[A case of pyothorax caused by Mycobacterium avium].

A 74-year-old woman was admitted to our hospital in December, 2003 because of anorexia and weight loss lasting from August, 2003. Chest CT scan showed empyema with a niveau in the right lung and infiltrative and nodular shadows in the left lung. Acid-fast bacilli were detected in pleural effusion. Polymerase chain reaction (PCR) test was negative for Mycobacterium tuberculosis (M. tuberculosis) but positive for Mycobacterium avium (M. avium). PCR test for M. avium was also positive in bronchial lavage fluid, and many colonies of M. avium complex ( MAC) were cultured from pleural effusion. After we administered 4 drugs including RFP, EB, SM, and CAM, cultured colonies of M. avium decreased, the inflammatory reaction improved, and infiltrates in the left upper lobe has disappeared. These improvements confirmed the diagnosis of empyema caused by M. avium. Since nontuberculous mycobacteria induced empyema has rarely been reported, the clinical features of this disease should further be examined.

[Case of pubic tuberculous osteomyelitis and pericarditis during anti-tuberculosis chemotherapy].

56 year-old man was referred to the department of orthopedics in our hospital for further investigation on right inguinal pain. The patient was initially diagnosed as bacterial myelitis in right pubic bone and was treated with antibiotics. Since his symptom did not improve, the curettage was performed. Histological examination of the pubic bone obtained during the operation showed epithelioid cell granulomas with caseous necrosis, supporting the diagnosis of tuberculous osteomyelitis. Chest X-ray film revealed small nodular lesions in both upper lung fields. Sputum was positive for acid-fast bacilli and Amplified Mycobacterium Tuberculosis Direct Test (TB-MTD) was positive. The diagnosis of pubic tuberculous osteitis and pulmonary tuberculosis was confirmed. Specimens from the pubic bone and sputum were both culture positive for Mycobacterium tuberculosis, and bacilli were sensitive to anti-tuberculosis drugs. The antituberculosis chemotherapy was started with INH, RFP, SM and PZA. Symptoms had gradually improved, however 3 months after starting treatment, high fever developed and chest X-ray revealed heart enlargement and bilateral pleural effusion. Pericardial effusion showed exudative nature with lymphocyte predominancy and high level of ADA, 98.4 U/l. Pleural effusion was transudate. TB-MTD and culture were negative both in pericardial and pleural effusion. Paradoxical reaction was thought to be the cause of pericarditis. TB chemotherapy was continued and pericardial drainage was performed. One month later, fever improved, and pleural effusion and pericardial effusion disappeared. Transient elevated transaminase was observed, and was thought to be the side effect of anti TB drugs. All symptoms gradually improved, and he was discharged after 6 months TB chemotherapy.

[Pulmonary empyema 48 years after Lucite-ball Plomb implantation for tuberculosis].

A 68-year-old woman was diagnosed as having empyema on the left side. She had a history of pulmonary tuberculosis and tuberculous pleurisy in 1949. She was treated with artificial pneumothorax and implantation of 7 Lucite-ball plombs in the left upper thorax. A chest radiograph taken 14 years after initial operation, revealed an increase in density inside some of the Lucite-ball plombs. She was again admitted after experiencing fever and dyspnea 48 years after initial operation. The chest radiograph then showed a large mass on the left side, which compressed the mediastinum to the right. Inside the mass, Lucite-ball plombs were detected. The fever and inflammatory findings were improved with antibiotic therapy, but the dyspnea was persistent. The Lucite-ball Plombs and coagulating tissue were removed successfully. The patient's symptoms and respiratory function improved after the second operation.