The value of fiberoptic bronchoscopy in culture-positive pulmonary tuberculosis patients whose pre-bronchoscopic sputum specimens were negative both for smear and PCR analyses

OBJECTIVE

This study assessed the diagnostic rate of pulmonary tuberculosis (PTB) using fiberoptic bronchoscopy (FBS) in patients with suspected PTB, and negative pre-bronchoscopy smear and polymerase-chain reaction (PCR) in sputum.

PATIENTS AND METHODS

We retrospectively reviewed 201 culture-positive PTB patients that underwent FBS because both smear and PCR results in sputum were negative. The positive rates of smear for acid fast bacilli, PCR for Mycobacterium tuberculosis, the presence of granuloma in transbronchial biopsy (TBB), and culture of M. tuberculosis were analyzed. In addition, the radiographic features, contribution of FBS to rapid and/or definitive diagnosis of PTB, and drug susceptibility results of M. tuberculosis were also reviewed.

RESULTS

There were 136 males and 102 patients under the age of 40 years; non-cavitary (156 cases) and minimal disease (119 cases) on radiographs predominated. The positive rates of FBS were: 44% (smear), 62% (PCR), 61% (TBB), and 87% (culture). These rates increased in smear and PCR examinations when taken from wider spread shadows on radiographs. The combination of the various bronchoscopy samples increased the diagnostic rate to 92% when all examinations were combined. Positive culture results depended on FBS procedures in 80 cases. Twenty-one cases showed resistance to at least one of the major anti-tuberculous agents.

CONCLUSION

This analysis revealed high positive rates of PTB from bronchoscopy samples, providing rapid and definitive ability for PTB diagnosis, and details of drug susceptibility. Therefore, FBS is an important diagnostic procedure in patients with suspected PTB whose sputum specimens were negative both for smear and PCR analyses.

[Rheumatoid arthritis diagnosis based on the detection of a pulmonary rheumatoid nodule in a patient with Hansen's disease]

A 77-year-old man with Hansen's disease was referred to our hospital because of a small nodular lesion detected adjacent to the pleura in the right lower lobe (S10) on chest CT. He had lost all ten fingers due to Hansen's disease and was using a prosthetic limb after amputation of the right lower leg. Although the patient had an 11-year history of shoulder and back pain and was suspected of having interstitial pneumonia 6 years previously, no detailed examination had been conducted. Bronchoscopy did not yield a definitive diagnosis, and a lung biopsy was performed under thoracoscopic guidance. Histological examination of the resected nodule with colliquative necrosis revealed palisading granulomas with multinucleated giant cells and plasma cell infiltration with formation of lymphoid follicles. Since serum levels of both anti-MMP3 and anti CCP antibodies were elevated, rheumatoid arthritis (RA) with rheumatoid lung was diagnosed. Therefore, the nodule was considered a rheumatoid nodule. Since diagnosis of rheumatoid arthritis is difficult when lacking characteristic joint manifestations, it is important to include rheumatoid nodules as a differential diagnosis and to measure RA specific autoantibodies, to make a comprehensive diagnosis for non-specific necrotizing granulomas.

Evaluation of norovirus removal performance in a coagulation-ceramic microfiltration process by using recombinant norovirus virus-like particles

Norovirus (NV) is a prototype strain of a group of human caliciviruses responsible for epidemic outbreaks of acute gastroenteritis worldwide. Because of the lack of a cell culture system or an animal model for this virus, studies on drinking water treatment such as separation and disinfection processes are still hampered. In the present study, we investigated NV removal performance as particles during a coagulation-ceramic microfiltration (MF) process by using recombinant NV virus-like particles (rNV-VLPs), which are morphologically and antigenically similar to native NV. We also experimentally investigated the behaviors of two widely accepted surrogates for pathogenic waterborne viruses, bacteriophages Qbeta and MS2, for comparison with the behavior of rNV-VLPs. More than 4-log removal was observed for rNV-VLPs with a 1.08 mg-Al/L dose of polyaluminium chloride in the coagulation-ceramic MF process. This high removal ratio of rNV-VLPs satisfies the U.S. Environmental Protection Agency requirement of 4-log removal or inactivation. In addition, the removal ratios of Qbeta and MS2 were approximately 2-log and 1-log, smaller than the ratio of rNV-VLPs. Accordingly, both bacteriophages have the potential to become appropriate surrogates for native NV in the coagulation-ceramic MF process, and, of the two, Qbeta is the more conservative surrogate.

Thumb polydactyly with symphalangism in young children

Six cases of young children with thumb polydactyly in which the radial component was complicated by symphalangism are reported. Since the symphalangism was cartilaginous, plain X-rays showed an apparent joint space. However, its continuity was confirmed at surgery. Thumb polydactyly with symphalangism may be more common than previously expected.

[A case of tuberculosis with multiple lung nodules, abdominal lymphadenopathy, and splenomegaly]

Abdominal tuberculous lymphadenitis is very rare. We report a case of pulmonary tuberculosis showing marked abdominal lymphadenopathy and splenomegaly. A 95-year-old man was admitted to our hospital because of abnormal chest X-ray and body weight loss in last 6 months. He had low grade fever with no abdominal pain. He did not have past history of tuberculosis. Laboratory examination showed mild renal dysfunction and mild glucose intolerance. Soluble interleukin 2 recepter was highly elevated (3800 U/ml). Tumor markers, such as carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA), and progastrin-releasing peptide (Pro GRP) were all within normal limit. Chest X-ray showed multiple nodules in bilateral lung fields. Chest computed tomography showed multiple nodules in bilateral lungs, especially in upper part of lungs, right hilar lymphadenopathy and upper mediastinal lymphadenopathy. Abdominal and pelvic enhanced computed tomography showed marked abdominal lymphadenopathy and splenomegaly (67 x 49 mm). Abdominal lymph nodes were hepatoduodenal (50 x 50 mm), splenic hilar (40 x 25 mm), upper paraaortic (30 x 60 mm), and small superior mesenteric (10 x 10 mm) lymph nodes. FDG-PET showed accumulation in the nodules of right lung field, right hilar lymph nodes, upper mediastinal lymph nodes, and abdominal lymph nodes. Bronchial lavage fluid (BAL) smear for acid-fast bacilli was positive, polymerase chain reaction for Mycobacterium tuberculosis was positive and acid-fast bacilli was cultured. Transbronchial lung biopsy specimen demonstrated non-specific intraalveolar organization and alveolitis. The patient was diagnosed as pulmonary tuberculosis, but about abdominal lymphadenopathy and splenomegaly we had to differentiate malignant lymphoma, and for definite diagnosis, laparotomy was necessary. But considering his age and general condition, we followed up carefully with anti-tuberculosis therapy. Pulmonary tuberculosis, abdominal lymphadenopathy and splenomegaly all showed marked improvement 4 months after starting anti-tuberculosis therapy with isoniazid, rifampicin, and ethambutol, so we clinically diagnosed abdominal tuberculous lymphadenitis and splenic tuberculosis.

Anomalously large anisotropic magnetoresistance in a perovskite manganite

The signature of correlated electron materials (CEMs) is the coupling between spin, charge, orbital and lattice resulting in exotic functionality. This complexity is directly responsible for their tunability. We demonstrate here that the broken symmetry, through cubic to orthorhombic distortion in the lattice structure in a prototype manganite single crystal, La(0.69)Ca(0.31)MnO(3), leads to an anisotropic magneto-elastic response to an external field, and consequently to remarkable magneto-transport behavior. An anomalous anisotropic magnetoresistance (AMR) effect occurs close to the metal-insulator transition (MIT) in the system, showing a direct correlation with the anisotropic field-tuned MIT in the system and can be understood by means of a simple phenomenological model. A small crystalline anisotropy stimulates a "colossal" AMR near the MIT phase boundary of the system, thus revealing the intimate interplay between magneto- and electronic-crystalline couplings.

Incidence and survival of dementia in a general population of Japanese elderly: the Hisayama study

OBJECTIVE

To estimate the incidence and survival rates of total and cause specific dementia in a general Japanese population.

METHODS

A total of 828 subjects without dementia, aged 65 years or over, were followed-up prospectively for 17 years. Dementia was subdivided into cause specific subtypes: namely, Alzheimer's disease (AD), vascular dementia (VD), dementia with Lewy bodies (DLB), combined dementia and other types of dementia. During the follow-up, 275 subjects developed dementia; of these, 251 (91.2%) were evaluated morphologically, with 164 subjected to brain autopsy examination and the remaining 87 to neuroimaging.

RESULTS

The incidences of total dementia, AD, VD, DLB, combined dementia and other types of dementia were 32.3 (n = 275), 14.6 (124), 9.5 (81), 1.4 (12), 3.8 (33), and 3.1 (16) per 1000 person years, respectively. The incidences of AD, combined dementia and other types of dementia rose with increasing age, particularly after the age of 85 years, but this tendency was not observed for VD or DLB. The survival curve of dementia cases aged 65-89 years was significantly lower than that of age and sex matched controls (10 year survival rate, 13.6% vs 29.3%; hazard ratio 1.67; 95% confidence interval 1.31 to 2.13). The 10 year survival rates were not significantly different among dementia subtypes.

CONCLUSIONS

Our findings suggest that the Japanese elderly population has a high risk for the development of dementia, specifically AD and VD, and once dementia is established, the risk of death is considerable.

Comparison of behaviors of two surrogates for pathogenic waterborne viruses, bacteriophages Qbeta and MS2, during the aluminum coagulation process

Differences in the behaviors of two surrogates for pathogenic waterborne viruses, F-specific RNA bacteriophages Qbeta and MS2, were investigated during the coagulation process by using river water spiked with these bacteriophages. The particle size and electrophoretic mobility of Qbeta and MS2 were similar, but the removal performances of infectious Qbeta and MS2, as measured by a plaque forming unit (PFU) method, differed markedly during the coagulation process. The removal ratio of the infectious Qbeta concentration was approximately 2log higher than that of the infectious MS2 concentration at all coagulant doses tested. The total Qbeta and MS2 bacteriophage concentrations, which were measured by a real-time reverse transcription-polymerase chain reaction (RT-PCR) method and represented the total number of bacteriophages regardless of their infectivity, were similar after the coagulation process, suggesting that the behaviors of Qbeta and MS2 as particles were similar during the coagulation process. The difference between total concentration and infectious concentration indicated that some of the bacteriophages were probably inactivated during the coagulation process. This difference was larger for Qbeta than MS2, meaning that Qbeta was more sensitive to the virucidal activity of the aluminum coagulant. Analysis of the PFU and real-time RT-PCR findings together suggested that the difference in removal performances of Qbeta and MS2 during the coagulation process was probably caused by differences not in the extent of bacteriophage entrapment in the aluminum floc particles but in the sensitivity to virucidal activity of the aluminum coagulant.

Effect of rice-cooking water to the daily arsenic intake in Bangladesh: results of field surveys and rice-cooking experiments

The effect of rice-cooking water to the daily arsenic intake of Bangladeshi people was investigated. At the first field survey, uncooked rice and cooked rice of 29 families were collected. Their arsenic concentrations were 0.22+/-0.11 and 0.26+/-0.15 mg/kg dry wt, respectively. In 15 families, arsenic concentration in rice increased after cooking. Good correlation (R(2)=0.89) was observed between arsenic in rice-cooking water and the difference of arsenic concentration in rice by cooking. In the second survey, we collected one-day duplicated food of 18 families. As a result, we estimated that six of 18 families likely used the arsenic contaminated water for cooking rice even they drank less arsenic-contaminated water for drinking purpose. We also conducted rice-cooking experiments in the laboratory, changing arsenic concentration in rice-cooking water. Clear linear relationships were obtained between the arsenic in rice-cooking water and the difference of arsenic concentration in rice by cooking. Factors that affect arsenic concentration in cooked rice are suggested as follows: (1) arsenic concentration in uncooked rice, (2) that in rice-cooking water, (3) difference in water content of rice before and after cooking, and (4) types of rice, especially, the difference between parboiled and non-parboiled rice.

Antithrombin effect on coagulation and fibrinolytic profiles after living donor liver transplantation: a pilot study

Early after liver transplantation, patients are in a hypercoagulable state because of an imbalance between coagulation and fibrinolysis because of the slow recovery of depleted anticoagulant proteins. Antithrombin (AT) is used in anticoagulant protocols to prevent thrombosis. The subjects of the present study were 17 men and eight women that underwent living donor liver transplantation. The initial 15 cases were administered AT concentrate (1500 U/day) on postoperative days (POD) 1 through 3 (AT group) and the following 10 consecutive cases were not administered AT (control). AT, thrombin-AT complex, plasmin-alpha2 plasmin inhibitor complex, thrombomodulin, fibrin degradation product D-dimer (FDP-DD) level, prothrombin time international normalized ratio, activated partial thromboplastin time, and platelet counts were measured. In the AT group, AT activity was maintained at levels >80% for 5 days after transplantation. In the control group, AT activity did not return to normal during the first 2 weeks after the operation. FDP-DD levels were significantly higher in the control group than in the AT group (P < 0.05). Six patients in the control group and three patients in the AT group required transfusions with platelet concentrate (P < 0.05). AT supplementation might reduce FDP-DD levels and prevent decreased platelet counts in the early stages after liver transplantation.

[A case of primary pulmonary cryptococcosis presenting with acute respiratory failure]

A 71-year-old previously healthy woman, presented with respiratory failure several days after initiation of cough and fever. A chest X-ray revealed multiple infiltrative shadows with airbronchograms in bilateral middle and lower lung fields. Transbronchial lung biopsy, performed after steroid pulse therapy which induced transient improvement, demonstrated exudative lesions with massive aggregation of histiocytes containing yeast-like fungi in their cytoplasm. Since the test for cryptococcal antigens was positive, a diagnosis of primary pulmonary cryptococcosis was made. Despite intravenous fluconazole injection for aweek, the severity of fungus infiltration increased. The treatment was therefore changed to a combination of intravenous amphotericin B and oral prednisolone, which achieved clinical improvement. In conclusion, in the case of rapidly progressive pulmonary cryptococcosis with widespread exudative lesions, addition of steroid therapy should be considered when antifungal agents alone prove ineffective.

[Usefulness of bronchofiberscopy for the diagnosis of pulmonary non-tuberculous mycobacteriosis--an analysis mainly on pulmonary M. avium complex disease]

OBJECTIVES

The aim of this study was to evaluate the usefulness of bronchofiberscopy (BFS) in the diagnosis of pulmonary non-tuberculous mycobacteriosis (PNTM).

MATERIALS AND METHODS

Among 909 PNTM patients admitted to our hospital during the period from 1995 to 2006, BFS was performed for the diagnosis of PNTM in 107 patients (12%) who had either a negative sputum-smear for acid-fast bacilli (AFB) (n = 100) or from whom it had been impossible to collect sputum (n =7). For these 107 cases, we retrospectively compared and analyzed the findings from specimens obtained by BFS, such as smears, cultures, polymerase-chain reaction (PCR), and transbronchial lung biopsy (TBLB), with clinical, radiological, and sputum examination disease, was also seen in the positive ratios of other nontuberculous mycobacteriosis cases. Type and/or spread of MAC disease on chest radiographs did not relate to positive ratios of BFS obtained specimens. Based on overall BFS findings, including the examination of sputum immediately after BFS, 68 of 92 (74%) patients met the diagnostic criteria of MAC disease. Furthermore, through a combination of positive-TBLB findings and positive-PCR findings of BFS specimens, we were able to obtain an early and strong indication of MAC disease in 17 of 36 (47%) patients.

CONCLUSION

Using BFS to obtain various kinds of specimens is a useful tool for the early and definite diagnosis of PNTM/pulmonary MAC disease.

[An adult case of double aortic arch]

Reports of surgical treatment are rare in adults with double aortic arch. We present such a case of a 15-year-old male who presented with dysphagia and dyspnea. Diagnosis was made by magnetic resonance imaging (MRI), showing a dominant right arch. The patient underwent divisions of left aortic arch and ligamentum arteriosum, and further dissections around esophagus and trachea. After the operation, both dysphagia and dyspnea were disappeared completely. By reviewing literatures in adult cases, cautions in surgical procedure were discussed in this article.

Pseudomonas aeruginosa infection after living-donor liver transplantation in adults

OBJECTIVES

Pseudomonas aeruginosa infection is a major cause of bacterial infection after deceased-donor liver transplantation. The incidence and risk factors of P. aeruginosa infection after living-donor liver transplantation (LDLT), however, are not known.

METHODS

We retrospectively reviewed the data from 170 adult patients who underwent LDLT at the University of Tokyo Hospital. The microbiologic and medical records of the patients from admission to 3 months after LDLT were reviewed. Uni- and multivariate analyses were performed to identify the independent risk factors for postoperative P. aeruginosa infection.

RESULT

Preoperative P. aeruginosa carriage was identified in 15 (9%) patients. Only 2 of the 15 patients later presented with postoperative P. aeruginosa infection. Postoperative P. aeruginosa infection occurred in 27 (16%) of 170 patients by median postoperative day 38. Among those 27 patients, surgical site infections were recorded in 8 (30%) and intra-abdominal infections in 14 (52%). In 5 of the 27 (19%) patients, P. aeruginosa isolates were multiple antimicrobial resistant. Postoperative bile leakage independently predicted postoperative P. aeruginosa infection.

CONCLUSION

P. aeruginosa infections were frequently detected after LDLT, including those by multiple antimicrobial-resistant isolates. Postoperative bile leakage predisposed patients to P. aeruginosa infection. Surveillance culture should be checked periodically after LDLT to ensure that appropriate antimicrobials can be administered for postoperative infection.

Heparin-induced thrombocytopenia after liver transplantation

BACKGROUND

Unfractionated heparin sodium (UFH) or low-molecular weight heparin (LMWH) is used in anticoagulant protocols at several institutions to prevent thrombosis after liver transplantation. Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated reaction to heparin, resulting in platelet count decreases of more than 50%. The frequencies of HIT after liver transplantation and platelet factor 4/heparin-reactive antibody (HIT antibody) positivity in liver transplantation patients, however, are unknown.

PATIENTS AND METHODS

The 32 men and 20 women underwent living donor liver transplantation. We started LMWH (25 IU/kg/h) on postoperative day (POD) 1, switching to UFH (5000 U/d) on POD 2 or 3. The dose of UFH was changed according to the activated clotting time level. HIT antibody levels were measured the day before surgery and on POD 7 and 14. Platelet count was measured daily for 3 weeks.

RESULTS

The average platelet counts preoperatively, and on POD 7, 14, and 21 were 65, 88, 149, and 169 x 10(9)/L, respectively. Two patients developed hepatic artery thrombosis on POD 11 and 19, respectively, although they were HIT antibody-negative and their platelet counts were stable. In 2 other patients, the platelet count decreased suddenly from 107 x 10(9)/L on POD 4 to 65 x 10(9)/L on POD 6 and from 76 x 10(9)/L on POD 7 to 33 x 10(9)/L on POD 9, respectively. The heparin-induced platelet aggregation test was negative in these patients. The percentage of HIT antibody-positive patients was 0.5% preoperatively, 5.6% on POD 7, and 5.6% on POD 14. None of the subjects/patients developed UFH-related HIT.

CONCLUSIONS

In our series, the occurrence of HIT after liver transplantation was uncommon.

Finite element 3D reconstruction of the pulmonary acinus imaged by synchrotron X-ray tomography

The alveolated structure of the pulmonary acinus plays a vital role in gas exchange function. Three-dimensional (3D) analysis of the parenchymal region is fundamental to understanding this structure-function relationship, but only a limited number of attempts have been conducted in the past because of technical limitations. In this study, we developed a new image processing methodology based on finite element (FE) analysis for accurate 3D structural reconstruction of the gas exchange regions of the lung. Stereologically well characterized rat lung samples (Pediatr Res 53: 72-80, 2003) were imaged using high-resolution synchrotron radiation-based X-ray tomographic microscopy. A stack of 1,024 images (each slice: 1024 x 1024 pixels) with resolution of 1.4 mum(3) per voxel were generated. For the development of FE algorithm, regions of interest (ROI), containing approximately 7.5 million voxels, were further extracted as a working subunit. 3D FEs were created overlaying the voxel map using a grid-based hexahedral algorithm. A proper threshold value for appropriate segmentation was iteratively determined to match the calculated volume density of tissue to the stereologically determined value (Pediatr Res 53: 72-80, 2003). The resulting 3D FEs are ready to be used for 3D structural analysis as well as for subsequent FE computational analyses like fluid dynamics and skeletonization.