[A young case of pulmonary tuberculosis with atypical tumor shadow on chest computed tomography and its difficulty in diagnosis].

BACKGROUND: Diagnosis of pulmonary tuberculosis is usually made by diagnostic imaging such as chest X-ray or computed tomography (CT), and sputum test including smear and polymerase chain reaction (PCR) test. However there is difficulty in making diagnose when atypical imaging and negative sputum test are presented, followed by diagnostic delay. CASE: A 26-year-old man from Philippines consulted other clinic because of dry cough and was pointed out mass shadow in right upper lung field in his chest CT. He visited our office because of positive interferon gamma release assay, but repeated sputum test could not find tuberculosis. Bleeding from mass lesion failed to perform biopsy by bronchoscope, and we failed to find tuberculosis by smear and PCR test from bronchial brushing and wash. Transthoracic needle biopsy from his mass lesion revealed multiple non-caseous granuloma, and lead to make a decision about starting medication. Four weeks later sputum culture from his first visit revealed positive, and diagnosis of tuberculosis was made. DISCUSSION: For avoiding therapy delay it is important to perform invasive diagnostic procedure including histological examination and clinical decision of starting medication, when conservative diagnostic procedure such as sputum test or diagnostic imaging present atypical finding for diagnosing tuberculosis.

Clinical and microbiological differences between Mycobacterium abscessus and Mycobacterium massiliense lung diseases.

In recent years, many novel nontuberculous mycobacterial species have been discovered through genetic analysis. Mycobacterium massiliense and M. bolletii have recently been identified as species separate from M. abscessus. However, little is known regarding their clinical and microbiological differences in Japan. We performed a molecular identification of stored M. abscessus clinical isolates for further identification. We compared clinical characteristics, radiological findings, microbiological findings, and treatment outcomes among patients with M. abscessus and M. massiliense lung diseases. An analysis of 102 previous isolates of M. abscessus identified 72 (71%) M. abscessus, 27 (26%) M. massiliense, and 3 (3%) M. bolletii isolates. Clinical and radiological findings were indistinguishable between the M. abscessus and M. massiliense groups. Forty-two (58%) patients with M. abscessus and 20 (74%) patients with M. massiliense infections received antimicrobial treatment. Both the M. abscessus and M. massiliense groups showed a high level of resistance to all antimicrobials, except for clarithromycin, kanamycin, and amikacin. However, resistance to clarithromycin was more frequently observed in the M. abscessus than in the M. massiliense group (16% and 4%, respectively; P = 0.145). Moreover, the level of resistance to imipenem was significantly lower in M. abscessus isolates than in M. massiliense isolates (19% and 48%, respectively; P = 0.007). The proportions of radiological improvement, sputum smear conversion to negativity, and negative culture conversion during the follow-up period were higher in patients with M. massiliense infections than in those with M. abscessus infections. Patients with M. massiliense infections responded more favorably to antimicrobial therapy than those with M. abscessus infections.

Desensitization therapy for allergic reactions to antituberculous drugs.

OBJECTIVE: We retrospectively evaluated the clinical usefulness of desensitization therapy for many patients showing allergic reactions to anti-mycobacterial drugs (INH and RFP) according to the proposition reported by the Japanese Society for Tuberculosis (JST). METHODS: Desensitization therapy for anti-mycobacterial drugs was performed according to the propositions of JST for forty-six patients with mycobacterial disease in several hospitals participating in the Chugoku-Shikoku Mycobacterial Disease Committee between January 1999 and December 2009. RESULTS: Adverse reactions occurred as drug-induced skin eruptions in 23 patients, drug-induced fever in 16, and drug-induced fever plus eruption in 7. The causative drugs suggested by the clinical course or DLST were RFP in 30 patients and INH in 16. The clinical effects of desensitization therapy for individual drugs was good in 23 of 30 patients (77%) receiving RFP, and in 13 of 16 (81%) receiving INH. Ten patients showing failure of desensitization included 5 elderly patients and 2 patients with a history of drug allergies. The interval until initiation of desensitization therapy ranged from 5 to 30 days after the disappearance of adverse reactions and the interval until the appearance of adverse reactions during desensitization therapy ranged from 3 to 18 days. A comparative study between the patient group with successful desensitization therapy and that with failure of desensitization did not show any significant differences except for the interval until initiation of desensitization therapy. CONCLUSION: We confirmed the clinical effectiveness of desensitization therapy for anti-mycobacterial drugs according to the propositions of JST in this multicenter study.

[Evaluation of the diaphragm in patients with COPD (emphysema dominant type) by abdominal ultrasonography].

UNLABELLED: The aim of this study was to clarify whether the diaphragm in patients with COPD (emphysema dominant type) can be evaluated by abdominal ultrasonography. We therefore established a method for diaphragm scanning: The dome of the right hemidiaphragm was detected by epigastric right oblique scan passing through the right edge of the inferior vena cava and the zone of apposition. Diaphragmatic flattening, correlation between the flattening and %FEV1.0, diaphragmatic motion, and the inspiratory time cycle were also measured. We studied 14 patients with COPD (emphysema dominant type) and 12 healthy control subjects. RESULTS: (i) Diaphragmatic flattening was recognized in patients with COPD and the radius of the right hemidiaphragmatic curvature (index of diaphragmatic flattening) correlated with %FEV1.0. (ii) Motion of the anterior diaphragm was poor in patients with COPD. (iii) Expiration time was prolonged in patients with COPD. CONCLUSION: Flattening and motion of the diaphragm, as well as the prolonged expiratory time were possible to evaluate by abdominal ultrasonography. Diaphragmatic flattening reflects %FEV1.0. Based on these observations we believe that abdominal ultrasonography may be useful to avoid underdiagnosis of COPD.

Significance of serum uric acid in patients with chronic respiratory failure treated with non-invasive positive pressure ventilation.

PURPOSE: The aim of the study was to evaluate serum uric acid (UA) levels before and after non-invasive positive pressure ventilation (NPPV) to assess the utility of serum UA as an indicator of acute exacerbation of chronic respiratory failure (CRF) in patients treated with NPPV. METHODS: We analyzed change in the serum UA level in 29 patients with CRF due to restrictive thoracic disease and treated with NPPV. RESULTS: After NPPV therapy, PaO2 was significantly increased and PaCO2 was significantly decreased in all patients. Sixty-two percent of patients (18 of 29) showed a decreased serum UA/creatinine (Cr) ratio after NPPV therapy, but, overall, there was no significant change in serum UA/Cr (P=0.0688). The change in serum UA/Cr was not correlated with the changes in PaO2 and PaCO2 after NPPV. When we compared patients in whom serum UA/Cr decreased (n=18) with patients in whom serum UA/Cr did not decrease (n=11), there were significantly fewer patients who suffered CRF exacerbation in the group with a decrease (P=0.0021). Furthermore, the cumulative proportion (Kaplan-Meier) of patients who did not suffer exacerbation of CRF was significantly higher in the group in which serum UA/Cr decreased (P=0.0003). CONCLUSIONS: Our data suggest that serum UA may be a useful clinical indicator of CRF exacerbation in patients treated by NPPV.

[Central diabetes insipidus caused by pituitary metastasis of lung cancer].

A 71-year-old man was admitted with high fever, thirst, polyposia and polyuria. After examination, lung cancer (adenocarcinoma T1NOM1, Stage IV) and central diabitus insipidus caused by pituitary metastasis of lung cancer, were diagnosed. We gave him desmopressin acetate, gamma knife surgery for pituitary metastasis and chemotherapy with paclitaxel and carboplatin, and his symptoms improved. However, his lung cancer progressed. Diabitus insipidus caused by lung cancer is rare.

[Cardiogenic oscillation--utility of classifying types of sleep apnea].

Cardiogenic pulse waves that travel along the airway wall are captured as airflow variations synchronized with the electrocardiogram at the airway exit. We have used airflow variations caused by cardiogenic pulse waves (hereinafter referred to as cardiogenic oscillation) to classify types of sleep apnea. Pulse waves do not travel downstream if there is an airway obstruction or choke point (wave speed theory). Thus, cardiogenic oscillation was detectable in central apnea or hypopnea, but not in obstructive apnea. In mixed-type sleep apnea, cardiogenic oscillation disappeared, and thus airway obstruction was judged to have occurred, during central sleep apnea. It was thought that obstructive sleep apnea followed central sleep apnea because there was an airway obstruction, although respiratory effort resumed after the end of central sleep apnea. The pattern of mixed-type sleep apnea was understood from the observation of cardiogenic oscillation. Cardiogenic oscillation is useful for not only classifying types of sleep apnea but also for detecting an airway obstruction.

[Diagnostic key-point of the pulmonary tuberculosis].

I have been engaged in the diagnosis and treatment of pulmonary tuberculosis for about 25 years. I have presented many interesting tuberculosis cases such as cavity, nodule, infiltration, miliary pattern, and bronchial tuberculosis. I summarized that the key point of the diagnosis for pulmonary tuberculosis is, 1) X-ray diagnosis shows no specific findings, so it is important to remind pulmonary tuberculosis as not unusual disease. I will make a proposal to insert pulmonary tuberculosis in the guideline for the diagnosis of pneumonia by the Japanese Respiratory Society. 2) Sputum PCR examination is very rapid and useful diagnostic method. The diagnostic evaluation of PCR is equal or over that of AFB culture. 3) CT diagnosis is useful for the detection of minimal pulmonary shadow or cavity lesion. 4) Brocho-fiberscopic examination is useful for the detection of the Mycobacterium in the bronchial brushing smear or washing samples. We should suspect bronchial tuberculosis in the cases with strongly positive sputum smear without cavity shadow. 5) The rate of complication with diabetes mellitus is significantly higher than that of 10 years ago in adult male tuberculosis patients. Recently 1 of 4 patients complicated with diabetes mellitus in adult male patients.

[Remission of pulmonary alveolar proteinosis during antituberculosis chemotherapy].

The patient was a 32-year-old man in whom pulmonary tuberculosis had occurred 5 years after the presumptive onset of pulmonary alveolar proteinosis. A diagnosis of pulmonary tuberculosis was made by sputum smears positive for acid-fast bacilli. Computer tomography of the chest showed ground glass opacities, consolidation and cavitation. Rifampicin, isoniazid and ethambutol were given daily, and streptomycin three times a week. Serial chest radiographs revealed progressive clearing not only of the new but also of the old lung infiltrates thought to be due to pulmonary alveolar proteinosis. Serum LDH and CEA returned to normal values. This case indicates the possibility of improving pulmonary alveolar proteinosis by tuberculosis infection or antituberculosis therapy.

[A case of tomato juice-induced oral allergy syndrome in which dyspnea onset occurred during the season of Japanese cedar pollen dispersion].

A 42-year-old-man with a history of Japanese cedar pollinosis repeatedly visited the emergency clinic due to dyspnea during the season of Japanese cedar pollen dispersion. Before each onset of this symptom, he had always drunk tomato juice. Swelling of the oral and nasal mucosa, and congestion of the bulbar conjuctiva was observed. No audible wheezing was present. His pulmonary function test results were normal (FEV 1.0 = 4.02 L, %FEV 1.0-124%, negative reversible test). The CAP RAST scores were 4 for tomatoes and 3 for Japanese cedar pollen. A result was obtained in a challenge test using tomato juice. Since tomato juice was involved in the development of the symptoms, a diagnosis of oral allergy syndrome induced by tomato juice was made. When tomato juice consumption was avoided, no symptoms developed. A common antigenicity was found between tomatoes and Japanese cedar pollen. This may be associated with the development of this allergy during the dispersion season of Japanese cedar pollen. The dyspnea may have reflected a feeling of pharyngeal narrowing which is a symptom of oral allergy syndrome. The possibility of oral allergy syndrome as the chief complaint should be considered also in patients with dyspnea. This is the first reported case of oral allergy syndrome induced by tomato juice.

[Effect of combined chemotherapy following the guidelines on treatment for Mycobacterium avium complex pulmonary disease].

We retrospectively investigated the clinical appropriateness of combined chemotherapy following the Japanese Society for Tuberculosis guidelines corresponding with those of the American Thoracic Society guideline for MAC pulmonary disease including a comparison with the past treatment for MAC pulmonary disease. The subjects of this study were 159 patients at several hospitals surveyed by the Chugoku-Shikoku Research Committee on Mycobacterium who were diagnosed as having MAC pulmonary disease between April 1995 and March 2001. Among them, 102 patients were treated using a regimen of antituberculous drugs with CAM, 33 patients received antituberculous drugs without CAM, and 24 patients were treated using other regimens. With a regimen of antituberculous drugs plus CAM, the sputum conversion rate was 45.1%, the relapse rate was 39.1% and clinical improvement was obtained in only 29.4%. On a regimen of only antituberculous drugs, the sputum conversion rate was 30.3%, the relapse rate was 70.0% and clinical improvement was obtained in 12.1%. Among the 102 patients receiving the regimen of antituberculous drugs plus CAM, 41 patients were treated with RFP, EB, SM and CAM following exactly the guidelines. The sputum conversion rate was 58.5%, the relapse rate was 37.5% and clinical improvement was obtained in 36.6%. Among 61 patients treated with other antituberculous drugs plus CAM, the sputum conversion rate was 36.1%, the relapse rate was 40.9% and clinical improvement was obtained in 24.6%. The clinical effect of the combined chemotherapy (RFP, EB, SM and CAM) was better than that of the other regimens throughout this study. However, the efficacy of this combined chemotherapy was unsatisfactory compared with the clinical effect for pulmonary tuberculosis. Therefore, the development of new companion drugs for the disease with mycobacteria other than M. tuberculosis is needed.