Efficacy of Diluted NBCA Mixture for Embolization of Arteriovenous Malformations

The purpose of this study is to evaluate the efficacy and problems of the embolization for cerebral arteriovenous malformations (AVMs) with diluted cyanoacrylate adhesives.

Twelve consecutive AVM cases were treated with N-butyl-2-cyanoacrylate (NBCA) glues between January 1997 and July 1998. The mean age of the patients was 37 years old. Intracerebral hemorrhage was the presenting symptom in seven cases, seizure in three, headache in one and mental deterioration in one. According to the classification of Spetzler and Martin, seven were Grade 11, five were Grade III. We used a mixture of NBCA (normally 25% Histoacryl, 75% Ethidol) for embolization. Microcatheter was navigated into the nidus and the tip of the catheter was set in a wedged position. Then the glue was injected using complete column technique.

Nineteen sessions of embolization were performed in 12 patients. The mean volume of each nidus was reduced from 22.5 ml to 3.4 ml (85%) after embolization. Four cases were cured by embolization alone. Surgical resection was performed after embolization without any residual nidus in three cases. Five were treated with stereotactic radiosurgery following embolization. One was completely cured in 18 months after and the other four have been decreasing their sizes of nidus. One case was suffered from delayed intracerebral hemorrhage three days after embolization, and resulted in mild hemiparesis and memory disturbance. The others had no complications and were clinically improved or unchanged after embolization.

It is possible to embolize the nidus of AVMs more accurately and safely with diluted mixture of NBCA, compared with the method using relatively higher concentration of NBCA glues. This technique is useful and effective method for the treatment of AVMs.

Efficacy and safety of voriconazole in the treatment of chronic pulmonary aspergillosis: experience in Japan

BACKGROUND

Though various clinical conditions of aspergillosis can occur, depending essentially on the host's immunological status, the focus of research in North American and European countries has mainly been on invasive pulmonary aspergillosis in immunocompromised patients. There are, however, also many problems to overcome in chronic forms of aspergillosis. One of those problems is that there are no codified treatment guidelines for chronic pulmonary aspergillosis (CPA). Especially in Japan, this issue is more serious, because there are more cases with CPA due to the many aged people with past history of tuberculosis. Several clinical cases and case series have reported the usefulness of the various antifungal agents that are available. The new triazole, voriconazole, in particular, seems to be effective in the treatment of CPA. The aim of the present study is to evaluate the efficacy and safety of voriconazole in the treatment of CPA in non-immunocompromised patients.

PATIENTS AND METHODS

We conducted a prospective, open-label, non-comparative, multicenter study over a 2-year period. For inclusion in the study, patients with confirmed or probable CPA were recruited in 11 hospitals of the National Hospital Organization in Japan. Clinical, radiological, serological, and mycological data were collected at baseline and 12 weeks after treatment or at the end of treatment.

RESULTS

Among 77 patients enrolled in the study, 71 patients (mean age 65.9 years, 56 males and 15 females) were eligible for the study. All of the eligible patients presented with underlying lung diseases, including sequelae of tuberculosis (n = 35), non-tuberculous mycobacterial lung disease (n = 8), chronic obstructive pulmonary disease (COPD) (n = 8), interstitial pneumonia (n = 7), cystic lung disease (n = 4), pneumothorax (n = 3), bronchial cancer (n = 1), and others (n = 5). Voriconazole was indicated in 48 cases (68 %) as the first-line treatment for CPA and 23 patients previously received other antifungal therapies. Based on a composite of clinical, radiologic, serological, and mycologic criteria, good response was seen in 43 patients (60.6 %), no response was observed in 19 patients (26.8 %), and 4 cases (5.6 %) got worse. Five patients (7.0 %) were unassessable for efficacy. The common adverse events were visual disturbances (17 patients, 23.9 %), abnormal liver function test results (12 patients, 16.9 %), adverse psychological effects (3 patients, 4.2 %), and others (10 patients, 14.0 %). Treatment with voriconazole had to be stopped in 2 cases (2.8 %) because of serious adverse events (abnormal liver function test results). There was no association between adverse effects and trough voriconazole levels in serum.

CONCLUSIONS

In Japan, voriconazole provides effective therapy of CPA in non-immunocompromised patients with an acceptable level of toxicity.

Pulmonary Mycobacterium avium complex infection associated with the IVS8-T5 allele of the CFTR gene

BACKGROUND

The T5 allele in intron 8 (IVS8) on specific haplotype backgrounds (e.g., long TG repeats) causes abnormal splicing in the cystic fibrosis transmembrane conductance regulator (CFTR) gene, and is also known to be associated with chronic airway diseases.

OBJECTIVE

To investigate the role of CFTR variations for susceptibility to pulmonary Mycobacterium avium complex (MAC) infection.

PARTICIPANTS

Three hundred patients with pulmonary MAC infection (72 males, 228 females; mean age at onset 61.6 + or - 12.4 years) took part in this study. Diagnosis of MAC infection was based on American Thoracic Society criteria. Clinical profiles were collected and blood samples were genotyped for TG repeats, poly-T and M470V polymorphisms.

RESULTS

We found significantly higher T5 frequency in MAC patients than in healthy controls from our own study (0.035 and 0.005, respectively, P = 0.023) and other reports. Homozygote for the T5 allele was found in two MAC patients. All T5 alleles were associated with longer TG repeats, the TG12 or TG13 allele. Seventeen of the 21 T5 alleles appeared to be associated with the V470 allele. Other polymorphisms did not show any significant differences in frequency.

CONCLUSIONS

These findings suggest that the IVS8 5T allele might be involved in susceptibility to pulmonary MAC infection.

Pulmonary Mycobacterium avium complex infection: association with NRAMP1 polymorphisms

The present study aimed to elucidate risk factors for nonimmunocompromised pulmonary Mycobacterium avium complex (MAC) infection. Epidemiological data and variations of candidate genes for mycobacterial diseases were analysed in 111 patients with pulmonary MAC infection. Four polymorphisms of the human natural resistance-associated macrophage protein (NRAMP)1 gene, the 5'(GT)n, 469+14 G/C, D543N and the 3'untranslated region (3'TGTG) insertion/deletion, were genotyped using PCR-based methods. Fok I and Taq I polymorphisms of the vitamin D receptor gene and -221 X/Y and codon 54 A/B polymorphisms of the mannose binding lectin gene were also evaluated. Females were more susceptible to MAC infection mainly affecting the right middle lobe or lingular segment of the lung. Patients' residence at the onset of the disease was distributed evenly irrespective of a waterfront or city water supply system. As compared with homozygotes for major alleles of the D543N and TGTG insertion/deletion polymorphism of the NRAMP1 gene, heterozygotes containing minor alleles were less often observed in MAC cases than in controls. This genetic effect was more significant in patients without comorbidity but not in patients with comorbidity. Other polymorphisms did not show any association with the MAC infection. The human natural resistance-associated macrophage protein 1 gene might be involved in susceptibility to pulmonary Mycobacterium avium complex infection.

Clinical evaluation of Amplicor Mycobacterium detection system for the diagnosis of pulmonary mycobacterial infection using sputum

SETTING

The Amplicor Mycobacterium detection kit was evaluated for the diagnosis of active pulmonary mycobacterial infection using sputum.

OBJECTIVE

To assess the clinical usefulness of the Amplicor Mycobacterium kit for the diagnosis of pulmonary tuberculosis and non-tuberculous mycobacterial infection in the country of medium prevalence.

DESIGN

All the patients were diagnosed with bacterial, histopathological, and clinical 'gold standard'. The sensitivity and specificity for diagnosing clinically active pulmonary tuberculosis and Mycobacterium avium and Mycobacterium intracellulare infections were evaluated comparing Amplicor results and clinical diagnosis.

RESULTS

A total of 1088 sputum specimens were collected from 780 in and out patients. Mycobacteria were recovered from 339 specimens by culture. The sensitivity and specificity of conventional culture method for the diagnosis of pulmonary tuberculosis were 60.2% and 99.8% respectively based on the number of patients. The figures for Amplicor were 61.8% and 97.4% respectively. There was no statistical significant difference between these methods. In rapidity, the Amplicor was significantly superior to the microscopy method in sensitivity.

CONCLUSION

Patients with Amplicor positive and conventional negative result had mostly mycobacteria related diseases. The Amplicor positive result indicated mostly active mycobacterial infection and was clinically useful for rapid diagnosis.

Potential use of Amplicor PCR kit in diagnosing pulmonary tuberculosis from gastric aspirate

Polymerase chain reaction (PCR) detection of mycobacteria from gastric aspirate for the diagnosis of tuberculosis is not fully evaluated up to now. A total of 116 gastric aspirate specimens were collected from patients with suspected pulmonary tuberculosis. The breakdown of diagnosis was 67 pulmonary tuberculosis, 16 nontuberculous mycobacterial infection, 5 extra pulmonary tuberculosis, and 28 other lung diseases. The conventional methods were shown to have a sensitivity of 47.8% and a specificity of 79.6%; on the other hand, Amplicor had 34.9% and 97.0%, respectively. The Amplicor provided a more rapid and specific method for diagnosing tuberculosis and was more useful than the conventional.

Prognostic significance of thrombomodulin expression and vascular invasion in stage I squamous cell carcinoma of the lung

Thrombomodulin (TM) is an important modulator of intravascular coagulation. TM exists on endothelial cells and on several types of tumor cells, especially squamous cell carcinoma cells. Tumor cell TM is thought to be associated with progression and metastasis of the tumor. To evaluate the prognostic significance of TM in lung cancer, we examined TM expression and vascular invasion in surgical specimens obtained from 90 patients with completely resected stage I non-small cell lung cancer (NSCLC). In addition, we correlate these pathologic data to other clinicopathologic data, including the outcome of the patients. Squamous cell carcinomas had a significantly higher incidence (P<0.0001) of TM expression (22/36 cases, 61%) than adenocarcinomas (9/54 cases, 17%). In 36 squamous cell carcinoma patients, both vascular invasion (P=0.0153; risk ratio 6.507) and TM non-expression (P=0.0282; risk ratio 3.584) were significant for a poor prognosis. Univariate analysis of patient survival rates also revealed that vascular invasion and TM expression were significant prognostic factors (P=0.0036 and 0.012, respectively). Further, combination analysis of vascular invasion and TM expression in the squamous cell carcinoma patients showed that the 5-year survival rate was 90% in patients with TM expression and without vascular invasion, but 21% in patients with vascular invasion and without TM expression (P=0.0004). Since our results suggest that vascular invasion and TM expression are independent prognostic factors of stage I squamous cell carcinoma of the lung, and since the two factors play different roles in the metastatic process of cancers (promotion of metastasis by vascular invasion and inhibition of metastasis by TM expression), the combination evaluation of vascular invasion and TM expression may be very significant in evaluating the prognosis of patients with completely resected stage I squamous cell carcinoma.

[HIV seroprevalence in patients with tuberculosis]

The number of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) in our hospital is increasing year after year. Although most patients were HIV tested because of miliary tuberculosis or extra-pulmonary tuberculosis, some patients were found HIV seropositive by chance. In order to determine the incidence of HIV seropositivity among TB patients, HIV testing was carried out in TB patients for two years from January 1998 with the consent of patients. TB patients who received anti-HIV antibody examination were 164 in 1998, and 149 in 1999 and among them HIV seropositive TB patients were 4 in 1998 and 6 in 1999. The incidence of HIV seropositivity was 3.2% in all TB patients, 28.6% in miliary TB patients, and 1.0% in typical TB patients. The number of patients co-infected with HIV and TB in Tokyo was estimated by using these HIV seropositivity, it was 23 cases/year among miliary TB patients and 16 cases/year among typical TB patients. As there were many HIV-infected persons and many TB patients in Tokyo, it was thought that HIV testing in TB patients was important for the early detection of HIV infection and the early initiation of HIV treatment.

[Tuberculosis of the elderly (above the age of 75) in national hospitals]

In Japan tuberculosis is becoming rapidly the disease of the elderly. We studied the background, the type and level of hospital cares needed, and the outcome of patients with pulmonary tuberculosis (sputum smear and/or culture positive) above the age of 75 who were admitted to 8 national hospitals during the period from January 1 to December 31, 1997. The study included 150 patients (male: 109, female: 41, mean age: 81.6), of whom 25% needed care in a single-bed room, 84.3% had underlying diseases (cardiovascular diseases: 43.3%, malignant diseases: 20.9%, neuro-psychiatric diseases: 13.4%), and 47.6% needed cares mainly in feeding and excretions. 92 patients (62.6%) improved and 45 patients (30.6%) died, of whom the cause of death was directly related to tuberculosis in 42. The mean hospital stay was 4.7 months. However, in 42 patients whose cause of death was related to tuberculosis, 66% died within 3 months, while in 102 patients who were discharged 71% stayed more than 3 months. The same comparison was done in 508 patients with bacteriologically proven tuberculosis above the age of 75 admitted to National Tokyo Hospital during the period from 1990 to 1999. The result was almost the same, among 133 patients died in the hospital 60% died within 3 months, while in 375 patients who were discharged hospital stay was more than 3 months in 70%. In the near future, the elderly will occupy more than 25% of the beds of the tuberculosis ward in Japan and most of them have underlying diseases other than tuberculosis. Because tuberculosis, once the disease of the young, is becoming rapidly the disease of the elderly, it is imperative for us to make necessary adjustments to meet this inevitable trend.

[Study of lymphocyte and NK cell activity during mild hypothermia therapy]

Infectious disease is a common complication of mild hypothermia therapy. However, very little has been reported about immune response during hypothermia. In the present study, the number and subset of peripheral lymphocytes and mitogen response to phytohaemagglutinin (PHA) and concanavalin A (Con-A) were examined in 14 patients who received mild hypothermia therapy. NK cell ratio and activity were also examined in the same patients. Six out of 14 patients had complicated infectious diseases during mild hypothermia therapy. Five of them had pneumonia and the remaining one had thrombophlebitis. The number of peripheral lymphocytes decreased in patients whose rectal temperature was less than 34.5 degrees C, whereas mitogen response of lymphocytes to PHA and Con-A remained unchanged in patients whose rectal temperature was above 34.0 degrees C. NK cell ratio and cytotoxicity decreased in patients whose rectal temperature was less than 34.5 degrees C, including infectious cases. These results suggested that, under hypothermia therapy, immune responses of the patients whose rectal temperature was less than 34.5 degrees C were disturbed because of the reduced number of peripheral lymphocytes and depression of NK cell activity.

[A study on the clinical features of pulmonary tuberculosis in elderly patients]

The clinical findings of pulmonary tuberculosis in elderly patients aged 75 years of age or older (elderly group) were compared with the middle-aged patients aged between 45 and 54 years of age (middle-aged group) and the young patients aged 34 years of age or younger (young group). The elderly patients who died in hospital were also compared with the elderly patients who survived. Study subjects were culture-positive pulmonary tuberculosis patients who were discharged from our hospital from December 1996 to November 1998. There were 79 patients in the elderly group, 95 in the middle-aged group, and 88 in the young group. The results were as follows. 1) The male/female ratio was significantly lower in the elderly group (1.9:1) than the middle-aged group (6.9:1). 2) Complication was noted more frequently in the elderly group. However, diabetes mellitus was noted less frequently in the elderly group (12.7%) than the middle-aged group (28.4%). 3) The frequency of cavitation was lower in the elderly group (59.5%) than the middle-aged group (87.4%). 4) The fever over 38 degrees C was noted less frequently in the elderly group (17.7%) than the other groups, while the frequency of the fever over 37 degrees C showed no significant difference between the elderly group and the other groups. 5) The frequencies of hypoalbuminemia and appetite loss were higher in the elderly group than the other groups. 6) The elderly group showed high mortality rate of 31.6%. The complication with cerebrovascular disease was noted significantly higher in the patients who died in hospital than those who survived. The frequency of widespread infiltrates, fever over 38 degrees C, neutrophilia, hypoalbuminemia and appetite loss were all significantly higher in the patients who died in hospital while their sputa were still positive on culture than those who survived. Our study clearly showed the features of elderly pulmonary tuberculosis patients in comparison with middle-aged patients and young patients. These features are very important to suspect the diagnosis of pulmonary tuberculosis in elderly patients with some atypical manifestation. Our study also suggests that the delay in diagnosing tuberculosis causes more frequently the patients' deterioration and death in elderly patients than in middle-aged patients and young patients.

[The causes of death in patients with non-MDR pulmonary tuberculosis in our hospital]

We studied the causes of death in 295 patients (mean (+/- SD) age 70.5 +/- 13.2 y.o.) with active non-MDR pulmonary tuberculosis who died in our hospital between 1991 and 1999. A hundred and twenty eight patients (43.4%, group A) died of tuberculosis, while 167 patients (56.6%) of other accompanying diseases. In 46 patients of the latter (15.6%, group B), pulmonary tuberculosis gave an unfavorable impact on their clinical course. In these patients the extent of pulmonary tuberculosis on chest roentgenograph was similar with the remaining 121 patients who also died of the accompanying diseases (41.0%, group C) and was less severe than those of the group A patients. Their nutritional conditions measured by serum albumin and choline-esterase level on admission, however, were as low as those of the group A patients and distinctly worse than those of the group C patients. Most patients of groups A and B died within 3 months after admission, while less than half patients of group C died during the same period. The age frequency distribution of the patients in groups B and C had a single peak in the age group 70 to 89, while that in group A showed two peaks, one similar peak as in groups B and C, and another peak in the age group 50 to 59. The numbers of homeless patients, of the patients with extensive cavitary lesions, and of the patients who died of ARDS (Adult Respiratory Distress Syndrome) or severe pneumothorax in group A were the most also in the age group 50 to 59, indicating that the patients' delay in admitting to hospitals was the major cause of high motality in this age group. As to detailed causes of death in group A, patients died of respiratory failure (32 cases), emaciation (28 cases), progression of pulmonary tuberculosis (20 cases), ARDS (15 cases), tuberculosis-related diseases such as pneumothorax, hemoptysis, and DIC (24 cases). In groups B and C patients died of organ failure (36 cases), infectious diseases (33 cases) and malignancy (30 cases). The total number of died patients has increased, and the proportion of cases dying of ARDS and infectious diseases has increased statistically significantly recently.

Comparative study of amplicor Mycobacterium PCR and conventional methods for the diagnosis of pleuritis caused by mycobacterial infection

OBJECTIVE

To assess the clinical significance of the Amplicor Mycobacterium system for the diagnosis of mycobacterial infection in patients with pleural fluid, and to compare its usefulness with that of conventional smear and culture methods.

DESIGN

Pleural fluid specimens were obtained randomly from in-patients admitted to National Tokyo Hospital between January and December 1996. All the patients were diagnosed with bacterial, histopathological and clinical gold standard. The sensitivity and specificity for diagnosis of mycobacterial infection were evaluated.

RESULTS

Seventy-five pleural fluid specimens were obtained. Conventional methods demonstrated a sensitivity of 30.6% and a specificity of 100%, while the Amplicor Mycobacterium demonstrated a sensitivity and specificity of 27.3% and 97.6% respectively. Lactic dehydrogenase, carcinoembryonic antigen, red blood cell, protein, glucose and types of inflammatory cells were not different in Amplicor positive and negative pleural fluid with mycobacterial infection.

CONCLUSION

There was not much improvement in the accuracy of diagnosis when Amplicor Mycobacterium was used to diagnose mycobacterial pleuritis among various diseases with pleural fluid; however, the assay time was dramatically reduced with the use of Amplicor Mycobacterium.

Serological diagnosis of idiopathic pulmonary alveolar proteinosis

Previously, we reported the specific occurrence of neutralizing autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF) in the bronchoalveolar lavage fluid from 11 Japanese patients with idiopathic pulmonary alveolar proteinosis (I-PAP). The autoantibody was also detected in sera from all 5 I-PAP patients examined. To determine that the existence of the autoantibody is not limited to the Japanese patients, we examined sera from 24 I-PAP patients in five countries and showed that the autoantibody was consistently and specifically present in such patients. Thus, detection of the autoantibody in sera can be used for diagnosis of I-PAP. To establish a simple and convenient method for diagnosis of I-PAP, we developed a novel latex agglutination test using latex beads coupled with recombinant human GM-CSF. GM-CSF binding proteins isolated from the sera using the latex beads were identified as the autoantibodies of IgG(1) and IgG(2). The titer of the autoantibody determined by this test correlated with that determined by ELISA. Agglutination was positive in 300-fold diluted sera from all 24 I-PAP patients, but negative in sera from four secondary PAP patients, two congenital PAP patients, 40 patients with other lung diseases, and 38 of 40 normal subjects. These results establish that the latex agglutination test is a reliable method for serological diagnosis of I-PAP with high sensitivity (100%) and specificity (98%).

[Acute respiratory failure caused by tuberculosis requiring mechanical ventilation]

The patients with active tuberculosis in whom respiratory failure requiring mechanical ventilation developed were studied retrospectively. Nine patients (M 8, F 1) were identified at the National Tokyo Hospital during 5 years from January, 1993 to December, 1997. Seven of 9 patients were single men, and the duration of symptoms before admission was over 1 month in all patients, while the time from first visit to diagnosis was less than 7 days. All patients were identified as malnourished, and 7 patients suffered from another underlying diseases. The patients were classified into two groups. Six of 9 patients had pulmonary tuberculosis and the other three had miliary disease. The proportion of cases requiring mechanical ventilation was 0.3% and 8.6%, respectively, in pulmonary tuberculosis and miliary tuberculosis. At the start of mechanical ventilation, PaO2/FIO2 was lower than 200 in all 9 patients, and 6 patients were probably ARDS. Steroids (methylprednisolone 250-1000 mg/day) were used in all 9 patients. Despite the use of mechanical ventilation and antituberculous therapy, 8 out of 9 patients died. Only one patient with miliary tuberculosis survived. The establishment of the therapy for acute respiratory failure is needed so as to improve prognosis of such cases. At the same time, the delay in consulting a doctor led to acute respiratory failure in most cases, so it is also important to encourage tuberculosis patients to visit a doctor as soon as possible, after the appearance of symptoms.

[Active pulmonary tuberculosis in patients with lung cancer]

To clarify the features of the coexistence of active pulmonary tuberculosis in patients with lung cancer, we analyzed clinical data on 25 cases with coexisting lung cancer and active pulmonary tuberculosis encountered at Tokyo National Chest Hospital during the period from 1991 to 1998. There were 23 men and 2 women, with a mean age of 70 years. The incidence of lung cancer among patients with active pulmonary tuberculosis at our hospital was 0.7 per cent, while the incidence of active pulmonary tuberculosis in untreated lung cancer patients at our hospital was 1.9 per cent. We classified the 25 cases into 2 groups as follows: (1) tuberculosis sequential to lung cancer (11 cases) and (2) tuberculosis concurrently detected with lung cancer (14 cases). All patients in the former group were transferred from other hospitals after diagnosing the coexistence of pulmonary tuberculosis during the management of lung cancer. Histological types of lung cancer were squamous cell carcinoma in 12, adenocarcinoma in 9, and small cell carcinoma in 4, and as to the disease stage, stages III to IV were predominant. Analysis on relationship of chest X-ray findings between lung cancer and pulmonary tuberculosis revealed that in general, the location of lung cancer and tuberculosis seemed to be independent. Tuberculosis in the sequential group was more extensive and severer than in the concurrent group. In the concurrent group, treatment for tuberculosis was successful except for one case, and coexisting tuberculosis did not seem to affect the course of lung cancer among this group. However, in the sequential group, 5 patients died within 3 months, 2 of them died of tuberculosis. We consider that in the management of lung cancer, physicians should consider the possibility of coexistent active pulmonary tuberculosis and should not make delay in the diagnosis of active pulmonary tuberculosis.

[Comparison of the newly developed MB redox system with mycobacteria growth indicator tube (MGIT) and 2% Ogawa egg media for recovery of mycobacteria in clinical specimens]

The rate of recovery and the mean time to detection of mycobacteria in clinical specimens were determined in a newly-developed MB Redox system based on liquid medium, and the results were compared with those of MGIT and 2% Ogawa egg media. From 587 sputum specimens processed, totally 203 mycobacterial isolates were detected, of which 177 (87.2%) with MB Redox, 185 (91.1%) with MGIT and 133 (65.6%) with 2% Ogawa medium. The difference in the percentages of positive cultures between either of the two liquid media and 2% Ogawa medium was significant (p < 0.0001). The mean time to detection of the Mycobacterium tuberculosis complex was 17.5 days with MB Redox, 18.7 days with MGIT, and 26.2 days with 2% Ogawa medium. The contamination rates were 1.5, 1.7, and 4.1% for MB Redox, MGIT, and 2% Ogawa medium, respectively. In conclusion, both MB Redox and MGIT systems, based on liquid medium, are more efficient than 2% Ogawa medium for the recovery of mycobacteria in clinical specimens.

[Parameters relating to the development of residual pleural thickening in tuberculous pleurisy]

To identify predictive parameters for the development of residual pleural thickening in tuberculous pleurisy, we investigated 58 tuberculous pleurisy patients retrospectively who could be followed up until their chest roentgenogram no longer changed. The patients were divided into the following three groups according to the final configuration of pleural space: group I costphrenic angle (C-P angle) of the affected side was completely or almost completely recovered (20 cases), group II C-P angle became dull (20 cases), group III pleural thickening of > 2 mm remained in the lateral chest wall above the diaphragmatic dome level (18 cases). Differences of the clinical, chest roentgenographic and laboratory data were compared between these three groups. There were no differences between groups I and II in all of the parameters compared, while there were some differences between groups I and/or II and group III. The mean age of group III (51.1 +/- 18.1 y.o.) was significantly higher than that of group I (40.7 +/- 18.6 y.o.) and group II (34.7 +/- 14.7 y.o.) (p < 0.05 and p < 0.005 respectively). Glucose level in pleural fluid of group III (32 +/- 31 mg/dl) was lower than that of group I (96 +/- 13 mg/dl) and group II (86 +/- 21 mg/dl) (p < 0.001, respectively), while the levels of LDH, TP and ADA in pleural fluid were not different significantly among three groups. BSR (blood sedimentation rate) and CRP (C-reactive protein) were higher in group III (77 +/- 30 mm/hr and 8.5 +/- 4.3 mg/dl) than those in group I (45 +/- 23 mm/hr and 4.1 +/- 5.4 mg/dl) (p < 0.01 and p < 0.05, respectively). The level of albumin in serum was lower and that of globulin was higher, and consequently that of A/G ratio in group III (0.78 +/- 0.17) was lower than that of group I (1.15 +/- 0.16) and group II (1.10 +/- 0.22) (p < 0.001, respectively). It should be emphasized that the level of gamma-globulin was higher in group III irrespective of the presence or absence of accompanying pulmonary tuberculosis. Most patients more than 40 years old with serum A/G ratio less than 0.95 belonged to group III (13/15 (87%)) while most of those with serum A/G ratio more than 0.95 belonged to group I or II (10/11 (91%)). Thus hyper (gamma-) globulinemia and the intensity of inflammatory reaction in the whole body and in the pleural space are the predictive factors for the development of residual pleural thickening in tuberculous pleurisy.

[Treatment and prognosis of nontuberculous mycobacterial pulmonary infection]

In performing NTM chemotherapy, particularly to mycobacterium avium-intracellulare complex (MAC) infection, we find difficulty in planning a rational protocol, and thus depend on previous experiences. We have studied retrospectively the effects of previous combination chemo-therapy cases of pulmonary MAC infections at National Tokyo Hospital. We selected 135 cases which had received the same chemotherapy continuously over six months. Having set a mean CFU of 3 times sputum culture before treatment as 100%, we calculated a six-months sequential bacillary response to a regimen and plotted the bacillary response curves. The response curves of various regimens of multidrug chemotherapy indicate that combinations of more than 3 drugs including aminoglycoside and clarithromycin are effective. The survival curve of 104 cases which could be observed over 10 years showed that median survival time is about 10 years.

[Clinical review of 74 cases with miliary tuberculosis]

Seventy-four cases of miliary tuberculosis were studied retrospectively. The mean age of the patients was 45.3 years. Twenty-two patients suffered from another underlying diseases. Six were infected with human immunodeficiency virus. Twelve had been treated with corticosteroids. Fever was present in 97.3 per cent of patients. Elevation of serum alkaline phosphatase was found in 67.6 per cent of cases. The skin reaction to tuberculin was positive in 61.2 per cent. Nodular shadows were found in the chest X-ray in 98.6 per cent of cases. The nodules were smaller than 2 mm in diameter in 52.7 per cent of cases. Other findings were enlargement of mediastinal lymph node (17.6%), cavities (23.0%), pleural effusion (27.0%), and consolidation (35.1%). Sputum cultures and urine cultures were positive for Mycobacterium tuberculosis in 76.8 per cent and 58.6 per cent of cases respectively. The diagnosis was confirmed by histopathological findings in some cases. The rate of positive biopsies was 61.5 per cent by bone marrow aspiration, 83.3 per cent by lymph node biopsy, 100 per cent by liver and lung biopsy. Antituberculosis therapy was successful in most of the patients. Seven patients died of miliary tuberculosis, 4 of them had adult respiratory distress syndrome.

[Lung cancer in patients with sequelae of tuberculosis]

To clarify features of lung cancer in patients with tuberculosis sequelae, we analyzed data on 15 cases (5.1%) who were diagnosed with lung cancer before death among 294 deceased cases with tuberculosis sequelae at our hospital. There were 12 men and 3 women, with a mean age of 64 years. Most of the 15 patients had pulmonary dysfunction, and 4 had received home oxygen therapy. All 12 men had a history of smoking, and 10 of them had squamous cell carcinoma of the lung. There was no definite correlation between the locations of the tuberculosis lesion and those of lung cancer lesion on chest X-rays. Twelve patients had had thoracoplasty for tuberculosis, and in 6 of these patients the lung cancer occurred in the same lung. Lung cancer was apt to be diagnosed in an advanced stage. However, in patients who received home oxygen therapy, diagnosis had been made at an early stage because of the frequent chest X-ray follow-up. We conclude that lung cancer is an important complication in patients with tuberculosis sequelae, and early diagnosis of lung cancer by careful follow-up is essential in the care of cases with tuberculosis sequelae who have poor pulmonary function and/or systemic conditions.

Early pulmonary resection for localized Mycobacterium avium complex disease

BACKGROUND

Results of antituberculous chemotherapy for Mycobacterium avium complex disease remain disappointing. Pulmonary resection during an early stage of the disease, therefore, may be beneficial to patients whose disease is localized and who can tolerate a resectional operation.

METHODS

Thirty-three patients with localized M avium complex disease underwent 33 pulmonary resections between 1979 and 1996. There were 17 males and 16 females, with a mean age of 50 years (range, 30 to 69 years). Lobectomy was performed in 26 patients, pleuropneumonectomy in 1, segmentectomy in 5, and wedge resection in 1.

RESULTS

There was no operative mortality. After pulmonary resection, 31 (94%) patients attained sputum-negative status. Bronchopleural fistula occurred in one patient who underwent a right upper lobectomy. There were two late deaths. A patient with bronchopleural fistula died of respiratory failure two years postoperatively. Another patient died of an unknown cause 12 years postoperatively. Of the 31 patients with negative sputum status postoperatively, only 2 patients (6%) had relapse at 1 and 9 years after operation.

CONCLUSIONS

We recommend that patients with this disease be considered for pulmonary resection as early as possible.

[The short-term effects of multidrug chemotherapy for pulmonary Mycobacterium avium-intracellulare complex (MAC) infection]

In performing MAC chemotherapy, we are faced with the following two problems: first, unlike for Mycobacterium tuberculosis, we have neither any suitable bacteriocidal drugs nor bacteriocidal regimens for MAC treatment; secondly, in case of MAC, unlike in the case of Mycobacterium tuberculosis, in vitro sensitivity does not correlate with in vivo sensitivity. For these reasons, we find difficulty in planning a rational protocol for MAC treatment, and thus depend on previous experiences of other physicians in MAC chemotherapy. Here, we have tried to evaluate such previous experiences objectively, and studied retrospectively the effects of previous combination chemotherapy cases of pulmonary MAC infections at National Tokyo Hospital. We selected 170 cases which had received the same chemotherapy continuously over a period of six months. Concentration of bacilli cultured, 8 weeks in Ogawa solid egg containing medium was translated semi-quantitatively to colony forming units (CFU) according to the Japanese guideline for acid fast bacilli test. Having set a mean CFU of 3 times sputum culture before treatment as 100%, we calculated a six month sequential bacillary response to a regimen and plotted the bacillary response curves. The response curve of the total 170 MAC treatment cases exhibits a minimum point of 42.9% at 2 months, and subsequently rises to 71.1% after six months compared to the state before treatment. The response curves of various regimens of multidrug chemotherapy indicate that combinations of more than 3 drugs including aminoglycoside and clarithromycin are most effective. However, although some effectiveness is indicated, neither the present drugs nor regimens are capable to achieve a bacteriocidal effect in MAC treatment.

[Pathologic reconsideration on allergic bronchopulmonary aspergillosis and mycosis]

We examined lung specimens that fulfilled the pathological criteria of Bosken and were obtained from 5, patients with allergic bronchopulmonary aspergillosis/mycosis (ABPA/M). A finding common to all 5 was the presence of hard mucous plugs containing numerous eosinophils and fungal hyphae in the bronchi, showing central bronchiectasis. Bronchocentric granulmatosis with tissue eosinophilia (4 cases), xanthogranulomatous lesions (3 cases), eosinohilic pneumonia (2 cases) and organizing pneumonia (3 cases) were recognized only in bronchi distal to the mucous plugs (BMP). Almost normal lung parenchyma could be seen in some areas distal to the BMP. We found clusters of degenerated eosinophils (CDE) showing a "fir-tree like structure" and fungal hyphae in both the mucous plugs and the peripheral lesions. Most CDEs were free in the exudate and were not engulfed by macrophages. The presence of fungi in the mucous plugs may have caused marked inflammation in the wall around the BMP, which may have made the walls fragile and caused central bronchiectasis. The fungi in the mucous plugs may have caused the peripheral lesions via aerogenous dissemination. For this reason, we conclude that ABPA/M is an infectious disease, and that the primary lesion in ABPA/M is the formation of mucous plugs. Therefore, the presence of mucous plugs containing fungi and many eosinophils is diagnostic of ABPA/M.

The use of bronchofiberscopy for diagnosis of allergic bronchopulmonary aspergillosis

To assess the use of bronchofiberscopy for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA), we retrospectively analyzed bronchofiberscopic and pathologic findings of specimens obtained by bronchofiberscopy in 8 patients who met the British criteria for ABPA. Two of the 8 patients completely met Rosenberg's primary criteria for ABPA, while the remaining 6 lacked only 1 or 2 immunologic and radiographic conditions of the criteria. Bronchofiberscopic inspection revealed the presence of mucus plugs in all patients. Pathologic examination of plug specimens obtained by suction from 6 of 7 of these patients showed that the plugs consisted of allergic mucin containing fungal hyphae, diagnostic of ABPA. Bronchofiberscopy appears to be a useful tool in the diagnosis of ABPA, if immunologic and radiographic findings are not typical of ABPA. This bronchofiberscopic method is easily applicable for diagnosing allergic bronchopulmonary fungal disease (ABPFD) in addition to ABPA.

Percutaneous transluminal angioplasty for acute thrombotic occlusion of the cervical internal carotid artery using a perfusion balloon catheter

SUMMARY

We performed emergency percutaneous transluminal angioplasty (PTA) with a perfusion balloon catheter (PBC) for PTCA and, at the same time, thrombolytic therapy was administered by urokinase (UK) perfusion in five cases of severe cervical internal carotid artery stenosis in which sudden cerebral hemisphere ischemia occurred due to acute thrombotic obliteration. In four out of the five cases, effective revascularization was obtained; three resulted in Good recovery, but one showed extensive cerebral infarction after PTA. In the remaining one case, where stenosis of the internal carotid artery of the opposite side occurred subclinically, effective revascularization by PTA was impossible resulting in the death of this patient. While "artery to aetery embolism" was confirmed in all four cases in which revascularization was successful, most emboli were dissolved by combined thrombolysis. As poor prognostic factors, findings of a low density area and closing of cerebral sulci in an initial CT and poor development of the collateral circulation mediating the circle of Willis and leptomeningeal collateral on the cerebral surface were indicated. Since PBC is capable of performing PTA while assuring circulation distant from the balloon, it facilitates gradual and prolonged balloon inflation, which is said to be safer and more effective, and is considered a reasonable method of revascularization at the time of an acute obliteration in the cervical internal carotid artery. In addition, this method can be used as a bridge to carotid endarterectomy. However, "artery to artery embolism" accompanying PTA in the acute stage remains a major problem, and a combination of thrombolysis seems indispensable.

[Mycetoma-forming pulmonary nocardiosis and endobronchial polypoid lesion]

A 46-year-old man was admitted to the hospital for evaluation of a dense infiltrative shadow in the right middle lung field. Bronchoscopic examination revealed a polypoid lesion in the right middle-lobe bronchus (Bb11(5)). Examination of a biopsy specimen showed a lump with many Nocardia asteroides bacteria. The response to chemotherapy, which included sulfomethoxazole, was poor, and therefore a right middle lobectomy was done. Three mycetomas were found inside the ectatic bronchi in the S5 area. Pulmonary Nocardia mycetoma is rare.

Non-Hodgkin's lymphoma with pulmonary infiltrates mimicking miliary tuberculosis

Miliary infiltrates observed on chest films in non-Hodgkin's lymphoma are extremely rare. We report a case with pulmonary infiltrates mimicking miliary tuberculosis associated with prominent eosinophilia and elevated IgE levels. The levels of circulating eosinophils correlated with disease activity as they transiently returned to normal after effective chemotherapy in a short period. However, the patient developed acute respiratory failure due to the rapid progression of the disease even with intensive chemotherapy. We emphasize that small nodular shadows appear to be a sign of the rapid progression of the disease and a poor prognosis.

[Tuberculosis in patients with human immunodeficiency virus infection]

Six men (mean age: 36.3 +/- 29 years) infected with the human immunodeficiency virus (HIV), four Japanese and two from Myammar, were admitted to our hospital for treatment of tuberculosis. In five, HIV positivity on serologic testing was first found when tuberculosis was diagnosed. The mean CD4 cell count was 37.3 +/- 29.6/microliters. Results of tuberculin skin tests were negative in 5 patients. One patient had pulmonary tuberculosis and 5 had miliary tuberculosis. Hilar and mediastinal lymphadenopathy was found on chest X-ray films in 4 patients and superficial lymphadenopathy was found in all patients. All patients had positive mycobacterial cultures of sputum and 2 patients had positive tests for acid-fast bacilli on smears of lymph-node aspirates. In one patient with tuberculosis meningitis, a culture of cerebrospinal fluid for acid-fast bacilli was positive. Epithelioid cell granulomas were found in samples of lung, liver, and bone marrow from 4 patients. Mycobacterium tuberculosis was isolated from all patients, and was not resistant to isoniazid, rifampicin, ethambutol, or streptomycin. Therefore all patients responded well to treatment of tuberculosis.

[Pathology of bronchopulmonary aspergillosis]

This paper concerns the morphology of 3 types of bronchopulmonary aspergillosis: saprophytic aspergillosis (SPA), invasive aspergillosis (IVA) and allergic bronchopulmonary aspergillosis (ABPA)/allergic bronchopulmonary mycosis (ABPM). To know whether Aspergillus (ASP) in SPA only colonizes in preexisting cavities or presents significant pathogenecity, we examined 38 surgical specimens of SPA and 10 post-tuberculous open cavities (PT-OC). Macroscopically, SPA cavities had macroscopic ulcers (81.6%) and bronchi originating from the cavities (68.4%), in contrary to PT-OC that had neither of them. Microscopically, SPA cavities showed shallow ulcers (100%), coagulation necrosis (42.1%) and granulomatous reaction (52.6%), although ASP invasion to the viable lung tissue couldn't be discovered. The lung tissue around the SPA cavities showed various inflammation caused by transbronchial ASP dissemination from the cavities. We concluded that (1) SPA should be considered chronic destructive infection by ASP, but not colonization, (2) SPA couldn't be differentiated in quality from semi-invasive/chronic necrotizing pulmonary aspergillosis, and both should be categorized into secondary bronchopulmonary aspergillosis. Respecting IVA, we investigated 10 autopsy cases. In those cases, the disease was brought about in the lungs having no preexisting lesions. Three forms were distinguished; (1) 5 cases in that coagulation necrosis was a main feature (CN-IVA). (2) 2 cases having lung balls in cavitary lesions (LB-IVA), and (3) 3 cases showing suppurative lesions (SP-IVA). In CN-IVA and LB-IVA cases, ASP invaded to the viable lung tissue. But in 2 cases of SP-IVA, fungal hyphae were identified only in necrotic lesions but not in the viable tissue. Because the "invasive" was vague in definition, we should categorized these cases into primary bronchopulmonary aspergillosis. To determine the primary lesion of ABPA/ABPM, 5 lobectomy specimen were examined. All cases had hard or firm mucous plugs in the proximal bronchi, peripheral to which we found inflammation with tissue eosinophilia (bronchocentric granulomatosis with tissue eosinophilia : 5 cases, xanthogranuloma-like lesions : 2 cases, eosinophilic pneumonia : 2 cases and organizing pneumonia : 4 cases). Conglomerates of degenerated eosinophils, sometimes showing fir-structure, and fungal hyphae were recognized in both of mucous plugs and the peripheral lesions. We concluded that the mucous plug was the primary lesion of ABPA/ABPM.

Is thrombomodulin useful as a tumor marker of a lung cancer?

To evaluate whether thrombomodulin (TM) can be considered a tumor marker of lung cancer, we examined serum TM levels in 179 lung cancer patients by an enzyme immunoassay. Further, in 91 resected cases, we also investigated the TM presence in lung cancer tissue by an immunohistochemical method. Our findings revealed that 58 (32%) of 179 lung cancer patients had higher serum TM levels than our cutoff levels. No difference was seen in the serum TM-positive ratio between histologic types, but patients with Stage IV disseminated cancer showed a higher serum TM-positive ratio than those with Stage I-IIIB localized cancer, especially cases of adenocarcinoma. Immunostaining results showed a TM presence in the cancer cells of 32 (35%) of 91 lung cancer cases. The TM presence in cancer cells was higher in cases with squamous cell carcinoma than with adenocarcinoma; no differences were seen among the disease stages. No correlation was found between the serum TM and the presence of TM in cancer cells. Further, serum TM status appears to have little clinical significance as a method to detect early lung cancer or for predicting the recurrence after the surgical excision of a lung cancer. Thus, we have concluded that, although serum TM levels are elevated in some lung cancer patients, it is doubtful that the TM status is useful as a tumor marker of lung cancer.

[Detection of Mycobacterium tuberculosis in clinical specimens other than sputum by the Mycobacterium Tuberculosis Direct Test (MTD)--assessment of sample preparation methods and clinical evaluation]

The Gen-Probe Amplified Mycobacterium Tuberculosis Direct Test (MTD) has been widely used as a rapid test for the identification of Mycobacterium tuberculosis complex in clinical samples, and several research groups have verified its clinical usefulness. However, most of the specimens they tested were sputum, and there have been few reports on other specimens. In particular, there have been no reports on assessments of methods of preparing samples other than sputum for the MTD. We assessed methods of preparing samples other than sputum and the influence of a local anesthetic and an anticoagulant that may be present in samples, and also evaluated the MTD as a means of detecting M. tuberculosis in pleural fluid, bronchial lavage cerebrospinal fluid, urine and ascitic fluid. 1. Assessment of three sample preparation methods, i.e., the NALC-NaOH method GuSCN-Diatom nucleic acid extraction method, and the ultrasonication method, revealed that the combination of the NALC-NaOH method and the ultrasonication method, widely used to prepare sputum samples, is also a valid method of preparing other samples. 2. The local anesthetic and the anticoagulant used clinically and remained in specimens did not affect the results of the MTD. 3. Seven (36.8%) of 19 pleural fluid samples from patients diagnosed as tuberculous pleurisy were positive of M. tuberculosis by the MTD, while five (27.8%) of 18 pleural fluid samples cultured for bacteria were positive for M. tuberculosis complex. None of the 20 pleural fluid samples from patients diagnosed as non-tuberculous pleurisy were positive for M. tuberculosis complex either by MTD or culture. 4. Eight (32.0%) of 25 bronchial lavage samples from patients diagnosed as pulmonary tuberculosis were positive for M. tuberculosis complex by the MTD, while 3 (12.0%) were positive by culture. None of the 18 bronchial lavage samples from patients diagnosed as non-tuberculous disease were positive for M. tuberculosis complex either by the MTD or culture. Based on these results, it is concluded that the MTD is a very useful method of detecting M. tuberculosis in clinical samples other than sputum because it is more sensitive than culture on Ogawa's egg medium in detecting M. tuberculosis complex in pleural fluid samples, bronchial lavage samples, and so on, with the same preparation method as used for sputum.

[The present situation, treatment and prognosis of drug-resistant pulmonary tuberculosis. Cooperative Study Unit of Chemotherapy of Tuberculosis of the National Sanitoria in Japan]

We studied 266 patients with drug-resistant pulmonary tuberculosis at national sanatoria in Japan. The patients included 218 men (mean age, 58 years) and 48 women (mean age, 62 years). The levels of isoniazid and rifampicin resistance were determined at 1 mcg/mL and 50 mcg/mL, respectively. The results were as follows. (1) Most patients with drug-resistant pulmonary tuberculosis were middle-aged or past middle-aged. (2) There were many cases of drug-resistant pulmonary tuberculosis in previously treated tuberculosis patients with active disease and several cases in previously untreated pulmonary tuberculosis patients. However, in some previously untreated patients active tuberculosis was convert relatively easily to inactive tuberculosis. (3) Concerning life style, bachelors who drank heavily were more likely to develop drug-resistant pulmonary tuberculosis. (4) Most cases of drug-resistant pulmonary tuberculosis had at least one cavity on chest radiographs. (5) Several patients with drug-resistant tuberculosis left the hospital against the advice of their attending doctors; therefore, it was difficult to treat their illnesses. (6) In more than half the cases in which Mycobacterium tuberculosis was resistant to isoniazid and rifampicin, tolerance to streptomycin and ethanbutol was also seen. (7) When patients with drug-resistant pulmonary tuberculosis continued to have tuberculous bacilli in their sputum after 3 months of chemotherapy, there was a tendency for them to expectorate tuberculous bacilli in their sputum. For these drug-resistant tuberculosis patients, we must pay attention not only to the medical aspects but also to the social aspects of their disease.

[Small airway changes in acute interstitial pneumonia and acute exacerbation of chronic interstitial pneumonia]

To study pathologic changes in small airways in acute interstitial pneumonia (AI), changes in the terminal or respiratory bronchioles in one patient with AI and in three patients with acute exacerbations of chronic interstitial pneumonia (grouped together as the AI group) were compared to those in five patients with chronic idiopathic interstitial pneumonia (IIP) without acute exacerbation. Specimens obtained during autopsy were examined by light microscopy. In the AI group, mononuclear cells had infiltrated the lumen in 47 (23.7%) of the 198 bronchioles examined, and granulation tissue was found in 101 (51.0%). In the IIP group, no changes were found in 37 (97.4%) of the 38 bronchioles examined. Therefore, mononuclear cell infiltration and granulation tissue are common in the bronchioles of patients with acute interstitial pneumonia, but not in those of patients with chronic interstitial pneumonia without acute exacerbation.

[Association of active pulmonary tuberculosis and malignant diseases: a clinical study]

The association of pulmonary tuberculosis and bronchogenic carcinoma has been reported by many authors, however, there are rather few studies about the association of pulmonary tuberculosis and other malignant diseases and how the latter affects the outcome of the former. Between 1980 and 1993, we had in our hospital 104 patients who had both active pulmonary tuberculosis and malignant diseases. Pulmonary tuberculosis was diagnosed at the time or after the diagnosis of malignant diseases in 74 patients, of whom 92% (68 patients) were males and 42% (31 patients) were over the age of 70. There were 23 stomach cancer (31%), and 15 lung cancer (20%). In 11 patients tuberculosis developed after the initiation of radiation and/or chemotherapy. 67 patients could be followed up for more than 6 months after the initiation of chemotherapy for tuberculosis and the negative conversion rate was as high as 95.5% at 3 months. The fact indicates that the association of malignant diseases does not influence the course of tuberculosis and that these patients could be treated safely in general hospitals, provided the diagnosis is made properly without unnecessary delay.

[Small airway obstruction in patients with idiopathic interstitial pneumonia (IIP)--comparison between acute and chronic types]

Small airway obstruction in patients with acute and chronic interstitial pneumonia was studied. Patients with acute interstitial pneumonia (IP, n = 3), and with acute exacerbation of chronic IP (n = 4) were studied as a group, and were compared to patients with chronic idiopathic interstitial pneumonia (IIP, n = 41). Small airway obstruction was defined on a logarithmic %VC-V25/VC plane, because the V25/VC (an index of both small airway obstruction and decreased lung compliance) depended on %VC. Six of seven patients (86%) with acute IP and 8 of 42 patients (19.5%) with chronic IIP had small airway obstruction (p < 0.01). Small airway obstruction was often seen in acute IP, but was not often seen in chronic IIP.

[Lung pathology of cryptococcosis]

To elucidate the relationship between the clinical manifestations and pathologic findings of the lung in patients with cryptococcosis, we reviewed 14 autopsied cases of cryptococcosis. Five patients had pulmonary cryptococcosis and 9 had disseminated cryptococcosis. Patients with pulmonary cryptococcosis showed granulomatous reactions of the lung, such as fibrocaseous cryptococcoma (n = 2), discrete granuloma (n = 2), and granulomatous pneumonia (n = 1). Patients with disseminated cryptococcosis showed intracapillary/interstitial involvement (n = 2), mucoid pneumonia (n = 3), histiocytic pneumonia (n = 1), and granulomatous pneumonia (n = 3). There was a distinct difference between pulmonary cryptococcosis and disseminated cryptococcosis in lung pathology. Intracapillary/interstitial involvement and mucoid pneumonia were fatal because of extensive hematogeneous dissemination to other organs. Hilar lymph node involvement of cryptococcosis was found in all of the nine patients with disseminated cryptococcosis and in one of the five patients with pulmonary cryptococcosis. Pleural involvement of cryptococcosis was found in six of the nine patients with disseminated cryptococcosis. We conclude that the clinical manifestations of cryptococcosis are closely associated with the variety of lung pathology of cryptococcosis. Clinicians should understand the morphologic features to cope with patients with cryptococcosis.

[Identification of the most appropriate time for lung transplantation in the patients with idiopathic interstitial pneumonitis]

In order to identify the most appropriate time for lung transplantation, we examined the natural courses of eight patients who died of idiopathic interstitial pneumonitis (IIP). Five of eight patients died within two years after they were diagnosed as IIP and six died within one year after the last admission. As the disease progressed, arterial oxygen pressure tended to decrease and serum LDH level to increase. But no parameter was able to predict the natural courses of patients. We conclude that it is very difficult to identify the most appropriate time for lung transplantation and the prognosis of IIP patient is very poor. Therefore as soon as patients are diagnosed as IIP, it is mandatory to assess their eligibility for lung transplantation.

[Clinical features of intestinal tuberculosis]

We had tuberculosis infection cases of gastrointestinal tract diagnosed histopathologically during January 1980 to December 1991 in Tokyo National Chest Hospital. There were 12 cases (male 8, female 4) from 24 y.o. to 88 y.o. (mean 50 y.o.). We got histopathological specimen by operation (6 cases), biopsy (4), and section (2). Pulmonary tuberculosis was complicated in 8 cases, 7 cases had cavity formation and another case was miliary tuberculosis. Distribution of tuberculous lesion was colon (7 cases), small intestines (5), cecum (2), rectum (1) and esophagus (1). First symptom was mainly abdominal symptom such as abdominal pain and diarrhea. There were a perforative peritonitis and a intestinal obstruction during chemotherapy. Three died cases complicated low albuminemia. We suppose that serum albumin is one of the useful marker of patient's prognosis.

[Tuberculin sensitivity to purified protein derivatives from Mycobacterium other than tuberculosis (PPD-B, PPD-Y, PPD-F and PPD-C) and PPDs among patients with mycobacteriosis--cooperative study of the Research Committee for the Mycobacteriosis in Japan]

Purified protein derivatives (PPDs) prepared from M. intracellulare (PPD-B), M. kansasii (PPD-Y), M. fortuitum (PPD-F), M. chelonei subsp. abscessus (PPD-C) and M. tuberculosis (PPDs) were simultaneously used in skin tests on patients diagnosed as having tuberculosis or atypical mycobacteriosis to reveal their specificity, clinical usefulness and immunological status of the patients. The mean diameter of reaction (redness) for patients with M. tuberculosis positive sputum (TB group, n = 71; age, 20-90 yrs) was PPDs, 20.4 mm; PPD-B, 7.9 mm; PPD-Y, 11.7 mm; PPD-F, 0.8 mm; and PPD-C, 0.3 mm. For M. avium complex positive patients (MAC group, n = 100; age, 31-89 yrs), the results were PPDs, 10.9; PPD-B, 16.9 mm; PPD-Y, 10.7 mm; PPD-F, 1.6 mm; and PPD-C, 0.3 mm. The M. kansasii positive patients (K group; n = 8) showed results of PPDs, 12.6 mm; PPD-B, 10.7 mm; PPD-Y, 20.8 mm; PPD-F, 0.5 mm; PPD-C, 0.0 mm. The M. fortuitum positive patients (F group; n = 5) had measurements of PPDs, 5.8 mm; PPD-B, 4.4 mm; PPD-Y, 9.8 mm; PPD-F, 17.8 mm; and PPD-C, 16.0 mm. The patients who were previously M. tbc. positive but presently negative patients (pre. TB group; n = 50) showed the following results: PPDs, 16.6 mm; PPD-B, 7.4 mm; and PPD-Y, 10.9 mm. For the patients who were previously M. avium complex positive (previous MAC group; n = 19), the results were PPDs, 10.4 mm; PPD-B, 9.9 mm; and PPD-Y, 7.7 mm. Also considering their frequency distribution curve, with exception of the previous MAC group, the patient groups showed specificity to the PPD of the bacilli detected. The previous MAC group recorded no significant difference in response to PPDs and PPD-B. Strong cross reactions were observed between PPD-F and PPD-C, and moderate reactions between PPDs, PPD-B and PPD-Y. Cross reactions were scarce between PPDs, PPD-B or PPD-Y and PPD-F or PPD-C. Though it is difficult to distinguish cross-reaction and multiple infections, majority of the patients (72-85%) showed greatest response to the PPD that corresponds with the species of bacilli detected. In conclusion, two or more PPDs applied simultaneously can be of aid in diagnosing mycobacteriosis especially in the early stages of the disease. Also, cross-reactions between atypical mycobacteria and PPDs should be taken into consideration when diagnosing infection caused by M. tuberculosis.

[Clinical studies on ceftriaxone in respiratory tract infections. CTRX Study Group]

We report that the results of clinical studies on ceftriaxone (CTRX) in respiratory tract infections (RTIs). Clinical efficacies and side effects of CTRX were as follows; 1. Clinical efficacies of CTRX in a total of 61 cases with RTIs were excellent in 11 cases, good in 23, fair in 11, poor in 12 and unknown in 4. Thus the overall clinical efficacy rate was 59.6%. In cases of patients with lung cancers, the efficacy rate was 42.9%. 2. Clinical efficacy rates with once daily dosage were 50.0% with a dose level of 1 g CTRX and 54.8% with that of 2 g CTRX. 3. Side effects were observed in 2 cases (3.1%) and laboratory abnormalities were observed in 1 case (1.6%). They were not serious, however. These data suggest that CTRX is one of the useful cephalosporins in treatment of RTIs.

[Diagnostic role of fiberoptic bronchoscopy for mycobacterial diseases]

From 1981 to 1991, 5,572 patients underwent bronchoscopic examination, in this series 3,754 patient's samples were sent for determination of mycobacterial isolation. In the 506 samples, mycobacterial bacilli were detected with smear or culture. In the low tuberculous incidence area like northern part of America, many reporters supported the opinion that routine bronchial aspirate detection for tuberculosis was not cost-effective. Inversely, in the high tuberculous incidence area like Hong Kong, M. lp et al. claimed the usefulness of routine bronchial aspirate examination for mycobacterial bacilli. Japan was regarded as moderate tuberculous incidence area. We review a ten-year experience with fiberoptic bronchoscopy for mycobacterial isolation. Our results suggest that in an area with a moderate prevalence of tuberculosis, bronchoscopic examination for mycobacterial disease is useful in the selected hospitals for the selected cases. In Japan, the smear positive prevalence has been on the increase from 1982. We estimate that the Japanese popularization of fiberoptic bronchoscopy may influence a part of the Japanese epidemic statistical analysis of mycobacteriosis.

[A case of inflammatory bronchial polyp associated with pulmonary and bronchial tuberculosis]

A 67-year-old man was admitted to our hospital because of cough and sputum. Chest X-ray revealed cavity and consolidation in the right upper lobe. Microscopical examination of stained specimens of sputum disclosed acid-fast bacilli (Mycobacterium tuberculosis). Cough and sputum resolved and cultures of sputum did not yield M. tuberculosis a month after administration of antituberculosis agents. However, a mass shadow in the right upper lobe was found 3 months later. Bronchofiberscopy revealed a polyp with a stalk at the orifice of right upper bronchus, which was elastic, soft in consistency, smooth surfaced, and movable. The pathological findings of the polyp showed non-specific inflammatory granulation which suggested to be inflammatory bronchial polyp. It was appeared in the healing process of bronchial tuberculosis.