Long-term, low-dose erythromycin monotherapy for Mycobacterium avium complex lung disease: a propensity score analysis.

Multidrug regimens are initially withheld in mild cases of pulmonary Mycobacterium avium complex (MAC) disease. Based on the anti-inflammatory effects of macrolides, some patients are treated with erythromycin, which does not appear to exhibit cross-resistance with clarithromycin in MAC. The aim of this study was to evaluate the effects and adverse events of erythromycin monotherapy in patients with pulmonary MAC disease. This was a retrospective propensity score analysis consisting of 31 patients treated with erythromycin alone and 72 patients on conservative therapy, all of whom met the ATS/IDSA criteria for pulmonary MAC disease. The primary outcome was exacerbation requiring administration of a multidrug regimen. The secondary outcome was the rate of response to the multidrug regimens after exacerbation as a surrogate variable for cross-resistance to clarithromycin. As a result, erythromycin monotherapy was found to be likely to suppress exacerbation throughout the 7-year observation period after the diagnosis of pulmonary MAC disease (P=0.045, Breslow test). Multivariate analysis showed that erythromycin tended to prevent exacerbation, albeit statistically insignificantly (hazard ratio=0.495, 95% confidence interval 0.198-1.235; P=0.132). In addition, the rate of response to the multidrug regimens after exacerbation in the erythromycin group (56%; 5/9) was similar to that observed in the control group (62%; 13/21) (P=0.528). Erythromycin monotherapy for patients with pulmonary MAC disease may have the potential to suppress exacerbation without inducing cross-resistance to clarithromycin. However, further prospective studies are needed to microbiologically verify the effectiveness and potential for cross-resistance of these drugs.

[A case of giant tumorous shadow by pulmonary tuberculosis].

A 63-year-old woman who had been treated for myelodysplastic syndrome had a high fever. Chest radiography and computed tomography revealed a giant tumorous shadow from the right mediastinum to the hilum. She was treated with antibiotics but with little effect. The culture of bronchial washing fluid and sputum revealed Mycobacterium tuberculosis infection. There were no malignant cells in the sputum or bronchial washing fluid. Tumor markers were within normal limits. She was treated with isoniazid, rifampicin, streptomycin and pyrazinamide. On the sixth day of treatment, high fever disappeared, and sputum culture for tuberculosis became negative after two months. The size of the mass decreased with clinical improvement. The final diagnosis was pulmonary tuberculosis with mediastinal lymphadenopathy. Since the patient was a compromised host, the giant mass was considered to be induced by atypical response to mycobacterial infection.

[A case of paragonimiasis westermani with a worm migration track on chest CT].

A 59-year-old man with rusty-colored sputum was admitted for evaluation of a nodular shadow on his chest radiograph. Chest computed tomography (CT) revealed nodules and nodular opacities with a cavity in the right S3. Chest CT also showed clearly a double linear shadow other than the bronchovascular bundle, with a different course from that of the bronchovascular bundle, suggesting a worm migration track. The diagnosis of paragonimiasis westermani was confirmed by detection of Paragonimus eggs in a bronchoscopic aspirate smear and by immunoserological examination. The linear lesion on the chest CT is uncommon in paragonimiasis, but the finding is thought to be useful for the diagnosis of this disease.

[Clinical characteristics of elderly patients with tuberculosis].

The purpose of this report is to elucidate the characteristics of elderly patients with tuberculosis (TB), based on 235 patients hospitalized in our institution from January 1999 to October 2001. The mean age of all patients was 60.8 years old and the male-to-female ratio was 2.1:1. The clinical features were compared between 121 patients aged 65 years old or more (elderly group) and 114 patients younger than 65 years old (non-elderly group). The time lag between onset of the symptoms and the first visit to a doctor was 19 days in the elderly and 49 days in the non-elderly (P < 0.01). Previous therapy, extrapulmonary TB, and underlying diseases were significantly frequent in the elderly (P < 0.05). Cavitation on chest X-ray film was found in 23% of the elderly and in 40% of the non-elderly (P < 0.01). The frequency of positive smear was similar in the two groups. Peripheral blood lymphocyte count, serum total protein, albumin and total cholesterol were lower in the elderly who died during admission than in the living elderly (P < 0.01). There was no significant difference in mortality due to TB between the two groups, although deaths due to non-tuberculous diseases were more frequent in the elderly. Pneumonia and other infectious diseases accounted for 50% of deaths in the elderly. Nutrition and infection other than TB should be taken into consideration in treating elderly patients with TB.

[A clinical study of miliary tuberculosis].

Eighteen patients with miliary tuberculosis (MTB) were admitted to our hospital from 1994 to 2003. The mean age of the patients was 63.9 years (range 19-92). Past history of tuberculosis was recognized in one case. Six cases suffered from another underlying diseases, and 3 of them had been treated with corticosteroids. Smear, PCR and culture of sputum were positive for mycobacterium tuberculosis in 61%, 79% and 94% of cases, respectively. Chest computed tomography revealed diffuse micronodular shadow and diffuse infiltration in 100% and 22% of cases, respectively. The laboratory findings of 18 patients with MTB were compared with 240 patients with non-MTB who were admitted to our hospital from 1999 to 2001. Body mass index, serum total protein, albumin and peripheral blood lymphocyte count were significantly lower in MTB patients than in non-MTB patients. Five patients died during admission, 3 of them died of MTB and 2 of them died of cardiac disease. In the 3 died patients due to MTB, 2 of them had been treated with corticosteroids for fever, 2 of them had acute respiratory distress syndrome and 3 of them had disseminated intravascular coagulation. Serum total protein, albumin and platelet count were lower in the died patients due to MTB than in the living patients.

Elevated levels of circulating adhesion molecules in patients with active pulmonary tuberculosis.

OBJECTIVE: Recent studies have indicated the importance of cell adhesion molecules in the pathogenesis of various inflammatory lung diseases. Our study was designed to determine whether five soluble adhesion molecules including soluble L-, E- and P-selectin (sL-, sE- and sP-selectin), intercellular adhesion molecule-1 (sICAM-1), and vascular cell adhesion molecule-1 (sVCAM-1) in serum reflect the severity of active pulmonary tuberculosis (TB), and whether there is a distinct profile of these soluble molecules in this disease. METHODOLOGY: Using enzyme-linked immunosorbent assays, we measured the serum levels of these five soluble adhesion molecules in 31 patients with active TB and 11 healthy volunteers. RESULTS: Serum levels of sE-selectin, sP-selectin and sICAM-1, but not sL-selectin or sVCAM-1, were significantly higher in patients with active TB than in the control subjects (P < 0.001, each). Significant correlations were detected only between serum levels of sE-selectin and sP-selectin, sE-selectin and sICAM-1, and sP-selectin and sICAM-1. There was a significant correlation between the Gaffky scale result (a scale assessing the number of mycobacteria bacilli present) and all of the above adhesion molecules, except for sL-selectin. Serum levels of sE-selectin, sL-selectin and sICAM-1 also correlated with the CXR radiological score. Higher levels of sL-selectin and sICAM-1 were detected in the serum of patients with radiological cavity formation compared to those without. The ESR, C-reactive protein and circulating neutrophil counts all correlated significantly with sE-selectin, sP-selectin, sICAM-1 and sVCAM-1. CONCLUSION: The results suggest that there is a distinct profile of soluble adhesion molecules in active pulmonary TB and that sE-selectin, sP-selectin, and especially sICAM-1 appear to be the most sensitive clinical measures of disease severity.

[A case of mixed infection by Nocardia asteroides and Mycobacterium tuberculosis].

A 55-year-old man with diabetes mellitus was admitted to our hospital because of abnormal shadows in his chest radiographs. Both chest radiography and CT revealed infiltrative shadows in the right upper lung field. Repeated sputum smears showed no mycobacterium, so bronchoalveolar lavage (BAL) was performed bronchoscopically at the right B3b. The BAL fluid and the sputum obtained on the day after BAL contained acid-fast, branching filamentous structures. The microorganism was identified as Nocardia asteroides. Trimethoprim-sulfamethoxazole (ST) and SPFX were therefore administered. Later, Mycobacterium tuberculosis was detected in a 6-week culture of the sputum and BAL fluid. This case was diagnosed as a mixed infection by Nocardia asteroides and Mycobacterium tuberculosis, so the three anti-tuberculosis agents INH, RFP and EB were added. After 6 months of the combined therapy, neither microorganism could be detected in the sputum, and the lesion in the CT scan had decreased markedly in size. Since such a mixed infection is very rare, no treatment strategy has yet been established. The combined therapy was judged to have been effective in this case.