(Vol.74 No.11 November 1999) <1> Kekkaku Vol.74,No.11:777-788,1999 CROSS-CONTAMINATION OF MYCOBACTERIUM TUBERCULOSIS CULTURE IN CLINICAL LABORATORIES 1*Kunihiko ITO, 1Mitsuyoshi TAKAHASHI, 1Takashi YOSHIYAMA, 1Masako WADA, 2Tomoaki NAKAZONO, 2Hideo OGATA, 2Seiji MIZUTANI, and 2Hironobu SUGITA 1*Research Institute of Tuberculosis, JATA. 2Department of Pulmonary Medicine, Fukujuji Hospital, JATA. For many years, it has been thought that positive culture of M. tuberculosis is a de- finitive diagnostic evidence of tuberculosis and cross-contamination of M. tuberculosis culture in clinical laboratories is rare. However recently introduced RFLP analysis has en- abled us to identify a strain of M. tuberculosis, and many cases of the cross-contamina- tion in clinical laboratories confirmed by RFLP analysis have been reported. In this report, we present the first case of the cross-contamination confirmed by RFLP in Japan. In our case, 5 patients without any personal link to each other were suspected based on clinical findings to have cross-contaminated results of M. tuberculosis culture. All their specimens were processed on the same day, and were smear negative and culture positive with only a small number of colonies (less than 8 colonies). The sputum from the suspected source of contamination processed on the same day was strongly positive for AFB smear and heavily culture positive. The RFLP patterns of these 6 patients were identical, so it was concluded that the positive cultures of the sputum from the 5 pa- tients who were not expected to be culture positive on clinical findings were caused by the cross-contamination in our hospital laboratory. We review all the charts of patients with M.tuberculosis culture positive results in the same year of this case, but we didn't find no other cases suspected of the cross-contamination. Then we reviewed the literature of M.tuberculosis culture cross-contamination. The patterns of the cross-contamination are divided into two. One is associated with mal- function of a sampling needle in the BACTEC 460 system and the other associated with the initial processing of the specimens, mostly involving reagents such as NaOH solution. Cross-contaminated specimens are usually smear negative with only a few colonies (less than 5), and processed just after the source specimen of the contamination in most reported cases, but not in all. In almost half of them the cross-contamination results had significant influence on the clinical management. The frequency of the cross-contamina- tion is estimated around 1 % of the patients with M.tuberculosis culture positive results. For early detection of the cross-contamination, not only clinicians but also laboratory staffs have important role and close cooperation between them is mandatory. To prevent the contamination, it is advisable to process smear positive and probable culture positive specimens separately from others, and not to use a large same container of reagents for processing of different specimens. Key words:Cross-contamination, M.tuberculosis, False-positive, RFLP analysis *3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 10 Jun. 1999/Accepted 16 Aug. 1999) <2> Kekkaku Vol.74,No.11:789-795,1999 CLINICAL ANALYSIS OF PULMONARY TUBERCULOSIS IN ASSOCIATION WITH CORTICOSTEROID THERAPY 1*Yoshihiro KOBASHI, 1Hirohide YONEYAMA, 1Niro OKIMOTO, 2Toshiharu MATSUSHIMA, and 3Rinzo SOEJIMA 1*Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School Ka- wasaki Hospital, 2Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School, 3Kawasaki Medical Welfare University In the last five years, five patients (three males and two females) among a total of 162 patients (3.1%) ranging from 63 to 79 years old developed pulmonary tuberculosis during the long-term corticosteroid therapy. The underlying diseases of these cases were pulmonary fibrosis in two, polyarteritis nodosa in one, RPGN+pulmonary bleeding in one, and mycosis fungoides in one. The total corticosteroid dose used until the clinical di- agnosis of pulmonary tuberculosis was 1.16g to 5.60g and the term of administration was two to nine and a half months. Other immunosuppressive drugs were administered to two patients. Though chemoprophylaxis with INH was done in two patients for three months, it was impossible to prevent the development of pulmonary tuberculosis. Since almost all patients except one complained no symptoms at the onset, the follow-up with chest roentgenograms seemed to be most important during corticosteroid therapy, and in fact, four patients were detected by the follow-up. Antituberculous chemotherapy was effective in four pa- tients but was not carried out for one patient due to the delay in the diagnosis. Careful clinical observation, such as by chest roentgenograms, seems to be appropriate for the early diagnosis and treatment of pulmonary tuberculosis in patients on corticosteroid therapy. Key words:Corticosteroid therapy, Pulmonary tuberculosis, Chest roentgenograms, Early diagnosis *2-1-80, Nakasange, Okayama-shi, Okayama 700-8505 Japan. (Received 14 May 1999/Accepted 18 Aug. 1999) <3> Kekkaku Vol.74,No.11:797-802,1999 ACTIVE PULMONARY TUBERCULOSIS IN PATIENTS WITH LUNG CANCER 1*Atsuhisa TAMURA, 2Akira HEBISAWA, 1Go TANAKA, 1Hideo TATSUTA, 1Tomomasa TSUBOI, 1Hideaki NAGAI, 1Koji HAYASHI, 1Yuzo SAGARA, 1Yoshiko KAWABE, 1Shinobu AKAGAWA, 1Naohiro NAGAYAMA, 1Kazuko MACHIDA, 1Atsuyuki KURASHIMA, 1Koji SATO, 1Kanae FUKUSHIMA, 1Hideki YOTSUMOTO, and 1Masashi MORI 1*Department of Respiratory Diseases, Tokyo National Chest Hospital, 2Department of Pathology, Tokyo National Chest Hospital To clarify the features of the coexistence of active pulmonary tuberculosis in patients with lung cancer, we analyzed clinical data on 25 cases with coexisting lung cancer and active pulmonary tuberculosis enocuntered at Tokyo National Chest Hospital during the period from 1991 to 1998. There were 23 men and 2 women, with a mean ago of 70 years. The incidence of lung cancer among patients with acitve pulmonary tuberculosis at our hospital was 0.7 per cent, while the incidence of active pulmonary tuberculosis in un- treated lung cancer patients at our hospital was 1.9 per cent. We classified the 25 cases into 2 groups as follows:(1) tuberculosis sequential to lung cancer (11 cases) and (2) tu- berculosis concurrently detected with lung cancer (14 cases). All patients in the former group were transferred from other hospitals after diagnosing the coexistence of pulmo- nary tuberculosis during the management of lung cancer. Histological types of lung can- cer were squamous cell carcinoma in 12, adenocarcinoma in 9, and small cell carcinoma in 4, and as to the disease stage, stages ‡V to ‡W were predominant. Analysis on relation- ship of chest X-ray findings between lung cancer and pulmonary tuberculosis revealed that in general, the location of lung cancer and tuberculosis seemed to be independent. Tuberculosis in the sequential group was more extensive and severer than in the concurrent group. In the concurrent group, treatment for tuberculosis was successful except for one case, and coexisting tuberculosis did not seem to affect the course of lung cancer among this group. However, in the sequential group, 5 patients died within 3 months, 2 of them died of tuberculosis. We consider that in the management of lung cancer, physicians should consider the possibility of coexistent active pulmonary tuberculosis and should not make delay in the diagnosis of active pulmonary tuberculosis. Key words:Lung cancer, Active pulmonary tuberculosis, Coexistence of lung cancer and pulmonary tuberculosis, Clinical findings *3-1-1, Takeoka, Kiyose-shi, Tokyo 204-8585 Japan. (Received 23 Mar. 1999/Accepted 19 Aug. 1999) <4> Kekkaku Vol.74,No.11:803-807,1999 A CASE OF PULMONARY TUBERCULOSIS WITH ACUTE RENAL FAILURE CAUSED BY READMINISTRATION OF RIFAMPICIN *Fuminobu KURODA, Takenori YAGI, Fumio YAMAGISHI, Fumio MIZUTANI, Yuka SASAKI, and Akihiko WADA *Department of Thoracic Disease, National Chiba Higashi Hospital We report a case of pulmonary tuberculosis with acute renal failure caused by readministration of Rifampicin (RFP). A 73 year-old man was admitted to a certain hospital complaining with dyspnea on exertion. As his sputum smear was positive for acid-fast bacilli, he was transferred to our hospital for the isolation and treatment. He was diagnosed as lung tuberculosis and was administrated RFP, Isoniazid (INH) and Ethambutol (EB). On the 20th day after the initiation of treatment, the administration of drugs were suspended, because of liver dysfunction. After recovery of liver dysfunc- tion, we have readministered antituberculous drugs, starting with EB, then INH, and fi- nally RFP. On the 22th day after the readministration of RFP, acute renal failure was observed. All medicatons were suspended and we started teratment with hydration and furosemide. His renal function recovered after 7 weeks. Histopathological examination of the kidney revealed interstitial infiltration and tubular nephritis. According to the histopathological examination and the clinical course, we concluded acute renal failure was induced by the readministration of RFP. This case suggests that we have to pay at- tention to renal side effect of RFP in the course of readministration. Key words:Rifampicin, Readministration, Renal failure, Interstitial nephritis, Tuberculosis, Side effect *673, Nitona-cho, Chuo-ku, Chiba-shi, Chiba 260-8712 Japan. (Received 7 Jul. 1999/Accepted 18 Aug. 1999) <5> Kekkaku Vol.74,No.11:809-815,1999 Commemorative Lecture of Receiving Imamura Memorial Prize STUDIES ON PREVENTION AND TRETMENT OF CHILDHOOD TUBERCULOSIS *Isamu TAKAMATSU *Department of Pediatrics, Osaka Prefectural Habikino Hospital We performed a retrospective analysis of 394 patients who were treated for active tu- berculosis (TB) at our hospital from 1976 to 1997. We had started early BCG vaccination campaign in Osaka Prefecture from 1995 and the coverage of BCG vaccination in infants rose up to about 90%. From that experience, we studied the current situations and measures on prevention and treatment of childhood tuberculosis. Pulmonary TB in children is successfully treated with 6-month standard short-course chemotherapy using isoniazid, rifampin, and pyrazinamide daily for 2 months, followd by isoniazid and rifampin daily for 4 months. Prognosis of childhood tuberculous meningitis (TBM) is poor, early diag- nosis and prevention of TBM is important. In order to promote TB control and eliminate childhood TB, especially in infants, the following is necessary;1) early detection and treatment of adult TB patients, source of infection, 2)prompt and appropriate contact examination and chemoprophylaxis, 3)BCG vaccination during early infancy, 4)protec- tion from MDR-TB are most important. Key words:Tuberculosis in children, 6-month standard short-course chemotherapy, Tuberculous meningitis, BCG, Chemoprophylaxis, Contact examination *3-7-1, Habikino, Habikino-shi, Osaka 583-8588 Japan. (Received 7 Sep. 1999) <6> Kekkaku Vol.74,No.11:817-832,1999 The 74th Annual Meeting Mini Symposium PREVENTION FROM NOSOCOMIAL TRANSMISSION OF TUBERCULOSIS AMONG HEALTH CARE WORKERS -Point of View from Nurses- Chairperson:*Takeko YAMASHITA *Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association Symposium Topics and Presenters: 1. Tuberculosis cases among nurses-Report from TB surveillance- Yuko YAMAUCHI(The Research Institute of Tuberculosis Association) 2. Report of nosocomial transmission of tuberculosis among nurses in the hospital- Situation among nurses in a general hospital- Ayako KANESHIRO(Nakagami Hospital in Okinawa) 3. Report of nosocomial transmission of tuberculosis among nurses in the hospital- Situation among public health nurses in a prefecture- Kaori FUNAHASHI(Aichi Prefectural Government) 4. Current situation of tuberculosis control education in nurse education courses in schools Keiko KOKUBU(Fukui Prefectural University College of Nursing) 5. Additional comment:Post graduate training course for public health nurses about tuberculosis Noriko KOBAYASHI(The Research Institute of Tuberculosis Association) 5.Suggestion Toru MORI(The Research Institute of Tuberculosis Association) The 73rd Annual Meeting Symposium was held in April, 1998, and there the report based on the nation-wide survey showed the close relationship between tuberculosis diag- nosis among in-hospital workers and tuberculosis nosocomial transmission control. Ac- cording to the research by Dr. Shishido, the incidence of tuberculosis to nurses in hospitals, where there are tuberculosis wards, was 66.2, which is obviously much higher than the nation-wide average;35.7. Moreover, the age group of those nurses was in their 20s and 30s. Also, in a regular hospital, tuberculosis incidence among nurses was 28.9. The age group of the nurses in 65% in their 20's, and 16.3% in their 30's. Tuberculosis new cases have been getting older year by year. In fact, 56.3% of smear-posi- tive cases who were registered as tuberculosis cases in 1997 were over 60 years old. There- fore, tuberculosis diagnosis check should be done to all elder patients, especially when then cough, at the first examination. Also, increase of the number of elderly smear-positive cases requires emphasis on tuberculosis control from the perspective of nurses. This tuber- culosis control should be focused on, especially, prevention of nosocomial transmission between nurses and patients, and/or among patients. Studies presented in this mini symposium was as follow: (1) Comparison of tuberculosis incidence between women in general and nurses (1987-1997). (2) Nosocomial tuberculosis transmission cases to nurses at a general hospital. (3) Nosocomial tuberculosis transmission cases to nurses in Aichi prefecture. (4) Nation-wide survey at public health nurse courses-the number of classes and cur- riculum of the study on tuberculosis control education- (5) Current situation of follow-up training for public health nurses on tuberculosis con- trol education. National Annual Report (1987-1997) and several cases indicate that the incidence of tu- berculosis among nurses in more common than women in general. This tendency is not applied only in tuberculosis specialized hospitals but also in general hospitals. We emphasize that nurses should understand they are at rest in terms of tuberculosis transmission, therefore, they should involve tuberculosis control more actively. From the perspective of doctors, Dr. Mori, the advisor, suggested strongly that all medical institutes and facilities unite and deal with tuberculosis control/nosocomial transmission. Key words:Nosocomial transmission, General hospital, Tuberculosis wards, In-hospital worker, Follow-up training *3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 13 Sep. 1999)