Kimihiko Masuda

Diagnosis of Active Tuberculous Serositis by Antigen-Specific Interferon-γ Response of Cavity Fluid Cells

BACKGROUND To develop a more accurate methodology for diagnosing active tuberculous pleurisy, as well as peritonitis and pericardits of tuberculous origin, we established an antigen-specific interferon gamma (IFN-gamma)-based assay that uses cavity fluid specimens. METHODS Over a 19-month period, 155 consecutive, nonselected patients with any cavity effusion were evaluated. Study subjects were 28 patients with bacteriologically confirmed active tuberculous serositis and 47 patients with definitive nontuberculous etiology. Culture was performed for 18 h with fluid mononuclear cells in the supernatant of the effusion together with saline or Mycobacterium tuberculosis-specific antigenic peptides, early secretory antigenic target 6 and culture filtrate protein 10. IFN-gamma concentrations in the culture supernatants were measured. RESULTS In patients with active tuberculous serositis, antigen-specific IFN-gamma responses of cavity fluid samples were significantly higher than those of nontuberculous effusion samples. Area under the receiver operating characteristic (AUROC) curve was significantly greater for cavity fluid IFN-gamma response (AUROC curve, 0.996) than for cavity fluid adenosine deaminase and whole-blood IFN-gamma responses (AUROC curve, 0.882 and 0.719, respectively; P = .037 and P < .001, respectively). Although the AUROC curve was greater for cavity fluid IFN-gamma response than for background cavity fluid IFN-gamma level (AUROC curve, 0.975), the AUROC curves were not statistically significantly different (P = .74). However, multivariate logistic regression analysis revealed that cavity fluid IFN-gamma responses were significantly associated with the diagnosis, even after adjustment for background IFN-gamma level (adjusted odds ratio, 1.21; 95% confidence interval, 1.03-1.42; P < .001). CONCLUSIONS The cavity fluid IFN-gamma assay could be a method for accurately and promptly diagnosing active tuberculous serositis.

DIAGNOSTIC VALUE OF THORACOSCOPIC PLEURAL BIOPSY FOR PLEURISY UNDER LOCAL ANAESTHESIA

Background:  We find pleural effusion in clinical practice frequently. However, it is difficult to make a diagnosis definitively by thoracocentesis or closed pleural biopsy. We directly examine the thoracic cavity by thoracoscopy under local anaesthesia, carry out pleural biopsy and make a definitive pathological diagnosis in pleurisy.

Bronchial artery embolization to control hemoptysis in patients with Mycobacterium avium complex.

BACKGROUND Hemoptysis frequently develops in patients with Mycobacterium avium complex (MAC) pulmonary disease. Bronchial artery embolization (BAE) has been established as one of the useful treatments of massive and persistent hemoptysis. We evaluated the efficacy and safety of BAE for controlling hemoptysis in MAC patients, and identified the risk factors of rebleeding after BAE. METHODS Among the 529 patients with MAC who were admitted to our institution from January 2007 to December 2012, we retrospectively reviewed the demographic data, imaging, sputum, and angiographic findings, and the clinical course of 43 patients who underwent BAE using coils, due to hemoptysis. RESULTS Among the 43 patients enrolled in the study, rebleeding developed in 13 cases (30.2%) with a mean follow-up period of 18 months. Median rebleeding-free time after BAE was 29.9 months and the cumulative hemoptysis control rates were 79.1%, 73.8%, and 63.3% in one, two, and three years, respectively. Rebleeding-free time significantly correlated with comorbid chronic pulmonary aspergillosis (CPA). When limited to 35 MAC patients without CPA, the rate increased to 88.6%, 82.1%, and 70.4%, respectively. Factors such as coexisting CPA, multiple embolized vessels at BAE, longer length of time from the diagnosis of MAC to BAE, and an administration of antibiotics for MAC at the time of hemoptysis, indicated statistically significant correlations with rebleeding. Major complications concerning BAE were not encountered. CONCLUSIONS BAE using coils is an effective and safe method for controlling hemoptysis in patients with MAC pulmonary disease. However, it is important to carefully observe patients with risk factors for rebleeding after BAE.

Clinical and Angiographic Characteristics of 35 Patients With Cryptogenic Hemoptysis

BACKGROUND: Hemoptysis can cause a life‐threatening condition and often needs to be treated urgently. Nearly 20% of hemoptysis cases are diagnosed as cryptogenic after clinical investigation. The purpose of this study was to clarify the clinical and angiographic characteristics of cryptogenic hemoptysis. METHODS: We retrospectively reviewed medical records of 35 patients admitted to our hospital with cryptogenic hemoptysis from October 2010 to September 2014. RESULTS: In the 35 cases, bronchial artery embolization was successfully performed in 33 patients (94.3%), whereas bronchoscopic hemostatic therapy was added in one patient (2.8%), and embolization was not performed in one patient (2.8%) because the bronchial artery was too narrow. In the successful embolization group, the non‐rebleeding rate was 97.0% for 20 months. The angiographic findings revealed that the diameter of the bronchial arteries was < 2 mm in 13 patients, 2 to 3 mm in 17 patients, and > 3 mm in five patients. Hypervascularization was detected in 29 patients (82.9%) and small bronchial aneurysms in eight patients (22.9%). The amount of hemoptysis was slight (< 50 mL/d) in 12, mild (50–100 mL/d) in 11, moderate (100–200 mL/d) in eight, and massive (> 200 mL/d) in four patients. No obvious relationship was found between the diameter of bronchial arteries and the amount of hemoptysis. CONCLUSIONS: BAE was highly effective for the management of cryptogenic hemoptysis. Most cases of cryptogenic hemoptysis have angiographic abnormalities, including small or microaneurysms, which were suspected as the cause in some cases.

A Stepwise Embolization Strategy for a Bronchial Arterial Aneurysm: Proximal Coil and Distal Glue with the Optional Use of a Microballoon Occlusion System

PurposeThis study aimed to demonstrate a transcatheter embolization strategy for bronchial artery aneurysms (BAAs) using coils for the proximal lesion and glue (n-butyl-2-cyanoacrylate [NBCA]) embolization for the distal lesion with or without the use of a microballoon occlusion catheter.Materials and MethodsFive patients with BAAs presenting with hemoptysis were enrolled in this study. A bronchial angiogram indicated a mediastinal BAA near the orifice, accompanied by dilated distal branches with or without intrapulmonary BAA. A stepwise procedure was performed. First, the intrapulmonary branches were embolized with glue, with or without the use of a microballoon catheter depending upon the anatomical and local flow hemodynamic conditions. Second, the mediastinal BAA was tightly packed with detachable coils.ResultsGlue embolization of intrapulmonary abnormal branches successfully controlled hemoptysis in all patients; microballoon catheters were used in five of the 10 arteries. The volume embolization ratio of coils within the mediastinal BAA ranged from 28 to 59%, and neither coil compaction nor signs of recanalization were observed during follow-up.ConclusionThe stepwise embolization procedure with the sequential use of glue (with or without a microballoon occlusion system) and detachable coils may represent a possible endovascular strategy for the treatment of complex BAAs.Level of Evidence IVLevel 4: Case Series.

An HIV-positive Case of Obstructive Jaundice Caused by Immune Reconstitution Inflammatory Syndrome of Tuberculous Lymphadenitis Successfully Treated with Corticosteroids

A 60-year-old man was admitted to our hospital because of a persistent fever with enlargement of multiple lymph nodes in the mediastinum and around the pancreatic head. He was diagnosed with tuberculosis and human immunodeficiency virus infection. We started antiretroviral therapy three weeks after the initiation of anti-tuberculous therapy. Two weeks later, jaundice appeared with dilatation of the biliary tract due to further enlargement of the lymph nodes, which seemed to be immune reconstitution inflammatory syndrome (IRIS). The administration of corticosteroids resolved the obstructive jaundice without surgical treatment or endoscopic drainage. Obstructive jaundice caused by IRIS should first be treated with corticosteroids before invasive treatment.

Thoracoscopic examination of empyema in a patient with sparganosis mansoni.

A 27-year-old man was admitted to our hospital with right pleural effusion. He had suffered from right chest and back pain and a high fever for one week prior to the admission. He had been treated with clarithromycin without improvement. Since thoracoscopy under local anesthesia revealed purulent effusion, synechiae and fibrous septa in the thoracic cavity, synechiotomy was performed and we started antibiotic treatment with the diagnosis of acute bacterial empyema. At the same time, we also suspected parasitic infection because of massive eosinophilic infiltration in pleural effusion and his dietary history of eating raw frogs. During the course of the disease, he had an infiltration in the right lower lobe and pneumothorax. Finally, we diagnosed him with sparganosis mansoni because his serum as well as pleural effusion was positive for the binding to sparganosis mansoni plerocercoid antigen, without any positive findings in bacteriology. His pleural effusion and lung infiltration were resolved after the administration of a high-dose praziquantel. We report this rare parasitic empyema with findings by thoracoscopic examination.

Six Cases of Pulmonary Mycobacterium shinjukuense Infection at a Single Hospital

Mycobacterium shinjukuense lung disease was diagnosed in 3 men and 3 women [mean age: 77.0±12.2 (57-93) years]. On imaging, 3 patients with previous pulmonary tuberculosis exhibited a fibrocavitary pattern, while the other 3 patients showed nodular bronchiectasis. A test with a tuberculosis rRNA identification kit (TRC Rapid(®) M. TB) was falsely positive for M. tuberculosis due to DNA sequence similarity in 16SrRNA. M. shinjukuense was identified by the gene sequences of rpoB, 16S rRNA, and hsp65. The symptoms and imaging findings of most of the patients have improved with chemotherapy with low minimum inhibitory concentrations of anti-tuberculosis drugs.