Kekkaku : [Tuberculosis]最新文献

Objective: To analyze the results of the external quality assessments (EQA) for anti-tuberculosis drug susceptibility testing (DST) and to set-up its rational passing criterion.

Method: Each participating laboratory in EQA performed DST, and the sensitivity, specificity, agreement (efficiency) and kappa coefficient were calculated from the results. We analysed the data of seven EQA results for DST from 2004 to 2010.

Results: A total of 20, 20, 10, 5, 10, 10, and 10 strains of M. tuberculosis with known susceptibility were sent to each participating laboratory in 2004, 2005, 2006, 2007, 2008, 2009, and 2010, respectively. The total of participating laboratories was 564. Each laboratory was asked to perform DST with its routine methods and reported 25,100 test results in these seven years. The laboratories showed relatively high specificity than sensitivity, and an improving sensitivity through the years. Sixteen laboratories participated the EQA continuously, and the sensitivity and specificity to isoniazid (INH), rifampicin (RFP), streptomycin (SM) and ethambutol (EB) were 0.999 (95% CI 0.992-1.000) and 0.998 (95% CI 0.991-1.000), 0.985 (95% CI 0.973-0.992) and 0.997 (95% CI 0.989-0.999), 0.932 (95% CI 0.912-0.948) and 0.977 (95% CI 0.962-0.986), and 0.965 (95% CI 0.947-0.977) and 0.978 (95% CI 0.966-0.986), respectively.

Discussion: The analyses revealed that the accuracy of DST for INH and RFP was highly maintained throughout the years. However, SM showed a high unevenness of performance quality and required situational considerations for evaluation. In conclusion, the EQA for DST would require a minimum number of 10 strains for each assessment, and INH and RFP should show over 95% of sensitivity and specificity with over 90% of efficiency to SM and EB as passing remark.

A 54-year-old man was admitted to our hospital because of fever, dyspnea, and low back pain. Chest computed tomography showed a 30-mm mass in the left lung and bilateral pleural fluids, multiple bone lesions, enlarged lymph nodes, and skin abscesses. Mycobacterium avium was isolated from his sputum, a pleural fluid sample, the right cervical lymph node, and a precordial skin abscess. We thus diagnosed his illness as disseminated nontuberculous mycobacterial infection (DNTM) and treated him with multiple chemotherapeutic agents. However, the disease progressed, and he ultimately died. He was not in an obvious immunocompromised state. DNTM with multiple bone lesions in a healthy adult is very rare and we therefore report this case.

A 58-year-old man was admitted to our hospital because of fever and night sweating. Laboratory examinations showed pancytopenia on admission. Examination of bone marrow smear specimens revealed many myeloblasts, thus the diagnosis of acute myeloid leukemia (AML) was made. In contrast, many central necrotic epithelioid granulomas were found in clot specimens prepared from the same bone marrow sample. Computed tomography showed small lymphadenopathies and hepatosplenomegaly. Mycobacterium tuberculosis was isolated only from the urine culture. These findings of the bone marrow and the urine culture led to the diagnosis of disseminated tuberculosis. Therefore, these results mentioned above led to the diagnosis of AML complicated with disseminated tuberculosis. After disseminated tuberculosis treatment with anti-tuberculosis drugs, induction chemotherapy for AML helped the patient to achieve complete remission (CR). During treatment and CR, he showed a paradoxical reaction with lymph node enlargement without worsening of disseminated tuberculosis. This is a rare case of AML complicated by disseminated tuberculosis.

Objective: To analyze tuberculosis outbreak index cases in order to improve preventative measures.

Methods: Outbreaks reported in Osaka City between 2008 and 2014 were investigated. The index cases were examined according to category group, sex, age, chest radiograph findings, sputum smear examination, patient delay, doctor delay, total delay in case finding, and adherence to regular health examinations. As controls, 467 patients in Osaka City with newly registered sputum smear-positive pulmonary tuberculosis in 2011 were included.

Results: Thirteen outbreaks occurred. The group categories included enterprises (9 outbreaks), preparatory schools (2), a junior high school (1), and other (1). The group of index cases consisted of 12 men (92.3%) and one woman (7.7%), with a mean age of 39.1 years; 11 (84.6%) were 30 to 50 years of age. Their ages ranged from 15 to 54 years. Of the control group of patients with sputum smear-positive pulmonary tuberculosis, 69.2% were 60 years or older, with a mean age of 65.4 years. These results suggest that the index case group was significantly younger (p < 0.001). There were ten cases (76.9%) of patient delay (initial visit 2 months or more after onset), and 8 (61.5%) of total delay (diagnosed 3 months or more after onset). These rates were significantly higher than those in the control group (p < 0.001). There were regular health examinations in four cases; among those, one did not see a doctor and another did not receive further examination. Chest radiographs revealed cavities in 12 cases (92.3%). All sputum smears were positive, with grades of 1 + in one case (7.7%), 2 + in two cases (15.4%), and 3 + in 10 cases (76.9%). These cases had a significantly higher rate of smear positivity than those in the control group (p < 0.001).

Discussion: The index cases were predominantly male, in their prime, and had higher infectivity rates. These findings suggest the importance of preventing delays in case findings and receiving regular and adequate health examinations.

A 66-year-old man was transferred to our hospital on November 2010 owing to a diagnosis of miliary tuberculosis. Treatment was initially started with INH, RFP, PZA, and EB. However, PZA and EB were discontinued because of their adverse effects. Subsequently, chest radiographic and laboratory findings gradually improved. However, the patient experienced lumbago, which exacerbated towards the end of March 2011. An abdominal CT scan showed an abdominal mass at the L3-L5 level between the abdominal aorta and lumbar vertebra. On the basis of the findings of abdominal ultrasonography, MRI, and PET-CT, infectious abdominal aortic aneurysm was highly suspected. Therefore, vascular graft replacement surgery was performed at the beginning of May 2011. The result of histopathological analysis showed the presence of acid-fast bacteria in the aneurysm and the lymph nodes around it, revealing that the aneurysm was due to systemic miliary tuberculosis. After the surgery, the patient was administered LVFX in addition to INH and RFP for 18 months and showed no recurrence.

Aim: To investigate the relationship between completion rates for community directly observed treatment short-course (DOTS) and treatment outcomes, according to implementation tactics, to improve the treatment outcomes.

Methods and subjects: We evaluated 529 newly registered patients with smear-positive pulmonary tuberculosis who underwent community DOTS (checking medication at least once per week) during 2010 and 2011 in Osaka City. DOTS completion was defined as checking medication 3 times or more per month, with checking medication missed less than 3 consecutive times. DOTS was implemented using the following 4 tactics: healthcare staff visited the patients' home or workplace (visiting type), the patients visited a health and welfare center (HWC type), the patients visited a pharmacy (P type), or the patients visited an outpatient department at a medical center (MC type). Regarding treatment outcomes, resolution of the tuberculosis or treatment completion was defined as "successful treatment", and treatment failure or default was defined as "unsuccessful treatment". We then analyzed the DOTS completion rate for each DOTS implementation tactic.

Results: DOTS was completed in 417 (78.8%) of the 529 patients. The completion rates were 79.7%, 75.4%, 75.9%, and 81.3% for patients who underwent visiting (n= 394), HWC (n = 61), P (n = 58), and MC (n = 16) DOTS, respectively; no significant difference was observed. The mean ages for each group were 62.8 years, 53.6 years, 45.0 years, and 56.6 years for patients who underwent visiting, HWC, P, and MC DOTS, respectively; patients who underwent P DOTS were significantly younger (P < 0.001). Among the 4 groups, the visiting DOTS group had the lowest percentage of full-time employees (16.2%) and the highest percentage of unemployed individuals (67.3%). In contrast, the percentage of full-time employees was 63.8% and 50.0% in the P and MC DOTS groups, respectively. The P DOTS group had the lowest unemployment percentage (19.0%) among the 4 groups. Thus, a significant correlation existed between the DOTS implementation tactics and the presence/ absence of the patients' occupations (P < 0.001). Among the 417 patients who completed DOTS, 99.8% achieved successful treatment. Among the 112 patients who did not complete DOTS, 89.3% achieved successful treatment, and this success rate was significantly lower than that for the group who completed DOTS (P < 0.00 1). Among the visiting, HWC, and P DOTS groups, the completion of DOTS resulted in a high treatment success rate.

Discussion: Patients who completed DOTS achieved better treatment outcomes; therefore, it is important to provide patients with medication support until their tuberculosis is resolved. The P DOTS group contained a higher percentage of full-time employees and had a significantly lower mean age; this was likely because pharmacies are accessible at night and dur

This is the first in a 4-series report based on the Tuberculosis Annual Report 2013. It summarizes general tuberculosis (TB) statistics and gives an overview of foreign-born TB patients notified and registered in Japan in 2013. TB notification has continued to decline since 2000, and a total of 20,495 patients with all forms of TB were notified in 2013, with a rate per 100,000 population of 16.1. The age of TB patients has increased, with 57.4% of all TB patients in 2013 more than 70 years old. The number of patients with latent TB infection drastically increased from 4,930 in 2010 to 10,046 in 2011, but has been declining since. The number of foreign-born TB patients increased from 739 in 1998 to 1,064 in 2013; similarly, the proportion of foreign-born patients among all TB patients increased from 2.1% in 1998 to 5.4% in 2013. Foreign-born TB patients aged 20-29 years accounted for 42.7% of all new TB patients in the same age group in 2013. Among foreign-born TB patients, more than half were from China (27.4%) and the Philippines (24.1%). Younger patients were more likely to have entered Japan within the previous 5 years (61.5% and 61.3% of foreign-born patients in their teens and twenties, respectively). The largest occupational category was "regular employees" (25%), which excluded service workers, health care workers, and teachers, followed by students (24%) and unemployed people (21 %). With the government relaxing restrictions on entry of foreign workers to cope with labor shortage in the construction industry ahead of the 2020 Tokyo Olympics, both the number and proportion of foreign-born TB patients is also expected to rise. Comprehensive programs are urgently required to ensure early diagnosis and treatment completion among one of the vulnerable populations in Japan.

Purpose: To investigate the mechanism of bone destruction in spinal tuberculosis (TB) by immunohistochemical analysis of the pathway that includes receptor activator of NF-κB (RANK), receptor activator of NF-κB ligand (RANKL), osteoprotegerin (OPG), and osteocalcin (OCN) in affected tissues.

Materials and methods: TB bone specimens were obtained from 30 surgically treated spinal TB patients (13 males and 17 females; average age, 67 years). Normal bone specimens were also obtained from 30 osteoarthritis patients (12 males and 18 females; average age, 70 years) who had undergone knee arthroplasty, wherein a piece of the non-weight-bearing part of the femur was obtained as a part of the resected bone for surgery. The two groups of specimens were examined for the expression of RANK, RANKL, OPG, and OCN by immunohistochemistry.

Results: Spinal TB specimens were significantly infiltrated by inflammatory cells, and bone resorption by multinucleated osteoclasts was observed. RANKL was predominantly expressed in lymphocytes and osteoblasts, whereas RANK was expressed in mononucleated osteoclast precursors among the inflammatory cells. In contrast, there was no infiltration of the inflammatory cells, and the expression of RANKL/RANK was poor in the control specimens. OCN, a bone formation marker, was expressed in the osteoblasts and in part of the bone matrix in normal tissues; however, it was poorly expressed in the tissues of the spinal TB patients. OPG, a neutralizer of the RANK-RANKL pathway, was expressed in the osteoblasts and stromal cells, and there was no significant difference in the expression between the two groups.

Discussion: In the tissues from spinal TB patients, the RANK-RANKL pathway was strongly activated, whereas the expression of its neutralizer OPG was not sufficiently induced. In addition, the bone formation marker OCN was poorly expressed, indicating a paucity of reactive bone formation. These findings are consistent with bone-resorption-predominant destruction, which is commonly observed in osteoarticular TB. Activation of the RANK-RANKL pathway has been considered to be caused by cytokines such as tumor necrosis factor-α and interleukin-6, which also play important roles in the immune response against TB. In severe pulmonary TB, an intense and prolonged immune reaction sometimes leads to tissue destruction and the formation of cavity lesions. Therefore, such an immune reaction against spinal TB may also cause activation of the RANK-RANKL pathway, thereby leading to bone destruction.

Objective: Despite the decreasing trend in tuberculosis (TB) cases reported within the general population, TB incidence remains high in certain high-risk groups in Japan. Many of the previous discussions and studies have concentrated mainly on the elderly and those with clinical risks; however, no comprehensive evaluation has been conducted to date. Our study thus sought to estimate the relative risk (RR) and the population attributable fraction (PAF) of selected risk groups in Japan and discuss their relevance to programming future research needs and policies.

Method: PAF and RR were calculated for patients with human immunodeficiency virus infection, diabetes, rheumatoid arthritis, those on dialysis, the elderly, health care workers, the homeless, people receiving public assistance, foreigners, prisoners, smokers, and those with alcohol problems, and were grouped into "high PAF" (PAF ≥ 5%), "middle PAF" (5% > PAF ≥ 1%), and "low PAF" (PAF < 1%) groups.

Results: The elderly and patients with diabetes showed the highest PAF and RR and should thus be prioritized for policies.

Objective: This is a retrospective study on six surgical cases of Mycobacterium abscessus pulmonary disease, including a comparison with M. avium complex (MAC) disease.

Subjects and methods: We performed surgery for six cases of M. abscessus pulmonary disease between July 2012 and June 2014. In all the cases, video-assisted thoracic surgery alone was performed. Age, sex, bacillus identification method, disease type, preoperative anti-glycopeptidolipid core immunoglobulin A antibody value, preoperative chemotherapy, preoperative chemotherapy period, adaptation of the operation, surgical method, result of the bacillus culture of an organization that was extracted at operation, postoperative hospitalization period, surgical complications, and postoperative relapse were examined for the six cases of M. abscessus pulmonary disease. In addition, the cases were compared with 36 cases of MAC disease for which operation was performed during the same period.

Result: None of the patients had major surgical complications or in-hospital death. Although three patients survived for more than 1 postoperative year and completed chemotherapy, relapses are not accepted in all cases at present. In the comparison with MAC disease, the mean preoperative chemotherapy period for M. abscessus pulmonary disease was 5.5 months, which was 18.9 months shorter than that for MAC disease, with a statistically significant difference. CONCLUSION AND CONSIDERATION: Surgery for M. abscessus pulmonary disease may be considered a safe and effective therapeutic procedure. Moreover, some physicians believe that surgical treatment is required at an earlier stage of M. abscessus pulmonary disease compared with MAC disease.