(Vol.74, No.7 July 1999) <1>Kekkaku Vol.74, No.7:549-553,1999 OUTBREAK OF MULTIDRUG-RESISTANT MYCOBACTERIUM TUBERCULOSIS INFECTION IN THE MIDDLE AND ADVANCED AGE *Yuka SASAKI, Fumio YAMAGISHI, Fumio MIZUTANI, Takenori YAGI, Fuminobu KURODA, and Akihiko WADA *Division of Thoracic Disease, National Chiba Higashi Hospital We experienced a small outbreak of multidrug-resistant Mycobacterium tuberculosis in- fection (MDR-TB) among persons of in the middle and advanced age. The index case was 48-year-old man, and had complained productive cough since January 1996. He visited a doctor due to his symptom, and chest X-ray revealed cavitary lesion and sputum smear was positive for tubercle bacilli. He could not continue his admission because of his absence without leave and drinking, he was discharged on Day 54. The drug resistance was observed for INH (0.1g/ml), RFP, and SM. Later, case 2, 52-year-old male, and case 3, 43-year-old-male, who were companions in mah-jongg with the index case, were diagnosed as pulmonary tuberculosis. The analysis of restriction fragment length polymorphism (RFLP) was done on 3 strains, and all showed the same pattern. Among other companions in mah-jongg with the index case, case 4, 28-year-old male, was treated as MDR-TB, and the drug resistance pattern was the same to that of the index case, but the details were unknown. Case 5, 65-year-old male was diagnosed as drug sensitive pulmonary tuberculosis, thus he might incidentally suffer from pulmonary tuberculosis at the same time. Case 6, 46-year-old male, who had been treated for alcoholic liver cirrhosis, was introduced to our hospital as his sputum smear was positive, and the drug resistance pattern was observed similar to that of the indexs case. All the companions in mah-jongg suffered from MDR-TB except case 5. The RFLP analysis showed that the index case, case 2, and case 3 were caused by the same strain of M.tuberculosis. The drug resistance pattern of, case 4 and case 6 was the same to that of the index case. Based on these findings, it is highly suspected that this small outbreak was originated from the index case. Key words:Pulmonary tuberculosis, Multidrug-resistant tuberculosis, Outbreak, Self-discharged patient *Nitona-cho 673, Chu-ou ku, Chiba 260-8712 Japan. (Received 11 Jan. 1999/ Accepted 3 Mar.1999) <2>Kekkaku Vol.74, No.7 :555-561, 1999 EPIDEMIOLOGICAL STUDY OF MICROEPIDEMICS OF TUBERCULOSIS BY RESTRICTION FRAGMENT LENGTH POLYMORPHISM ANALYSIS (1)Aki TAMARU, and (2)Yasuhiko SUZUKI (1*)Department of Microbiology and (2)Department of Pathology Osaka Prefectural Institute of Public Health Restriction fragment length polymorphism (RFLP) analysis was performed with 13 events considered as microepidemics of tuberculosis occurred on Osaka prefecture from July 1995 to July 1998. In 7 out of 13 events, isolates from patients involved in each event showed indentical RFLP patterns, hence these events were verified as microepidemics. Out of 7 microepidemics, three were intrafamily infection, the other three occurred in work places and the remaining one was in a school occurred among stu- dents. The total number of patients who were involved in microepidemics was 19 and their ages distributed in the wide range from 18 to 69 years old, but 11 were at twenties or forties. The total delay in case-finding was 2 months in the shortest case, and more than 14 months in the longest. In the remaining 6 of 13 events, the isolates from patients were showed different RFLP patterns, although they were suspected as microepidemics. Furthermore, in the 2 microepidemics, one isolate showed different RFLP pattern form the other isolates involved in each events. These facts suggest that there could be many overlooked sources of tuberculosis infection in Osaka. Key words:Pulmonary tuberculosis, Microepidemic, RFLP analysis, Family infection, Total delay in case-finding *Nakamichi 1-3-69, Higashinari-ku, Osaka 537-0025 Japan. (Received 7 Dec. 1998/ Accepted 18 Mar.1999) <3>Kekkaku Vol.74, No.7:563-570, 1999 EFFECTS OF SECRETORY LEUKOCYTE PROTEASE INHIBITOR ON THE PRODUCTION OF SOME CYTOKINES AND NITRIC OXIDE BY MURINE PERITONEAL MACROPHAGES IN RESPONSE TO LIPOPOLYSACCHARIDE STIMULATION AND M.AVIUM COMPLEX INFECTION Chiaki SANO, Toshiaki SHIMIZU, Katsumasa SATO, Keiko OGASAWARA, and (*)Haruaki TOMIOKA (*)Department of Microbiology and Immunology, Shimane Medical University Secretory leukocyte protease inhibitor (SLPI), a serine protease inhibitor abundantly found in mucous secretions of lung, is thought to serve as an important protective com- ponent in the secretory fluids at sites of degenerative and inflammatory diseases. In this study, we examined the effects of SLPI on the production of a proinflammatory cytokine, TNF-, and immunosupressive cytokines, IL-10 and transforming growth factor-@ (TGF-) by macrophages (Ms), in response to lipopolysaccharide (LPS)-mediated stimulation and M.avium complex (MAC) infection, using recombinant half-sized SLPI (1/2 SLPI) consisting of C-terminal domain (Arg(55)-Ala(107)) of intact SLPI. In addition, effects of SLPI on the production of nitric oxide radicals (NO), important antimicrobial effectors of Ms against micro-organisms, by these Ms were studied. First, when the number of TNF- producing cells in the LPS-stimulated M population was counted by the ELISPOT assay, more than half on the Ms acquired TNF- secreting ability at 24 hr after LPS stimulation. On the other hand, MAC-inefected Ms produced detectable amounts of TNF- into culture fluid during the first 24 hr. In both cases, 1/2 SLPI did not affect the LPS-or MAC-induced TNF- production by Ms. Second, when the pro- duction of IL-10 and TGF- by Ms was determined by measuring the amounts of these cytokines accumulated in M culture fluids by ELISA, the following were observed. M IL-10 production was rapidly increased in the early phase of cultivation after LPS stimulation or MAC infection, peaking on day 1 and thereafter declining to normal level by day 14. Half-sized SLPI did not affect IL-10 production of LPS-stimulated Ms, while it caused slight enhancement of IL-10 production by MAC-infected Ms. M TGF- production was initiated in the middle phase (day 7) of M cultivation and continued until day 14. Notably, 1/2 SLPI markedly potentiated the TGF- producing ability of the LPS-stimulated Ms. Moreover, 1/2 SLPI caused moderate increase in the TGF-@ production by MAC-infected Ms. Third, significantly potentiated NO production was observed in Ms during the first 2 days after LPS stimulation and MAC infection. Half-sized SLPI did not affect the NO production by LPS-stimulated or MAC-infected Ms. These findings indicate that SLPI up-regulates the production of some immunoregulatory cytokines including IL-10 and TGF-, particularly the latter, by Ms in response to LPS stimulation or MAC infection, thereby suggesting the possibility that SLPI may ex- hibit antiinflammatory effects in vivo, especially patients with bacterial infections includ- ing MAC diseases, through the modulation of M expression of some immunosuppressive cytokines. Key words :SLPI, M.avium complex, Macrophage, TGF- *89-1 Enya-cho, Izumo-shi, Shimane 693-8501 Japan (Received 17 Feb. 1999/ Accepted 23 Mar.1999) <4>Kekkaku Vol.74, No.7:571-577, 1999 MISs AND MBCs OF LEVOFLOXACIN, CLARITHROMYCIN, AND KRM-1648 FOR MYCOBACTERIUM TUBERCULOSIS AND M.AVIUM COMPLEX RESIDING IN MONO-MAC-6 HUMAN MACROPHAGE-LIKE CELL AND A-549 HUMAN TYPE U@ ALVEOLAR EPITHELIAL CELL LINES Katsumasa SATO, Keiko OGASAWARA, Tatsuya AKAKI and, (*)Haruaki TOMIOKA *Department of microbiology and Immunology, Shimane Medical University In this study, we determined the MICs and MBCs of levofloxacin (LVFX), clari- thromycin (CAM), and KRM-1648 (KRM) for Mycobacterium tuberculosis (MTB) strain Kurono and M.avium complex (MAC) strain N-444 residing in MONO-MAC-6 human macrophage-like cells (MM6-Ms) and A-549 human type U alveolar epithelial cells (A -549 cells). First, the MICs of LVFX for MTB replicating in MM6-Ms (1g/ml) and A-549 cells (2g/ml) were 4 to 8 times higher than its MICs for extracellular MTB grow- ing in 7HSF medium. In contrast, the MICs of CAM for intracellular MTB residing in both the cells (2`4g/ml) were 4 to 8 times less than its MICs for extracellular MTB organisms. On the other hand, the MICs of KRM for extracellular MTB were nearly the same as its MICs for intracellular MTB residing in both types of the cells. Secondly, the MICs of LVFX and CAM for extracellular MAC were not significantly different from their MICs for intracellular MAC residing in MM6-Ms and A-549 cells. The MIC of KRM for MAC residing in A-549 cells was 0.25g/ml, and this value was 32 times higher than its MIC for MAC residing in MM6-Ms (0.008g/ml). Thirdly, the MBCs of test drugs for intracellular MTB and MAC residing in both types of the cells were some-what longer than their MBCs for extracellular organisms. These findings indicate that, in the case of pulmonary infections with MTB or MAC, the therapeutic efficacy of a given drug, especially KRM, is more or less influenced by the bacterial location in the host lung tissues where the mycobacterial pathogens survive and multiply, i.e., either al- veolar Ms, type U alveolar epithelial cells, or surrounding environment. Key words : Levofloxacin, Clarithromycin, KRM-1648, Mycobacterium tuberculosis, Mycobacterium avium, Type II alveolar epithelial cells, Macrophages *89-1 Enya-cho, Izumo-shi, Shimane 693-8501 Japan. (Received 14 Dec. 1998/ Accepted 25 Mar. 1999) <5>Kekkaku Vol.74, No.7:579-584, 1999 TWO CASES OF DUODENAL TUBERCULOSIS (1,2*)Kei TAKESHITA, (1)Tomoaki SAKONJU, (1)Hiroyuki TAKAYASU, (1)Kodo ISHII, (1)Keiichi KIKUCHI, and (2)Kazuhiro YAMAGUCHI (1)National Kanagawa Hospital, (2*)Department of Medicine, Keio University School of Medicine The present study described 2 cases of patients with duodenal tuberculosis. Case 1 was a 55 year-old Japanese male patient with pulmonaly tuberculosis and past medical his- tory of subtotal gastrectomy (Billroth II reconstruction). Tubercle bacilli were positive both on smear and culture from his sputum and feces. Bacause of complaining right hypochondralgia, upper gastrointestinal endoscopy was performed and revealed multiple ringed ulcers in the afferent limb of duodenum. Histopathological study of biopsy speci- men demonstrated granulomatous inflammation as well as acid-fast bacilli confirmed by Ziehl-Neelsen staining. Tissue culture was positive for M.tuberculosis. Colonic tuberculo- sis was demonstrated by barium enema. Case 2 was a 45 year-old male patient with pul- moanary tuberculosis in association with severe uncontrolled diabetes mellitus. Sputum polymerase chain reaction test was positive for M.tuberculosis. Granulomatous inflam- mation and positive acid-fast bacilli in biopsy specimen obtained from ulcers in the de- scending portion of the duodenum made a diagnosis of duodenal tuberculosis. No other intestinal tuberculous lesion was recongnized. Since 1988, 11 cases of duodenal tuberculosis including the presented two cases have been reported in Japan. Most of the recent cases had tuberculous lesions in the descending portion of the duodenum and were diagnosed as duodenal tuberculosis by endoscopic examinations, while the majority of the cases re- ported before 1987 had tuberculosis in the more distant portions of the duodenum and were diagnosed mainly by surgical procedures. Key words:Tuberculosis, Duodenum, Intestine *35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582 Japan. (Received 11 Nov. 1998/Accepted 4 Mar. 1999)