[Evaluation of care for elderly pulmonary tuberculosis patients].

PURPOSE: To examine the clinical problem of elderly pulmonary tuberculosis patients. METHODS: Clinical findings of pulmonary tuberculosis in elderly patients, who admitted to our hospital from 2001 to 2003, were analyzed in their status, complication, treatment, and prognosis. RESULTS: There were 145 patients, and the early elders from 65 to 74 years old were 67, and the latter elders over 75 years old were 78. Most of the cases were treated by the standard tuberculosis treatment, but in the latter elders, less patients were treated by the short course treatment with PZA than the early elders. The rate of negative conversion of sputum culture was good in both the early and the latter elders who were able to continue treatment. But, the elderly pulmonary tuberculosis patients were severe status and their prognosis was in general not good. The elderly pulmonary tuberculosis patients needed frequent care continuously. Tuberculosis problem should be understood more correctly in the medical and the nursing facilities.

[A case of intractable hemoptysis originating from the branches of the right subclavian artery, successfully treated with arterial coil embolization].

A 30-year-old woman was admitted because of persistent and severe hemoptysis in November 2005. She had been given a diagnosis of interstitial pneumonia (IP) and pulmonary aspergilloma in 2001, and she was treated with oral prednisolone and itraconazole. However she had persistent and intractable hemoptysis. Multi-detector row computed tomography (MDCT) revealed that hemoptysis from the right upper lobe did not originate in bronchial arteries, but the abnormal branches of the right subclavian artery. Surgery was not performed because of her pulmonary function, but she was successfully treated by non-bronchial arterial coil embolization. At 10 months after the embolization, hemoptysis has not recurred. MDCT was very useful for diagnosing the cause of hemoptysis and selective nonbronchial arterial coil embolization might be helpful in treating intractable or refractory hemoptysis.

[Outbreak of pulmonary tuberculosis in which tuberculosis developed from QuantiFERON-TB second generation (QFT-2G) test negative persons].

PURPOSE: To clarify the points to be considered when QFT-2G tests are used in the contacts examination by public health center. OBJECT & METHOD: We analyzed the results of contacts examination on 43 workplace colleagues (39 y/o and younger) of a pulmonary tuberculosis patient (bII2, Gaffky 9, cough for 1.5 months). RESULTS: After two months of the last contact with the index case, tuberculin skin tests, QFT-2G tests and chest X-rays were undertaken. After 6 months, chest X-rays were taken, and after 9 months, QFT-2G tests and chest CT scans were also undertaken. The tuberculin skin tests after two months showed a bimodal distribution, and 10 were QFT-2G positive and 2 showed doubtful reaction. The latter 12 persons underwent chemoprophylaxis. After 6 months, however, out of 31 QFT-2G negative persons, 2 developed pulmonary tuberculosis. Moreover, after 9 months, chest CT scans revealed 5 pulmonary tuberculosis patients. Three out of 7 new patients showed positive or doubtful reactions in QFT-2G tests undertaken after 9 months. DISCUSSION AND CONCLUSION: The sensitivity of QFT-2G tests is reported to be 80 to 90%, and the possibility of false negative is not negligible. We propose measures for public health center to conduct the contacts examination as follows; In case of high QFT-2G positive (including doubtful reaction) rate and/or a bimodal distribution of tuberculin skin test result, many infected persons are likely to be included in the group; and the following measures are recommended; 1) Necessity of chemoprophylaxis should be judged considering both tuberculin skin test results and the situation of contact with the index case, and not only by QFT-2G test results. 2) QFT-2G negative persons also need to be followed with chest X-rays.

[Tuberculosis of the sternoclavicular joint].

Tuberculosis is seen in every part of the body, but sternoclavicular joint tuberculosis is rare. We report a case of tuberculosis of the sternoclavicular joint in 70-year-old woman having complained of the right sternoclavicular joint swelling. She had a previous history of pulmonary tuberculosis, and visited her doctor for right sternoclavicular joint swelling on February 2006. A chest CT scan showed a low density area with destructive osseous changes in the right sternoclavicular joint. Definite diagnosis could not be done by twice needle biopsy, but we diagnosed her as tuberculosis of the sternoclavicular joint based on the clinical course and the findings of the examination. As her condition did not improve after 3 months treatment with anti-tuberculous drugs, we conducted therapeutic surgical procedure. Definite diagnosis of sternoclavicular joint tuberculosis was made on the basis of the presence of mycobacteria in the histological specimen and PCR-TB positive result. We kept the wound opened and continued administration of anti-tuberculous drugs, and her condition does not deteriorate. Tuberculosis should be considered in case of a patient with arthritis and previous history of tuberculosis, even if it is seen in rare location. Diagnostic and therapeutic surgical procedure should be taken into consideration, if there is no improvement of the condition after a diagnosis of bone and joint tuberculosis, and the administration of chemotherapy for tuberculosis.

[Case of disseminated tuberculosis complicated with tuberculous meningitis while investigating an abdominal lymphadenopathy].

In February 2005, a 33-year-old man visited A hospital complaining of fever. The blood screening test revealed the liver dysfunction, then computed tomography showed swelling of abdominal lymph nodes. In April, headache and disorientation appeared. He was diagnosed as disseminated tuberculosis and tuberculous meningitis based on chest X-ray and computed tomography findings and examination of cerebrospinal fluid. After admission to our hospital, anti-tuberculous drugs were prescribed, but the cerebral infarction happened. The disturbance of consciousness and the left half of his body paralysis appeared. They did not improve and hydrocephalus was complicated in August, though he was treated by steroids. He needed all helps because of the left half of his body paralysis and an advanced sequelae was left. It was thought that the abdominal lymph adenopathy preceded as one of symptoms of the disseminated tuberculosis in this case. It is said to be rare that abdominal lymph node swelling is seen in the early stage of disseminated tuberculosis. But, we think that it is necessary to keep in mind that the possibility of disseminated tuberculosis as one of the diseases in differential diagnosis, when we examine enlargement of abdominal lymph nodes with symptoms suggesting the presence of infection such as fever.

[Clinical review of patients with pulmonary tuberculosis who were detected by the screening of homeless persons admitted in the shelter facilities].

PURPOSE AND METHODS: There has been a recent increase in the number of non-profit facilities that provide shelter for the homeless. These social service facilities aim to assist the social rehabilitation of homeless persons. The Public Health Center of Chiba City screened 1,054 residents of these homeless shelters between November 2002 and August 2004 and found 17 individuals (1.6%) with active pulmonary tuberculosis. We clinically reviewed these cases. RESULTS: All 17 individuals were male, and their ages ranged from 44 to 70 years (mean 54.9 years). Four cases were smear positive and three cases were smear negative but culture positive by sputum examination for acid-fast bacilli. Nine cases had cavitary lesions on chest X-ray. There were three cases complicated with hepatitis C, two cases with diabetes mellitus and two cases with past history of gastrectomy. Of the 17 individuals, 13 were treated as inpatients, and four as outpatients. The mean hospitalization duration was 146.7 days excluding two patients who were discharged by themselves. Of the 11 inpatients, four remained hospitalized until the completion of treatment. Final outcome of the treatment was the following; 12 patients were cured, while five patients dropped out or discontinued treatment. CONCLUSION: The screening performed by the Public Health Center of Chiba City revealed a very high prevalence of tuberculosis among shelter residents. Thus, in the future, public health centers and medical institutions must work in collaboration to actively screen and provide treatment for residents of homeless shelters. This study also revealed that in spite of recommended hospitalization or long-term treatment, patients often self-discharged or discontinued regular outpatient treatment. Health centers and other public agencies must therefore work in close cooperation to help the homeless to continue hospitalization and subsequent medication and treatment even after their discharge from hospital.

[Current situation of contacts examination and chemoprophylaxis for persons exposed to multi-drug resistant tuberculosis in ordinance-designated cities in Japan].

PURPOSE: To evaluate the current situation of contacts examination and chemoprophylaxis for those who were exposed to multi-drug resistant tuberculosis (MDR-TB) in Japan. OBJECT AND METHOD: The questionnaire survey was conducted about the MDR-TB patients and their contacts examination enforced in the ordinance-designated cities in Japan from 1998 to 2002. RESULT: Nine cities out of total 13 ordinance-designated cities replied to the questionnaire (69.2%). The cases newly diagnosed as MDR-pulmonary tuberculosis were 189 cases from 1998 to 2002. Out of 189 cases, 34 MDR pulmonary tuberculosis patients were the source of MDR-TB infection. Among 659 individuals who were exposed to 34 MDR-TB, 58 persons (8.8%) were diagnosed as the contacts who were infected with MDR-TB. Out of 58 persons, 41 had chemoprophylaxis; 18 with isoniazid (INH), 3 with Ethionamide (TH), 2 with INH + Rifampin (RFP) + Ethambutol (EB), and each one with EB + Pyrazinamide (PZA) + TH, PZA + TH, PZA + Levofloxacin, PZA + EB. In 6 persons, INH was changed to other medicines, and 8 persons were treated with unknown prescription. Thirteen contacts developed MDR-TB, and out of them, 9 cases had several problems when they developed MDR-TB. Those problems were the delay in detection, infection from hospitalization refused cases, infection at the time of bacteriological relapse, and no use of chemoprophylaxis. CONCLUSION: MDR-TB bacilli produce the tuberculosis infection similarly as the sensitive tubercle bacilli, and it is necessary to re-examine the action plan of contacts examination including chemoprophylaxis.

[A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis].

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.

[A study on cases developed pulmonary tuberculosis after receiving gastrectomy].

OBJECTIVE: Patients who had undergone gastric resection are considered to be high risk of developing tuberculosis. We investigated the factors leading to pulmonary tuberculosis after gastrectomy. MATERIALS AND METHODS: We retrospectively examined 654 pulmonary tuberculosis patients discharged from Chiba-East National Hospital from January 1999 to December 2001. RESULTS: Fifty-five patients (31-84 years old, mean 63.5 +/- 12.5 years, 48 males and 7 females) had the history of gastric resection. The proportion of patients receiving gastrectomy among patients with pulmonary tuberculosis was 8.4 percent. The mean age of patients received gastric resection was 50.2 +/- 16.6 years, and the mean interval from gastrectomy to the development of pulmonary tuberculosis was 13.6 +/- 11.0 years. On admission to our hospital, 34 out of 55 cases were smear positive by sputum examination for acid-fast bacilli and 39 cases had cavitary lesions on chest X-ray. Gastrectomy was done due to carcinoma of the stomach in 31 cases, peptic ulcer in 21 cases, adenomatous polyp in two cases, and accidental injury in one case. Out of total 55 cases, 52 patients improved, but three cases died of pulmonary tuberculosis. None had the recurrence of carcinoma of the stomach. Body weight, Body mass index, Prognostic nutritional index (PNI; 10 x serum albumin concentration + 0.005 x peripheral lymphocyte count) which was proposed by Onodera, serum albumin level and serum total cholesterol level were lower in the gastrectomy group than in the non-gastrectomy group. The odds ratio of developing tuberculosis among gastrectomy patients compared with the appropriate controls in 30 to 59 year-old-men was 3.8. CONCLUSION: This study confirms that gastrectomy is one of the risk factors of developing tuberculosis in 30 to 59 year-old-men. However, whether gastrectomy in itself is a risk factor or whether it is secondarily associated with another risk factor such as underweight status and/or inadequate nutrition following surgery remains unclear.

[A study on pulmonary tuberculosis retreatment cases].

OBJECTIVE: To investigate the factors leading to the retreatment for tuberculosis. MATERIALS: Forty-seven retreatment cases with pulmonary tuberculosis, who were discharged from the National Chiba Higashi Hospital from 2000 to 2002. METHODS: Data on all retreatment cases were studied as to the condition of the original treatment and factors leading to the retreatment. RESULTS: Of the 47 cases, 33 cases received the original treatment in our hospital. Of the 33 cases, 24 cases were relapsed cases and 9 cases were defaulters. Most relapsed cases were male aged 50s and 12 cases (50%) were jobless. As the factors leading to retreatment, the delay in the negative conversion of sputum culture accounted for 11 cases (45.8%) out of 24 cases. No specific factors were found in three cases (12.5%). Among the defaulters, no bias was seen as to age and occupation of cases, but all the cases were male, and they defaulted during the maintenance phase of treatment at the out-patient department. CONSIDERATION: The delay in the negative conversion of sputum culture was the main factor relating to the relapse. Diabetes mellitus (DM) is one of the factors leading to the relapse, but many factors were observed in DM patients. Male cases aged 50s had many factors leading to the relapse. An intensive management for out-patients and involvement of welfare department aiming at the completion of treatment for the socially vulnerable groups might be necessary as the measure to prevent defaulting. CONCLUSION: The delay in the negative conversion of sputum culture was the main factor leading to relapse, and intensive management for out-patients aiming at the completion of treatment is necessary to prevent the defaulting.

[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 far-advanced cavitary pulmonary tuberculosis cases].

In cases with far-advanced cavitary pulmonary tuberculosis, the most serious lesions according to the chest X-ray classification by the Japanese Society of Tuberculosis (b I 3), their prognosis is believed to be poor due to their emaciated general conditions, and a retrospective clinical study was made on these cases admitted to our hospital. The subjects consisted of 95 cases, and among them 87 were male and 8 were female, and their mean age was 49.5 +/- 13.0 years. Eighty four cases were detected by symptomatic visits to clinics, 10 cases during their treatment for other diseases, and 1 case was discovered accidentally. Sputum examination for acid fast bacilli was all smear positive. As to their social background, the majority were occupied by socially vulnerable groups; 31 cases (32.6%) were jobless on admission, 24 cases (25.3%) were day laborers, and 25 cases (26.3%) were receiving poor relief. Regarding their general condition on admission, 40 cases were very serious and they could not stand by themselves, and their nutritional conditions were poor, and 19 cases (20%) died during hospitalization. All of them were male, and they were found by symptomatic visit to clinics. The period from hospital admission to death was short, the average was 35.0 +/- 39.8 days, and the median was 11.0 days. Among 84 patients detected by symptomatic visit, the patient's delay was 5.5 +/- 5.0 months, while the doctor's delay was 0.3 +/- 0.9 months. Major cause of late detection at advanced stage of these cases was patient's delay which caused poor prognosis of these cases, and various measures to shorten the delay in case-detection must be taken.

[Clinical review of pneumothorax cases complicated with active pulmonary tuberculosis].

Pneumothorax is an important and dangerous complication of pulmonary tuberculosis. Forty-six pneumothorax cases complicated with active pulmonary tuberculosis at National Chiba-Higashi Hospital were studied retrospectively. From Jan. 1987 to Dec. 1997, we experienced 3611 patients with pulmonary tuberculosis, and among them 46 patients (18-90 years old, 38 males and 8 females) had pneumothorax. On admission, 33 out of 46 cases (71.7%) were smear positive by sputum examination of mycobacteria and 41 out of 46 cases (89.1%) had cavitary lesions on chest X-ray. Eleven cases had mild pneumothorax, thirty-two had moderate, and three had severe. Pneumothorax was present on admission in 23 patients and developed during treatment for tuberculosis in the other 23 patients. Eleven patients were treated with bed rest alone, four were thoracentesis and aspiration, twenty-four were intrathoracic tube drainage and seven were operated. Thirty-one patients were recovered, but fifteen passed away, among them 13 due to respiratory failure. The Prognostic nutritional index (PNI; 10 x serum albumin concentration +0.005 x peripheral lymphocyte count) which was proposed by Onodera, serum albumin level and Body mass index were lower in the fatal group than in the survival group. We consider these indices are useful to evaluate the prognosis of active tuberculosis patients complicated with pneumothorax.

[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.