(Vol.77 No.4 April 2002) <1>Kekkaku Vol.77, No.4:329-339, 2002 Original Article DISCUSSING THE CURRENT SITUATION OF TUBERCULOSIS CASE-FINDING BY MASS MINIATURE RADIOGRAPHY IN JAPAN 1Masako OHMORI, 1Masako WADA, 1Kazuhiro UCHIMURA, 2Kenji NISHII, 3Yoshinobu SHIRAI, and 4Masakazu AOKI Abstract The system of tuberculosis(TB) case-finding by mass miniature radiography(MMR) was established and expanded for almost all Japanese citizens in the 1950s. And, as stipulated by the TB Prevention Law, periodic mass screenings for schools, inhabitants, employees and institutions have been carried out. Among those aged over 25 years, the proportion of people screened by MMR was estimated to be 60.3%. This means that about 54 million people aged over 25 years are receiving medical service with MMR every year. However, the detection rates of TB cases by MMR have declined markedly compared with those in 1950s. As of 1998, the detection rate was 0.03 per 1,000 for school children and students, 0.06 per 1,000 for employees, and 0.16 per 1,000 for inhabitants. The proportion of cases detected by MMR among newly notified TB cases was 12.8% in 1998, and this ratio has been almost constant for the last 10 years. This ratio was greater among young adult TB cases. Approximately 20% of notified TB cases aged 20-39 years were detected by MMR for employees. Although the purpose of MMR is to find the cases before discharging TB bacilli, 35.1% of the cases were bacteriologically confirmed, and this proportion was greater among elderly TB cases. The Japan Anti-Tuberculosis Association (JATA) has been carrying out MMR for a long time, Eight selected branches of JATA that has been doing high quality case-finding reported 228 TB cases out of 965,440 inhabitants aged over 40 years examined by MMR in 1996. Based on these results, the cost per TB case detected by MMR was calculated. The cost was 4.4 millions yen (\) per case for all of TB, \2.3 millions for male, \8.4 millions for female, \7.3 millions for those aged 40-49 years and \1.8 millions for those aged over 80 years. TB detection rate by MMR for inhabitants was correlated with TB incidence rate in various areas, and based on this correlation, the cost was calculated for various incidence rates. For all forms of TB, the cost was \4.0 millions per case for an incidence rate of 30 per 100,000, and \6.7 millions for an incidence rate of 20 per 100,000. MMR is not economically cost-effective even among elderly people and in areas with incidence rate less than 50 per 100,000, because the medical expense for a TB patient treated under hospitalization for 2 months and outpatient's clinic for 4 months is approximately \0.9 millions in 1996. The decision making in continuation or abolition or limitation of MMR should be discussed from a wide range of cost-effectiveness analyses as well as from the view of public health service and willingness of people. For the purpose of decision making, this study provides the detection rates; the costs stratified by sex, age and incidence; and the proportion of cases detected by MMR among newly notified TB cases by age-group and bacteriological status. Key words:Tuberculosis, Notification rate, Incidence rate, Case-finding, Mass miniature radiography (MMR), Detection rate, Cost-effectiveness analysis 1Research Institute of Tuberculosis, 2Department of Respiratory Medicine, Okayama Institute of Health and Prevention, 3Chiba Anti-Tuberculosis Association, 4Japan Anti-Tuberculosis Association Correspondence to:Masako Ohmori, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (E-mail:ohmori@jata.or.jp) <2>Kekkaku Vol.77, No.4:-, 2002 Original Article INVESTIGATION ON PREVENTIVE MEASURES OF TUBERCULOSIS INFECTION AND ONSET OF TUBERCULOSIS IN NURSING HOMES FOR THE AGED Shinji SHISHIDO and Toru MORI Abstract The need to strength on preventive measures of tuberculosis infection in Japanese medical institutions (include nursing homes) has been discussed in recent several years. The actual performance of measures to prevent the spread of tuberculosis infection among employees in hospitals has gradually become clearer, and various trials to improve the performance have simultaneously been made. However, actual performance of these preventive measures has not yet become clear in nursing homes for the aged. Therefore, we assessed actual status of preventive measures of infection and the incidence of tuberculosis among employees and residents in nursing homes for the aged where there are many elderly persons who are almost bed ridden, and we intended to solve problems in preventive measures for tuberculosis in welfare facilities for the aged. Measures to prevent infection were well considered in a few facilities, but these measures were in general not sufficient. The incidence of tuberculosis among employees and residents were lower compared with these in the agematched general population, however, it could be possible that there was no responses from the welfare facilities where outbreak of tuberculosis was present. We outlined the essential points for concrete measures to prevent tuberculosis infection in nursing homes for the aged. Key words:Nursing home, Tuberculosis, Nosocomial infection, Prevention of tuberculosis infection The Research Institute of Tuberculosis, JATA Correspondence to:Shinji Shishido, The Research Institute of Tuberculosis, JATA, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (E-mail:sshishido@jata.or.jp) <3>Kekkaku Vol.77, No.4:347-354, 2002 Original Article THE FREQUENCY PROFILES OF SIZE OF TWO-STEP TUBERCULIN SKIN TESTS WITH HISTORIES OF BCG VACCINATIONS AND TUBERCULIN TESTS AMONG HOSPITAL EMPLOYEES 1Mitsunori HINO, 1Yasushi ONO, 1Yutaka KOKUBO, 1Tomoyuki SOMA, 1Yousuke Tanaka, 1Masatoshi OMATA, 1Kozo ICHINO, 1Takashi UEHARA, 2Shoji KUDOH, and 3Naoaki HAYAMA Abstract In 1998, Prevention Committee of the Japanese Society for Tuberculosis announced guidelines for dealing with nosocomial tuberculosis infections. These guidelines recommended the two-step tuberculin tests (TST) as baseline data for each medical employee when they started to work. If accurate records of previous TSTs are available in addition to baseline data, they are useful to evaluate the presence of tuberculosis infection when they started to work. We therefore studied the frequency profile of size of TST among medical employees in INBA-HITEC Medical Center and discussed methods to improve investigative measures for tuberculosis infection, and prior to skin testing we asked self-reporting questionnaires regarding history of previous BCG vaccinations and TSTs. We expected that their records of previous TSTs were accurately preserved, however, records of previous TSTs reported by medical employees were found to be inaccurate. From two-step TSTs results, the magnitude of booster phenomenon was defined by diameter of erythema and induration. Results demonstrated that the increase of induration size was larger in subjects 41-years-old than in subjects <41-years-old. Regarding booster phenomenon, no statistically significant differences were detected according to type of duty post. Many subjects with size of TST erythema 30 mm on the first test showed increase erythema 10 mm on the second test. We therefore suggest that the second test be made for those showing reaction size 30 mm on the first test. Key words:Two-step tuberculin skin test, Booster phenomenon, Hospital Employee 1Nippon Medical School INBA-HITEC Respiratory Center, 2Forth Department of Internal Medicine, Nippon Medical School, 3Committee for Nosocomial Infection, Nippon Medical School INBA-HITEC Medical Center Correspondence to:Mitsunori Hino, Nippon Medical School INBA-HITEC Respiratory Center, 1715 Kamakari, Inbamura, Inba-gun, Chiba 270-1964 Japan. (E-mail:hino@nms.ac.jp) <4>Kekkaku Vol.77, No.4:355-360, 2002 Report and Information THE CURRENT STATUS AND PROBLEMS OF THE INTESTINAL TUBERCULOSIS THROUGH A REVIEW OF THE ANNUAL OF THE PATHOLOGICAL AUTOPSY CASES IN JAPAN 1,2Hirofumi SUZUKI, 1Keiichi NAGAO, and 2Masaru MIYAZAKI Abstract Form 1997 to 1999 the incidence rate of tuberculosis increased and extrapulmonary tuberculosis has also increased during the same period. Among various types of extrapulmonary tuberculosis, intestinal tuberculosis is one of the diseases difficult to diagnose. Recently doctors could not make appropriate diagnosis of intestinal tuberculosis because they did not pay much attention to tuberculosis. With a background described above, we reviewed the Annual of the Pathological Autopsy Cases in Japan in previous five years 1994-1998, in order to investigate a current status of intestinal tuberculosis. Out of 140,358 autopsied cases, the number of cases with active and old tuberculosis was 5,103 (3.6%), in which the intestinal tuberculosis was accompanied in 80 (0.057%). The 80 cases were consisting of 45 males and 35 females and their mean age was 72.7 years old ranging from 28 to 96. Of the 80 intestinal tuberculosis cases, 71 were seen in pulmonary tuberculosis cases and six cases were considered to be intestinal tuberculosis alone. In terms of the location of intestinal tuberculosis the most commonly affected site was ileocecum which occupied 72.7% of all intestinal tuberculosis. Among the 80 cases, 14 cases were complicated with malignant tumor and only 30 cases (37.5%) were diagnosed clinically as intestinal tuberculosis before their death. Clinical diagnosis of other cases were ileus, simple constipation, severe diarrhea, malignant tumor or its tumor. The delay in diagnosing intestinal tuberculosis may result in fatal outcome in the aged persons, so that in general practice much attention should be paid not only to pulmonary but also extrapulmonary tuberculosis including intestinal tuberculosis. Key words:Intestinal tuberculosis, Annual of the Pathological Autopsy Cases in Japan. 1Health Sciences Center Chiba University, 2Department of General Surgery, Graduate School of Medicine, Chiba University Correspondence to:Hirofumi Suzuki, Health Sciences Center Chiba University, 1-33, Yayoi, Inage-ku, Chiba-shi, Chiba 263-8522 Japan. <5>Kekkaku Vol.77, No.4:361-366, 2002 Case Report A CASE OF MULTIPLE BONE AND JOINT TUBERCULOSIS WHICH HAD BEEN MISDIAGNOSED AS THE RHEUMATOID ARTHRITIS AND TREATED WITH PREDNISOLONE FOR ELEVEN MONTHS 1Etsu TSUDUKI, 1Hiroshi KAWADA, 1Yuichiro TAKEDA, 1Emiko TOYODA, 1Nobuyuki KOBAYASHI, 1Koichiro KUDO, 2Koji OSUKA, 2Hirofumi KUROKI, and 3Toyohiko MORITA Abstract A 34-year-old man had a multiple arthralgia for about eleven months. The swelling of his right wrist and foot had appeared in the dorsal side, and he had been misdiagnosed as the rheumatoid arthritis. He was treated with prednisolone in the dosages of 2.5 mg per day for one month, and 10 mg per day for ten months. When he admitted to our hospital, the bone X-ray examinations of the wrist and foot revealed the marked atrophy and destruction of the carpal and tarsal bones. The aspiration fluid from the swelling around his wrist and foot was positive for acid-fast bacilli on smear and Mycobacterium tuberculosis was found on culture. He was treated with isoniazid, rifampicin, ethambutol and pyrazinamide, however, these medication was not adequately effective to his complications of tuberculous arthritis. Curettage, irrigation and synovectomy of his right carpal and tarsal bone were performed in order to control his bone and joint infection. He recovered from his arthritis and tenosynovitis after these operations. The clinical practitioners should not omit tuberculosis from the differential diagnosis of persistent osteoarthralgia. Key words:Bone and joint tuberculosis, Rheumatoid arthritis, Corticosteroid, Pulmonary tuberculosis, Polyarthralgia 1Department of the Respiratory Medicine, 2Orthopedic Surgery, 3Pathology, International Medical Center of Japan Correspondence to:Etsu Tsuduki,Department of the Respiratory Medicine, International Medical Center of Japan, 1-21-1, Toyama, Shinjuku-ku, Tokyo 162-8655 Japan. (E-mail:etsuduki@imcj.hosp.go.jp) <6>Kekkaku Vol.77, No.4:367-371, 2002 Case Report A CASE OF PLEURAL MALIGNANT LYMPHOMA ASSOCIATED WITH CHRONIC TUBERCULOUS PYOTHORAX Natsuko TANIGUCHI, Atsuhiko FUKUOKA, Itsuto AMANO, Hideo OKAMURA, Hideaki TAKENAKA, Takeshi MORII, Yukinori OKAMOTO, Masanori YOSHIKAWA, Mitsuru KONISHI, Katsuhiko TSUKAGUCHI, Kaoru HAMADA, Takahiro YONEDA, and Nobuhiro NARITA Abstract We report a case of pleural malignant lymphoma associated with chronic tuberculous pyothorax. A 67-year-old male was hospitalized because of left lateral chest swelling and pain. He had suffered from pulmonary tuberculosis at the age of six and tuberculous pleurisy at the age of 24. We made a histologic diagnosis of malignant lymphoma diffuse large B-cell type. He was medicated THP-COP(THP, CY, VCR, PSL) therapy and his chest pain and swelling has improved gradually. From the view point of molecular biology, we detected Epstein-Barr virus (EBV) infection in the pyothorax wall. In conclusion, we should be more careful about medical examination in patients with EBV positive tuberculous pyothorax considering the complication of malignant lymphoma. Key words:Chronic pyothorax, Tuberculous pleuritis, Malignant lymphoma, Non-Hodgkin's lymphoma, Epstein-Barr virus Second Department of Internal Medicine, Nara Medical University Correspondence to:Natsuko Taniguchi, Second Department of Internal Medicine, Nara Medical University, 840 Shijo-cho, Kashihara-shi, Nara 634-8522 Japan. (E-mail:afukuoka@nmu-gw.naramed-u.ac.jp) <7>Kekkaku Vol.77, No.4:373-376, 2002 Case Report A CASE OF MULTIDRUG-RESISTANT (MDR) TUBERCULOSIS WITH COLLAPSE OF THE LEFT LUNG AFTER HEMOPTYSIS Yoshiyuki ABE, Satoshi KURITA, Yasuyuki OHKUBO, Toshinori HASHIZUME, and Tadahiko FUJINO Abstract An 82-year-old female was admitted to our hospital with multidrug-resistant (MDR) tuberculosis, defined as resistance to both isoniazid and rifampicin. Chest X-ray showed massive infiltrates with a large cavitary lesions in the left lung fields. No antituberculous agents were useful in improving her clinical condition and at 6th months after admission, she exhibited sudden onset of massive hemoptysis, which was successfully treated by bronchial artery embolization. After hemoptysis, her chest X-ray showed collapse of the left lung and computed tomography showed a coagula-like shadow in the left main bronchus, and sputum examination revealed no Mycobacterium tuberculosis colonies. The patient was discharged 5 months after the onset of hemoptysis. Key words:Mycobacterium tuberculosis, Multidrug-resistant (MDR), Hemoptysis, Atelectasis, Bronchial artery embolization Department of Respiratory Disease, National Sanatorium Kanagawa Hospital Correspondence to:Yoshiyuki Abe, Department of Respiratory Disease, National Sanatorium Kanagawa Hospital, 666-1, Ochiai, Hadano-shi, Kanagawa, 259-8585 Japan. (E-mail:abey@kanagawa.hosp.go.jp)