(Vol.74 No.10 Octber 1999) <1> Kekkaku Vol.74, No.10:701-706,1999 EVALUATION OF THE USEFULNESS OF A SERODIAGNOSIS KIT, THE DETER- MINER TBGL ANTIBODY FOR TUBERCULOSIS:SETTING REFERENCE VALUE 1*Toshio KISHIMOTO, 2Osamu MORIYA, 3Jun-ichi NAKAMURA, 4Toshiharu MATSUSHIMA, and 5Rinzo SOEJIMA 1*Department of Health Care Medicine, Kawasaki Medical School, 2Moriya Osamu Clinic, 3Department of Internal Medicine, Kawasaki Hospital, Kawasaki Medical School, 4Division of Respiratory Disease, Department of Internal Medicine, Kawasaki Medical School, 5Division of Medical Welfare, Kawasaki University of Medical Welfare The determiner TBGL antibody developed by Kyowa-Medex co., ltd. is a new serodia- gnostic kit for tuberculosis. To set cut-off point suitable for the kit, TBGL antibody titer of serum from healthy subjects were analyzed in relation to age, sex, previous and family history on tuberculosis. Based on results of healthy subjects, cut-off point was set by using several analytical methods. We propose 2U/ml as a cut-off point for screen- ing of patients with tuberculosis considering the diagnostic efficiency by receiver operat- ing characteristics (ROC) curve analysis and 4U/ml for diagnosis of tuberculosis, which was determined by parametric method considering its specificity. Key words:Tuberculosis, Diagnosis, Sero-diagnosis, Enzyme immunoassay, Cord factor, TBGL(tuberculous glycolipid antigen) *577 Matsushima, Kurashiki-shi, Okayama 701-0192 Japan. (Received 23 Mar. 1999/Accepted 3 Jun. 1999) <2> Kekkaku Vol.74, No.10:707-713,1999 COMPARISON OF THE NEWLY DEVELOPED MB REDOX SYSTEM WITH MYCOBACTERIA GROWTH INDICATOR TUBE (MGIT) AND 2% OGAWA EGG MEDIA FOR RECOVERY OF MYCOBACTERIA IN CLINICAL SPECIMENS 1*Chiyoji ABE, 1Kazue HIRANO, 1Masako WADA, 2Eiro TSUBURA, 2Masaaki YAMANAKA, 3Teruo AOYAGI, 3Mitsuhiko OSUMI, 3Masao TAKEDA, 4Atsuyuki KURASHIMA, 5Akiko YONEYAMA, and 5Katsuko OKUZUMI 1*Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 2Osaka Hospital, Japan Anti-Tuberculosis Association, 3National Higashi Hospital, 4National Tokyo Chest Hospital, 5University of Tokyo School of Medicine The rate of recovery and the mean time to detection of mycobacteria in clinical speci- mens were determined in a newly-developed MB Redox system based on liquid medium, and the results were compared with those of MGIT and 2% Ogawa egg media. From 587 sputum specimens processed, totally 203 mycobacterial isolates were detected, of which 177 (87.2%) with MB Redox, 185 (91.1%) with MGIT and 133 (65.6%) with 2% Ogawa medium. The difference in the percentages of positive cultures between either of the two liquid media and 2% Ogawa medium was significant (p<0.0001). The mean time to de- tection of the Mycobacterium tuberculosis complex was 17.5 days with MB Redox, 18.7 days with MGIT, and 26.2 days with 2% Ogawa medium. The contamination rates were 1.5, 1.7, and 4.1% for MB Redox, MGIT, and 2% Ogawa medium, respectively. In con- clusion, both MB Redox and MIGT systems, based on liquid medium, are more efficient than 2% Ogawa medium for the recovery of mycobacteria in clinical specimens. Key words:MB Redox, MGIT, 2% Ogawa medium, Detection of M. tuberculosis *3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 31 May 1999/Accepted 19 Jul. 1999) <3> Kekkaku Vol.74, No.10:715-719,1999 A CASE OF PULMONARY INFECTIOUS DISEASE DUE TO MYCOBACTERIUM SZULGAI 1*Yoshihiro KOBASHI, 1Niro OKIMOTO, and 2Rinzo SOEJIMA 1*Division of Respiratory Diseases, Department of Medicine, Kawasaki Medical School Kawasaki Hospital, 2Kawasaki Medical Welfare University A 49-year-old male was admitted to our hospital complaining of cough and general fatigue. There was nothing unusual about his past history, and he has been healthy. On admission, a chest roentogenogram revealed an infiltrative shadow with a cavity in the left middle and lower fields. Because the acid fast staining of a bronchoscopic specimen was positive for mycobacteria, he was transferred to another hospital to be treated as pulmonary tuberculosis. Culture tests of multiple specimens were positive, and were iden- tified as Mycobacterium szulgai, and the case was diagnosed as pulmonary atypical mycobacteriosis caused by M.szulgai. He was treated with isoniazid, rifampicin and ethambutol daily, but because of side effects, such as drug eruptions, all drugs were stopped. However, his clinical symptoms and infiltration shadow improved gradually. We described a rare case of pulmonary disease with Mycobacterium szulgai infection appearing in a healthy male without underlying diseases. Key words:Healthy male, Mycobacterium szulgai, Pulmonary atypical mycobacteriosis *2-1-80, Nakasange, Okayama-shi, 700-8505 Japan. (Received 13 May 1999/Accepted 15 Jul. 1999) <4> Kekkaku Vol.74, No.10:721-724,1999 A CASE OF ELDERLY PATIENT WITH PULMONARY TUBERCULOSIS CONSIDERED TO BE CAUSED BY EXOGENOUS REINFECTION *Atsuhiko TADA, Shin KAWAHARA, Naokatsu HARITA, Akihide HORIBA, Akihiko TAMAOKI, Chiharu OKADA, Ryo SODA, and Kiyoshi TAKAHASHI *Department of Internal Medicine, National Minami-Okayama Hospital A 84-year-old woman presented with chronic febrile illness and anorexia from June 1998. She was diagnosed as pulmonary tuberculosis and was admitted to our hospital in August 1998. Her sputum smear was Gaffky 2, and the type of chest radiograph was b‡V3. By family contact examination in August 1998, chest radiological examinations of her husband, a 86-year-old man, showed consolidation in middle lobe, right pleural effu- sion and two calcified mediastinal lymphnodes. He was diagnosed as pulmonary tubercu- losis complicated with pleurisy. He had poor controlled diabetes mellitus. Tubercle bacilli isolated from their sputa showed the same pattern in restriction fragment length poly- morphism analysis. Pulmonary tuberculosis of the husband was considered to be caused by exogenous reinfection. Key words:Exogenous reinfection, Elderly patient, Pulmonary tuberculosis *4066, Hayashima, Hayashima-cho, Tsukubo-gun, Okayama 701-0304 Japan. (Received 12 May. 1999/Accepted 16 Jul. 1999) <5> Kekkaku Vol.74, No.10:725-727,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS Chairpersons:1*Tsuyoshi OGURA, 2Shigeru KOHNO 1*Department of Internal Medicine of National Toneyama Hospital, Department of Internal Medicine, Nagasaki University School of Medicine Symposium Topics and Presenters: 1. Activities cytolysis and in apoptotic induction of Mycobacteria on human THP-1 derived macrophage :Yoshitsugu MIYAZAKI,et al. (Second Department of Internal Medicine, Nagasaki University School of Medicine) 2. Host factors promoting the occurrence and exacerbation of tuberculosis:signifi- cance of Th1-Th2 cytokine balance:Kazuyoshi KAWAKAMI(The first Department of Internal Medicine, Faculty of Medicine, University of the Ryukyus) 3. Clinical factors for the development and the exacerbation of active tuberculosis:a. Children, Young adult:Isamu TAKAMATSU (Department of Pediatrics, Osaka Prefectural Habikino Hospital) 4. Clinical factors related to the onset and exacerbation of tuberculosis:b. Middle- aged and elderly patients:Masaru NAKAGAWA (Division of Internal Medicine of National Toneyama Hospital) 5. The infection and prognosis of tuberculosis among patients with immunodeficiency, especially HIV-infected patients:Hideaki NAGAI (Department of Respiratory Dis- eases, National Tokyo Hospital) 6. Recent socio-medical characteristics of tuberculosis and their perspectives in Japan: Masako OHMORI (Research Institute of Tuberculosis, Japan Anti-Tuberculo- sis Association) In recent years, tuberculosis in Japan shows several problems such as high incidence of tuberculosis compared to other developed countries, evident by increased number of new cases, or outbreaks of tuberculosis. Thus, it is required to cope with tuberculosis as a re- emergence disease in Japan. To have effective strategies for these problems, it needs to understand not only bacteriology of M.tuberculosis, host defense mechanism for M.tu- berculosis infection, interaction between M.tuberculosis and human immune system, but also patients clinical and social background. In this symposium, we focused on the factors re- lated to progression and exacerbation of tuberculosis in order to acquire up-to-date knowledge of tuberculosis. In general, only a few of the people with M. tuberculosis infection have clinical tuber- culosis in their life time, because host defense systems keep M. tuberculosis in dormant stage. Human alveolar macrophages and several cytokines play an essential role on this host defense systems. However, the changes in these defense system leading to onset of tuberculosis is intriguing. Dr. Miyazaki presented the relationship between the virulence and the ability which induce human macrophages to undergo apoptosis or necrosis of mycobacteria. On the other hand, Dr. Kawakami presented the effects of Th1-Th2 cyto- kine balance, including IFN-gamma, IL-12 and IL-18, on prevention from mycobacterial infection using M. tuberculosis infection and immunocompromised murine model. In addition, increasing of elderly tuberculosis patient induced the slowering tendency of decrease of tuberculosis incidence rate in Japan. However, among young people rate of in- fection with M. tuberculosis is decreasing rapidly. Thus, it is very important to under- stand the difference of background between young and aged tuberculosis patients. Dr. Takamatsu presented clinical factors for the development and the exacerbation of active tuberculosis in children and young adults, and Dr. Nakagawa also presented those in mid- dle-aged and elderly tuberculosis patients. Moreover, it is thought that patient with HIV infection reflects the mechanism of devel- oping of tuberculosis because these patients are usually have impaired cell mediated im- mune system. Dr. Nagai presented the clinical features, immune system and treatment of tuberculosis among patients with immunodeficiency, especially HIV-infected patients, and finally Dr. Ohmori presented recent socio-medical characteristics of tuberculosis and their perspectives in Japan. We believe it was very meaningful to hold this symposium because M. tuberculosis in- fection is a threat to us again as a re-emerging infection, and every investigator who had presentation is the expert in this area expressed their concern on this important issue. Key words:Tuberculosis, Exacerbation, Cytokine-balance, Age, HIV infection, Incidence rate *5-1-1, Toneyama, Toyonaka-shi, Osaka 560-8552 Japan. (Received 30 Aug. 1999) <6> Kekkaku Vol.74, No.10:729-733,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBRATION OF TUBERCULOSIS 1. ACTIVITIES IN CYTOLYSIS AND IN APOPTOTIC INDUCTION OF MYCOBACTERIA ON HUMAN THP-1 DERIVED MACROPHAGE *Yoshitsugu MIYAZAKI, Hideaki OHNO, Koichi IZUMIKAWA, Kazunori TOMONO, and Shigeru KOHNO *Second Department of Internal Medicine, Nagasaki University School of Medicine Cytolysis resulted in cell death was detected with propidium iodide, and apoptosis with Annexin V by using flow cytometry. The more vilurent strain in known murine infec- tions showed the higher cytolytic activity. However in those mycobacterial strains that had the higher cytolytic activity on THP-1 cell, the lower level of apoptosis induction was observed. Addition on IFN-ƒÁ or TNF-ƒ¿ to THP-1 derived macrophage did not effect on cytolytic activities nor apoptosis induction. Since mycobacteria with the higher cytolytic activity showed the lower apoptosis induction, it was suggested that apoptosis of human macrophage in mycobacterial infection is a beneficial phenomenon to the host. Key words:Mycobacteria, THP-1 cell, Apoptosis, Cytolysis *1-7-1, Sakamoto, Nagasaki 852-8501 Japan. (Received 7 Sep. 1999) <7> Kekkaku Vol.74, No.10:735-740,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS 2. HOST FACTORS PROMOTING THE OCCURRENCE AND EXACERBATION OF TUBERCULOSIS:SIGNIFICANCE OF TH1-TH2 CYTOKINE BALANCE *Kazuyoshi KAWAKAMI *The First Department of internal Medicine, Faculty of Medicine, University of the Ryukyus The Problem of tuberculosis is emerging again with increase in the population of aged people and immunocompromised patients in Japan. It has been well documented that cell- mediated immunity play a central role in host resistance to infection with Mycobacterium tuberculosis. A decade years ago, Mosmann et al. found that helper T (Th) cells are diviaed into two subsets, Th1 and Th2, based on the cytokines which they produce. Th1 cells produce IFN-ƒÁ, while Th2 cells secrete IL-4, IL-10 and IL-13. Many recent studies have provided evidences suggesting that the Th1-Th2 cytokine balance may deteramine the outcome of some diseases. For example, predominant production of Th1 cytokines may prevent the occurrence of infectious diseases caused by intracellularly growing pathogens and Th2 cytokines may be involved in the exacerbation of allergic diseases. On the other hand, IL-12 plays an essential role in the differentiation of Th1 cells from naive T cells, and IL-18 potentiates this effect although it does not show such effect by itself. In the present study, we examined the role for these two cytokines in host resistance to mycobacte- rial infection by using an animal model with either IL-12 or IL-18 gene-disrupted mice. The organ loads of this pathogen in lung, liver and spleen were significantly larger in these gene-disrupted mice than those in control mice. There are several host factors which determines the outcome of mycobacterial infection. Among them, steroid treatment and AIDS are important factors. In this study, we determined the effect of these patho- logical conditions on Th1-Th2 cytokine balance and outcome of mycobacterial infection using murine models. In both conditions, the exacerbated infection was well correlated with the reduced production of IFN-ƒÁ. Furthermore, we also discussed about the relation- ship between other host factors and balance in the production of Th1 and Th2 cytokines. Key words:Tuberculosis, Exacerbating factors Host defense, Cytokines, Th1-Th2 balance *207 Uehare, Nishihara, Okinawa 903-0215 Japan. (Received 30 Aug. 1999) <8> Kekkaku Vol.74, No.10:741-746,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS 3. CLINICAL FACTORS FOR THE DEVELOPMENT AND THE EXACERBATION OF ACTIVE TUBERCULOSIS a. Children, Young adult *Isamu TAKAMATSU *Department of Pediatrics, Osaka Prefectural Habikino Hospital We reviewed the reports about the development and the exacerbation of active tubercu- losis and performed a retrospective analysis of 394 patients who were treated for active tuberculosis (TB) at our hospital from 1976 to 1997. The factors for the development and the exacerbation of active tuberculosis were the bacteriological status of the source, the age of the person infected, the degree of tuberculin sensitivity, BCG non-vaccination, non -chemoprophylaxis, the medical condition that increases the risk for tuberculosis, the presence of other infection, poor nutrition. Key words:Factors for the development and the exacerbation of active tuberculosis, Bacteriological status of the source, Age, Degree of tuberculin sensitivity, Medical condition that increases the risk for tubercu- losis, Children, Young adult *3-7-1, Habikino, Habikino-shi, Osaka 583-0872 Japan. (Received 30 Aug. 1999) <9> Kekkaku Vol.74, No.10:747-752,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS 4. CLINICAL FACTORS RELATED TO THE ONSET AND EXACERBATION OF TUBERCULOSIS b. Middle-aged and elderly patients *Masaru NAKAGAWA *Division of Internal Medicine of National Toneyama Hospital Exacerbating factors of tuberculosis were evaluated from the viewpoint of intractabil- ity of the disease including the effectiveness of chemotherapy by comparing patients with intractable tuberculosis and those with nonintractable tuberculosis. Of the patients aged 30 years or above admitted to our hospital for the initial episode of tuberculosis, 42 pa- tients with intractable tuberculosis and 247 controls were compared. No difference was observed between the two groups in life-style factors such as smoking, drinking, and liv- ing alone or complications such as diabetes mellitus and cerebrospinal diseases. In the re- fractory group, a poor general condition with fever and body weight losses on admission, massive discharge of tubercle bacillus, and delayed diagnosis and treatment were fre- quently observed. Also, patients with a lymphocyte count of 500/mm(3) or less such as those with anemia, hypoproteinemia/hypoalbuminemia, high LDH and CRP levels, and a low cholinesterase level were significantly more frequent, and resistant bacteria were de- tected more frequently in this group. Key words:Intractable tuberculosis, Diabetes mellitus, Drug registance, Peripheral lymphocyte *5-1-1, Toneyama, Toneyama-shi, Osaka 560-8552 Japan. (Received 30 Aug. 1999) <10> Kekkaku Vol.74, No.10:753-758,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS 5. THE INFECTION AND PROGNOSIS OF TUBERCULOSIS AMONG PATIENTS WITH IMMUNODEFICIENCY, ESPECIALLY HIV-INFECTED PATIENTS *Hideaki NAGAI *Department of Respiratory Diseases, National Tokyo Hospital The number of people infected with human immunodeficiency virus (HIV) is gradually increasing in Japan, and the morbidity rate from tuberculosis in the Japanese people is high. Accordingly, the number of cases with both infections is considered to increase in the future. Our hospital has already encountered 22 cases of HIV associated tuberculosis. HIV infects mainly CD4-positive cells. The extreme decrease in the cell count results in serious cellular immunological disorder. CD4-positive cell disorder induces disorders of B lymphocytes, cytotoxic T cells, natural killer cells, and macrophage functions. These de- structive conditions show the state of immunodeficiency including macrophage that are most important for defense of acid-fast bacterial infection. Migration and activation of macrophages with cytokines derived from T cells are impaired to induce the following phenomena:hypoplasia of granuloma, failure of tubercle bacillus sppression, the spread to regional lymph nodes (hilar or mediastinal lymph nodes), and hematogenous dissemi- nation. On this occasion, caseous necrosis and cavitation are unlikely to occur, and false- negative tuberculin reaction is often observed. The incidence of severe cases, which include miliary tuberculosis, tuberculous meningi- tis, etc., and extrapulmonary tuberculosis, are high among acquired immunodeficiency syndrome (AIDS) - associated tuberculosis cases. HIV-infected tuberculosis cases are gener- ally regarded as endogenous exacerbation, but they include primary infection and reinfection as well. Even during the treatment for drug-sensitive strains particularly, some cases may have reinfection with multidrug-resistant bacteria, suggesting that cau- tion shuold be taken ageinst this point. Conversely, the association of tuberculosis is a factor for the poor prognosis of HIV infection, since it facilitates the development of HIV infection. If the bacteria belong to a drug-sensitive strain, the infection with them responds well to antituberculous drugs, the same as in tuberculosis cases without HIV in- fection, showing a favorable prognosis. However, the mortality rate of infection with multidrug-resistant tuberculosis is extremely high. Key words:Tuberculosis, Human immuno- deficiency virus, Acquired immunodeficiency syndrome, Protease inhibitor *3-1-1, Takeoka, Kiyose-shi, Tokyo 204-8585 Japan. (Received 30 Aug. 1999) <11> Kekkaku Vol.74, No.10:759-766,1999 The 74th Annual Meeting Symposium ‡V. FACTORS FOR THE ONSET OF AND THE EXACERBATION OF TUBERCULOSIS 6. RECENT SOCIO-MEDICAL CHARACTERISTICS OF TUBERCULOSIS AND THEIR PERSPECTIVES IN JAPAN *Masako OHMORI *Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association In the late 1970s the decline of TB incidence rate has begun to slow down among both eld- erly populaton and younger one. This phenomenon mostly owed the reactivation of dor- mant M. tuberculosis infection among the elderly people and small TB outbreaks in the younger generation. The micro-epidemics among adolescent and young adults have been reported since 1980. The latest data showed the TB incidence in 1997 was 33.9 per 100,000 population, increased from 33.7 per 100,000 in 1996. To explain the situation above, sev- eral sociomedical factors were discussed as follow: (1) Age distribution of TB: The highest peak of newly registered TB patients shifted to the elder age cohorts and was the age group between 65 and 74 years in 1997, contrasting small peaks observed in 20-29 years age group remained unchanged. (2) Characteristics of infection route: Overall incidence rates of smear positive TB cases slightly increased in 1980s and leveled off thereafter. However the number of smear positive cases among persons elder than 70 years old sharply increased, 1, 779, 3, 744, 5, 728, in 1977, 1987 and 1997, respectively. Several papers showed that about one quarter of TB patients was diagnosed as TB while being treated for diseases other than TB. This may have con- tributed to the current TB infection. (3) Delay in case-finding: Patient's delay in symptomatic smear positive cases, especially among male ptaients in 30-54 age group, has been increased during last 10 years. This may also contrib- ute to the current TB issue to the younger people. (4) TB problems in the cities: TB incidence rate in a certain area of some big cities was much higher than the other areas and the regional difference became magnificent due to serial socioeco- nomic problems of vulnerable population there. (5) Notification of TB: One study using mailed questionnaires showed that only 76 percent of medical doc- tors knew the TB notification system under the TB control law. It concluded that contact tracing would become more important issue in case-finding and the 100 per- cent of TB notification in mdedical institutions would be indispensable. Key words:Incidence of tuberculosis, Elderly people, Micro- epidemic, Patient's delay, Notification. *3-1-24, Matsuyama, Kiyose-shi, Tokyo 204-8533 Japan. (Received 30 Aug. 1999)