(Vol.73 No.12 December 1998) <1> Kekkaku Vol.73,No.12:697-704,1998 THE FIRST-THREE YEAR REPORT OF THE TUBERCULOSIS CONTROL PROJECT, LUMBINI, RUPANDEHI Hidenori MASUYAMA*, Akira TAKASE, Masakazu AOKI, Tadao SHIMAO The Tuberculosis Control Project, Lumbini, Rupandehi (TCPLR) is a bilateral cooperative venture between two NGO's, the Nepal Anti-Tuberculosis Association (NATA) and the Japan Anti-Tuberculosis Association (JATA), which consists of planning and implementing pilot tuberculosis control activities in Lumbini, Rupandehi district in Nepal, aiming at achieving high cure rate of newly detected smear-positive pulmonary tuberculosis patients before introducing DOTS strategies. Between December 1993 and July 1996, 349 tuberculosis(TB) cases were enrolled in the TCPLR. The categories of cases were as follows:138 cases (40%) of new smear-positive pulmonary TB [new Sm(+) PTB], and 54 cases (15%) of smear positive pulmonary TB other than new Sm(+) PTB [other Sm(+) PTB] including such cases as continued treatment and relapse, 106 cases (30%) of new smear-negative TB [new Sm(-) TB], and 51 cases (15%) of other smear-negative TB other than New Sm(-) PTB [other Sm(-) TB]. The number and proportion of new Sm(+) PTB cases enrolled in the project have been increasing [6 cases (23%) for the first year, 102 cases (54%) for the third year] although the proportion is still low (40% overall). The regimens of chemotherapy in the initial intensive and the continuation phases of treatment according to the categories of TB were as follows: New Sm(+) PTB;2HRZE(S)/6HE, other Sm(+) PTB;2HRZES/1HRZE/5HRE, and Sm(-) TB;2HRZ/6HE. The proportion of cases treated by the appropriate regimen of chemotherapy has increased. The cohort analysis of the teratment outcome of the cases enrolled in the project showed the following. The proportion of cured cases plus smear-unconfirmed cases completing treatment among new Sm(+) PTB was 74% overall, however, the proportion of defaulters increased in the third year. The proportion of cured cases plus smear-unconfirmed cases completing treatment among other Sm(+) PTB cases was 66% overall, which is slightly lower than that of new Sm(+) PTB cases, however, the difference was not so marked. The proportion of treatment completed cases among smear-negative pulmonaly TB cases was 77% overall, however, proportion of defaulters increased in the third year. The teratment outcome in this report was obtained before the adoption of DOTS strategies: However, is showed that cure and teatment completion rates were comparable to those obtained in the SEARO countries which adopt DOTS starategies. The treatment outcome could be improved after the introduction of DOTS strategies in 1997. Key words:International cooperation, NGOs, Tuberculosis, DOTS, Cohort analysis, Nepal *From the Dai-ichi Dispensary, Japan Anti-Tuberculosis Association (JATA), 1-3-12 Misaki-cho, Chiyoda-ku, Tokyo 101-0061 Japan. (Received 19 Jun. 1998/Accepted 8 Aug. 1998) <2> Kekkaku Vol.73,No.12:705-711,1998 CLINICAL ANALYSIS OF FOREIGN PATIENTS WITH TUBERCULOSIS FOUND IN CHUGOKU-SHIKOKU AREA Yoshihiro KOBASHI*, Toshiharu MATSUSHIMA, Shin KAWAHARA, Atsuhiko TADA, Shinji SHISHIDO, Shuichi YANO, Eriko SHIGETOU, Tomoyuki YOKOSAKI, Haruaki TOMIOKA, hiroyasu TAKEYAMA, Kazutaka NISHIMURA, Masahiro SHIODE, Hiroo UEDA, Toshihiko KURAOKA, Kyousuke INBA In this study, we investigated 45 foreign patients who had been diagnosed as having tuberculosis in Chugoku-Shikoku area during the past 12 years. Regarding regional characteristics, in Hiroshima prefecture an epidemic of tuberculosis was experienced among patients coming from South America, but antituberculous therapy was performed for 87% of the patients because of the high coverage of the health insurance scheme. But in Okayama prefecture, most of the patients were female and came from Asian countries, such as, the Philippines. Antituberculous therapy was not performed for nine patients because of no coverage of the health insurance scheme. In the other prefectures, only a few cases of tuberculosis were experienced , but in Yamaguchi prefecture two of three foreign patients were multidrug-resistant tuberculousis. Key words:Tuberculosis of foreigners, Acid-fast bacilli examination, Antituberculous therapy, Regional Characteristics *From the Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki City, Okayama 701-0192 Japan. (Received 13 May 1998/Accepted 10 Aug. 1998) <3> Kekkaku Vol.73,No.12:713-718,1998 A TUBERCULOSIS EPIDEMIC AMONG FOUR RELATIVES WHO LIVE IN THE NEIGHBORHOOD OF INDEX CASE. Hiroko SAKAMOTO*, Riyo FUJIYAMA, Hisashi OHNISHI, Toshiyasu SAKURAI, Kimihide TADA, Hiromi TOMIOKA, Hironobu IWASAKI, Hitoshi NAKAI. Miki OKAZAKI, Mieko CHIHARA, Mitsuo HIRAMI. A tuberculosis epidemic occured among 4 relatives who live in the neighborhood of the index case. A thirty-three year old female was admitted to a hospital in July 1994 with high fever and cervical lymphoadenopathy. Culture examination of her sputum was positibe for acid-fast bacilli and her chest X-ray showed diffuse small nodules. During the following sixteen months, five new patients with pulmonary tuberculosis were found among the relatives who lived in the neghborhood of the index case. The contact examination was first limited in her own family menbers, however, after detection of the second case, the examination was extended to other relatives living nearby, and another four patients were found. The results of PPD skin test of ten contact children showed strongly positive reaction, and chemoprophylaxis was indicated. Contacts examination is very important especially for patients with highly infectious tuberculosis. Key words:Tuberculosis, Epidemic, Outbreak of pulmonary tuberculosis in close families, Family contact examination, Contact Examination *From the Division of Respiratory Disease, Nishi-Kobe Medical Center, 5-7-1 Koujidai, Nishi-ku, Kobe 651-2273 Japan. (Received 27 Apr. 1998/Accepted 12 Aug. 1998) <4> Kekkaku Vol.73,No.12:719-722,1998 A CASE OF BRONCHIECTASIS WIHT ABUNDANT EXPECTORATION OF MYCOBACTERIUM GORDONAE Yutaka ITOU*, Yoshirou MOCHIZUKI, Yasuharu NAKAHARA, Tetsuji KAWAMURA, Shigeki WATANABE and Shin SASAKI A 68 year old woman consulted our hospital because of 6 month history of dry cough. Her chest X-ray revealed bronchiectasis in the left lung. Three sputum specimens were culture positive for acid fast bacilli(AFB) 200 colonies. The bacilli were scotochromogenic, niacin test was negative and hydrolysis of tween 80 was positive, and they were identified as M.gordonae. M.gordonae is ravely implicated as a pathogen but a few reports suggest it may be pathogenic. Though our patient had clinical symptom and expected abundant M.gordonae, her chest X-ray revealed no progression. Thus, it was hardly possible to consider this case as a case caused by the infection with M.gordonae. In preveous reports of M.gordonae pulmonary disease, chest X-ray findings showed cavity, infiltration and consolidation, however, no case with bronchiectasis was reproted and chest X-ray findings of this case are interesting. Key words:Mycobacterium gordonae, Bronchiectasis, Small nodules *From the Department of Pulmonary Medicine, National Himeji Hospital, Honmachi 68, Himeji 670-8520 Japan. (Received 2 Apr. 1998/Accepted 8 Jul. 1998) <5> Kekkaku Vol.73,No.12:723-725,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH Chairpersons:Fujiya KISHI*, Takuya KURASAWA** Symposium Topics and Presenters: 1. Evaluation on the clinical background on early death in patients with pulmonary tuberculosis during the past five years:Masaru AMISHIMA(Internal Medicine, National Sapporo Minami Hospital), et al. 2. A clinical study of causes of death from active pulmonary tuberculosis with chemo- therapy:Atsuo SATO, et al. (Respiratory Medicine, National Minami-Kyoto Hospital) 3. Report of national survey on death due to tuberculosis in 1994 in national hospitals and the treatment and prognosis of tuberculous patients with mechanical ventilation: Kazuko MACHIDA, et al. (Department of Respiratory Disease, National Tokyo Chest Hospital) 4. Evaluation of Home - Oxygen - Therapy for old tuberculosis cases, especially emphasis on the medical support for more comfortable life:Toshihiko KURAOKA, et al. (Internal Medicine, Kyosai-Yoshijima Hospital) 5. The causes of death of pulmonary tuberculosis:Late sequelae of pulmonary tuberculosis: Kazunori TOMONO(The 2nd Department of Internal Medicine, Nagasaki University, School of Medicine) In Japan, the rate of tuberculous death was 2.3:100 thousants population in 1996 and had been decreased gradually. But in recent years, the count of tuberculosis death has been about 3,000 per year. Concerning the epidemiology of tuberculosis in recent Japan, some problems such as the slowering tendency of decrease of incidence rate in youth and prime, the persistence of high incidence rate in aged population, the slight increase of rate positive smears and cultures and so on were pointed out. In this symposium, two viewpoints about acute phase (infection-related) and late phase (sequelae-related) death due to pulmonary tuberculosis (PTB) were discussed. First, Dr Machida, K. presented the summary of national survey on death due to tuberculosis in 1994, and pointed out the problems about tuberculous death in Japan. Second, Dr Amishima, M. and Dr Sato, A. presented the clinical problems of actue phase death with chemotherapy, third, Dr Machida, K. presented the problems of treatment of respiratory failure due to active PTB. Fourth, Dr Kuraoka, T. and Dr Tomono, K. presented about the late phase death. Dr. Kuraoka reported the results of home-oxygen- therapy to chronic respiratory failure due to healed PTB and Dr Tomono reported late complications such as respiratory failure, infection and malignancy. How to decrease the acute tuberculous death and how to control the sequelae are the problems to be resolved on tuberculosis, to which the methods of chemotherapy has been established. We think that this symposium were beneficial to understand the present status and to restart for the resolve of the presented problems. Key words:Tuberculous death, Respiratory failure, Far-advanced stage, Sequellae, Home-oxygen-therapy *From the Internal Medicine, National Sapporo Minami Hospital, Shirakawa 1814, Minami-ku Sapporo 061-2276 Japan. **From the Department of Respiratory Medicine, National Minami-Kyoto Hospital, Naka-ashihara 11, Joyo, Kyoto 610-0113 Japan. (Received 30 Sep. 1998) <5> Kekkaku Vol.73,No.12:727-731,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH 1. EVALUATION ON THE CLINICAL BACKGROUND ON EARLY DEATH IN PATIENTS WITH PULMONARY TUBERCULOSIS DURING THE PAST FIVE YEARS Masaru AMISHIMA*, Fujiya KISHI, Arisu KAMADA, Nariyoshi SAITO, Eiji HAMADA, Yasuo HIRAI and Masaaki SHINAGAWA We evaluated the clinical background of early death (within 3 months after admission to our hospital) in patients with active pulmonary tuberculosis durling the past five years(1992-1996). Among 65 active pulmonary tuberculosis patients who died during the past five years, 32 (49%) died directly of tuberculosis. Thirteen (41%) of those 32 patients died of acute respiratory faiture and 9 patients (28%) died in emacitation state. Twenty two patients (69%) died within 3 months after admission to our hospital (the early death group) and 10 patients (31%) died after 3 months (the late death group). Thirteen patients (59%) in the early death group died of acute respiratory failure. On the other hand, none in the late death group died of acute respiratory failure but 4 patients deid of chronic heart and/or respiratory failure and 4 patients died in emarciation state. Compared to the patients in the late death group, more patients in the early death group had long total delays (patient's and doctor's delays), had coexisiting diseases, had fallen into acute respiratory failure, and were under malnutrition. We evaluated the nutritional condition of patients using the Onodera's PNI (Prognostic Nutritional Index;10 x serum almumin concentration + 0.005 x peirpheral lymphocyte count) and the PNI value was lower among the patients in the early death group than among those in the late death group. To prevent death due to tuberculosis, we emphasize that it is important to start anti -tuberculosis therapy before patients fall into acute respiratory failure and/or malnutrition. Key words:Pulmonary tuberculosis, Cause of death, Acute respiratory failure, malnutrition, Prognostic nutritional index *From the Internal Medicin, National Sapporo Minami Hospital, 1814 Shirakawa, Minami-ku, Sapporo 061-2276 Japan. (Received 30 Sep. 1998) <6> Kekkaku Vol.73,No.12:733-738,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH 2. A CLINICAL STUDY OF CAUSES OF DEATH FROM ACTIVE PULMONARY TUBERCULOSIS WITH CHEMOTHERAPY Atsuo SATO*, Tetsuro INOUE, Takuya KURASAWA, Nobuaki IKEDA, Koichi NAKATANI, Takashi IKEDA, Takakazu YOSHIMATSU We evaluated retrospectively the causes of death from active pulmonary tuberculosis by the review of records and chest radiograohs of 364 patients (male 282, female 82) with active pulmonary tuberculosis, who were admitted to our hospital during 1995 to 1998. 43 patients (male 33, female 10) were died under anti-tuberculous chemotherapy. 20 cases were tuberculous death;death from acute progression of tuberculosis without response to chemotherapy (acute progression group) in eight cases and death from debility in spite of partial response to chemotherapy (debility group) in eight cases. 23 cases were died from underlying diseases;death from malignant neoplasmas (malignant group) in nine cases and death from complication of bacterial pneumonia (pneumonia group) in seven cases. In acute progression group, the age (mean}SE) was 64.8}5.2 years old and the survival period from admission was 11.8}4.2 days. Five cases were laborer or unemployed. This group was characterized with far advanced diseases presenting extensive lung lesions complicated with DIC or hepatic dysfunction, low performance status (PS), severe malnutrition and lymphocytepenia. In debility group, the age was 70.8}3.9 years old and the survival period from admission was 254.6}90.7 days. Five cases were laborer or unemployed. This group was characterized with multiple underlying deseases, low PS, previous anti-tuberculous chemotherapy and resistence to INH and/or RFP. In malignant group, the age was 69.3}3.2 years old and the survival period from admission was 99.9 } 21.2 days. This group was characterized with relatively well nourished, relatively good PS in comparison with other groups, and lymphocytepenia. In pneumonia group, the age was 82.8}1.7 years old and the survival period from admission was 153.3}54.5 days. This group was characterized with remarkably advanced age, low PS related to underlying disorders of central nervous system. In the causes of death with active pulmonary tuberculosis under chemotherapy, inhomogenous groups were included. Extensive disease, low PS, malnutrition, lymphocytopenia, previous chemotherapy, resistence to INH and/or RFP, and poorer social circumstances seemed to be risk factors for tuberculous death. In contrast, underlying malignant nepolasma, lower PS, and far advanced age were seemed to be the risk factors for non- tuberculous death. Key words:Tuberculous death, Performance status, Occupation, Social circumstances, Nutrition, Lymphocyte, Drug resistance aging *From the Respiratory Medicine, National Minami-Kyoto Hospital, 11 Naka-ashihara, Joyo, Kyoto 610-0013 Japan. (Received 30 Sep. 1998) <7> Kekkaku Vol.73,No.12:739-745,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH 3. REPORT OF NATIONAL SURVEY ON DEATH DUE TO TUBERCULOSIS IN 1994 IN NATIONAL HOSPITALS AND THE TREATMENT AND PROGNOSIS OF TUBERCULOUS PATIENTS WITH MECHANICAL VENTILATION Kazuko MACHIDA*, Tuyoshi TANAKA, Tomomasa TSUBOI, Yoshiko KAWABE, Toru KATAYAMA, Masashi MORI 1. National survey on died patients with active tuberculosis (tbc) or tbc sequelae had been held in national hospitals every five year from 1959 (3433 cases) to 1994 (688 cases). In 1994 330 patients died due to pulmonary tbc. Recent study revealed the decreased rate of death due to operation, or far advanced cavitary cases, and the increased rate of nontuberculous death, aged people (>60 yrs), and nontuberculous complications. Main causes of death in pulmonary tbc were lung insufficency (about half) and general weakness (almost one fifth) in any survey. Rapid progression of pulmonary tbc had been increased cause of death (20.9% in 1994). Main attributable factors of death in 1994 in pulmonary tbc cases were severe condition on admission (38.4%), disturbed lung function (31.2%) and old age (33.2%). Delayed treatment (13.9%) and complications (12.1%) were increasing factors. Early death within 3 months from onset in 1994 was seen in patients<60yrs as well as in patients> 80yrs. Severity due to delayed treatment and rapid progression were supposed to the causes of early death. 2. During 1994 to 1997, mechanical ventilation (MV;>24hours) was applied to 18 patients with active pulmonary tuberculosis;10 acute respiratory failure (ARF), 5 chronic respiratory failure (CRF), 2 central nervous system tbc and 1 hemoptysis. Only 1 ARF case and three CRF ones survived. ARF cases had low Pao2/FIO2(about 100), low albuminemia, short MV period (7 cases:<7 days) and steroid therapy (9 cases). CRF cases had higher Pao2/FIO2(294), longer MV period (4 cases:>30 days) and all CO2 narcosis. 3. Nonivasive positive pressure ventilation (NIPPV) was applied to 23 patients with pulmonary tbc sequelae. In 13 patients with stable chronic respiratory failure (mean Pao2 91mmHg, Paco2 82mmHg) 10 continued NIPPV and started home mechanical ventilation (HMV). In 10 patients with acute on chronic respiratory failure (mean Pao2 61mmHg, Paco2 92mmHg) 2 patients fell into tracheal intermittent positive pressure ventilation (TIPPV). Eight patients recovered with NIPPV and 5 started HMV. NIPPV is supposed to be very effective to treat severe chronic hypercapmic respiratory failure. Key words:Death due to tuberculosis, Active pulmonary tuberculosis, Mechanical ventilation, Pulmonary tuberculosis sequela(e), Respiratory failure, Noninvasive positive pressure ventilation(NIPPV) *From the Department of Respiratory Diseases, National Tokyo Chest Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo 204-8585 Japan. (Received 30 Sep. 1998) <8> Kekkaku Vol.73,No.12:747-749,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH 4. EVALUATION OF HOME-OXYGEN-THERAPY FOR OLD TUBERCULOSIS CASES, ESPECIALLY EMPHASIS ON THE MEDICAL SUPPORT FOR MORE COMFORTABLE LIFE Toshihiko KURAOKA*, Hiroshi MURAI, Naoki OKAMOTO We investigated the home-oxygen-therapy (HOT) for old tuberculosis patients. Tuber- culosis cases are 100 of 296 all home-oxygen-therapy during the period from Aug. 1986 to Dec. 1997. 36 dead cases of these 100 were evaluated. Average period for HOT was 988 days (32.9 months). The mean rate of home stay was 78.9%. HOT is very useful for sup- porting comfortable home stay life. Our Medical respiratory Care (MRC) system is consist of primary education on HOT start, respiratory rehabilitaion, mass education, annual rehabilitation trip and home nursing. Our MRC team is consist of 2 doctors, 12 nurses, 3 physical therapists, a dietician, a pharmacist and a medical clerk. We consider that it's important to support more comfortable life of the patients with chronic respiratory distress syndrome due to old tuberculosis. Key words:Old tuberculosis, Home-oxygen-therapy, Medical respiratory care system, More comfortable life *From the Internal Medicine, Kyosai-Yoshijima-Hospital, Yoshijima-higashi- -3-2-33, Naka-ku, Hiroshima 730-0822 Japan. (Received 30 Sep. 1998) <9> Kekkaku Vol.73,No.12:751-754,1998 The 73rd Annual Meeting Symposium śM. TUBERCULOUS DEATH 5. THE CAUSES OF DEATH OF PULMONARY TUBERCULOSIS LATE SEQUELAE OF PULMONARY TUBERCULOSIS Kazunori TOMONO* We investigated the causes of death of late sequelae of pulmonary tuberculosis. Chronic respiratory failure is one of the most frequent cause of death in the patients of late sequelae of pulmonary tuberculosis. We conpared the long term prognosis of chronic respiratory failure in case of emphysema and pulmonary tuberculosis. In the patients with chronic respiratory failure by pulmonary emphysema, the prognosis was poor in those with pulmonary hypertension. But in case of late sequelae of pulmonary tuberculosis, prognosis was not affected by presence or absence of pulmonary hypertension. The determinants of prognosis of late sequelae of pulmonary tuberculosis are the indication of home oxgen therapy, malnutrition, and hypoxemia. Fungal infection, especially aspergilloma, is a common secondary infection of late sequelae of pulmonary tuberculosis. We invesigated forty-two cases of aspergilloma as late sequelae of pulmonary tuberculosis, and of those 15 patients died. The causes of death were pneumonia and respiratory failure. Measurement of galactomannan antigen of aspergillus in serum using ELISA or PCR, it was apparent that the outcome was poor in the patients positive for antigen. It sugested that the prognosis of the patients with aspergilloma related with some degree of invasion of Aspergillus in parenchyma. It was reported that neoplasm is closely related to chronic tuberculous empyema. Lymphoma is most frequently complicated with chronic tuberculous empyema, and squamous cell carcinoma, adenocarcinoma, sarcoma and carcinoid were reported as complication of chronic empyema. We reproted the case of angiosarcoma, originated from chronic empyema in left thoracic cavity formed after being treated for tuberculosis with atificial pneumothorax. Recentlly, the number of patients with late sequelae of pulmonary tuberculosis have been decresed, but some severe cases of patients of pulmonary tuberculosis will suffer from late sequelae of pulmonary tuberculosis, and thaat is still a great problem of the clinical course of pulmonary tuberculosis. Key words:Tuberculous death, Late sequelae of pulmonary tuberculosis, Chronic respiratory failure *From the Second Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501 Japan. (Received 30 Sep. 1998)