(Vol.75. No.1 January 2000) <1> Kekkaku Vol.75, No.1: 1-7, 2000 BCG VACCINATION IN THE WORLD *Ichiro TOIDA *Japan BCG Laboratory BCG vaccination programme and BCG vaccination coverage in the world were summa- rized mainly based on the published informations from official organizations, such as World Health Organization (WHO), International Union Against Tuberculosis and Lung Disease (IUATLD) and Centers for Disease Control and Prevention (CDC). From this review, we can see how widely BCG has been used for the prevention of tu- berculosis in the world. In most of the developing countries, especially in Africa, the Americas, and Pacific Re- gion, BCG vaccination is carried out to newborn babies soon after birth by intradermal injection according to the recommendations from WHO, but some of the developing coun- tries in Asia and Europe have their own modified BCG vaccination programmes. In economically developed countries, BCG vaccination programme has been established according to the tuberculosis status of each countries. Some countries have general vacci- nation policy, and other countries have selected vaccination policy, but there is no coun- try where BCG vaccination is not carried out at all. Among G8 contries, as representatives of the economically developed countries, Japan, United Kingdom, France and Russian Fed- eration have BCG-general vaccination policy for the specified age group, In these 4 coun- tries revaccination(s) of BCG are still carried out. In Germany, some provinces have general vaccination policy and some others have selected vaccination policy. In the United States of America, BCG vaccination is recommended to selected high risk infants and health care workers by CDC. There are many debates as for the efficacy and safety of BCG vaccination, and the developement of new vaccine better than BCG has been actively discussed and some en- couraging results in animal models have been reported from several laboratories. But, there is almost no possibility to be able to use a new vaccine in the routine practice within a couple of years. From the practical point of view, therefore, the operational re- searches for the better and more appropriate usage of BCG are equally important and more practical than the researches for the development of new vaccines. Key words :BCG, BCG vaccination programme, BCG vaccination status * 3-1-5, Matsuyama, Kiyose-shi, Tokyo 204-0022 Japan. (Received . 16 Sep. 1999/Accepted 5 Nov. 1999) <2> Kekkaku Vol.75, No.1: 9-18, 2000 EFFECT OF SEROTYPE SPECIFIC GLYCOPEPTIDOLIPID(GPL) ISOLATED FROM MYCOBACTERIUM AVIUM COMPLEX(MAC) ON PHAGOCYTOSIS AND PHAGOSOME-LYSOSOME FUSION OF HUMAN PERIPHERAL BLOOD MONOCYTES *Yoshinori TAKEGAKI *Department of Bacteriology and Urology, Osaka City University Medical School Mycobacterium avium complex (MAC) is a typical intracellular parasite similar to M. tuberculosis and is one of the most important pathogens that coinfects AIDS patients. Attention has been focused on M. avium infection causing immunosuppression of hosts. Specific serotype-subspecies such as 1, -4 or -8 serotypes can be isolated frequently in humans nfected with HIV. Furthermore, the prognosis after infection differs depending on the serotype. Serotype-4 in general shows unfavourable prognosis, while serotype-16 yields rapid recovery. Therefore, we have been interested in the immunomodifying activ- ity of the surface glycopeptidolipid (GPL) antigen. However, no information has been available to date dealing on the virulent factor of MAC that is directly related with intracellular bactericidal activity. Recently, we have tried to test the effect of various GPLs purified from MAC on phagocytic processes of human peripheral blood monocytes (PBMC). We have used GPL-coated heat-killed staphylococcal cells to be phagocytosed by PBMC, and phagosome-lysosome fusion (P-L fusion) was estimated by the acridine orange staining of fused vesicles and bacteria. Results showed strong promotion of phagocytosis and marked inhibition of P-L fusion by serotype-4 GPL, while neither pro- motion of phagocytosis nor inhibition of P-L fusion in phagocytic cells were shown by serotype-16 GPL. Serotype-8 GPL showed concomitant stimulation of both phagocytosis and P-L fusion. These effects may be due to some unknouwn interaction between specific carbohydrate chain and organella membranes and serotype-4 GPL may be one of the possible virulent factors in MAC. Comparison with known possible virulent factors such as trehalose 6,6'-dimycolate (TDM), trehalose 6-monomycolate (TMM), glucose 6-mono- mycolate (GM) or sulfatide was also reported. Key words :Mycobacterium avium complex (MAC), Glycopeptidolipid (GPL), Phagocytosis, Phagosome-lysosome fusion *1-4-54, Asahi-machi, Abeno-ku, Osaka-shi, Osaka 545-0051 Japan. (Received 15 Mar. 1999/Accepted 4 Oct. 1999) <3> Kekkaku Vol.75, No.1:19-25, 2000 ISOLATION OF MYCOBACTERIUM AVIUM COMPLEX FROM THE "24-HOUR BATH" 1*Hajime SAITO, 1Kazuyasu MURAKAMI, 2Norihisa ISHII, and 3Han KWON 1*Hiroshima Environment and Health Association, 2Yokohama City University, 3Seoul Health College The "24-HOUR BATH" is an apparatus which circulates the bath water, keeps it clean and warm, and makes it possible to take a bath at any time during the day or night. It consists of apparatus for cleaning (sponge or mesh filter and filter amterial), heating (ceramic heather), and sterilizing (UV lamp). Recently, three cases of skin disease due to M. avium infection in private homes, in which "24-HOUR BATH" water was suspected to be the source of infection, have been reported. We attempted to isolate M. avium complex from the water (32 specimens), sponge filter (29 specimens), and filter material (32 specimens) of the "24-HOUR BATH". One hundred-ml samples of bath water, and 50-ml samples of rinse from a sponge filter or filter material were centrifuged at 3000 rpm for 20 min. Sediment was suspended in distilled water and a smear was prepared, and then digested and decontaminated with 2 % sodium hydroxide. The processed specimens were cultured on 2 % Ogawa medium containing ofloxacin (1ƒĘg/ml) and ethambutol (2.5ƒĘg/ ml) for 8 weeks at 37Ž. Positive smears were 3 (9.4%), 25 (86.2%) and 25 (78.1%) specimens from the water, sponge and filter material, respectively. A few bacterial clumps were observed, especially in the sponge specimens. The number of positive culture was 5 (15.6%), 24 (82.8%) and 25 (78.1%) from the water, sponge and filter material, respectively. Among them the number of Runyon's Group ‡V-positive cultures was 5 (100%), 22 (91.7%) and 20 (80%) in the water, sponge, and filter material specimens, respectively. In most cases, cultures were positive for both the sponge and filter material specimens. All of the Group ‡V mycobacteria were smooth, grew at 28, 37, 42, and 45 Ž, negative for niacin, nitrate reductase, semiquantitative catalase, urease and Tween 80 hydrolysis, and positive for 68Ž catalase. All of the strains reacted with M.avium com- plex AccuProbe and M.avium AccuProbe, but none of the strains reacted with M. intracellulare AccuProbe. Therefor, all the Group ‡V isolates were identified as M.avium by the culture, biochemical and genetical characteristics. Key words :Mycobacterium avium complex, Mycobacterium avium, "24-HOUR BATH" *9-1, Hirosekita-machi, Naka-ku, Hiroshima-shi Hirosima 730-8631 Japan. (Received 29 Jul. 1999/Accepted 4 Oct. 1999) <4> Kekkaku Vol.75, No.1: 27-31, 2000 TWO-STEP TUBERCULIN SKIN TEST IN NURSE STUDENTS AND HOSPITAL EMPLOYEES *Eriko SHIGETO, Yasuyuki YOKOSAKI, and Isao MURAKAMI *Department of Respiratory Diseases, National Hiroshima Hospital Booster phenomenon (recall effect) of tuberculin skin test, which disturbs diagnosis of tuberculous infection, is prevalent among BCG vaccinated population. We retested 34 nurse students whose initial tuberculin reaction was smaller than 30mm by erythema (Group A) and 53 hospital employees whose initial reaction was smaller than 20mm by erythema (Group B). Among the people whose diameter of erythema was less than 10mm by the first test, 88 percent (8/9) of group A and 43% (6/14) of group B showed reac- tion 10mm … by erythema and among those whose induration was ƒ10mm, 54% (6/11) of group A and 48% (12/25) of group B showed reaction 10mm … in the second testing. Mean and standard deviation of [the difference between the diameter of the 2nd and the 1st testing] was +7.3}11.8mm in group A, +9.8}11.1mm in group B by erythema and +2.6}5.9mm in group A, +2.9}5.1mm in group B by induration. These results in- dicate that booster phenomenon is highly prevalent among the tested group and there can be no appropriate criteria to distinguish new infection and booster phenomenon. Though two-step tuberculin skin test is recommended to get rid of booster phenomenon. Only a little is known about the value of this test to diagnose new infection in Japanese popu- lation, majority of whom being BCG vaccinated. Further investigations are required to apply two-step tuberculin skin test for diagnosis of new infection among hospital em- ployees and health care workers in Japan. Key words : Tuberculin skin test, Two-step tuberculin skin test, Booster phenomenon, Recall effect, Health care worker *513, Jike, Saijo-cho, Higashihiroshima-shi, Hiroshima 739-0041 Japan. (Received 21 Jul. 1999/Accepted 27 Oct. 1999) <5> Kekkaku Vol.75, No.1: 33-36, 2000 A CASE OF PULMONARY TUBERCULOSIS COMPLICATED WITH SUBCUTANEOUS PHAEOHYPHOMYCOSIS 1*Yoshinori MITA, 1Kunio DOBASHI, 2Tsugio NAKAZAWA, and 1Masatomo MORI 1*First Department of Internal Medicine, Gunma University Faculty of Medicine, 2Gunma University School of Health Sciences A 78-year-old male was admitted to our hospital because of fever, sputum and cough. Chest X-ray showed infiltrative shadows in the right lung field. Smears of his sputum were positive for acid-fast bacilli. We found multiple subcutaneous abscesses on the right distal forearm. Microscopic examination of skin biopsy specimens revealed granulation tissues with the proliferation of epitheloid cells with the scattering infiltrations of neurophils, giant cells and histiocytic cells. The examination of the PAS stained specimen revealed fungal elements and a black fungus, Exophiala jeanselmei, was isolated by the cultures of pus from the abscess. He was diagnosed as pulmonary tuberculosis compli- cated with subcutaneous phaeohyphomycosis caused by Exophiala jeanselmei and was suc- cessfully treated with anti-tuberculosis drugs and anti-fungal agent, 5-fluorocytosine. Key words :Subcutaneous phaeohyphomycosis, Pulmonary tuberculosis *3-39-15, Showa-machi, Maebashi-shi, Gunma 371-8511 Japan. (Received 7 Sep. 1999/Accepted 13 Oct. 1999) <6> Kekkaku Vol.75, No.1: 37-39, 2000 The 74th Annual Meeting Symposium ‡T. ENDOSCOPIC APPROACH TO PULMONARY DISEASES Chairpersons:1Shigeki HITOMI 2*Yoshiki ISHII 1Department of Thoracic Surgery, Kyoto University, 2*Department of Pulmonary Medicine and Clinical Immunology, Dokkyo University School of Medicine Symposium Topics and Presenters: 1. Transbronchial needle aspiration:Miki OKAZAKI, et al. (Department of Respira- tory Disease, Kobe City General Hospital) 2. Bronchoscopy for critical respiratory care in neonates, infants, and children:Seiki HASEGAWA, et al.(Department of Thoracic Surgery, Kyoto University Hospital) 3. Usefulness of endobronchial ultrasonography: Noriaki KURIMOTO (Iwakuni Minami Hospital) 4. LIFE (lung imaging fluorescence endoscope) system:Masami SATO(Tohoku Uni- versity) 5. Clinical utility of medical thoracoscopy in diagnosis of pleural diseases:Yoshiki ISHII(Department of Pulmonary Medicine and Clinical Immunology, Dokkyo Uni- versity School of Medicine), et al. 6. Usefulness of the mediastinoscopy:Masayoshi KUWABARA, et al. (Respiratory Diseases Center, Kyoto-Katsura Hospital) Endoscopy is an essential tool for the diagnosis and treatment of thoracic diseases. Thoracic endoscopy encompasses bronchoscopy, mediastinoscopy, and thoracoscopy. Re- cently, many new techniques and devices have been developed in this field. With regard to the devices, videobronchoscope, ultrasound bronchoscope, ultra-thin bronchoscope, autoflouorescence bronchoscope, etc. have been developed. With regard to techniques, transbronchial needle aspiration (TBNA), various thoracoscopic procedures, etc. have been developed. Endoscopy is preformed not only for adults but also for neonates, infants, and children. In this symposium, 6 up-to-date topics about thoracic endoscopy were selected as follows;TBNA, bronchoscopy for children, endobronchial ultrasonography, autofluores- cence bronchoscopy, medical thoracoscopy, and mediastinoscopy. Six speakers presented their experience of newly developed endoscopic procedures and discussed on the indication, utility, and complication of the procedures. TBNA is a useful technique to get cytological and histological diagnosis from peritracheal and peribronchial lesions. Bronchoscopy is a safe and useful modality for the critical respiratory care of infants and children. Endobronchial ultrasonography is a newly developed device for detection of peribronchial lesion and it is useful to determine the depth of tumor infiltration into the bronchial wall or adjacent structures. LIFE (lung imaging fluorescence endoscope) system is a new system of detection for early lung cancer using a He-Cd laser through a conventional fiberoptic bronchoscope. This system is able to capture and processing the autofluores- cence from the bronchial mucosa and to show it in a video screen in real time. Medical thoracoscopy under local anesthesia is easy and safe procedure to obtain accurate diagno- sis of pleural diseases. Mediastinoscopy is used for obtaining histological diagnosis from mediastinal lesions and it is useful for staging of lung cancer. Key words :Thoracic endoscopy, Bronchoscopy, Thoracoscopy, Mediastinoscopy *880, Kitakobayashi, Oaza, Mibu-machi, Shimotsuga- gun, Tochigi 321-0293 Japan. (Received 9 Nov. 1999) <7> Kekkaku Vol.75, No.1: 41-46, 2000 The 74th Annual Meeting Symposium ‡T. ENDOSCOPIC APPROACH TO PULMONARY DISEASES 1. TRANSBRONCHIAL NEEDLE ASPIRATION *Miki OKAZAKI, Syunzi TAKAKURA, Hiroshi FUJII, Takashi NISHIMURA, Tsuyoshi HASEGAWA, Nobuyuki KATAGAMI, Kyousuke ISHIHARA, and Bun-ichi UMEDA *Department of Respiratory Disease, Kobe City Gneral Hospital Transbronchial needle aspiration (TBNA) is a bronchoscopic technique to obtain cytolo- gic and histologic specimen from deep site of bronchial wall. We investigated the utility and safety of TBNA in 200 patients who had mass lesions in the lung or in the mediastinum. 101 patients had submucosal or peribronchial malig- nant lesions (central malignancy)and TBNA was the only diagnostic method in 28 patients (28%). 39 patients had peripheral malignant lesions (peripheral malignancy) and TBNA was the only diagnostic method in 12 patients (31%). The other 60 patients had benign lesions and TBNA was diagnostic in only 5 ptients (8%) ; bronchogenic cyst in 2, tuberculous lymph adenitis in 1, parathyroid adenoma in 1 and lung abscess in 1. In cen- tral malignancy, the yield of TBNA as exclusive means of diagnosis was higher for mediastinal tumor than for lung cancer. In peripheral malignancy it was higher for metastatic lung tumor than for primary lung tumor. In order to stage patients of lung cancer, we sampled 39 lymph nodes and 21 of them were proved to be positive. TBNA was thought to be of greatest value in the diagnosis of peritracheal mediastinal tumor and peribronchial metastatic lung tumor and in the staging of lung cancer. We used 19-gauge transbronchial histology needle in 8 patients and 2 cases were diagnostic. Low diagnostic yields were probably due to the lack of our experience and it was expected that training on this technique would increase diagnositc utility of the his- tology needle. No significant complications occurred and all patients tolerated TBNA well. Key words :Transbronchial needle aspiration, Mediastinal tumor, Staging of lung cancer, Metastatic lung cancer *4-6, Naka-machi, Minatojima, Chuo-ku, Kobe-shi, Hyogo 650-0046 Japan. (Received 9 Nov. 1999) <8> Kekkaku Vol.75, No.1: 47-50, 2000 The 74th Annual Meeting Symposium ‡T. ENDOSCOPIC APPROACH TO PULMONARY DISEASES 2. BRONCHOSCOPY FOR CRITICAL RESPIRATORY CARE IN NEONATES, INFANTS, AND CHILDREN *Seiki HASEGAWA, Hiromi WADA, and Shigeki HITOMI *Department of Thoracic Surgery, Kyoto University Hospital Of the 605 pediatric patients admitted to our intensive care unit during the past 6 years, 90 underwent 380 bronchoscopies for diagnostic and therapeutic purposes. The indi- cations for bronchoscopy were atelectasis/retention of airway secretion (n=52), pneumo- nia(n=31), airway bleeding (n=14), pulmonary edema (n=11), tracheobronchomalacia/ airway stenosis (n=11), and airway foreign body/aspiration (n=7). Visualizaiton of the airway was helpful for the diagnosis of respiratiory problems ; in 9 infants, bronchoscopy revealed tracheobronchial stenosis which other diagnostic modalities failed to detect. In 25 of the 31 patients with pneumonia, specimens taken by bronchoscopy were positive for specific pathogens. Bronchoscopy also proved to have significant therapeutic value, espe- cially for airway cleaning ; bronchial suctioning resulted in immediate reexpansion of the collapsed lung in 25 of 34 cases of physiotherapy-resistant atelectasis. A rigid broncho- scope was used to remove airway foreign body in 2 cases. Prototype channeled-ultrathin fiberscopes were utilized in 99 of 380 bronchoscopies. No complications were noted except for severe hypoxia and bradycardia in one infant. We conclude that bronchoscopy is a safe and useful modality for the critical respiratory care of infants and children. Key words :Bronchoscopy, Pediatric, Respiratory care, Critical care, Ultrathin fiberscope *53, Kawara-cho, Shogoin, Sakyo-ku, Kyoto-shi, Kyoto 606-8397 Japan. (Received 9 Nov. 1999) <9> Kekkaku Vol.75, No.1: 51-56, 2000 The 74th Annual Meeting Symposium ‡T. ENDOSCOPIC APPROACH TO PULMONARY DISEASES 5. CLINICAL UTILITY OF MEDICAL THORACOSCOPY IN DIAGNOSIS OF PLEURAL DISEASES 1,2*Yoshiki ISHII and 1,3Satoshi KITAMURA 1Department of Pulmonary Medicine, Jichi Medical School, 2*Department of Pulmonary Medicine and Clinical Immunology, Dokkyo University School of Medicine, 3Department of Occupational Therapy, School of Health and Social Services, Saitama Prefectural University Thoracoscopy is useful for diagnosis of a number of lung diseases. We report our recent experience of medical thoracoscopy performed under local anesthesia in 142 cases. Of 124 pa- tients with pleural effusion, 46 had pleuritid carcinomatosa, 11 had pleuritis tuberculosa, and 10 had malignant mesothelioma. We evaluated the utility of thoracoscopic observa- tion and pleural biopsy in these three disases. Almost of patients with malignant pleural effusion initially undiagnosed by the cytology of pleural effusion were diagnosed by tho- racoscoy. Especially in malignant mesothelioma, thoracoscopy allowed accurate diagnosis. No serious complication was observed. Since medical thoracoscopy under local anesthesia is a rapid, easy, safe, and well-tolerated procedure with an excellent diagnostic yield, it is recommended as a diagnostic procedure for cases with pleural effusion. Key words :Thoracoscopy, Pleural biopsy, Pleuritis carcinomatosa, Malignant mesothelioma, Pleuritis tuberculosa *880, Kitakobayashi, Oaza, Mibu-machi, Shimotsuga-gun, Tochigi 321-0293 Japan. (Received 9 Nov. 1999) <10> Kekkaku Vol.75, No.1: 57-63, 2000 The 74th Annual Meeting Symposium ‡T. ENDOSCOPIC APPROACH TO PULMONARY DISEASES 6. USEFULNESS OF THE MEDIASTINOSCOPY *Masayoshi KUWABARA and Yoshito MATSUBARA *Respiratory Diseases Center, Kyoto-Katsura Hospital The purposes of this study are to show the diagnostic values and the role of the mediastinoscopy for the respiratory diaseases. From 1971 to 1998, mediastinoscopy were performed on 1664 patients admitted to our hospital with respiratory diseases. For the superior mediastinal diseases, mediastinal tumor and lymphadenopathies without cancer, two or three samples were obtained by mediastinoscopy. For lung cancer, biopsy was rou- tinely performed at the 6 nodal stations, right and left paratracheal(ň2), right and left tracheobronchial(ň4), pretracheal(ň3), and subcarinal(ň7) lymphnodes. From 1994, we have used video-mediastinoscopy, which was combined with scope and TV-camera. Using video-mediastinoscopy, many staffs could observe the mediastinal findings on TV-moni- tor during mediastinal manipulation. The positive findings were observed in 17% (221/1299) for lung cancer, 100% (32/32) for sarcoidosis, 100%(2/2) for malignant lymphoma, 65% (11/17) for mediastinal tumor, 9.8% (13/132) for pulmonary tuberculosis. The positive rate according to the histological types of lung cancer were 20.5% (148/721) for adenocarcinoma, 9.4%(39/415) for squamous cell carcinoma, 31.6%(24/76) for small cell carcinoma, 21.3% (10/47) for large cell carcinoma. Complications developed in a total of 3.6%, and these were bron- chial arterial damage (1.8%), recurrent nerve paralysis (0.7%), azygos vein damage (0.4%), pleural rupture(0.4%), superior vena cava damage(0.2%) and tracheal lacera- tion (0.1%). However, there were no severe complications and operative deaths in this series. Mediastinoscopy is a minimal invasive and safety surgical procedure that is widely used as a diagnostic method for investigating the superior mediastinum, mediastinal tumor and lymhadenopathies. It is useful for obtaining histological diagnosis, as well as for staging lung cancer. Video-mediastinoscopy is more safety and educational, because many staffs could observe the findings. Key words :Mediastinoscopy, Superior mediastinal lesions, Lung cancer, Staging of lung cancer, Video-mediastinoscopy *17, Yamada-Hirao-cho, Nishikyo-ku, Kyoto-shi, Kyoto 615-8256 Japan. (Received 9 Nov. 1999)