Kekkaku : [Tuberculosis]最新文献

A 71-year-old man with myelodysplastic syndrome (MDS) was admitted to our hospital because of recurrent high-grade fever. He was examined for bacterial and fungal infections and treated with antibiotics and antifungal agents. However, he did not achieve a definitive diagnosis and had no apparent improvement for more than a month. Bone marrow aspiration revealed transformation of MDS to acute myeloid leukemia and hemophagocytosis. In addition, Mycobacterium intracellulare was isolated from both a bone marrow specimen and a blood sample. Therefore, he was diagnosed with disseminated Mycobacterium avium complex (MAC) infection with hemophagocytosis. An antibody test was negative for human immunodeficiency virus (HIV). His general condition improved with anti-mycobacterial drug and steroid treatments. Clinicians should suspect disseminated nontuberculous mycobacterial infections in unexplained febrile patients with hematological disorders.

Unlabelled: Abstract

Purpose: In this study, we analyzed pulmonary tuberculosis treatment outcomes among foreign nationals of different backgrounds.

Methods: The research was conducted between January 2006 and December 2011. One hundred fifty nine foreign nationals residing in Osaka city had pulmonary tuberculosis during this period. Patients were grouped according to treatment outcomes. We conducted three different types of comparisons. First, we compared backgrounds of patients with treatment success or default. Second, backgrounds of patients who continued treatment in Japan or who moved overseas (transfer out) were compared. Third, treatment outcomes of foreign nationals between 20 and 39 years of age were compared with those of age-matched Japanese patients registered between 2010 and 2011.

Results: (1) The treatment outcomes were as follows: cured, 53 cases (33.3%); treatment completed, 55 cases (34.6 %); treatment failure, 0 cases (0.0%); treatment default, 14 cases (8.8%); moved overseas, 17 cases (10.7%); moved to another location inside Japan, 13 cases (8.2%); died, 6 cases (3.8%); and under treatment, 1 case (0.6%). (2) Comparison of treatment success and default among foreign nationals with pulmonary tuberculosis revealed a default rate among smear-negative cases of 14.5%, significantly higher than in smear-positive cases (2.1%; P < 0.05). (3) We compared backgrounds between foreign nationals with pulmonary tuberculosis who continued taking treatment in Japan and those who moved abroad (transfer out). The rate of overseas transfer out (44.4%) was higher among patients not covered by health insurance. This was significantly higher than among patients covered by public insurance or assistance (9.0%; P < 0.01). (4) Comparison of foreign and Japanese nationals between 20 and 39 years of age revealed a default rate in foreign nationals with pulmonary tuberculosis of 13.6%. This was significantly higher than that of Japanese patients (4.0%; P < 0.01). The rate of transfer out among foreign nationals with pulmonary tuberculosis was 19.1%, also significantly higher than that of Japanese patients (5.3%; P < 0.001).

Discussion: The rates of treatment default and transfer out among patients between 20 to 39 years of age were significantly higher among foreign nationals than in Japanese patients. Lack of knowledge about treatment and language problems may contribute to this finding. This suggests that adequate support and definitive directly observed treatment short-course programs are needed for foreign nationals. Patients who moved abroad (overseas transfer out) may also be ultimately categorized as treatment default. However, it is difficult to determine final treatment outcomes of patients who moved abroad. Further measures are needed to ensure that foreign nationals continue to receive treatment when they transfer overseas.

Background: In the 1950s, high doses (40-70 mg/kg/day) of pyrazinamide were reported to cause drug-induced liver injury (DILI). It remains unclear whether adding pyrazinamide (Z) at the currently accepted low dose (20-25 mg/kg/day) to a regimen of isoniazid (H), rifampicin (R), and ethambutol (E) increases the risk of DILI.

Method: We reviewed adult patients admitted for smear-positive tuberculosis who were treated with a daily HRE or HRZE regimen. A Cox model was used to analyze the impact of pyrazinamide on the occurrence of DILI.

Results: We reviewed 195 patients (123 men [63%], 72 women [37%], average age 65 ± 19 years, 65 HRE patients [33%], 130 HRZE patients [67%]). The incidence of DILI in the first two months was 15% (29/195). The HRZE regimen was not associated with DILI (hazard ratio 0.55, P = 0.263).

Conclusion: Addition of low-dose (20-25 mg/kg/day) pyrazinamide to the HRE regimen does not appeared to be associated with increased DILI incidence during the first two months of treatment.

Purpose: To investigate the trends in the number of infants diagnosed with Koch phenomenon after BCG vaccination following the change in the timing of the vaccination.

Method: We extracted and analyzed data from infants aged ≤ 1 year diagnosed with latent tuberculosis infection (LTBI) or active tuberculosis, registered in the Japanese tuberculosis surveillance system, from May 2012 to the end of the year, and from May 2013 to the end of the year.

Result: There was no increase in active tuberculosis cases between the two periods (5 patients each). However, the number of infants with LTBI doubled (45 to 90), presumably because Koch phenomenon developed after BCG vaccination.

Conclusion: After changing the timing of vaccination, the number of infants experiencing Koch phenomenon appears to have increased. However, more in-depth analysis of this finding is required.

Objective: There are few reports describing pleurisy caused by nontuberculous pulmonary mycobacteriosis; in addition, there are few reports describing the frequency of cases.

Method: We retrospectively studied 116 consecutive cases of nontuberculous mycobacteriosis occurring between January 2009 and January 2014.

Result: Of these, 7 patients (6.0%) were diagnosed with pleuritis caused by nontuberculous pulmonary mycobacteriosis. One patient each had a history of ulcerative colitis, rheumatoid arthritis treated with steroids, and retinitis pigmentosa. Pleural effusion was examined in all 7 cases. In addition, nontuberculous mycobacteria were cultured from pleural effusion in 4 of the 7 cases; all were cases of Mycobacterium avium complex infection. The mean adenosine deaminase level in pleural effusion was 86 U/mL, and in 5 out of 7 cases, the adenosine deaminase level was greater than 50 U/mL. Pneumothorax occurred with pleuritis in 5 cases. Pleuritis was treated with NTM therapy in 5 cases, and pleural effusion decreased or cleared completely in all cases.

Conclusion: To reveal pleurisy accompanied by nontuberculous mycobacteriosis, further consideration is needed.

Re-treatment frequency among patients newly diagnosed with tuberculosis (TB) might indicate inadequate prior treatment. Of 21,283 patients diagnosed with TB in 2012, 1,336 had received prior TB treatment. Among patients requiring re-treatment, more than half (n = 749) had received treatment after 2000. The initial recommended TB treatment regimen in Japan consisted of a combination of isoniazid, rifampicin, pyrazinamide, and ethambutol or streptomycin. This regimen was used to treat approximately 90% of patients aged 15-49 years with all forms of TB. However, the proportion of patients substantially declined among patients ≥ 80 years of age. Of 13,650 patients who started a pyrazinamide TB treatment regimen in 2011, approximately 10% were unable to complete the 2-month-long pyrazinamide regimen by the end of 2012. In 2012, 16,432 patients were newly diagnosed with pulmonary TB (PTB). The proportion of patients hospitalized at the beginning of TB treatment increased among those ≥ 30 years of age. The median hospitalization duration among newly diagnosed patients with all forms of TB in 2011 was 64 days. The durations for those who had a new positive sputum smear result, were undergoing re-treatment, had a positive sputum result in other bacteriological tests, and had bacteriologically negative sputum PTB were 70, 72, 44, and 39 days, respectively. The median hospitalization duration was 43 days among patients with extrapulmonary TB. At the end of 2012, the median treatment duration in patients diagnosed in 2011 with all forms of TB was 273 days. The treatment success rates for patients who had a new positive sputum smear result (n = 7,736), were undergoing re-treatment (n = 747), had a positive sputum result in other bacteriological tests (n = 6,049), and had a bacteriologically negative sputum result (including other PTB patients) (n = 2,917) registered in 2011 were 50.6%, 41.2%, 58.0%, and 62.5%, respectively. The rate of loss to follow-up among patients who had a new positive sputum smear result and were undergoing re-treatment was 3.3% each, well below 5%. The mortality rate among patients with new sputum smears posi- tive for PTB was 21.6%; > 20% died before completing the treatment course. Patients 70-79, 80-89, and ≥ 90 years of age had relatively high death rates (23.9%, 36.6%, and 44.0%, respectively) compared with the other age groups.

A 48-year-old woman, who had been suffering from systemic lupus erythematosus for one year and receiving steroid therapy, was admitted to our hospital because of pulmonary tuberculosis. The tuberculosis was treated with INH, RFP, EB, and PZA after having doubled the dose of steroid, but terminated three weeks later due to the appearance of erythema exsudativum multiforme. Treatment was resumed with PZA, SM, and LVFX after resolution of the eruption. However, the addition of INH to the regimen provoked a recurrence of the eruption, which progressed rapidly to toxic epidermal necrolysis (TEN). Steroid pulse therapy stopped progression of the TEN, and treatment for tuberculosis was resumed. Although the choice of drug was rendered difficult by other adverse reactions, the patient was able to complete her tuberculosis treatment with RFP, EB, and TH. INH was most likely to be the offending agent in this case. Eruptions induced by antitubercular drugs are often seen, but there are few reports of severe toxic epidermal necrolysis.

Purpose: Several reports show smoking as a risk factor of tuberculosis (TB) infection, especially in prisoners, emigrants, the homeless, or people in areas where TB is endemic. These reports mostly used the tuberculin test to detect TB. However, there is no report evaluating smoking as a risk factor of TB infection among people coming into contact with TB with the use of the Interferon-Gamma Release Assays (IGRA) test.

Material & method: We compared TB infection in smokers and non-smokers who came into contact with TB infection by using the IGRA test. We retrospectively collected information about people coming into contact with TB who visited the Daiichi Dispensary from July 1, 2011 to June 30, 2012. They were divided into 2 groups (IGRA positive or negative) and smoking (present/past or never).

Result: Out of 390 subjects who came into contact with TB examined, 229 were male and 161 were female. The mean age was 39.0 years, 98 were present smokers, 69 were past smokers, and 223 were never-smokers. There were 19 IGRA-positive and 371 IGRA-negative subjects. The IGRA positive rate was 4.9%. Out of 19 IGRA-positive subjects, 13 were smokers or ever-smoker (68.4%). Out of 371 IGRA-negative subjects, 154 cases were smoker or ever-smoker (41.5%). Smoking experience (present and past) was statistically significant in the IGRA-positive group. There were no significant differences in sex, age, drinking habits, and level of contact. Multivariate analysis showed smoking was only one independent risk factor for being IGRA-positive (odds ratio 3.06, 95% confidence interval: 1.14-8.21, p = 0.027).

Discussion: Our results suggest that smoking experience in subjects coming into contact with TB is a risk factor for TB infection. TB cases in smokers are reported to be more severe and have delayed detection of disease. They are also more likely to infect those who come in contact with them. If TB source cases and their contacts are both smokers and co-exist in a narrow and limited area, the contacts might be at higher risk of exposure to TB-contaminated air than non-smokers.

Background: Drugs for tuberculosis and non-tuberculosis mycobacterial diseases are limited. In particular, no new drugs for non-tuberculosis mycobacterial disease have been developed in recent years. Antimycobacterial drugs have many adverse reactions, for which drug desensitization therapy has been used.

Purpose: Rapid drug desensitization (RDD) therapy, including antituberculosis drugs and clarithromycin, has been implemented in many regions in Europe and the United States. We investigated the validity of RDD therapy in Japan.

Patients and method: We report our experience with RDD therapy in 13 patients who developed severe drug allergy to antimycobacterial treatment. The desensitization protocol reported by Holland and Cernandas was adapted.

Result: The underlying diseases were 7 cases of pulmonary Mycobacterium avium complex disease and 6 cases of pulmonary tuberculosis. Isoniazid was readministered in 2 (100%) of 2 patients; rifampicin, in 8 (67.7%) of 12 patients; ethambutol, in 4 (67.7%) of 6 patients; and clarithromycin, in 2 (100%) of 2 patients.

Conclusion: In Japan, the desensitization therapy recommended by the Treatment Committee of the Japanese Society for Tuberculosis have been implemented generally. We think RDD therapy is effective and safe as the other desensitization therapy. We will continue to investigate the efficiency of RDD therapy in patients who had discontinued antimycobacterial treatment because of the drug allergic reaction.

We, group of tuberculosis experts, made discussions over how to improve the quality of treatment of multidrug resistant tuberculosis using a newly developed anti-tuberculosis drug, and at the same time, how to prevent the disadvantages of the treated patients and also that of persons who would be infected with newly produced drug-resistant bacilli, by preventing the emergence of resistance to the new drug. A series of proposals are made.