Kekkaku : [Tuberculosis]最新文献

[Methods] We retrospectively studied 115 con- secutive pulmonary tuberculosis patients whose sputum smear was .negative, diagnosed by positive culture and/or PCR of various samples, or positive QFT. [Results] The culture positive rate of tuberculosis by spu- tum, gastric aspirate, bronchoscopy, and computed tomogra- phy (CT)-guided needle biopsy samples was 55.7%, 45.6%, 73.2%, and 71.4%, respectively. In multivariate analysis, negative or unknown sputum PCR, negative or unknown gastric aspirate, and minimal spread of tuberculosis were risk factors for negative culture from both sputum and gas- tric aspirate. Sputum culture was positive in only one of the four patients with multi-drug resistant Mycobacterium tuberculosis. [Conclusion] Invasive diagnostic procedures such as fiber- optic bronchoscopy should be considered in patients with negative sputum PCR and minimal spread of tuberculosis.

[Objective] To compare the tuberculosis (TB) surveillance systems of Japan and low TB-incidence western countries in terms of institutional design. [Method] We conducted a descriptive comparative study for TB surveillance systems in Japan, the Netherlands, the United Kingdom, and the United States. The following information was collected from self-administrated question- naires and relevant published data: 1) TB notification, 2) TB registration, 3) quality assurance and data protection mechanisms, 4) linkage with other surveillance, and 5) data disclosure. [Result] The basic structure common to all countries sur- veyed was that TB notifications were reported quickly through an online system, as required by law. TB registration data, which included detailed demographic and clinical informa- tion, was shared via the database and available to all admin- istrative levels. In addition, aggregated data reports were published periodically. Information related to TB genotype and data quality assurance, for example, detection of duplication of records, was available in surveillance systems in countries other than Japan. [Conclusion] We propose that developing a sharing mechanism for TB genotype and ensuring better quality assurance would strengthen the Japanese TB surveillance system.

[Background] Interferon-gamma release assay (IGRA) is necessary for evaluating Mycobacteriun tuber- culosis infection in Japan. Application of IGRA for contact surveys has been extended for the aged population; how- ever, there is little information on positive rates with Quanti- FERON® in Tube (QFT-3G) and T-SPOT.®TB (T-SPOT), which sometimes makes it difficult to interpret the results of IGRA performed in contact investigation including the aged population. [Objective] To estimate the positive rate of IGRAs by age group in the general population as well as among healthcare workers. [Methods] We requested all public health centers in Japan to provide contact investigation data for which the risk of infection is limited. Collected data included results of IGRAs in the target group, sputum bacteriological examinations and chest-image findings, and symptoms of the index cases as well as closeness and duration of contact between the index case and the target group. We scrutinized all the cases and exclude data that were not eligible for this study. Positive rates by age group were calculated by summing the number of contacts who were "positive" and dividing by the number of examinees. [Results] In spite of our effort to exclude newly infected persons from the index case, a small portion (probably 3%) may be due to those newly infected by a source case, as it is difficult to exclude those who get infected by casual contact. It is sometimes difficult to collect information on the close- ness and overall duration of contact with the index case, which is a limitation in the questionnaire. Positive rates of IGRA by age group in the general popula- tion were one third to one fifth of the predicted prevalence of infection, which is consistent with findings in the study using QFT Gold (QFT-2G) that IGRA wanes after infection. There were no differences of IGRA positive rate between the general population and health care workers. It may be because the risk of infection for health care workers is similar, as the number of infectious TB patients has been decreasing and infection control in hospitals has generally improved. It may be also because targets for IGRA in contact examina- tion among health care workers tend to be broad including a certain number of low risk staff. [Conclusion] With reference to past studies, we estimated that IGRA positive rates were 5% in the 60's and 15% in the 70's. It will be useful in assessing the possibility or spread of infection for aged groups in contact investigation.

[Objective] To compare the tuberculosis (TB) surveillance systems of Japan and low TB-incidence western countries in terms of reported data items. [Method] We conducted a descriptive comparative study for TB surveillance systems in Japan, the Netherlands, the United Kingdom, and the United States. Data items reported by the surveillance systems were collected and summarized by the categories prepared by the authors. Additionally, relevant published data were collected. [Result] The data items collected in each country surveyed was around 40 categories, among which 21 categories were common to the all surveyed countries. Regarding data items collected from the surveyed countries other than Japan, information related to risk factors such as drug addiction, imprisonment history, and history of residence in nursing home; TB genotype; and contact investigation were available in the surveillance system. In Japan, treatment outcomes are automatically determined by a preset algorithm, which leads to high percentage of outcomes not being evaluated. [Conclusion] Potential suggestions for the Japanese TB surveillance system are reconsidering risk factor items, collecting and evaluating contact investigation information through the surveillance system, adding genotype information, and introducing manual assessment of treatment outcome.

We present a case of a 59-year-old man with pulmonary tuberculosis and esophago-bronchial fistulas after chemoradiotherapy (CRT) for esophageal cancer. A lung nodule was detected in the right upper lobe and diagnosed as an inactive old inflammatory tumor by several examinations, including bronchoscopy. He was admitted to our hospital because of dysphagia 3 months later. The esophagoscopy showed advanced, stage IVa esophageal cancer. He received CRT at the university hospital and experienced partial remission. Two months later, he called an ambulance for dyspnea and chest roentgenography showed pneumonia in the right lung fields. The respiratory failure was severe and required mechanical ventilation. The intubation and bronchoscopy were performed in the emergency room. The bronchoscopy showed the esophago-bronchial fistulas due to recurrent esophageal cancer and backward flow of digestive juice. Mycobacterium tuberculosis was isolated from aspi- rated sputum several days later. Administrations of isoniazid/ levofloxacin and intramuscular injection of streptomycin were started. The patient moved to a medical center with a tuberculosis ward while on the respirator. The tuberculosis was not detected in the ward for 2 months. The patient returned to our hospital, but his esophageal cancer had progressed with distant metastases, he died 3 weeks later. When performing CRT, we should be careful for relapse of tuberculosis.

[Objectives] To investigate the adverse reactions of antimicrobial drugs in multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR- TB) patients. [Results] Sixty-six patients with MDR-TB who have been treated from 2010 through 2014 were evaluated in the retro- spective analysis. Variety of adverse reactions including psychological reaction, central nervous system toxicity, ophthalmic toxicity, peripheral neurotoxicity, gastrointestinal reactions, hematologic abnormalities, musculoskeletal adverse effects, and endocrine disorder, were observed. However, there was no fatal case due to the adverse reactions of the anti-tubercu- losis drugs in this observation. [Conclusions] Drugs for MDR-TB and XDR-TB treatment are limited and the adverse reactions of drugs for MDR-TB and XDR-TB are not well-known. Therefore, the treatment may fail due to inappropriate management of adverse events. MDR-TB and XDR-TB should be treated by the experts of the adverse reactions of all anti-tuberculosis drugs.

A 40-year-old woman was admitted to our hos- pital with cough and sputum production. A chest computed tomography (CT) scan revealed a diffuse nodular shadow in the upper lung. The patient was diagnosed with pulmonary tuberculosis, based on a positive T-SPOT®.TB test result of peripheral blood and a positive polymerase chain reaction (PCR) test result for Mycobacterium tuberculosis in gastric aspirates. M.tuberculosis was subsequently isolated from the gastric aspirate specimen. After 2 months of treatment with antituberculous medication, the patient developed a low grade fever and left-sided chest pain. A CT scan revealed a left pleural effusion and a right subphrenic abscess. Tuber- culous pleurisy with paradoxical response was diagnosed on the basis of an increased lymphocyte count and increased adenosine deaminase activity in the pleural fluid exudate. A percutaneous ultrasound-guided needle biopsy of the sub- phrenic abscess was performed. Histological analysis revealed epithelioid cell granulomas with necrosis and PCR for M. tuberculosis using puncture needle washing fluid returned positive results. Based on these findings, a diagnosis of subphrenic abscess with paradoxical response, caused by M. tuberculosis, was made. Subphrenic abscess caused by M. tuberculosis is an important consideration during antituber- culous therapy.

[Objective] To contribute to countermeasures against pulmonary tuberculosis in patients with HIV infection through analyzing and evaluating its treatment outcomes and patient management. [Methods] The 'subjects were pulmonary tuberculosis patients newly registered between 2008 and 2014 in whom concomitant HIV infection was detected. For the control, sex- and generation-matched pulmonary tuberculosis patients newly registered in Osaka City -between 2012 and 2014 were adopted. On analysis, the X² test and Fisher's exact test were used, and a significance level below 5% was regarded as significant. [Results] 1) There were 25 pulmonary tuberculosis patients complicated by HIV. All were male -and the mean age was 43.2 years old. 2) The sputum smear positivity rate was 76.0% in the pulmonary tuberculosis patients complicated by HIV and 50.8 % in 250 control pulmonary tuberculosis patients, showing a significantly higher rate in the former. 3) Risk factors for the discontinuation of medication for tuberculosis: In the patients complicated by HIV, the follow- ing risks of the discontinuation of medication were noted in the order of a decreasing frequency: 'Lack of medication helpers' in 68.0%, 'Side effects' in 48.0%, 'Financial prob- lems' in 32.0%, and 'Liver damage' in 28.0%. Those in the control pulmonary tuberculosis patients were 33.2%, 22.8 %, 16.0%, and 11.6%, respectively, showing a significant difference in each factor. 4) The DOTS executing rates were 68.0% and 94.8% in the patients complicated by HIV and control patients, respectively, showing that it was significantly lower in the patients complicated by HIV. On comparison of the treatment outcomes excluding died, on treatment, transferred out, not evaluated, treatment succeeded in 72.7% in the patients complicated by HIV and 92.9% in the control patients, showing a significantly lower success rate in the patients complicated by HIV. The numbers of risk factors of discon- tinuation in. 16 and 6 patients complicated by HIV in whom treatment succeeded and treatment failed/defaulted were 3.8 and 2.8, respectively, showing that the number was higher in patients with successful treatment, and the DOTS execution rates were 75.0% and 33.3%, respectively, showing a higher rate in the successful treatment cases. [Conclusion] The treatment outcome was significantly poorer in pulmonary tuberculosis patients complicated by HIV than in the control pulmonary tuberculosis patients. More risk factors for the discontinuation of medication were observed and the DOTS execution rate was lower in the patients complicated by HIV, suggesting that risk assess- fient for the discontinuation of medication should be appro- priately performed, and support for medication should be strengthened.