Kekkaku : [Tuberculosis]最新文献

Objective: The incidence rate of nontuberculous mycobacterial (NTM) infection has been increasing globally in recent years. However, reports of osteoarticular NTM infection are relatively rare. We report the characteristic clinical features of patients with osteoarticular NTM infection.

Patients and methods: We examined 14 patients with osteoarticular NTM infection (mean age, 68 years) were treated in our hospital in the 20 years between 1995 and 2015.

Results: The rate of osteoarticular NTM infection in whole osteoarticular infection during the same period in our hospital was 2.7%. The NTM species. isolated from the 14 patients included Mycobacterium avium (n = 7), M. intracellulare (n = 5), M. fortuitum (n = 1), and M. kansasii (n = 1). Twelve patients had spinal involvements, and their levels were categorized as thoracic (n = 3), lumbar (n = 4), thoracolumbar (n = 1), and cervicothoracic (n = 4), with an average number of affected vertebra of 4.4. Nine patients had pulmonary lesions, including fibrocavitary (n = 5) and nodular/ bronchiectatic types (n = 4). Nine patients had lesions in sites other than the spinal and pulmonary regions, including the skin (n = 6), rib (n = 2), ilium (n = 2), humerus (n = 2), ulna (n = 1), wrist (n = 1), knee joint (n = 1), femur (n = 2), tibia (n = 1), toe (n = 1), and kidney (n = 1). In the initial examination, 11 patients were misdiagnosed, which delayed the final diagnosis in 7 patients. Six patients received chemotherapy with rifampicin, ethambutol, and clarithromycin, and 8 patients received other macrolide-based therapy. Five patients underwent surgical treatments in former hospitals, and 8 patients underwent surgical treatments (including salvage surgeries) in our hospital. With regard to outcome, 9 patients achieved healing, 2 patients with relapse were healed after retreatment, 1 patient was undergoing treatment, 1 patient had interrupted treatment, and 1 patient died during the treatment period.

Discussion: Osteoarticular NTM infection presented widely spread lesions in the spine and other various locations, mostly developed as a part of disseminated infection. Most patients were aged or immunosuppressed, but some patients were healthy individuals with no relevant medical history. Thus, if a patient is diagnosed with disseminated NTM infection, examination for possible lesions in other sites, including the bone and joint, should be performed. Cutaneous lesions, including subcutaneous abscess, were also characteristic. It is worth mentioning that such lesions can develop even under chemotherapy. Given the increasing trend in the overall incidence of NTM infection, awareness that NTM is a causative organism of osteoarticular infection is important.

Purpose: The usefulness of a rifampicin (RFP) suppository for treatment of pulmonary tuberculosis was examined in patients who had difficulty with oral consumption of medication.

Subjects and methods: Among inpatients receiving first-time treatment for pulmonary tuberculosis susceptible to both isoniazid (INH) and RFP, and who underwent standard 3- or 4-drug treatments including INH and RFP, we compared the number of days required for obtaining two and three consecutive negative sputum smears and cultures, respectively, in patients who received hospital-made suppositories or standard oral RFP administration.

Results: There was no significant difference between groups in the number of days required for negative cultures and smears; although the times were equivalent, there were more number of elderly patients and those in generally poor condition in the RFP suppository group than the oral intake group.

Conclusion: RFP suppositories may be one method for administration of standard tuberculosis treatment in patients with difficulty in oral consumption of medication.

A 78-year-old woman who had been treated for two years with ITCZ for chronic pulmonary aspergillosis associated with prior pulmonary tuberculosis was admitted to our hospital because of general fatigue and hemosputum along with deterioration of her chest radiographic findings. Mycobacterium abscessus had been isolated once from her sputum one year before admission. We performed fiberoptic bronchoscopy (FOB) in order to help establish a final diagnosis. Sputum aspirated from her bronchus on FOB stained positive for acid-fast bacilli and was negative for Tbc and MAC using PCR. From these results, we diagnosed the patient with pulmonary M. abscessus infection. Chemotherapy with AMK, IPM/cs, and CAM was initiated. Because her symptoms rapidly improved, we switched the chemotherapy to long-term oral CAM and LVFX, and she has been in a good condition at 12 months after the initiation of the therapy. Recently, subtypes of M. abscessus complex, such as M. massiliense, have been recognized, which are more sensitive to chemotherapy. Considering the good response to therapy, there is a possibility that is the patient in the current case had a M. massiliense infection.

In 2013, tuberculosis (TB) case findings from the nationwide TB surveillance data in Japan were reviewed with regard to the mode of detection, symptom at diagnosis, diagnostic delay, proportion of far-advanced cavitary lesions, co-existence of human immunodeficiency virus (HIV) infection and diabetes mellitus (DM), and drug susceptibility testing (DST). Among the 20,495 new TB cases in 2013, 83.1% were diagnosed when the patients sought medical attention for TB symptoms or attended medical facilities because of other chief complaints. Among the 15,972 patients with pulmonary TB, 26.4% had only respiratory symptoms, 30.5% had respiratory and non-respiratory symptoms, 17.8% had only non-respiratory symptoms, and 24.5% were asymptomatic. The proportion of patient and doctor delays among the 11,933 symptomatic pulmonary TB cases was analyzed. A large proportion--around 30%--of patients aged 45-54 years with symptomatic pulmonary TB exhibited a patient delay of ≥ 2 months. The proportion of patients with a total delay (i.e., the sum of patient and doctor delays) of ≥ 3 months exhibited a similar tendency to that of those with a patient delay. The proportion of patients aged ≥ 65 years with a doctor delay of ≥ 1 month surpassed that of age-matched patients with a patient delay. Among symptomatic smear-positive TB, a patient delay of ≥ 2 months exhibited a bimodal distribution, and its peak was > 35%. The proportion of patient delay in those aged 30-39 years decreased compared to that of recent years. Meanwhile, the proportion of patients--approximately 15%--with a doctor delay of ≥ 1 month was relatively stable across all the age groups. The proportion of patients with pulmonary TB who had far-advanced cavities in the lungs increased from 1.5% in 1975 to approximately 2% and then remained stable from 1985 to 2013. Among the 50 new TB cases with HIV in 2013, 5 occurred in women and 10 in foreigners. From 2007 to 2013, there were 416 patients with newly diagnosed TB and HIV infections, 359 (86.3%) and 57 (13.7%) of whom were men and women, respectively, including 86 (20.7%) foreigners. The proportions of newly diagnosed TB cases with DM in 2013 were 14.5% (2,964/20,495), of which 16.6% (2,072/12,504) occurred in men and 11.2% (892/7,991) in women. The DST results were obtained through the surveillance system for 7,701 (73.2%) of 10,523 culture-positive pulmonary TB cases in 2013. In previously untreated patients, the proportions of patients with multi-drug resistant TB, any isoniazid resistance, and any rifampicin resistance were 0.4%, 4.5%, and 0.6%, respectively; meanwhile, in previously treated patients, the proportions were 3.7%, 8.0%, and 5.1%, respectively. In previously untreated patients, the proportions of multi-drug resistant TB and any isoniazid resistance decreased comparing with 2012.

Disseminated nontuberculous mycobacteriosis (NTM infection) is a disease that causes multiple organ lesions and occurs against an immunodeficiency background. Several host factors for this disease have been identified. Recently, neutralizing anti-interferon-γ autoantibodies (IFN-γ Ab) have been detected in some cases of disseminated NTM infection that had no previously known immunodeficiency, garnering attention as a new form of acquired immunodeficiency. We previously reported on methods for detecting IFN-γ Ab in clinical specimens as part of the diagnostic process that are being used to evaluate suspected cases at various institutions. Overseas reports of positive results were achieved by administration of the anti-CD20 antibody rituximab in addition to antibacterial chemotherapy in cases of intractable disseminated NTM infection that tested positive for IFN-γ Ab. This highlights the importance of diagnosis as well. Clinicians should consider the existence of this pathology. Although many host factors for NTM infection have yet to be identified, IFN-γ Ab positivity should be investigated further as a new disease concept, not only for its pathological dimensions but also from the standpoint of treatment strategies. In the future, more cases need to be examined and analyzed to obtain further epidemiological and pathological findings.

In 2013, 66 patients with pediatric tuberculosis (TB; age range: 0-14 years) were newly notified in Japan, corresponding to a notification rate of 0.40 per 100,000 population. Since 2006, the annual number of notified patients with pediatric TB has been less than 100. Among the 66 patients with pediatric TB who were notified in 2013, 27 (40.9%) were aged 0-4 years, 14 (21.2%) were aged 5-9 years, and 25 (37.9%) were aged 10-14 years. The largest proportion of pediatric TB patients was aged 0-4 years. In 2013, two cases of TB meningitis and no cases of miliary TB were reported in children. Case detection occurred at rates similar to previous years, with 20 patients (30.3%) identified at medical institutions and 33 (50%) via household contact investigations. Since 2000, the number of all elderly patients (aged 65 years or older) with TB had decreased rapidly and remained stable until recently. However, the number of such patients has declined gradually since 2012. The proportion of TB patients aged 65 years or older has consistently increased to as high as 64.5% in 2013; notably, the proportion of TB patients aged 80 years or older has also increased to 36.1%. Since 1999, the TB notification rates in Japan have been consistently higher among patients aged 85 years or older than among those aged 65-84 years. The rate of notification for TB patients aged 65 years or older decreased by 0.6% from 2012 (13,307 patients) to 2013 (13,227 patients). The proportion of bacteriologically positive TB patients among the general population of pulmonary TB (PTB) patients was higher among those aged 65 years or older than among those aged 15-64 years. Among all symptomatic patients, the proportion of PTB patients with only non-respiratory symptoms increased with age to 30.3% among those aged 85 years or older. The proportion of TB patients with a patient delay of two months or longer was lower among patients aged 65 years or older than among those aged 15-64 years (14.2% vs. 25.6%), whereas the proportion of TB patients with a doctor delay of one month or longer was slightly higher among patients aged 65 years or older than among those aged 15-64 years (23.0% vs. 20.3%). Among TB patients aged 65 years or older who were newly notified in 2012, 32.2% died within one year after the initiation of TB treatment; of these patients, 19.2% died within three months. Among patients aged 65 years or older, the proportion of deaths within three months after the initiation of TB treatment increased substantially with age from 7.8% of those aged 65-69 years to 37.7% of those aged 90 years or older.

Objective: To evaluate the efficiency of the direct tuberculosis-loop-mediated isothermal amplification (TB-LAMP) assay by using non-centrifuged sputum samples. STUDY PERIOD AND METHODS: The study was conducted between June 2013 and February 2014. We collected 111 sputum samples from patients who had been radiographically diagnosed with tuberculosis and had not received any treatments for longer than 5 days. In the direct TB-LAMP assay, a loop-mediated isothermal amplification kit and 60-μL sputum samples were used. A direct smear microscopy test was used as the smear test. Then, the same sputum samples were processed with a CCE pretreatment reagent, and 100 μL of the solution samples were cultured by using the mycobacterial growth indicator tube (MGIT) culture method.

Results: Forty-six of the 111 samples were positive in the smear microscopy tests. All the smear-positive samples were positive in both the MGIT and direct TB-LAMP assay (100%). The mean positive detection time with the direct TB-LAMP assay was 13 minutes 55 seconds. Of 56 smear-negative and MGIT positive samples, 44 (78.6%) were judged to be positive using the direct TB-LAMP assay, with a mean positive detection time of 15 minutes 59 seconds.

Discussion: The direct TB-LAMP assay using non-centrifuged sputum samples was demonstrated to have a high detection rate and thus may be considered useful for rapid and effective tuberculosis diagnosis.

We report a case of a 75-year-old man with pleural effusion and an occupational history of asbestos exposure. Fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) examination revealed FDG up-takes along his pleura, leading to an initial suspicion of pleural mesothelioma. Pathological findings of a diagnostic video-associated pleural biopsy showed epithelioid cell granuloma. Repeated sputum cultures were positive for Mycobacterium intracellulare. The patient was diagnosed with pleuritis caused by non-tuberculous mycobacteria (NTM). NTM should be considered a potential cause of pleuritis.

Background: Mycobacterium kansasii is the second most common nontuberculous mycobacterial pulmonary disease pathogen in Japan. Fibrocavitary disease is characteristic of M. kansasii pulmonary disease in male patients.

Objective: To clarify the clinico-microbiological characteristics of M. kansasii pulmonary disease in recent years in a Tokyo hospital specializing in mycobacteriosis.

Methods: A retrospective chart review was performed on 77 M. kansasii culture-positive cases from January 2003 to December 2010. Sequence analysis of the hsp65 gene using PCR-restriction enzyme pattern analysis (hsp65-PRA) was used to identify bacterial genotypes.

Results: Seventy-four cases fulfilled the diagnostic criteria for inclusion. Female patients comprised 22% of cases (16 cases, 63.2 ± 24.6 years of age) and were older than male patients (58 cases, 55.5 ± 17.5 years of age). Although the peak distribution among men was patients in their 50s, female patients showed a bimodal distribution with increased occurrence in older women. Radiological examination showed that approximately 90% of male and younger female patients had fibrocavitary disease. However, elderly female patients tended to have nodular bronchiectatic disease. Genotype analysis revealed that all bacterial strains from both genders were subtype I.

Conclusions: Compared to previous reports, the number of female patients with M. kansasii pulmonary disease had increased, with an unusual age distribution. These different age-related radiological findings might be due to host factors.

We report a rare surgical case of a solitary pulmonary nodule due to Mycobacterium kansasii. A 59-year-old man was admitted to our hospital for examination of an abnormal shadow in the left upper lobe incidentally found on a chest radiogram. Computed tomography of the chest showed that the nodule was located in the left segment 1+2 and was irregularly shaped with a diameter of 35 mm. Thoracic fluorine-18 fluoro-deoxy-glucose positron emission tomography showed a high metabolic pulmonary lesion, with a maximum standardized uptake value of 5.1, consistent with findings for lung cancer. A bronchoscopy was performed to establish the diagnosis of lung cancer; however, it failed to show malignant cells. Because we could not confirm the diagnosis by bronchoscopic examination, video-assisted thoracoscopic surgery was performed. The intraoperative rapid diagnosis of the nodule was epithelioid cell granuloma. Smear test of the resected specimen was positive for acid-fast bacilli, and a culture was also positive for mycobacteria, which were identified as Mycobacterium kansasii. Antibiotic treatment for M. kansasii infection was administered for a year after the surgical resection. Few cases of Mycobacterium kansasii infection present with solitary pulmonary nodules.