(Vol.74 No.2 February 1999) <1>Kekkaku Vol.74 No.2:83-90,1999 GLOBAL SITUATION OF TB AND ITS CONTROL Tadao SHIMAO* Tuberculosis occupies 4th place among major causes of death, and the number of new cases is estimated at 7.25 million in 1997, and 99% of TB deaths and 95% of new TB cases are seen in developing countries. TB had been brought under control in developed countries by applying modern TB control programme including chemotherapy, as basic health infrastructure was already well developed, and their economy can afford cost of control programme including TB drugs. The rapid decline of TB due to the success of TB control in deveolped countries had lowered the concern on TB, thus bought about the re- duction in research grant for TB and difficulty in bringing up successors engaging in TB control. Similar trend was seen also in developing countries, where TB still remains one of most improtant health problems due to poor quality of the programme caused by poorly developed health infrastructure including man-power, budget and institutions. New obstacles which hinder the smooth implementation of TB control programme have appeared, and they are the rapid expansion of global population, the move of population, the impact of HIV epidemic on TB and the multi-drug-resistant TB (MDRTB). The growth of population automatically increases the number of TB cases and gives heavier burden for TB control. TB has moved from developing to developed countries with the move of the population, and currently approximately half of new TB cases in developed countries is occupied by foreign-born patients. Among several opportunistic infections seen in AIDS cases, TB comes out first as the viru- lence of tubercle bacilli is much higher than the other germs causing opportunistic infec- tions. The pathogenesis of TB changes markedly among HIV positives, and the incidence becomes much higher, and the time interval from the primary infection to the disease, and that from the detection of the disease to death without any effective treatment are shortened, and the fatality rate becomes much higher. Because of the atypical clinical pic- ture, attenuated tuberculin sensitivity and high incidence of side-effects of TB drugs, in particular thiacetazone, clinical management of HIV positive TB is much more dificult than ordinary TB. MDRTB is produce by the bad quality of TB control, and by improving treatment com- pletion rate as well as the cure rate, decline in the prevalence of drug resistance, both primary and acquired, could be expected together with the decline of TB itself. WHO has made a great challenge with TB after the nomination of Dr Kochi to chief medical officer, TUB in 1989. Currently, Global TB Programme (GTB) is promoting so- called DOTS strategy of TB control, consisting of the committment of the government to give high priority to TB control, passive case-finding with sputum smear examination by microscopy, directly observed treatment by standardized short-course regimen of che- motherapy, well-organized logistics for TB drugs, and the provision of reporting and monitoring system of TB including the evaluation of treatment outcome by cohort analy- sis. Marked achievements have been obtained in several countries introduced DOTS strat- egy. Japan is asked to intensify its efforts in international cooperation in TB control. Key words:Global TB situation, HIV epidemic and TB, MDRTB, DOTS *From the Japan Anti-TB Association, 1-3-12, Misaki-cho, Chiyoda-ku, Tokyo 101-0061 Japan. (Received 18 Nov. 1998) <2>Kekkaku Vol.74 No.2:91-97,1999 PARAMETERS PELATING TO THE DEVELOPMENT OF RESIDUAL PLEURAL THICKENING IN TUBERCULOUS PLEURISY Naohiro NAGAYAMA*, Atsuhisa TAMURA, Atsuyuki KURASHIMA and Kouji HAYASHI To indentify predictive parameters for the development of residual pleural thickening in tuberculous pleurisy, we investigated 58 tuberculous pleurisy patients retrospectively who could be followed up until their chest roentgenogram no longer changed. The patients were devided into the following three groups according to the final configuration of pleu- ral space:group I costphrenic angle (C-P angle) of the affected side was completely or almost completely recovered (20cases), group II C-P angle became dull (20cases), group III pleural thickening of >2mm remained in the lateral chest wall above the diaphrag- matic dome level (18cases). Differences of the clinical, chest roentgenographic and labo- ratory data were compared between these three groups. There were no differences between groups I and II in all of the parameters compared, while there were some differences between groups I and/or II and group III. The mean age of group III (51.1}18.1y.o.)was significantly higher than that of group I (40.7}18.6y.o.)and group II (34.7}14.7y.o.) (p<0.05 and p<0.005 respectively). Glucose level in pleural fluid of group III (32}31mg /dl)was lower than that of group I (96}13mg/dl)and group II (86}21mg/dl)(p<0.001, respectively), while the levels of LDH, TP and ADA in pleural fluid were not different significantly among three grous. BSR (blood sedimentat ion rate )and CRP (C-reactive protein) were higher in group III (77}30mm/hr and 8.5}4.3mg/dl)than those in group I (45}23mm/hr and 4.1}5.4mg/dl)(p<0.01 and p<0.05, respectively). The level of albumin in serum was lower and that of globulim was higher, and consequently that of A/G ratio in group III (0.78}0.17)was lower than that of group I (1.15}0.16)and group II (1.10 }0.22)(p<0.001, respectively). It should be emphasized that the level of -globulin was higher in group III irrespective of the presence or absence of accompanying pulmonary tuberculosis. Most patients more than 40 years old with serum A/G ratio less than 0.95 belonged to group III (13/15 (87%)) while most of those with serum A/G ratio more than 0.95 belonged to group I or II (10/11 (91%)). Thus hyper (-) globulinemia and the inten- sity of inflammatory reaction in the whole boby and in the pleural space are the predic- tive factors for the development of residual pleural thickening in tuberculous pleurisy. Key words: Tuberculosis, Pleurisy, Pleural thickening, Hyper-globlinemia *From the Department of Internal Medicine, Tokyo National Chest Hospital, Takeoka 3-1-1, Kiyose City, Tokyo 204-8585 Japan. (Received 1 Jun. 1998/Accepted 21 Sep. 1998) <3>Kekkaku Vol.74 No.2:99-105,1999 CHARACTERISTICS OF THE MEDICAL STATUS AND LIVING CONDITIONS OF THE HOMELESS REGISTERED AS TUBERCULOSIS PATIENTS IN NAGOYA CITY Katsumi YAMANAKA*, Tomi AKASHI, Masaru MIYAO, Shin'ya ISHIHARA An Investigation by questionnaire was conducted in 1996 to know the tuberculosis (TB) status and living conditions of 50 homeless people registered as TB patients at one of Nagoya city`s 16 heatlth centers. 1. All patients had one or more symptoms of TB, 64% of them showed positive TB ba- cilli on smear, and 35.3% of them had a previous history of TB treatment. However, only 15.2% suspected they had TB at the onset of symptoms. 2. Main reasons of seeking medical treatment: 28.6% arrived by ambulance after fal- ling down from exhaustion, 25.7% had consulted with welfare agencies after the onset of symptoms, and 20.0% had been diagnosed during the treatment of other diseases. 3. When they were admitted to the hospital they had many concerns:29.0% loss of in- come, 19.4% living expenses, 19.4% smoking prohibition, 12.9% admission fee, and 9.7% privacy. 4. They lived in the following:42.9% construction camps, 20.2% parks or streets, 17.1 % single room occupancy hotels, 17.1% daily or monthly paid apartments, and 11.4% sauna baths. 5. Past medical histories of the subjects included 40.6% injuries by labor accidents, and 25.0% stomach ulcers. Current diseases were 15.6% mental diseases, 15.6% liver diseases, 15.6% diabetes mellitus, and 9.4% alcoholic dependance. Seventy percent of them con- sumed alcohol daily (average pure ethanol 125ml per day). 6. From the results outlined above, the following proposals relating to TB control of the homeless should be considered. 1)Educating the homeless as to the need for a health check when TB symptoms are present. 2)Opening a clinic for the homeless for easy access to consultation on TB. 3)Directly observed therapy, short-course, for TB in the homeless. 4)Health examination of the employees of single-room occupancy hotels and sauna baths which are used frequently by the homeless. 5)A fundamental countermeasure to deal with alcoholic dependancy among the home- less. Key words: Tuberculosis, Homeless, Living condition *From the Nagoya City Central School of Nursing, 1- 4-7 Aoi, Higashi-ku, Nagoya 461-0004 Japan. (Received 16 Jul. 1998/Accepted 1 Oct. 1998) <4>Kekkaku Vol.74 No.2:107-113,1999 NONTUBERCULOUS MYCOBACTERIAL DISEASE IN A GENERAL HOSPITAL Yuko AKITA*, Masayuki NISHIO, Ken MAENO, Yuka YAMADA, Yuji MASE, Kosho YOSHIKAWA, Takashi NIIMI, Shigeki SATO, Masahiko YAMAMOTO Annual incidence of nontuberculous mycobacterial (NTM) disease has been gradually in- creasing in the last 10 years in Japan. It is likely to encounter this desease not only in hospitals specialized in mycobacterial diseases but also in general hospitals. NTM were isolated from 97 cases between January 1990 and June 1996 at our hospital. Out of them, 41 patients were diagnosed as NTM disease. Mycobacterium avium complex (MAC) was the most frequent pathogens (68.3%) and M. kansasii (22%) was the next. Other pathogens were M.chelonae (4.9%), M.fortuitum (2.4%) and M.szulgai (2.4%). Results obtained in our hospital were very similar to the rates which have been reported previously. Pa- tients with MAC infection showed relatively poor prognosis (eight patients were died out of 28 patients with MAC) in this study compared with the cases reported in previous pa- pers, and this result could be explained by the severity of illness when they were admit- ted to our hospital, the insufficiency of the initial treatment which shuld be started with the combined use of three to four antibacterial drugs including clarithromycin, and to a low dosage of clarithromycin compared with conventionally adopted dosage. Unlike tuberculosis, human to human transmission is considered to be negligible in the case of NTM disease, and general hospitals are able to provide medical care to the patients with NTM disease. Rather, if general hospitals which are located in the region near to the pa- tients residence can play more active role in the treatment of NTM disease, it would be more beneficial to patients requiring long-term follow-up observation. Based on the result that similar therapeutic results were obtained for infections with other NTM as re- ported in previous papers, it is indicated that general hospitals are able to provide medi- cal care to patients with NTM disease if therapeutic regimens recommended by specialist are sufficiently understood and applied. Key words:Nontuberculous mycobacteriosis, Mycobacterium avium complex disese, Chemotherapy *From the Department of Respiratory Disease, Daido Hospital, Hakusui-cho 9, Minami-ku, Nagoya 458-0818 Japan. (Received 3 Jun. 1998/Accepted 12 Oct. 1998) <5>Kekkaku Vol.74 No.2:115-120,1999 A CASE OF PARTIAL ADDISON'S DISEASE ACTIVATEED WITH THE ADMINISTRATION OF RIFAMPICIN (RFP) Shoko OKUDAIRA*, Katuyoshi SHIMOJI, Yutaka YOGI, Satomi YARA, Atushi SAITO The patient was a 76 year-old female with tuberculous tendonitis, treated with anti- tuberculous drugs including rifampicin (RFP). About two weeks after the start of RFP, she noticed general malaise and started vomiting, and the laboratory data showed severe hyponatremia. Because of mild liver dysfunction, RFP was discontinued and her symp- toms gradually improved. Abdominal X-ray and CT showed swellings and calcifications of adrenal glands bilaterally. Serum ACTH level was high and cortisole, 17-OHCS, and 17-KS levels were normal. Her responce to rapid ACTH stimulation was blunted significantly. After another trial of RFP, she started to vomit and complain general malaise again. We diagnosed her as partial Addison's disease and adiministered hydrocortisone with RFP. After this treatment her improvement was rapid. It has been kown that RFP causes induction of enzymes in hepatic microsomes which increase the catabolism of glucocorticoids. To avoid the risk of adrenal insufficiency, pa- tients with insufficient adrenal hormone reserve should receive compensatory hydrocorti- sone while they are taking RFP. Key words:Partial Addison's disease, Rifampicin, Hepatic microsomal enzyme, Hyponatremia *From the Department of Internal Medicine, Yonabaru- Chuo Hospital, 2905 Yonabaru, Yonabaru-cho, Okinawa 901-1303 Japan. (Received 26 Jun. 1998/Accepteed 7 Sep. 1998) <6>Kekkaku Vol.74 No.2:121-124,1999 Commemorative Lecture of Receiving Imamura Memorial Prize ESTABLISHMENT OF THE QUANTITATIVE INTRATRACHEAL INFECTION MODEL OF EXPERIMENTAL MURINE MYCOBACTERIOSIS Norio DOI* An intratracheal infection method (IT) of experimental murine mycobacteriosis was de- veloped for an in vivo study of antimycobacterial agents. IT-model with either of M. bovis, M.tuberculosis or M.intracellulare exhibited a much more distinct lung-specific infection than intravenous model (IV) with the same dose of respective mycobacterial strains. Through a series of comparative studies of benzoxazinorifamycin (KRM) with rifabutin (RBT) or rifampicin (RFP) against murine tuberculosis models, therapeutic efficacy in the lungs of IT-model was superior to those of IV-model with the same dose of respective drugs(Fig.2). In IT-model of M.bovis Ravenel infection, three rifamycin derivatives gave "distinctive dose-response curves" in the correlation of dose sizes with the mean survival times or "log(10)CFU/lungs reductions". Moreover, based on the results of "log(10)CFU re- ductions" in different organs in M.tuberculosis Kurono infection models, "characteristic in vivo activity patterns of each rifamycin" was obtained. An outline of the new meth- ods for evaluating and characterizing the in vivo activities of antimycobacterial agents was presented in Fig.3. This IT-model may be useful not only for the in vivo assessment of antimycobacterial agents but also for the comparison of virulence among various mycobacterial atrains. Key words:Intratracheal infection, Intravenous infection, Mouse, Mycobacterium tuberculosis, Chemotherapy *From the Department of Basic Research, Research In- stiutute of Tuberculosis, Japan Anti-Tuberculosis Asso- ciation, 3-1-24, Matsuyama, Kiyose, Tokyo 204-8533 Japan (Receuved 4 Dec. 1998) <7>Kekkaku Vol.74 No.2:125-127,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS Chairpersons:Kotaro OISUMI*, Emiko TOYOTA** Panelist: 1. Diagnosis and Treatment of Mycobacterial Diseases in a Community General Hospital:Tadashi MATSUMURA, et al. (Maizuru Municipal Hospital) 2. The Problems of Management of the Patients Diagnosed Pulmonary Tuberculosis after Administration to the Respiratory Ward of University Hospital Having No an Isolation Ward for the Tuberculous Patients:Hitoshi HIRAOKA, et al (Res- piratory Department of Internal Medicine, Koshigaya Hospital, Dokkyo Univer- sity School of Medicine) 3. Current Status of Tuberculosis Patient Care in University Hospitals and General Hospitals in Japan:Shuji KURANE, et al. (4th Department of Internal Medi- cine, Nippon Medical School) 4. Actual Status of the Management of Tuberculosis Patients in a University Hos- pital without Isolation Wards for Infectious Diseases:Keiko KAKO, et al. (De- partment of Pulmonology and Allergology, Fujita Health University School of Medicine) 5. The Manegement of the Patients Excreting Tubercle Bacilli in a University Hos- pital without Isolation Ward for Tuberculosis:Harumichi KATO (Second De- partment of Internal Medicine, Aichi Medical University), et al. 6. Clinical Study on Pulmonary Tuberculosis Associated with Lung Cancer Patients :Akira WATANABE (Department of Respiratory Oncology and Molecular Medi- cine, Institute of Development, Aging and Cancer, Tohoku University), et al. Seven speakers from six institutes;one general hospital and five University hospital which have no isolation ward for tuberculous patient, discussed the problems in treating the patients with tuberculosis, especially smear-and/or culture-positive patients. After the presentations and discussion, the following conclusions were reached. One is that the most urgent subject to be dissolved at present is the education and training of the students and physicians so that they can make a rapid and definite diagnosis of tu- berculosis and treat the patient adequately. The solution of this problem will result in the prevention of out-break of tuberculosis by decreasing the incidence of doctor's delay in making diagnosis of active tuberculosis. The second problem which was mentioned by all the participants of the workshop in common is to prepare several rooms for the iso- lation of patients with active tuberculosis in a general ward. The rooms should be equipped with air conditioning devices with air filter. By utilizing the isolation room. it becomes possible to treat the tuberculous patients who are expectorating infectious sputa and are having severe underlying diseases. Key words:Isolation ward, Isolation room *From the First Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011 Japan. **From the Respiratory Department, International Medical Center of Japan, 1-21-1 Toyamacho, Shinjuku-ku, Tokyo 162-8655 Japan. (Received 3 Dec.1998) <8>Kekkaku Vol.74 No.2:129-131,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS 1.DIAGNOSIS AND TREATMENT OF MYCOBACTERIAL DISEASES IN A COMMUNITY GENERAL HOSPITAL Tadashi MATSUMURA*, Koji WATANABE 94 patients with tuberculosis were identified in a 236-bed community general hospital without a dedicated tuberculosis ward from June 1986 to February 1998. 69 patients had bacteriological proof of tuberculosis, and the remaining 25 had clinical evidence thereof. The mean age of all patients was 63.0 years (range:23`89 years), and the male to fe- male ratio was 2:1. 70 of these cases were admitted. During this same period of time, the total number of inpatients admitted to the internal medicine ward reached around 11,000. Excluding 6 cases who were referred to other hospitals with a tuberculosis ward, the mean duration of hospital stay of the remaining 64 cases was 51.6 days. Among all 94 cases, 62 had pulmonary tuberculosis and the other 32 had extra- pulmonary manifestations. The latter group was comprised of 11 with miliary dissemina- tion, 8 pleuritis, 4 osteomyelitis, 2 peritonitis, 2 urinary tract disease, 1 pericarditis, 1 intestinal disease, 1 meningitis, 1 intracranial tuberculoma and 1 genital disease. 3 cases of miliary tuberculosis with dissemination died with antemortem diagnoses of fever of unknown orgin, pneumonia, and lung cancer with brain metastasis. These 3 cases illus- trate the importance of heightened suspicion of tuberculosis among our patient popula- tion. Referral of patients with positive sputum smears to hospitals with a tuberculosis ward has occasionally been difficult because of inaccessibility. Critical comorbid diseases such as chronic renal failure requiring hemodialysis and malignancies are additional limiting factors to transfer to such facilities. Therefore, because of the prevalence and extent of this disease, its myriad clinical presentations, challenges associated with establishing an early diagnosis, and need to prevent spread to family, other patients, and staff, dedi- cated beds for care of tuberculosis in general hospitals are mandatory. Key words:Pulmonary tuberculosis, Extra- pulmonary tuberculosis, Miliary tuberculosis, Dedicated bed *From the Maizuru Municipal Hospital, 150-11, Aza- Mizoshiri, Maizuru, Kyoto 625-0035 Japan. (Received 3 Dec. 1998) <9>Kekkaku Vol.74 No.2:133-137,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS 2. THE PROBLEMS OF MANAGEMENT OF THE PATIENTS DIAGNOSED PULMONARY TUBERCULOSIS AFTER ADMINISTRATION TO THE RESPIRATORY WARD OF UNIVERSITY HOSPITAL HAVING NO AN ISOLATION WARD FOR THE TUBERCULOUS PATIENTS Hitoshi HIRAOKA*, Kaori HASHIMOTO, Atsuko AKIYAMA, Tokuro ABE, Hiroki FUJIWARA, Yousuke YAMAI, Ichirou MOTOMURA, Suguru OKUYAMA, Kousyu NAGAO The management of 28 patients, diagnosed pulmonary tuberculosis by bacteriological or pathologic findings after the administration to the Koshigaya Hospital of Dokkyo uni- versity school of Medicine from January 1994 through september 1997, which had no an isolation ward for tuberculosis patients was analyzed. The mean age of the patients was 50.6}16.7(18-85), and the number of male and female patients was 22 and 6 respec- tively. The underlying diseases found in 10 patients were gastric cancer, breast cancer, osteo- chondrosarcoma, collagen disease, diabetes mellitus, liver cirrhosis, pneumoconiosis, and bronchial asthma. Two patients were complicated by a lung cancer. Six of 28 patients showed smear-positive and culture-positive specimens and 22 of 28 patients showed smear-negative and culture-positive specimens. The detection of mycobacterial DNA in the samples after amplification by the polymerase chain reaction (PCR) used in 15 pa- tients and was positive for 7 of 15 patients. The pathological study of the specimens ob- tained by Transbronchial lung biopsy was performed for 14 patients. The pathological finedings were compatible with tuberculosis in 7 of 14 patients. The chief complaints of the 11 patients admitted to the hospital with in 3 days after first visit, were fever in all patients and in 5 patients with pleural effusion. A few patients showed smear- negative and PCR positive specimens and complicated by lung cancer or other mailgnancy, were treated in non isolation ward in the particular case of emergency evacuation befor admmission, careful examination such as a tuberculin test, bacterial examinaiton, and PCR of sputum should be performed in the patients suspected of having pulmonary tuber- culosis. The patients isolating tubercule bacilli afeter administration should be tranceferred to the hospital with isolated ward for tuberculosis or isolated room in gen- eral hospital in the particular case of emergency evacuation wiht the greatest care. Key words:General hospital, The respira- tory department of internal medicine, Tuberculosis, Hospital infection, Compromized host *From the Respiratory Depaartment of Internal Medi- cine, Koshigaya Hospital, Dokkyo University School of Medicine, 2-1-50 Minamikoshigaya, Koshigaya City, Saitama 343-0845 Japan. (Received 3 Dec. 1998) <10>Kekkaku Vol.74 No.2:139-143,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS 3. CURRENT STATUS OF TUBERCULOSIS PATIENT CARE IN UNIVERSITY HOSPITALS AND GENERAL HOSPITALS IN JAPAN Shuji KURANE*, and Shoji KUDOH A recent epedemiological survey has revealed that the incidence of Mycobecterium tu- berculosis (TB) patients in Japan has just increased again after four decades of decline. In fact, recently there have been numerous reports of TB outbreaks in health-care facili- ties. Although our medical school hospital does not have TB isolation rooms, we have to take care of more than a few TB patients, most of whom have been transferred from pri- mary care clinics. Although, some of these TB patients have highly infectious (sputum smear positive), most of them have not been diagnosed as having highly infectious TB, and threfore, some of their patients ultimately have to be retransferred to a TB hospi- tal. This indicates that most physicians in primary care clinics have little knowledge about TB. This may be partly because of lack of training regarding TB druing their medical student days and residencies. To elucidate current TB patient care status in uni- versity hospitals in Japan, a survey of physicians working in such hospitals was con- ducted from September 1997 to January 1998. The survey (questionnaire) revealed that the majority (76%) of these hospitals do not have TB isolation rooms. However, these hospitals have to take care or TB patients in their outpatient clinics and sometimes on their wards because the patients have serious complications that can not be treated in ordinary TB hospitals. The survey also showed that for this reason and from an educational point of view, the majority of the physi- cians (90%) working in these hospitals thought that university hospitals should have iso- lation rooms for such patients. Another questionnaire revealed that few physicians and nurses in university hospitals have sufficient experiences in taking care of TB patients. This situation may have been responsible for producing physicians with little knowledge about TB. Recent scientific advances have made it possible to construct TB isolation rooms in or- dinary wards by means of separate ventilation systems. Although combatting TB requires a variety of strategies, appropriate education for both medical students and residents using isolation rooms in university hospitals may be an effective means of preventing spread of TB, and this approach may also increase awareness concerning the prevention of TB outbreaks in hospitals and health-care facilities. Key words:Isolation room, University hos- pital, Infectious tuberculosis patients *From the 4th Department of Internal Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8602 Japan. (Received 3 Dec. 1998) <11>Kekkaku Vol.74 No.2:145-150,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS 4. ACTUAL STATUS OF THE MANAGEMENT OF TUBERCULOSIS PATIENTS IN A UNIVERSITY HOSPITAL WITHOUT ISOLATION WARDS FOR INFECTIOUS DISEASES Keiko KATO*, Hiroki SAKAKIBARA, Motohiko SATOU, and Susumu SUETSUGU We retrospectively evaluated clinical findings and the actual status of management of 69 tuberculosis patitents admitted to the Fujita Health University Hospital, a hospital without isolation wards for infectious diseases, between 1991 and 1994. Forty-nine pa- tients were smear-positive and 22 patients were smear-negative and culture-positive. Twenty-five cases (36.2%) were classified as typy II (cavitary) and 29 cases (42.0%) as type III (non-cavitary) according to the GAKKAI classification of findings on chest X- ray films for pulmonary tuberculosis. Physicians in charge did noto diagnose twenty-four patients (34.8%) as tuberculosis on admission. Physicians in charge tended not to suspect smear-negative patients of tuberculosis. Most of the patients with cavities on their chest X-ray films were strongly suspected of tuberculosis on admission, but in some of them, tuberculosis was not considered at all. Smear-positive patients with strongly suspected tuberculosis were diagnosed with the desease within three hospital days, while it took about three weeks in patients who were not considered as tuberculosis on admission to be diagnosed as tuberculosis. In the case of smear-negative patients. it took about one month and two months respectively to diagnose the case as tuberculosis. About half (51.1%) of the smear-positive patients were admitted and treated in single-bed rooms while 44.7% were attended in multiple-bed rooms for 11 days before they were trans- ferred to single-bed rooms. When acid-fast bacilli were detected, 57.4% of the smear-positive patients were transferred to hospitals with isolation wards for infectius diseases, while the remaining smear-positive patients were treated in single-bed rooms at the university hospital. About one-third (31.7%) of the smear-negative patients had already left the hospital when specimens were found to be culture positive for tubercle bacilli. In conclusion, it is utmost important for physicians to suspect to tuberculosis for the early diagnosis ot the disease. Key words:Pulmonary tuberculosis, Hospi- tal infection, Compromised host, Tuberculosis control program *From the Department of Pulmonology and Allergolo- gy, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake City, Aichi 471-1101 Japan. (Received 3 Dec. 1998) <12>Kekkaku Vol.74 No.2:125-127,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS 5. THE MANAGEMENT OF THE PATIENTS EXCRETING TUBERCULE BACILLIN A UNIVERSITY HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS Harumichi KATO*, Ei-ichi SAKURAI, Munehiko MORISHITA, Yoshio OKI, Kazuchika WATANABE, Tomoko KAWAJIRI, Hajime MIYARA, Yang SHANZHONG, Masakazu NITTA, and Masaharu INOUE The Japanese low ruled that the patients excreting tubercle bacilli should be treated in the isolated ward for tuberculosis. However, it is often difficult to transfer a patient with serious illness to the isolated ward with insufficient medical facilities. We investi- gated retrospectively the manner of the management of patients excreting tubercle bacilli in the Aichi Medical University Hospital without the isolation ward for tuberculosis. Materials were 166 patients (0.17%) out of 97,275 in-patients during 11years since 1986 to 1996. Respiratory symptoms were observed in 114 patients (68.7% of 166 pa- tients) on admission. The initial bacteriological examination was ordered by the attendant doctor within a week in 93 patients (81.6%) of 114 patients with respiratory symptoms. On the other hand, a half of the 52 patients without respiratory symptoms on admission were not examined for sputum bacteriology beyond a week. Anti-tuberculous treatment was started within a week after positive bacteriological results in 129 patients (77.7% of the whole 166 patients), while the treatment was not carried out or delayed in 21 patients (12.6%) because of the communication failure of the bacteriological report to the physicians. Some complications were observed in 101 patients:21 diabetes mellitus, 20 cancers, 15 hematological disorders, 9 collagen diseases, 6 renal failures on dialysis. Serious illnesses were observed in 33 patients (20.6% of the 166 patients). Twenty-four patients (73% of the seriously ill patients) were died of renal failure, pancytopenia, can- cer or respiratory failure. We considered that an isolated room for infectious tuberculosis with independent air conditioning system in a general hospital or a educational hospital was very convenient not only to the treatment of the patients with serious complications, but also to the edu- cation and training on tuberculosis for the medical student or medical stuffs. Key words:Tuberculosis ward, Tuberculo- sis bacteriological examination, Tuberculo- sis control measure, Molecular biological test *From the Second Department of Internal Medicine, Aichi Medical University, 21 Karimata, Yazako, Nagakute-cho, Aichi-gun, Aichi 480-1103 Japan. (Received 3 Dec. 1998) <13>Kekkaku Vol.74 No.2:157-162,1999 The 73rd Annual Meeting Workshop MANAGEMENT OF MYCOBACTERIOSIS IN GENERAL HOSPITAL WITHOUT ISOLATION WARD FOR TUBERCULOSIS PATIENTS CLINICAL STUDY ON PULMONARY TUBERCULOSIS ASSOCIATED WITH LUNG CANCER PATIENTS Akira WATANABE*, Yutaka TOKUE, Hiroshi TAKAHASHI, Ken SATO, Toshihiro NUKIWA, Yoshihiro HONDA, and Shigeru HUJIMURA Sixteen of 758 lung cancer in-patients (2.1%) were found to have coexisting pulmo- nary tuberculosis. Of the above 16 of 758 patients (fifteen men and one woman), 4 of 214 patients (1.9%) were found from 1988 to 1989, and 12 of 544 patients (2.2%) from 1991 to 1994. In six patients, pulmonary tuberculosis and lung cancer were found at the same time by clinical work up. In five cases each, pulmonary tuberculosis preceded lung cancer, and lung cancer preceded pulmonary tuberculosis, respectively. Ten patients had adenocarcinoma, 4 had squamous cell carcinoma, and one each had large cell carcinoma and small cell carcinoma, respectively. Five patients were in stage "II", one in "IIIa", two in "IIIb", and eight in "W" of clinical stage of lung cancer. As regards extent of pulmonary tuberculosis, one patient was in category "II" of the classification of the Japanese Society for Tuberculosis, 13 were in "III", and two were in "W". Among 544 lung cancer patients from 1991 to 1994, 9 of 151 patients (6.0%) with a past history of pulmonary tuberculosis, had active pulmonary tuberculosis, and 3 of 393 patients (0.8%) with no history of pulmonary tuberculosis, had active pulmonary tuber- culosis (statistically significant;p<0.005). Five smear-positive patients were transferred to a tuberculosis hospital or a tuberculosis ward, and the remaining 11 patients were treated in isolation in the ward where they were. The efficacy of anti-tuberculous chemo- therapy was almost comparable to that in patients without lung cancer. However, prog- nosis was poor, in line with that of lung cancer. Main discussion was devoted to the reason why the incidence (in asoociation with tu- berculosis) of adenocarcinoma exceeded that of squamous cell carcinoma in our present study at variance with the studies of other investigators. Key words:Lung cancer, Pulmonary tuberculosis, Complications, Adenocarcinoma, History(of Pulmonary tuberculosis) *From the Department of Respiratory Oncology and Molecular Medicine, Institute of Development, Aging and Cancer, Tohoku University, 4-1, Seiryo-cho, Aoba-ku, Sendai 980-8575 Japan. (Received 3 Dec. 1998)