clinical features of pulmonary mycobacterium avium complex

493
MAC Diagnosed with Gastric Aspirate / A. Takasa et al.
思われる。また，気管支鏡による診断はより確実だが，
3 ） 倉 島 篤 行 ： 日 本 に お け る 非 結 核 性 抗 酸 菌 症 の 動 向.
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胃液採取に比して患者へ与える苦痛や医療者の負担は大
きく，胃液検査で診断可能であれば，患者・医療者双方
4 ） 日本結核病学会非結核性抗酸菌症対策委員会, 日本呼
吸器学会感染症･結核学術部会：肺非結核性抗酸菌症
にとってより有益である。
以上から今回の検討で，胃液培養検体は喀痰排出困難
診断に関する指針 ─2008年. 結核. 2008 ; 83 : 525 526.
5 ） Edwards LB, Palmer CE: Isolation of
例および気管支鏡施行困難例に対しては，その診断の一
atypical myco-
bacteria from healthy persons. Am Rev Respir Dis. 1959 ;
助となる可能性が示唆された。
80 : 747 749.
6 ） 杉原栄一郎, 檀原 高, 饗庭三代治, 他：高齢者非結核
性抗酸菌症の臨床的検討. 日老医誌. 2007 ; 44 : 503 506.
著者の COI（conflicts of interest）開示：本論文発表内
7 ） Mitarai S, Tanoue S, Sugita C, et al. : Potential use of
容に関して特になし。
Amplicor PCR kit in diagnosing pulmonary tuberculosis
from gastric aspirate. J Microbiol Methods. 2001 ; 47 : 339
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in the presumptive diagnosis of tuberculosis. Am J Med
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2 ） Pratt PC, Atwell RJ: The diagnostic reliability of acid-fast
9 ） 土屋典子, 萩原恵里, 馬場智尚, 他：外科的切除にて最
bacilli demonstrated in aspirated gastric contents. Am Rev
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−−−−−−−−Original Article−−−−−−−−
CLINICAL FEATURES OF PULMONARY MYCOBACTERIUM AVIUM COMPLEX
DISEASE DIAGNOSED THROUGH GASTRIC ASPIRATE CULTURE
1, 2
Akiyuki TAKASA, 1 Eri HAGIWARA, 1Akimasa SEKINE, 1 Hajime SASANO,
1
Yoshihiro SUIDO, 1 Hideya KITAMURA, and 1 Takashi OGURA
Abstract [Objectives] The diagnostic significance of gastric
aspirate culture has been established in pulmonary tuberculosis, but not in pulmonary Mycobacterium avium complex
(MAC) disease. This study aimed to verify the diagnostic
significance of gastric aspirate culture in pulmonary MAC
disease.
[Subjects and Methods] This retrospective study analyzed
77 cases of pulmonary MAC disease tentatively diagnosed
through gastric aspirate culture in comparison with 308 cases
diagnosed through sputum culture.
[Results] There was no significant difference in the clinical
symptoms, laboratory data, or type of disease in both groups.
Patients diagnosed through gastric aspirate culture had a
significantly lower chance of having underlying respiratory
disease (26.0％ vs. 46.8％), which indicates the difficulty in
obtaining sputum specimens from this group of patients. In
114 patients without chemotherapy intervention, more patients
achieved spontaneous remission in the gastric aspirate group
than in the sputum group. Among 271 patients treated with
chemotherapy, there were no significant differences in the
course of radiological findings and clinical symptoms between
both groups. During the observation period, a definitive diagnosis through sputum culture or histological confirmation was
reached in 34 of 47 patients (72％). There was no significant
difference in the clinical characteristics, course of radiological findings, and clinical symptoms in the definitive group and
tentative group.
[Conclusion] Gastric aspirate is a minimally invasive, easy
to conduct, and useful test for diagnosing pulmonary MAC
disease.
Key words : Nontuberculous mycobacteriosis, Gastric aspirate, Diagnosis, Mycobacterium avium complex
1
Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 2 Department of Internal
Medicine, Japan Red Cross Tsukui Hospital
Correspondence to: Akiyuki Takasa, Department of Internal
Medicine, Japan Red Cross Tsukui Hospital, 256 Nakano,
Midori-ku, Sagamihara-shi, Kanagawa 252 _ 0157 Japan.
(E-mail: [email protected])
502
結核 第 89 巻 第 4 号 2014 年 4 月
−−−−−−−−Original Article−−−−−−−−
ANALYSIS ON WORKLOAD FOR HOSPITAL DOTS SERVICE
Yoko NAGATA, Minako URAKAWA, Noriko KOBAYASHI, and Seiya KATO
Abstract [Background and Objective] A directly observed
treatment short course (DOTS) trial was launched in Japan in
the late 1990s and targeted patients with social depression at
urban areas. Based on these findings, the Ministry of Health,
Labour and Welfare established the Japanese DOTS Strategy
in 2003, which is a comprehensive support service ensuring
the adherence of tuberculosis patients to drug administration.
DOTS services are initially provided at the hospital to patients
with infectious tuberculosis who are hospitalized according to
the Infectious Diseases Control Law. After being discharged
from the hospital, the patients are referred to a public health
center. However, a survey conducted in 2008 indicated that all
the patients do not receive appropriate DOTS services at some
hospitals. In the present study, we aimed to evaluate the
protocols and workload of DOTS at hospitals that are actively
involved in tuberculosis medical practice, including DOTS, to
assess whether the hospital DOTS services were adequate.
[Method] We reviewed a series of articles on hospital
DOTS from a Japanese journal on nursing for tuberculosis
patients and identified 25 activities regarding the hospital
DOTS service. These 25 items were then classified into 3
categories : health education to patients, support for adherence,
and coordination with the health center. In total, 20 hospitals
that had ＞20 authorized tuberculosis beds were selected
─ while considering the geographical balance, schedule of this
survey, etc. ─ from 33 hospitals where an ex-trainee of the
tuberculosis control expert training program in the Research
Institute of Tuberculosis (RIT) was working and 20 hospitals
that had collaborated with our previous survey on tuberculosis
medical facilities. All the staff associated with the DOTS
service were asked to record the total working time as well as
the time spent for each activity. The data were collected and
analyzed at the RIT.
[Result] The working times for each activity of the DOTS
service for nurses, pharmacists, ward clerks, head nurses, and
doctors were 100, 90, 87, 86, and 63 min, respectively. For
other professions, including medical social workers, nursing
aids, nutritionists, and physical therapists, the working times
for each activity of the DOTS service were 31, 18, 10, and 8
min, respectively.
The professionals who spent a longer time on health
education, support for patient adherence, and coordination
with the health center were pharmacists, doctors, and head
nurses; nurses, pharmacists, and doctors; and head nurses,
doctors, and ward clerks, respectively.
[Discussion] Aging of tuberculosis patients was associated
with problems on adherence in many patients, including
patients who were not suited for a standard regimen, patients
whose activity of daily life had deteriorated due to senile
dementia, patients with diabetes mellitus, etc. Smoking
cessation and mental care for cases of multi-drug resistant
disease are new challenges in tuberculosis patient care. The
present study clearly indicated that activities including patient
education, support for patient adherence, and coordination
with the health center ─ essential components of the hospital
DOTS service according to the Japanese DOTS Strategy ─
were performed by a team of professionals including doctors,
nurses, pharmacists, medical social workers, etc., depending
on the features and roles that they serve and the needs of each
patient. For good practice of hospital DOTS, it is essential to
not only provide DOTS, but also effectively provide individual
or group health education and coordinate with health centers,
thus aiming towards a better community DOTS service after
patient discharge.
Key words : Hospital DOTS, Workload, Education to patients,
Support for adherence, Coordination
Research Institute of Tuberculosis, Japan Anti-Tuberculosis
Association
Correspondence to: Yoko Nagata, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, 3_ 1_ 24,
Matsuyama, Kiyose-shi, Tokyo 204_ 8533 Japan.
(E-mail: [email protected])
508
結核 第 89 巻 第 4 号 2014 年 4 月
−−−−−−−−Original Article−−−−−−−−
EFFECTIVENESS OF INTERFERON-GAMMA RELEASE ASSAYS
IN THE TUBERCULOSIS CONTACT INVESTIGATION
OF ELDERLY PEOPLE
Junji SETO and Tadayuki AHIKO
Abstract [Purpose] To confirm the effectiveness of interferon-gamma release assays (IGRAs) in the tuberculosis (TB)
contact investigation of elderly people, we analyzed the results
of the QuantiFERON® TB Gold in tube (QFT-3G) test, which
is a commercially available IGRA.
[Methods] We analyzed the results of the QFT-3G test in
2,420 subjects who were in close contact with TB patients.
We investigated subjects with latent TB infection and those
showing the onset of TB among the QFT-3G-positive subjects.
[Results] The QFT-3G-positive rate was 7.3％ (95％ confidence interval, 6.2％ _ 8.3％). In addition, we demonstrated
that the QFT-3G-positive rate increased with age (P＜0.001).
[Discussion] The QFT-3G-positive rate was high, particularly in elderly people (≧60 years), but the rate was significantly lower than the predicted prevalence of TB infection.
Therefore, it was assumed that the QFT-3G test does not
always provide a positive result, even in cases of subjects with
a previous TB infection. Furthermore, data from the QFT-3Gpositive subjects indicated that approximately one half of
subjects aged 60 _ 69 years, approximately one-third of those
aged 70 _ 79 years, and approximately one-quarter of those
aged over 80 years have had recent TB infections. In conclusion, the results of the QFT-3G test in elderly people need to
be carefully evaluated according to the contact situation with
TB patients; nevertheless, the QFT-3G test is useful for the
screening of latent TB infection in elderly people who were in
close contact with TB patients.
Key words : QFT-3G, Elderly, Contact investigation, Previous
TB infection, Recent TB infection
Yamagata Prefectural Institute of Public Health
Correspondence to: Junji Seto, Department of Microbiology,
Yamagata Prefectural Institute of Public Health, 1_ 6 _ 6, Tokamachi, Yamagata-shi, Yamagata 990 _ 0031 Japan.
(E-mail: [email protected])
513
Fatal M. kyorinense Infection / Y. Sakakibara et al.
−−−−−−−−Case Report−−−−−−−−
FATAL NONTUBERCULOUS MYCOBACTERIAL LUNG DISEASE
CAUSED BY MYCOBACTERIUM KYORINENSE :
A CASE REPORT WITH FIVE YEARS OF FOLLOW-UP
1, 2
Yumi SAKAKIBARA, 2, 3 Kumiko KISHIMOTO, 2 Kaoru KOJIMA, 1, 2 Toshihide FUJIE,
and 1 Naohiko INASE
Abstract An 85-year-old man with dementia first visited our
hospital 5 years ago, complaining of hemoptysis. He was
hospitalized 2 years later owing to fever, cough, and dyspnea.
A chest computed tomography scan showed infiltration with
a cavity in the left upper lobe. He was diagnosed with nontuberculous mycobacterial lung infection on the basis of the
presence of acid-fast bacilli in the sputum and repeated
bronchoalveolar lavage specimens; however, we were unable
to identify the isolate by DNA‒DNA hybridization. Although
his general condition had slightly improved after treatment
initiation, intermittent chemotherapy owing to the adverse
effects of the drugs and dementia led to rapid disease
progression and death. After his death, the isolated mycobacterium was identified as Mycobacterium kyorinense by
sequence analysis of the hsp 65 and rpoB genes.
Key words : Mycobacterium kyorinense, Nontuberculous
mycobacterial disease, Fatal disease, Elderly, Compliance
1
Department of Respiratory Medicine, Tokyo Medical and
Dental University, 2 Department of Respiratory Medicine,
Toshiba General Hospital, 3 Department of Respiratory Medicine, Toho University Ohashi Medical Center
Correspondence to: Yumi Sakakibara, Department of Respiratory Medicine, Tokyo Medical and Dental University, 1_
5 _ 45, Yushima, Bunkyo-ku, Tokyo 113 _ 8519 Japan.
(E-mail: [email protected])
520
結核 第 89 巻 第 4 号 2014 年 4 月
6 ） 大阪市保健所：
「大阪市の結核 2010 H21 年結核発生
14） 松本健二, 辰巳朋美, 神谷教子, 他：結核集団接触者
動向調査年報集計結果」.
健診におけるツベルクリン反応と QFT を用いた感染の
7 ） 大阪市保健所：
「大阪市の結核 2011 H22 年結核発生
動向調査年報集計結果」.
リスクの検討. 結核. 2010 ; 85 : 547 552.
15） 青木正和：第 62 回総会特別講演「結核感染をめぐる諸
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問題（1）」. 結核. 1988 ; 63 : 33 38.
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団接触者健診の評価. 結核. 2009 ; 84 : 491 497.
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−−−−−−−−Field Activities−−−−−−−−
TUBERCULOSIS CONTACT INVESTIGATION IN HOSPITALS
1
Kenji MATSUMOTO, 1Jun KOMUKAI, 1Sachi KASAI, 1Satoshi HIROTA,
1
Shinichi KODA, 2 Kazuhiko TERAKAWA, and 3Akira SHIMOUCHI
Abstract [Objective] To contribute to measures against
hospital-acquired infections by analyzing and evaluating
tuberculosis contact investigations in hospitals.
[Methods] This study included 202 tuberculosis cases
between January 2010 and September 2011 in which contact
investigations were requested from the Public Health Office
in Osaka City.
[Results] 1) To assess the necessity for contact investigation
and the demographics of index cases, contact investigations
were conducted for 66 of the 202 cases. Index cases with
higher rates of contact investigation included those with
higher degree of sputum smear positivity, respiratory symptoms, period from hospitalization to tuberculosis diagnosis
of 8 days or longer, and high-risk procedures (including
endotracheal intubation, endotracheal aspiration, and bronchofiberscopy). 2) A total of 632 contact persons from the following professions underwent QuantiFERON ®-TB (QFT) testing:
59 doctors, 492 nurses, 60 other hospital staff members, and
21 patients, and the positive QFT rates were 18.6, 10.8, 13.3,
and 14.3％, respectively. 3) Among the 66 index cases for
which contact investigations were conducted, there were 0
QFT-positive contact persons in 37 cases (56.1％), 1 or more
in 29 (43.9％), and 2 or more in 18 cases (27.3％). Assuming
the dependent variable to be 0 and 1, respectively, for index
cases with 0 and 2 or more QFT-positive contact persons,
we performed a multiple logistic regression analysis with
independent variables that included the presence or absence of
high-risk procedures, period from hospitalization to diagnosis
either within 7 days or 8 or more days, presence or absence of
cough and cavity, and the degree of sputum smear positivity
(1＋/2＋/3＋). Among these variables, those significantly
associated with cases with 1 and 2 or more QFT-positive
persons included the presence of high-risk procedures and
period from hospitalization to diagnosis of 8 days or longer
(P＜0.05).
[Discussion] Our results suggest that early diagnosis and
appropriate responses during high-risk procedures may be
necessary measures to prevent hospital-acquired infections.
Key words : Tuberculosis, Nosocomial infection, Contact
investigation, Doctor’
s delay, Tracheal aspiration, QFT
1
3
Osaka City Public Health Office, 2 Health Bureau, Osaka City,
Health and Welfare Center of Nishinari Ward, Osaka City
Correspondence to: Kenji Matsumoto, Osaka City Public
Health Office, 1 _ 2 _ 7 _ 1000, Asahimachi, Abeno-ku, Osakashi, Osaka 545_ 0051 Japan.
(E-mail: [email protected])