A case of yellow nail syndrome with dramatically improved nail discoloration by oral clarithromycin.

An 80-year-old woman was admitted to our hospital with pneumonia and exacerbation of sinobronchial syndrome (SBS). She presented with yellow discoloration of the nail beds of all fingers and toes, and her nails were recognized as growing slowly. Chest X-ray revealed bronchiectasis in the bilateral lower lobe and bilateral pleural effusion. We diagnosed her as having yellow nail syndrome (YNS), based on the triad of yellow nails, lymphedema, and lung disease. After treatment with antibiotics [ampicillin/sulbactam and clarithromycin (CAM)] for pneumonia and SBS, her general condition improved, and the yellow nails disappeared in some fingers. When she was previously treated with 200 mg CAM for SBS, her yellow nails had not shown improvement. This time, her yellow nails improved after treatment with 400 mg CAM. The literature reports vitamin E, zinc, and topical corticosteroid plus active vitamin D3 to be effective in the treatment of yellow nails. Two studies have reported treatment for YNS using CAM, though they found a lack of efficacy. Thus, the present case is the first to report improved yellow nails using CAM alone. We conclude that not only SBS and lung disease but also YNS were improved by treatment with 400 mg CAM.

[Case of cavitary coccidioidomycosis with fungus balls in the apices of both lungs].

Pulmonary cavitary coccidioidomycosis with a fungus ball was observed in a immunocompetent case. A 32-year-old Japanese man visited Arizona to play golf. After 1 month he consulted a local hospital complaining of a prolonged cough and hematopysis. The laboratory examination revealed eosinophillia and chest radiograph showed 2 cavitary lesions, surrounded by small nodules in the apices of both lungs. Pulmonary tuberculosis was suspected and treated with 4 antituberculosis drugs for 3 months. However, the cavities enlarged and he was admitted to our hospital for further examination and treatment. Transbronchial lung biopsy was performed and serologically, bacteriologically and histologically a diagnosis of chronic coccidioidmycosis was made. It is very rare for fungus ball formation and coexistence of spherules and hyphae of Coccidioides immitis to be seen. Fluconazole was temporarily effective, causing cavities to shrink and eosinophilia to decrease, however Amphotericin B needed to be used later. Eosinophilia was closely related to the severity of the disease gravity.

[Effects of new discharge criteria incorporating DOTS on treatment outcome of patients with smear-positive tuberculosis].

BACKGROUND: Some problems remain in the treatment of tuberculosis (TB) in Japan, with a higher prevalence of TB, low percentages of completed therapy and cases given DOTS, and longer admission period compared to the United States. We defined our own new criteria for discharge as sputum smear negativity instead of culture negativity, modified according to CDC criteria with shortened admission periods. However, the effects on treatment outcome have not been evaluated. OBJECTIVES: The aim of this study was to ensure the effectiveness of the new criteria, including DOTS undertaken after discharge. PATIENTS/METHODS: Group I comprised 459 cases hospitalized between January 2000 and December 2002 that were discharged under the old criteria, while Group II comprised 259 cases hospitalized between January 2003 and April 2004 that were discharged under the new criteria. We tried to undertake DOTS in cooperation with local health centers. The main outcome measures were admission period, treatment completion and relapse rates at 1 year after the completion of treatment. RESULTS: The new criteria enabled median admission period to be shortened from 84 days to 69 days, although patients in Group II were older and displayed more severe tuberculosis lesions compared to Group I. DOTS coverage rate increased significantly from 5.9% to 40.5%, and treatment completion rate, percentage of lost cases and relapse rate for completed cases at 1 year changed from 83.0% to 86.6%, 6.3% to 3.9%, and 2.5% to 2.5%, respectively. No significant differences in these 3 rates were noted between Groups I and II. CONCLUSION: The new criteria incorporating DOTS enabled shortened admission period without any adverse effect on treatment outcomes.