘On the days
when you drank, how many drinks did you usually have?’’ The
response categories were the number of drinks including the type of
alcoholic beverage used. A drink was defined as a 12-ounce (oz)
bottle or can of beer, a 4-oz glass of wine, or 1.5-oz shot of distilled
liquor (National Institute on Alcohol Abuse and Alcoholism, 2003).
There is no precedent for correlating the amount of lifetime alco-
hol use and the risk of more severe forms of pulmonary TB (defined
as cavitary disease). We estimated the total lifetime alcohol use as
follows: (average number of drinks per dayaverage number of
drinking days per week52number of years drinking). Persons
were considered daily drinkers if they responded ‘‘daily’’ or ‘‘nearly
daily’’ to the alcohol frequency question.
Data Analysis
Questionnaire and medical record review data were entered into
longitudinal databases (Epi Info version 6.02b; CDC, Atlanta GA
and Microsofts
Access, Redmond, WA). Statistical analyses were
performed with STATAs
Version 8.2 SE (College Station, TX).
Statistical analyses included logistic regression analysis using cavita-
tion (as a dichotomous variable) as the dependent or outcome
variable. The independent variables of interest included lifetime
alcohol use and years of alcohol use (continuous variables), ever
smoking, or ever using drugs. In addition, other behavioral, social,
and demographic covariates were analyzed. Criteria for inclusion in
multivariate logistic regression model included covariates significant
in the univariate analysis at a p-value less than 0.2, as well as bio-
logically plausible covariates that best described the relationship
between cavitation, and other possible confounders. Possible con-
founders included in the models were age, gender, foreign birth,
history of incarceration or homelessness, smoking, and history of
diabetes (Bacakoglu et al., 2001; Erwin and Miller, 2000; Perez-
Guzman et al., 2000).
RESULTS
The study group consisted of 1,250 HIV-negative indi-
viduals, ages 18 years or older, who had culture-positive
pulmonary disease. A total of 672 (64%) patients pre-
sented with cavitary disease (age SD, 44.4 14.8; 486
males, 72%), and 578 (36%) subjects without cavitary
disease (age SD, 48.9 17.6; 406 males, 70%).
Univariate Comparison Between Cavitary Versus
Noncavitary Cases (Table 1)
Socio-Demographic Characteristics. Individual vari-
ables that significantly predicted cavitary disease were
history of incarceration (p 5 0.004) and history of home-
lessness (p 5 0.010). Patients presenting with cavitary
disease were significantly younger than patients with non-
cavitary disease (po0.001). Patients of Asian ethnicity
were significantly less likely to present with cavitary dis-
ease (p 5 0.001). No significant association was found with
gender or other ethnic groups (African Americans, Whites,
and Hispanics). Increased cavitary disease was noted
among smokers and patients with a history of incarcer-
ation. Foreign-born patients, and those with more than
a high school education were less likely to have cavitary
disease.
34 MORAN ET AL.

3. Alcohol Use. A significantly higher proportion of cavi-
tary disease was observed among subjects reporting ever
drinking alcohol (p 5 0.027), subjects who drank alcohol
in the previous 30 days (p 5 0.002) or the previous 6
months (p 5 0.004). The number of years using alcohol
was significantly associated with cavitation when the anal-
ysis was adjusted for age (p 5 0.049). Daily alcohol use, the
number of drinks per day or per week, or the amount of
lifetime alcohol used were not associated with risk of
cavitary disease.
Comorbid Conditions. Significantly lower rates of cavitary
disease were seen among patients with chronic obstructive
pulmonary disease (p50.006), previous diagnosis of any type
of cancer (p50.028), or lung cancer (p50.022), and renal
failure (p50.030). More cavitary disease was found among
subjects with diabetes mellitus or hypertension.
Variables Associated With Cavitary Disease on the Basis of
Multivariate Logistic Regression Model
The variables analyzed by multivariate logistic regres-
sion modeling in patients reporting alcohol use within
30 days (n 5 1,240) or 6 months (n 5 1,241) before the
diagnosis of TB cavitary disease are listed in Table 2.
Similarly, the variables analyzed by multivariate logis-
tic regression modeling for the years of alcohol use
(n 5 1,227) and for patients reporting daily drinking
(n 5 1,235) are shown in Table 3.
Diabetes mellitus independently predicted cavitary dis-
ease among patients reporting alcohol use within 30 days
or within 6 months before the diagnosis of TB cavitary
disease (p 5 0.002, Table 2). An education level greater
than high school was associated with less cavitary disease
among patients reporting alcohol use within 6 months
before diagnosis (p 5 0.049). A trend of association with
cavitary disease was observed for this covariate in patients
reporting alcohol use within 30 days before diagnosis
(p 5 0.054). Neither alcohol use within 30 days nor use
within 6 months was independently associated with increased
risk for cavitary disease.
No association was found between the amount of alco-
hol used (assessed as the number of years drinking alcohol
or daily alcohol use for any amount of time) and cavitary
disease (Table 3). Among patients reporting daily alcohol
use, diabetes mellitus was the only variable significantly
associated with cavitary disease (p 5 0.002).
Table 1. Univariate Analysis of Variables Associated with Cavitary Disease (n 5 1,250)
Variables
n (%)
OR (95% CI) p-value
Cavitary (n 5 672) Noncavitary (n 5 578)
Age, years SD 44.4 14.8 48.9 17.6 0.98 (0.97–0.99) 0.001
Male 486 (72) 406 (70) 1.11 (0.86–1.41) 0.410
Ethnicity (n 5 671)a
(n 5 575)a
Black 248 (37) 186 (32) 1.00
White 137 (20) 118 (21) 0.87 (0.63–1.18) 0.380
Hispanic 222 (33) 180 (31) 0.92 (0.70–1.21) 0.570
Asian 64 (10) 91 (16) 0.52 (0.36-0.76) 0.001
Foreign birth 226 (33) 223 (39) 0.81 (0.63–1.01) 0.069
Education greater than high school 115 (17) 122 (21) 0.77 (0.58–1.02) 0.077
Homeless (history) 146 (22) 92 (16) 1.46 (1.09–1.94) 0.009
Incarceration 371 (55) 273 (47) 1.38 (1.10–1.73) 0.004
Smoker 478 (71) 384 (67) 1.24 (0.97–1.58) 0.074
Drug rehabilitation 58 (9) 38 (7) 1.34 (0.87–2.05) 0.172
Comorbid conditions
Diabetes mellitus 141 (21) 100 (17) 1.26 (0.95–1.68) 0.100
COPDb
39 (6) 58 (10) 0.55 (0.36–0.84) 0.006
Lung cancer 5 (0.7) 14 (2) 0.30 (0.10–0.84) 0.022
Any cancer 22 (3) 34 (6) 0.54 (0.31–0.93) 0.028
Renal failure 11 (2) 21 (4) 0.44 (0.21–0.92) 0.030
Hypertension 73 (11) 82 (14) 0.73 (0.52–1.03) 0.076
Alcohol use
Any alcohol use 555 (83) 450 (78) 1.37 (1.03–1.82) 0.027
Use 30 days prior to symptom onset 282 (42) 193 (33) 1.44 (1.14–1.82) 0.002
Use 6 months prior to symptom onset 404 (60) 300 (52) 1.39 (1.11–1.74) 0.004
Daily alcohol use 247 (37) 193 (34) 1.16 (0.92–1.47) 0.188
Drinks per day 7.0 11.0 6.7 13.5 1.00 (0.99–1.01) 0.632
Drinks per week 36.7 67.3 35.7 92.8 1.00 (0.99–1.01) 0.821
Years drinkingc
17.2 14.1 17.1 15.3 1.01 (1.00–1.02) 0.049
Lifetime drinksc
48,167 112,170 46,802 109,863 1.00 (1.00–1.00) 0.830
a
The total number of subjects is 1,246 because we excluded Native American and other ethnicities due to small number of subjects in these
categories.
b
COPD, Chronic obstructive pulmonary disease.
c
Analysis was age-adjusted.
OR, odds ratio; SD, standard deviation.
35
ALCOHOL USE IN TUBERCULOSIS

4. DISCUSSION
Our results provide population-based evidence that
there is no association between cavitary disease in TB
patients with frequency and quantity of alcohol use (esti-
mated as total lifetime alcohol use, use within 30 days and
6 months before diagnosis, and daily drinking).
The host’s immune status influences the clinical presen-
tation of TB, which can vary from asymptomatic infection
to progressive primary TB, to disease reactivation and
parenchymal lung destruction with cavitary disease. Cav-
itary disease in adult patients with TB is associated with
the predominance of T-helper (Th)2 CD41 cells in the
alveolar fluid (Mazzarella et al., 2003). Tumor necrosis-a
(TNF-a) enhances MTB control in the presence of a pre-
dominant Th1 CD41 response (Flynn and Chan, 2001;
Starkenburg et al., 2001); however, it can cause significant
tissue damage in combination with a Th2 CD41 response
(Mazzarella et al., 2003). Alcohol enhances the Th2 CD41
response (MacGregor, 1986; Malin and McAdam, 1995;
Nelson et al., 1995; Roselle, 1992; Szabo, 1999), and blunts
the MTB-induced elevation of serum TNF-a levels in ex-
perimental models of the infection (Nelson et al., 1995). In
humans, alcohol has been shown to decrease TNF-a–in-
duced macrophage mycobactericidal activity and decrease
TNF-a levels in alveolar fluid in patients with MTB infec-
tion (Nelson et al., 1995), which could explain the increased
risk of TB disease observed among patients who use alco-
hol (MacGregor, 1986; Nelson et al., 1995). The lack of
association between alcohol use and cavitary disease in
our study population may be explained by the presence of
decreased levels of TNF-a in the alveolar fluid, coupled
with a predominantly Th2 CD41 response, induced by
alcohol (Balasubramanian et al., 1994; Flynn and Chan,
2001; Jo et al., 2003; Mazzarella et al., 2003; Nelson et al.,
1995).
Multiple studies have shown an increased risk of acquir-
ing TB infection and developing active TB disease in
individuals who drink alcohol at various levels of use
(Chapman and Claydon, 1992; Friedman et al., 1987;
Jacobson, 1992; Moss et al., 2000; Tekkel et al., 2002),
and that alcohol use is also associated with a higher risk of
respiratory failure and death in patients with TB disease
(Barnes et al., 1988; Zafran et al., 1994). Three additional
studies have investigated the association of alcohol use and
radiological severity of pulmonary TB. In a survey per-
formed among adults receiving treatment in a TB clinic in
Australia, investigators found that alcohol use (arbitrarily
defined as 410 drinks/d) was associated with a higher
frequency of cavitation in chest X-ray (Milne, 1970).
Radiologically more advanced pulmonary TB disease was
found to be more frequent among unmarried alcoholic
men diagnosed with TB disease in a Swedish clinic
(Homdahl, 1967). However, none of these studies quanti-
fied alcohol use taking into consideration factors such as
drinking days/week or years drinking to evaluate the effect
of the amount of lifetime alcohol use or performed an
analysis adjusting for other variables such as homeless-
ness, age, gender, smoking, and other medical conditions,
such as diabetes mellitus, known to be associated with
severity of TB disease and cavitary lesions in chest radio-
graphy. In a retrospective chart review of patients
admitted to a Dallas hospital with pulmonary infections
among male adults, the authors found an increased
incidence of pulmonary TB in alcoholic patients,
compared with nonalcoholic patients. The frequency of
TB cavitary disease in alcoholic patients was not different
from that of nonalcoholic patients (Carpenter and
Huang, 1991). In this study, however, alcohol use was not
Table 2. Variables Associated With Cavitary Disease on the Basis of
Multivariate Logistic Regression Analysis for the Alcohol Use Within 30
Days (n 5 1,240) or Within 6 Months (n 5 1,241) of Cavitary TB Disease
Diagnosis
Variable
Alcohol use
within 30 days
Alcohol use
within 6 months
OR (95% CI) p-value OR (95% CI) p-value
Male gender 1.00 (0.75–1.34) 0.956 1.02 (0.74–1.34) 0.990
Foreign birth 0.83 (0.62–1.12) 0.240 0.84 (0.63–1.13) 0.260
Homeless 1.27 (0.91–1.76) 0.146 1.28 (0.92–1.77) 0.133
Education greater
than high school
0.74 (0.55–1.00) 0.054 0.74 (0.55–0.99) 0.049a
Incarceration 0.98 (0.72–1.34) 0.910 0.98 (0.72–1.34) 0.924
Smoker 1.22 (0.90–1.66) 0.190 1.23 (0.91–1.68) 0.169
Diabetes mellitus 1.62 (1.19–2.21) 0.002a
1.60 (1.18–2.18) 0.002a
Lung cancer 0.43 (0.15–1.23) 0.116 0.41 (0.14–1.19) 0.104
Renal failure 0.54 (0.25–1.18) 0.126 0.54 (0.25–1.17) 0.121
COPD 0.72 (0.45–1.14) 0.166 0.71 (0.45–1.12) 0.145
Alcohol useb
1.20 (0.92–1.57) 0.156 1.14 (0.87–1.50) 0.326
a
Variables that were independently associated With cavitary disease.
b
Within 30 days or within 6 months, respectively.
OR, odds ratio; COPD, chronic obstructive pulmonary disease.
Table 3. Variables Associated With Cavitary Disease on the Basis of
Multivariate Logistic Regression Analysis for the Number of Years of
Alcohol Use (n 5 1,227) and Daily Alcohol Use (n 5 1,235)
Variable
Years of alcohol use Daily alcohol use
OR (95% CI) p-value OR (95% CI) p-value
Male gender 0.99 (0.73–1.33) 0.950 1.02 (0.76–1.37) 0.864
Foreign birth 0.82 (0.61–1.10) 0.200 0.83 (0.62–1.12) 0.229
Homeless 1.26 (0.91–1.75) 0.150 1.25 (0.90–1.74) 0.175
Education greater
than high school
0.74 (0.55–1.99) 0.049a
0.75 (0.56–1.01) 0.059
Incarceration 0.97 (0.71–1.33) 0.870 0.98 (0.72–1.34) 0.944
Smoker 1.23 (0.90–1.68) 0.170 1.25 (0.92–1.70) 0.141
Diabetes mellitus 1.62(1.19–2.21) 0.002a
1.61 (1.18–2.20) 0.002a
Lung cancer 0.42 (0.14–1.21) 0.109 0.41 (0.14–1.19) 0.103
Renal failure 0.47 (0.21–1.05) 0.060 0.47 (0.21–1.04) 0.065
COPD 0.74 (0.46–1.18) 0.210 0.74 (0.46–1.18) 0.209
Alcohol useb
1.00 (0.99–1.01) 0.441 1.06 (0.81–1.40) 0.643
a
Variables that were independently associated with cavitary disease.
b
Years of alcohol use or daily alcohol use, respectively.
OR, odds ratio; 95% CI, 95% confidence interval; COPD, chronic
obstructive pulmonary disease.
36 MORAN ET AL.

5. quantified, the diagnosis of alcoholism was made
retrospectively, it was not a population-based study, and
adjustment for variables such as homelessness, diabetes,
age, gender, or race was not reported. To our knowledge,
our study is the first population-based study that
explores the association between chronic alcohol use, total
lifetime alcohol use, and TB cavitary disease (Bacakoglu
et al., 2001; Erwin and Miller, 2000; Perez-Guzman et al.,
2000).
Diabetes mellitus was independently associated with
cavitary disease. Our findings are in agreement with those
of previous studies in which patients with diabetes mellitus
were found to have a high frequency of cavitation in all age
groups (Aktogu et al., 1996; Perez-Guzman et al., 2000)
and particularly in insulin-dependent diabetic patients
(Bacakoglu et al., 2001). An education level greater than
high school was also significantly associated with or
showed a trend toward less cavitary disease. This finding
is similar to previous studies in which patients with higher
education levels tend to seek medical attention earlier and
therefore present with milder disease (Tekkel et al., 2002).
Reports suggest that, in addition to having a greater
frequency of TB, patients who use alcohol present with
more severe disease (requiring mechanical ventilation
more frequently that patients who do not drink) and have
a higher mortality rate (Barnes et al., 1988). We did not
study such variables, given the nature of the available data.
In the present study, quantity and frequency of alcohol
use, assessed as daily drinking, lifetime use, and years
drinking, were not associated with more severe pulmonary
TB disease, defined as the presence of cavitation. We did
not find a temporal association between alcohol use and
cavitary disease, when the variables ‘‘alcohol use within
30 days’’ or ‘‘alcohol use within 6 months’’ before diagnosis
were analyzed.
As our study is population-based, we believe that our
findings accurately reflect the effects of alcohol use in the
presence of cavitary disease in adults living in cities like
Houston. However, future studies should include the
evaluation of other indicators of extent and severity of dis-
ease in TB such as positive sputum smears, miliary TB,
and extensive alveolar infiltrates, which may be associated
with alcohol use, given its effects in the host immune
response to TB infection (Barnes et al., 1988). Attention is
also needed in addressing adherence and response to TB
treatment among patients who use alcohol, as it has
been recognized as a predictive factor of poor response
(Jacobson, 1992; Milne, 1970).
REFERENCES
Aktogu S, Yorgancioglu A, Cirak K, Kose T, Dereli SM (1996) Clinical
spectrum of pulmonary and pleural tuberculosis: a report of 5480
cases. Eur Respir J 9:2031–2035.
Bacakoglu F, Basoglu OK, Cok G, Sayiner Ates M (2001) Pulmonary
tuberculosis in patients with diabetes. Respiration 68:595–600.
Balasubramanian V, Wiegeshaus EH, Taylor BT, Smith DW (1994)
Pathogenesis of tuberculosis: pathway to apical localization. Tuber
Lung Dis 75:168–178.
Barnes PF, Leedom JM, Chan LS, Wong SF, Shah J, Vachon LA, Over-
turf GD, Modlin RL (1988) Predictors of short-term prognosis in
patients with pulmonary tuberculosis. JID 158:366–371.
Buskin SE, Gale JL, Weiss NS, Nolan CM (1994) Tuberculosis risk
factors in adults in King County, Washington, 1988 through 1990.
Am J Public Health 84:1750–1756.
Carpenter Jl, Huang DY (1991) Community-acquired pulmonary
infections in a public municipal hospital in the 1980s. South Med J
84:299–306.
Chapman RC, Claydon SM (1992) Mycobacterium tuberculosis:
a continuing cause of sudden death in west London. J Clin Pathol
45:713–715.
Erwin M, Miller C (2000) Decreased natural killer cell responses and
altered interleukin-6 and interleukin-10 production in alcoholism:
an interaction between alcohol dependence and African–American
Ethnicity. Alcohol Clin Exp Res 24:560–569.
Flynn JL, Chan J (2001) Immunology of tuberculosis. Annu Rev
Immunol 19:93–129.
Friedman LN, Sullivan GM, Bevilaqua RP, Loscos R (1987) Tubercu-
losis screening in alcoholics and drug addicts. Ann Rev Respir Dis
136:1188–1192.
Holmdahl SG (1967) Four population groups with relatively high
tuberculosis incidence in Goteburg 1957–1964. Scand J Resp Dis
48:308–320.
Jacobson JM (1992) Alcoholism and tuberculosis. Alcohol Health Res
World 16:39–45.
Jo E, Park J, Dockrell H (2003) Dynamics of cytokine generation in
patients with active pulmonary tuberculosis. Curr Opin Infect Dis
16:205–210.
Lauzardo M, Ashkin D (2000) Phthisiology at the dawn of the new cen-
tury: a review of tuberculosis and the prospects for its elimination.
Chest 117:1455–1473.
MacGregor RR (1986) Alcohol and immune defense. JAMA 256:
1474–1479.
Malin AS, McAdam KPWJ (1995) Escalating threat from tuberculosis:
the third epidemic. Thorax 50:37S–42S.
Mazzarella G, Bianco A, Perna F, D’Auria D, Grella E, Moscariello E,
Sanduzzi A (2003) T lymphocyte phenotypic profile in lung segments
affected by cavitary and non-cavitary tuberculosis. Clin Exp Immunol
132:283–288.
Milne RC (1970) Alcoholism and tuberculosis in Victoria. Med J Aus-
tralia 2:955–960.
Moss AR, Hahn JA, Tulsky JP, Daley CL, Small PM, Hopewell PC
(2000) Tuberculosis in the homeless. A prospective study. Am J Respir
Crit Care Med 162:460–464.
National Institute on Alcohol Abuse and Alcoholism (2003) The Physi-
cian’s Guide to Helping Patients With Alcohol Problems, 2nd ed.,
Department of Health and Human Services, National Institutes of
Health, National Institute on Alcohol Abuse and Alcoholism,
Bethesda, MD, USA. Publication no. NIH 03–3745.
Nelson S, Mason C, Bagby G, Summer W (1995) Alcohol, tumor
necrosis factor, and tuberculosis. Alcohol Clin Exp Res 19:
17–24.
Perez-Guzman C, Torres-Cruz A, Villareal-Velarde H, Vargas MH
(2000) Progressive age-related changes in pulmonary tuberculosis
images and the effect on diabetes. Am J Respir Crit Care Med 162:
1738–1740.
Rehm J, Greenfield TK, Walsh G, Xie X, Robson L, Single E (1999)
Assessment methods for alcohol consumption, prevalence of high
risk drinking and harm: a sensitivity analysis. Int J Epidemiol 28:
219–224.
Roselle GA (1992) Alcohol and the immune system. Alcohol Health Res
World 16:16–22.
37
ALCOHOL USE IN TUBERCULOSIS

6. Starkenburg S, Munroe MW, Waltenbaugh C (2001) Early alteration in
leukocyte populations and Th1/Th2 function in ethanol-consuming
mice. Alcohol Clin Exp Res 25:1221–1230.
Szabo G (1999) Consequences of alcohol consumption on host defense.
Alcohol Alcohol 34:830–841.
Tekkel M, Rahu M, Loit HM, Baburin A (2002) Risk factors for pul-
monary tuberculosis in Estonia. In J Tuberc Lung Dis 6:887–894.
Tiruviluamala P, Reichman LB (2002) Tuberculosis. Annu Rev Public
Health 23:403–426.
Yaganehdoost A, Graviss EA, Ross MW, Adams GJ, Ramaswany S,
Wanger A, Frothingham R, Soini H, Musser JM (1999) Complex
transmission dynamics of clonally related virulent Mycobacterium
tuberculosis associated with barhopping by predominantly Human
Immunodeficiency Virus—positive gay men. J Infect Dis 180:
1245–1251.
Zafran N, Heldal E, Pavlovic S, Vuckovic D, Boe J (1994) Why do our
patients die of active tuberculosis in the era of effective therapy?
Tubercle Lung Dis 75:329–333.
38 MORAN ET AL.