[Analysis of usefulness of a whole blood interferon gamma assay (QuantiFERON TB-2G) for diagnosing active tuberculosis in immunocompromised patients].

PURPOSE: Recently, there have been many reports that QuantiFERON TB-2G (QFT-2G) is useful for diagnosing active tuberculosis. However, it remains controversial whether QFT-2G is useful for diagnosing active tuberculosis in immunocompromised patients as well as immunocompetent ones. Therefore, we analyzed whether QFT-2G sensitivity is decreased in immunocompromised patients compared with that in immunocompetent patients and what factors affect the QFT-2G sensitivity. SUBJECTS AND METHODS: The subjects consisted of 159 patients (105 males, 54 females; age 64.0 years [14-91]) who were diagnosed with active tuberculosis and underwent the QFT-2G test in Nishi Kobe Medical Center between July, 2006 and December, 2008. We analyzed these patients with regard to age, sex, white blood cell count in peripheral blood (WBC), lymphocyte count in peripheral blood (Lym), serum total protein, serum albumin, and QFT-2G sensitivity, and compared the findings between immunocompetent and immunocompromised patients. Immunocompromised patients consisted of those with diabetes mellitus, malignant disease, chronic renal failure, systemic steroid administration and AIDS. To test significance of differences, we used Mann-Whitney test for categorical variables, and t test for continuous variables. RESULTS: One hundred fifty one patients had pulmonary tuberculosis (including 8 with bronchial tuberculosis), 11 tuberculous pleurisy, 2 miliary tuberculosis, 2 intestinal tuberculosis, 1 tuberculous lymphadenitis, 1 tuberculosis of the hip joint, and 1 tuberculosis of the vertebra (there was some overlap among cases). In the entire patient group, positive QFT-2G results were detected in 125 (78.6%). In the immunocompetent and immunocompromised patients, positive results were seen in 82 (78.8%) and 43 (78.2%), respectively; these proportions were not significantly different (p = 1.00). In all patients, Lym was significantly lower in patients with intermediate, negative or indeterminate QFT-2G results than in QFT-2G-positive patients (p < 0.001). CONCLUSION: In our analysis, QFT-2G sensitivity did not significantly differ between immunocompetent and immunocompromised patients. Therefore, it is considered that QFT-2G is useful for diagnosing active tuberculosis in immunocompromised as well as immunocompetent patients.

Health-related quality of life in patients with idiopathic pulmonary fibrosis--cross-sectional and longitudinal study.

OBJECT: To validate the cross-sectional and longitudinal use of the Medical Outcome Study Short Form 36 (SF-36) for measuring health-related quality of life (HRQL) in patients with idiopathic pulmonary fibrosis (IPF). METHODS: Patients were administered the SF-36 and concomitantly underwent laboratory and physiologic tests and high-resolution computed tomography (HRCT). Forty-six patients participated in the initial cross-sectional study, and 32 patients who were available more than one year later again underwent these studies under the same conditions. RESULTS: Patients with IPF had significantly lower scores across all 8 domains of the SF-36 when compared with the general population. Significant decline of HRQL was observed in 2 physical domains. There were significant differences in within-subject changes in a few domains according to worsening of the physiologic parameters. Vital capacity as percent of predicted was significantly correlated with the results of 6 subscales and its changes were significantly correlated with those of 4 subscales. The 6-min-walk distance was correlated significantly with 3 subscales and its changes were significantly correlated with those of 4 subscales. Changes in the HRCT ground-glass score were significantly correlated with those of 3 subscales. No significant correlations between changes in 3 domains and those of any clinical parameters were observed. CONCLUSION: Patients with IPF had significantly impaired HRQL in both physical and psychological functions. This disease clearly decreased the physical aspects of HRQL over time. HRQL instruments should be incorporated into routine evaluations of IPF patients, since they measure dimensions not fully estimated by clinical assessment.

Acute exacerbation of idiopathic pulmonary fibrosis: role of Chlamydophila pneumoniae infection.

BACKGROUND AND OBJECTIVES: Patients with idiopathic pulmonary fibrosis (IPF) may experience acute exacerbations of their illness. The actual trigger(s) of such exacerbations is unknown. Chlamydophila pneumoniae infection can cause exacerbation of asthma and COPD. A prospective study was conducted to investigate the possible role of C. pneumoniae infection in triggering acute exacerbations of IPF. METHODS: A prospective observational study over 5 years of consecutive IPF patients who fulfilled the criteria for acute exacerbation. Sputum, blood cultures and acute and convalescent serology for C. pneumoniae IgG and IgA (ELISA) were performed. RESULTS: Previous infection with C. pneumoniae is common. Of the 27 study patients, 15 had a C. pneumoniae IgG index of 1.10-2.99 (positive) and 3 had a C. pneumoniae IgG index of >2.99 (strongly positive) at the time of presentation with an acute exacerbation. In addition, 15 subjects had a C. pneumoniae IgA index of 1.10-2.99 (positive) and 6 subjects had a C. pneumoniae IgA index of >2.99 (strongly positive). However, only two of the 15 subjects (13%) for whom paired sera were tested exhibited a significant rise in antibody response (change in index of 1.90 for C. pneumoniae IgG and 1.54 for IgA, respectively) indicating either acute or reactivated infection with C. pneumoniae. There were 15 deaths (56%) despite supportive care that included high-dose corticosteroid therapy and oxygen supplementation. CONCLUSIONS: Mortality is high with acute exacerbation of IPF. Acute infection with C. pneumoniae is uncommon at the time of presentation with acute exacerbation of IPF.

[Successful telithromycin therapy of Legionella pneumonia --report of three cases].

Legionella species have been widely recognized as among the important causative organisms of community-acquired pneumonia in Japan. A delay in the start of adequate treatment has a negative influence on the outcome of the disease. Telithromycin, the first oral ketolide antibacterial, was developed for the treatment of community-acquired pneumonia, including Legionella pneumonia. However, few reports have indicated the efficacy of telithromycin in community-acquired pneumonia caused by Legionella species. We report three cases of Legionella pneumonia, that were improved by early telithromycin therapy. The first patient (67-year-old man) had bronchiectasis as an underlying disease, and the second patient (73-year-old man) had diabetes mellitus and chronic renal failure. The third patient (62-year-old man) developed pneumonia after a spa tour. The diagnosis of Legionella pneumonia was made on the basis of the presence of a single IgG titer of 1/256 in case 1 and positive antigenuria in cases 2 and 3. The patients were classified into a mild group (case 1) and a moderate group (cases 2 and 3) based on the severity of the community-acquired pneumonia according to the 2005 Japanese Respiratory Society Guidelines. The results support the efficacy of telithromycin in mild to moderate Legionella pneumonia.

A pilot study of aerosolized N-acetylcysteine for idiopathic pulmonary fibrosis.

OBJECTIVE: Idiopathic pulmonary fibrosis poses a significant therapeutic challenge because of its progressive course. Since oxidative stress plays an important role in the pathogenesis of idiopathic pulmonary fibrosis, an open, randomized trial of long-term inhalation therapy with the antioxidant, N-acetylcysteine was conducted. METHODOLOGY: A total of 30 patients with idiopathic pulmonary fibrosis were randomly assigned to one of the following inhalation therapies: N-acetylcysteine (352 mg per day) or bromhexine hydrochloride (4 mg per day) as the control. Efficacy was assessed by analysing changes occurring from baseline to 12 months in pulmonary function, the 6-min walking test, high-resolution CT, health-related quality of life, and serum KL-6-values. RESULTS: Four patients (n=2 in each group) died within 12 months due to progression of idiopathic pulmonary fibrosis. A total of 22 patients (control, n=12; N-acetylcysteine, n=10) completed the study. At 12 months there were significant differences between the N-acetylcysteine and control groups in terms of mean changes in lowest SaO(2) during the 6-min walking test (-0.3+/- 2.1% vs -6.8+/-1.8%, P<0.05), serum KL--6 (-482+/-220 U/mL vs 176+/-204 U/mL, P<0.05), and the ground-glass score on high-resolution CT (-1.3+/-1.6 vs 6.7+/-1.5, P<0.01). No significant differences were observed in pulmonary function, 6-min walking distance or quality of life. CONCLUSIONS: These data suggest that although long-term aerosolized N-acetylcysteine administration did not influence pulmonary function or quality of life, it may delay disease progression as evidenced by exercise desaturation, high-resolution CT, and serum KL-6.

[Clinical analysis of 10 cases of chest wall tuberculosis].

AIM/METHODS: A series of 10 cases of chest wall tuberculosis (man/woman=7/3, average age 62 +/- 17 years old) during past seven years were reviewed. RESULTS: Acid-fast bacillus was detected from an abscess in 60% by smear, 30% by culture, and 75% by polymerase chain reaction (PCR). It was characteristic that enhanced CT of abscess revealed a low density mass with peripheral enhancement, 'rim enhancement findings', in all cases. CT also showed ipsilateral pleural thickening in all cases, suggesting lymphogenous pathogenesis of chest wall lesions from tuberculous pleurisy. As for the treatment, antituberculosis chemotherapies were done in all cases. In addition, open drainage was done in 8 cases and curettage of abscess was performed in 5 cases. None of these ten cases had relapsed during the follow-up periods for 12 to 77 months. CONCLUSIONS: Chest wall tuberculosis is still important as a disorder of a chest wall mass requiring differential diagnosis. Contrasting CT is thought to be useful for the diagnosis. It should be emphasized that 50% of the cases had good outcome without curettage.

[Problems about the management of active pulmonary tuberculosis patients undergoing haemodialysis--our experiences and nation-wide questionnaire survey].

UNLABELLED: End-stage renal failure patients on chronic dialysis are high risk groups of tuberculosis due to attenuated cellular immunity. Patients receiving haemodialysis stay prolonged time inside the health-care facilities, thereby increased risk of tuberculosis transmission if a patient has active disease. So management of active pulmonary tuberculosis undergoing haemodialysis is important, however, the number of hospitals which are capable of taking care of such patients is estimated to be few in Japan. METHODS: From August 1994 through July 2002, 1059 active pulmonary tuberculosis patients (mean age; 57 +/- 19, male/female = 773/286) were admitted to Nishi-Kobe Medical Center, a 500-bed teaching hospital. Out of them, patients undergoing haemodialysis were retrospectively studied to describe the clinical characteristics of such cases. Then we conducted a questionnaire survey regarding the management of active pulmonary tuberculosis patients undergoing haemodialysis for 86 self-governing bodies in Japan. RESULTS: (1) Clinical characteristics of active pulmonary tuberculosis undergoing haemodialysis. We encountered 14 cases (mean age; 65 +/- 11, male/female = 7/7) of pulmonary tuberculosis undergoing haemodialysis during 8 years. In addition to pulmonary involvement, 3 pleural, one knee joint and one lymph node involvement was detected. Primary renal disease included diabetic nephropathy (n = 3), chronic glomerulonephritis (n = 3), congenital anomaly (n = 1), and unknown (n = 7). Nine cases were referred to our hospital from health-care facilities located out of city or prefecture. In five cases it took more than three months from the onset or detection of abnormal chest X-ray findings to the admission to our hospital. Five cases developed pulmonary tuberculosis within the first year after the initiation of dialysis. None of the patients had a past history of tuberculosis. Cavitary lesion on chest X-ray was observed in only one case. Triple antituberculosis therapy was used in 9 patients, and 4 antituberculosis drugs were used in 5 patients. Antituberculosis therapy was successfully done in all cases except two patients who died of apoplexy and cerebral infarction. (2) The nation-wide questionnaire survey. Of the 86 self-governing bodies we mailed, 66 self-governing bodies replied. Of them, 31% reported that they have experienced difficulties in the management of active pulmonary tuberculosis patients undergoing haemodialysis, and 25% reported the lack of health-care facilities to take care of such cases in their territory. They have referred such patients to hospitals located in the nearby prefectures or they have recommended antituberculosis therapy visiting a local haemodialysis facility. CONCLUSION: There are sometimes difficulties to manage active pulmonary tuberculosis patients undergoing haemodialysis in Japan. Health-care facilities to take care of such patients should be arranged and the formation of the network is necessarily.

[A case of Japanese summer-type hypersensitivity pneumonitis: monitoring with serum KL-6 and examination of the phenotype of HLA].

A 55-year-old woman was admitted with a cough and fever in August. A diagnosis of Japanese summer-type hypersensitivity pneumonitis was made on the basis of radiological, serological and pathological findings, in addition to positive returning home provocation. Serum KL-6 was monitored during the clinical course. Although KL-6 fluctuated slowly in comparison with the clinical symptoms and HRCT findings, it was considered useful for confirming the effects of treatment. Serum anti-Trichosporon antibody and the phenotype of HLA were studied in both the patient and her asymptomatic roommate, with whom she had no blood relationship. Though both were sensitized immunologically, HLA-DQ 3, which was reported to be associated with Japanese summer-type hypersensitivity pneumonitis, was detected in the patient but not in her roommate. It was suggested that HLA plays a role in the development of this disease.