Factors Related to Successful Tuberculosis Treatment in Vulnerable Groups / 대한내과학회지

Background/Aims@#Although the incidence and mortality of tuberculosis are decreasing in South Korea, the number of applications for financial assistance with the cost of tuberculosis treatment made by individuals from vulnerable groups was 3.8 times higher in 2019 compared to 2017 (Tuberculosis Relief Belt Project, 2019). @*Methods@#We analyzed the data of patients who received financial aid for tuberculosis treatment (in the period 2014-2018) from the Tuberculosis Relief Belt Project, which was designed to assist vulnerable groups. This study analyzed 137 subjects, and the independent variables included patient factors (age, gender, nationality, tuberculosis type, number of comorbidities, and place of residence) and treatment type (outpatient or inpatient). The dependent variable was the treatment outcome. @*Results@#The likelihood of treatment success was significantly lower for patients with one (odds ratio [OR] 0.202), two (OR 0.147), or three or more (OR 0.070) comorbidities compared to those with no comorbidities. This was also the case for patients living alone (OR 0.097), and for those classified as homeless (OR 0.053). Korean patients (OR 8.512) had a significantly higher probability of a successful treatment outcome than foreigners. @*Conclusions@#Appropriate community-based management of individuals with tuberculosis from vulnerable groups, including foreigners, people with comorbidities, people living alone, and people with an unstable residential situation or homeless status, is important.

Revised Korean Cough Guidelines, 2020: Recommendations and Summary Statements / 결핵및호흡기질환

Cough is the most common respiratory symptom that can have various causes. It is a major clinical problem that can reduce a patient’s quality of life. Thus, clinical guidelines for the treatment of cough were established in 2014 by the cough guideline committee under the Korean Academy of Tuberculosis and Respiratory Diseases. From October 2018 to July 2020, cough guidelines were revised by members of the committee based on the first guidelines. The purpose of these guidelines is to help clinicians efficiently diagnose and treat patients with cough. This article highlights the recommendations and summary of the revised Korean cough guidelines. It includes a revised algorithm for the evaluation of acute, subacute, and chronic cough. For a chronic cough, upper airway cough syndrome (UACS), cough variant asthma (CVA), and gastroesophageal reflux disease (GERD) should be considered in differential diagnoses. If UACS is suspected, first-generation antihistamines and nasal decongestants can be used empirically. In cases with CVA, inhaled corticosteroids are recommended to improve cough. In patients with suspected chronic cough due to symptomatic GERD, proton pump inhibitors are recommended. Chronic bronchitis, bronchiectasis, bronchiolitis, lung cancer, aspiration, intake of angiotensin-converting enzyme inhibitor, intake of dipeptidyl peptidase-4 inhibitor, habitual cough, psychogenic cough, interstitial lung disease, environmental and occupational factors, tuberculosis, obstructive sleep apnea, peritoneal dialysis, and unexplained cough can also be considered as causes of a chronic cough. Chronic cough due to laryngeal dysfunction syndrome has been newly added to the guidelines.

Revised Korean Cough Guidelines, 2020: Recommendations and Summary Statements / 결핵및호흡기질환

Cough is the most common respiratory symptom that can have various causes. It is a major clinical problem that can reduce a patient’s quality of life. Thus, clinical guidelines for the treatment of cough were established in 2014 by the cough guideline committee under the Korean Academy of Tuberculosis and Respiratory Diseases. From October 2018 to July 2020, cough guidelines were revised by members of the committee based on the first guidelines. The purpose of these guidelines is to help clinicians efficiently diagnose and treat patients with cough. This article highlights the recommendations and summary of the revised Korean cough guidelines. It includes a revised algorithm for the evaluation of acute, subacute, and chronic cough. For a chronic cough, upper airway cough syndrome (UACS), cough variant asthma (CVA), and gastroesophageal reflux disease (GERD) should be considered in differential diagnoses. If UACS is suspected, first-generation antihistamines and nasal decongestants can be used empirically. In cases with CVA, inhaled corticosteroids are recommended to improve cough. In patients with suspected chronic cough due to symptomatic GERD, proton pump inhibitors are recommended. Chronic bronchitis, bronchiectasis, bronchiolitis, lung cancer, aspiration, intake of angiotensin-converting enzyme inhibitor, intake of dipeptidyl peptidase-4 inhibitor, habitual cough, psychogenic cough, interstitial lung disease, environmental and occupational factors, tuberculosis, obstructive sleep apnea, peritoneal dialysis, and unexplained cough can also be considered as causes of a chronic cough. Chronic cough due to laryngeal dysfunction syndrome has been newly added to the guidelines.

Tuberculosis Relief Belt Supporting Project (Tuberculosis Patient Management Project for Poverty Group) / 결핵및호흡기질환

BACKGROUND: The “Tuberculosis Relief Belt Supporting Project (Tuberculosis Patient Management Project for Poverty Groups)” is a national program for socioeconomically vulnerable tuberculosis (TB) patients. We sought to evaluate the clinical and socioeconomic characteristics of poverty-stricken TB patients, and determined the need for relief. METHODS: We examined in-patients with TB, who were supported by this project at the National Medical Center from 2014 to 2015. We retrospectively investigated the patients' socioeconomic status, clinical characteristics, and project expenditures. RESULTS: Fifty-eight patients were enrolled. Among 55 patients with known income status, 24 (43.6%) had no income. Most patients (80%) lived alone. A total of 48 patients (82.8%) had more than one underlying disease. More than half of the enrolled patients (30 patients, 51.7%) had smear-positive TB. Cavitary disease was found in 38 patients (65.5%). Among the 38 patients with known resistance status, 19 (50%) had drug-resistant TB. In terms of disease severity, 96.6% of the cases had moderate-to-severe disease. A total of 14 patients (26.4%) died during treatment. Nursing expenses were supported for 12 patients (20.7%), with patient transportation costs reimbursed for 35 patients (60%). In terms of treatment expenses for 31 people (53.4%), 93.5% of them were supported by uninsured benefits. CONCLUSION: Underlying disease, infectivity, drug resistance, severity, and death occurred frequently in socioeconomically vulnerable patients with TB. Many uninsured treatment costs were not supported by the current government TB programs, and the “Tuberculosis Relief Belt Supporting Project” compensated for these limitations.

Determinants of Nicotine Dependence in Chronic Obstructive Pulmonary Disease / 결핵및호흡기질환

BACKGROUND: Smoking cessation is the most powerful intervention to modify progress of chronic obstructive pulmonary disease (COPD), and nicotine dependence is one of the most important determinants of success or failure in smoking cessation. We evaluated nicotine dependence status and investigated factors associated with moderate to high nicotine dependence in patients with COPD. METHODS: We included 53 current smokers with COPD in the Korean Obstructive Lung Disease II cohort enrolled between January 2014 and March 2016. Nicotine dependence was measured by using Fagerstrom test for nicotine dependence (FTND). Cognitive function was assessed by Korean version of Montreal Cognitive Assessment. RESULTS: The median FTND score was 3, and 32 patients (60%) had moderate to high nicotine dependence. The median smoking amount was 44 pack-years, which was not related to nicotine dependence. Multiple logistic regression analysis revealed that high education status (odds ratio, 1.286; 95% confidence interval, 1.036–1.596; p=0.023), age <70 (odds ratio, 6.407; 95% confidence interval, 1.376–29.830; p=0.018), and mild to moderate airflow obstruction (odds ratio, 6.969; 95% confidence interval, 1.388–34.998; p=0.018) were related to moderate to high nicotine dependence. CONCLUSION: Nicotine dependence does not correlate with smoking amount, but with education level, age, and severity of airflow obstruction. Physicians should provide different strategies of smoking cessation intervention for current smokers with COPD according to their education levels, age, and severity of airflow obstruction.

The Korean Cough Guideline: Recommendation and Summary Statement / 결핵및호흡기질환

Cough is one of the most common symptom of many respiratory diseases. The Korean Academy of Tuberculosis and Respiratory Diseases organized cough guideline committee and cough guideline was developed by this committee. The purpose of this guideline is to help clinicians to diagnose correctly and treat efficiently patients with cough. In this article, we have stated recommendation and summary of Korean cough guideline. We also provided algorithm for acute, subacute, and chronic cough. For chronic cough, upper airway cough syndrome (UACS), cough variant asthma (CVA), and gastroesophageal reflux disease (GERD) should be considered. If UACS is suspicious, first generation anti-histamine and nasal decongestant can be used empirically. In CVA, inhaled corticosteroid is recommended in order to improve cough. In GERD, proton pump inhibitor is recommended in order to improve cough. Chronic bronchitis, bronchiectasis, bronchiolitis, lung cancer, aspiration, angiotensin converting enzyme inhibitor, habit, psychogenic cough, interstitial lung disease, environmental and occupational factor, tuberculosis, obstructive sleep apnea, peritoneal dialysis, and idiopathic cough can be also considered as cause of chronic cough. Level of evidence for treatment is mostly low. Thus, in this guideline, many recommendations are based on expert opinion. Further study regarding treatment for cough is mandatory.

Renal Complications and Their Prognosis in Korean Patients with Middle East Respiratory Syndrome-Coronavirus from the Central MERS-CoV Designated Hospital

Some cases of Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) infection presented renal function impairment after the first MERS-CoV patient died of progressive respiratory and renal failure. Thus, MERS-CoV may include kidney tropism. However, reports about the natural courses of MERS-CoV infection in terms of renal complications are scarce. We examined 30 MERS-CoV patients admitted to National Medical Center, Korea. We conducted a retrospective analysis of the serum creatinine (SCr), estimated glomerular filtration rate (eGFR), urine dipstick tests, urinary protein quantitation (ACR or PCR), and other clinical parameters in all patients. Two consecutive results of more than trace (or 1+) of albumin and blood on dipstick test occurred in 18 (60%) (12 [40%]) and 22 (73.3%) (19 [63.3%]) patients, respectively. Fifteen (50.0%) patients showed a random urine ACR or PCR more than 100 mg/g Cr. Eight (26.7%) patients showed acute kidney injury (AKI), and the mean and median durations to the occurrence of AKI from symptom onset were 18 and 16 days, respectively. Old age was associated with a higher occurrence of AKI in the univariate analysis (HR [95% CI]: 1.069 [1.013-1.128], P = 0.016) and remained a significant predictor of the occurrence of AKI after adjustment for comorbidities and the application of a mechanical ventilator. Diabetes, AKI, and the application of a continuous renal replacement therapy (CRRT) were risk factors for mortality in the univariate analysis (HR [95% CI]: diabetes; 10.133 [1.692-60.697], AKI; 12.744 [1.418-114.565], CRRT; 10.254 [1.626-64.666], respectively). Here, we report renal complications and their prognosis in 30 Korean patients with MERS-CoV.

Drug-induced Hepatotoxicity of Anti-tuberculosis Drugs and Their Serum Levels

The correlation between serum anti-tuberculosis (TB) drug levels and the drug-induced hepatotoxicity (DIH) remains unclear. The purpose of this study was to investigate whether anti-TB DIH is associated with basal serum drug levels. Serum peak levels of isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), and ethambutol (EMB) were analyzed in blood samples 2 hr after the administration of anti-TB medication. Anti-TB DIH and mild liver function test abnormality were diagnosed on the basis of laboratory and clinical criteria. Serum anti-TB drug levels and other clinical factors were compared between the hepatotoxicity and non-hepatotoxicity groups. A total of 195 TB patients were included in the study, and the data were analyzed retrospectively. Seventeen (8.7%) of the 195 patients showed hepatotoxicity, and the mean aspartate aminotransferase/alanine aminotransferase levels in the hepatotoxicity group were 249/249 IU/L, respectively. Among the 17 patients with hepatotoxicity, 12 showed anti-TB DIH. Ten patients showed PZA-related hepatotoxicity and 2 showed INH- or RMP-related hepatotoxicity. However, intergroup differences in the serum levels of the 4 anti-TB drugs were not statistically significant. Basal serum drug concentration was not associated with the risk anti-TB DIH in patients being treated with the currently recommended doses of first-line anti-TB treatment drugs.

Drug-induced Hepatotoxicity of Anti-tuberculosis Drugs and Their Serum Levels

The correlation between serum anti-tuberculosis (TB) drug levels and the drug-induced hepatotoxicity (DIH) remains unclear. The purpose of this study was to investigate whether anti-TB DIH is associated with basal serum drug levels. Serum peak levels of isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), and ethambutol (EMB) were analyzed in blood samples 2 hr after the administration of anti-TB medication. Anti-TB DIH and mild liver function test abnormality were diagnosed on the basis of laboratory and clinical criteria. Serum anti-TB drug levels and other clinical factors were compared between the hepatotoxicity and non-hepatotoxicity groups. A total of 195 TB patients were included in the study, and the data were analyzed retrospectively. Seventeen (8.7%) of the 195 patients showed hepatotoxicity, and the mean aspartate aminotransferase/alanine aminotransferase levels in the hepatotoxicity group were 249/249 IU/L, respectively. Among the 17 patients with hepatotoxicity, 12 showed anti-TB DIH. Ten patients showed PZA-related hepatotoxicity and 2 showed INH- or RMP-related hepatotoxicity. However, intergroup differences in the serum levels of the 4 anti-TB drugs were not statistically significant. Basal serum drug concentration was not associated with the risk anti-TB DIH in patients being treated with the currently recommended doses of first-line anti-TB treatment drugs.

Pulmonary Cryptococcosis That Mimicked Rheumatoid Nodule in Rheumatoid Arthritis Lesion / 결핵및호흡기질환

Recently, the incidence of pulmonary cryptococcosis is gradually increasing in rheumatoid arthritis (RA) patients. Pulmonary rheumatoid nodules (PRN) are rare manifestations of RA. Eighteen months ago, a 65-year old woman was admitted to hospital due to multiple nodules (2.5x2.1x2 cm) with cavitations in the right lower lobe. She was diagnosed with RA three year ago. She had been taking methotrexate, leflunomide, and triamcinolone. A video-assisted thoracoscopic surgery biopsy was performed and PRN was diagnosed. However, a newly growing huge opacity with cavitation was detected in the same site. Pulmonary cryptococcal infection was diagnosed through a transthoracic computed tomograpy guided needle biopsy. Cryptococcus antigen was detected in serum but not in cerebrospinal fluid. The patient was treated with oral fluconazole which resulted clinical improvement and regression of the nodule on a series of radiography. Herein, we report the case of pulmonary cryptococcosis occurring in the same location as that of the PRN.

Klebsiella pneumoniae Liver Abscess Complicated With Septic Pulmonary Embolism

Klebsiella pneumoniae has been reported to be the most common pathogen causing pyogenic liver abscess. K. pneumoniae liver abscess occurs fairly often in patients with diabetes mellitus, and is commonly associated with metastatic infections such as brain abscess, endophthalmitis, lung abscess, osteomyelitis, prostatitis, necrotizing fasciitis and infection in other sites. Although septic pulmonary embolism (SPE) is uncommon, it is a serious metastatic complication of K. pneumoniae liver abscess. Chest computed tomography (CT) scans are crucial in making the early diagnosis of SPE; however, it does not provide the basis for a definitive diagnosis. A 70-year-old man was referred to the Department of Pulmonology due to cough and an abnormal chest radiography. The chest CT scans revealed relatively well-demarcated, round multiple nodules with peripheral preponderance, cavitary mass in the right upper lobe of the lung and low-density hepatic cystic masses. Bronchoscopic examination and percutaneous needle aspiration of the lung were performed, but there was no evidence of malignancy. Finally, K. pneumoniae was grown from a bronchial washing specimen and blood culture. Intravenous carbapenem was administered over a 3-week period and follow-up CT scans showed improvement in both the lung and the liver. We report a case of K. pneumoniae liver abscess complicated with SPE requiring differential diagnosis of hematogenous metastatic malignancy on CT scans in an elderly patient.

Diagnostic Accuracy of Notified Cases as Pulmonary Tuberculosis in Private Sectors of Korea

The diagnostic accuracy of the data reported in the Korean tuberculosis surveillance system (KTBS) has not been adequately investigated. We reviewed the clinical data of pulmonary tuberculosis (PTB) cases notified from private medical facilities through KTBS between January and June, 2004. PTB cases were classified into definite (culture-proven), probable (based on smear, polymerase chain reaction, histology, bronchoscopic finding, computed tomography, or both chest radiograph and symptoms) or possible (based only on chest radiograph) tuberculosis. Of the 1126 PTB cases, sputum AFB smear and culture were requested in 79% and 51% of the cases, respectively. Positive results of sputum smear and culture were obtained in 43% and 29% of all the patients, respectively. A total of 73.2% of the notified PTB cases could be classified as definite or probable and 81.7% as definite, probable, or possible. However, where infection was not confirmed bacteriologically or histologically, only 60.1% of the patients were definite, probable, or possible cases. More than 70% of PTB notified from private sectors in Korea can be regarded as real TB. The results may also suggest the possibility of over-estimation of TB burden in the use of the notification-based TB data.

Streptococcus salivarius pneumonia with pulmonary nocardiosis in a rheumatoid arthritis patient treated with immunosuppressants / 대한내과학회지

Streptococcus salivarius is a Gram-positive organism that belongs to the viridians group of streptococci. It is a relatively non-virulent bacterium that is part of the normal flora. It is rarely isolated from blood and is usually considered a contaminant. Nevertheless, S. salivarius may cause life-threatening infections, especially in immunocompromised hosts. There have been relatively few reports of S. salivarius pneumonia. Nocardiosis is also a rare opportunistic infection. Pulmonary nocardiosis is difficult to diagnose and, consequently, the diagnosis is often delayed. We report an unusual presentation with multiple pulmonary mass-like consolidations caused by a mixed infection of S. salivarius and Nocardia sp. in a 58-year-old man with rheumatoid arthritis who was taking oral corticosteroid, methotrexate, and leflunomide. The patient's symptoms and radiographic findings improved after six weeks of antibiotic therapy

The diagnostic accuracy of notified new culture-negative pulmonary tuberculosis patients in public healthcare centers / 대한내과학회지

BACKGROUND/AIMS: The notification rate based on the Korean tuberculosis (TB) surveillance system has been widely used to evaluate the TB burden in Korea. However, few studies have examined the accuracy of TB diagnosis among notified cases. This study evaluated the diagnostic accuracy of microbiologically not proven cases notified as 'new pulmonary TB patients' at public healthcare centers. METHODS: We reviewed the clinical symptoms and initial and follow-up chest radiographs of notified smear-and-culture- negative TB cases in randomly selected healthcare centers between Jan 2005 and Dec 2005. Patients who had symptoms, initial chest radiographs compatible with pulmonary TB, and radiological improvements after treatment were diagnosed as 'probable TB', while patients who did not meet these three criteria were diagnosed as 'probably not TB'. RESULTS: The analysis included 263 patients. The median age of the notified TB cases was 41 years, 60.8% of them were male, and 43.2% were 'probable TB' patients. Overall, 82.0% of the patients had either initial chest radiographs compatible with pulmonary TB or radiological improvements after treatment. Ultimately, 4.9% were 'probably not TB' patients. CONCLUSIONS: Most of the new notified pulmonary TB patients not confirmed microbiologically in public clinics can be considered real TB patients, although there are some over diagnosed cases.

Consolidative Bronchioloalveolar Carcinoma Presenting as Pneumonia, and This Led to a Late Diagnosis due to the Improvement after Antibiotic Therapy / 결핵및호흡기질환

Non-resolving or slowly resolving pulmonary infiltrates in spite of administering adequate antimicrobial therapy are a clinical diagnostic challenge for physicians. The rate of radiographic resolution varies with the patients' age, the underlying comorbidities, the extent of radiographic involvement, the functional status and the causal pathogens. It is important to differentiate non-resolving or slowly resolving bacterial pneumonia from other uncommon infectious pneumonias or malignancies that require invasive diagnostic techniques to confirm the diagnosis. Bronchioloalveolar carcinoma can present with various clinical and radiographic features. Unfortunately, the radiographic similarity of consolidative BAC to pneumonia often leads to an incorrect diagnosis of pneumonia and possibly significant delays in obtaining appropriate diagnostic studies. We describe here a case of a mixed adenocarcinoma and bronchioloalveolar carcinoma that was initially diagnosed as pneumonia due to the consolidation pattern on the radiography and the patient's initial improvement with antibiotic treatment.

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.