Clinical implication and risk factor of pneumonia development in mild coronavirus disease 2019 patients

Background/Aims@#Although a majority of coronavirus disease 2019 (COVID-19) cases were characterized as mild, data assessing the development of pneumonia in mild COVID-19 patients are limited. We aimed to examine the effect of pneumonia development on the clinical course of mild COVID-19 in hospitalized patients. @*Methods@#A retrospective cohort study was conducted via medical record review between February 25, 2020 and April 11, 2020 at a single center. The impact of pneumonia development on the time to viral clearance in mild COVID-19 patients was evaluated. Risk factors associated with the development of pneumonia were also identified. @*Results@#Chest radiographs revealed the development of pneumonia in 26.8% of mild COVID-19 patients. The time to pneumonia development was a median of 8.0 days from the onset of symptoms and 3.5 days after hospital admission. A multivariate analysis for predicting pneumonia development identified age ≥ 65 years (odds ratio [OR], 3.15; 95% confidence interval [CI], 1.14 to 8.73), cough (OR, 2.18; 95% CI, 1.29 to 3.68), dyspnea (OR, 3.58; 95% CI, 1.10 to 11.69), and diarrhea (OR, 2.69; 95% CI, 1.51 to 4.78) as significant variables. The time to negative conversion was longer in mild COVID-19 patients who developed pneumonia (23.6 days vs. 18.4 days, p = 0.003). In Kaplan–Meier estimation and multivariate Cox regression analyses, newly developed pneumonia was significantly related with delayed time to negative conversion (log-rank test, p = 0.02; hazard ratio, 2.90; 95% CI, 1.06 to 7.97). @*Conclusions@#The development of pneumonia delayed viral clearance in patients with mild COVID-19. Elderly patients or those suffering from diarrhea should be closely monitored, given the increased risk of developing pneumonia.

Chest computed tomography scan as an initial diagnostic method for tuberculosis infection detected by mass screening

Background/Aims@#We assessed the diagnostic yield of chest computed tomography (CT) as an initial diagnostic method for patients with a tuberculosis (TB) infection detected by mass screening in a country with an intermediate TB burden. @*Methods@#A retrospective study was conducted on patients with TB infection detected by mass screening performed between January 2015 and March 2018. The patients were classified according to whether they had a chest X-ray (CXR) or CT scan as an initial diagnostic test to exclude active TB. @*Results@#Of 542 patients with TB infection detected by mass screening, 222 and 320 were initially examined by CXR and CT, respectively; the two modalities showed no significant difference in rate of detection of patients with active TB (0.9% and 2.5%, respectively; p = 0.110). However, chest CT was associated with further invasive tests using bronchoscopy and respiratory specimens, and significantly increased the frequency of hospital visits. @*Conclusions@#Chest CT was not supported as an initial diagnostic method to rule out active TB in patients with a TB infection detected by mass screening in a country with an intermediate TB burden.

The Impact of Erosive Reflux Esophagitis on the Decline of Lung Function in the General Population

Background@#The impact of reflux esophagitis on the decline of lung function has been rarely reported. This study was performed to evaluate the association between erosive reflux esophagitis and lung function changes. @*Methods@#We included patients with normal lung function who underwent esophagogastroduodenoscopy for health screening from a health screening center. Patients with persistent erosive reflux esophagitis on two discrete endoscopic examinations were designated as the erosive reflux esophagitis group. We also selected patients without erosive reflux esophagitis and matched them 1:4 with patients from the erosive reflux esophagitis group. We estimated annual forced expiratory volume in 1 second (FEV1 ) and forced vital capacity (FVC) changes from baseline and compared these estimates by the linear mixed regression model. We also estimated the biannual incidence of chronic obstructive pulmonary disease (COPD). @*Results@#In total, 1,050 patients (210 patients with erosive reflux esophagitis, and 840 matched controls) were included. The median follow-up duration for spirometry was six years. In patients with erosive reflux esophagitis, mild reflux esophagitis (A grade) was most common (165 patients, 78.6%). The adjusted annual FEV1 change in patients with erosive reflux esophagitis was −51.8 mL/yr, while it decreased by 46.8 mL/yr in controls (P = 0.270).The adjusted annual FVC decline was similar between the two groups (−55.8 vs. −50.5 mL/ yr, P = 0.215). The estimated COPD incidence during the follow-up period was not different between the erosive reflux esophagitis and control groups. @*Conclusion@#In patients with normal lung function, the presence of erosive reflux esophagitis did not affect the annual declines in FEV1 or FVC.

The Impact of Erosive Reflux Esophagitis on the Decline of Lung Function in the General Population

Background@#The impact of reflux esophagitis on the decline of lung function has been rarely reported. This study was performed to evaluate the association between erosive reflux esophagitis and lung function changes. @*Methods@#We included patients with normal lung function who underwent esophagogastroduodenoscopy for health screening from a health screening center. Patients with persistent erosive reflux esophagitis on two discrete endoscopic examinations were designated as the erosive reflux esophagitis group. We also selected patients without erosive reflux esophagitis and matched them 1:4 with patients from the erosive reflux esophagitis group. We estimated annual forced expiratory volume in 1 second (FEV1 ) and forced vital capacity (FVC) changes from baseline and compared these estimates by the linear mixed regression model. We also estimated the biannual incidence of chronic obstructive pulmonary disease (COPD). @*Results@#In total, 1,050 patients (210 patients with erosive reflux esophagitis, and 840 matched controls) were included. The median follow-up duration for spirometry was six years. In patients with erosive reflux esophagitis, mild reflux esophagitis (A grade) was most common (165 patients, 78.6%). The adjusted annual FEV1 change in patients with erosive reflux esophagitis was −51.8 mL/yr, while it decreased by 46.8 mL/yr in controls (P = 0.270).The adjusted annual FVC decline was similar between the two groups (−55.8 vs. −50.5 mL/ yr, P = 0.215). The estimated COPD incidence during the follow-up period was not different between the erosive reflux esophagitis and control groups. @*Conclusion@#In patients with normal lung function, the presence of erosive reflux esophagitis did not affect the annual declines in FEV1 or FVC.

Thromboembolism in Mycobacterium tuberculosis Infection: Analysis and Literature Review / 감염과화학요법

BACKGROUND@#Tuberculosis is associated with hypercoagulation; however, there are few reports of cases thromboembolism and tuberculosis at the same time in the real world. The purpose of this study was to report the incidence and clinical course of thromboembolism in patients diagnosed with tuberculosis.@*MATERIALS AND METHODS@#We retrospectively analyzed the data of patients who were diagnosed with both tuberculosis and thromboembolism including pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT) at Seoul National University Boramae Medical Center from January 2000 through March 2015.@*RESULTS@#Among the 7905 tuberculosis patients, 49 (0.6%) exhibited PTE, DVT, or both at or after the time of tuberculosis diagnosis. All patients treated for tuberculosis started with isoniazid, ethambutol, rifampicin, and pyrazinamide. Eight patients were switched to treatment with second-line medication because of resistance or adverse events. About half of the patients (n = 21, 44.7%) had thrombosis at the time of tuberculosis diagnosis. Of 48 patients treated for thromboembolism, 36 received warfarin. A total of 20 patients improved symptom caused by thrombosis, and 10 patients were confirmed cure by image study such as computed tomography or doppler ultrasonography. Eight patients who were treated with warfarin had persistent thrombosis. Five patients (10.2%) experienced major bleeding that required hospitalization. All of these bleeding events were associated with warfarin therapy.@*CONCLUSIONS@#Careful attention to PTE/DVT is needed at the time of diagnosis of tuberculosis and during anti-tuberculosis therapy. Warfarin therapy administered with anti-tuberculosis medication requires frequent monitoring to prevent major bleeding.

The effect of metformin on culture conversion in tuberculosis patients with diabetes mellitus

BACKGROUND/AIMS: Patients with diabetes mellitus (DM) and tuberculosis (TB) have increased morbidity and a high risk of treatment failure or recurrence. It is important to manage both diseases simultaneously. Among anti-diabetic drugs, metformin inhibits intracellular growth of mycobacteria. Therefore, we examined the effects of metformin on TB treatment, especially in patients with DM. METHODS: This retrospective cohort study included patients with culture-positive pulmonary TB diagnosed between 2011 and 2012. The primary study outcome was sputum culture conversion after 2 months of treatment. RESULTS: Of 499 patients diagnosed with culture-positive pulmonary TB, 105 (21%) had DM at diagnosis. Among them, 62 (59.5%) were treated with metformin. Baseline characteristics, except for the presence of chronic renal disease, were not significantly different between the metformin and non-metformin groups. Metformin treatment had no significant effect on sputum culture conversion (p = 0.60) and recurrence within 1 year after TB treatment completion (p = 0.39). However, metformin improved the sputum culture conversion rate in patients with cavitary pulmonary TB, who have higher bacterial loads (odds ratio, 10.8; 95% confidence interval, 1.22 to 95.63). CONCLUSIONS: Among cavitary pulmonary TB patients with DM, metformin can be an effective adjunctive anti-TB agent to improve sputum culture conversion after 2 months of treatment.

Effect of Prophylactic Use of Silymarin on Anti-tuberculosis Drugs Induced Hepatotoxicity / 결핵및호흡기질환

BACKGROUND: The first line of anti-tuberculosis (TB) drugs are the most effective standard of drugs for TB. However, the use of these drugs is associated with hepatotoxicity. Silymarin has protective effects against hepatotoxicity of anti-TB drugs in animal models. This study aims to investigate the protective effect of silymarin on hepatotoxicity caused by anti-TB drugs. METHODS: This is a prospective, randomized, double-blind and placebo-controlled study. Patients were eligible if they were 20 years of age or order and started the first-line anti-tuberculosis drugs. Eligible patients were randomized for receiving silymarin or a placebo for the first 4 weeks. The primary outcome was the proportion of patients who showed elevated serum liver enzymes more than 3 times the upper normal limit (UNL) or total bilirubin (TBil) > 2× UNL within the first 8 weeks of anti-TB treatment. RESULTS: We enrolled a total of 121 patients who silymarin or a placebo to start their anti-TB treatment, for the first 8 weeks. The proportions of elevated serum liver enzymes more than 3 times of UNL at week 2, week 4, and week 8 did not show any significant difference between the silymarin and placebo groups, at 0% versus 3.6% (p>0.999); 4.4% versus 3.6% (p>0.999); and 8.7% versus 10.8% (p=0.630), respectively. However, patients with TBil >2× ULN at week 8 were significantly low in the silymarin group (0% versus 8.7%, p=0.043). CONCLUSION: Our findings did not show silymarin had any significant preventive effect on the hepatotoxicity of anti-TB drugs.

Prediction of Anthracofibrosis Based on Clinico-Radiographic Findings

PURPOSE: Because anthracofibrosis (AF) is associated with tuberculosis (TB), detection of AF is clinically relevant in Korea, a TB endemic region. We thus sought to develop and validate a predictive model for AF using clinical radiographic data. MATERIALS AND METHODS: Between January 1, 2008 and March 31, 2014, 3849 adult patients who underwent bronchoscopies were retrospectively included from an observational registry. We dichotomized patients based on the presence (n=167) or absence (n=242) of AF. After analyzing their clinico-radiographic characteristics, a logistic prediction model was developed. An area under the curve (AUC) was drawn using the weighted score in logistic regression model. To evaluate the degree of overfitting of the predictive model, a 5-fold cross-validation procedure was performed. RESULTS: In multivariate logistic regression, clinical findings such as age >70 years, female gender, active TB, and computed tomography findings including atelectasis, stenosis, bronchial wall thickening, enlarged and calcified lymph nodes were significant diagnostic predictors for AF. The weighed score had an AUC of 0.939 [95% confidence interval (CI)=0.911–0.960], similar to the AUC obtained from internal validation (AUC=0.926, 95% CI=0.896–0.949). CONCLUSION: The prediction model may be helpful for predicting AF based only on clinical and radiographic findings. However, further external validation is necessary.

Acceptability of Sputum Specimens for Diagnosing Pulmonary Tuberculosis

The evaluation of the quality of a sputum specimen prior to bacterial culture has been an accepted practice. However, optimal sputum criteria for pulmonary tuberculosis (TB) are not well established. We investigated indicators for sputum acceptability in tuberculosis cultures and acid-fast bacilli (AFB) smear. A post-hoc analysis of a randomized trial with 228 sputum specimens from 77 patients was conducted. In the trial, pulmonary TB suspects were requested for collecting three sputum specimens. We performed both TB study (AFB smear and M. tuberculosis culture) and Gram staining in each specimen. By using generalized estimating equations, the association between sputum characteristics and positive TB testings were analyzed. Although acceptable specimens for bacterial pneumonia showed higher TB-culture positive rates than unacceptable specimens (adjusted odds ratio [aOR]=1.66; 95% confidence interval [CI]=1.11-2.49), a specimen with > or =25 white blood cells/low-power field was the better predictor for positive M. tuberculosis cultures (aOR=2.30; 95% CI=1.48-3.58) and acid-fast bacilli smears (aOR=1.85; 95% CI=1.05-3.25). Sputum leukocytosis could be an indicator of sputum acceptability for diagnosing pulmonary tuberculosis.

The Impact of Lifestyle Behaviors on the Acquisition of Pandemic (H1N1) Influenza Infection: A Case-Control Study

PURPOSE: The purpose of this study was to evaluate the effects of lifestyle behaviors and health habits on the risk for acquiring pandemic influenza (H1N1) virus infection. MATERIALS AND METHODS: We conducted a case-control study in a secondary care hospital in South Korea between November 2009 and August 2010. We enrolled patients with H1N1 infection, as confirmed by a positive result of the real-time reverse transcriptase polymerase chain reaction assay; for each patient, we enrolled 4 age- and gender-matched controls with no history of H1N1 infection or severe acute respiratory illness during the H1N1 pandemic in South Korea (1:4 match). RESULTS: During the study period, 33 cases and 132 age- and gender-matched controls were enrolled. The case group had a higher percentage of current smokers (p<0.01), fewer subjects reporting regular physical activity (p=0.03), or regular vitamin supplementation (p<0.01), and more subjects reporting a higher annual incidence of the common cold (p=0.048) as compared to the control group. In the multivariable analysis, 2 factors were independently associated with the acquisition of H1N1 infection: current smoking [adjusted odds ratio (OR)=5.53; 95% confidence interval (CI), 1.60-19.16; p<0.01] and a higher annual incidence of the common cold (adjusted OR=1.24; 95% CI, 1.002-1.53; p=0.048). CONCLUSION: A current smoking status and a history of frequent colds were associated with an increased risk of acquiring H1N1 infection.

Clinical Effects of Gemifloxacin on the Delay of Tuberculosis Treatment

Although gemifloxacin has low in vitro activity against Mycobacterium tuberculosis, the effect of gemifloxacin on the delay of tuberculosis (TB) treatment has not been validated in a clinical setting. The study group included patients with culture-confirmed pulmonary TB who initially received gemifloxacin for suspected community-acquired pneumonia (CAP). Two control groups contained patients treated with other fluoroquinolones or nonfluoroquinolone antibiotics. Sixteen cases were treated with gemifloxacin for suspected CAP before TB diagnosis. Sixteen and 32 patients were treated with other fluoroquinolones and nonfluoroquinolones, respectively. The median period from the initiation of antibiotics to the administration of anti-TB medication was nine days in the gemifloxacin group, which was significantly different from the other fluoroquinolones group (35 days). The median times for the nonfluoroquinolone group and the gemifloxacin group were not significantly different. There were no significant differences between the gemifloxacin and other fluoroquinolone group in terms of symptomatic and radiographic improvements. However, the frequency of radiographic improvement in the other fluoroquinolones group tended to be higher than in the gemifloxacin group. Gemifloxacin might be the preferred fluoroquinolone for treating CAP, to alleviate any concerns about delaying TB treatment.

Retrospective Comparison of Levofloxacin and Moxifloxacin on Multidrug-Resistant Tuberculosis Treatment Outcomes

BACKGROUND/AIMS: To compare the effect of levofloxacin and moxifloxacin on treatment outcomes among patients with multidrug-resistant tuberculosis (MDR-TB). METHODS: A retrospective analysis of 171 patients with MDR-TB receiving either levofloxacin or moxifloxacin was performed. Treatment responses were categorized into treatment success (cured and treatment completed) or adverse treatment outcome (death, failure, and relapsed). RESULTS: The median age of the patients was 42.0 years. Approximately 56% of the patients were male. Seventeen patients had extensively drug-resistant tuberculosis, and 20 had a surgical resection. A total of 123 patients (71.9%) received levofloxacin for a median 594 days, and 48 patients (28.1%) received moxifloxacin for a median 673 days. Other baseline demographic, clinical, and radiographic characteristics were similar between the two groups. The moxifloxacin group had a significantly higher number of resistant drugs (p < 0.001) and a higher incidence of resistance to ofloxacin (p = 0.005) in the drug sensitivity test. The treatment success rate was 78.9% in the levofloxacin group and 83.3% in the moxifloxacin group (p = 0.42). Adverse reactions occurred at similar rates in the groups (p = 0.44). Patients in the moxifloxacin group were not more likely to have treatment success than those in the levofloxacin group (adjusted odds ratio, 0.76; 95% confidence interval, 0.24 to 2.43; p = 0.65). CONCLUSIONS: Both levofloxacin and moxifloxacin showed equivalent efficacy for treating MDR-TB.

Successful Management of Tracheobronchomalacia Associated with Empyema Using a Covered Metallic Tracheobronchial Stent: A Case Report / 대한구급학회지

Tracheobronchomalacia is developed by excessively weakened walls of the trachea and bronchi, and shows dynamic collapse of the airway on expiration and causes dyspnea. Airway stenting or surgical correction of the airway may be helpful. We report a case with tracheobronchomalacia which was combined with chronic empyema and treated successfully with stent insertion.

Incidence and Risk Factors of Steroid-induced Diabetes in Patients with Respiratory Disease

Glucocorticoids are effective for treating several respiratory diseases. However, they can cause hyperglycemia. This study determined the incidence and risk factors of steroidinduced diabetes mellitus (S-DM) in patients treated with glucocorticoid for respiratory diseases. A retrospective study examined patients with respiratory diseases treated with a prednisolone-equivalent glucocorticoid dose exceeding 20 mg/day for at least 4 weeks between January 2003 and December 2008. Patients whose initial random glucose level exceeded 200 mg/dL or who had pre-existing diabetes were excluded. S-DM was defined as a fasting glucose concentration exceeding 126 mg/dL or a random glucose concentration exceeding 200 mg/dL at least twice after beginning steroid treatment. A total of 231 patients with respiratory diseases met the inclusion criteria. Their median age was 55 yr, and 139 were female. The median cumulative prednisolone-equivalent glucocorticoid dose was 4,965 mg, and the median duration of steroid treatment was 193 days. S-DM was diagnosed in 34 (14.7%) of 231 patients. Multivariate logistic regression identified older age (odds ratio 1.05, 95% confidence interval 1.02-1.09) as a risk factor for S-DM. S-DM is frequent among patients with respiratory diseases treated with glucocorticoid. Clinicians should be aware of the possibility of S-DM, especially among elderly patients.

The Correlation of Brain Natriuretic Peptide (BNP), Pulmonary Arterial Pressure, and St. George Respiratory Questionnaire (SGRQ) and Their Changes with a Trial of an Angiotensin Converting Enzyme Inhibitor / 결핵및호흡기질환

BACKGROUND: Pulmonary hypertension is considered as a poor prognosis factor in patients with chronic obstructive pulmonary disease (COPD). There has been reported brain natriuretic peptide (pro-BNP) is related with increased right ventricular (RV) workloads. However, there are few studies that evaluate the relationship between BNP and pulmonary arterial pressure (PAP), RV function and St. George Respiratory Questionnaire (SGRQ) score in patients with COPD, and the effects of angiotensin converting enzyme inhibitor (ACEI) on these parameters. METHODS: Pulmonary function test, echocardiography, blood BNP, and SGRQ score were evaluated in stabilized moderate degree COPD patients (FEV1/FVC<70%, 50%< or =FEV1<80%) aged 45 years and over, without worsening of symptoms within recent 3 months. After treating with ramipril 10 mg for 3 months, the same evaluation was repeated. RESULTS: Twenty-two patients were included in this study. BNP was significantly correlated with PAP (Pearson coefficient rho=0.51, p=0.02), but not with RV ejection fraction (EF) and predicted FEV1%. The values for predicted FEV1% showed significant correlation with SGRQ total score and activity score, but not with BNP or PAP. After ramipril treatment, PAP showed significant decrease (42.8+/-8.1 vs. 34.5+/-4.5 mm Hg p=0.0003), tricuspid annular plane systolic excursion significant increase (21.5+/-3.3 vs. 22.7+/-3.1 mm p=0.009). BNP showed a tendency to decrease without statistical significance (40.8+/-59.6 vs. 18.0+/-9.1 pg/mL p=0.55). SGRQ scores showed no significant change. CONCLUSION: BNP showed significant correlation with resting PAP, which means BNP could be used as markers for pulmonary hypertension. Treatment with ACEI didn't show significant change in the level of BNP, while pulmonary hypertension and RV function were improved.

The number of resident physicians and the mortality rate in a medical intensive care unit / 대한내과학회지

BACKGROUND/AIMS: The treatment outcome of patients hospitalized in intensive care units (ICUs) can be influenced by physician factors, including both intensivists and resident physicians. We evaluated the association between the number of residents who are exclusively responsible for the ICU and the mortality rate in a medical ICU. METHODS: The data obtained from an open medical ICU in a teaching hospital from Jan. 2005 to Dec. 2009 were analyzed retrospectively. We evaluated the associations between the ICU mortality rate and both the number of resident physicians and the number of patient-days per resident physician using multivariate Poisson regression analysis adjusted for year and month. RESULTS: The months with fewer than two residents tended to have a higher ICU mortality rate, although this difference was not significant in the univariate analyses. Multivariate Poisson regression analysis showed that months with fewer than two residents had a significantly higher ICU mortality rate compared with months with two residents (incidence risk ratio (IRR) 1.59, 95% confidence interval (CI) 1.05-2.41; p=0.029). The number of ICU patient-days per resident physician was not associated with the ICU mortality rate (IRR; 1.00, 95% CI, 0.99-1.01; p=0.649). CONCLUSIONS: The presence of fewer than two residents exclusively responsible for the medical ICU was an independent risk factor of a higher ICU mortality rate. However, no association was found between the number of ICU patient-days per resident physician and the ICU mortality rate.

Long-Term Effects of ACE Inhibitors in Post-Tuberculosis Emphysema / 결핵및호흡기질환

BACKGROUND: Little is known about the long-term effects of angiotensin-converting enzyme (ACE) treatment on post-tuberculosis emphysema. This study evaluated the effects of ACE inhibition on cardiac function and gas exchange in patients with post-tuberculosis emphysema. METHODS: At baseline and at 6 months after initiation of ACE inhibition therapy, patients underwent pulmonary function testing, arterial blood gas analysis, and echocardiography, both at rest and post exercise. Cardiac output (CO) and right ventricular ejection fraction (RVEF) were measured at those time points as well. RESULTS: After ACE inhibition; resting and post-exercise RVEF (Mean+/-SEM, 61.5+/-1.0, 67.6+/-1.2%, respectively) were higher than at baseline (56.9+/-1.2, 53.5+/-1.7%). Resting and post-exercise CO (6.37+/-0.24, 8.27+/-0.34 L/min) were higher than at baseline (5.42+/-0.22, 6.72+/-0.24 L/min). Resting and post-exercise PaO2 (83.8+/-1.6, 74.0+/-1.2 mmHg, respectively) were also higher than at baseline (74.2+/-1.9, 66.6+/-1.6 mmHg). Post-exercise PaCO2 (46.3+/-1.1 mmHg) was higher than at baseline (44.9+/-1.1; Resting 42.8+/-0.8 vs. 42.4+/-0.9 mmHg). Resting and post-exercise A-a O2 gradient (12.4+/-1.4, 17.8+/-1.5 mmHg) were lower than at baseline (22.5+/-1.5, 26.9+/-1.6 mmHg). CONCLUSION: In post-tuberculosis emphysema, RVEF and CO were augmented with a resultant increase in peripheral oxygen delivery after ACE inhibition. These findings suggest that an ACE inhibitor may have the potential to alleviate co-morbid cardiac conditions and benefit the patients with post-tuberculosis emphysema.

A Case of Bilateral Gynecomastia Associated with Isoniazid / 결핵및호흡기질환

Gynecomastia is a benign enlargement of the male breast attributable to proliferation of the ductal elements. Gynecomastia has been rarely reported as an adverse effect of isoniazid therapy. We report the case of a 35-year-old man who was prescribed with isoniazid, rifampicin, ethambutol and pyrazinamide to treat pulmonary and lymphatic tuberculosis. After five months of treatment, the patient complained of painful engorgement in the bilateral breasts and the presence of male gynecomastia was confirmed with a physical examination and radiographical methods. The serum level of estradiol was also increased. Common causes of male gynecomastia were excluded through history taking and the laboratory findings. The anti-TB drugs were changed to a second line regimen due to radiographical progression and the intolerance of the patient to gynecomastia. Gynecomastia was relieved very slowly and a tender subareolar palpable mass decreased in size and consistency over five-month period after stopping the probable causative drug, isoniazid. From a review of the literature, gynecomastia has been shown to be a side effect of treatment with first line anti-tuberculosis drugs, and especially with isoniazid. We report the rare case.

Endobronchial Tuberculosis

Endobronchial tuberculosis is defined as a specific inflammation of the trachea or major bronchi caused by tubercle bacilli. Active disease can be diagnosed when certain endobronchial lesions-such as whitish gelatinous material, ulcer, tumor, stenosis, or inflammation-exist on bronchoscopy and tuberculosis is proven by bronchoscopic biopsy of these lesions. In pulmonary tuberculosis, resected lung specimens frequently show either ulceration or stenosis of the draining bronchioles or bronchi, and the same endobronchial processes may result in bronchiectasis due to destruction of the bronchial wall. These lesions are included in the disease entity of pulmonary tuberculosis rather than that of endobronchial tuberculosis because those endobronchial lesions distal to lobar bronchi do not have clinical significance. Fibrotic stenosis of bronchi may be inactive lesions resulting from prior endobronchial tuberculosis though sputum examination for acid-fast bacilli is positive, since the sequela of endobronchial tuberculosis and reactivated pulmonary tuberculosis can be present coincidentally. Therefore, it is necessary to obtain histologic proof of tuberculosis for a definite diagnosis of endobronchial tuberculosis. Endobronchial tuberculosis is a specific form or a significant complication of pulmonary tuberculosis, and it frequently causes matters of grave concern; (1) delay in diagnosis, (2) misdiagnosis as bronchial asthma, and (3) bronchial stenosis. The human immunodeficiency virus (HIV) epidemic and multidrug-resistant strains of tubercle bacilli may be associated with a higher incidence of endobronchial tuberculosis. Therefore, endobronchial tuberculosis continues to be a health problem, though the incidence of tuberculosis affecting respiratory organs including the trachea and bronchi has been greatly reduced. Endobronchial tuberculosis should be borne in mind when patients are young female adults or adolescents who present with symptoms suggestive of asthma and/or with unusual roentgenographic patterns, or in patients with HIV infection.

Diagnostic and Therapeutic Problems of Pulmonary Tuberculosis in Elderly Patients

To identify differences in the clinical, radiologic, and microbiologic features of pulmonary tuberculosis (TB) in the young ( or =65 yr), we performed a retrospective analysis of the medical charts and chest radiographs of 207 young and 119 elderly pulmonary TB patients. Hemoptysis and a febrile sense were more frequent in the young, whereas weakness, dyspnea, anorexia, and mental change were more frequent in the elderly. Elderly patients showed higher frequencies of cardiovascular and chronic lung diseases, whereas the young showed a higher proportion of underlying liver disease. In addition, chest radiography showed a significantly higher frequency of mid or lower lung involvement by TB lesions in the elderly (10.6% vs. 22.7%, p<0.05). Lesions were frequently misdiagnosed as pneumonia or lung cancer in the elderly. However, there was no difference between these two groups in terms of sputum acid-fast bacilli positivity. The elderly showed a higher frequency of adverse drug reactions (18.5% vs. 40.7%, p<0.05), and higher TB-related mortality (1.3% vs. 11.1%, p<0.05). In conclusion this study showed that young and elderly pulmonary TB patients have similar microbiologic features; however, the elderly showed higher frequencies of atypical clinical and radiologic presentations, adverse drug reactions, and higher TB-related mortality.