(Vol.76, No.7 July 2001) <1>Kekkaku Vol.76, No.7:519-524,2001 THE ALTERNATIVE OR SIMULTANEOUS EXCRETION OF DIFFERENT SPECIES OF MYCOBACTERIA IN ATYPICAL MYCOBACTERIOSIS -15 CASES IN 7 YEARS- 1*Takesuke HIRAOKA, 1Koji NAMBA, 2Hiroyuki OGATA, and 2Hiroshi SAITOU 1*Internal Medicine, 2Clinical Laboratory, National Miyazaki Hospital Five hundreds and five cases of Mycobacterium tuberculosis infection admitted to our hospital during 7 years from 1993 to 1999. Numbers of newly diagnosed cases were 390, of which 329 (84.4%) were bacilli positive with sputum examination on admission. The recurrent cases were 115, of which 55 (47.8%) were bacilli positive cases. During the same period, mycobacteria other than tuberculosis (atypical mycobacteria) were detected in the sputum of other 121 cases. The 63 (52.1%) out of these 121 cases were diagnosed as atypical mycobacteriosis (AM) due to repetitive detection of bacilli with fulfilled the criteria according to the Japanese Mycobacteriosis Research Group of the National Chest Hospitals. The ratio of 63 AM cases to 329 bacilli positive TB cases was 19.1%, but it range from 8.2% to 31.3% year by year. In these 63 AM cases, 9 (14.3%) cases excreted AM bacilli simultaneously or alter- nately with TB bacilli. The other 15 (23.8%) cases excreted different AM bacilli simulta- neously or alternately. The changes or combinations with M.avium and M.intracellulare were most frequently observed (in 12 cases). The manners of changes and combinations with different species were described in detail. Key words:Mycobacterium tuberculosis, Atypical mycobacteriosis, Criteria, Change, Combination *19403-4, Kawaminami, Kawaminami-cho, Koyu-gun, Miyazaki 889-1301 Japan (Received 31 Jan. 2001/ Accepted 30 Mar. 2001) <2>Kekkaku Vol.76, No.7:525-531,2001 PULMONARY MYCOBACTERIUM KANSASII INFECTION IN THE SOUTHERN AREA OF FUKUOKA PREFECTURE *Yoshinari KITAHARA, Sanae OCHIAI, Yasuko HARADA, Akira KAJIKI, Takashi MITUYAMA, Yukari IKEDO, Kentaro WAKAMATSU, Nobuhiko NAGATA, Susumu HARADA, and Masahiro TAKAMOTO *Department of Internal Medicine, National Ohmuta Hospital Cases of pulmonary infection caused by Mycobacterium kansasii (Mk) in our hospital located at the mid-northern area of the Kyushu district, which is in the southern part of Fukuoka prefecture were evaluated. Mk infection is not so rare in other areas of Japan, such as Tokyo and Kinki district, however, there has been no publiched report on the disease from the Kyusyu district. Therefore, the frequency and the clinical features of our cases of Mk infection were analyzed. During 17 years from 1982 to 1998, there were 14 patients of Mk infection out of 241 nontuberculous mycobacteriosis (NTM). There were 595 patients of culture-positive pulmonary tuberculosis without prior treatment (Tbc). The proportion of Mk/Tbc was 2.4% and that of Mk/NTM was 5.8%. During the period A (from 1982 to 1994) the ratio of Mk/Tbc was 5/462 (1.1%), while on the other side that of Mk/Tbc during the period B. (from 1995 to 1998) it was 9/133 (6.8%), which was significantly (P<0.01) higher compared with that in the period A. Although the patients of Mk infection in our hospital had been rare until 1994, from the results mentioned above, it was considered that the frequency of Mk infection in our hospital has increased to some extent since 1995. One of the characteristics in our cases was that the ratio of female (42.9%) was rela- tively high. All the female patients were considered to be compromised hosts. The results of the drug resistance tests were consistent with the other reports in our country. By the combination treatment including rifampicin as the major drug, the negative conversion of culture were obtained within 2 months in all our cases. Key words:Infection caused by M.kansasii, Atypical mycobacteriosis, Nontuberculous mycobacteriosis, Regional difference, Rifampicin *1044-1, Tachibana, Omuta-shi, Fukuoka. 837-0911 Japan. (Received 21 Aug. 2000/ Accepted 23 Apr. 2001) <3>Kekkaku Vol.76, No.7:533-543,2001 TUBERCULOSIS OF THE ELDERLY (ABOVE THE AGE OF 75) IN NATIONAL HOSPITALS Cooperative Study Unit of Chemotherapy of Tuberculosis of the National Hospitals in Japan 1*Masashi MORI, 1Kazuko MACHIDA, 1Yoshiko KAWABE, 1Atsuyuki KURASHIMA, 1Hideki YOTSUMOTO, 2Toshiaki TSUCHIYA, 3Fumio YAMAGISHI, 3Yuka SASAKI, 4Takeo KAWASHIRO, 4Takeo TOYODA, 5Mitsunori SAKATANI, 6Shin KAWAHARA, 7Susumu HARADA and 8Kazutaka NISHIMURA 1*National Tokyo Hospital, 2National Nishiniigata-Chuo Hospital, 3National chibahigashi Hospital, 4National Higashisaitama Hospital, 5National Kinki-Chuo Hospital, 6National Minamiokayama Hospital, 7National Ohmuta Hospital, 8National Ehime Hospital In Japan tuberculosis is becoming rapidly the disease of the elderly. We studied the background, the type and level of hospital cares needed, and the outcome of patients with pulmonary tuberculosis (sputum smear and/or culture positive) above the age of 75 who were admitted to 8 national hospitals during the period from January 1 to December 31, 1997. The study included 150 patients (male:109, female:41, mean age:81.6), of whom 25% needed care in a single-bed room, 84.3% had underlying diseases (cardiovascular diseases:43.3%, malignant diseases:20.9%, neuro-psychiatric diseases:13.4%), and 47.6 % needed cares mainly in feeding and excretions. 92 patients (62.6%) improved and 45 patients (30.6%) died, of whom the cause of death was directly related to tuberculosis in 42. The mean hospital stay was 4.7 months. However, in 42 patients whose cause of death was related to tuberculosis, 66% died within 3 months, while in 102 patients who were dis- charged 71% stayed more than 3 months. The same comparison was done in 508 patients with bacteriologically proven tuberculosis above the age of 75 admitted to National Tokyo Hospital during the period from 1990 to 1999. The result was almost the same, among 133 patients died in the hospital 60% died within 3 months, while in 375 patients who were discharged hospital stay was more than 3 months in 70%. In the near future, the elderly will occupy more than 25% of the beds of the tubercu- losis ward in Japan and most of them have underlying diseases other than tuberuclosis. Because tuberculosis, once the disease of the young, is becoming rapidly the disease of the elderly, it is imperative for us to make necessary adjustments to meet this inevitable trend. Key words:Tuberculosis in the elderly, Prevalence of underlying diseases, Types of cares, Hospital stay period *3-1-1, Takeoka, Kiyose-shi, Tokyo 204-8585 Japan. (Received 19 Oct. 2000/ Accepted 25 Apr. 2001) <4>Kekkaku Vol.76, No.7:545-548,2001 CAT SCRATCH DISEASE SHOWING CLINICAL PICTURE RESEMBLING TUBERCULOUS LYMPHADENITIS:A CASE REPORT *Toshihiko MACHI *Department of Internal Medicine, Keiju General Hospital On February 18th, 1197, a 61-year-old woman visited our hospital because of a left inguinal mass. On physical examination, the mass was soft without inflammatory sign. About one month later, the node was excised. Pathological examination revealed granulomas with caseous necrosis and Langhans giant cells, suggesting tuberculosis, although acid fast stain was negative. Thereafter, re-history taking in detail disclosed that a kitten had often scratched her. We reexamined the pathology and checked her for serum antibodies to Bartonella henselae, the etiological microbe of cat scratch disease (CSD), using enzyme immunoassay. Histopathological reexamination of the excised mass revealed suppurative granulomas in addition to caseous ones. The level of IgG (negative:<12 units) to B. henselae was 78 units on March 25th, 138 units on April 19th, and 18 units on July 18th, while the level of IgM (negative:12 units) was negative at each determination. These serological results strongly suggested current infection of B. henselae. The diagnosis of CSD could be established based on the history and the laboratory findings. When one encounters a case of granulomatous lymphadentis, CSD should be considered for the differential diagnosis, and in this regard, anamnesis about contact with cats should be asked. Key words:Cat scratch disease, Lymphadenopathy, Mycobacterium tuberculosis, Tuberculous lymphadenitis, Bartonella henselae, Suppurative granuloma *94, Tomioka-machi, Nanao-shi, Ishikawa 926-8605 Japan. (Received 29 Jan. 2001/ Accepted 16 Apr. 2001) <5>Kekkaku Vol.76, No.7:549-557,2001 The 76th Annual Meeting Special Lecture TUBERCULOSIS CONTROL STRATEGY IN THE 21ST CENTURY IN JAPAN -For Elimination of Tuberculosis in Japan- *Masakazu AOKI *Japan Anti-Tuberculosis Association Modern tuberculosis control programme has been launched in 1951 by the major revision of the previous Tb. Control Law in Japan. Main control measures were BCG vaccination programme for tuberculin negatives, annual screening of Tb. by miniature radiophotography (MMR), charge free diagnosis and treatment of Tb. patients, registration and case-holding at Health Centres throughout the country and so on. Thanks to the efforts of the Gov- ernment and people concerned, Tb. incidence has decreased with the annual reduction rate of 11% during 1961 and 1977. However, Tb. decrease has stagnated after that, and it is increasing slowly in these 3 years since 1998. Moreover, regional variations of Tb. incidence are considerable, and Tb. is concentrated in specific risk groups such as elderly persons, homeless, foreign born individuals and so on. However, the present Tb. Control measures were introduced prior to the discovery of most major anti-Tb. drugs and all modern internationally accepted Tb. Control strategies, so that it is strongly desired to improve the present control programme from rather classical present Tb. control measures to global standard one to overcome the resurgence of Tb. in Japan. At first, the author stressed that the priority of Tb. Control programme should be changes according to the development of science and the change of epidemiological situa- tions. BCG vaccination and Tb. screening by MMR might be very important when the annual risk of Tb. infection was very high-about 4% in 1950. Now it is around 0.05% and the incidence of Tb. among 0`14 years of age is 1.1 per 100,000 so that the priority should be given on treatment of the detected cases instead of BCG vaccination or MMR. The doctors in the public health field should give more strong concern on clinical aspects of Tb. Control Programme at present. It was considered that the main urgent problems to be improved in the present Tb. control measures are as follows. ‡@It is strongly recommended to spread the global standard regimen with 2HRZE/ 4HR(E) more widely and rapidly. Because the standard regimen is used in only 50% of new smear positive cases at present although 15.3% of Tb. patients are 80 years or more, or 56.3% of them are 60 years or more, and the side effects by PZA are higher among elderly patients. @‡AShortening of the hospitalization duration is required because 76.7% of newly detected bacilli positive cases are hospitalized at first, and the median of the period of hospitalization is 4 months, and 18.4% of them are hospitalized 6 months or more at present. @‡BDOT treatment has been introduced for special groups in the big cities in 2000 for the first time in Japan. but it is needed to spread DOT treatment more widely, for example, by increasing health insurance payment for the institutions where DOT treatment is being implemented. @‡CIt is recommended to build special rooms to accept Tb. patient at general hospitals and/or university hospitals to avoid the neglect of Tb. by general medical doctors. @‡DFollow-up of Tb. patients after treatment completion at Health Centres is not needed now, because the relapse rate is so low. @‡EIndiscriminative screening programme for all the people aged 19 years old or more should be stopped, at least up to 39 years of age, because Tb. detection rate has become so low as 0.0069% at present. As Tb. decrease is so slow, or is increasing in some areas, that the contact surveys among the young aged 20 to 39 should be strengthened in the future. @‡FAs Japan Anti-Tb. Association is being carrying out mass screening programme extensively at present, so that the Association has started to discuss the future health check system. Because of the rapid and constant increase of the lung cancer, the Associa- tion is discussing the method to detect the lung cancer, too. In any way, it is needed to focus the screening programme for special high risk groups instead of indiscriminative screening. @‡GBCG vaccination for infants should be continued a little more, because BCG vaccina- tion can protect the development of 7 miliary Tb. and/or meningitis cases during 15 years if BCG is given 70% of the infants in 2000. However, it was strongly recommended to stop re-vaccination of BCG, because it is not so effective, and disturb the diagnosis of Tb. infection by tuberculin testing. @‡HTreatment of latent Tb. infection will become more and more important, so that it's indication should be expanded to the adults in the future instead of the present indication up to 29 years of age. It is needed to revise Tuberculosis Control Low to improve control programme in Japan. The author hoped that the members of Japan Tuberculosis Society will promote the improvement and to support the Government to improve the Law. Key words:Tuberculosis control, Japan *1-3-12, Misaki-cho, Chiyoda-ku, Tokyo 101-0061 Japan. (Received 10 May. 2001)