(Vol.77, No.7 July 2002) <1>Kekkaku Vol.77, No.7:499-502,2002 Issue DIAGNOSIS OF PULMONARY TUBERCULOSIS IN CONNECTION WITH THE GUIDELINE FOR COMMUNITY-ACQUIRED PNEUMONIA Kunihiko ITO Abstract The decision when to make chest X-ray examination is important for early diagnosis of pulmonary tuberculosis and community-acquired pneumonia as well. And for early diagnosis of pulmonary tuberculosis, differential diagnosis with community-acquired pneumonia is important. For this reasons, guideline for the diagnosis and treatment of community- acquired pneumonia should include when to make chest X-ray examination, and how to exclude the possibility of pulmonary tuberculosis. For example, empiric choice of anti-microbial for apparent pneumonia should be an agent without anti-tuberculosis effect. Clinical evaluation of the effect of anti-microbial should be done carefully, because pulmonary tuberculosis can be clinically improved spontaneously. In the guideline for the diagnosis and treatment of community-acquired pneumonia could include the above-mentioned view on early diagnosis of pulmonary tuberculosis, the guideline could be much more helpful for the tuberculosis program. Key words:Pulmonary tuberculosis, Early diagnosis, Community- acquired pneumonia, Guideline, New quinolone Medical Doctors Training Division, Department of Program Support, Research Institute of Tuberculosis Correspondence to:Kunihiko Ito, Medical Doctors Training Division, Department of Program Support, Research Institute of Tuberculosis, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (E-mail:ito@jata.or.jp) <2>Kekkaku Vol.77, No.7:503-512,2002 Original Article FREQUENCY OF PREVIOUS TUBERCULOSIS HISTORY IN PATIENTS WITH AND WITHOUT ACTIVE TUBERCULOSIS ADMITTED TO OUR HOSPITAL IN 1980-83 AND IN 1997-99 Naohiro NAGAYAMA, Motoo BABA, Akihiro HORI, Atsuhisa TAMURA, Hideaki NAGAI, Shinobu AKAGAWA, Yoshiko KAWABE, Kazuko MACHIDA, Atsuyuki KURASHIMA, Hideki YOTSUMOTO, and Masashi MOURI Abstract To study recurrence rate over a long period after recovery from previous tuberculosis history, we examined the frequency of previous tuberculosis history in patients who were admitted to our hospital in 1980-83 and in 1997-99 and the comparison was made between cases with and without culture-positive tuberculosis. The tuberculosis groups comprised of 297 patients in 1980-83 and 688 patients in 1997-99. The non-tuberculosis groups (control groups) comprised of 373 patients in 1980-83 and 1092 patients in 1997-99 with non- tuberculosis diseases other than the tuberculosis-related diseases such as non-tuberculosis mycobacteriosis, pulmonary aspergillosis, bronchiectasis, chronic bronchitis and tuberculosis sequelae. The patients with viral chronic hepatitis previously operated and transfused were also excluded as they might be operated because of pulmonary tuberculosis in the era of surgical treatment for tuberculosis. In both tuberculosis and control groups, they had previous tuberculosis history most frequently when they were twenties. In the control groups, the frequency of previous tuberculosis history among cases admitted in 1980-83 and were born in 1910-19, 20-29, 30-39, 40-49 were 15/84 (17.9%), 22/93 (23.7%), 11/77 (14.3%) and 3/43 (7.0%), respectively, and those admitted in 1997-99 were 11/70 (15.7%), 30/231 (13.0%), 28/288 (9.7%), and 10/230 (4.3%), respectively. In those 4 birth year groups, frequency of previous tuberculosis history among cases admitted in 1997-99 were significantly lower than that admitted in 1980-83 (p<0.05, one-sided paired t-test), and the fact suggests that persons with tuberculosis history died earlier than those without it. In the tuberculosis groups, the frequencies of previous tuberculosis history among cases admitted in 1980-83 and were born in 1910-19, 20-29, 30-39 and 40-49 were 20/35 (57.1%), 31/58 (53.4%), 19/48 (39.6%), and 11/53 (20.8%), respectively, and those among cases admitted in 1997-99 were 30/99 (30.3%), 58/125 (46.4%), 22/102 (21.6%) and 17/136 (12.5%), respectively. The frequency of previous tuberculosis history among cases admitted in 1997-99 was significantly lower than that admitted in 1980-83 (p<0.01) as was the case in the control groups. As recurrence within 5 years had occurred in only 4 out of 113 tuberculosis patients (3.5%) in the above-mentioned 4 birth year groups, almost all tuberculosis patients were assumed to have recovered completely from previous tuberculosis. Comparison between the recurrence rate from previous tuberculosis and the incidence rate from the remotely infected persons without previous tuberculosis history in the same birth year group can be done by calculating the prevalence of tuberculosis infection for each birth year group using a model of annual risk of tuberculosis infection appropriate for Japanese. The ratios between the recurrence rate from previous tuberculosis patients and the incidence rate from remotely infected persons without previous tuberculosis history were 4.71, 2.33, 1.78 and 1.11 in 1980-83 and 1.84, 3.99, 1.80 and 1.11 in 1997-99 for groups born in 1910-19, 20-29, 30-39 and 40-49, respectively. The ratio did not change systematically with time in these groups, indicating the recurrence rate did not change with time more than ten years after recovery from previous tuberculosis. The ratio was about 3 for groups born in 1910-19 and 20-29 and 1 for group born in 1940-49. Almost all patients born in 1940-49 could receive chemotherapy for tuberculosis in their twenties, while most of the patients born in 1910-29 could not. Therefore, the above-mentioned fact may reflect the reccurrence rate of patients treated successfully with chemotherapy is almost the same as the incidence rate from remotely infected persons, while that the recurrence rate from previous tuberculosis patients spontaneously recovered is 3 times higher than the incidence rate from remotely infected persons. Key words:Long-term recurrence rate of tuberculosis, Frequency of previous tuberculosis history classified by year of birth, Incidence rate of tuberculosis, Chemotherapy, Natural recovery from tuberculosis Department of Respiratory Medicine, Tokyo National Sanatorium Hospital Correspondence to:Naohiro Nagayama, Department of Respiratory Medicine, Tokyo National Sanatorium Hospital, 3-1-1, Takeoka, Kiyose-shi, Tokyo 204-8585 Japan. (E-mail:nagayama@tokyo.hosp.go.jp) <3>Kekkaku Vol.77, No.7:513-519,2002 Original Article THE STUDY ON THE DURATION OF TREATMENT IN THE STANDARD SHORT COURSE CHEMOTHERAPY CONTAINING PYRAZINAMIDE Yasuhiro YAMAZAKI, Hiroyuki MATSUMOTO, and Satoru FUJIUCHI Abstract Based on the results of a questionnaire for the tuberculosis specialists in the whole country, we investigated whether the standard short course chemotherapy containing pyrazinamide (four drugs regimen:HRZE/S) were given for adequate duration. The results of a questionnaire revealed that the duration of treatment was prolonged in 60% of 848 cases due to several reasons. The reasons for the longer duration of treatment were (1)complication of other disease, (2)delay in the improvement on chest X-ray, (3)delay in negative conversion of bacilli, (4)drug resistance, (5)patient's request, and (6)others. According to our own experience in the National Dohoku Hospital for the past four years, the duration of therapy was prolonged in 86% of cases treated with the four drugs regimen, and in 64% of cases with the three drugs regimen (HRE/S). Four drugs regimen was preferred for severer cases and the three drugs regimen for older patients. The reasons for the prolonged duration of treatment in our hospital were similar to those in the results of a questionnaire in the whole country. We recognized that the treatment was prolonged due to several meaningless reasons such as "no particular reason", "anxiety on relapse" and "patient's request". In order to decide the adequate duration of treatment, it is needed to know the relapse rate in cases with the short course chemotherapy and its relationship with complications. It is hoped to establish the guideline for tuberculosis treatment including the duration of treatment based on the results of detailed clinical studies. Key words:Pulmonary tuberculosis, Standard short course chemotherapy, Pyrazinamide, Treatment duration Department of Pulmonary Medicine, National Dohoku Hospital Correspondence to :Yasuhiro Yamazaki, Department of Pulmonary Medicine, National Dohoku Hospital, 7, Hanasaki-cho, Asahikawa-shi, Hokkaido 070-8644 Japan. (E-mail:yamazaki@douhoku.hosp.go.jp) <4>Kekkaku Vol.77, No.7:521-526,2002 Field Activities UNDERSTANDING LEVEL ON TUBERCULOSIS AMONG HOSPITAL NURSES 1Hideko ISHII, 2Satori ODAUCHI, 3Kaori FUNABASHI, 4Kazuko OHTA, and 5Takeko YAMASHITA Abstract Tuberculosis control in big cities should be focused on preventing defaulting from treatment, and the prevention of the emergence of multi-drug resistant tuberculosis, and the improvement of treatment success rate. Since it is needed to organize continued case management system starting from hospitalization, discharge, management of regular drug taking at outpatient clinics and final cure, close collaboration should be made between hospital nurses and public health nurses. For this purpose, there should be no difference about the understanding on tuberculosis control between clinical and public health nurses. This research was aimed to examine "How much interest and recognition do hospital nurses have about tuberculosis control." The Aichi Nursing Association cooperated with this research. The results showed that 60% of tuberculosis ward nurses were more than forty years old, and they have served more than ten years in TB word. The levels of understanding on tuberculosis among nurses working in tuberculosis hospitals were much higher than those in general hospitals. However, it is necessary to organize a collaboration system between hospitals and public health center to improve TB case management. Key words:Tuberculosis nurse, Public health nurse, Under standing level, Case management, Team care 1Nagoya Minami Health Center, 2Nagoya Minato Health Center, 3Aichi Chita Health Center, 4Aichi Nursing Association, 5Research Institute of Tuberculosis Correspondence to:Hideko Ishii, Nagoya Minami Health Center, 5-1-1, Higashimatabee-cho, Minami-ku, Nagoya-shi, Aichi 457-0833 Japan. (E-mail:h-ishii@kctv.ne.jp) <5>Kekkaku Vol.77, No.7:527-531,2002 Case Report A CASE OF TUBERCULOSIS PLEURITIS DEVELOPING CONTRALATERAL PLEURAL EFFUSION DURING ANTI-TUBERCULOSIS CHEMOTHERAPY, FALLING INTO CHRONIC RESPIRATORY FAILURE 1Yasuo ITOH, 1Tadashi ISHIGUCHI, 1Yuji HIGASHIMOTO, 1Hisashi FUJIMOTO, 1Masahiro OHATA, 1Hidekazu ITOH, 2Akihide NISHIYAMA, 2Kuniyuki OKAMURA, 2Hideya ONO, 2Kazumi KAWABE, 2Akiko UEDA, and 2Tadatoshi SURUDA Abstract The patient was a 74 year-old male presenting right pleural effusion with mild fever. His temperature was 37.0. Culture of a pleural biopsy specimen revealed Mycobacterium tuberculosis, although culture of sputum and pleural effusion were negative. Therapy was begun with 300mg of isoniazid (INH) per day, 600mg of rifampicin (RFP) per day, and 1200mg of pyrazinamide (PZA) per day. His temperature improved temporarily. One week after beginning of the therapy he had a fever over 38.0. On the 17th day after starting chemotherapy, a chest radiological examination showed left pleural effusion in which numerous lymphocytes were found but Mycobacterium tuberculosis was negative. We assumed that the left pleural effusion was due to a paradoxical reaction to the anti-tuberculosis chemotherapy. After 3 days' discontinuation, the same regimen was resumed with an addition of prednisolone, but bilateral pleural effusion remained and the case finally fell into chronic respiratory failure. Key words:Tuberculous pleuritis, Pleural effusion, Paradoxical reaction, Anti-tuberculosis chemotherapy, Chronic respiratory failure 1Department of Internal Medicine, Wakayama Medical University Kihoku Hospital,2Department of Pulmonary medicine, National Wakayama Hospital Correspondence to:Yasuo Itoh, Department of Internal Medicine, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113 Japan. (E-mail:fuki-s@smile.ocn.ne.jp) <6>Kekkaku Vol.77, No.7:533-535,2002 Short Report A STUDY OF INH 0.1g/ml RESISTANT M.TUBERCULOSIS STRAINS ASSESSED BY BrothMIC MTB-1 METHOD 1Hiroko YOSHIDA, 1Hiromi ANO, 1Chieko ISHIDA, 1Nobuko TANIGAWA, 1Masanori KIKUI, 2Tetsuya TAKASHIMA, and 3Izuo TSUYUGUCHI Abstract In the antimycobacterial susceptibility test for INH using the egg-based Ogawa media, 3 concentrations (0.1, 1, or 5g/ml) of INH were used, and 1g/ml was used as a critical concentration for INH resistance. However, it was controversial whether INH 0.1 g/ml resistant M.tuberculosis was clinically significant or not. We investigated the MIC values of INH 0.1 g/ml resistant strains by using BrothMIC MTB-1 method, and 115 strains of M.tuberculosis confirmed by DNA-prove test were used. The distribution of MIC values of 115 strains determined by Ogawa INH susceptibility test was shown in figure. By BrothMIC MTB-1 method, they were classified into 3 groups;susceptible, low resistant and high resistant groups. The mean MIC value of INH 0.1g/ml resistant M.tuberculosis was estimated to be 4.53 g/ml with its 95% confidence interval 3.21-5.85g/ml, and they were determined as "resistant" in BrothMIC MTB-1 method. These results supported the idea that patients with INH 0.1g/ml resistant M.tuberculosis strains should be regarded as clinically "resistant". Key words:BrothMIC MTB-1 method, INH 0.1g/ml resistant M.tuberculosis 1Department of Clinical Pathology Laboratory, 2First Department of Internal Medicine, Osaka Prefectural Habikino Hospital, 3The President of Osaka Prefectural Habikino Hospital Correspondence to:Hiroko Yoshida, Department of Clinical Pathology Laboratory, Osaka Prefectural Habikino Hospital, 3-7-1, Habikino, Habikino-shi, Osaka 583-8588 Japan. (E-mail:ZUM11464@nifty.ne.jp)