(Vol.76, No.6 June 2001) <1> Kekkaku Vol.76, No.6: 447-454,2001 A STUDY ON THE CLINICAL FEATURES OF PULMONARY TUBERCULOSIS IN ELDERLY PATIENTS 1,2*Yasuhiro YAMAGUCHI, 1Yoshiko KAWABE, 1Naohiro NAGAYAMA, 1Atsuhisa TAMURA, 1Hideaki NAGAI, 1Shinobu AKAGAWA, 1Kazuko MACHIDA, 1Atsuyuki KURASHIMA, 1Hideki YOTSUMOTO, and 1Masashi MORI 1Department of Respiratory Diseases, National Tokyo Chest Hospital, 2*Department of Geriatric Medicine, School of Medicine, University of Tokyo The clinical findings of pulmonary tuberculosis in elderly patients aged 75 years of age or older (elderly group) were compared with the middle-aged between 45 and 54 years of age (middle-aged group) and the young patients aged 34 years of age or younger (young group). The elderly patients who died in hospital were also compared with the elderly patients who survived. Study subjects were culture-positive pulmonary tuberculosis patients who were discharged from our hospital from December 1996 to November 1998. There were 79 patients in the elderly group, 95 in the middle-aged group, and 88 in the young group. The results were as follows. 1) The male/female ratio was significantly lower in the elderly group.(1.9:1) than the middle-aged group(6.9:1). 2) Complication was noted more frequency in the elderly group. However, diabetes mel- litus was noted less frequently in the elderly group (12.7%) than the middle-aged group (28.4%). 3) The frequency of cavitation was lower in the elderly group (59.5%) than the middle- aged group (87.4%). 4) The fever over 38Ž was noted less frequently in the elderly group (17.7%) than the other groups, while the frequently of the fever over 37Ž showed no significant differ- ence between the elderly group and the other groups. 5) The frequencies of hypoalbuminemia and appetite loss were higher in the elderly group than the other groups. 6) The elderly group showed high mortality rate of 31.6%. The complication with cerebrovascular disease was noted significantly higher in the patients who died in hospital than those who survived. The frequency of widespread infiltrates, fever over 38Ž, neutrophilia, hypoalbuminemia and appetite loss were all significantly higher in the patients who died in hospital while their sputa were still positive on culture than those who survived. Our study clearly showed the features of elderly pulmonary tuberculosis patients in comparison with middle-aged patients and young patients. These features are very impor- tant to suspect the diagnosis of pulmonary tuberculosis in elderly patients with some atypical manifestation. Our study also suggests that the delay in diagnosing tuberculosis causes more frequently the patients' deterioration and death in elderly patients than in middle-aged patients and young patients. Key words:Pulmonary tuberculosis, Elderly patients, cavitation, Hypoalbuminemia, Appetite loss, Diabetes mellitus, Cerebrovascular disease *7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655 Japan. (Received 27 Dec. 2000 /Accepted 5 Mar. 2001) <2> Kekkaku Vol.76, No.6: 455-460,2001 A STUDY ON FAMILY INFECTION OF TUBERCULOSIS *Izumi HAMAJIMA *Sapporo Atsubetsu District Health Center The guideline for contacts examination and chemoprophylaxis for tuberculosis was revised in 1993. Secondary cases and chemoprophylaxis cases found by the contacts exami- nation of family members were analyzed in Sapporo City. The average age of index cases and of secondary cases has become higher. Many secondary cases were found among spouse of the index case and children of male index case. Chemoprophylaxis cases were found mostly among children of male or female index cases and grandchildren of male index cases. The results of family contacts examination carried out during the period from 1994 to 1999 were compared with those from 1987 to 1992. The incidence of family infection of tuberculosis and the number of newly infected persons and of secondary cases have decreased in the latter period. The time interval from the registration of the index case to the detection of secondary cases has become shorter, and the ratio of sputum smear positive cases among secondary cases has also decreased. Male to female ratio of the index cases was 2:1, that of secondary cases was 3:5, and that of children indicated chemoprophylaxis was 4:5. All secondary cases found by the contacts examination carried out within 6 months after the previous examination were sputum smear negative for tubercle bacilli, and there were a few smear positive cases among secondary cases who were found by the examination with longer interval with the previous examination. Such cases with longer interval from the last periodic examination was found oftener among younger cases below 40 years of age. Most smear negative tuberculosis cases were found by the family contacts examina- tion, while most smear positive cases were found by symptomatic visit to doctors. Key words:Family infection of tuberculosis, Family contacts examination, Extraordinary examination, Chemoprophylaxis *5-3-2, Atsubetsu Chuo 1-jo, Atsubetsu-ku, Sapporo-shi, Hokkaido 0004-8612 Japan. (Received 18 Oct. 2000 /Accepted 15 Mar. 2001) <3> Kekkaku Vol.76, No.6: 461-471,2001 A STUDY ON RESISTANCE OF MYCOBACTERIUM TUBERCULOSIS TO FOUR FURST-LINE ANTI-TUBERCULOSIS DRUGS IN JAPAN:COMPARISON OF RESULTS IN THE LOCAL FACILITIES AND IN THE REFERENCE LABORATORY, IN 1997 Kazue HIRANO, Masako WADA, *Chiyoji ABE, Teruo AOYAGI, 78 Cooperating Institutions *Tuberculosis Research Committee (Ryoken) (Chair:Teruo Aoyagi) Five years after the last survey of drug-resistant tuberculosis in Japan, a nationwide survey was conducted by the Tuberculosis Research Committee (Ryoken). A total of 78 hospitals in various districts of Japan participated in this cooperative study. Each collaborating laboratory sent all the isolated mycobacterial cultures during June 1 to November 30, 1997 to the Research Institute of Tuberculosis (RIT), which is one of the Supranational Reference Laboratories of the WHO/IUATLD Global Project on Anti- tuberculosis Drug Resistance Surveillance. At RIT identification and drug susceptibility of Mycobacterium tuberculosis isolates were reexamined. The RIT received a total of 2,167 cultures. Among them, 523 cultures were excluded from further examinations because of various reasons, such as growth of mycobacteria other than tubercle bacilli (MOTT, 453), mixed cultures of M.tuberculosis and MOTT (16), and contamination or non-viability (54). Thus drug susceptibility test results were available for 1,644 cultures, including 47 from foreign-born people. In the local laboratories, the absolute concentration method using 1% Ogawa egg slant (standard method, 26 hospitals), its modified methods using a 48-well plate (Microtiter method, 29 hospitals) and a 16-well plate (Well-pack method, 7 hospitals), combination of above 2 or 3 methods (13 hospitals), and other method (3 hospitals) were used for drug susceptibility testing, and the proportion method using 1% Ogawa egg slant was used in the RIT. The results in the local labora- tories were compared with those in the RIT. A high concordance rate (over 90%) was seen in the testing for 1 ƒĘg/ml of isoniazid (INH), rifampin (RFP) and streptomycin (SM), but the rate was lower (under 90%) in the testing for 0.1ƒĘg/ml of INH and ethambutol (EMB). However, there was no significant difference in the concordance rates according to the test drugs among methods for drug susceptibility testing used in the local laboratories. Median concordance rates between the results with the standard method, Microtiter method and Well-pack method in the local laboratories, and those in the RIT were 95.9%, 93.2% and 96.4% respectively. Relatively lower concordance rates were seen in the laboratories using the Microtiter method related to high overestimation rates (median overestimation rate of 5.3%), compared with 1.2% and 2.3% in the laboratories using the standard method and Well-pack method, respectively. However, relatively lower concordance rates (less than 90%) were seen in the laboratories using any of the three methods, indicating that there are variations among facilities. Part of the results concerning the resistance patterns to four first-line anti-tuberculosis drugs were reported elsewhere. Key words:Drug resistant tuberculosis, Nationwide survey, Drug susceptibility testing, Quality control of test *C/o Research Institute of Tuberculosis, Japan Anti- Tuberculosis Association, 3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 10 Jan. 2001/Accepted 19 Mar. 2001) <4> Kekkaku Vol.76, No.6: 473-478,2001 A CASE OF TUBERCULOUS ENDOMETRITIS DETECTED BY CYTOLOGY OF MASS SCREENING FOR GYNECOLOGIC CANCER 1*2Seiyu HIRATA and 3Tetushi SHONO 1*Department of the 3rd Surgery, Tokyo University, Branch Hospital, 2Tateyama Hospital, 3Shono-Ladys Clinic, Tateyama A 55-year-old infertile woman was referred to our clinic for further investigation on extragenital tuberculosis, as tuberculous endometritis was strongly suspected by cyto- logy of her vaginal smear carried out on the occasion of the mass examination for gynecologic cancer screening. Her vaginal smear revealed epithelioid cell clusters which are characteristic for tuberculosis, and cultures of her vaginal discharge were positive for M.tuberculosis consecutively. Moreover, she was exposed for tuberculosis infection from her father who died of active pulmonary tuberculosis when she was ten years old. Her tuberculin test was strongly positive, and her chest radiography showed no abnormality, but a small nodular shadow evaluated as primary focus of tuberculosis located beneath the pleura of the right lower lung field was confirmed by chest CT. In addition, calci- fication of her para-aortic abdominal lymphnode was detected by simple abdominal X- ray. Based on these data, she was diagnosed as tuberculous endometritis via abdominal cavity, and three antituberculous drugs, namely RFP, INH and EB, were administrated. The mycobacterial cultures of vaginal discharge converted to negative, and chemotherapy was terminated after 9 months treatment. A risk factor leading to the onset of gynecologic tuberculosis, in this case was an exposure to infection from her father. In order to evaluate risk factors relating to the development of gynecologic tuberculosis, bibliographic studies were made on 19 cases of tuberculous endometrites reported recently in Japan regarding their age, its pathogenesis and immuno-suppressive conditions, and the summarized results were as follows. 1. approximately 80% of them were elderly, namely 79% were above 50 years, 63% above 60 years, and 26% above 70 years. 2. 50% of them were caused by endogenous reactivation. 3. 25% of them were immuno-compromised host. It can be concluded that more than 70% of the patients with tuberculous endometritis had risk factors on the host side to develop tuberuclosis. Key words:Tuberculous endometritis, Vaginal smear, Infertility, Endogenous reactivation *3-28-6, Mejirodai, Bunkyo-ku, Tokyo 112-0015 Japan. (Received 13 Feb. 2001/Accepted 13 Mar. 2001) <5> Kekkaku Vol.76, No.6: 479-484,2001 A CASE OF TUBERCULOUS PERITONITIS DIAGNOSED BY A DIRECT SMEAR OF ASCITIC FLUID COMPLICATED WITH AN ACTIVE PULMONARY TUBERCULOSIS AND INTESTINAL TUBERCULOSIS *Hiroshi MIZUTANI, Michiaki HORIBA, Joh SHINDOH, Tomoki KIMURA, Masami SON, and Keiko WAKAHARA *Department of Respiratory Medicine, Ogaki Municipal Hospital We sometimes encounter difficulties in differentiating tuberculous peritonitis from other inflammatory disorders or ascites due to carcinomatous peritonitis. Acid-fast bacilli are very rarely detected in ascites. In this study, we reported a case of tuberculous peritonitis accompanied with active pulmonary tuberculosis in which acid-fast bacilli were detected in ascites. The patient was a 37-year-old single man who had been admitted to our hospital on February 28, 2000, because acid-fast bacilli were detected in sputum, faces and ascites by a direct smear. He had a lower abdominal distention and pain. His serum CA 125 level was high, 121 U/ml. Abdominal ultrasonography showed marked ascites in Douglas pouch. However adenosine deaminase level was not high in his ascites. During treatment by the combination chemotherapy with INH, RFP, EB, and PZA, serum CA 125 level was decreased. Key words:Tuberculous peritonitis, Ascites, Intestinal tuberculosis, Active pulmonary tuberculosis, CA 125 *4-86, Minaminokawa-cho, Ogaki-shi, Gifu 503-8502 Japan. (Received 27 Nov. 2000/Accepted 14 Mar. 2001) <6> Kekkaku Vol.76, No.6: 485-489,2001 A CASE OF MYCOBACTERIUM INTRACELLULARE LUNG DISEASE OCCURRED IN A MIDDLE-AGED MAN WHO COMPLAINED HEMOPTYSIS WITH NORMAL CHEST ROENTOGENOGRAM *Shin SASAKI, Yoshiro MOCHIZUKI, Yasuharu NAKAHARA, Akira TANAKA, and Tetsuji KAWAHARA *Division of Internal Medicine, National Himeji Hospital A 45-year-old man visited our clinic because of intermittent bloody sputum. The chest roentogenogram was normal, but the high-resolution computed tomography (HRCT) showed very small nodules and bronchiolitis adjacent to pleura in the upper right lung field. The bronchoscopic examination revealed blood-streaked bronchial secretion in the right upper lobe bronchus, and the cultures of the sputa and the bronchial washing specimen showed acid-fast bacilli identified as Mycobacterium intracellulare by DNA- DNA hybridization (DDH) method. This case was diagnosed as Mycobacterium intracellulare lung disease. The patient received isoniazid, levofloxacin, and clarithromycin for three years without clinical and bacteriological improvement. His hemoptysis and the number of colonies recovered from sputum cultures decreased without any medication later. The serial chest roentogenograms and HRCTs have showed no changes for 6 years after the diagnosis. This case may show some clues to elucidate the mechanism of the onset of Mycobacterium intracellulare lung disease without predisposing conditions. Key words:Mycobacterium intracellulare, Mycobacterium avium-intracellulare complex lung disease, High-resolution computed tomography(HRCT) *68, Honmachi, Himeji-shi, Hyogo 670-8520 Japan. (Received 16 Nov. 2000/Accepted 28 Mar. 2001)