[15 cases of pulmonary Mycobacterium scrofulaceum infection].

OBJECTIVES: We described clinical features of pulmonary Mycobacterium scofulaceum disease. MATERIALS AND METHODS: We described 15 cases of pulmonary Mycobacterium scrofulaceum infection admitted to National Hospital Organization Omuta National Hospital from 1989 to 2003 and reviewed the clinical feature, the findings of chest radiograph, and clinical course. RESULTS: Sex ratio was 8 male cases and 7 female cases, and the average age was 65.9 years old. Smoking history was found in 8 patients and occupational history of the dust inhalation was found in 7 patients with pulmonary M. scrofulaceum infection. There were 11 cases of tuberculosis-like form and 4 cases of nodular-bronchiectasis form according to the NTM Research society classification based on the findings of chest radiography. Improvement of the findings of chest radiography was seen in 4 patients by therapy, while no change or aggravation in 11 patients. Five patients died and among them, 3 died due to aggravation of pulmonary M. scrofulaceum infection. DISCUSSION: Cases showing tuberculosis-like form were dominant, and most of them showed extensive lesions when they were diagnosed, and these facts were considered to be major factors of difficulty in the treatment of this infection. The facts that 7 cases had occupational exposure to the dust, obstructive pulmonary disease in 3 cases, and 6 cases showed sputum culture positive for other nontuberculous mycobacteriosis, suggest that local resistance of lung might be attenuated, and this could be one of factors of onset and development of this infection. Only 4 cases showed improvement, while 5 cases died (primary disease death in 3 cases) and it was thought that the prognosis of the disease was in general poor.

[A case of follicular bronchiolitis preceding rheumatoid arthritis].

A 52-year-old woman was admitted to Yame General Hospital because of persistent cough, wheeze, and shortness of breath at age 48. Chest X-ray and computed tomography (CT) showed bilateral centrilobular shadows. Pulmonary function test revealed obstructive dysfunction. She also had chronic sinusitis. Initially, diffuse panbronchiolitis was diagnosed and she was given macrolides, but no improvement was observed. Thus video-assisted thoracoscopic lung biopsy (VATS) was performed in order to establish a definitive diagnosis. Histopathological findings were compatible with a diagnosis of follicular bronchiolitis. Treatment with corticosteroid (oral prednisolone, 50 mg/day) improved her condition. However, on reducing the steroid doze, her symptoms and chest X-ray film/CT findings became exacerbated. In addition, polyarthritis appeared. Further investigations revealed a diagnosis of rheumatoid arthritis. Only 2 cases of follicular bronchiolitis preceding rheumatoid arthritis have been reported in Japan.

Production of cytokines in patients with primary pulmonary Mycobacterium avium-intracellulare complex disease.

To clarify the immunological state of patients with pulmonary Mycobacterium avium-intracellulare complex (MAC) disease, we compared the production of IFN-gamma, IL-10 and TNF-alpha by peripheral blood mononuclear cells (PBMC) between MAC disease patients with different levels of disease activity and healthy volunteers. The patients had no complication of systemic immunological diseases or preexisting pulmonary diseases. PBMC obtained from 46 patients and 15 healthy control volunteers were incubated with a protein antigen extracted from Mycobacterium intracellulare (PPD-B) for seven days, and IFN-gamma, IL-10 and TNF-alpha concentration in the supernatant of the cultures was measured by enzyme-linked immunosorbent assay (ELISA). We categorized the patients into 3 groups based on the findings of chest radiography or results of sputum culture for MAC: group I in a stable state of the disease activity (15 patients), group II in an unstable state (16 patients) and group III in an active state of the disease (15 patients). IFN-gamma was low in all three patient groups compared to the healthy group. There was no difference of the concentration of IFN-gamma among the three patient groups. IL-10 was high in the patient groups compared to the healthy group, and the concentration of IL-10 in the patients of groups II and III was significantly higher than in the healthy group. Although the production of TNF-alpha in group I was significantly suppressed compared to the healthy group, the production of TNF-alpha was significantly elevated in groups II and III compared to group I. There was no difference in the production of these cytokines between the patients of group III with tuberculosis-like form and with nodular-bronchietasis form. These findings suggested that the Th1-type reaction in the patients with primary pulmonary MAC disease is suppressed (lower than the healthy persons) irrespective of the disease activity state and that the Th2-type reaction is increased in parallel with disease activity.

[A clinical study on cases with pulmonary M. avium complex (MAC) disease followed up for more than 10 years].

We performed a clinical study on 22 cases with pulmonary M. avium complex disease followed up for more than 10 years. The mean age of these patients at the first visit was 60.1 years old and the extent of the disease among them was minimum or moderate. The progression of the disease was relatively slow. There were 5 cases of tuberculosis-like type and 11 cases of nodular-bronchiectasis type among the primary infection type and 6 cases of the secondary infection type. Classifying these cases by the grade of progression on chest X-ray findings, 2 cases improved, 11 cases slightly progressed, 4 cases moderately progressed and 5 cases severely progressed. Seven cases of the nodular-bronchiectasis type of the primary infection type were observed among 11 slightly progressed cases. This suggested that the prognosis of cases with nodular-bronchiectasis type was relatively good. The frequency of a reaggravation of chest X-ray findings was significantly higher in the severely progressed cases than in the slightly and moderately progressed cases. Generally, the number of used drugs was more and the duration of treatment was longer in the severely progressed cases. This suggested that these cases were intractable. The results of sputum culture for M. avium complex were consistent with the progression of the disease shown on chest X-ray findings among many cases. However, sputum culture negative was observed in some cases with the nodular-bronchiectasis type in spite of the reaggravation on chest X-ray findings. On the other hand, there were some cases in which few reaggravation was observed in spite of continued sputum culture positive. Based on these results, we made some remarks on the treatment and management of pulmonary M. avium complex disease.

[A clinical study of deceased cases of pulmonary M. Avium complex (MAC) disease--: in contrast with survived cases followed-up for 5 years or longer].

We performed a clinical study of pulmonary M. avium complex (MAC) disease comparing decreased cases and survived cases followed-up for 5 years or longer. The results were as follows: 1. At the time of starting the initial medical treatment for pulmonary MAC disease, the deceased cases were older than the survived cases, and the deceased cases were severe than the survived cases in clinical conditions. The spread of the lesions was more extensive and cavities were more frequently observed in the deceased cases than in the survived cases. 2. We classified the clinical pattern of pulmonary MAC disease into a primary infection type and a secondary infection type. Then, we subclassified the primary infection type into a localized type, which contained a tuberculosis-like type and middle, lingular or other lobar pneumonia type, and a diffuse type. The secondary infection type was more frequent in the deceased cases than in the survived cases, and any middle, lingular or other lobar pneumonia type was not observed in the deceased cases. 3. We classified the mode of progression of pulmonary MAC disease in the deceased cases into a tuberculosis-like progression and a diffuse progression. The tuberculosis-like type and the secondary infection type frequently showed the tuberculosis-like progression and the diffuse type frequently showed the diffuse progression. The patients who showed the tuberculosis-like progression were frequently sputum culture positive for MAC, while all patients showing the diffuse progression were culture negative at the time of death. An interval from the estimated onset of the disease to death was shorter in the tuberculosis-like progression type than in the diffuse progression type.

[A case of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall].

A 61-year-old woman with schizophrenia that had been treated in a psychiatric hospital was admitted to our hospital because of subileus and back pain. Though subileus was improved, she had a sudden attack of fever 7 days later and developed right pleural effusion, a cold abscess in the anterior chest wall and swelling of a thumb-sized right cervical lymph node which broke through the skin. We made a diagnosis of cervical and mediastinal lymph nodes tuberculosis, tuberculous pleurisy, spinal caries and cold abscess in the anterior chest wall due to the biopsy findings of the specimen taken from the cervical lymph node, examination of pleural effusion, chest CT, bacteriological examination of the cold abscess and spinal MRI. We started chemotherapy with the antituberculous drugs (HRSZ) and symptoms except back pain improved. She complained of paresis of the both lower extremities, which completely paralyzed 8 months later in spite of continued chemotherapy. Thereafter her paralysis was gradually improved and she was able to walk by herself after 12 months chemotherapy.

[A case of pulmonary mucormycosis diagnosed through video-assisted thoracoscopic surgery--report of a case].

We report a case of pulmonary mucormycosis successfully treated by medical methods only. The patient was a 51-year-old man with diabetes mellitus who presented with general fatigue and appetite loss. His chest radiograph and CT scan showed multiple thin-walled cavities in the left upper lobe. Because we could arrive at a clear diagnosis, video-assisted thoracoscopic surgery was performed. Lung biopsy of the left upper lobe revealed pulmonary mucormycosis. Our diagnosis was pulmonary mucormycosis with diabetes mellitus and alcohol addiction. The patient was treated with antifungal drugs--mainly amphotericin-B--while the diabetes mellitus was well controlled, and his diet and nutritional state was improved, resulting in the disappearance of symptoms, improvement of the radiological findings, and the absence of any relapse of the disease of at least 3 years.

[Immunological studies in cases of pulmonary Mycobacterium avium complex infection without predisposing conditions].

Peripheral blood mononuclear cells (PBMCs) taken from 39 primary pulmonary MAC patients and 11 control subjects were stimulated in vitro with a protein antigen PPD-B derived from M. intracellulare. Then, the activated response of the peripheral blood lymphocytes (PBLs) and the production of interferon-gamma (IFN-gamma) and interleukin-10 (IL-10) were measured. The 39 primary pulmonary MAC patients were divided into A and B groups the former patients satisfying all of the criteria for the diagnosis of nontuberculous mycobacterial disease proposed by the American Thoracic Society, with the exception of the bacteriologic criteria, and the latter, who satisfied all without exception. The 39 patients were also divided into 3 groups according to disease severity judged from chest CT features. Severity in grades 1, 2 and 3 groups were mild, moderate and severe, respectively. We compared the activated response of PBLs and the production of IFN-gamma and IL-10 by PBMCs of the control group and each patient group. The number of lymphocytes and activated T cells and the concentration of the IFN-gamma after stimulation with PPD-B were lower in each group of primary pulmonary MAC patients than in the control group. IL-10 was significantly higher in each group of primary pulmonary MAC patients than in the control group (36.6 +/- 11.8 pg/ml), and higher in group B (131.6 +/- 14.9) than in group A (81.1 +/- 31.5). There was no significant difference in the IL-10 concentration between the grade 1, 2 and 3 groups. These results suggested that the cell-mediated immunity of primary pulmonary MAC patients was suppressed as the disease progressed, and the increased production of IL-10 was related to this suppression.