High Detection Rates of Urine Mycobacterium tuberculosis in Patients with Suspected Miliary Tuberculosis.

Objective The utility of detecting Mycobacterium tuberculosis in urine samples from patients with pulmonary tuberculous with diffuse small nodular shadows (suspected miliary tuberculosis (MTB)) is still unclear in Japan. A retrospective cross-sectional study was conducted to investigate the detection rates of M. tuberculosis in urine of patients with suspected MTB. Methods Among 687 hospitalized patients with tuberculosis, 45 with culture-confirmed suspected MTB and the data of culture and polymerase chain reaction (PCR) for M. tuberculosis in urine and sputum samples were investigated. The detection rates of M. tuberculosis in urine using cultures and PCR were calculated. The detection rate of urine was then compared with that of bone marrow aspiration. Results Fourteen patients with suspected MTB were ultimately analyzed. A diagnosis of miliary tuberculosis was suspected in all patients before anti-tuberculosis chemotherapy. Positive results by PCR (11 [78.6%] cases) and culture (8 [57.1%]) were obtained from urine samples. In patients with suspected MTB, there was no significant difference in the detection rates between M. tuberculosis in urine using a combination of PCR and culture (85.6% [12/14 cases]) and bone marrow aspiration (66.7% [8/12 cases]) (p>0.05). Conclusion Using PCR and culture, we demonstrated high detection rates of M. tuberculosis in the urine of patients with suspected MTB. A combination of PCR and culture compared favorably with the detection rates achieved with bone marrow aspiration. We believe that detection of M. tuberculosis from urine and sputum samples may be easy and safe for patients with disseminated tuberculosis infections such as definitive MTB.

A necrotic lung ball caused by co-infection with Candida and Streptococcus pneumoniae.

INTRODUCTION: A necrotic lung ball is a rare radiological feature that is sometimes seen in cases of pulmonary aspergillosis. This paper reports a rare occurrence of a necrotic lung ball in a young male caused by Candida and Streptococcus pneumoniae. CASE REPORT: A 28-year-old male with pulmonary candidiasis was found to have a lung ball on computed tomography (CT) of the chest. The patient was treated with ß-lactams and itraconazole and then fluconazole, which improved his condition (as found on a following chest CT scan) and serum ß-D-glucan level. The necrotic lung ball was suspected to have been caused by coinfection with Candida and S. pneumoniae. CONCLUSION: A necrotic lung ball can result from infection by Candida and/or S. pneumoniae, indicating that physicians should be aware that patients may still have a fungal infection of the lungs that could result in a lung ball, even when they do not have either Aspergillus antibodies or antigens.

Respiratory failure caused by intrathoracic amoebiasis.

A 41-year-old male was admitted to the hospital with symptoms of diarrhea, fever and rapidly progressive respiratory distress. A chest radiograph and computed tomography (CT) of the chest and the abdomen showed a large amount of right pleural effusion and a large liver abscess. The patient was thus diagnosed to have amoebic colitis, amoebic liver abscess and amoebic empyema complicated with an HIV infection. The patient demonstrated agranulocytosis caused by the administration of trimethoprim-sulfamethoxazole. However, the administration of granulocyte colony-stimulating factor made it possible for the patient to successfully recover from agranulocytosis, and he thereafter demonstrated a good clinical course.

Addison's disease induced by miliary tuberculosis and the administration of rifampicin.

We herein report a rare occurrence of Addison's disease caused by acute adrenal gland tuberculosis occurring in association with miliary tuberculosis and the administration of rifampicin. An 82-year-old woman with miliary tuberculosis was treated with antituberculous chemotherapeutic agents including rifampicin (RFP), but she still demonstrated general malaise in addition to hyponatremia. Abdominal CT showed an enlargement of the right adrenal gland. However, after discontinuing RFP, the patient's symptoms improved. We carefully reinitiated the administration of RFP. The patient's condition thereafter did not worsen, and the treatment could thus be maintained. It is extremely important to immediately recognize adrenal crisis precipitated by the administration of RFP.

Medical Thoracoscopy Performed Using a Flexible Bronchoscope Inserted through a Chest Tube under Local Anesthesia.

Background and Objectives. Many cases of pleural effusion can remain undiagnosed following thoracentesis. We evaluated our own technique for performing thoracoscopy under local anesthesia using a 32 Fr chest tube and a flexible fiberoptic bronchoscope without a rigid thoracoscope for the diagnosis, inspection, and management of patients with pleurisy. Methods. Seven patients with pleural effusion who underwent thoracoscopy under local anesthesia using a 32 Fr chest tube and a flexible fiberoptic bronchoscope were retrospectively studied. Results. Thoracoscopy was safely performed in the diagnosis and management of pleural effusion in all cases. The visualization of the pleura, diaphragm, and lung using this instrumentation was excellent in comparison to that normally obtained during surgical thoracoscopy. A forceps biopsy of the pleura or diaphragm could therefore be easily and effectively performed. Conclusion. This technique is considered to have clinical utility as a diagnostic tool for pleurisy; furthermore, this method is safe, effective and inexpensive, not only for surgeons but also for physicians.

Multiple myeloma presenting initially with pleural effusion and a unique paraspinal tumor in the thorax.

We herein report an extremely rare case of a patient with IgD-lambda positive multiple myeloma presenting with myelomatous pleural effusion and ascites. A 58-year-old man visited our hospital with dyspnea as his initial symptom. His chest radiograph findings on admission revealed a left pleural effusion, and later, bilateral involvement. Computed tomography (CT) of the chest showed a paraspinal tumor with extension from the upper mediastinum to the abdomen. The cytological examination demonstrated myeloma cells in the pleural effusion and ascites, and histologically, in the pleura, an abdominal subcutaneous tumor and bone was observed. The pleural effusion was an exudate and slightly bloody. The ADA was 70 IU/L. Pleural effusion accompanying myeloma or primary pleural myeloma is very rare and, furthermore, the extremely rare findings of both myeloma cells in the ascites (although the ascites was mainly caused by liver cirrhosis) and a high ADA activity in the pleural fluid were also observed in this case.

[Comparison of ciprofloxacin with biapenem in patients with moderate or severe pneumonia].

We conducted the comparative study to clarify the clinical efficacy and features of ciprofloxacin (CPFX) and biapenem (BIPM) in the treatment of moderate or severe pneumonia. Among 209 patients enrolled, 173 patients (CPFX; 87, BIPM; 86) complying with the protocol were evaluated for safety and 171 (CPFX; 85, BIPM; 86) for efficacy. No significant difference was noted between groups in patient profiles. Both groups were similar in efficacy, as evaluated by the following variables: fever, WBC, CRP, and chest X ray score. The incidence of adverse drug reactions was 16.1% (14/87 patients) in the CPFX group and 16.3% (14/86 patients) in the BIPM group. Phlebitis occasionally occurred in the CPFX group and drug eruption and liver function disorder occasionally in the BIPM group. In conclusion, both CPFX and BIPM were useful in treating moderate or severe pneumonia and no difference was seen between groups in efficacy. Some differences were noted in adverse reactions, however.

Helicobacter pylori infection rate in patients with nontuberculous mycobacteriosis who are on longterm combination chemotherapy of clarithromycin and rifampicin.

Clarithromycin resistance in Helicobacter pylori has increased the incidence of eradication failure. Clarithromycin is a key drug in the current treatment regimens for H. pylori infection, and it is also used for nontuberculous mycobacteriosis (NTM). The rate of H. pylori infection in 15 patients with NTM who were on longterm clarithromycin, rifampicin, and other drug therapy was examined, using the [(13)C] urea breath test. H. pylori was detected in 5 of the 15 patients (33.3%), which was significantly lower than the prevalence of H. pyloriin subjects who had routine upper gastrointestinal endoscopy in Japan (P = 0.0006). Thus, H. pylori resistance to clarithromycin is suggested to be low in patients with longterm administration, and the possibility exists of a combination of clarithromycin and rifampicin as a second-line therapy for the eradiation of H. pylori.

Fatal rapidly progressive interstitial pneumonitis associated with amyopathic dermatomyositis and CD8 T lymphocytes.

A patient with amyopathic dermatomyositis associated with fatal rapidly progressive interstitial pneumonitis resistant to therapy is described. Pathologic examination of a transbronchial lung biopsy specimen showed diffuse alveolar damage and nonspecific interstitial pneumonia-organizing pneumonia-like findings. Bronchoalveolar lavage fluid contained many CD8+ lymphocytes, considered to be cytotoxic T cells. Analysis of bronchoalveolar lavage fluid in this case may provide prognostically and pathogenetically important information.

Clinical utility of lipoarabinomannan antibody in pleural fluid for the diagnosis of tuberculous pleurisy.

We studied the clinical utility of the detection of lipoarabinomannan antibody, using MycoDot, in pleural fluid for the diagnosis of tuberculous pleurisy. Nine patients with active tuberculous pleurisy, 1 patient with chronic tuberculous empyema, and 16 patients with nontuberculous pleural effusions were studied. The results were positive in 5 patients with tuberculous pleural disease. Sensitivity was 50% (5 of 10; including the 1 patient with chronic tuberculous empyema) and specificity was 93.8% (15 of 16). Detection of lipoarabinomannan antibody using MycoDot in pleural fluid is a specific diagnostic tool for tuberculous pleurisy; furthermore, this diagnostic method is simple, rapid, and cost-effective.

[Pulmonary tuberculosis mimicking fungus ball].

We treated a 42-year-old man with pulmonary tuberculosis presenting as a round mass in a cavitary lesion that resembled a fungus ball. These findings appeared within a short time. The diagnosis was confirmed by isolation of Mycobacterium tuberculosis from his sputum. He also had diabetes mellitus that was poorly controlled. The patient was treated with antituberculous chemotherapy and insulin therapy. With these treatments, the roentgenographic abnormalities resolved fairly rapidly.

Tuberculosis associated with gastrectomy.

We describe the incidence and clinical features of patients with tuberculosis who had undergone gastric resection in our hospital. A total of 26 patients with tuberculosis who had undergone gastric resection were studied. The prevalence of gastrectomy among patients with tuberculosis was 8.0% (7/87) in 2000, 5.1% (4/78) in 2001, and 13.2% (10/76) in 2002. The average 3-year incidence was 9.1%. The patients' body mass indexes (BMIs) were below 18 kg/m2 in 9 of the 21 patients in whom it was possible to determine BMI and above 22 kg/m2 in only 2 of these 21 patients. Analysis of impaired glucose tolerance revealed oxyhyperglycemia or diabetes mellitus as one risk factor for the development of tuberculosis. Furthermore, poor nutrition among patients who have undergone gastrectomy may provide prognostic information for the development or reactivation of tuberculosis. In Japan, a fairly large percentage of elderly people have undergone gastrectomy for gastric cancer or gastric ulcer, and many have a past history of tuberculosis. Gastrectomy may be a risk factor for the reactivation of tuberculosis.

[Tuberculosis in elderly].

We compared patients with active tuberculosis treated at Kurume University Hospital between cases 65 years and above and below 65. The comparison included immunologic and clinical features. Anergy to tuberculin skin tests with purified protein derivative (PPD) was evident in 7% of patients under 65 and in 14% of those over 65. Older patients had fewer lymphocytes in peripheral blood and lower serum concentrations of interferon (IFN)-gamma than younger patients. Complications were more frequently seen in patients above 65, but the time required for negative conversion of sputum cultures did not differ by age. Adequacy of the regimen of chemotherapy and the sensitivity to anti-mycobacterial drugs were the most important determinants of the time for negative conversion of sputum culture. Major clinical problems of old tuberculosis patients were concurrent diseases, bed ridden states, necessity of nursing care, and poor performance status of patients.

[Tuberculosis in patients undergoing hemodialysis].

We studied patients who were diagnosed as active tuberculosis while undergoing hemodialysis at Kurume University Hospital. The observation included immunologic and clinical features. Cellular immunity was depressed in our patients undergoing hemodialysis, as evident from the decreased numbers of lymphocytes and anergy to tuberculin skin tests with purified protein derivative (PPD). Further, in a few patients, hemodialysis was shown to eliminate IFN-gamma from the blood. Various antituberculous chemotherapy regimens have been studied in hemodialysis patients. Although the incidence and mortality of tuberculosis have been reported to be higher in hemodialysis patients than in the general population, the clinical outcome of our cases was favorable in this study. One important notice is to recognize promptly peripheral neuropathy while treating tuberculosis associated with hemodialysis, and this could be prevented by the adequate use of pyridoxine.

Bacteremic and leukopenic pneumococcal pneumonia: successful treatment with antibiotics, pulse steroid, and continuous hemodiafiltration.

We describe a case of bacteremic, leukopenic pneumococcal pneumonia with respiratory failure, accompanied by diabetic ketoacidosis and hypothermia. Pulmonary leukostasis may play a role in the pathogenesis of the acute respiratory distress syndrome (ARDS) in pneumococcal pneumonia. The patient recovered with mechanical ventilation, intravenous antibiotics, pulse-steroid therapy, and continuous hemodiafiltration (CHDF). In particular, administration of steroid and the use of CHDF may improve the status of pulmonary leukostasis in leukopenic pneumococcal infection.