Solitary pulmonary nodules due to non-tuberculous mycobacteriosis among 28 resected cases.

BACKGROUND: In some patients, non-tuberculous mycobacteria (NTM) infections manifest in solitary nodules (solitary nodular [SN] type) generally caused by Mycobacterium avium complex (MAC). In patients treated using surgical resection, the American Thoracic Society guidelines state that postoperative chemotherapy is not necessary in the absence of lesions, although there have been a few reports of such cases. METHODS: Twenty-eight patients diagnosed with NTM who underwent solitary pulmonary nodule resection at Toneyama Hospital, Osaka, Japan, between January 2000 and October 2012 were enrolled. We evaluated the influence of the surgical procedure and chemotherapy on outcomes in this retrospective study. RESULTS: Of the 28 patients, 12 were males and 16 were females; the mean age was 58.6 ± 13.2 years. Twenty-five patients were asymptomatic and bronchoscopy was performed in 18; only 2 had a definitive diagnosis of NTM. The pathogen responsible was MAC in 27 patients and M. kansasii in 1. The surgical procedure used was wedge resection in 22 patients, segmentectomy in 1 and lobectomy in 5. Postoperative chemotherapy was administered to 9 patients. Twenty-six patients had no recurrence. CONCLUSION: We believe that wedge resection is a valid surgical intervention for SN type NTM; additional postoperative chemotherapy is unnecessary in cases with no residual lesions in the operated lung lobe.

Validation of a commercial serodiagnostic kit for diagnosing pulmonary Mycobacterium avium complex disease.

SETTING: A commercial serodiagnostic kit for diagnosing pulmonary disease due to Mycobacterium avium complex (MAC-PD) was developed and launched in Japan in 2011. OBJECTIVE: To evaluate the performance of this kit in routine clinical settings. METHODS: In this retrospective single-centre study, data on serum levels of anti-glycopeptidolipid (GPL) core IgA antibody (U/ml) measured using the kit were analysed in patients diagnosed with MAC-PD according to American Thoracic Society criteria, in those with pulmonary tuberculosis (PTB) or pulmonary M. kansasii disease and in healthy volunteers. RESULTS: The anti-GPL-core IgA antibody levels of serum were significantly higher (P < 0.0001) in patients with MAC-PD (n = 485) than in those with PTB (n = 133) or pulmonary M. kansasii disease (n = 23) or in healthy subjects (n = 265). When the cut-off level was set at 0.7 U/ml, the sensitivity and specificity were respectively 78.6% and 96.9%. Higher antibody levels were observed in patients with greater extent of disease on chest computed tomography (P < 0.0001). CONCLUSIONS: The serodiagnostic kit revealed good sensitivity and specificity. The antibody levels may reflect disease activity. Additional work is needed to determine whether the diagnostic assay could be used in conjunction with current diagnostic criteria to improve the diagnosis of MAC-PD.

Long-term radiographic outcome of nodular bronchiectatic Mycobacterium avium complex pulmonary disease.

BACKGROUND: Although Mycobacterium avium complex pulmonary disease (MAC-PD) is a growing health problem, little is known about long-term radiographic outcome and factors for deterioration in patients with MAC-PD. METHODS: Data on patients with nodular bronchiectatic (NBE) MAC-PD who underwent regular follow-up for >5 years were retrospectively reviewed. Changes in plain chest radiograph (CXR) and baseline characteristics were compared between the stable and deteriorated groups. RESULTS: Seventy-two patients were investigated, including 30 patients who were examined 10 years after the initial visit. One patient (1.4%) showed progressive or remarkably progressive disease on CXR at 1 year; this rate increased to 22.2% at 5 years and to 53.3% at 10 years. Body mass index (BMI) at the initial visit was lower in the deteriorated group than in the stable group. Cavitary disease and resistance to a macrolide were seen more frequently at the initial visit in the deteriorated group than in the stable group. CONCLUSIONS: NBE MAC-PD is a slowly but substantially progressive long-term infection (5-10 years). Our data suggest that patients with lower BMI, cavitary disease and resistance to a macrolide at initial visit are more likely to progress to deteriorating disease.

Serological test and chest computed tomography findings in patients with Mycobacterium avium complex lung disease.

The present authors have previously reported the usefulness of a serodiagnostic test to detect serum glycopeptidolipid (GPL) core antibody in diagnosing Mycobacterium avium complex (MAC) lung disease in immunocompetent patients. The aim of the present study was to investigate correlations between the levels of antibody against GPL core and chest computed tomography (CCT) findings in patients with MAC lung disease. A total of 47 patients with MAC-positive culture from their sputum and who had radiographic abnormalities were investigated. Thirty-three patients met the American Thoracic Society criteria for MAC disease; 14 did not. All patients underwent both CCT examination and the serodiagnostic test for MAC at the same time. Small nodular shadows were seen on CCT in all 47 patients and bronchiectasis shadows were seen in 39 (83%) of them. There was a significant positive correlation between the extent of the disease and the level of GPL core immunoglobulin (Ig)A antibody. The levels of GPL core IgA antibody were significantly elevated in patients who had nodular shadows (10-30 mm) compared with patients who had small nodular shadows (<10 mm). The present results document that the levels of immunoglobulin A antibody against glycopeptidolipid core correlate with the chest computed tomography findings of Mycobacterium avium complex lung disease.

Liquid chromatography/mass spectrometry analysis of small-scale glycopeptidolipid preparations to identify serovars of Mycobacterium avium-intracellulare complex.

AIMS: The antigenic glycopeptidolipids (GPLs) from Mycobacterium avium-intracellulare complex (MAC) are grouped into 28 serovars on the basis of the variable oligosaccharide sequences and the core structures. To facilitate the identification of MAC serovars by employing liquid chromatography/mass spectrometry (LC/MS), the diversity in fatty acyl moieties and the number of acetyl groups of GPLs should be characterized. METHODS AND RESULTS: Employing a small-scale preparation method, sufficient quantities of intact GPLs could be obtained from several colonies of MAC within 4 h. Tandem mass spectrometry of GPLs showed the presence of common fragment ion at m/z 1048 in the main molecular species of all reference strains. It revealed that the acyl moieties had similar diversity among all serovars. Furthermore, intact GPLs had mainly one or two acetyl groups. This allowed us to determine the masses of each serovar based on intact GPLs and to classify 16 isolates from patients by LC/MS. CONCLUSIONS: The present serotyping method using LC/MS analysis improved the precision of measurements and shortened the procedure time compared with conventional thin-layer chromatography or the seroagglutination test method. SIGNIFICANCE AND IMPACT OF THE STUDY: This proposed method proves useful for identifying serovars of MAC for epidemiological and pathogenic research purposes.

Impairments and prognostic factors for survival in patients with idiopathic pulmonary fibrosis.

The aim of the present study was to evaluate exercise limiting factors using cardiopulmonary exercise testing (CPET) in patients with idiopathic pulmonary fibrosis (IPF), and to investigate whether these parameters are related to survival after CPET. We evaluated 41 patients with IPF (mean 68.2 years, 27 male) who performed CPET. The exercise capacity in patients with IPF was limited more strongly by gas exchange and/or ventilatory impairments, compared with cardiac impairment. Using univariate analysis, the severity of exercise-induced hypoxemia (EIH) evaluated by deltaPaO2/deltaVO2 (PaO2-slope), oxygen uptake at maximum exercise, oxygen pulse at maximum exercise, ventilatory equivalent for carbon dioxide at maximum exercise and age were significantly related to the survival rate. Interestingly, the PaO2-slope was most closely correlated with the survival rate using multiple analysis with a stepwise evaluation. Nevertheless, PaO2 at rest and at maximum exercise were not factors influencing survival. In patients with IPF, CPET can simultaneously evaluate the ability of both the cardiovascular and respiratory systems, and should be available so that parameters can be derived to make the necessary prognostic estimations, with the most useful parameter being the degree of EIH as represented by the PaO2-slope.

Clinical evaluation of anti-tuberculous glycolipid immunoglobulin G antibody assay for rapid serodiagnosis of pulmonary tuberculosis.

Previously we reported the development of a highly sensitive enzyme-linked immunosorbent assay specific for anti-tuberculous glycolipid (anti-TBGL) for the rapid serodiagnosis of tuberculosis. In this study, the usefulness of an anti-TBGL antibody assay kit for rapid serodiagnosis was evaluated in a controlled multicenter study. Antibody titers in sera from 318 patients with active pulmonary tuberculosis (216 positive for Mycobacterium tuberculosis in smear and/or culture tests and 102 smear and culture negative and clinically diagnosed), 58 patients with old tuberculosis, 177 patients with other respiratory diseases, 156 patients with nonrespiratory diseases, and 454 healthy subjects were examined. Sera from 256 younger healthy subjects from among the 454 healthy subjects were examined as a control. When the cutoff point of anti-TBGL antibody titer was determined as 2.0 U/ml, the sensitivity for active tuberculosis patients was 81.1% and the specificity was 95.7%. Sensitivity in patients with smear-negative and culture-negative active pulmonary tuberculosis was 73.5%. Even in patients with noncavitary minimally advanced lesions, the positivity rate (60.0%) and the antibody titer (4.6 +/- 9.4 U/ml) were significantly higher than those in the healthy group. These results indicate that this assay using anti-TBGL antibody is useful for the rapid serodiagnosis of active pulmonary tuberculosis.

Slow N-acetyltransferase 2 genotype affects the incidence of isoniazid and rifampicin-induced hepatotoxicity.

SETTING: Japanese in-patients with pulmonary tuberculosis and normal liver function receiving treatment with isoniazid and rifampicin (INH + RMP). OBJECTIVE: To elucidate the relationship between N-acetyltransferase 2 (NAT2) genotype and the incidence of isoniazid + rifampicin-induced hepatotoxicity. DESIGN: Prospective study. After NAT2* genotyping, 77 patients were classified into three groups according to their NAT2* genotypes: rapid-type (a homozygote of NAT2*4), intermediate-type (a heterozygote of NAT2*4 and mutant alleles) and slow-type (a combination of mutant alleles). Their biochemical profiles of liver function test were investigated for 3 months to assess the development of serum aminotransferase elevation. RESULT: Of the 77 patients, 18.2% developed adverse hepatic reaction within the first month of INH + RMP treatment. A significant association was observed between hepatotoxicity and NAT2* genotype: compared with rapid-type, the relative risk was 4.0 (95% CI 1.94-6.06) for intermediate-type and 28.0 (95%CI 26.0-30.0) for slow-type. Especially in slow-type, the incidence of hepatotoxicity and serum aminotransferase elevation was significantly higher than in the other two types. CONCLUSION: Slow NAT2* genotype significantly affected the development of INH + RMP-induced hepatotoxicity. This suggests the possibility that NAT2* genotyping prior to medication may be useful in evaluating patients with high risk for INH + RMP-induced hepatotoxicity.

Anti-cord factor (trehalose 6,6'dimycolate) IgG antibody in tuberculosis patients recognizes mycolic acid subclasses.

The detection of anti-cord factor (trehalose 6,6'-dimycolate) IgG antibody in active (smear-and/or culture-positive) and inactive (smear-and culture-negative) tuberculosis patients is a useful serodiagnostic tool that can be used for early clinical diagnosis of the disease. We estimated the titers of anticord factor IgG antibody in the sera of tuberculosis patients, and compared them with those of Mycobacterium avium-infected patients. Most of the serum samples obtained from the tuberculosis patients were highly reactive against M. tuberculosis (MTB) cord factor isolated from M. tuberculosis H37Rv, a human-type mycobacterial strain, whereas they were less reactive against M. avium (MAC) cord factor. Similarly, most of the serum samples of the MAC-infected patients were highly reactive against MAC cord factor and less reactive against MTB cord factor. These results suggest that anti-cord factor IgG antibody recognizes the mycolic acid subclasses as an epitope which comprises cord factor, since MTB and MAC cord factor differ in mycolic acid subclasses and molecular species composition. To clarify the exact antigenic epitope in cord factor and to find out a more sensitive and specific diagnostic test antigen, we examined the reactivity of patients' sera to glycolipids containing trehalose (cord factor and sulfolipid) obtained from various mycobacterial species. Furthermore, the reactivity of human antisera to various mycolic acid subclasses (alpha-, methoxy and keto mycolic acids) of MTB cord factor was compared. We found that anti-cord factor IgG antibody in the sera of human tuberculosis patients most strikingly recognized methoxy mycolic acid in the cord factor of M. tuberculosis, whereas it recognized alpha- and keto mycolic acids weakly. Pre-absorption studies of antibody with MTB cord factor or methoxy mycolic acid methyl ester showed that anti-cord factor antibody was absorbed partially, but consistently. This is the first report describing that the specific subclass of mycolic acid from mycobacteria is antigenic in the humoral immune system of human tuberculosis infection.

[Effectiveness of isoniazid inhalation in patients with endobronchial tuberculosis].

The clinical effectiveness of isoniazid (INH) inhalation was studied retrospectively in 34 patients with endobronchial tuberculosis. Diagnoses of endobronchial tuberculosis and assessments of bronchial stenosis were based on bronchoscopic examinations. We divided the patients into 2 groups: 13 who received systemic chemotherapy for lung tuberculosis only, and 21 who received systemic chemotherapy combined with INH inhalation (200 mg/day). No significant differences distinguished the groups with respect to duration of positive sputum culture or ESR normalization. However, a significant alleviation of bronchial stenosis and earlier reduction of respiratory symptoms were observed in the patients who received systemic chemotherapy with INH inhalation. We concluded that INH inhalation in addition to standard therapy for lung tuberculosis is effective in patients with endobronchial tuberculosis.

Rapid serodiagnosis of Mycobacterium avium-intracellulare complex infection by ELISA with cord factor (trehalose 6, 6'-dimycolate), and serotyping using the glycopeptidolipid antigen.

Mycobacterium avium-intracellulare complex (MAC) is one of the most important opportunistic pathogens, particularly in patients with acquired immunodeficiency syndrome (AIDS). The aim of this study was to determine whether an enzyme-linked immunosorbent assay (ELISA) using trehalose 6,6'-dimycolate (TDM) as an antigen can be used for the rapid serodiagnosis of MAC infection. We also identified MAC serotypes by ELISA using serotype-specific glycopeptidolipid (GPL) antigen. To confirm our findings, the thin-layer chromatographic (TLC) behavior of serotype-specific GPL of the strains isolated from MAC-infected patients was also tested. Forty patients infected with MAC and 30 healthy controls were tested. Thirty-two of the 40 MAC-infected patients had higher titers of serum antibodies against MAC TDM than against MTB TDM, while all 30 healthy control sera were unreactive to MAC TDM and MTB TDM. Results of the GPL ELISA indicated that 20 of the 40 MAC-infected patients' sera were reactive against serotype 4 GPL, 3 against serotype 8 GPL, and 1 against serotype 16 GPL. A TLC analysis of the GPL of the 40 MAC isolates showed that 16 strains were of serotype 4, 5 of serotype 8, and 2 of serotype 16. Results of the GPL ELISA were in good accord with those of the TLC analysis for most patients. Our findings suggest that ELISA using TDM is useful for rapid serodiagnosis of MAC infection, and that complementary ELISA testing using serotype-specific GPL gives additional detailed information concerning MAC serotypes.

[The indication of surgical management in patients with pulmonary disease caused by Mycobacterium avium-intracellulare complex].

The surgical management of patients with nontuberculous Mycobacteriosis caused by Mycobacterium avium complex (MAC) was studied regarding the following cases: (1) We investigated whether there had been an appropriate time for surgical management of patients with MAC who had not responded to medication and who died after their conditions became worse retrospectively. During the past 10 years, 49 patients diagnosed with MAC died at the Toneyama national hospital. 26 patients of them died of respiratory failure, apparently due to the worsening of MAC. Excluding 2 patients who were extremely elderly, we investigated whether surgical management could have been applied in the remaining 24 patients. We found that surgical management would have been possible in only one patient, and that at the time of diagnosis of MAC in 23 patients, surgical management was already not possible. (2) There are patients with MAC who do not respond to medication and who continue to excrete bacilli, chest X-ray findings gradually become worse for several years. In 1989 we retrospectively studied chest X-ray findings from MAC patients and found that 36 out of 103 patients (35%) showed worsening chest X-ray findings. The strains were identified in 44 of the 103 patients by the DNA probes method. However, of 37 patients with M.avium (41%), 15 had worsening of chest X-ray findings, while none out of 7 patients with M. intracellulare had worsening of chest X-ray findings. We then observed the clinical course of 37 patients who showed continuous excretion of bacilli and whose serotypes had been identified (20 with serovars 4, 1 with serovars 6, 6 with serovars 8, 2 with serovars 12, 4 with serovars 14 and 5 with serovars 16) by using the fast-atom bombardment mass spectrometry (FAB/MS). Chest X-ray findings later worsened in 14 (70%) of 20 patients with serovars 4. Nine of these patients have since died; excluding one patient who had liver cancer, eight died of respiratory failure due to worsening of MAC. In 17 patients with serotypes except serovars 4, 4 (24%) patients had worsening of chest X-ray findings, but none of the 5 deaths in this group were due to respiratory failure owing to worsening of MAC. These results suggest that it is difficult to establish the indication of surgical management in MAC patients, except for patients with repeated hemoptysis at present. The prognosis and surgical management of pulmonary disease caused by M. avium complex should be considered.

Enzyme immunoassay to detect antituberculous glycolipid antigen (anti-TBGL antigen) antibodies in serum for diagnosis of tuberculosis.

We report the development of an EIA specific for antituberculosis antibody in human serum for the clinical evaluation of tuberculosis. We developed a TLC immunostaining method to detect specific antigens for antibodies in the serum of patients with tuberculosis. The detected specific antigens, TDM and specific gylcolipid fraction, were individually purified from M. tuberculosis H37Rv by column chromatography. The two purified fractions were mixed and the mixture, termed TBGL antigen, was applied to an enzyme immunoassay suitable for the measurement of antituberculosis antibodies in serum. This EIA meets all the requirements of routine clinical assay in terms of sensitivity (detection limit: 0.125 U/ml), reproducibility (total CV : 3.3-6.0%), accuracy (recovery: 96-105%), simplicity and rapidity (< 2.5 h). Clinical validation of the assay was confirmed by the measurement of the anti-tuberculosis antibody in the serum of normal subjects and patients with pulmonary tuberculosis. The EIA tested in this study showed a high serodiagnostic discriminating power (90% sensitivity and 98% specificity).

[A cooperative clinical study on the evaluation of an antibody detection test kit (MycoDot Test) for mycobacterial infections. Cooperative Study Group for MycoDot Test].

To determine the usefulness of a diagnostic kit for mycobacterial infection, we performed a five-hospital cooperative clinical study using serodiagnosis kits (MycoDot Test) to detect antibody for lipoarabinomannan (LAM) which is a membrane-derived component of mycobacterial species. We tested LAM antibody in the sera of patients with mycobacterial infection as well as healthy persons. Procedures for using the serodiagnosis kit are actually simple. Out of 130 cases of active pulmonary tuberculosis, 103 cases (79%) were positive for anti-LAM, and cases out of 24 cases of active atypical mycobacterial infection, 15 (63%) were positive. On the contrary, only 4% of healthy volunteers (1 out of 25 persons) were positive on this test. In conclusion, this diagnostic kit might be a useful test for early and supportive diagnosis of mycobacterial infections based on its sensitivity and specificity.

Clinical evaluation of rapid serodiagnosis of pulmonary tuberculosis by ELISA with cord factor (trehalose-6,6'-dimycolate) as antigen purified from Mycobacterium tuberculosis.

Immunoglobulin G (IgG) antibodies against purified cord factor (trehalose-6,6'-dimycolate) prepared from Mycobacterium tuberculosis H37Rv were determined by enzyme-linked immunosorbent assay (ELISA), and its diagnostic usefulness was evaluated. Serum specimens from 65 patients with active pulmonary tuberculosis, 58 patients with inactive pulmonary tuberculosis, 36 patients with diseases other than tuberculosis, and 66 healthy adults were examined. Patients with active pulmonary tuberculosis showed significantly higher titers of IgG antibodies against cord factor than did other groups (p < 0.001). The antibody titer greater than 0.29 in absorption difference (492 to 630 nm) of 160-times diluted serum was set as positive in ELISA. For patients with active and untreated pulmonary tuberculosis, the ELISA had a sensitivity of 81% and a specificity of 96%. From these results, it was concluded that the detection of IgG antibodies against cord factor is useful for serodiagnosis of active pulmonary tuberculosis. It was also indicated that the anticord factor antibody titers decline to the normal level as a result of antituberculosis chemotherapy.

[Diagnostic role of fiberoptic bronchoscopy for mycobacterial diseases--serological diagnosis].

Detection of IgG antibodies against purified cord factor (trehalose-6, 6'-dimycolate) prepared from Mycobacterium tuberculosis H37Rv was carried out by the method of enzyme-linked immunosorbent assay (ELISA) and its diagnostic usefulness was also evaluated in this study. Sera from 65 patients with active pulmonary tuberculosis, 58 patients with inactive pulmonary tuberculosis, 36 patients with diseases other than tuberculosis and 66 healthy adults were examined. Patients with active pulmonary tuberculosis showed significantly higher titers of IgG antibodies against cord factor than other groups (p < 0.001). Patients with inactive pulmonary tuberculosis also showed significantly higher titers of IgG antibodies against cord factor than patients with diseases other than tuberculosis and healthy adults (p < 0.001). An antibody titers of greater than 0.29 were established as a positive ELISA test. For patients with active pulmonary tuberculosis, the ELISA had a sensitivity of 85% and a specificity of 96%. From these results, it is concluded that the detection of IgG antibodies against cord factor is useful for the serodiagnosis of active or inactive pulmonary tuberculosis.

[Clinical characteristics of the patients with primary infection of Mycobacterium avium complex].

Clinical characteristics are analyzed in patients with primary infection of Mycobacterium avium complex (MAC). The definition of primary infection of MAC are determined as follows; 1) MAC is found several times since the beginning of the disease, 2) clinical symptoms or abnormal shadow corresponding to MAC infection on chest roentgenogram, 3) no old tuberculous lesions nor other abnormal shadows like bronchiectasis, 4) no abnormal serological results suggesting other bacterial or viral infections. According to this definition, 17 out of 84 MAC patients are diagnosed as primary MAC infection, and clinical features are analyzed in these 17 patients. Average age of patients is 61.1 +/- 12.9 year old. This age is significantly higher than that of inpatients with pulmonary tuberculosis in our hospital, and lower than that of all MAC patients including secondary infection. Five (29.4%) are male and 12 (70.6%) are female, the ratio of male to female is 1 to 2.4. This value is significantly different with that of inpatients with pulmonary tuberculosis in our hospital who show about 3 to 1. Most of the patients complained of cough with sputum, especially of hemosputum. Eleven out of 17 patients (64.7%) complained repeated hemosputum. The frequency of hemosputum is very high compared with that of the patients with pulmonary tuberculosis (about 20%). No compromised condition was present except for a patient with Behçet's disease who are taking steroid hormone. Roentgenographic features of primary infection are those of scattered small nodular lesions in the peripheral part of the lung, thin wall cavity formation, no contraction of the diseased lung nor dislocation of the trachea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prognosis in chronic pulmonary disease and cor pulmonale].

Echocardiography and cardiac catheterization were performed in 30 patients of chronic pulmonary disease and cor pulmonale. We studied the relation of echo-cardiographic data and pulmonary hemodynamics to prognosis in these patients. In the nonsurvival group (12 patients) the extent of dyspnea was worse significantly (p less than 0.05), PaO2 was decreased significantly (p less than 0.05, 7 +/- 8.2 Torr), right ventricular preejection period (RPEP)/right ventricular ejection time (RVET) ratio increased significantly (p less than 0.05, 0.51 +/- 0.07), left ventricular diastolic diameter index (LVDdI) was shortened significantly (p less than 0.05, 23.5 +/- 3.1 mm/m2), and pulmonary capillary wedge mean pressure (PCWm) rose significantly (p less than 0.05, 11.9 +/- 6.9 mmHg) in comparison with the survival group (12 patients). In the survival group PaO2, RPEP/RVET ratio, LVDdI and PCWm averaged 60.9 +/- 12.8 Torr, 0.41 +/- 0.09, 27.5 +/- 5.1 mm/m2, 6.2 +/- 3.3 mmHg, respectively. The rate of survival was decreased significantly (p less than 0.05) in pulmonary vascular resistance (PVR) of greater than 400 dyne.sec.cm-1 or stroke volume index (SVI) of less than 35 ml/m2. These factors and 3 factors of obesity, %VC and pulmonary artery mean pressure (PAPm) differentiated nonsurvivors from survivors with linear discriminant function.