(Vol.77, No.6 June 2002) <1> Kekkaku Vol.77, No.6: 435-441, 2002 Original Article THE EFFECT OF COMBINED CHEMOTHERAPY FOLLOWING THE GUIDELINES ON TREATMENT FOR MYCOBACTERIUM AVIUM COMPLEX PULMONARY DISEASE 1Yoshihiro KOBASHI, 1Niro OKIMOTO, 2Toshiharu MATSUSHIMA, 3Eriko SHIGETOU, 3Toshihiko KURAOKA, 3Hiroyasu TAKEYAMA, 3Ryousuke EDA, 3Shuichi YANO, 3Kanako KOBAYASHI, 3Takayuki OHNISHI, 3Kenichi MORI, 3Yoshio UEDA, 3Tomonori MORITAKA, 3Kazutaka NISHIMURA, and 3Takahiro ABE Abstract We retrospectively investigated the clinical appropriateness of combined chemotherapy following the Japanese Society for Tuberculosis guidelines corresponding with those of the American Thoracic Society guideline for MAC pulmonary disease including a comparison with the past treatment for MAC pulmonary disease. The subjects of this study were 159 patients at several hospitals surveyed by the Chugoku-Shikoku Research Committee on Mycobacterium who were diagnosed as having MAC pulmonary disease between April 1995 and March 2001. Among them, 102 patients were treated using a regimen of antituberculous drugs with CAM, 33 patients received antituberculous drugs without CAM, and 24 patients were treated using other regimens. With a regimen of antituberculous drugs plus CAM, the sputum conversion rate was 45.1%, the relapse rate was 39.1% and clinical improvement was obtained in only 29.4%. On a regimen of only antituberculous drugs, the sputum conversion rate was 30.3%, the relapse rate was 70.0% and clinical improvement was obtained in 12.1%. Among the 102 patients receiving the regimen of antituberculous drugs plus CAM, 41 patients were treated with RFP, EB, SM and CAM following exactly the guidelines. The sputum conversion rate was 58.5%, the relapse rate was 37.5% and clinical improvement was obtained in 36.6%. Among 61 patients treated with other antituberculous drugs plus CAM, the sputum conversion rate was 36.1%, the relapse rate was 40.9% and clinical improvement was obtained in 24.6%. The clinical effect of the combined chemotherapy (RFP, EB, SM and CAM) was better than that of the other regimens throughout this study. However, the efficacy of this combined chemotherapy was unsatisfactory compared with the clinical effect for pulmonary tuberculosis. Therefore, the development of new companion drugs for the disease with mycobacteria other than M.tuberculosis is needed. Key words:MAC pulmonary disease, Treatment guideline, CAM, Antituberculous drugs 1Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School Kawasaki Hospital, 2Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, 3Chugoku-Shikoku Mycobacterium Research Committee Correspondence to:Yoshihiro Kobashi, Division of Respiratory Disease, Department of Medicine, Kawasaki Medical School Kawasaki Hospital, 2-1-80, Nakasange, Okayama-shi, Okayama 700-8505 Japan. (E-mail:kh-info@po.rweb.ne.jp) <2> Kekkaku Vol.77, No.6:443-448, 2002 Original Article A STUDY ON FAR-ADVANCED CAVITARY PULMONARY TUBERCULOSIS CASES Yuka SASAKI, Fumio YAMAGISHI, Takenori YAGI, Hideki YAMATANI, Fuminobu KURODA, and Hideaki SHODA Abstract In cases with far-advanced cavitary pulmonary tuberculosis, the most serious lesions according to the chest X-ray classification by the Japanese Society of Tuberculosis (bI3), their prognosis is believed to be poor due to their emaciated general conditions, and a retrospective clinical study was made on these cases admitted to our hospital. The subjects consisted of 95 cases, and among them 87 were male and 8 were female, and their mean age was 49.5}13.0 years. Eighty four cases were detected by symptomatic visit to clinics, 10 cases during their treatment for other diseases, and 1 case was discovered accidentally. Sputum examination for acid fast bacilli was all smear positive. As to their social background, the majority were occupied by socially vulnerable groups; 31 cases (32.6%) were jobless on admission, 24 cases (25.3%) were day laborers, and 25 cases (26.3%) were receiving poor relief. Regarding their general condition on admission, 40 cases were very serious and they could not stand by themselves, and their nutritional conditions were poor, and 19 cases (20%) died during hospitalization. All of them were male, and they were found by symptomatic visit to clinics. The period from hospital admission to death was short, the average was 35.0}39.8 days, and the median was 11.0 days. Among 84 patients detected by symptomatic visit, the patient's delay was 5.5}5.0 months, while the doctor's delay was 0.3}0.9 months. Major cause of late detection at advanced stage of these cases was patient's delay which caused poor prognosis of these cases, and various measures to shorten the delay in case-detection must be taken. Key words:Pulmonary tuberculosis, Far-advanced cavity type, Far-advanced tuberculosis, Tuberculosis death Division of Thoracic Disease, National Chiba Higashi Hospital Correspondence to:Yuka Sasaki, Division of Thoracic Disease, National Chiba Higashi Hospital, 673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (E-mail:sasakiy@chibae.hosp.go.jp) <3> Kekkaku Vol.77, No.6:449-455, 2002 Original Article RELIABILITY OF AMPLICOR(R) MYCOBACTERIA KIT FOR DETECTION OF MYCOABCTERIUM TUBERCULOSIS COMPLEX AND MYCOBACTERIUM INTRACELLULARE: RESULTS OF COOPERATIVE STUDY AMONG 331 LABORATORIES IN 2000 1Yoshimi HIGURASHI, 2Kazuyoshi MIYAKE, 1*Katsuko OKUZUMI, 3*Mitsuaki NAGASAWA, 4*Masaharu WATANABE, 5**Yuichi TACHIBANA Abstract Amplicor(R) Mycobacterium Kit (Roch Diagnostics:Japan) is the most widely used kit in Japan for the diagnosis of mycobacteria infections, especially those caused by Mycobacterium tuberculosis, Mycobacterium avium and Mycobacterium intracellurare. We evaluated the reliability of the kit in co-operation with 331 laboratories using the kit in routine examination. We distributed specially prepared 4 test samples to each laboratories. The negative sample was NALC-NaOH treated sputum which showed "negative" when tested by this kit and positive samples were NALC-NaOH treated sputum containing M.bovis or M.intracellurare. False-positive results were reported in 6 out of 331 laboratories (1.8%) and false-negative results were reported from 7 laboratories (2.1%). (The details were 1 out of 331 labs for TB-H sample, 5 out of 331 labs for TB-L sample and 1 out of 316 in MIN sample.) Statistical significance between MWP method and COBAS method was not significant. After receiving and evaluating the test results on the 4 samples, the follow up questionnaires were sent out to 22 laboratories which reported incorrect results and low optical density (O.D.) on positive control. Results of this questionnaire suggested that it was important to follow the package insert instructions and to follow the correct procedures for PCR assay. These results suggested that Amplicor Mycobacterium Kit is reliable for rapid diagnosis of Mycobacteria infections. Key words:Amplicor, Mycobacterium spp., PCR(polymerase chain reaction), Co-operative blind study 1Department of Clinical Laboratory, University of Tokyo Hospital, 2PCR product section, Roche diagnostic K.K, 3Department of Laboratory Medicine, National Defence Medical College Hospital, 4Division of Clinical Laboratory, Chiba University Hospital, 5Department of Clinical Laboratory, Juntendo University Hospital, *Committee of PCR Diagnosis for Infectious Disease, **Chairman for Committee of PCR Diagnosis for Infectiouns Disease Correspondence to:Yoshimi Higurashi, Department of Clinical Laboratory, University of Tokyo Hospital, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655 Japan. (E-mail:HIGURASHI-LAB@h.u-tokyo.ac.jp) <4> Kekkaku Vol.77, No.6:457-463, 2002 Field Activities QUESTIONNAIRE ABOUT IMPRESSION AND KNOWLEDGE OF TUBERCULOSIS IN EMPLOYEES AND STUDENTS IN A UNIVERSITY HOSPITAL 1Yoichi NAKANISHI, 1Miiru IZUMI, 2Kihachiro ABE, 1Taishi HARADA, 1Koji INOUE, 1Hiroshi WATAYA, 1Takahiro MINAMI, 1Yasuhiro HORIUCHI, 1Rie ISHIBASHI, and 1Nobuyuki HARA Abstract The aim of the study is to search the efficient way for the prevention of nosocomial tuberculosis (TB) infection in a university teaching hospital. Through a questionnaire, informations on the degree of interest in TB, on the way how they try to learn about TB infection and on basic knowledge of TB epidemiology were obtained. The study subjects were most employees including physicians, nursing staffs, medical technicians, pharmacists, clerks as well as medical and dental students, who were younger than 40 years. The study was done from 1999 through 2001, and a total of 2,159 questionnaires in which age, sex and occupational category were completely described were analyzed. Out of total participants, 61.8% participants showed interest in TB, however, only 3.0% had actually attended lecture meeting or collected materials on TB infection. Out of 619 nursing staffs, 431 (69.6%) felt anxiety for TB infection and the disease, and it was significantly higher than the other occupational groups. Of 2,159 participants, 1472 (68.2%) participants desired to have health examination for TB. On the other hand, less than 50% participants including physicians answered correctly to questions about basic knowledge of TB epidemiology. Through the present study, it was suggested that employees and students in a university hospital do not voluntarily learn about TB, or do not have enough knowledge on TB in spite of their anxiety or interest, but that they are well prepared to obtain essential informations on the prevention of TB infection. Thus, it would be worthwhile to establish a system of education and health examination for the prevention of nosocomial TB infection. On the other hand, the degree of interest in and anxiety about TB in clerical employees was relatively low. Since they have some risk of TB infection through a service at window, the strengthening of health education on TB for them would be necessary. Key words:Questionnaire, Hospital acquired infection, University hospital employee, Medical student, Nursing staff, Anxiety 1Research Institute for Diseases of the Chest. Graduate School of Medical Sciences, Kyushu University, 2Special Patient Oral Care Unit of Kyushu University Dental Hospital Correspondence to:Yoichi Nakanishi, Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582 Japan. (E-mail:yoichi@kokyu.med.kyushu-u.ac.jp) <5> Kekkaku Vol.77, No.6:465-470, 2002 Case Report A CASE OF CUTANEOUS TUBERCULOSIS UNDER STEROID & IMMUNOSUPPRESSANT THERAPY FOR DERMATOMYOSITIS 1Masakuni FUJITA, 1Kenichiro ARAKAWA, 1Shiro MIZUNO, 1Masanobu WAKABAYASHI, 1Yoshitaka TOTANI, 1Yoshiki DEMURA, 1Shingo AMESHIMA, 1Isamu MIYAMORI, 2Takeshi ISHIZAKI, and 3Takahiro SAWAI Abstract A 44-year-old man had been admitted for high fever and leg edema on November 1998. By the laboratory data, electromyography, and muscle biopsy, he was diagnosed as having polymyositis. Steroid (prednisolone 60 mg/day) and immunosuppressant (methotrexate 7.5 mg/week) therapy was administered and the symptoms were improved, so he had been followed up in out-patient clinic. After half a year, high fever and leg edema relapsed and erythema on the bilateral forearms appeared, so he was admitted again on January 2000. The symptoms, skin involvement and laboratory data suggested the disease of dermatomyositis. Steroid pulse therapy was administered again. But the symptoms were not improved. Skin biopsy was performed but it showed only inflammatory changes. Several antibiotics and cyclospolyn A were undertaken but they were not effective. On February 12th he passed away because of respiratory failure. The autopsy was undertaken and it revealed tuberculosis in the skin, subcutaneous tissues and muscles, however, pulmonary tuberculosis was not found. The patient with collagen disease is considered to be "compromised host", especially during corticosteroid therapy. We must keep in mind potential incidence of tuberculosis and do careful clinical observation for early diagnosis and be prepared for antituberculous chemotherapy. Chemoprophylaxis for tuberculosis seems to be desirable for higher risk patients. Key words:Collagen disease, Dermatomyositis, Cutaneous tuberculosis, Steroids, Immunosuppressant 1Third Department of Internal Medicine, 2Department of Fundamental Nursing, 3Dermatology, Fukui Medical University Correspondence to:Masakuni Fujita, Third Department of Internal Medicine, Fukui Medical University, 23 Shimoaizuki, Matsuoka-cho, Yoshida-gun, Fukui 910-1193 Japan. (E-mail:masakuni@fmsrsa.fukui-med.ac.jp)