Microorganisms isolated at admission and treatment outcome in sputum smear-positive pulmonary tuberculosis.

Cured or completed cases in newly diagnosed sputum smear-positive pulmonary tuberculosis (TB) is 47.7% in Japan in 2016. Aging of TB patients and their underlying conditions could affect treatment outcome. We analyzed the association between the isolation of microorganisms from sputum at admission and the 180-day mortality rate of the sputum smear-positive pulmonary TB patients in Chiba-East Hospital in Japan. Total subjects were 761 (median age: 63 years). Sputum test for microorganisms was conducted in 708 patients. Microorganisms other than the normal oral flora were isolated in 128 cases (18.1%). Details of the isolated microorganisms were as follows: methicillin-resistant Staphylococcus aureus 23 cases, Klebsiella pneumoniae 17 cases, Pseudomonas aeruginosa 16 cases. Mortality was significantly elevated in the patients with those microorganisms than the others (39.8% vs. 10.2%) (P < 0.01). Fifty-one of 128 patients with those microorganisms died, and 10 of them died of infectious disease, which is the most frequent cause of deaths. The factors associated with the isolation of those microorganisms were as follows: respiratory failure (adjusted odds ratio (aOR):2.5 [95% confidence interval (CI) 1.3-4.7]), performance status 3 or 4 (aOR:2.9 [95% CI 1.6-5.4]), serum albumin <3.0 mg/dL (aOR:2.1 [95% CI 1.3-3.6], age of 65 years or older (aOR:2.0 [95% CI 1.2-3.4]). Those strains were isolated from one of sixth patients. Patients with those microorganisms did not always develop infectious diseases; however, treatment outcomes were poor, with higher mortality. The isolations of microorganisms were associated with various underlying conditions, leading to death. Thus, attention should be paid to TB patients with the above factors.

Comparison of interferon-γ release assays, QuantiFERON TB-GIT and T-Spot.TB, in renal transplantation.

Renal transplant recipients are at increased risk of reactivating latent tuberculosis infection (LTBI) and progressing to active tuberculosis (TB). This study was conducted in National hospital for tuberculosis and renal transplantation (RT) in Japan. The purpose is to compare two interferon-γ release assays (IGRAs), QuantiFERON®-TB Gold in Tube (QFT) and T-SPOT®.TB (TSPOT), in patients after renal transplantation for detecting latent TB infection (LTBI). Total 92 renal transplant recipients (median age 46 years, range 17-75) were prospectively enrolled, and QFT and TSPOT were concurrently examined. Total subjects were 92 patients (median age 46 years, range 17-75). The positive rate in QFT and TSPOT were 6.5% (95% confidence interval (CI) 3.0-13.5) and 2.2% (95% CI 1.0-7.6), respectively. There was a significant difference in IGRAs positivity (P < 0.05). The negative rate in QFT and TSPOT were 91.3% (95% CI 83.8-95.5) and 95.7% (95% CI 89.3-98.3), respectively. There was no significant difference in IGRAs negativity. No patients among either IGRAs negative patients developed active TB during median follow-up of 994 days. Neither QFT nor TSPOT reaches estimated TB infection rate in Japan, especially elderly recipients aged 60 year-old or more. Therefore, both IGRAs might underestimate LTBI owing to immune suppressive therapy and aging. Physicians for renal transplantation need to understand the characteristics of both IGRAs and pay attention to the possibility of developing active TB even in patients of negative IGRAs results.

Advanced stage of chronic kidney disease is risk of poor treatment outcome for smear-positive pulmonary tuberculosis.

Chronic kidney disease (CKD) is an increased risk for the development of active tuberculosis, but few studies have analyzed the treatment outcome of pulmonary tuberculosis among CKD patients. A retrospective cohort study was conducted at Chiba-East Hospital in Chiba, Japan. Our study estimated the treatment outcomes in smear-positive pulmonary tuberculosis in relation to CKD and its stages. Total subjects were 759 patients (12-99 years) hospitalized between 2007 and 2012. Patients suffering from multi-drug-resistant tuberculosis were excluded. Patients with CKD were 19.3% aged <65 years (n = 384), and 49.6% aged ≥ 65 years, respectively (P < 0.001). Successful treatment was 52.7% in CKD (n = 260) and 67.3% in non-CKD (n = 499) (P < 0.001). Death was 25.4% in CKD and 12.4% in non-CKD (P < 0.001). Treatment outcome was especially poor in patients with low estimated glomerular filtration rate (eGFR) of <30 ml/min/1.73 m(2), as successful treatment was 20.0%, and death was 50.0%, significantly lower than in other CKD and non-CKD patients. After multivariate logistic regression analysis, eGFR<30 ml/min/1.73 m(2) was an independent factor affecting successful treatment and death, and its adjusted odds ratios (aOR) were 0.20 (95% confidence interval (CI) 0.07-0.50) and 2.99 (95%CI 1.20-7.51), respectively. Other factors affecting successful treatment were serum albumin <3.0 mg/dl, steroid therapy for underlying disease and cardiovascular disease, with aOR (95%CI) of 0.28 (0.20-0.39), 0.32 (0.16-0.63) and 0.49 (0.28-0.86), respectively. Several factors were associated with poor treatment outcome of smear-positive pulmonary tuberculosis. Advanced stage of CKD with eGFR of <30 ml/min/1.73 m(2) was a risk factor for poor treatment outcome.

Association of isoniazid-metabolizing enzyme genotypes and isoniazid-induced hepatotoxicity in tuberculosis patients.

BACKGROUND: Isoniazid (INH), a key drug of antituberculosis therapy, is metabolized by arylamine N-acetyltransferase2 (NAT2), cytochrome P450 2E1 (CYP2E1) and glutathione S-transferase (GST). We studied the possible influence of genetic polymorphisms of INH-metabolizing enzymes on serum concentrations of INH and its metabolites, as well as on the incidence of hepatotoxicity. PATIENTS AND METHODS: A total of 144 tuberculosis patients who received antituberculosis treatment were followed prospectively. Their NAT, CYP2E1 and GST genotypes were determined using a polymerase chain reaction with restriction fragment length polymorphism method. Blood samples were collected from the patients and serum concentrations were determined by HPLC. The severity of hepatotoxicity was judged by the increases in either aspartate aminotransferase or alanine aminotransferase levels from the upper limit of the corresponding normal range. RESULTS: Incidence of hepatotoxicity was highest in pulmonary tuberculosis patients with the slow acetylator (SA) phenotype and lowest in those with the rapid acetylator (RA) phenotype, although no clear relationship of genetic polymorphism of INH-metabolizing enzymes on the severity of hepatotoxicity were confirmed. CONCLUSION: The risk of side-effects, such as hepatic disorder, may rise in these patients with an SA phenotype, because of an increase in serum INH concentration. The evidence presented in this study, albeit based on the examination of a low number of patients, suggests that a safe INH dosage for tuberculosis patients with SA phenotype should be less than the dosage which is usually recommended for tuberculosis patients.

[The present situation of measures against tuberculosis in hemodialysis facilities in Chiba Prefecture].

PURPOSE: To observe the current situation of tuberculosis and its control measures in hemodialysis facilities in Chiba Prefecture, Japan. METHOD: Questionnaires on medical dialysis and tuberculosis were sent to hemodialysis facilities in Chiba Prefecture. RESULTS: The questionnaires were answered by 55 of 127 facilities. Of the respondents, 46 (83.6%) were not aware of the recommendation of treatment for latent tuberculosis infections in Japanese patients. Moreover, 30 (54.5%) facilities did not examine patients for tuberculosis prior to the initiation of hemodialysis. Of the 21 facilities that did assess patients for tuberculosis infection, only 5 (23.8%) performed a tuberculin skin test or QuantiFERON TB-2G. Three of the five (60.0%) that were treating tuberculosis by themselves expressed fear or uncertainty about the diagnosis and treatment of latent tuberculosis infections. During January 2006 through December 2007, tuberculosis patients were detected in 11 facilities, and the proportion of extrapulmonary tuberculosis among these patients was 52.4%. Seven facilities reported that they took no control measures against tuberculosis. CONCLUSION: It is important to inform medical dialysis facilities about latent tuberculosis infections, the early diagnosis of tuberculosis, and the combination of nosocomial infection control. It is also important for experts in hemodialysis and tuberculosis to work closely together.

[A DRG/PPS simulation in the medical care of tuberculosis].

PURPOSE: To study the expected usefulness of the introduction of the DRG-PPS (Diagnosis-Related Group/Prospective Payment System, in which an insurer pays a fixed medical fee per hospitalization) into the current medical care of tuberculosis (TB) in Japan. METHOD: The medical fees were reviewed for all TB inpatients at 19 hospitals under the National Hospital Organization who were discharged in either June 2007 or February 2008. The sum of the fixed fee by the DRG was assumed based on the bivariate regression analysis of each patient's hospital days and his or her total actual fees during the hospital stay under the current (fee for care) system, since it was difficult to directly calculate the daily fees for every patient that would be the basis of DRG-PPS. RESULTS: Linear regression analysis estimated that the medical fees (including fees for the medical examinations and the treatments) for a hospital stay of 60 days, which is the standard for TB treatment, was 1,192,470 yen (19,870 yen per person per day) in June 2007, and 1,167,600 yen (19,460 yen per person per day) in February 2008. DISCUSSION: If we assume an average medical fee of about Y1.1-1.2 million yen for the standard hospital care of TB, the economic balance of the hospitals is negative, with a deficit of 0.6-0.7 million yen, given the estimated expenses of 1.8 million yen (i.e., 30,000 yen per person per day x 60 days). CONCLUSION: If the DRG-PPS is to be implemented based on the current medical fee rating system, the hospital administrators could not accept its introduction to the TB medical care service as it is, because it may undermine the economic management of hospitals.

[A hospital based study on evaluation of causes of death in 52 patients with pulmonary tuberculosis].

PURPOSE: To examine the clinical problems of died cases with pulmonary tuberculosis. METHODS: Clinical findings of 52 patients with active pulmonary tuberculosis, who had died in our hospital between April 2005 to March 2007, were analyzed. RESULTS: Mean age was 72.3 10.6 years old, 9 cases (17.3 %) were relapsed, and 35 cases (67.3%) had cavity on the chest X-ray. 34 cases (65.4%) were PS4 and none was PS0 or PS1 on admission. Complications were malignancy in 11 cases, diabetes mellitus in 10 cases, and respiratory diseases in 6 cases. 15 cases (28.8%) were treated with drugs including INH, RFP and PZA, 14 cases (26.9%) with drugs including INH and RFP, 16 cases (30.8%) with the other drugs, and 7 cases (13.5%) were not able to be administered any drug. 35 cases (67.3%) died of tuberculosis and 17 cases (32.7%) died of non-tuberculous conditions. CONCLUSION: Many died cases were under very poor general condition, needed frequent care, had many kind of complications and had difficulty with standard treatment on admission. Tuberculous death were observed highly, but death by complications were observed in many cases. It is necessary to control complications and enlighten society and docters about importance of early diagnosis and treatment of tuberculosis continuously.

[A case of pericostal tuberculosis occurred in a long period after thoracoplasty].

A 79-year-old man with past history of thoracoplasty due to pulmonary tuberculosis visited a general clinic complaining of left back pain and left axillary tumor. As the pus of tumor aspirated was positive for PCR-TB, the patient was diagnosed as pericostal tuberculosis and introduced to our hospital. At first, the operation was considered, but the patient had high risk for the operation because he was old and low body weight and the lesion of tuberculosis in his thorax was very extensive. Anti-tuberculous drugs were administrated and exclusion of pus by needle aspiration was repeated. After starting the treatment, the size of tumor had reduced guradually. Pericostal tuberculosis should be taken into consideration in case of pericostal mass with past history of tuberculosis, and the method of treatment should be decided with considering patient's condition.

[Research and control of relapse tuberculosis cases].

UNLABELLED: With this symposium, we focused on the relapse of tuberculosis in Japan. Out of 19,893 tuberculosis patients registered in 2007 in Japan, 7.48% were classified as relapse cases. Relapse cases have the risk of acquired drug resistance. But we have few analyses of the proportion of relapse tuberculosis cases with standard short course regimens for six months, factors contributing to tuberculosis relapse and the proportion of drug resistance among relapse TB cases in Japan. Therefore we analyzed the relapse tuberculosis cases in two rural areas and three urban areas. We also analyzed the proportion of drug resistance among relapse cases with the data of drug susceptibility survey of Ryoken. 1. Research of relapse tuberculosis cases: Makoto TOYOTA (Kochi City Public Health Center). To clarify the relapse rate and factors contributing to tuberculosis relapse, we investigated the relapse tuberculosis cases in the municipality where the proportion of elderly tuberculosis patients was high. Out of 902 tuberculosis patients registered in Kochi City Public Health Center during 10 years, 20 pulmonary tuberculosis patients were confirmed relapse cases with initial registered records. Pretreatment cavitations, sputum culture positivity at 2 months, medical miss-management (e.g. number of doses, duration of therapy) and poor adherence were considered to be factors contributing to tuberculosis relapse. Out of 20 relapse cases, 12 cases were detected with symptoms, while only 3 cases were detected by examination in law. 2. A clinical study on relapse cases of pulmonary tuberculosis: Shuichi TAKIKAWA (National Hospital Organization Nishibeppu National Hospital). The relapse of pulmonary tuberculosis was investigated. In the cases with a treatment history before short course chemotherapy, drug resistance rate was high, and thus it needs to be cautious of drug resistance at the time of the retreatment. In the cases with a treatment history of short course chemotherapy, relapse cases were recognized more significantly in male cases aged 70's. In the cases that deviated from the standard treatment and that became impossible to use rifampicin, it should be careful to emergence of isoniazid resistance. 3. The current status of the recurrence tuberculosis cases in Tokyo: Michiko NAGAMINE (Specific Disease Control Section, Tokyo Metropolitan Government Bureau of Social Welfare and Public Health). As for the background of the patient whose disease has relapsed, unstable elements are observed. After any symptom, more patients are diagnosed as a relapse case rather than finding by a medical check up. And more than half are related to homeless or life without fixed address. Their status of insurance is the livelihood protection, no insurance or the national health insurance. By RFLP analysis in Shinjuku city, some clusters have recurrent cases, one of clusters has both a relapse and exogenous reinfection. This is able to elucidate an infectious state. Like this, the analysis of each cluster can help effective countermeasures. 4. Recurrence of tuberculosis in the City of Yokohama between 2004 and 2008: Michihiko YOSHIDA (Shinagawa Public Health Center), Takahiro TOYOZAWA (Yokohama Public Health Center). To identify the TB recurrence rate, we studied a cohort of 40 cases (treatment completion 36 cases, interruption 4 cases) of whom had a previous history of TB treatment including isoniazid and rifampicin. The time for relapse was 7.9 +/- 8.6 years and the overall relapse rate was 0.6% (0.47-0.7%). Our study suggested the relapse was almost equal to the low incident countries but the long-term follow-up and surveillance data should be carefully evaluated. 5. Comparison of the retreatment cases of pulmonary tuberculosis: Yuka SASAKI (National Hospital Organization Chiba-East National Hospital). To investigate the factors of the retreatment of pulmonary tuberculosis, 134 retreatment cases were studied. The factors leading to retreatment were cavitary and large lesions in chest X-p, sputum smear positive and heavy alcohol-drinkers. The factors leading to defaulting of the treatment were lack in understanding of the treatment and their economic problems. Reexamination of the treatment and support of the patients are important to prevent the retreatment of the pulmonary tuberculosis. 6. Proportion of drug resistance among relapse tuberculosis cases, summary of Ryoken studies 1977-2002: Takashi YOSHIYAMA (Fukujuji Hospital). BACKGROUND AND OBJECTIVE: We have no historical analysis of the proportion of drug resistance among relapse TB cases. Therefore we would like to analyze the proportion of drug resistance among relapse cases in Japan. METHOD: Re-analysis of the data of drug susceptibility survey of Ryoken from 1977 to 2002. RESULT: The proportion of relapse cases among Ryoken has decreased in 1982-1987 and that proportion was 10% in 2002. The average age of relapse cases was 5 years older than the new cases and it was 66 years in 2002. The proportion of drug resistance among relapse cases has decreased form 39% (in 1977) to 16% (in 2002) for isoniazid, was stable and around 10% for rifampicin with 7.5% in 2002. The risk factors for drug resistance were younger age, foreigners and part time job. The proportion of drug resistance was higher among cases that were failure with previous treatment, then default with previous treatment and lower among cases with cure/completion at the previous treatment but this tendency was without significance.

[A case of miliary tuberculosis with interstitial nephritis due to re-administration of rifampicin treated successfully with steroid].

A 26-year-old man was admitted to a hospital complaing of continuous high fever and abdominal swelling. As his sputum and ascites culture was positive for acid-fast bacilli and PCR-TB, he was diagnosed as miliary tuberculosis, tuberculous with pleuritis and peritonitis, and transferrd to our hospital. After initiation of treatment with isoniazid, rifampicin (RFP), ethambutol, and pyrazinamide, RFP was suspended because of direct-reacting hyperbilirubinemia. As the liver function recovered after discontinuation of RFP, low dose of RFP was re-administrated and renal dysfunction was observed. The renal dysfunction continued after discontinuation of suspicious drugs including RFP. As renal biopsy revealed interstitial nephritis, prednisolon 20 mg/day was started and renal function recovered quickly. From the clinical course and examination, we considered interstitial nephritis was due to re-administration of RFP and steroid therapy was effective.

Effects of N-acetyltransferase 2 (NAT2), CYP2E1 and Glutathione-S-transferase (GST) genotypes on the serum concentrations of isoniazid and metabolites in tuberculosis patients.

For the purpose of a side-effect monitoring of isoniazid (INH), we investigated the relationship between the genotypes of drug-metabolizing enzymes involved in INH metabolism and the serum concentrations of INH and its metabolites in 129 tuberculosis patients hospitalizing in the National Hospital Organization Chiba-East Hospital. Genotype distributions of N-acetyltransferase 2 (NAT2), CYP2E1*5B, CYP2E1*6, Glutathione-S-transferase (GST) M1 and GST T1 were similar to those already reported in Japanese populations. Acetylating pathway of INH to acetyl isoniazid (AcINH) tended to shift to the hydrolytic pathway generating hydrazine (Hz) with the increase of mutant alleles in NAT2 gene. Serum concentration of Hz was significantly higher in slow acetylators than in rapid acetylators of NAT2. And also, serum concentration of Hz was significantly higher in the group that showed a high concentration of rifampicin (RFP) than in which RFP was not detected. The effect of CYP2E1 gene polymorphisms on the serum concentration of Hz was rarely observed, while that of GST gene polymorphism was observed in intermediate acetylators of NAT2. Hz tended to accumulate in patients with GST M1 null genotype. Therefore, it is conceivable that the risk factors of Hz accumulation are as follows: NAT2 slow acetylator phenotype, high concentration of serum RFP, and GST M1 null genotype. In these cases, we think it's necessary to pay attention to the development of hepatic disorder caused by Hz.

Comparison of the sensitivity and specificity of two whole blood interferon-gamma assays for M. tuberculosis infection.

OBJECTIVES: To compare the sensitivity and the specificity of the QuantiFERON-TB Gold (QFT-G) and QuantiFERON-TB Gold In Tube (QFT-GIT) diagnostic tests for Mycobacterium tuberculosis infection. METHODS: One-hundred patients with culture and/or PCR confirmed M. tuberculosis infection and 168 volunteers with no risk factors for M. tuberculosis infection were tested to estimate sensitivity and specificity, respectively. RESULTS: Analysis of data from the tuberculosis (TB) patients with valid results found the sensitivity of QFT-GIT (92.6%, 87/94) to be significantly higher than that for the QFT-G test (81.4%, 79/97; p=0.023). The specificity of both QFT-GIT and QFT-G was 98.8% (CI: 95.1%-99.8%) with 2 of the 160 low risk subjects with valid results for both tests being positive. Data analysis confirmed the manufacturer's recommended test cut-off as being optimal, but identified higher sensitivity could be obtained by using a lower cut-off, with only a moderate decrease in specificity. CONCLUSIONS: The QFT-GIT test had enhanced sensitivity for detection of M. tuberculosis infection over the QFT-G test, whilst maintaining equivalent high specificity. The logistic benefits of the QFT-GIT test format, as well as its higher sensitivity, should enable enhanced TB control.

[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.

[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.

[The clinical features for tuberculosis in compromised hosts].

We investigated the clinical features and measures for tuberculosis with diabetes mellitus, AIDS, gastrectomy, malignant tumor, or receiving anti-tumor necrosis factor-alpha. In these days, tuberculosis patients with diabetes mellitus are increasing. Their tuberculosis is often found in advanced cases and the periods of symptomatics are short. In short, in tuberculosis with diabetes mellitus, the progress of tuberculosis is fast. Japanese patients of tuberculosis with AIDS are frequent in mid-life and increasing. Extra-pulmonary tuberculosis including disseminated tuberculosis is frequent with patients of AIDS. The prognosis of them is improved with the spread of HAART treatment. The most frequent occasion for gastrectomy is gastric cancer and the prognosis is good. Many of them are thin and malnutrition. The prognosis of tuberculosis with malignant tumor is bad, especially with lung cancer and malignant lymphoma. People receiving infliximab, an antitumor necrosis factor-alpha, are frequent to have onset of tuberculosis. Particularly, extra-pulmonary tuberculosis, including disseminated tuberculosis are often. Tuberculin reaction before receiving infliximab are weak. No one, receiving chemoprophylaxis, has onset of tuberculosis. When the rate of chemoprophylaxis increases, the number of tuberculosis patients decreases. Immunocompromised hosts need to be examined periodical or extraordinary when they had symptoms of tuberculosis to discover the onset of tuberculosis. To prevent the onset of tuberculosis, patients who previously infected tuberculosis should receive active chemoprophylaxis regardless of their age.

[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.

[Chemoprophylaxis for tuberculosis].

In Japan, a person who is 29 or younger, contacted a tuberculosis patient recently and judged to have received infection is the object of the chemoprophylaxis by the public expenditure. On the other hand, in ATS/CDC, they call chemoprophylaxis as the treatment of latent tuberculosis infection, and if there is a strong possibility that a person may appear tuberculosis, they start chemoprophylaxis, regardless of age. We usually prescribe isoniazid for latent tubercular infection. The period of prescription is at least 6 months, which is effective, but 9 months is more desirable. Recently, in the West, tuberculosis are frequent among patients who are administered Infliximab, anti-tumor necrosis factor-alpha. In Japan, after 6 months' evaluation period for Infliximab medication to rheumatoid arthritis, 11 out of 2,000 became tuberculosis (100,000 to 550). As for the tuberculin reaction before Infliximab medication, 2 were un-carrying out and 4 were negative. Moreover, even in positive examples, many of them were small redness. From this result, the Japanese Society for Tuberculosis and the Japan College of Rheumatology advised jointly. Those who are using immunosuppressant drugs and a doctor judged that they need chemoprophylaxis are supposed to the start medication if they are positive in tuberculin reaction, or there are some proof of tubercular infection on chest X-ray film, or there are high possibility of having received tubercular infection. By carrying out active chemoprophylaxis regardless of age, tuberculosis from high risk group is expected to decrease.