(Vol.77, No.5 May 2002) <1> Kekkaku Vol.77, No.5:395-399, 2002 Original Article CLINICAL REVIEW OF PNEUMOTHORAX CASES COMPLICATED WITH ACTIVE PULMONARY TUBERCULOSIS Takenori YAGI, Fumio YAMAGISHI, Yuka SASAKI, Fumio MIZUTANI, Akihiko WADA, and Fuminobu KURODA Abstract Pneumothorax is an important and dangerous complication of pulmonary tuberculosis. Forty-six pneumothorax cases complicated with active pulmonary tuberculosis at National Chiba-Higashi Hospital were studied retrospectively. From Jan. 1987 to Dec. 1997, we experienced 3611 patients with pulmonary tuberculosis, and among them 46 patients (18-90 years old, 38 males and 8 females) had pneumothorax. On admission, 33 out of 46 cases (71.7%) were smear positive by sputum examination of mycobacteria and 41 out of 46 cases (89.1%) had cavitary lesions on chest X-ray. Eleven cases had mild pneumothorax, thirty-two had moderate, and three had severe. Pneumothorax was present on admission in 23 patients and developed during treatment for tuberculosis in the other 23 patients. Eleven patients were treated with bed rest alone, four were thoracentesis and aspiration, twenty-four were intrathoracic tube drainage and seven were operated. Thirty-one patients were recovered, but fifteen passed away, among them 13 due to respiratory failure. The Prognostic nutritional index (PNI;10 x serum albumin concentration + 0.005 x peripheral lymphocyte count) which was proposed by Onodera, serum albumin level and Body mass index were lower in the fatal group than in the survival group. We consider these indices are useful to evaluate the prognosis of active tuberculosis patients complicated with pneumothorax. Key words:Pulmonary tuberculosis, Pneumothorax, Complication, Prognostic nutritional index Division of Thoracic Disease, National Chiba-Higashi Hospital Correspondence to:Takenori Yagi, Division of Thoracic Disease, National Chiba-Higashi Hospital, 673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (E-mail:yagit@bd6.so-net.ne.jp) <2> Kekkaku Vol.77, No.5:401-408, 2002 Original Article AN OUTBREAK OF PULMONARY TUBERCULOSIS PROBABLY DUE TO EXOGENOUS REINFECTION AT A NURSING HOME FOR THE ELDERLY 1Ariyoshi KONDO, 2Norihiro OKETANI, 2Katsuhiro KUWABARA, 2Yoshie MARUYAMA, 2Hiromi MIYAO, 2Yasuharu SAITO, 2Michio MARUYAMA, 2Michiko OHNO, 2Koichi WADA, and 2Toshimasa TSUCHIYA Abstract In Japan and other countries where tuberculosis is not so common, people who were once infected with tuberculosis are thought to rarely suffer from the disease again due to exogenous reinfection. We experienced a mass outbreak of tuberculosis with 27 patients (including the source of infection) at a nursing home for the elderly. Epidemiological investigation suggested that the source of infection was an 82-year- old woman resident. For about 2 years before this outbreak, she had complained of a productive cough. At the time of the diagnosis of tuberculosis, chest radiography revealed a cavitary lesion and a smear of her sputum revealed organisms rated as Gaffky No.8. Sputum culture was also positive (++++). Of the 27 patients, 19(including the source) underwent restriction fragment length polymorphism (RFLP) analysis of isolates from the sputum. Eighteen patients showed an identical RFLP pattern, indicating that the infection had arisen from one source. Out of all patients, the source case of infection, 9 others with the same RFLP pattern, and other 3 who did not undergo RFLP analysis were admitted to our hospital. In 12 patients (3 men and 9 women excluding the source case) aged 80.6 years (range:67-89 years), chest radiography disclosed tuberculous lesions, and smears, the polymerase chain reaction, and culture of sputum demonstrated Mycobacterium tuberculosis. As the prevalence of tuberculosis infection in Japanese aged 80 years at the time of the mass outbreak (1995) was presumed to be about 80%, the disease seemed to be caused by exogenous reinfection in most of these patients. All of the patients had senile dementia and other complications, and they were bedridden and undernourished. Anemia, hypoalbuminemia and lymphocytopenia were also observed in most of the cases. Malnutrition due to these complications appeared to be a possible risk factor of tuberculosis caused by exogenous reinfection. Key words:Tuberculosis in the elderly, Endogenous reactivation, Exogenous reinfection, RFLP analysis, Outbreak 1Niigata Tetsudo-Kenshin Center, East Japan Railway Company, 2Department of Respiratory Medicine, National Nishi-Niigata-Chuo Hospital. Correspondence to:Ariyoshi Kondo, Niigata Tetsudo-Kenshin Center, East Japan Railway Company, 2Department of Respiratory Medicine, National Nishi-Niigata-Chuo Hospital. Correspondence to:Ariyoshi Kondo, Niigata Tetsudo-Kenshin Center, East Japan Railway Company, 1-1-1, Saiwai-Nishi, Niigata-shi, Niigata 950-0908 Japan. (E-mail:jrkensin@plum.ocn.ne.jp) <3> Kekkaku Vol.77, No.5:409-413, 2002 Original Article LONGITUDINAL ASSESSMENT OF IFN-ƒÁ PRODUCTION IN PATIENTS WITH PULMONARY TUBERCULOSIS COMPLICATED WITH DIABETES MELLITUS 1Katsuhiko TSUKAGUCHI, 1Hideo OKAMURA, 1Kuniaki MATSUZAWA, 1Mouka TAMURA, 1Ryuji MIYAZAKI, 2Shinji TAMAKI, and 2Hiroshi KIMURA Abstract Patients with diabetes mellitus (DM) are more susceptible to bacterial infection including pulmonary tuberculosis. To define the immunopathologic mechanisms underlying pulmonary tuberculosis in patients with DM, the production of IFN-ƒÁ by CD4(+)T cells or PBMC were followed up longitudinally during antituberculous chemotherapy. At the time of diagnosis, IFN-ƒÁ production by CD4(+)T cells in either tuberculosis patients without DM(TB) or with DM was significantly lower than that in the healthy control. CD4(+)T cells in tuberculosis patients with DM under poor control (DM(p)TB) produced significantly less IFN-ƒÁ than did patients with DM under good control (DM(g)TB). In longitudinal studies, IFN-ƒÁ production in both TB DM(g)TB patients returned to the control level by 6 months, whereas the production in DM(p)TB patients remained depressed. There was no significant relation between regimens of anti-tuberculous chemotherapy and the production of IFN-ƒÁ by PBMC in all subject groups. IFN-ƒÁ production was depressed in DM(p)TB patients treated with HREZ for 6 months. These results indicate that depressed production of IFN-ƒÁ in DM(p)TB patients is prolonged not due to tuberculous infection but intrinsic defect presumably induced by poorly controlled DM. Key words:Pulmonary tuberculosis, Diabetes mellitus, IFN-ƒÁ, Longitudinal study, Regimens for chemotherapy 1Department of Internal Medicine, National Nishinara Hospital, 2Second Department of Internal Medicine, Nara Medical University Correspondence to:Katsuhiko Tsukaguchi, Department of Internal Medicine, National Nishinara Hospital, 2-789, Shichijo, Nara-shi, Nara 630-8053 Japan. (E-mail:katsuka@wnara.hosp.go.jp) <4> Kekkaku Vol.77, No.5:415-419, 2002 Case Report THYMOMA COMPLICATED WITH MILIARY TUBERCULOSIS Akira KISOHARA, Noriaki TAKAHASHI, Yoshiaki YOYA, and Takashi HORIE Abstract We report a case of thymoma complicated with miliary tuberculosis. A 69-year-old woman was admitted to a hospital because of body weight loss, general fatigue, and dyspnea. Chest X-ray showed a small, diffuse granular shadows in both lungs. Biopsied-specimens from bone marrow and left pharynx revealed granuloma with both giant cells and caseous necrosis. The diagnosis of miliary tuberculosis was made. The patient was then transferred to our hospital. Both chest X-ray and computed tomography conducted on admission revealed a mass in the mediastinum as well as diffuse granular shadows in both lungs. We suspected a presence of thymoma. Anti-tuberculosis therapy was started, and extended thymectomy was performed. The diagnosis of thymoma was confirmed pathologically. Immunological analysis of peripheral blood lymphocytes was done before and after the operation. Negative conversion of PPD reaction was observed after thymectomy. Although the response of peripheral lymphocytes to phytohaemoagglutinin (PHA) and concanavalin A recovered after thymectomy, a marked decrease of the number of CD4 T cells, a decrease of T helper 1 cells, a slight increase in the number of B cells and cells expressing natural killer cell-related surface markers were observed throughout the course of illness. Key words:Thymoma, Miliary tuberculosis, Immunology, Th1 First Department of Internal Medicine, Nihon University School of Medicine Correspondence to:Akira Kisohara, First Department of Internal Medicine, Nihon University School of Medicine, 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-0032 Japan. (E-mail:kisohara@med.nihon-u.ac.jp) <5> Kekkaku Vol.77, No.5:421-425, 2002 Case Report A CASE OF PULMONARY INFECTION CAUSED BY MYCOBACTERIUM SZULGAI Shusaku HARANAGA, Yoko SATO, Masaki TOHYAMA, Masato TOYAMA, Tomohiko ISHIMINE, Takayuki MIYARA, Takashi SHINZATO, Futoshi HIGA, Masao TATEYAMA, and Atsushi SAITO Abstract We report a case of pulmonary non-tuberculous mycobacteriosis caused by Mycobacterium szulgai. A thirty-nine-year-old man with no relevant significant past history underwent an annual medical check. His chest X-ray and CT scan showed an infiltrative shadow with a cavity in the right upper lobe. As it was suggestive of pulmonary tuberculosis, he was referred to our hospital. Smear tests of his sputum, gastric fluid, and transbronchial fluid showed no mycobacterial organisms, but culture of the samples revealed growth of mycobacteria. The organism was identified as M. szulgai using a DNA-DNA hybridization method, and the case was diagnosed as pulmonary non-tuberculous mycobacteriosis caused by M.szulgai. By anti-mycobacterial drug treatment with isoniazid, rifampicin, and ethambutol, the infiltrative shadow on chest roentogenogram and CT showed improvement. Culture of his sputum and gastric fluid showed no growth of mycobacteria after starting treatment. Key words:Non-tuberculous mycobacteriosis, Mycobacterium szulgai First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus Correspondence to:Shusaku Haranaga, First Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus, 207 Nishihara-cho, Nakagami-gun, Okinawa 903-0215 Japan. (E-mail:f014936@med.u-ryukyu.ac.jp) <6> Kekkaku Vol.77, No.5:427-431, 2002 Case Report PULMONARY INFECTION CAUSED BY MYCOBACTERIUM SZULGAI:A CASE REPORT Tatsuyoshi IKEUE, Shigeki WATANABE, Takakazu SUGITA, Sadao HORIKAWA, Yujiro SUZUKI, Hideki NISHIYAMA, and Nobuo MAEKAWA Abstract We reported a case of pulmonary infection caused by Mycobacterium szulgai(M.szulgai) in an immunocompetent, asymptomatic 55-year-old man without underlying disease. A chest radiograph of an annual health examination revealed a right upper lobe infiltrate with thin-walled cavities, which was not present in the previous year. An acid-fast stain of bronchial washing fluid was positive, and antimycobacterial chemotherapy with isoniazid (400mg/day), rifampin (450 mg/day), and ethambutol (750mg/day) was initiated on presumptive diagnosis of the case as tuberculosis. DNA-DNA hybridization of sputum and bronchial washing samples identified M.szulgai as the causative organism. Antimicrobial susceptibility testing indicated that the isolate was sensitive to most common antimycobacterial drugs except capreomycin (CPM) and p-aminosalicylic acid (PAS), and was also sensitive to clarithromycin and fluoroquinolones including ofloxacin, levofloxacin, sparfloxacin, and ciprofloxacin. After 12 months of therapy, a repeat chest radiograph demonstrated improvement of the right upper lobe infiltrate. When M.szulgai is isolated, it almost always represents a true pathogen. Therefore, the detection of even a small number of M.szulgai warrants treatment based on susceptibility testing. Key words:Nontuberculous mycobacteriosis, Mycobacterium szulgai, Diagnosis, Susceptibility testing, Therapy Department of Respiratory Disease, Japan Red Cross Society, Wakayama Medical Center Correspondence to:Tatsuyoshi Ikeue, Department of Respiratory Disease, Japan Red Cross Society, Wakayama Medical Center, 4-20, Komatsubara-dori, Wakayama-shi, Wakayama 640-8558 Japan. (E-mail:tikeue@wakayamanet.or.jp)