Kyung-Wook Jo

Risk Factors for Recurrence after Successful Treatment of Mycobacterium avium Complex Lung Disease

ABSTRACT This study analyzed the recurrence rate and risk factors for recurrence of Mycobacterium avium complex (MAC) lung disease in patients successfully treated for this disease. The medical records of 158 patients successfully treated for MAC lung disease at a tertiary referral center in South Korea between March 2000 and December 2009 were retrospectively analyzed. Recurrence was recorded, and factors associated with recurrence were analyzed. The mean age of the 158 patients was 60.7 ± 11.1 years. The etiologic agent was Mycobacterium avium in 77 patients (48.7%) and Mycobacterium intracellulare in 81 patients (51.3%). Radiographic features included nodular bronchiectatic disease in 95 (60.1%), fibrocavitary disease in 49 (31.0%), and an unclassifiable form in 14 (8.9%) patients. Almost all (98.7%, 156/158) patients had been previously treated with a macrolide-containing regimen, and 68 (43.0%) patients had received treatment with an aminoglycoside. During a median follow-up of 43.8 months after completion of therapy, 50 patients (31.6%) experienced recurrence, at a median of 11.9 months after treatment completion. Multivariate analysis showed that only the nodular bronchiectatic form of the disease (hazard ratio, 2.39; 95% confidence interval, 1.19 to 4.81) was independently associated with an increased risk of recurrence. Recurrence after successful treatment is frequent in patients with MAC lung disease. The recurrence rate was significantly higher in patients with the nodular bronchiectatic form than in those with the fibrocavitary form or an unclassifiable form of the disease.

Treatment outcomes of refractory MAC pulmonary disease treated with drugs with unclear efficacy.

We aimed to investigate the treatment outcomes of patients with refractory Mycobacterium avium complex (MAC) lung disease treated with regimens containing drugs with unclear efficacy. Of all patients diagnosed with MAC lung disease between April 2004 and September 2012 at a tertiary referral center in South Korea, the outcomes of 51 patients treated with regimens containing drugs with unclear efficacy (clofazimine, moxifloxacin, rifabutin, and linezolid) because of treatment failure after receiving standard treatment were retrospectively analyzed. The mean age (standard deviation) of the 51 patients was 59.0 (10.3) years and 29 (56.9%) were male. The etiologic agent was M. avium in 17 patients (33.3%) and Mycobacterium intracellulare in 34 patients (66.7%); 42 patients (82.4%) had the fibrocavitary form of the disease. Of the 51 patients, 26, 28, 35, and 7 received clofazimine-, moxifloxacin-, rifabutin-, and linezolid-containing regimens (numbers are not mutually exclusive), with median drug administration durations of 147, 128, 209, and 88 days, respectively. Overall, 8 patients (15.7%) had a favorable response. Treatment outcomes did not differ by drug regimen or even by the combination of more than 2 drugs. The treatment outcomes of patients with refractory MAC lung disease were unsatisfactory with regimens containing possibly effective drugs such as clofazimine, moxifloxacin, rifabutin and linezolid.

Prevalence of Latent Tuberculosis Infection among Health Care Workers in South Korea: A Multicenter Study

Background We investigated the prevalence of latent tuberculosis infection (LTBI) among the health care workers (HCWs) and analyzed its risk factors in South Korea. Methods A standard questionnaire regarding the baseline demographics and risk factors for LTBI was given to each participant and tuberculin skin test (TST), QuantiFERON-TB GOLD In-Tube (QFT-GIT) assay, and chest radiography were performed. Results A total of 493 participants, 152 (30.8%) doctors and 341 (69.2%) nurses were enrolled in eight tertiary referral hospitals. The mean age of the subjects was 30.6 years old, and 383 (77.7%) were female. Of the 152 doctors, 63 (41.4%) and 36 (23.7%) were positive by TST and by QTF-GIT, respectively, and among the 341 nurses, 119 (34.9%) and 49 (14.4%) had positive TST and QFT-GIT results, respectively. Overall, the agreement between the two tests was 0.22 by the chance corrected proportional agreement rate (kappa coefficient) in 493 subjects. Experience of working in tuberculosis (TB)-related departments was significantly associated with positive LTBI test results by QFT-GIT assay, not by TST. In multivariate analysis, only age was independently associated with increased risk of a positive TST result, while age and experience of working in TB-related departments (odds ratio, 2.29; 95% confidence interval, 1.01-5.12) were independently associated with increased risk of a positive QFT-GIT result. Conclusion A high prevalence of LTBI was found among South Korean HCWs. Considering the association between the experience of working in TB-related departments and high risk of LTBI, QFT-GIT may be a better diagnostic test for LTBI than TST in HCWs.

Natural history of Mycobacterium avium complex lung disease in untreated patients with stable course

Little is known about the long-term natural history of Mycobacterium avium complex lung disease (MAC-LD) in untreated patients with stable course. The aim of this study was to investigate the natural course of untreated stable MAC-LD, with a focus on factors associated with clinical deterioration, spontaneous sputum conversion and prognosis. Of 488 patients diagnosed with MAC-LD between 1998 and 2011, 305 patients (62.5%) showed progressive MAC-LD resulting in treatment initiation within 3 years of diagnosis and 115 patients (23.6%) exhibited stable MAC-LD for at least 3 years with a median follow-up duration of 5.6 years. Patients with stable MAC-LD were more likely to have higher body mass index and less systemic symptoms at initial diagnosis compared with patients with progressive MAC-LD, while positive sputum acid-fast bacilli smear, fibrocavitary type and more extensive disease in radiological findings were more associated with progressive MAC-LD. Of the untreated patients with stable MAC-LD, 51.6% underwent spontaneous sputum conversion, with younger age, higher body mass index and negative sputum acid-fast bacilli smear at initial diagnosis found to be predictors of this occurrence. Advanced age, fibrocavitary type and abnormal pulmonary function were negative prognostic factors for survival in patients with stable MAC-LD. Host predisposing factors are relatively more important than microbiological factors in stable MAC-LD patients http://ow.ly/nf9N306AQd0

Risk factors for 1-year relapse of pulmonary tuberculosis treated with a 6-month daily regimen

BACKGROUND We aimed to identify the 1-year relapse rate and risk factors for patients with pulmonary tuberculosis (TB) treated with a 6-month daily regimen. METHODS A total of 317 patients with pan-susceptible pulmonary TB who completed a 6-month daily course of treatment [2HRZ(E)/4HR(E)] were retrospectively analyzed. RESULTS The mean age was 50.0 ± 16.8 years and men were predominant (61.2%). All of 137 adults tested for HIV were negative. Six (1.9%) cases relapsed within one year. Relapse rate was higher in patients with a positive culture after 2 months of treatment (10.0%, p = 0.049) and in patients with both a positive culture after 2 months of treatment and cavitation on initial chest radiograph (18.2%, p = 0.015), whereas relapse rate in patients with cavitation alone was comparable to that of the total population (2.7%). Among various risk factors known to increase risk of relapse, the combined variable of cavitation and positive culture at 2 months (OR = 15.56, 95% CI 2.56-98.71, p = 0.003) was only associated with increased relapse rate in a multivariate analysis. CONCLUSIONS Even with a 6-month daily treatment regimen throughout the intensive and continuation phases, the relapse rate was unacceptably high in patients with both a positive culture at 2 months of treatment and cavitation on baseline chest radiography. Intensification of treatment, such as an extension of treatment duration, should be considered in this category of patients.

Mycobacterial diseases developed during anti-tumour necrosis factor-α therapy

Nontuberculous mycobacterial (NTM) disease and tuberculosis (TB) develop during anti-tumour necrosis factor (TNF)-α therapy. We compared clinical characteristics and outcomes between the two diseases. A total of 1165 patients were screened for TB and treated with TNF-α antagonists from July 2004 to July 2013 for the following conditions: inflammatory bowel disease (n = 422), rheumatoid arthritis (n = 320), and ankylosing spondylitis (n = 389). TB and NTM disease were diagnosed at baseline screening in four and three patients, respectively, and developed during anti-TNF-α therapy in 19 and six patients, respectively. The incidence rate of TB and NTM disease was 747.7 per 100 000 and 238.2 per 100 000 person-years, respectively. Patients with NTM disease were older, with a greater proportion of females. All cases of NTM disease involved the lung, with rheumatoid arthritis (83.3%) being the most frequent underlying disease. The most common radiological feature was consolidation in NTM disease, and honeycombing was present in two rheumatoid arthritis patients with NTM disease. The most common pathogen was Mycobacterium intracellulare (n = 3) followed by Mycobacterium avium (n = 2). Both the NTM and TB group showed favourable outcomes. The clinical characteristics differed between NTM disease and TB that developed on anti-TNF-α agents, but clinical outcomes were favourable in both diseases. Clinical characteristics differ between nontuberculous mycobacterial disease and TB that develop on anti-TNF-α agents http://ow.ly/xSQ0o

Diagnosis of latent tuberculosis infection before initiation of anti-tumor necrosis factor therapy using both tuberculin skin test and QuantiFERON-TB Gold In Tube assay

Abstract Background: Reactivation of latent tuberculosis infection (LTBI) is an important complication in patients treated with tumor necrosis factor-alpha (TNF-α) blocking agents. However, the best method for LTBI detection before initiation of anti-TNF therapy remains to be determined. Methods: From January 2010 to August 2013, anti-TNF therapy was initiated in 426 patients with immune-mediated inflammatory diseases (IMIDs). Tuberculin skin test (TST) and Quantiferon-TB Gold In Tube (QFT-GIT) assay were performed before starting anti-TNF treatment. LTBI was defined as a positive TST (induration ≥ 10 mm) or as a positive QFT-GIT result. Patients were followed up until December 2013. Results: The positive TST and QFT-GIT rates were 22.3% (95/426) and 16.0% (68/426), respectively, yielding a total of 27.0% (115/426) of positive LTBI results. LTBI treatment was initiated in 25.1% (107/426) and was completed in 100% (107/107) of patients. During a median 294 days of follow-up, active TB occurred in 1.4% (6/426) of the patients with negative TST and QFT-GIT results at baseline. Conclusion: The either test positive strategy, using both TST and QFT-GIT assay, is acceptable for LTBI screening before commencing anti-TNF therapy in patients with IMIDs.

Vitamin D deficiency in Parkinson's disease patients with orthostatic hypotension

The purpose of our study was to investigate the associations between serum vitamin D3 levels and orthostatic hypotension (OH) in patients with Parkinsons disease (PD).

Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security

PURPOSE Extracorporeal membrane oxygenation (ECMO) is useful for providing hypoxic patients with ventilatory support, but its usefulness in the management of patients with central airway obstruction has rarely been reported. Nineteen cases in one center where venovenous (VV) ECMO was used to support patients with severe central airway obstruction while they underwent lifesaving interventions are reported here. METHODS In total, 113 cases of VV ECMO were performed in Asan Medical Center between January 2009 and June 2012. In 19 cases (18 patients), VV ECMO was used to support patients with severe airway obstruction. RESULTS Of the 18 patients, 13 were male, and their median age was 62.5 (range, 16-82) years. The main reasons for using ECMO to provide airway security were malignant mass removal with a rigid bronchoscope (8 cases) and insertion of a tracheal stent (7 cases). The median ECMO time was 20.9 (range, 2.2-113.4) hours. In 1 case, a patient died of massive bleeding after a malignant mass was removed. Weaning off ECMO therapy occurred successfully in the remaining 18 cases. CONCLUSIONS Venovenous ECMO may be useful in patients with central airway obstruction because it provides short-term airway security while lifesaving procedures are being performed.

Incidence, characteristics, and treatment outcomes of mycobacterial diseases in transplant recipients.

The incidence, clinical characteristics, and treatment outcomes of tuberculosis (TB) and nontuberculous mycobacterial (NTM) disease developed after transplantation (TPL) in transplant recipients were investigated retrospectively. Between 1996 and 2013, 7342 solid‐organ transplantation and 1266 hematopoietic stem cell transplantation were performed at a tertiary referral center in South Korea. Among them, TB and NTM disease developed in 130 and 22 patients, respectively. The overall incidence of TB was 257.4 cases/100 000 patient‐years (95% confidence interval [CI], 215.1–305.7) and that of NTM disease was 42.7 cases/100 000 patient‐years (95% CI, 26.8–64.7). The median interval from organ TPL to the development of mycobacterial disease was 8.5 months (95% CI, 6.3–11.4) in recipients with TB patients and 24.2 months (95% CI, 13.5–55.7) in those with NTM, respectively. Among NTM patients, Mycobacterium avium–intracellulare complex was the most common causative organism, and nodular bronchiectatic type (77.8%) was the most frequent radiologic feature. Favorable treatment outcome was achieved in 83.7% (95% CI, 76.4–89.1) and 68.8% (95% CI, 44.4–85.8) of TB and NTM patients, respectively (P = 0.166). In conclusion, the overall incidence of TB was higher than that of NTM disease in transplant recipients and treatment outcomes were favorable in both drug‐susceptible TB and NTM patients.