(Vol.74 No.12 December 1999) <1> Kekkaku Vol.74,No.12:843-847,1999 CHANGE ON CHEST CT FINDINGS OF "PRIMARY INFECTION OF PULMONARY MYCOBACTERIUM AVIUM COMPLEX" *Yutaka ITOU, Yoshirou MOCHIZUKI, Yasuharu NAKAHARA, Tetsuji KAWAMURA, Sigeki WATANABE, and Shin SASAKI *Department of Pulmonary Medicine, National Himeji Hospital We reviewed the chest CT findings of 15 patients with "primary infection of Mycobac- terium avium complex". All of them were female and the average age of them was 64.9 years old. They received no or only insufficient therapy. Comparing the chest CT findings followed up for the average of 60.9 months interval, only three patients showed clear progression. All of the cases with less than three lobes involved at the onset unchanged or improved. On the radiographic features at the onset, small nodulousor infiltrative shad- ows were seen in all patients, and bronchiectasis in three patients. Cavity was not seen. The lesions of 12 patients were located in the right upper lobe, 13 patients in the right middle lobe and 14 patients in the left lingula. Mild and limited cases may have poten- tial with no or very slow progression, and case by case selective treatment should be con- sidered. Key words:Mycobacterium avium complex, Primary infection, Chest CT, No treatment *68, Honmachi, Himeji-shi, Hyogo 670-8520 Japan. (Received 31 May 1999/Accepted 10 Sep. 1999) <2> Kekkaku Vol.74,No.12:849-854,1999 AN OUTBREAK OF MYCOBACTERIUM TUBERCULOSIS INFECTION AMONG YOUNG ADULTS IN CLOSE CONTACT *Yuka SASAKI, Fumio YAMAGISHI, Takenori YAGI, Fuminobu KURODA, Hideki YAMATANI, and Hideaki SHODA *Division of Thoracic Disease, National Chiba Higashi Hospital We experienced an outbreak of tuberculosis among young adults in close contact. The index case (case 1) was 22-year-old builder and was symptomatic for 9 months before di- agnosis as pulmonary tuberculosis (PTB). His sputum smear was positive for tubercle ba- cilli. On immediate family contacts examination carried out at our hospital, his brother and sister (case 3, case 4) were detected as having PTB. His mother (case 5) and father (case 6) were later detected as having PTB by their symptomatic visits after some months, as tuberculin test as not done at first examination. Case 7 was 19-year-old-man, and was undiagnosed for 5 months. His sputum smear was positive. Immediately, contacts examination for case 7 as carried out at our hospi- tal, and his colleague (case 8) was detected as having PTB. By interview with the case 7, it was found that the case 1 and the case 7 were close friends and spent long time to- gether. Case 10 was 30-year-old builder, and he was accidentally referred to our hospital and was diagnosed as PTB. By the interview with the case 10, it was found that the case 1 and case 10 were members of builders group. This fact was informed to the F health cen- ter, and contacts examination for other members of the group were carried out by the F health center, and two young men were detected as having PTB. Analysis of restriction fragment length polymorphism (RFLP) showed that the case 1, the case 5, the case 7, and the case 10 were caused by the same strain of M.tuberculosis. Based on these findings, it is highly suspected that this outbreak was origined from the case 1, and 13 developed tuber- culosis and 13 were primarily infected among contacts. The characteristics of this outbreak was that the family and contacts examination were enforced and most of the cases were detected at our hospital. If the outbreak of tuberculosis highly suspected, physicians should actively cooperate with health centers for contacts examination. Key words:Outbreak, Tuberculosis, Contacts examination *673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (Received 12 Jul. 1999/Accepted 22 Sep. 1999) <3> Kekkaku Vol.74,No.12:855-861,1999 AN EPIDEMIOLOGIC STUDY ON THE INCIDENCE RATE OF TUBERCULOSIS IN TOCHIGI PREFECTURE *Masayo KOBAYASHI *Ansoku Public Health and Welfare Center, Prefectural Government of Tochigi The purpose of the study is to clarify chronological changes and the regional difference of the incidence of tuberculosis in Tochigi Prefecture. The difference between the first pe- riod (1980-1984) and the second period (1990-1994) was analyzed. The results are as follows; 1. The decrease of incidence in the age groups of 20-29 years and over 70 years slowed down in all types of tuberculosis and infectious pulmonary tuberculosis. 2. The incidence of tuberculosis in the southern part of Tochigi Prefecture was higher than in the other parts, and this could be explained by the fact that the people in the southern part were exposed heavier to tuberculosis infection in the past than the people in other parts. 3. In the public health center areas where the incidence rate of tuberculosis was high, the slow decline or even increase of the incidence rate among age groups less than 30 years and over 70 years of age was observed and this seemed to affect the higher inci- dence in these areas. Key words:Tochigi Prefecture, Tuberculosis incidence, Chronological change, Regional difference *1-2006, Ohashi-cho, Ashikaga-shi, Tochigi 326-0051 Japan. (Received 19 Jul. 1999/Accepted 1 Oct. 1999) <4> Kekkaku Vol.74,No.12:863-868,1999 OUTBREAK OF TUBERCULOSIS AMONG MIDDLE AGED EMPLOYEES IN AN OFFICE 1*Tomoyo NARITA, 2Yoko NAGATA, and 3Kazuko UEMA 1*Sakuradai Branch of Nerima-ku Public Health Center, 2Itabashi-ku Itabashi Health and Welfare center, 3Public Health Promotion Division, Bureau of Public Health, Tokyo Metropolitan Government We experienced an outbreak of tuberculosis in a salesmen's office during the period from 1993 to 1997. The outbreak was detected retrospectively. In July, 1997, a 47-year-old man was diagnosed as pulmonary tuberculosis. As he worked with a 42-year-old man who was already registered in our health center, we suspected an outbreak and started a survey. Contact examinations were carried out for 9 employees of his office and 3 mem- bers of his friends. As the result of these examinations, one employee showed strongly positive tuberculin skin test, and was indicated isoniazid chemoprophylaxis. Furthermore, some contacts told us that seven cases of active tuberculosis and three cases of primary infection indicated chemoprophylaxis had occurred among employees and their family members. The index case was a 41-year-old man who was diagnosed as tuberculosis in January, 1993. The second case among employees had previous history of pulmonary tu- berculosis. Almost the patients among the employees had a hard life suffering from debts, and had heavy alcohol use. These facts may partly explain the spread of tuberculosis in this office. As each case was registered at different health centers, we hadn't noticed the outbreak for 4 years. But it is true that insufficient approach of health centers to contacts caused a serious delay of detecting the outbreak. A thorough investigation for contacts and com- plete contact examinations are needed. Key words:Pulmonary tuberculosis, Outbreak, Middle age, Contact examination, Office, Health center *2-22-15, Toyotamaue, Nerima-ku, Tokyo 176-0011 Japan. (Received 25 Jun. 1999/Accepted 20 Sep. 1999) <5> Kekkaku Vol.74,No.12:869-872,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS Chairpersons:1*Takashi ARAI 2Kotaro OIZUMI 1*National Hospital Tokyo Disaster Medical Center, 2Kurume University School of Medicine Symposium Topics and Presenters: 1. Effects of INH (isoniazid) inhalation in patients with endobronchial tuberculosis (EBTB):Soichiro YOKOTA and Keisuke MIKI (Department of Internal Medicine, Toneyama National Hospital) 2. Aerosolized therapy with streptomycin and steroids in treatment of bronchial stenosis due to endobronchial tuberculosis:Toru RIKIMARU and Kotaro OIZUMI (First Department of Internal Medicine, Kurume University School of Medicine) 3. Medical treatment for bronchial stenosis due to endobronchial tuberculosis:Noriaki TAKAHASHI and Takashi HORIE(First Department of Internal Medicine, Nihon Uni- versity, School of Medicine.) 4. Surgical treatment for tuberculous tracheobronchial stenosis: Masafumi KAWAMURA, Masazumi WATANABE, and Koichi KOBAYASHI (Department of Syrgery, School of Medicine, Keio University) 5. Surgical treatment and endobronchial stentplacement for tuberculous tracheobronchial strictures:Yutsuki NAKAJIMA and Yuuji SHIRAISHI (Department of Chest Surgery, Fukujuji Hospital, Japan Anti-Tuberculosis Association) The bronchial tuberculosis is recently becoming more frequently observed, although the number of the patients of pulmonary tuberculosis have been rapidly decreased. Since the bronchial tuberculosis have sometimes no pulmonary lesions which indicates the presence of tuberculosis, the correct diagnosis happens to be delayed and it leads to the serious complications with cicatrical stricture of the bronchus. Establishment of standard methods of the prevention and treatment of the bronchial tuberculosis is required. The methods were discussed in this symposium for prevention and treatment of bronchial stenosis in tuberculous patients. Development of bronchial stenosis depends on the stage of the disease at the beginning of treatment and also the method of the treatment. It is the most ideal, if the method of prevention of the stenosis is established. Inhalation therapy with aerosolized anti-tuberculous drugs is one of the most expected method for prevention of the stenosis. It was concluded that aerosol inhalation of anti- tuberculous drugs was effective for prevention of stenosis by both S. Yokota and T. Rikimaru. By the comparison between systemic chemotherapy alone and systemic chemotherapy combined with corticosteroids, N. Takahashi suggested the combined chemotherapy was use- ful for prevention of stenosis. Once the development of cicatrical stenosis was completed, dilatation followed by stenting or surgical treatment might be necessary. Y. Nakajima and M. Kawamura dis- cussed concerning this problem. Dilatation with laser therapy alone for cicatrical stenosis was temporarily effective, but it resulted necessarily in recurrence of stenosis. Stenting methods were also not indicated for prevention of stenosis, since it might dis- turb the healing of active bronchial lesion. The results of surgical procedures were reported by Y. Nakajima and also by M. Kawamura. Standard method of surgery was bronchoplasty with or without resection of the lobe. Surgical treatment aimed mainly for improvement of lung function and preven- tion of pneumonia. Both Y. Nakajima and M. Kawamura showed that the lung function test after bronchoplasty revealed apparent improvement of FEV1 and FEV1%. It was concluded by both symposists that surgery should be done after an adequate period of chemotherapy. It was also necessary for minimize the occurrence of post-operative compli- cations, which have been decreased by various technical improvement for prevention. In this symposium it was considered to be necessary to standardize the classification of the stage of the disease and degree of the stenosis, for comparing the effectiveness by vari- ous procedures of prevention or treatment. Key words:Bronchial stenosis, Tuberculosis, Prevention, Treatment *3256, Midori-cho, Tachikawa-shi, Tokyo 190-0014 Japan. (Received 18 Oct. 1999) <5> Kekkaku Vol.74,No.12:873-877,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS 1.EFFECTS OF INH (ISONIAZID) INHALATION IN PATIENTS WITH ENDOBRONCHIAL TUBERCULOSIS (EBTB) *Soichiro YOKOTA and Keisuke MIKI *Department of Internal Medicine, Toneyama National Hospital The effects of INH (Isoniazid) inhalation on clinical findings were studied retrospec- tively in 39 patients with endobronchial tuberculosis (EBTB). The diagnosis of EBTB and the assessment of bronchial stenosis were based on broncho- scopic examination. We divided the patients in two groups:13 patients had been treated with only systemic chemotherapy of lung tuberculosis, and 26 patients had been treated with systemic chemotherapy and INH inhalation (INH 200 mg/day). As a result, there were no significant differences between both groups for duration of sputum culture positive and until ESR normalization. However, a significant improve- ment in bronchial stenosis and reduction of respiratory symptoms were seen in patients treated with systemic chemotherapy and INH inhalation. In conclusion, INH inhalation in addition to standard chemotherapy of lung tuberculosis is useful to prevent bronchial stenosis for the patients with EBTB. Key words:Endobronchial tuberculosis, Isoniazid, Aerosol therapy *5-1-1, Toneyama, Toyonaka-shi, Osaka 560-8552 Japan. (Received 18 Oct. 1999) <6> Kekkaku Vol.74,No.12:879-883,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS 2.AEROSOLIZED THERAPY WITH STREPTOMYCIN AND STEROIDS IN TREATMENT OF BRONCHIAL STENOSIS DUE TO ENDOBRONCHIAL TUBERCULOSIS *Toru RIKIMARU and Kotaro OIZUMI *First Department of Internal medicine, Kurume University School of Medicine We had reported that aerosolized thrapy with streptomycin and steroids is useful for ulcerative EBTB. However, the effectiveness of this therapy for bronchial stenosis has yet to be clarified. This study was undertaken to determine the effectiveness of aerosolized streptomycin and steroids in the treatment of bronchial stenosis due to EBTB. We performed flexible bronchoscopy in 64 patients with active erosive or ulcerative EBTB. Flexible bronchoscopy was performed at least twice in 54 patients, 27 patients treated with conventional therapy and 27 patients treated with aerosol therapy. In those, we estimated the degree of bronchial stenosis between the first and last bronchoscopic ex- aminations. We compared conventional therapy with aerosol therapy to clarify the use- fulness of aerosol therapy for bronchial stenosis. We graded bronchial stenosis as minimal, mild, moderate, severe, or obstructive. We assessed the follow-up of bronchial stenosis as aggravation, no change, or improvement, using the first and last endoscopic findings. "Improvement" was defined as the last endoscopic findings improving by at least two grades. "Aggravation" was defined as the last endoscopic findings worsening by at least two grades. Other cases were defined as "no change". Conventional therapies led to aggravation in 13 patients, no change in 13 patients, and improvement in 1 patient. Aerosol therapy led to no change in 24 patients, improvement in 3 patients. No patients developed aggra- vation. The differences between the therapeutic groups were significant. We concluded that aerosol therapy with streptomycin and steroids helps to treat bronchial stenosis due to ulcerative EBTB. Key words:Endobronchial tuberculosis, Aerosol therapy, Streptomycin, Bronchial stenosis *67, Asahimachi, Kurume-shi, Fukuoka 830-0011 Japan. (Received 18 Oct. 1999) <7> Kekkaku Vol.74,No.12:885-889,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS 3. MEDICAL TREATMENT FOR BRONCHIAL STENOSIS DUE TO ENDOBRONCHIAL TUBERCULOSIS *Noriaki TAKAHASHI and Takashi HORIE *First Department of Internal Medicine, Nihon University, School of Medicine. It is needless to say that early diagnosis and appropriate treatment for endobronchial tuberculosis are most important, and bronchoscopic examination is necessary for early di- agnosis. Although endobronchial tuberculosis frequently causes bronchial stenosis, there are no specific therapies to prevent the complication. To determine the effectiveness of corticosteroids in the prevetion of complication of endobronchial tuberculosis, this study was undertaken. 18 patients with endobronchial tuberculosis whose bronchoscopic findings showing ulcer formation or endobronchial polyp, out of 35 patients with endobronchial tuberculosis who were treated in Nihon University hospital from 1996 to 1998, were evalu- ated to determine the effectiveness of corticosteroids in the prevention of bronchial stenosis. We divided the patients into 2 groups:11 who received systemic chemotherapy for tuberculosis only, and 7 who received systemic chemotherapy combined with oral corticosteroid. No significant differences distinguished the groups with respect to dura- tion of positive sputum culture or reduction of respiratory symptoms. However, a signifi- cant alleviation of bronchial stenosis was observed in the patients who received systemic chemotherapy combined with oral corticosteroid. This study suggested that corticosteroid therapy in addition to standard chemotherapy for tuberculosis was effective for preven- tion of complication of endobronchial tuberculosis, such as bronchostenosis. Key words:Endobronchial tuberculosis, Bronchial stenosis, Medical treatment, Corticosteroied *30-1, Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610 Japan. (Received 18 Oct. 1999) <8> Kekkaku Vol.74,No.12:891-896,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS 4.SURGICAL TREATMENT FOR TUBERCULOUS TRACHEOBRONCHIAL STENOSIS *Masafumi KAWAMURA, Masazumi WATANABE, and Koichi KOBAYASHI *Department of Surgery, School of Medicine, Keio University Thirty-nine patients with bronchial tuberculosis underwent bronchoplastic surgery. The modes of procedures were left upper sleeve lobectomy in 13 patients, sleeve resection of the left main bronchus in 11 patients, sleeve resection of the left main bronchus with concomitant left upper lobectomy in 2 patients, right upper sleeve lobectomy in 6 pa- tients, sleeve resection of the right intrmediate bronchus in 2 patients, right sleeve supe- rior segmentectomy of the lower lobe in one patient, sleeve resection of the trachea with concomitant left pneumonectomy in one patient, left lower sleeve lobectomy in one pa- tient, carinal resection with right upper sleeve lobectomy and middle lobectomy in one patient, and dilatation of the left main bronchus with a free skin graft reinforced with a steel wire in one patient. There were one operation death and one operation related death in 1950's. FEV1.0% of 12 patients whose records of pulmonary function tests per- formed before and after surgery were available, were increased significantly from 67 } 10 % to 82 } 8% in average. Three patients of laryngotracheal stenosis due to tuberculosis were treated with silicon T-tube. In 2 patients their stenotic lesions were repaired by stenting only, for 36 and 56 months. In one patient, T-tube could not be removed due to laryngeal malacia for more than 12 years. Key words:Tuberculosis, Tracheobronchial stenosis, Bronchoplasty, Stent, T-tube *35, Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan. (Received 18 Oct. 1999) <9> Kekkaku Vol.74,No.12:879-905,1999 The 74th Annual Meeting Symposium U. PREVENTION AND TREATMENT OF BRONCHIAL STENOSIS 5. SURGICAL TREATMENT AND ENDOBRONCHIAL STENTPLACEMENT FOR TUBERCULOUS TRACHEOBRONCHIAL STRICTURES *Yutsuki NAKAJIMA and Yuuji SHIRAISHI *Deparment of Chest Surgery, Fukujuji Hospital, Japan Anti-Tuberculosis Association [Materials and Results] We have seventeen cases of operation for the tuberculous tracheobronchial cicatric strictures. Ten of them were tracheobronchial reconstructions to the strictures, and other seven cases were resections of the peripheral destroyed or in- fected pulmonary tissues (lobectomy 1, pneumonectomy 6). In the reconstruction seven cases were of sleeve lobectomy (left 6, right 1), three were of segmental resection of left main bronchus and trachea. The results were good in 6 sleeve lobectiomies and 2 segmental resections of left main bronchus. All these 8 cases had no marked tracheal strictures, and their postoperative troubles were mild. Two cases with tracheal stricture (left sleeve lobectomy and tracheal segmental resection with left pneumonectomy) suffered from post- operative major complications. In the former the tracheal stentplacement was needed for a long time, in the latter its tracheal anastomosis was disrupted and the patient died six months later. Peripheral pulmonary resections could get the good results to disappear their longstanding various symptoms and signs. We tried to do the endoscopic dilatation or stenting to three tracheal strictures. One case was treated by the endoscopic electocauteries and baloon dilatations totally in 15 times, but its late prognosis was poor and the patients died of the ventilatory disturbance 53 months later. Another one was the case of left upper sleeve lobectomy with tracheal stricture, and already mentioned its tracheal stent. In the third case the tracheal wall was damaged so deeply and extensively that the tracheomalacia might cause to suffocate. Then the tracheal stricture had been dilated with several sized stents step by step, finally a silicon long T-tube was inserted into the trachea successfully. But 10 days later a hard mucous plung impacted inside the tube and the patient died. In recent Japanese literatures and meeting reports, there were sixty cases of endoscopic surgeries and stentplacement for tuberculous tracheobronchial strictures. In these cases about half ones were for the left main bronchus, one third for the trachea. In the former the rupture of bronchial wall happened in 6%, the dislocations of stent in 22% and restrictures came out in 26%. In the latter the complication death occurred in 14%, stent dislocations in 30% and restrictures in 46%, so it was only 30% to become to be free form tracheal stents. [Conclusions] For the treatment of tuberculous cicatric tracheobronchial strictures, the reconstruction of main bronchus in cases without marked tracheal stenosis is a good indication to regain the lost pulmonary function. The resection of peripheral lung is also a good indication to reduce many symptoms and signs from them. However various endoscopic tretments involving stentplacement has not been established yet enough, especially in a point of late prognosis, so we have to be careful to do such procedures. The new apparatus with more durable and easily handled will be expected to develop in near future. Key words:Tuberculosis, Tracheobronchial stricture, Bronchial reconstruction, Bronchofiberscope, Stent *3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8522 Japan. (Received 18 Oct. 1999)