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We report five cases of surgical treatment for pulmonary nontuberculous mycobac- teriosis (NTM) resisting chemotherapy in twenties. Of the five, one was male and four were female. They had cavitary or nodular lesion in their lung. After chemotherapy, partial resection or lobectomy was performed.Though postoperative chemotherapy had contin- ued for only 6 months or 1 year, there was no relapse/recurrence at more than 86 months in average after surgery. Consideration. In younger patients, NTM lesions in the lung are sometimes more localized than senior patients, therefore they can be removed as a smaller portion by the operation, and we can sometimes keep more pulmonary function of the patient.Surgical treatment for twenties patients with pulmonary nontuberculous mycobacteriosis resisting chemo- therapy should be carried out aggressively at an early stage to resect a smaller portion of the lung and also decrease relapse/ recurrence after surgery.

Patients receiving surgical treatment for Mycobacterium avium complex (MAC), lung disease should be followed up with careful attention paid to relapse/recurrence, but there is some debate regarding the findings based on which relapse/recurrence should be diagnosed.We hypothesized that we might be able to use anti-GPL core IgA antibodies (MAC antibodies), which have been attracting attention as a factor that may support diagnosis of MAC lung disease, to diagnose postoperative relapse/recurrence. Therefore, we compared the levels of these antibodies before and at the time of relapse/recurrence, and also compared antibody titers before and after surgery.MAC antibody titers were elevated by an average of about 50% at the time of relapse/recurrence compared to those before relapse/recurrence for 6 patients. In contrast, MAC antibody titers were about 30% lower after surgery compared to those before surgery for 37 patients.It may be possible to use MAC antibodies as an indicator of postoperative relapse/recurrence for MAC lung disease.

Pulmonary disease caused by nontuberculous mycobacteria has a variable clinical course. Although this is possibly the result of not only host factors, but also bacterial factors, many questions remain to be answered regarding these manifestations.To assess the relationship between the progression of pulmonary Mycobacterium avium disease and bacterial factors we performed variable number tandem repeats (VNTR) typing analysis of M. avium tandem repeats (MATR) in M. avium isolates from 46 patients with different clinical courses, and furthermore, examined the association between disease progression and a pMAH135 plasmid derived from M. avium.In patients whose treatment was initiated because of worsenedchest radiograph findings and/or clinical symptoms within 18 months after being diagnosed with pulmonary M. avium disease, the detection rate of 6 genes located in pMAH135 was 35.3-47.1% for 17 isolates. However, in untreated patients with a stable condition, these rates were 10.3-13.8% in 29 isolates. MATR-VNTR typing analysis showed that isolates from patients with worsened disease and those with stable disease are clustered differently. In cluster III, the number of isolates from patients with worsened disease was higher than that from patients with stable disease (p = 0.019), and furthermore, the number of isolates carrying pMAH135 genes was higher than that not carrying pMAH135 genes (p ≤ 0.001).These results indicate an association between the progression of pulmonary M. avium disease and pMAH135. The presence of pMAH135 genes might be a useful prognostic indicator for pulmonary M. avium disease and may serve as one criterion for treatment initiation.

This is a retrospective study on six surgical cases of Mycobacterium abscessus pulmonary disease, including a comparison with M. avium complex (MAC) disease.We performed surgery for six cases of M. abscessus pulmonary disease between July 2012 and June 2014. In all the cases, video-assisted thoracic surgery alone was performed. Age, sex, bacillus identification method, disease type, preoperative anti-glycopeptidolipid core immunoglobulin A antibody value, preoperative chemotherapy, preoperative chemotherapy period, adaptation of the operation, surgical method, result of the bacillus culture of an organization that was extracted at operation, postoperative hospitalization period, surgical complications, and postoperative relapse were examined for the six cases of M. abscessus pulmonary disease. In addition, the cases were compared with 36 cases of MAC disease for which operation was performed during the same period.None of the patients had major surgical complications or in-hospital death. Although three patients survived for more than 1 postoperative year and completed chemotherapy, relapses are not accepted in all cases at present. In the comparison with MAC disease, the mean preoperative chemotherapy period for M. abscessus pulmonary disease was 5.5 months, which was 18.9 months shorter than that for MAC disease, with a statistically significant difference. CONCLUSION AND CONSIDERATION: Surgery for M. abscessus pulmonary disease may be considered a safe and effective therapeutic procedure. Moreover, some physicians believe that surgical treatment is required at an earlier stage of M. abscessus pulmonary disease compared with MAC disease.

We, group of tuberculosis experts, made discussions over how to improve the quality of treatment of multidrug resistant tuberculosis using a newly developed anti-tuberculosis drug, and at the same time, how to prevent the disadvantages of the treated patients and also that of persons who would be infected with newly produced drug-resistant bacilli, by preventing the emergence of resistance to the new drug. A series of proposals are made.

In this study, we aimed at determining the cause of resistance to tuberculosis treatment by performing genetic analyses of bacteria obtained from a patient who developed multidrug-resistant tuberculosis (MDR-TB) during the initial course of treatment for tuberculosis.Specimens obtained before and after the development of MDR-TB were subjected to spoligotyping, drug-resistance gene analysis, and variable-number tandem repeat (VNTR) typing. The patient's clinical background was also reviewed.After the development of resistance, the bacterial genome had changed with regard to only 1 mutation: S531L in the rpoB gene. Spoligotyping revealed that the genotype was that of the Beijing strain. VNTR typing confirmed all 35 loci. Review of the patient's clinical background showed that diabetes mellitus was present as a complication.There was no evidence of reinfection or polyclonal infection. The strain belonged to a sublineage of the Beijing genotype that is a common precipitating cause of MDR-TB due to this genotype. The patient had diabetes mellitus and was thus vulnerable to the development of resistance. Factors associated with both the host and bacteria, therefore, contributed to the development of resistance in this case, which seemed to result in the rapid development of MDR-TB.

This is a retrospective study on relapse/recurrence of surgical cases of pulmonary nontuberculous mycobacteriosis (NTM). Surgical treatment was performed at one hospital and by one surgeon.Fifty patients had undergone surgical treatment from August 2004 to July 2011 in hospital. From this group, 37 patients were selected after one year, and of these, 9 patients had a relapse/recurrence (group A) and the others (28 patients without relapse/recurrence, group B). Data was recorded about their age, gender, pre-operative image score, cavernous lesions, residual lesions after operation, drugs of pre-operative chemotherapy, the duration of pre-operative chemotherapy, the duration of any follow-up after operation, type of mycobacteria, the results of bacterial cultivation of surgical specimens, type of mycobacterium and operative procedure.Three factors, the result of bacterial cultivation of surgical specimens, duration of chemotherapy before operation and existence of residual lesions, showed a significant difference statistically. No case with major surgical complication and hospital death was recognized.The visible foci should be removed as thoroughly as possible. Pre-operative chemotherapy should not be continued unnecessarily, and surgical treatment should be chosen at an early stage. The results of bacterial cultures of surgical specimens could be very useful for predicting the possibility of relapse/recurrence after operation. Surgical treatments of our patients were carried out safely. However, as the patients have a risk of relapse/recurrence, they require careful monitoring and post-operative chemotherapy over along period.

Mycobacterium avium complex (MAC) were the most frequently isolated (about 80%) and most common cause of lung nontuberculosis. Its rate of infection is globally increasing, especially in Japan. In this situation, it is urgently needed to provide scientific evidences and develop therapeutic interventions in MAC infections. Recently, more and more patients are elderly women with no history of smoking, and they have reticulonodular infiltrates and patchy bilateral bronchiectasis. However the prognostic and intractable factors of MAC infections are poorly known. In this symposium, we address five novel strategies for MAC infection, concerning the more accurate incidence and prevalence rates compared with other countries, host defense associated with Th1/Th17 balance, route of MAC infection related soil exposure, MAC IgA antibody as a diagnosis maker, and improved chemotherapy including aminoglycoside or new quinolone. Appropriate clinical intervention may help to reduce the prolongation of MAC infection or enhance the activity of chemotherapy for the improved control of MAC. Below are the abstracts for each of the five speakers. 1. Review of current epidemiological study of pulmonary nontuberculous mycobacterial disease in Japan and the rest of the world: Kozo MORIMOTO (Respiratory Center, Fukujuji Hospital, Japan Anti-Tuberculosis Association) The studies on pulmonary nontuberculous mycobacterial (NTM) disease prevalence were started in early 1970s in Japan by the Mycobacteriosis Research Group of National Chest Hospitals. They were followed by a questionnaire survey in 1990s, by the National Tuberculosis and NTM Survey in late 1990s, and recently by the questionnaire surveys conducted by the NTM Disease Research Committee. The latest data in Japan (from 2007) indicated a morbidity rate of 5.7 per 100,000 population. Deaths from NTM disease were reported for the first time in 1970 and showed a marked, steady increase until 2007, with 912 deaths in that year. We estimated NTM prevalence in our country in 2005 to be 33-65/100,000 using death number and the 1-2% fatality rate obtained from in our hospital. Epidemiologic study conducted by some regions, states and countries estimated the incidence or prevalence of NTM by unique methods in each. Although the microbiologic criteria of diagnosis is attractive to get information of prevalence, we think the most reliable method is to use the health insurance claims that should be done in future in Japan. 2. The elucidation of the pathogenesis of pulmonary MAC disease by using gene modified mice: Masashi MATSUYAMA, Yukio ISHII, Nobuyuki HIZAWA (Division of Respiratory Medicine, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba), Kenji OGAWA (Department of Clinical Research, National Hospital Organization Higashi Nagoya National Hospital) Thl immune responses are associated with protective immunity to intracellular pathogens. T-bet is the master regulator for Thl cell differentiation. We therefore investigated the role of T-bet in the host defense against pulmonary MAC infection using T-bet knockout (T-bet-/-) mice and T-bet overexpressing (T-bet tg/tg) mice. Pulmonary MAC infection was induced by intratracheal instillation with 1 X 10(7) CFU of Mycobacterium avium subsp. hominissuis. The degrees of pulmonary inflammation and the number of organisms were much enhanced in T-bet-/- mice than in wild-type mice and T-bet tg/tg mice after MAC infection. A significant decrease in Th1 cytokines and increase in Th17 cytokines were observed in the lungs of T-bett-/-mice, compared with wild-type mice and T-bet tg/tg mice. Interestingly, however, the level of Th2 cytokines was not different among mice genotypes in response to MAC. These findings indicate that T-bet plays a central role in controlling MAC disease progression, through the regulation of both Th1 and Th17, but not Th2 responses. 3. Route of infection in Mycobacterium avium-intracellulare complex disease: Yutaka ITO (Department of Respiratory Medicine, Department of Infection Control and Prevention, Kyoto University) Environmental exposure is considered to be the primary route for Mycobacterium avium-intracellulare complex (MAC) infection. MAC is isolated from drinking water distribution systems, bathroom and showerheads and the genetic relatedness of clinical isolates from MAC patients with water isolates have been reported. We reported that patients with pulmonary MAC disease had significantly more soil exposure (2 per week) than noninfected control patients after adjustments for the potential confounding diseases and conditions in pulmonary MAC disease. Moreover, we found six pairs of clinical isolates and corresponding soil isolates with identical variable numbers of tandem repeats profiles among patients with high soil exposure, suggesting that residential soils are a likely source of pulmonary MAC infection. 4. Clinical data analysis of Mycobacterium avium complex serodiagnosis kit: Yuta HAYASHI (Department of Respiratory Medicine, National Hospital Organization Higashi Nagoya National Hospital), Taku NAKAGAWA, Kenji OGAWA (Department of Clinical Research, National Hospital Organization Higashi Nagoya National Hospital) Mycobacterium avium complex (MAC) serodiagnosis kit was covered by health insurance in August 2011 in Japan, but experience with this kit in daily clinical practice is still scarce. We analyzed the clinical data of MAC serum diagnostic kit in our hospital. Considering the high diagnostic performance of this kit (specificity 92.9%), that can also be incorporated into the diagnostic criteria. However it should be noted that there can be false-negative even in patients with active pulmonary MAC. Although this test is also expected usefulness as a marker of disease activity, at the present time should be kept for reference. 5. Clinical effect of combined chemotherapy containing aminoglycoside or new quinolone antibiotics for Mycobacterium avium complex disease: Yosihiro KOBASHI, Mikio OKA (Department of Respiratory Medicine, Kawasaki Medical School) Because it was possible to administrate CAM 800 mg/day for the treatment of Mycobacterium avium complex (MAC) disease after 2008, we compared the clinical effect of combined chemotherapy (RFP, EB, CAM 800 mg/day) containing aminoglycoside (SM) and combined chemotherapy (RFP, EB, CAM 400 mg/day or 600 mg/day) containing SM before 2007. Subsequently, the latter treatment was significantly better in the sputum conversion rate and clinical improvement such as clinical symptoms or radiological findings than the former treatment. Concerning the side effects or abnormal laboratory findings, although gastrointestinal symptoms were frequently appeared in the latter period, there was no significant difference between both periods.

A variable-number tandem-repeat (VNTR) typing method using the Mycobacterium avium tandem repeat (MATR) loci (MATR-VNTR) is employed in Japan for epidemiological studies using clinical isolates of M. avium. In this study, the usefulness of this MATR-VNTR typing method was compared with that of the IS1245-restriction fragment length polymorphism (IS1245-RFLP) typing method and a mycobacterial interspersed repetitive-unit (MIRU)-VNTR typing method reported previously (Boschiroli, C. Hubbans, P. Overduin, K. Stevenson, M. C. Gutierrez, P. Supply, and F. Biet, Clin Microbiol.) Seventy clinical isolates identified as M. avium from human immunodeficiency virus-negative patients with MAC infections were used. MATR-VNTR typing using 15 loci distinguished 56 patterns of different allele profiles, yielding a Hunter-Gaston discriminatory index (HGDI) of 0.990. However, IS1245-RFLP and MIRU-VNTR typing yielded HGDIs of 0.960 and 0.949, respectively, indicating that MATR-VNTR has an excellent discriminatory power compared with MIRU-VNTR and IS1245-RFLP typing. Moreover, concomitant use of the MATR-VNTR method and IS1245-RFLP typing increased the HGDI to 0.999. MATR-VNTR typing is inexpensive and easy to perform and could thus be useful in establishing a digital multifacility database that will greatly contribute to the clarification of the transmission route and pathophysiology of M. avium infections. Mycobacterium avium (n=81) from patients with pulmonary infections who were HIV-negative and isolates (n=33) from HIV-positive patients were subjected to genetic analysis by PCR detection of three M.avium-specific insertion sequences (IS901, IS1245 and IS1311) and nucleotide sequencing of the heat-shock protein 65 (hsp65) gene. All clinical isolates were identified as 'M. avium subspecies hominissuis' by sequence analysis of hsp65. Compared with clinical isolates of M. avium reported elsewhere, IS1245 was found less frequently in Japanese isolates (96/114 isolates, 84%) and IS901 was detected more frequently (76/114 isolates, 67%). One isolate was found to lack IS1311, which has not been reported previously for 'M. avium subsp. hominissuis.' Nucleotide sequence analysis of the PCR products for IS901 revealed that all clinical isolates had the same new insertion sequence, designated ISMav6, which had 60 point mutation compared with the nucleotide sequence of the original IS901. These results suggest that 'M. avium subsp. hominissuis' with ISMav6 is prevalent in Japan. ISMav6 may have implications for the virulence of M. avium and contribute to an increase of M. avium infections in this country. Clarithromycin (CAM) is the key drug in the various treatment regimens of Mycobacterium avium complex (MAC) diseases and the only drug for which drug susceptibility has been shown to correlate with a clinical response in these diseases. A point mutation at position 2058 or 2059 of the 23S rRNA gene has been reported to occur in high-level CAM-resistant isolates. This study examined a correlation between the results from a drug susceptibility test and the mutation of genes involved in drug resistance in MAC. Furthermore, we adapted a rapid detection method using amplification refractory mutation system (ARMS)-PCR to identify a mutation in 23S rRNA gene in MAC isolates. Using MICs of CAM, drug susceptibility was tested for 253 clinically-isolated MAC strains. Of these, 28 CAM-sensitive strains and 26 CAM-resistant strains were analysed by sequence analysis and ARMS-PCR. The drug susceptibility test showed that a bimodal distribution was associated with 227 CAM-sensitive strains and 26 CAM-resistant strains. Sequence analysis revealed that all 28 CAM-sensitive strains tested were wild type, whereas 24 of the 26 CAM-resistant strains were mutant type. The sensitivity of the sequence and ARMS-PCR analyses were 92.3% and 84.6%, respectively, and specificity of both was 100%. We found a correlation between drug susceptibility testing and the mutation of drug-resistant genes in this study. ARMS-PCR allowed rapid determination of CAM resistance, even when samples consisted of the mixed type of CAM-sensitive and CAM-resistant strains. MAC is divided into Mycobacterium avium, and the less-epidemiologically studied Mycobacterium intracellulare. Genetic typing for M. intracellulare using variable number of tandem repeats (VNTR) has not yet been developed. The aim of this study was to identify VNTR loci in the genome of M. intracellulare and apply them as an epidemiological tool to clinical isolates. Here, we identified 25 VNTR loci on the M. intracellulare genome, which 16 showed variations among clinical isolates in the number of tandem repeat motifs. Among the 74 M. intracellulare isolates, 49 genotypes were distinguished using the 16 VNTR loci, resulting in a Hunter-Gaston discriminatory index of 0.988. Moreover, all 16 VNTR loci were stable in different sets of isolates recovered within time intervals ranging from 2 to 1551 days from 14 separate patients. These results indicate that for use as epidemiological markers of M. intracellulare, the loci in this VNTR assay highly discriminating and stable over time.

The pulmonary disease caused by Mycobacterium avium shows diverse clinical manifestations. Little is known about the potential association between the genetic characteristics of M. avium strains and disease progression.We enrolled 89 patients with disease caused by M. avium, from 12 hospitals in Japan and collected the corresponding M. avium isolates and clinical data. We divided the 89 patients into 2 groups: one group comprising 43 patients with progressive disease despite chemotherapy ("progressive"), and the other group comprising 46 patients with untreated disease ("untreated"). We compared clinical and bacteriological characteristics between these groups. The bacteriological characteristics that we examined were drug susceptibility, variable-number tandem-repeat (VNTR) typing, and presence of the insertion sequence ISMav6. Seventeen patients in the "untreated" group were started on chemotherapy because their condition had clinically deteriorated during follow-up.The result of VNTR typing showed that there was no specific clustering according to geographical region or clinical group in the "untreated" or "progressive" groups. Six out of eight cases those of polyclonal infection, and 11 of 12 isolates that were highly resistant to clarithromycin were isolated from patients with progressive disease. The frequency of isolates with ISMav6 inserted into upstream region of the cfp29 gene, which is involved in the induction of interferon-gamma production, was significantly higher in patients with deteriorating disease than in stable patients in the "untreated" group (p = 0.002).Polyclonal infection and clarithromycin resistance may be involved in disease progression. ISMav6 inserted into the cfp29 gene is also suggested to be a factor related to the deterioration of pulmonary Mycobacterium avium complex disease.

To make more effective use of variable number tandem repeat (VNTR) typing, we identified novel VNTR loci in Mycobacterium avium and used them for modified M. avium tandem repeat-VNTR (MATR-VNTR) typing.Analysis of a DNA sample extracted from a clinical isolate (strain HN135) with the FLX system genome sequencer (Roche Diagnostic System) led to discovery of several novel VNTR loci. The allelic diversity of the novel VNTR loci was evaluated for 71 clinical isolates and compared with the diversity of the MATR-VNTR loci. To improve efficacy of MATR-VNTR typing, we tested typing using 2 sets of loci selected from the newly identified loci and the MATR loci, i.e., one set containing 7 and another 16 loci. Hunter Gaston's discriminatory index (HGDI) was calculated for these sets.Six VNTR loci were newly identified, of which 5 showed a high diversity. The HGDI was 0.980 for the improved new typing using a set of 7 loci, and 0.995 for another set of 16 loci, while it was 0.992 for the conventional MATR-VNTR typing.VNTR typing with the set of the 7 loci enabled a rapid analysis, and another set of 16 loci enabled a precise analysis, as compared with conventional MATR-VNTR typing. A method that uses only VNTR loci with relatively high allelic diversity is considered to be a useful tool for VNTR typing of MAC isolates.

To determine the characteristics of Mycobacterium avium in Japan, we compared the genetic properties of M. avium isolated in different countries.A Mycobacterium avium tandem-repeat variable-number tandem-repeat (MATR-VNTR) analysis was performed using South Korean strains (n = 119) and Japanese strains (n = 76). In addition, we compared the frequencies of a new insertion sequence, ISMav6.A phylogenetic analysis identified different clusters between the two countries' strains. The prevalence of ISMav6 was significantly different between them, i.e., 75.0% in Japanese strains and 59.8% in the Korean ones (P0.035). The frequency of strains with IS Mav6 in the Shine-Dalgarno (SD) sequence of the cfp29 gene that is involved in the interferon-gamma induction was also different, with stronger significance (Japan: 38.2%, Korea: 12.4%, P0.001).It is possible that M. avium strains prevalent in Japan and in Korea are genetically distinct. The analyses of the presence of ISMav6, as well as the VNTR patterns of M.avium strains from many different countries would be a promising methodology in elucidating the causes of the recent increase in cases of pulmonary MAC diseases.

A 63-year-old woman was referred to our hospital because of bilateral infiltrations and nodular opacities in her chest radiograph taken in the mass radiography screening in September 2010. The chest computed tomography showed patchy infiltrations with bronchiectasis in the lower lung fields on both sides. She was diagnosed with pulmonary Mycobacterium avium complex (MAC) disease based on the bacteria recovered from the sputum and the bronchoalveolar lavage fluid. To elucidate an environmental MAC source, we investigated her home, and isolated M. avium and M. gordonae from the bathtub and shower tap, respectively, in her residential bathroom. Analysis of the hsp65-PRA variants digested with BamHI and some insertion sequences showed that the clinical strains recovered from sputum and strains from the bathtub were M. avium subsp. hominissuis. A dendrogram of the Mycobacterium avium tandem repeat loci variable-number tandem-repeat (MATR-VNTR) analysis of the MAC strains showed that the bathtub strains formed a polyclonal colonization, and that 1 of the 5 MATR-VNTR patterns was identical to the corresponding pattern of the sputum strain from the patient. In conclusion, we believe that the residential bathroom of the patient was the environmental source of her pulmonary MAC disease, as has been previously reported.

This study was designed to identify clinical risk factors for adverse effects of antituberculous therapy and their frequency.A retrospective study of cohorts was undertaken from April 2004 to March 2007. We analyzed the clinical records of 861 patients with tuberculosis treated at Higashi Nagoya Hospital. The factors that were associated with adverse effects in univariate analysis (P0.1) were then subjected to multivariate Cox regression analysis for calculation of the hazard ratios (HRs) and their 95% confidence intervals (95% CIs).Suspension of antituberculous therapy was necessary because of adverse effects in 247 patients (28.7%). The chief adverse effects leading to discontinuation of treatment were liver dysfunction (12.9%), skin rash (6.7%), and gastrointestinal dysfunction (4.1%), while other effects accounted for less than 5.0% of discontinuations. Risk factors for liver dysfunction according to Cox proportional hazards analysis were HCV infection (HR 2.86; 95% CI 1.59 to 5.15; p0.001); hepatocellular damage at admission (HR 2.06; 95% CI 1.25 to 3.39; p = 0.005) and high-dose isoniazid (increase per mg/kg: HR 1.36; 95% CI 1.18 to 1.56; p0.001). Collagen disease was a risk factor for skin rash (HR 6.06; 95% CI 2.81 to 13.05; p0.001). Risk factors for gastrointestinal dysfunction were a high body mass index (increase per kg/m2: HR 0.80; 95% CI 0.71 to 0.91; p0.001) and advanced age (increase per year: HR 1.03; 95% CI 1.01 to 1.06; p 0.018).Adverse effects may lead to substantial additional medical costs because of the need for more medications and tests, as well as a longer hospital stay. Identification of the risk factors for adverse effects of antituberculous therapy should help to minimize such events in tuberculosis patients.

Preventing the spread of drug-resistant tuberculosis is a clinically important challenge. In this effort, rifampicin (RFP)-resistant gene examination by line probe assay (LiPA) was evaluated for its clinical application for rapid detection of tuberculosis.The RFP-resistant gene was examined in a total of 110 samples of sputum obtained from patients that were definitively diagnosed with pulmonary tuberculosis by auto-LiPA. The difference in detection sensitivity between the results of the smear and culture examinations was evaluated. Culture-positive samples were compared with the results of the drug susceptibility test.Smear-positive samples were LiPA positive in 69 of 73 samples (sensitivity: 94.5%), and smear-negative samples were LiPA positive in 25 of 37 samples (67.6%). More than half of the samples were LiPA positive, even those that were culture-negative or contaminated. Comparison of the 76 culture-positive samples with the results of the drug susceptibility test found that all samples were wild type among the RFP-sensitive strains. Among the 8 RFP-resistant strains, 6 were mutation type. All samples shown to be mutation type were obtained from patients with multi-drug resistant tuberculosis.Using LiPA, the amount of smear can be used as a factor for detection of RFP-resistant genes. Detection was possible even with culture-negative and contaminated samples, allowing more rapid diagnosis of patients with multi-drug resistant tuberculosis.

To know the number of patients with MDR-TB and XDR-TB newly diagnosed annually and the number of those with continuously culture-positive in spite of continued treatment.To fill the questionnaire sent to all the TB hospitals in Japan and to investigate the number of beds for TB, MDR-TB cases newly admitted to each hospital in 2006 and chronic bacillary cases in spite of continued treatment.We sent the questionnaires to all the TB hospitals in Japan and 81% of 270 hospitals replied. As the result, 93 MDR-TB were newly hospitalized (12 cases were with XDR-TB). 76 cases of them were newly diagnosed MDR-TB. Almost after 1 year treatment, patients with XDR-TB showed lower negative conversion rate than other MDR-TB (42.9% vs 63.8%) and higher fatality rate (42.9% vs 7.2%). Excluding above 93 new MDR-TB cases, 103 cases with chronic MDR-TB including 44 cases with XDR-TB had been treated during the observation period, 84 case had been hospitalized and other 19 cases at OPD.Since 2000, extensive multi-resistant (XDR) TB has been a global topic. In Japan, nation-wide survey on 2002 showed the ratio of MDR and XDR were 1.9% and 0.6% respectively out of 3122 TB stains investigated. XDR/MDR rate was higher than those in other countries. Our clinical based investigation showed total XDR/MDR rate was 28.6% (56/196) and it was similar to that of previous bacteriological survey in 2002.We investigated the number of patients with MDR-TB and XDR-TB newly diagnosed in 2006 and the number of those who were continuously culture-positive. The survey showed that there were 196 patients with MDR-TB, and 56 patients of them (28.6%) were with XDR-TB. Many of them were in the districts of Kinki area and Kanto-Shinetsu area and 70% of them had been treated in the hospitals belonging to the National Hospital Organization.

Pyrazinamide is an antituberculous drug that is administered as a two-month course during treatment of pulmonary tuberculosis. Adverse reactions to pyrazinamide have been reported to include hyperuricemia. We performed a retrospective multicenter epidemiological survey to assess the relationship between various patient characteristics and the uric acid level, the changes of uric acid during pyrazinamide administration, and the use of medications for uric acid control as well as attacks of gout or arthralgia at the onset of hyperuricemia. A total of 226 patients who were admitted to four hospitals with pulmonary tuberculosis between January and December 2006 and received short-term intensive pyrazinamide therapy were studied.There were 172 men and 54 women with an average age of 59.5 years and an average body mass index of 19.8 kg/m2. The average serum uric acid concentration before pyrazinamide treatment was 4.73 +/- 1.78 mg/dl, while the average uric acid level after pyrazinamide treatment was 10.63 +/- 2.67 mg/dl, which was significantly higher than the pretreatment level (p0.0001). During treatment, hyperuricemia (Serum uric acidor = 8 mg/dl) was reported in 84.5% of patients and arthralgia developed in 4.42%. Although the therapy instituted in 51 patients (22.57%) had to be interrupted or discontinued due to liver dysfunction and skin rashes, which were probably caused by isoniazid and rifampicin, no patient ceased taking pyrazinamide due to an increase of uric acid. Drugs for uric acid control were administered to 21 patients (9.29%). Pyrazinamide is an important agent for intensive short-term antituberculous therapy. Hyperuricemia due to this drug can be managed by observation and does not require interruption of administration.

This study was designed to evaluate incidence of clinical risk factors for side effects due to the use of antituberculous drugs.We retrospectively analyzed clinical records of 229 elderly patients with tuberculosis treated at our hospital.Temporary stop of antituberculous therapy proved to be needed because of side effects in 77 patients (33.6%). Adverse effects leading to drug discontinuation were liver dysfunction (15.7%), gastrointestinal dysfunction (7.0%), and skin rash (5.7%); other effects accounted for discontinuation in 5.2%. Risk factors for liver dysfunction according to Cox proportional hazards regression analysis were complications of HCV infection (hazard ratio or HR, 2.97; 95% confidence interval or CI, 1.20 to 7.38; p=0.019); hepaocellular injury present at admission (HR, 3.37; 95% CI, 1.56 to 7.29; p=0.002); and dose of isoniazid (per mg/kg, HR, 1.40; 95% CI, 1.05 to 1.85; p=0.02). Body mass index was a risk factor for gastrointestinal dysfunction (per kg/m2, HR, 0.83; 95% CI, 0.70 to 0.98; p=0.026).Such identification of risk factors for side effects from antituberculous therapy in elderly tuberculosis patients would minimize adverse effects.

To study rifampicin (RFP) suppository formulations that were prepared by adding an absorption promoter and a holding agent to conventional rifampicin suppositories in order to achieve higher blood drug levels.The subjects were 3 healthy volunteers who gave consent to participate in this study. Suppository formulations were prepared by adding sodium caprinate (the absorption promoter) to 600 mg, 750 mg, or 900 mg of RFP at about 3% of the suppository weight and sodium alginate (the holding agent) at 25% of the RFP content. Serum samples collected at 2, 6, and 10 hours after insertion of a suppository were subjected to RFP concentration analysis.In subject no. 1, the maximum concentration was 0.807 Lg/ml, 1.093 microg/ml, and 1.291 microg/ml after administration of a suppository containing 600 mg, 750 mg, or 900 mg of RFP, respectively.Since an injectable RFP formulation has not been approved in Japan, formulation studies of RFP suppositories are important to achieve a better clinical response and to prevent the development of resistance. The present formulation that delivered a blood concentration of RFP considerably higher than 1 microg/ml was considered to have therapeutic potential. Its clinical utility will be examined in further formulation studies.

The new discharge criteria devised by the National Hospital Organization have three patterns (A, B and other). It was predicted that the hospitalization period would be markedly shortened by the pattern A. In order to judge whether these patterns were adequately applied, we used an assessment sheet. We investigated the adoption rate of the pattern A and the changes in the hospitalization period after its induction.There was a low adoption rate for the pattern A; namely 18%, and the main reasons for not following it were severity illness and the presence of complications. Hospitalization for less than 4 weeks was seen in 25%, while it was over 8 weeks in 42%. The average period of hospitalization was shortened by 20 days and the average number of patients per day also decreased.Interpretation of discharge criteria is standardized by using the assessment sheet, allowing us to perform smooth induction of a clinical path and guide patients along it. Shortening of hospitalization raises patient turnover and allows more rational management of pulmonary tuberculosis. These results could help to refine the clinical path in the future.

We reviewed the interaction between rifampicin (RFP) and clarithromycin (CAM) during treatment of pulmonary Mycobacterium avium complex infection.The subjects were patients with pulmonary non-tuberculous acid-fast bacillus infection during the period from September 2004 to January 2006 who consented to this study. Drug blood concentrations were compared with the minimum inhibitory concentrations for M. avium isolated from sputum and blood levels of CAM were assessed when the time of administration was changed for RFP.The blood concentration of CAM showed a marked decrease in all cases (n = 6) when administered together with RFP, but there was no significant difference in the blood concentration of 14-R-hydroxy-clarithromycin (M-5), the active metabolite of CAM. However, the total blood concentration of CAM and M-5 showed a significant fall, similar to the blood concentration of CAM alone. When the blood concentration and bacterial MIC were compared for RFP, the blood concentration exceeded five MIC(s) in six samples as did the CAM+M-5 level in four out of six samples. There was no significant difference in the blood concentration of CAM (n = 5) when the time of RFP administration was altered. CONCLUSION; Because the total blood concentration of CAM+M-5 fell markedly by co-administration of RFP, this might have an influence on the antibacterial effect of CAM. In addition, examination of the administration of RFP and CAM at different times showed that the blood concentration of CAM did not increase and the influence of induction of hepatic drug-metabolizing enzymes by RFP could not be avoided.

We evaluated the usefulness of Variable Numbers of Tandem Repeats (VNTR) analysis, which was recently reported as a new typing method of Mycobacterium avium strains of animal origin, for strain differentiation of clinical isolates of M. avium in comparison with the standard IS1245-RFLP typing method. In addition, forty M. avium isolates recovered from sputum samples of same patient in different times were analyzed with VNTR typing method.The subjects were twenty-four clinical isolates of M. avium stocked at Higashi Nagoya National Hospital and discriminatory power was evaluated with Hunter Gaston Discriminatory Index (HGDI). Furthermore, forty M. avium isolates recovered from sputum samples of one patient obtained at four different times were analyzed by using this VNTR typing method.VNTR typing showed better discriminatory power for twenty-four clinical isolates than IS1245-RFLP method (HGDI: 0.975 vs 0.866). In the second study, polyclonal infection of four genotype strains with different allele profiles were detected. The ratio of mixture of the four different genotype strains varied during clinical course.We considered that VNTR typing method was very useful for discriminatory examination of M. avium.

The purpose of this study was to elucidate retrospectively the clinical effects of using RFP, EB, CAM, LVFX, and SM for pulmonary Mycobacterium avium-intracellulare complex infection.During 9-year (1995-2003) period, 72 patients diagnosed according to the criteria of the Japanese Society for Tuberculosis Guidelines and treated for at least 6 months were available for this study.The age averaged 68 (range, 32-92) years. The male to female ratio was approximately 2 : 3. The follow-up period averaged 344 (190-365) days. 59 of 72 patients were treated for the first time. 58 of 72 patients were diagnosed as primary infection type. Among them, 20, 38, and 14 patients were treated by RFP, EB, and CAM (REC group), RFP, EB, CAM and LVFX (LVFX group), and RFP, EB, CAM, and SM (SM group), respectively. Comparing the baseline patient characteristics among three groups, we found significant difference (measured by ANOVA) in gender (male/female, REC group: 8/12, LVFX group: 20/18, and SM group: 2/12, p0.05), age (REC group: 75.2 +/- 9.1, LVFX group : 66.5 +/- 12.5, and SM group: 63.9 +/- 11.9, p0.01) and body mass index (REC group: 17.2 +/- 2.9, LVFX group: 18.9 +/- 2.8, and SM group: 19.7 +/- 2.4, p0.05). However, we did not find any significant difference in the clinical outcomes (improving rate of the symptoms, change of the erythrocyte sedimentation rate, improving rate of the chest X-ray, and the results of follow-up on bacteriological effect). In the 60 of 72 patients treated for 1 year, the results were superior to those of some previous reports (1-year improving rate of the symptoms, 1-year improving rate of the chest X-ray, 1-year improving rate of the sputum conversion, and 1-year rate of the relapse were 54.3%, 65.0%, 60.0%, and 15.3%, respectively).Further study was warranted that no advantage was shown by an additional use of LVFX or SM on REC from the point of view of the clinical effects for pulmonary Mycobacterium avium-intracellulare complex infection, in spite of the higher age and deteriorated nutritional status of REC group.

A 23-year-old man was admitted to our hospital because of cough and sputum in April 2001. A chest roentgenogram revealed infiltrative shadow with cavity formation in the bilateral lung fields. He was treated with sensitive antituberculous drugs. After starting the antituberculous therapy with INH, RFP, EB and PZA, bilateral cervical lymphadenopathy developed. Three months later, pericostal abscess appeared in the left anterior chest wall. Microscopic examination of the specimen obtained by needle aspiration biopsy disclosed positive for acid-fast bacilli. Smears of the pus showed acidfast bacilli identified as Mycobacterium tuberculosis by DNA-DNA PCR method. He developed tuberculous bilateral cervical lymphadenopathy and pericostal abscess during the course of antituberculosis chemotherapy. Drug sensitivity test revealed that tubercle bacilli in this case were sensitive. One year after the administration of chemotherapy, cervical lymphadenopathy and pericostal abscess were improved. Both masses were discontinuous with pulmonary tuberculosis and the possibility of lymphogenous spread of organism was speculated as its etiology. We assumed that both masses were due to paradoxical response to the antituberculosis chemotherapy.

A 20-year-old woman was admitted to our hospital because of cough and dyspnea in April 2001. On admission, laboratory data showed positive inflammatory signs. A chest roentogenogram revealed infiltrated shadow in the bilateral lung fields. Sputum smear examination showed acid-fast bacilli identified as Mycobacterium tuberculosis by DNA-DNA PCR method. Four days after admission, she had an acute respiratory distress syndrome (ARDS) and serious liver dysfunction. Moreover, drug sensitivity test revealed that this case was multidrug-resistant tuberculosis (MDR-TB), and she was treated with sensitive anti-tuberculous drugs (PZA, SM, LVFX). Three months later, her sputa converted to negative for tubercle bacillis, however, a chest computed tomogram (CT) revealed multiple giant cysts in the bilateral lung fields, which developed during treatment. Pneumothorax of both sides was repeatedly observed, and it was difficult to treat. At present (1 year after admission), multiple giant cysts stopped its progression and treatment for tuberculosis is being continued.