[A case of multidrug-resistant pulmonary tuberculosis cured by the regimen including thiacetazone].

A 30 years-old-male was referred to our hospital for surgical treatment of multidrug-resistant tuberculosis in April 1998, three years after diagnosis of tuberculosis. All first-line anti-tuberculosis drugs and second-line anti-tuberculosis drugs were resistant on drug susceptibility tests by Ogawa medium. The right upper lobectomy was done because of massive hemoptysis and enlargement of cavitary lesion in June 1998, but this surgical operation was complicated with, bronchial fistula and chronic empyema. Open drainage surgical treatment for chronic empyema was done one month after lobectomy. Sputum culture for M. tuberculosis converted 4 months after the lobectomy, but bacteriological relapse occurred 17 months after initial operation. The new cavitary lesion on middle left lung field developed and sputum smear and culture were continuously positive. Immunotherapy with interferon-gamma via aerosol didn't show any clinical effect. Thiacetazone, sparfloxcin, pyrazinamide, cycloserine was prescribed after 21 months of the initial operation. Four months after changing the regimen sputum smear and culture converted to negative. Chemotherapy was terminated in June 2003, two years after negative conversion. Three years after the termination of treatment no relapse occurred. We considered thiacetazone was effective in this case, because all of the drugs was companied with thiacetazone were resistant by the drug susceptibility tests and were previously used.

[Clinical studies on the pathogenetic factors of cavitary and nodular bronchiectatic types in pulmonary Mycobacterium avium complex disease].

We investigated the clinical, laboratory and radiological findings of 273 newly diagnosed cases of pulmonary Mycobacterium avium complex (MAC) disease, who were diagnosed in our hospital during 7 years from January 1996 to December 2002. Radiological findings of all cases were classified at the time of diagnosis into 2 patterns, the cavitary (Cav) type and the nodular bronchiectasis (NB) type. Clinical and laboratory findings at the time of diagnosis of 44 death cases were compared with those of 273 newly diagnoses cases, to analyze the prognostic factors of this disease. MAC disease cases showed a marked increase in number in recent years, but only in women. Mean age at the first visit was 65.7 years in men and 63.2 years in women, and when limited to fatal cases, it was 72.3 years in men and 69.4 years in women. Low body weight in terms of body mass index (BMI) and moderately low serum albumin level were found at the time of the first hospital visit in all the newly diagnosed and death cases. In the fatal cases, the peripheral blood lymphocyte counts revealed a relatively smaller number than the normal range, and the PPD skin test showed a negative reaction in 57.7% of all cases, suggesting the presence of lowered cell-mediated immunity at the time of diagnosis. Whether malnutrition occurs as a result of MAC disease or the individuals with lower nutrition level are easy to develop to MAC disease remains to be clarified. In regard to radiological findings, many cavitary (Cav) type cases were found in men and nodular bronchiectasis (NB) type in women among newly diagnosed cases, while the cavitary type was observed in many in both men and women fatal cases. The mean duration period from diagnosis to death was 28.3 months in men and 60.2 months in women, showing a longer survival after diagnosis, perhaps due to earlier hospital visits by women. The average age at death was 74.4 years old in men and 73.8 years old in women, and the two radiological patterns did not change throughout the entire disease course.

[Pulmonary Mycobacterium avium complex disease showing nodular bronchiectasis--: pathological findings in two cases].

Histopathological examinations were carried out on 2 cases of Mycobacterium avium complex (MAC) disease of nodular bronchiectasis (NB) type on radiograms. The removed lung specimens revealed histological findings of granulomatous bronchiolopneumonia, consisting of epithelioid cell granulomas with lymphocytic infiltrations without exudation in the alveolar areas surrounding the respiratory bronchiole. The central bronchiolar walls were also affected by epithelioid cell granulomas with lymphocytic infiltration, occasionally showing polypoid protrusion into the bronchiolar lumen accompanying emphysema in the peripheral alveolar area. Bronchial lesions seemed to progress from peripheral to central airway with consequent atrophy and disappearance of intramural smooth muscles, resulted in bronchioloectasis. These histological findings well correspond to radiographical 'nodular bronchiectasis'. Large histiocytic granulomas without caseous necrosis developed in some area, which are not usually found in tuberculosis lesions. Epithelioid cell granulomas were occasionally found in the hilar lymph nodes as well as in the walls of lymphatic vessel in the pulmonary interlobular tissues, indicating intrapulmonary lymphatic spread of the mycobacteria.

[Pulmonary Mycobacterium avium complex (MAC) disease showing middle lobe syndrome--pathological findings of 2 cases suggesting different mode of development].

Two different processes have been proposed for pathogenesis of Mycobacterium avium complex (MAC) disease which show the middle lobe syndrome: 1) middle lobe bronchiectasis followed by MAC infection and 2) MAC disease resulted in secondary bronchiectasis. Two surgical specimen from MAC cases showing middle lobe syndrome were studied histo-pathologically. The first case was a 60 year-old female with frequent bloody sputum, who had been diagnosed as bronchiectasis in her childhood. Pathological examination of the resected middle lobe showed prominent cylindric bronchiectasis in the indurated middle lobe, and epithelioid cell granulomas were scattered limited to the fibrous bronchial walls, without any granulomas in the lung parenchyma. These findings suggested a secondary infection of MAC to the non-specific pre-existed bronchiectasis. The second case of a 55 year-old female having repeated bloody sputum, who was diagnosed to be tuberculosis but no improvement with anti-tuberculosis drugs. Pathological examination of the middle lobe showed scattered epithelioid cell granulomas with lymphocytic infiltration in the lung parenchyma. A few epithelioid cell granulomas were also found in the mucosa of middle lobe bronchi. In this case, pulmonary MAC lesions seemed to precede the central bronchial lesion with later development of bronchiectasis. Summarizing above findings two different mode of pathogenesis ways may be considered; one is non-specific bronchiectasis followed by middle lobe MAC disease and the other is pulmonary MAC lesion in the middle lobe as a primary change.