clinical investigation of tuberculosis patients in a general hospital

494
結核 第 91 巻 第 5 号 2016 年 5 月
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18） 長山直弘：肺外結核にどのようなものがあるか.「結核
Up to Date」 改訂第3版, 四元秀毅, 倉島篤行編, 南江
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13） Nakao M, Sone K, Kagawa Y, et al.: Diagnostic Delay of
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Distress Syndrome Associated with Aspiration Pneumonia:
第 3 版, 四元秀毅, 倉島篤行編, 南江堂, 東京, 2013,
Two Case Reports from Japan. J Infect Chemother. Exp Ther
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20） Whitehorn J, Ayles H, Godfrey-Faussett P : Extra-pulmonary
14） 生方 智, 神宮大輔, 矢島剛洋, 他：在宅医療における
and smear-negative forms of tuberculosis are associated with
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treatment delay and hospitalisation. Int J Tuberc Lung Dis.
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15） 赤川志のぶ：高齢者の結核の現状と治療の実際. 日老
21） 町田和子：標準的な治療.「結核 Up to Date」改訂第3 版,
医誌. 2010 ; 47 : 165 173.
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16） 地域医療情報システム（日本医師会）：愛知県 海部医
22） 長山直弘：副作用対策.「結核 Up to Date」改訂第 3 版,
療圏. http://jmap.jp/cities/detail/medical_area/2302（2015
年 8 月31日アクセス）
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17） Lin CY, Lin WR, Chen TC, et al. : Why is in-hospital
diagnosis of pulmonary tuberculosis delayed in southern
と対策. 日本胸部臨床. 2015 ; 74 : S153 160.
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Taiwan? J Formos Med Assoc. 2010 ; 109 : 269 277.
う対応するか. 結核. 2015 ; 90 : 723 726.
−−−−−−−−Original Article−−−−−−−−
CLINICAL INVESTIGATION OF TUBERCULOSIS PATIENTS
IN A GENERAL HOSPITAL LACKING A TUBERCULOSIS WARD
IN WESTERN AICHI PREFECTURE
1
Makoto NAKAO, 1Hideki MURAMATSU, 1Kazuki SONE, 1Yuto SUZUKI,
1
Yusuke KAGAWA, 1Ryota KUROKAWA, 2Sachiko AOKI, 3Hironaga OKAWA,
and 1Hidefumi SATO
Abstract [Background] With the recent decrease in the
number of tuberculosis wards and increase in elderly tuberculosis patients with comorbidities, the role of regional referral hospitals has become more important in tuberculosis
management.
[Objective] This study aimed to assess the current state
of tuberculosis management and related issues in a general
hospital lacking a tuberculosis ward.
[Methods] We retrospectively evaluated the clinical characteristics and course of patients diagnosed with tuberculosis
by culture testing from April 2008 to March 2015 at Kainan
Hospital.
[Results] A total of 146 patients (83 males and 63 females;
mean age 76, range 18 _ 94 years) were diagnosed with active
tuberculosis. Of these, 129 were diagnosed with pulmonary
tuberculosis (23 had pulmonary tuberculosis with pleurisy),
and 17 patients were diagnosed with extrapulmonary tuberculosis. The chief complains were cough/sputum in 40 cases,
fever in 24, and no symptoms in 36. Associated major
comorbidities included diabetes mellitus, chronic kidney
disease, and malignancy. In 33 patients, over 30 days were
required to diagnose tuberculosis after initial evaluation.
Drug-resistant strains were detected in 14 patients. 57 were
diagnosed with smear-positive pulmonary tuberculosis, and
66 were transferred to a tuberculosis hospital. Modify in antituberculosis therapy due to adverse reactions were reported
in 27 patients.
[Conclusion] This study evaluated the current state of
tuberculosis management in our hospital. Further educational
guidance regarding tuberculosis is needed for the hospital
staff, and is important for improvement of tuberculosis
management in our hospital.
Key words : General hospital, Tuberculosis ward, Delay in
diagnosis, Treatment of tuberculosis, Comorbidity
1
Department of Respiratory Medicine, 2 Department of Palliative Care Medicine, 3 Department of Clinical Laboratory,
Kainan Hospital Aichi Prefectural Welfare Federation of
Agricultural Cooperatives
Correspondence to: Makoto Nakao, Department of Respiratory Medicine, Kainan Hospital Aichi Prefectural Welfare
Federation of Agricultural Cooperatives, 396 Minami-honden,
Maegasu-cho, Yatomi-shi, Aichi 498 _ 8502 Japan.
(E-mail: kokoro1979@gmail.com)
502
結核 第 91 巻 第 5 号 2016 年 5 月
−−−−−−−−Original Article−−−−−−−−
COMPLIANCE RATE OF STANDARD TREATMENT REGIMEN AND
OPTIMAL DOSE OF ANTI-TUBERCULOSIS DRUGS
IN LATE ELDERLY PATIENTS WITH PULMONARY TUBERCULOSIS
Haruka CHINO, Eri HAGIWARA, Akimasa SEKINE, Hideya KITAMURA,
Tomohisa BABA, Takeshi SHINOHARA, Shigeru KOMATSU, and Takashi OGURA
Abstract [Purpose] The proportion of the elderly in patients
with pulmonary tuberculosis is increasing, and failure to
complete the standard treatment regimen is not uncommon
in these patients. We examined the compliance rate and problems of the standard regimen in the late elderly pulmonary
tuberculosis patients.
[Methods] We reviewed the medical records of late elderly
patients with pulmonary tuberculosis aged 75 or above who
were smear-positive and treated in Kanagawa Cardiovascular
and Respiratory Center between January 2011 and December
2014. Our retrospective study examined patient characteristics, imaging findings, laboratory results, and outcomes. The
compliance rate of standard regimen during the hospitalization period was calculated. We compared the discontinuation rate and the incidence of adverse drug reactions by
body weight equivalent doses of anti-tuberculosis drugs.
[Results] A total of 298 patients were included in this
study, and 76％ of those patients were aged 80 or above.
Anti-tuberculosis therapy was not able to be initiated for 3
patients (1％), and treatment other than standard regimen
was inevitably introduced at initiation in 21 patients. The
remaining 274 patients (92％) were administered the standard regimen. Among them, at least one medication was
subsequently discontinued for 85 patients (29％), and the
medication was changed due to drug resistance in 6 patients
(2％). The remaining 183 patients (61％) complied with the
standard regimen during hospitalization. In the comparison
by body weight equivalent dose, significantly more patients
discontinued their medication in the group using ethambutol
with a higher standard dose per weight (37％ vs. 21％,
p＝0.02).
[Conclusion] Nearly 40％ of the late elderly patients could
not comply with the standard regimen. We may need to be
more careful when calculating ethambutol equivalent dose.
Key words : Late elderly, Pulmonary tuberculosis, Standard
regimen, Compliance rate, Body weight
Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center
Correspondence to : Haruka Chino, Department of Respiratory
Medicine, Kanagawa Cardiovascular and Respiratory Center,
6 _ 16_ 1, Tomioka-higashi, Kanazawa-ku, Yokohama-shi,
Kanagawa 236 _ 0051 Japan.
(E-mail: hchino-tky@umin.ac.jp)
507
Tuberculosis in the Emergency Room / T. Yajima et al.
8 ） Sokolove PE, Rossman L, Cohen SH: The emergency
11） dos Santos JWA, Torres A, Michel GT, et al. : Non-infectious
department presentation of patients with active pulmonary
and unusual infectious mimics of community-acquired
tuberculosis. Acad Emerg Med. 2000 ; 7 : 1056 1060.
pneumonia. Respir Med. 2004 ; 98 : 488 494.
9 ） Tsai TC, Hung MS, Chen IC, et al.: Delayed diagnosis of
12） Moran GJ, Barrett TW, Mower WR, et al. : Decision
active pulmonary tuberculosis in emergency department.
instrument for the isolation of pneumonia patients with
Am J Emerg Med. 2008 ; 26 : 888 892.
suspected pulmonary tuberculosis admitted through US
10） Liam CK, Pang YK, Poosparajah S: Pulmonary tuberculosis
presenting as community-acquired pneumonia. Respirology.
emergency departments. Ann Emerg Med. 2009 ; 53 : 625
632.
2006 ; 11 : 786 792.
−−−−−−−−Original Article−−−−−−−−
TUBERCULOSIS DIAGNOSIS FOLLOWING A VISIT TO THE EMERGENCY ROOM
Takehiro YAJIMA, Daisuke JINGU, Satoshi UBUKATA, Makoto SHOJI,
and Hiroshi TAKAHASHI
Abstract [Objective] We aimed to evaluate the clinical characteristics of patients admitted to the emergency room (ER)
and diagnosed with tuberculosis.
[Method] We conducted a retrospective study of patients
aged ≧16 years admitted to the hospital between April 1980
and March 2015 and diagnosed with tuberculosis. We compared patient clinical characteristics and type of tuberculosis
between ER and non-ER patients. We also compared the
incidence of delayed diagnosis of tuberculosis between ER
patients with and without respiratory symptoms. We compared
the tuberculosis encounter rate and the time to diagnosis of
tuberculosis in ER and non-ER patients.
[Results] A total of 255 patients, including 54 ER and 201
non-ER patients were enrolled in this study. The average age
was higher in ER patients than in non-ER patients (71.7±16.3
vs. 63.3±20.3 years, p＝0.006). The reasons for visiting the
ER included acute conditions such as fracture of the lumbar
spine, acute myocardial infarction, hemorrhagic gastric ulcer,
brain infarction, and carbon monoxide intoxication, requiring
immediate treatment. The time to diagnosis of tuberculosis
in ER patients without respiratory symptoms (n＝21) was
approximately three times longer than that in patients with
respiratory symptoms (n＝33) as urgent treatment is prioritized. The tuberculosis encounter rate was 1/1,800 for patients transported by ambulance and 1/22,000 for emergency
outpatients. The time to diagnosis of tuberculosis for patients
transported by ambulance was approximately 4 _ 6 days longer than that for emergency outpatients or non-ER patients.
[Conclusion] Physicians should seek to rule out the possibility of tuberculosis in all patients admitted to the ER, even
where more urgent clinical conditions are prioritized.
Key words : Tuberculosis, Emergency room, Ambulance,
Emergency visit, Delay of diagnosis
Department of Respiratory Medicine, Saka General Hospital
Correspondence to : Takehiro Yajima, Department of Respiratory Medicine, Saka General Hospital, 16 _ 5, Nishiki-cho,
Shiogama-shi, Miyagi 985 _ 0024 Japan.
(E-mail: conver_stey92@yahoo.co.jp)
513
Liver Toxicity of RFP / K. Ito
うっ滞型肝障害」以外の肝障害であっても ALP ないし
一般 _ 001（研究代表者 石川信克）」の補助を受けて行
γGTP の動きによって原因薬剤を推定することが困難な
われている。
のであれば，多剤併用の肝障害出現後の再投与において
も，典型的「胆汁うっ滞型肝障害」以外の肝障害のほと
著者の COI（conflicts of interest）開示：本論文発表内
んどの場合には RFP による再投与を INH よりも優先す
容に関して特になし。
ることになるものと思われる。なお本調査ではビリルビ
文 献
ン値の測定を行っていないため，ビリルビン値上昇の有
無については不明であるが，ビリルビン値上昇は RFP 薬
1 ） 日本結核病学会編：「結核診療ガイドライン」改訂第 3
版. 南江堂, 東京, 2015, 85 89.
3)
理作用の一部であり ，上昇が観察された場合でもその
2 ） 重藤えり子：抗結核薬による重症肝障害. 結核. 2007 ;
解釈は困難であろうと思われる。
謝辞：第一健康相談所呼吸器内科外来の諸先生方の御
協力に感謝いたします。
82 : 467 473.
3 ） 日本結核病学会編：「非結核性抗酸菌症診療マニュア
ル」. 医学書院, 東京, 2015, 110 111.
追記：本調査は「平成 27 年度 新興・再興感染症に対
4 ） 厚生労働省：重篤副作用疾患別対応マニュアル/薬物
する革新的医薬品等開発推進研究事業・地域における結
核対策に関する研究（課題管理番号：H26 _ 新興実用化 _
性肝障害. 平成 20 年 4 月.
−−−−−−−−Original Article−−−−−−−−
LIVER TOXICITY DUE TO RIFAMPICIN MONOTHERAPY
IN LATENT TUBERCULOSIS INFECTION
Kunihiko ITO
Abstract [Purpose] To investigate the outcome of rifampicin (RFP) monotherapy for latent tuberculosis infection
(LTBI) and the incidence of RFP-induced liver toxicity.
[Method] We conducted a retrospective chart review of
patients who received RFP monotherapy as LTBI treatment
at the Daiichi Dispensary Clinic.
[Result] Of 61 patients who received RFP monotherapy, the
treatment completion rate was 88.5％, self-termination rate
was 3.3％, abandonment rate due to adverse drug effects was
8.2％ (5 cases : 3 cases of skin eruption and 2 cases of liver
dysfunction). Among the 2 cases of liver dysfunction, 1 was
not associated with abnormal alkaline phosphatase (ALP) or
gamma-glutamyl transferase (γ
γGTP) levels. Among patients
with liver dysfunction who did not discontinue RFP monotherapy, no cases of severely abnormal ALP and/or γGTP
levels were reported.
[Conclusion] The incidence of liver toxicity due to RFP is
lower than that observed with isoniazid, and liver dysfunction
due to RFP was not always associated with abnormal of ALP
and/or γGTP levels.
Key words : Rifampicin, Isoniazid, Liver toxicity, Latent
tuberculosis infection
Research Institute of Tuberculosis, Japan Anti-Tuberculosis
Association
Correspondence to : Kunihiko Ito, Research Institute of
Tuberculosis, Japan Anti-Tuberculosis Association, 3 _ 1 _ 24,
Matsuyama, Kiyose-shi, Tokyo 204 _ 8533 Japan.
(E-mail: ito@jata.or.jp)
518
結核 第 91 巻 第 5 号 2016 年 5 月
る場合や画像検査を拒否する場合には喀痰・胃液の塗抹・
培養・核酸増幅法，IGRA を実施すべきである。結核合
併妊娠において母子死亡例が報告されており，確実に診
断することが望ましいと考える。
3 ） 乗松克政：診断および予後を中心として. 結核. 1973 ;
48 : 377 380.
4 ） 磯部 全, 須賀達夫, 濱口重人：妊娠11週で発症した
粟粒結核症に急性呼吸窮迫症候群を合併した 1 例. 日
呼吸会誌. 2007 ; 45 : 874 878.
5 ） 安川久吉, 南 理志, 永井 景, 他：私たちはこうして
著者の COI（conflicts of interest）開示：本論文発表内
容に関して特になし。
いる 結核合併妊婦の管理. 産婦人科治療. 2007 ; 95 :
85 88.
6 ） Medchill MT, Gillum M : Diagnosis and management of
文 献
tuberculosis during pregnancy. Obstet Gynecol Surv. 1989 ;
1 ） Nieuwenhoven AL, Heineman MJ, Faas MM: The immunology of successful pregnancy. Hum Reprod Update 2003 ;
9 : 347 357.
2 ） 勝呂 長：最近における成人粟粒結核症の臨床疫学.
結核. 1973 ; 48 : 369 372.
44 : 81 84.
7 ） Valentin J : Pregnancy and medical radiation. ICRP Publication 84. Ann ICRP. 2000 ; 30 : 5 7.
8 ） 日本産婦人科学会, 日本産婦人科医会：「産婦人科診
療ガイドライン産科編」. 杏林舎, 2014, 58.
−−−−−−−−Case Report−−−−−−−−
CASE OF TUBERCULOSIS COMPLICATIONS DURING PREGNANCY
LEADING TO AN INFECTION OUTBREAK
Emiko NISHIKAWA, Shuichi YANO, Mitsuhiro TADA, Shinichi IWAMOTO,
Toru KADOWAKI, Masahiro KIMURA, Kanako KOBAYASHI, and Toshikazu IKEDA
Abstract A 31-year-old woman developed a constant cough
during the 8th week of pregnancy and was diagnosed with
bronchial asthma. She was prescribed prednisolone and inhaled
corticosteroids. At 28 weeks of pregnancy, she showed
worsening weight loss, fever, night sweats, hoarseness, and
coughs. At 31 weeks of pregnancy, a scatter shadow and
cavitary lesions were detected on the chest radiograph. Acidfast bacilli smear test and tuberculosis (TB) polymerase chain
reaction tests yielded positive results (G-8), and she was
diagnosed with TB. Contact tracing and screening indicated
3 patients with TB onset and 18 patients with latent TB infection attributed to the initial patient, who infected a total of
36 people. In the present case, physicians were reluctant to
order a chest radiograph for fear of harming the fetus and did
not order sputum or interferon gamma release (IGRA) assay
tests either. The diagnosis was delayed by 152 days, which
was considered as a factor that caused the outbreak. The diagnosis of TB in a pregnant patient may be very challenging
because symptoms may initially be ascribed to the pregnancy, and delayed diagnosis and treatment of military TB can
lead to the death of the mother and fetus. Consequently, to
ensure early diagnosis and treatment, chest radiography and
sputum and IGRA tests are recommended for pregnant women
who have TB symptoms or are at high risk for TB.
Key words : Pulmonary tuberculosis, Tuberculosis during
pregnancy, Group infection
Department of Pulmonary Medicine, National Hospital
Organization Matsue Medical Center
Correspondence to: Emiko Nishikawa, Department of Pulmonary Medicine, National Hospital Organization Matsue
Medical Center, 5 _ 8 _ 31, Agenogi, Matsue-shi, Shimane
690 _ 0015 Japan. (E-mail: emiko.nishikawa@mmedc.jp)
525
TB Annual Report 2014 (3)
割合の推移, 1975∼2014 年. http://www.jata.or.jp/rit/ekiga
文 献
ku/info/kaisetu/（ 上記ページ内の結核年報 2014 旧図表,
1 ） 旧図 新登録肺結核患者中胸部 X 線写真での広汎空洞型
追加表―患者発見・診断時病状にアクセス）
−−−−−−−−Report and Information−−−−−−−−
TUBERCULOSIS ANNUAL REPORT 2014
─ (3) Case Finding and Condition of Tuberculosis Patients on Diagnosis ─
Tuberculosis Surveillance Center (TSC), RIT, JATA
Abstract Tuberculosis (TB) surveillance data from 2014
was reviewed, with respect to modes of detection, symptoms
at diagnosis, diagnostic delay, radiographic findings, comorbidity, and drug susceptibility test (DST) results.
Of the 19,615 newly registered TB cases, 82.8％ were
diagnosed while seeking care for, or during treatment of, other
illnesses.
Of the 15,149 patients with pulmonary TB (PTB), 55.9％
presented with respiratory symptoms, while 18.0％ presented
with non-respiratory symptoms, and 25.5％ were asymptomatic.
Considerable delay to the initiation of treatment following
the appearance of symptoms was observed among the younger
symptomatic smear-positive TB patients. Over 35％ of patients
aged 35 _ 59 years did not seek care for more than 2 months
after the initial appearance of symptoms.
The proportion of PTB patients with advanced or faradvanced cavitation peaked at 49.9％ among males aged 60 _
64 years, while it remained constant at around 25％ among
females in all age groups.
Positive HIV test results were obtained in 0.2％ (n＝45)
of the newly registered TB patients, among which 86.7％ were
male and 22.2％ were foreign-born. In addition, 16.3％ of
male and 10.5％ of female newly diagnosed patients had
diabetes mellitus.
Of the 10,259 culture-positive PTB patients, DST results
were available for 74.5％ of patients. In previously untreated
patients, the proportions of multi-drug resistant TB, any
isoniazid resistance, and any rifampicin resistance were 0.6
％, 4.1％, and 0.8％, respectively; among previously treated
patients, these proportions were 3.3％, 12.7％, and 3.8％,
respectively.
Key words : Tuberculosis, Delay to diagnosis, Smear
positivity, Cavities, Complications, Anti-tuberculosis drug
susceptibility test
Research Institute of Tuberculosis (RIT), Japan Anti-Tuberculosis Association (JATA)
Correspondence to: Kiyohiko Izumi and Kazuhiro Uchimura,
Department of Epidemiology and Clinical Research, Research
Institute of Tuberculosis (RIT), JATA, 3 _ 1 _ 24, Matsuyama,
Kiyose-shi, Tokyo 204 _ 8533 Japan.
(E-mail: tbsur@jata.or.jp)