A case of multidrug-resistant pulmonary tuberculosis cured by the regimen including thiacetazone

A 30 years-old-male was referred to our hospital for surgical treatment of multidrug-resistant tuberculosis in April 1998, three years after diagnosis of tuberculosis. All first-line anti-tuberculosis drugs and second-line anti-tuberculosis drugs were resistant on drug susceptibility tests by Ogawa medium. The right upper lobectomy was done because of massive hemoptysis and enlargement of cavitary lesion in June 1998, but this surgical operation was complicated with, bronchial fistula and chronic empyema. Open drainage surgical treatment for chronic empyema was done one month after lobectomy. Sputum culture for M. tuberculosis converted 4 months after the lobectomy, but bacteriological relapse occurred 17 months after initial operation. The new cavitary lesion on middle left lung field developed and sputum smear and culture were continuously positive. Immunotherapy with interferon-gamma via aerosol didn't show any clinical effect. Thiacetazone, sparfloxcin, pyrazinamide, cycloserine was prescribed after 21 months of the initial operation. Four months after changing the regimen sputum smear and culture converted to negative. Chemotherapy was terminated in June 2003, two years after negative conversion. Three years after the termination of treatment no relapse occurred. We considered thiacetazone was effective in this case, because all of the drugs was companied with thiacetazone were resistant by the drug susceptibility tests and were previously used.     

Incipient stage of pulmonary Langerhans-cell histiocytosis complicated with pulmonary tuberculosis was examined by high-resolution computed tomography

A 29-year-old man with a smoking history of 20 pack years was diagnosed with tuberculosis because Mycobacterium tuberculosis was detected in his gastric juice. His chest radiograph showed multiple nodular opacities on left upper lobe. He was treated with anti-tuberculosis drugs in our hospital. Six months after the therapy, he began to complain of dry cough and shortness of breath on exertion. Chest radiograph showed reticular opacities in both upper and middle lung fields. Multiple thick- and thin-walled bizarre-shaped cysts and ill-defined centrilobular opacities were seen mainly in upper and mid-lungs on high-resolution computed tomography (HRCT). He was diagnosed with pulmonary Langerhans-cell histiocytosis (PLCH) by transbronchial lung biopsy specimens from right upper lobe. HRCT findings before the treatment of tuberculosis were retrospectively examined. Several small thin-walled centrilobular cysts were scattered in the right upper and middle lung fields without apparent nodular lesions. We must consider the possibility of PLCH when these findings are detected on HRCT.     

Pulmonary tuberculosis with cerebellar lesion in a patient after anti-TNF-alpha (infliximab) treatment for rheumatoid arthritis]

We report a case of pulmonary tuberculosis in a 51-year-old Japanese woman, who received treatment with infliximab for active rheumatoid arthritis. She had cough and sputum after the second infusion of the drug, small nodular lesions of right lung field and left lower lobe on her chest CT and a small nodular lesion of right cerebellar lobe on her cranial MRI were identified. Mycobacterium tuberculosis was cultured from her sputum. Therefore, we diagnosed her illness as pulmonary tuberculosis with a cerebellar lesion. The patient was treated with anti-tuberculosis drugs and showed marked improvement in lesions of the lung and brain. We considered this case a tuberculosis reactivation after infliximab treatment because of the short interval between the administration of infliximab and the occurrence of tuberculosis, and the complication of extrapulmonary lesion that suggested brain tuberculoma.     

A case of primary pulmonary sporotrichosis

We report the first case of primary pulmonary sporotrichosis in Japan. A 53-year-old man was admitted to our hospital for further examination of the abnormal shadows on chest X-ray film. Six months before admission, he was admitted to another hospital because of alcoholic liver disease and diabetes mellitus. Since the initial chest film showed cavities with infiltration in the left upper lung field, he was treated with antituberculous drugs despite negative sputum cultures for mycobacterium. In spite of the medication, his chest X-ray film revealed another cavitary lesion, so he was referred to our hospital. He had been asymptomatic during this period. Chest X-ray on admission disclosed multiple cavities in the left upper lobe and a cavity in the right lower lobe. Repeated sputum specimens, bronchial washings and brushings for cytology and cultures were all negative. In an attempt to clarify the pathogen, percutaneous lung aspiration (PLA) was performed. The PLA sample yielded a positive culture of Sporothrix shenckii. After the diagnosis, S. schenckii was also cultured from sputa. A sporothrix skin test and yeast agglutination test for S. schenckii were positive. In the absence of a history for skin lesion, the patient was diagnosed as a primary pulmonary sporotrichosis. As iodide therapy was ineffective, he was started on a regimen of intravenous amphotericin B. However his renal function progressively deteriorated, so amphotericin B was discontinued. Now he receives miconazole intravenously and is still under careful observation. As far as we know, this is the first report of primary pulmonary sporotrichosis in Japan. The possibility of sporotrichosis should be considered in any cases of undiagnosed cavitary lung diseases.     

The effectiveness of steroid as adjunctive therapy in the management of two patients with febrile reaction due to antituberculous drugs]

Antituberculous treatment could be continued by using steroid as adjunctive therapy in two patients showing febrile reaction to antituberculous drugs in spite of desensitization therapy. Case 1 (39-year-old man) was admitted to our hospital with positive sputum-smear and bilateral cavitary tuberculosis (b II 2) on chest X-ray. He showed fever of 38-39 degrees C after 8 days of HREZ treatment. Desensitization therapy of RFP with the combined use of prednisolone was enforced, since the exothermic reaction continued in spite of stopping the 4 medicines, and the treatment became possible. Case 2 (40-year-old woman) was admitted with positive sputum-smear and bilateral cavitary tuberculosis (b II 2) on chest X-ray. The administration of drugs was stopped as temperature rose to 38-39 degrees C after 12 days of HREZ treatment. Though the DLST of INH was positive, the treatment with INH became possible by the combined use of PSL.     

A case of tuberculous peritonitis

We report a case of a 73-year-old man with tuberculous peritonitis. He had sought treatment at a clinic near his house for his fever and abdominal distension. Massive ascites were found and he was referred to our hospital. The endoscopy and abdominal CT scan performed on admission revealed no abnormal findings except the massive ascites. Mycobacterium tuberculosis (MT) DNA was detected in the ascitic fluid by polymerase chain reaction (PCR) and ascitic adenosine deaminase (ADA) activity was 127.6 U/l. He was diagnosed as tuberculous peritonitis and transferred to the Department of Respiratory Medicine. A chest CT scan showed predominant right pleural effusion with no other abnormal findings in bilateral lung fields. His sputum were all positive by smear acid-fast staining, MT DNA and culture on MT. His final diagnosis was tuberculous peritonitis, pulmonary tuberculosis, and tuberculous pleuritis. Treatment was started by anti-tuberculosis drugs with combined use of isoniazid, rifampicin, ethambutol, and pyrazinamide. The therapy was continued for 6 months. The culture for MT (Mycobacteria Growth Indicator Tube) converted to negative after 2 weeks of treatment and the C-reactive protein level became normal after a month. The pleural effusion and ascites disappeared after 2 and 3 months, respectively. Tuberculous peritonitis is a relatively rare disease, however when we encounter unexplained ascites, MT PCR and the measurement of ADA should be done considering a rapid diagnosis of tuberculous peritonitis, before invasive diagnostic laparoscopy.     

A case of tuberculous pleurisy developing contralateral effusion during anti-tuberculosis chemotherapy

A 55-year-old woman was admitted to our hospital because of chest pain, fever, and right pleural effusion that was exudative and lymphocyte-dominant with a high level of adenosine deaminase (ADA). Since her blood QuantiFERON-TB 3G test (QFT) was positive, she was diagnosed with tuberculous pleurisy. After initiation of anti-tuberculosis chemotherapy with isoniazid, rifampicin, ethambutol, and pyrazinamide, her symptoms improved. Later, liquid culture of the pleural effusion turned positive for Mycobacterium tuberculosis. On the 18th day of treatment, her chest X-ray and computed tomography exhibited pleural effusion in a moderate amount in the left thorax, with subsiding pleural effusion in the right thorax. Thoracocentesis demonstrated that the left thorax effusion was also exudative and lymphocyte-dominant, with elevated QFT response and high ADA concentration, suggesting tuberculous pleurisy. Mycobacterium tuberculosis was detected in the culture of a left pleural biopsy specimen obtained by thoracoscopy. We assumed that the left pleural effusion was due to paradoxical worsening because (1) on admission no effusion or lung parenchymal lesion was detected in the left hemithorax, (2) on the 14th day of treatment she was afebrile without pleural effusion on both sides, and (3) the bacilli were sensitive to the drugs she had been taking regularly. We performed drainage of the left effusion and continued the same anti-tuberculosis drugs, which led to the elimination of all her symptoms and of the pleural effusion on both sides. In conclusion, paradoxical worsening should be included in the differential diagnosis when contralateral pleural effusion is detected during the treatment of tuberculosis.     

A cases of isoniazid-induced lupus

A case of isoniazid (INH)-induced lupus occurring in a 62-year-old man is presented. He visited our hospital in May 1986 and a cavitary lesion was found in the right upper lobe on a chest roentgenogram. He had no previous history of treatment with antituberculotic agents. Though acid-fast bacilli were not found in his sputum, pulmonary tuberculosis was strongly suspected and INH, rifampicin and ethanbutol were administered. Four days after starting the treatment, minimal left pleural effusion was seen on chest X-ray film. Three months later he began to complain polyarthralgia in his digital joints. In a pleural effusion many lymphocytes were found; and the antinuclear antibody (ANA), the anti-extractable nuclear antigens (ENA) antibody, and the RNase resistant anti-ENA antibody were positive, and their titres were 20x, 1000x and 1000x, respectively, and the immune complex (IC) was 16.0 micrograms/ml (LT5). In blood serum, the ANA test the anti-ENA antibody and the RNase resistant anti-ENA antibody were positive with titres 40x, 640x and 640x respectively; and the IC was 14.0 micrograms/ml, and the RA test was positive. The improvement of clinical findings and disappearance of auto-antibodies seen after stopping INH confirmed the diagnosis as INH-induced lupus.     

A case of isoniazid (INH)-induced pneumonitis]

A 58-year-old man was referred for the evaluation of a lung nodule on chest X-ray. On admission, chest X-ray showed a solitary nodule with cavitation in the left lung field. Histological examination revealed epithelioid cell granulomas and the diagnosis of pulmonary tuberculosis was made. He was treated with INH, ethambutol (EB), and rifampicin (RFP). On the 16th day of treatment, he developed dry cough and high fever. On the 20th day, dyspnea developed and PaO2 was decreased to 38.2 Torr. Chest X-ray showed new widespread infiltrates in both lung fields and bilateral pleural effusions. The size of the cavitary lesion was decreased. Transbronchial biopsy specimen showed slight interstitial thickening, lymphocyte infiltration, and multiple granulomas. Drug lymphocyte stimulation test was positive only with INH (230%). INH-induced pneumonitis was highly suspected. All drugs was discontinued and hydrocortisone 2400 mg daily was started. He soon became afebrile, and dyspnea and dry cough resolved. Chest X-ray film showed resolution of infiltrative shadows. He was subsequently successfully treated with streptomycin, EB, and RFP without any adverse effects. To our knowledge, this is the sixth reported case of INH-induced pneumonitis.     

A case of receipieut of kidney transplantation presenting life-threatning preumothorax due to the rupture of intrapulmonary multiple infections cavities caused by Absidia corymbifera and methicillin-resistant Staphylococcus aureus

We report a rare case of life-threatning pneumothorax induced by multiple intrapulmonary cavitary lesion due to Absidia corymbifera and methicillin-resistant Staphylococcus aureus (MRSA). The patient was a 58-year-old man who had undergone kidney transplantation three year ago due to diabetes renal failure. He had been treated with immunosuppressive drugs and prednisolone, but he had neutropenia and an abnormal shadow on the chest X-ray. His chest X-ray findings became worse inspite of broad-spectrum antibiotis, vancomycin, antivirus drug, gamma-globulin and antifungal drug therapy. He came to our emergency center because of dyspnea due to right massive pleural effusion and peumothorax about two months after onset of neutropenia. His arterial blood gas showed severe hypoxia and the chest CT scan showed birateral pleural effusion and multiple intrapulmonary cavities. He was treated with chest tube drainage and intubated, but he died of progressive respiratory failure on admission day 3. Macroscopic and microbiologic findings of necroptic lung revealed the cavity with fistula in the middle lobe, which included debris with mucor and MRSA. The species of mucor identified as Absidia corymbifera as a result of analysis of BLAST with nested-PCR using the palafin-block.     

脓肿分枝杆菌肺病47例临床分析

目的　提高对脓肿分枝杆菌肺病临床表现的认识。方法 对1998年1月—2001年12月收治的脓肿分枝杆菌肺病47例临床资料进行回顾分析。结果 无合并结核分枝杆菌肺病32例(68.1%),合并结核分枝杆菌肺病15例(31.9%)。有反复抗结核病治疗史31例(66%)。主要症状为咳嗽、咳痰、咯血(痰)。X线胸片中,病灶在3个肺野以上37例(78.7%);两侧受累者28例(59.6%),右侧15例(31.9%),左侧4例(8.5%),病灶内有空洞23例(48.9%),其中右上空洞16例(69.6%),左上空洞9例(39.1%)。对H、R、S、E、Th1321、D、L耐药率高,对A、C、V、CTM耐药率相对低。结论 脓肿分枝杆菌肺病病程长,症状无特异,耐药率高,抗结核治疗疗效差。     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

A case of pleural tuberculoma with intra-pulmonary invasion during anti-tuberculosis therapy

A 27-year-old woman who had been treated for pulmonary tuberculosis with anti-tuberculosis drugs for three months was admitted to our hospital because of pain in the chest and back. Chest CT showed improvement in the pulmonary tuberculosis lesions in the right middle lobe and S8, but there was a large pleural mass in the right lower lung field. Histopathological findings of the percutaneous biopsy showed epithelioid cell granulomas that were negative for acid-fast bacilli. We diagnosed the mass as pleural tuberculoma with intrapulmonary invasion. The pleural tuberculoma improved without any additional therapy.     

Two cases of tuberculous uveitis

Uveitis has many etiologies, but tuberculous uveitis is rare. We herein report 2 cases of uveitis due to tuberculosis infection. The first case was a 28-year-old man who was showed abnormal shadows in the chest radiographic examination performed in search of the etiology of uveitis. Computed tomography (CT) of the chest revealed hilar and mediastinal lymphadenopathy, small nodules, and consolidation, with a small cavity in the right upper lobe. An ulcerated nodule in the truncus intermedius and stenosis of the right middle lobe bronchus were found on bronchoscopy. The biopsy of the nodule in the truncus intermedius showed a small granuloma containing giant cells, consistent with mycobacterial infection. The culture of bronchial washings from the right upper lobe grew Mycobacterium tuberculosis. Diagnosis of pulmonary tuberculosis, tuberculous lymphadenitis, bronchial tuberculosis, and tuberculous uveitis was made. The patient was treated with antituberculosis drugs and his disease, including uveitis, improved. The second case was a 36-year-old man who presented with right hemiparesis, dysarthria, and visual loss of the left eye. He was diagnosed with neuro-Sweet disease causing optic neuritis and visual loss. His chest CT showed a nodule with centrilobular opacities in the left lower lobe that suggested mycobacterial infection. PCR of the bronchial washing from the left lower lobe was positive for M.tuberculosis and the diagnosis of pulmonary tuberculosis was established. Treatment with antituberculosis drugs and corticosteroids was initiated and his pulmonary lesion improved. However, bilateral tuberculous uveitis developed 15 days after initiation of the treatment. The uveitis gradually deteriorated thereafter despite continuation of antituberculosis therapy. Photocoagulation finally halted the disease progression. In both patients with uveitis presented here, chest radiographs and CT scans were important in determining the etiology of the uveitis. It is difficult to find the etiology of uveitis, and general examinations including the lungs are helpful to pinpoint tuberculosis as the etiology of uveitis. As tuberculous uveitis is sometimes asymptomatic and resistant to treatment, ophthalmological examination is recommended for patients with pulmonary tuberculosis.     

Pneumonia due to Scedosporium apiospermum in a patient with HIV infection

A 29-y-old woman from Congo Democratic Republic was admitted to hospital with dyspnoea of 5-months duration. Chest X-ray showed left white lung and infiltrates of the right superior lobe. The patient underwent left pneumonectomy. Histopathological examination showed pulmonary cavitary lesions and bronchectasis full of branching septated fungi. Cultures yielded Scedosperium apiospermum.     

A case of tuberculosis showing immune reconstitution syndrome after the initiation of antiretroviral therapy for HIV infection

Abstract A 27-year-old man admitted for high fever, wet cough and abnormality on his chest radiograph. He was diagnosed as pulmonary tuberculosis, and started treatment with INH, RFP, EB, and PZA. After other examinations, he was diagnosed as having a acquired immunodeficiency syndrome, too. We gave him zidovudine and lamivudine/ abacavir sulfate to treat HIV infection. After starting treatment with anti-tuberculosis drugs his fever alleviated, but after 10 days from the start of anti-HIV drugs, he showed high fever, and abnormality of his chest radiograph exacervated. We diagnosed him as immune reconstitution syndrome, and gave him prednisolone 30 mg/day. His symptoms improved gradually.     

A case of pulmonary tuberculosis with diminished lung function whose paradoxical reaction led to death

Paradoxical reaction in tuberculosis treatment is not generally fatal. On rare occasion it can lead a patient with diminished lung function and poor general condition to death. A 60-year-old man with history of left upper lobe resection from tuberculosis was referred to our hospital due to the recurrence of tuberculosis. Sputum examination showed a positive smear with a Gaffky score of 10, and the chest X-ray and CT revealed pulmonary infiltrate with many cavities (bII2) on the whole left lung field. Anti-tuberculosis drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) were administered, but his high fever persisted, and the infiltrate on the chest X-ray deteriorated. While the positive sputum smear persisted, the culture became negative after one month. The tuberculous bacilli were susceptible to all anti-tuberculosis drugs in vitro. Though we performed examinations and trial treatments for non-tuberculous conditions such as pneumonia and drug-induced pneumonia, the patient died after 6 months. A necropsy specimen taken from the worsening lesion (the right upper lobe) as shown on the chest X-ray revealed many epithelioid granulomas. The patient had malnutrition, diabetes, alcoholic hepatic disorder, and insanity. It is supposed that although antituberculosis drugs were effective, a large quantity of killed organisms was continuously excreted from many cavities in the left lung toward the right lung. Lesions in the right lung thus newly produced in this paradoxical reaction seemed to reduce the remaining lung function. In addition, poorly controlled diabetes caused deteriorated heart function. These multiple factors contributed to the poor prognosis of the patient and his ultimate death.     

Mycobacterium abscessus infection complicated with diabetes mellitus]

We report a case of Mycobacterium abscessus infection complicated with diabetes mellitus. A 38-year-old man with diabetes mellitus as an underlying disease, was admitted to our hospital because of a productive cough. He had had pulmonary tuberculosis two years before. Chest radiography revealed infiltration in both lung apices and chest CT showed a cavitary lesion in the left upper lobe. Gaffky 2 was found on a sputum smear. However, in the examination of PCR on sputum, not only M. tuberculosis but M. avium complex was negative, and repeated cultures of sputum were positive for M. abscessus. On the basis of the diagnosis of an M. abscessus infection, the patient was initially treated with amikacin, imipenem/cilastatin and levofloxacin during hospitalization while receiving insulin for diabetes mellitus. The smear and culture of sputum became negative for Mycobacterium, and the findings of chest radiography and chest CT improved. After discharge, treatment was continued with clarithromycin and levofloxacin. It is considered that the choice of effective drugs and the additional treatment of an underlying disease are very important for the treatment of a Mycobacterium abscessus infection.     

Bronchiolo-alveolar cell carcinoma arising after active pulmonary tuberculosis' report of two cases]

We report on two patients diagnosed as having active pulmonary tuberculosis who later developed lung cancer. In both cases, the lung cancer was detected during the treatment of pulmonary tuberculosis. Both patients were initially considered to be experiencing exacerbation of pulmonary tuberculosis. Case 1 was seen in a 74-year-old man. His chest roentgenogram revealed microscopic cavitary lesions with infiltration into both lung fields. His sputum tested positive for acid-fast bacilli. Although he was treated with isoniazid (INH), rifampicin (RFP), ethambutol (EB) and pyrazinamide (PZA), his general condition deteriorated, and the infiltrative shadows in the lung fields had expanded on subsequent chest radiography. Transbronchial lung biopsy (TBLB) yielded findings compatible with a diagnosis of bronchiolo-alveolar cell carcinoma. Case 2 occurred in a 52-year-old man. His chest radiograph revealed cavitary lesions with infiltration into both lung fields. His sputum also tested positive for acidfast bacilli. Despite medication with INH, RFP, EB and PZA, the infiltrative shadow in his chest radiograph increased in size. Bronchiolo-alveolar cell carcinoma was confirmed after examination of the sputum cytology. Case 1 was diagnosed as lung cancer 10 months after being admission to the hospital, and Case 2, seven months after hospitalization. Recent discussion concerning the simultaneous occurrence of pulmonary tuberculosis and bronchogenic carcinoma suggests a high frequency of coexistence of the two diseases. However, the coexistence of active tuberculosis with bronchiolo-alveolar cell carcinoma, as in our cases, is rare.     

A case of secondary pulmonary cryptococcosis complicating diabetes mellitus]

In this case, a 65-year-old man complained of fever and productive cough while being treated for diabetes mellitus at the outpatient clinic. His chest CT scan revealed multiple infiltrative lesions in both the right and left lower pulmonary lobes. He was therefore given an antibiotic on suspicion of having bacterial pneumonia, and he also received nutritional instruction in relation to diabetes mellitus, and remission resulted. However, he could not maintain sufficient glycemic control thereafter, and his pulmonary lesions persisted. Because his lesions changed into cavitied multiple nodular lesions, as seen on a chest CT scan, a transbronchial lung biopsy was performed. Histopathological examination of the biopsy specimen demonstrated Cryptococcus organisms, and the Cryptococcus antigen titer was high, which led to a diagnosis of pulmonary cryptococcosis. After oral treatment with fluconazole for 1 year and 4 months, only a small nodule in the right lower lobe and a funicular lesion in the left lower lobe remained on a chest CT scan, and the patient had neither subjective symptoms nor evidence of inflammation, although he still had a positive antigen titer for Cryptococcus. Thus, the treatment was terminated. Improvement of the clinical symptoms and of the laboratory and radiological findings demonstrated the therapeutic efficacy of this treatment.