Monocytes predict prognosis and successful treatment in older patients with miliary tuberculosis.

Background: The increasing number of patients with miliary tuberculosis (MTB) is a concern in an aging society because of its high mortality rate. Several prognostic biomarkers for MTB have been identified; however, the predictive ability of monocytes as biomarkers remains unknown. This study demonstrates the usefulness of monocytes as prognostic biomarkers for MTB. Materials and methods: We retrospectively compared the clinical findings of 52 patients with MTB hospitalized between April 2013 and October 2021. The predictive ability of biomarkers for 3-month prognosis and their cutoff values were calculated. Survival times and longitudinal changes in monocytes after initiating treatment were compared. Results: A smaller number of monocytes (#M), higher lymphocyte-monocyte ratio (LMR), higher neutrophil-monocyte ratio, and poorer performance status were associated with death within 3 months. #M was an independent prognostic factor. #M and LMR exhibited the highest predictive performance compared to others using receiver operating characteristic curve analysis (area under the curve = 0.86 and 0.85, respectively). Survival time was shorter in patients with #M ≤ 200 cells/µL and LMR > 2.5. Rapidly increasing #M after treatment was related to better prognosis in patients with #M ≤ 200 cells/µL at diagnosis. Conclusions: #M at diagnosis and longitudinal changes in monocytes are related to MTB prognosis.

Combined home and clinic-based therapy versus home-based exercise programme after distal radial fracture: a randomized controlled study.

We investigated outcomes of clinic-based hand therapy combined with a home-based exercise programme after anterior plating for distal radial fractures. A total of 102 patients were randomly assigned to one of three groups: a home-based exercise programme alone; a home-based exercise programme combined with four hand therapy sessions in the clinic; and a home-based exercise programme with seven sessions in the clinic. Mean Patient-Rated Wrist Evaluation scores at 6 weeks were significantly better for the group of patients with seven sessions in the clinic than in those with only home exercises (12 vs. 30), but the difference was no longer significant at 12 weeks. Grip strength was significantly better at 6 and 12 weeks. Combined home- and clinic-based hand therapy may facilitate an earlier return of function after anterior plating for distal radius fractures.Level of evidence: II.

Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall.

The tubercular abscess of the chest wall remains one of the differential diagnoses of a chest wall tumour, and the management strategy is controversial. We reviewed the medical records of 22 patients treated at our institution. Two patients were managed by antitubercular medications alone; eight patients were managed by medication and open drainage. Five patients underwent open drainage with subsequent radical surgery at a constant interval of time, and the mean duration between open drainage and radical surgery was 9.8 weeks (range, 3-12). Seven patients underwent radical surgery without prior open drainage. Five patients required rib resections, and curettage of infected pleural peel was necessary in 5 patients. Antitubercular drugs were administered basically for more than 6 months regardless of surgical management, including for more than 1 month prior to radical surgery. Postoperative empyema was seen in 1 patient after radical surgery. The mean follow-up duration was 32.8 months (range, 3-100), and there was no recurrence. Complete resection of the tubercular abscess with sufficient antitubercular therapy resulted in a satisfactory outcome. Antitubercular therapy with or without open drainage can be a viable choice.

Hypersensitivity pneumonitis associated with inhalation of catechin-rich green tea extracts.

A 51-year-old man presented with fever and fatigue after 3.5 months of antituberculosis therapy. High-resolution computed tomography of his chest revealed new ground-glass opacities and poorly defined centrilobular nodules. He had undergone catechin inhalation for 1 month. We diagnosed hypersensitivity pneumonitis (HP) based on the clinical course, bronchoscopy and a challenge test. Cases of HP due to inhalation of extracted catechin powder are rare. Although it has many known positive attributes, it is necessary to be aware that catechin can cause HP.

[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.

Reversed halo sign in pneumocystis pneumonia: a case report.

BACKGROUND: The reversed halo sign may sometimes be seen in patients with cryptogenic organizing pneumonia, but is rarely associated with other diseases. CASE PRESENTATION: We present a case study of a 32-year-old male patient with acquired immunodeficiency syndrome, who had previously been treated with chemotherapy for non-Hodgkin's lymphoma. A chest X-ray showed bilateral patchy infiltrates. High-resolution computed tomography revealed the reversed halo sign in both upper lobes. The patient was diagnosed with pneumocystis pneumonia, which was successfully treated with sulfamethoxazole trimethoprim; the reversed halo sign disappeared, leaving cystic lesions. Cases such as this one are rare, but show that the reversed halo sign may occur in patients who do not have cryptogenic organizing pneumonia. CONCLUSION: Physicians can avoid making an incorrect diagnosis and prescribing the wrong treatment by carefully evaluating all clinical criteria rather than assuming that the reversed halo sign only occurs with cryptogenic organizing pneumonia.

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.

[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.