Metabolic activity in skeletal muscles of patients with non-hypoxaemic chronic obstructive pulmonary disease studied by 31P-magnetic resonance spectroscopy.

OBJECTIVE: An alteration of high energy phosphate metabolism in muscles may contribute to exercise intolerance. The objective of this study was to clarify the changes in high energy phosphate metabolites in muscles during exercise in patients with non-hypoxaemic chronic obstructive pulmonary disease (COPD), which influences the impairment of muscle metabolism. METHODOLOGY: Calf muscle energy metabolism was studied in eight stable non-hypoxaemic COPD patients and eight control subjects, using 31P-magnetic resonance spectroscopy (MRS). MRS spectra were acquired at rest, during exercise at two levels of intensity, and during recovery. The control subjects exercised under both normoxic and hypoxic conditions. The intensity of exercise was standardized by the maximal isometric voluntary contraction (MVC) of the calf muscle and the cross-sectional area (CSA) of calf muscle. RESULTS: MVC and CSA were lower in COPD patients. No significant differences in intracellular pH, inorganic phosphate/phosphocreatine ratio or percentage recovery in inorganic phosphate/phosphocreatine ratio were observed between the two groups in muscles at rest, during exercise or during recovery. CONCLUSIONS: Muscle metabolites, during exercise standardized by muscle CSA and MVC, did not differ between non-hypoxaemic COPD patients and control subjects. MVC, CSA or both, are assumed to be closely related to muscle metabolism, as no difference in high energy phosphate metabolites was observed for COPD patients compared to control subjects when the load was standardized for MVC and CSA. This suggests that high energy metabolites are consumed to a similar extent in the same muscle volume in non-hypoxaemic COPD patients and control subjects.

[A case of perforative peritonitis complicated with lung and intestinal severe tuberculosis].

A 27-year-old man was admitted to our hospital in September 18, 2000, complaining of fever, cough, appetite loss and body weight loss. He was diagnosed as advanced lung tuberculosis, because of chest X-ray findings and positive acid-fast bacilli in his sputum. He was administrated rifampicin (RFP), isoniazid (INH) and ethambutol (EB). Two days after starting treatment he complained of abdominal pain and the signs of perforating peritonitis. Emergency laparotomy was performed and we observed multiple ulcers and a perforation of ileum. We resected a part of distal ileum and ascending colon and made ileostomy. Histopathologic examination of resected ileum and colon showed multiple ulcers and epithelioid cell granulomas with caseous necrosis. Many acid bacilli were identified from the lesion by specially stained tissue sections. He was administrated streptomycin and INH by injection post-operatively while oral administration was impossible. Six days after the first operation, we found the signs of perforation in another part of the ileum. So we were obliged to perform second laparotomy and resect the part involved. Five days after the second operation, he was able to take RFP, INH, and levofloxacin per oral route. On February 8, 2001 we performed ileocolonal reconstruction with side to side anastomosis and closed ileostomy at the third laparotomy. He had continued chemotherapy and went back to Korea in April 7, 2001. Although intestinal tuberculosis has sharply declined in Japan thanks to development of effective antituberculous drugs, we should keep in mind that it could be a possible cause of the acute abdomen.

[A study on low performance status cases of pulmonary tuberculosis in the elderly].

The subjects consisted of 42 patients aged over 60 years, whose performance status (PS) was grade 3 or 4, and who had been admitted for pulmonary tuberculosis at National Chiba-Higashi Hospital between 1997 and 1998. The average age (+/- SD) of the 34 men and 8 women was 77.6 (+/- 8.5) years (range, 60-91 years). The mean stay in the hospital of the improved patients was 166.6 days (range, 57-303 days), and the mean survival period from admission to death was 43.4 days (range, 2-179 days in died patients). On admission to our hospital, 26 cases were sputum smear positive, 8 cases were smear negative and culture positive, and 8 were negative both on smear and culture. The cavity was observed in 30 cases (71.4%) on the chest X-ray. The laboratory data on admission revealed low nutritional condition. The mean serum total protein, albumin, and cholesterol level on admission were 6.2 (+/- 0.82) g/dl, 2.7 (+/- 0.62) g/dl, and 143.0 (+/- 41.9) mg/dl. Most of the patients had a difficulty in taking foods, and 20 cases (47.6%) were performed parenteral nutrition by central venous catheter. 23 cases (54.8%) received oxygen therapy by facial mask or nasal tube. The most common cause of low PS on admission was pulmonary tuberculosis in 14 cases (33.3%), followed by cerebrovascular diseases in 11 cases, and orthopedic disease in 8 cases. The proportion of patients whose cause of low PS was not due to lung tuberculosis increased with age. Observing the mortality by the route of administration of antituberculosis medications on admission, 19 (55.9%) of 34 cases who could take drugs per oral route died. One (50.0%) of 2 cases who were administered drugs through gastric tube died, and all (100.0%) of 5 cases who could not take drugs per oral route and were injected isoniazid and streptomycin died. One case who could not administer any drug died. 16 cases improved and 26 cases died, of whom the most common cause of death was pulmonary tuberculosis in 11 cases (42.3%), followed by bacterial pneumonia in 5 cases, and cerebrovascular disease in 3 cases. The mortality by the PS on admission were as follows: 10 (47.6%) of 21 cases with PS 3 died. 16 (76.2%) of 21 cases with PS 4 died. 16 (6.4%) of 249 cases aged over 60 years with PS 0, 1 or 2, and were admitted for pulmonary tuberculosis at the same hospital during the same period died. This study confirms that the prognosis of low performance status patients of pulmonary tuberculosis in the elderly was significantly poor. We have to detect tuberculosis patients in the early stage, and give them antituberculosis medications per oral route as far as possible.