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結核 第91巻 第 5 号 2016年 5 月494
12） 結核研究所疫学情報センター：結核年報 2011（2）小児結核・高齢者結核. 結核. 2013 ; 88 : 611‒616.
13） Nakao M, Sone K, Kagawa Y, et al. : Diagnostic Delay of Pulmonary Tuberculosis in Patients with Acute Respiratory Distress Syndrome Associated with Aspiration Pneumonia:Two Case Reports from Japan. J Infect Chemother. Exp Ther Med. 2016 (in press).
14） 生方 智, 神宮大輔, 矢島剛洋, 他：在宅医療における結核発症状況と臨床的特徴の検討. 結核. 2014 ; 89 : 649‒654.
15） 赤川志のぶ：高齢者の結核の現状と治療の実際. 日老医誌. 2010 ; 47 : 165‒173.
16） 地域医療情報システム（日本医師会）：愛知県 海部医
療圏. http://jmap.jp/cities/detail/medical_area/2302（2015年8月31日アクセス）
17） Lin CY, Lin WR, Chen TC, et al. : Why is in-hospital diagnosis of pulmonary tuberculosis delayed in southern Taiwan? J Formos Med Assoc. 2010 ; 109 : 269‒277.
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, 南江堂, 東京, 2013, 116‒120.
19） 益田公彦：結核性胸膜炎, 膿胸.「結核Up to Date」改訂第 3版, 四元秀毅, 倉島篤行編, 南江堂, 東京, 2013, 126‒128.
20） Whitehorn J, Ayles H, Godfrey-Faussett P: Extra-pulmonary and smear-negative forms of tuberculosis are associated with treatment delay and hospitalisation. Int J Tuberc Lung Dis. 2010 ; 14 : 741‒744.
21） 町田和子：標準的な治療.「結核Up to Date」改訂第3版,四元秀毅, 倉島篤行編, 南江堂, 東京, 2013, 59‒66.
22） 長山直弘：副作用対策.「結核Up to Date」改訂第3版,四元秀毅, 倉島篤行編, 南江堂, 東京, 2013, 75‒77.
23） 中澤真理子, 根本健司, 齋藤武文：抗結核薬の副作用と対策. 日本胸部臨床. 2015 ; 74 : S153‒160.
24） 重藤えり子：抗結核薬によるアレルギー性副作用にどう対応するか. 結核. 2015 ; 90 : 723‒726.
Abstract [Background] With the recent decrease in the number of tuberculosis wards and increase in elderly tuber-culosis patients with comorbidities, the role of regional refer-ral 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 char-acteristics 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 tuber-culosis. 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 anti-tuberculosis 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
1Department of Respiratory Medicine, 2Department of Pal-liative Care Medicine, 3Department of Clinical Laboratory, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives
Correspondence to: Makoto Nakao, Department of Respira-tory Medicine, Kainan Hospital Aichi Prefectural Welfare Federation of Agricultural Cooperatives, 396 Minami-honden, Maegasu-cho, Yatomi-shi, Aichi 498_8502 Japan. (E-mail : [email protected])
－－－－－－－－Original Article－－－－－－－－
CLINICAL INVESTIGATION OF TUBERCULOSIS PATIENTS IN A GENERAL HOSPITAL LACKING A TUBERCULOSIS WARD
IN WESTERN AICHI PREFECTURE
1Makoto NAKAO, 1Hideki MURAMATSU, 1Kazuki SONE, 1Yuto SUZUKI, 1Yusuke KAGAWA, 1Ryota KUROKAWA, 2Sachiko AOKI, 3Hironaga OKAWA,
and 1Hidefumi SATO
結核 第91巻 第 5 号 2016年 5 月502
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 prob-lems 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 characteris-tics, imaging fi ndings, laboratory results, and outcomes. The compliance rate of standard regimen during the hospitaliza-tion period was calculated. We compared the discontinua-tion 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 stan-dard 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, signifi cantly 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 Cardiovas-cular 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 : [email protected])
－－－－－－－－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
Tuberculosis in the Emergency Room/T.Yajima et al. 507
Abstract [Objective] We aimed to evaluate the clinical char-acteristics 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 com-pared 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 priori-tized. The tuberculosis encounter rate was 1/1,800 for pa-tients 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 lon-ger than that for emergency outpatients or non-ER patients. [Conclusion] Physicians should seek to rule out the possi-bility 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 Respi-ratory Medicine, Saka General Hospital, 16_5, Nishiki-cho, Shiogama-shi, Miyagi 985_0024 Japan. (E-mail : [email protected])
－－－－－－－－Original Article－－－－－－－－
TUBERCULOSIS DIAGNOSIS FOLLOWING A VISIT TO THE EMERGENCY ROOM
Takehiro YAJIMA, Daisuke JINGU, Satoshi UBUKATA, Makoto SHOJI, and Hiroshi TAKAHASHI
8 ） Sokolove PE, Rossman L, Cohen SH: The emergency department presentation of patients with active pulmonary tuberculosis. Acad Emerg Med. 2000 ; 7 : 1056‒1060.
9 ） Tsai TC, Hung MS, Chen IC, et al. : Delayed diagnosis of active pulmonary tuberculosis in emergency department. Am J Emerg Med. 2008 ; 26 : 888‒892.
10） Liam CK, Pang YK, Poosparajah S: Pulmonary tuberculosis presenting as community-acquired pneumonia. Respirology. 2006 ; 11 : 786‒792.
11） dos Santos JWA, Torres A, Michel GT, et al. : Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med. 2004 ; 98 : 488‒494.
12） Moran GJ, Barrett TW, Mower WR, et al. : Decision instrument for the isolation of pneumonia patients with suspected pulmonary tuberculosis admitted through US emergency departments. Ann Emerg Med. 2009 ; 53 : 625‒632.
Liver Toxicity of RFP /K. Ito 513
Abstract [Purpose] To investigate the outcome of rifam-picin (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 (γγGTP) levels. Among patients with liver dysfunction who did not discontinue RFP mono-therapy, no cases of severely abnormal ALP and/or γγGTP 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 γγGTP 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 : [email protected])
－－－－－－－－Original Article－－－－－－－－
LIVER TOXICITY DUE TO RIFAMPICIN MONOTHERAPY IN LATENT TUBERCULOSIS INFECTION
Kunihiko ITO
うっ滞型肝障害」以外の肝障害であってもALPないし
γγGTPの動きによって原因薬剤を推定することが困難な
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
んどの場合にはRFPによる再投与を INHよりも優先す
ることになるものと思われる。なお本調査ではビリルビ
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
理作用の一部であり3)，上昇が観察された場合でもその
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。
追記：本調査は「平成27年度 新興・再興感染症に対
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_
一般_001（研究代表者 石川信克）」の補助を受けて行
われている。
著者のCOI（confl icts of interest）開示：本論文発表内
容に関して特になし。
文 献
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.
2） 重藤えり子：抗結核薬による重症肝障害. 結核. 2007 ; 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.
4） 厚生労働省：重篤副作用疾患別対応マニュアル/薬物性肝障害. 平成20年 4月.
結核 第91巻 第 5 号 2016年 5 月518
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. Acid-fast 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 infec-tion 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 diag-nosis of TB in a pregnant patient may be very challenging
because symptoms may initially be ascribed to the pregnan-cy, 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 Pul-monary Medicine, National Hospital Organization Matsue Medical Center, 5_8_31, Agenogi, Matsue-shi, Shimane 690_0015 Japan. (E-mail : [email protected])
－－－－－－－－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
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。
著者のCOI（confl icts of interest）開示：本論文発表内
容に関して特になし。
文 献
1 ） Nieuwenhoven AL, Heineman MJ, Faas MM: The immu-nology 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.
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 tuberculosis during pregnancy. Obstet Gynecol Surv. 1989 ; 44 : 81‒84.
7 ） Valentin J : Pregnancy and medical radiation. ICRP Publica-tion 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.
TB Annual Report 2014 (3) 525
－－－－－－－－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 fi ndings, comor-bidity, 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 asympto-matic. 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 far-advanced 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-Tuber-culosis 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 : [email protected])
文 献
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
割合の推移, 1975～2014年. http://www.jata.or.jp/rit/ekigaku/info/kaisetu/（上記ページ内の結核年報2014旧図表,追加表―患者発見・診断時病状にアクセス）
