It is estimated that the number of sputum smear-positive and culture-negative cases (SPCN) has recently been increasing in Japan.
Although this phenomenon has been well known since the early stage of tuberculosis chemotherapy era, its clinical significance is as yet not so clear
From the review of literatures and based on the author's own experiences, it may be summarized as follows:
Some of this phenomenon are caused by technical errors during the procedure of staining or microscopical examination.
The routine culture method widely employed at present is reliable enough for clinical purpose, if it is performed very carefully; for example, the immediate inoculation after alkali treatment, reduced inoculum size and stable temperature during incubation.
The incubation period of all SPCN specimens should be extended up to sixteen weeks.
The SPCN cases found during the course of primary chemotherapy with intensive regimens are regarded as a normal step prior to negative conversion of bacilli both on smear and culture, in spite of the possible growth in extended incubation period.
The phenomen of repeated SPCN was found mainly in patients treated with long-term chemotherapy. If colonies grow during the extended incubation in such a case, a risk of deterioration in the future is high and the prognosis is not favourable.
Briefly, it may be concluded that the SPCN cases have no clinical significance, if there is no growth during the extended incubation period.

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For the purpose of evaluating whether safety reduction in the number of mass chest X-ray ex-aminations of adult population is possible or not, the incidence of pulmonary tuberculosis as well as the type of disease, methods and duration of treatment was observed among employees of iron factories in Tokyo area during the period from 1976 to 1979. All the factories were small in size, and the average employees per one factory was approximately 50.
The detection rate of new cases of pulmonary tuberculosis was 0.03% among those examined by the mass X-ray examination, and the incidence rate of pulmonary tuberculosis diagnosed by symptomatic visit to physicians was 0.04% for all employees, hence the overall incidence of pulmonary tuberculosis was 0.06%. In 1976, the majority of new cases (11) were detected by symptomatic visit to physicians and only 2 cases were found by the mass X-ray examination, while in later years, the difference in the number of new cases found by the passive and active case-finding became smaller, namely 13 cases were diagnosed by symptomatic visit and 10 cases by the mass survey.
The incidence rate of pulmonary tuberculosis among those who have not been examined by the mass survey was 0.71%, and the rate was much higher than the rate (0.20%) among those who were examined by the mass survey in the previous year. Comparing the severity of the disease at the time of diagnosis, more extensive and cavitary cases as well as bacillary cases and cases complicated with pleurisy were found more among cases found by symptomatic visit than among cases found by the mass survey. So-called rapid cases who were healthy in the previous year and develop bacillary and/or cavitary tuberculosis were found mainly in symptomatic cases. Hospitalization was indicated more for symptomatic cases, and the duration of treatment was also longer in symptomatic cases.
Loss of income during temporary disability of work due to hospitalization, however, has become smaller, as the duration of hospitalization became shorter, and none had lost his job because of tuberculosis. Comparing the increase in the expense for medical treatment when the mass examination is stopped against the decrease in the expense for the mass survey, the former is smaller than the latter, and the radiation hazards are also reduced when the annual X-ray examination is stopped. Taking into account the above circumstances, it is reasonable to reduce the number of mass chest X-ray examinations especially for young adult, and the emphasis of case-finding programme should be given for the promotion of symptomatic visit to physicians.

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Previously, Tsukamura observed that there were a number of patients, who showed negative conversion of sputum cultures within three months after the onset of lung disease due to M. avium-M. intracellulare complex (M. avium complex) and showed the closure of cavities within six months. Such cases were named as “transient infection” cases. In the present study, the frequency and the back ground factors of the transient infection cases were investigated.
The disease due to M. avium complex was diagnosed according to the criteria shown in Table1, and types of the disease were classified and defined as shown in Table2. For the diagnosis of transient infection, it is important to make daily sputum examinations at early stage of the disease, as, in these cases, sputum conversion occurs soon after the onset of disease. In the National Chubu Hospital, daily sputum examinations were carried out in all newly hospitalized patients since 1974. The frequency of transient infection cases thus found among patients with the disease due to M. avium complex was ca. 22% (9/41) (Table3).
No patient with dusty occupation was found among the patients with transient infection, whereas such patients* were found at a rate of 24% (7/29) among intermittent and continuous excreters (Table4) (*Three welders, one cloisonne worker, one ceramist (potter), one molding worker, and one artificial teeth factory worker.).
All patients with transient infection showed fresh lesions in their chest X-ray at the onset of disease, and were considered to belong to “primary infection-type”. In contrast, ca. 55% (16/29) of intermittent and continuous excreters showed cavities with sclerotic lesion (Table 5), which were suggested to belong to “secondary infection-type” (infection to tuberculous cavities).
The average age of patients with transient infection was younger than that of intermittent or continuous excreters (Table6).
The frequency of transient infection in three other hospitals, Kinki, Tokyo and Fukuoka, where no intended daily sputum examinations were carried out, was ca. 6% (13/225) (Table7). The X-ray feature, sex, and age of patients in all four hospitals are shown in Tables 8 and 9, and the chemotherapy used for the patients with transient infection is shown in Table 10. Out of 22 patients with transient infection, five (23%) showed negative conversion by a regimen of SM-INH-PAS, which has never been reported as effective for the treatment of the disease due to M. avium complex. Moreover, there is no paper which has reported that the use of antituberculous agents succeeded certainly to produce the negative conversion in this disease. Considering these facts, it is suggested that the phenomenon of transient infection is not due to a success of chemotherapy but due to host superiority in host-parasite-relationship. Such background of transient infection as younger age, presence of fresh lesions, and absence of the history of dusty occupation, supports the above concept. It is considered that transient infection is a type of disease produced by a better balance of the host-parasite-relationship, and that the transient infection occupies the position of intermediate type between asymptomatic infection and established infection, in which persistent excretion of the organism and persistent presence of cavities are seen.

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Seventy one surgical treatment was carried out for 67 patients with tuberculous cervical lympha-denitis during the last 10 years (1969-1978) in our hospital.
Although the morbidity rate at the national level has been decreasing gradually, there was no decline in the number of our cases throughout this period.
Most of them did not show typical local inflammatory symptoms, and characteristic conglomer-ation as recognized in no more than about half of cases and abscess formation in about 40%. They were mostly involved hemilaterally and the upper cervical nodes were involved a little more than the lower ones. In spite of the sufficient treatment with anti-tuberculous drugs, one-third of all cases showed worsening of local signs. Active pulmonary tuberculosis was found in 61.2% on chest X-ray and there were 10 cases combined with tuberculous lymphadenitis in other sites.
Surgical procedures of treatments were the incision alone for 12 cases, the simple resection of a swollen node for 34 cases, the radical dissection for 24 cases and the curettage for 1 case. Of these, the incision was employed for 28 cases primarily, but the second radical operation was necessary for 18 cases within 3 months.
Operative wounds healed almost completely with sufficient post operative anti-tuberculous chemo-therapy, and the recurrence rate was 5.3% during 2 years after the surgical treatment.
The cultures of tuberculous bacilli in involved lymphnodes showed positive in only 20.6% of all examined cases. On the other hand, typical tuberculous lesions were pathohistologically demonstrated in 84% of examined cases. The preoperative anti-tuberculous chemotherapy for more than 3 months was significantly effective on the culture positive rate of tubercle bacilli especially in caseous lesions. Dur-ing the follow-up, 5 recurrent cases were found until the end of 1979. Common factors of them were recognized as follows: Preoperative chemotherapy was shorter than 3 months (4/5), positive culture of tubercle bacilli in lymphnodes (4/5) and simple resection of a swollen node (3/5). Contrary to our expectation, no significant relation was recognized concerning the duration of postoperative anti-tuberculous chemotherapy.
From these results, we conclude that the surgical treatment for tuberculous cervical lymphadenitis should be performed to truly indicated cases with the sufficient postoperative anti-tuberculosis chemotherapy for more than 6 months. Even in such cases, it is advisable to give effective anti-tuberculous chemotherapy for more than 3 months before the operation.

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We present a case of 52 year old male patient with tuberculous mediastinal lymphadenitis. During diagnostic process, CT scan was considered to be especially effective in the differentiation from other mediastinal tumors.
It was quite useful in diagnostic process to predict the internal structure of the lesion by the grade of CT density.
From this point of view, the accumulation of the basic data is mandatory in order to apply CT scan for diagnosing the character of lesions such as calcification and caseous necrosis.

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