Uremic patients have impaired immunity. In order to clarify the characteristics of kidney and urinary tract tuberculosis in dialysis patients, an epidemiological study was made.
Study subjects were 7, 274 dialysis patients including 150 tuberculosis treated in 161 institutions. Among them 11 males and 16 females were kidney and urinary tract tuberculosis. They were between 20s and 60s of age. Two males and five females died from it.
As the causative diseases of renal failure, the frequency of glomerulonephritis was low and the frequency of renal tuberculosis and of polycystic kidney was high among the kidney and urinary tract tuberculosis patients in contrast with those among all dialysis patients and with those among all tuberculosis patients on dialysis. Kidney and urinary tract tuberculosis in dialysis patients was frequently accompanied with tuberculous lesions in other organs especially lung, peritoneum and bone and joint. The frequency of onset of kidney and urinary tract tuberculosis became high during the 3 months before the initiation of dialysis therapy. The maximal frequency was observed during the initial 3 months of dialysis therapy. The frequency decreased along with the dialysis therapy, although it remained high in comparison with that of the general population. Seventy five percent of the patients had a past history of tuberculosis 17.9 years ago on an average. Kidney and urinary tract had been very often involved in the past episode of tuberculosis. These facts can be interpreted that the kidney and urinary tract tuber culosis in dialysis patients develops frequently as a relapse. Pyuria was the most common among the symptoms and signs that led to the diagnosis, then followed by fever, cough, fatigue, lumbago, etc.
Thus, the present study demonstrated the features of kidney and urinary tract tuberculosis among dialysis patients.

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Production of mycobacterial lipase inhibitor (MLI) in the unheated culture filtrate of Mycobacterium tuberculosis H37Rv and its purification and characterization were studied.
The activity of MLI against lipase prepared from guinea pig peritoneal macrophages was measured fluorimetrically. Production of MLI reached the maximum level six weeks after incubation at 37°C on a modified Sauton liquid medium. Purification of MLI was performed by successive procedures with ammonium sulfate saturation, ion-exchange chromatography and gel filtrations. Four MLIs (MIA-1, 2, 3 and 4) were finally isolated. The molecular weights were estimated to be 150, 000, 62, 000, 29, 000 and 600, 000, respectively, by gel filtration on a Sephacryl S-300 column. All the MLIs were resistant to heating at 100 for 20min in boiling water, to treatment with butanol or Streptomycin, whereas they were sensitive to proteolytic enzymes such as trypsin, pronase and protease. The results obtained from gel filtration on a Sephadex G-200 column and preliminary SDS-polyacrylamide gel disc electrophoresis strongly support the idea that some of these MLIs would be aggregates composed of similar poly peptides.
The activity of MLIs against lipase from guinea pig peritoneal macrophages was more pronounced when 4-methylumbelliferyl (4-MU)-oleate was used as a substrate than 4-MU palmitate or 4-MU-elaidate as a substrate. MLIs acted little against lipase preparations from human peripheral blood leukocytes, guinea pig polymorphonuclear leukocytes and mouse peritoneal macrophages, and none of other lysosomal acid hydrolases such as acid phosphatase, β -glucuronidase, N-Ac-β-glucosaminidase and N-Ac-β-galactosaminidase prepared from guinea pig peritoneal macrophages.

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Tuberculosis in lower lung field without concomitant active lesion of the upper lobe was found in 33 (7%) out of 471 patients with active pulmonary tuberculosis admitted to the Osaka Hospital of JATA between January 1977 and December 1982. In our study on 33 patients, it was observed that there was a higher incidence in female (19.5%) than in male patients (2.8%). Twenty-one out of 33 patients were under 40 years of age. The majority of the patients had respiratory symptoms; such as cough, sputum, fever or hemoptysis. Radiographic findings showed predominance in the left side in 17 patients to 14 in the right, also bilateral lesions were found in two patients. Cavitation in 16 patients (48%) was usually small in size and solitary ones. There was no larger cavity above 4cm in diameter. Hilar lymphadenopathy was found in 7 patients, pleural effusion in 3 and only one was confirmed primary tuberculosis with recent conversion of PPD skin reaction. The lesions confined to the superior segment of the lower lobe in 11 patients, middle lobe or lingular segment in 7, basal segments in 8 and the whole lower lobe in 7. Eight patients with lesion in the superior segment of the lower lobe had cavitation and 5 of them had a history of hemoptysis. Five patients with lesion of the middle lobe or lingular segment were incorrectly diagnosed at first but the correct diagnosis was established over three months later. The caseous pneumonia involving the whole lower lobe was observed in 6 patients. They showed acute onset, severe symptoms and air space consolidation similar to bacterial pneumonia. However, the majority of them failed to improve with the usual anti bacterial chemotherapy, and shortly later tubercle bacilli were proved from their sputum. Initial intensive chemotherapy with INH, RFP and SM or EB proved to be effective and revealed similar sputum conversion in patients with upper lobe lesions.
To conclude, in diagnosing patients with abnormal radiographic appearance, such as lesions in the lower lung field, we should always consider the possibility of pulmonary tuber culosis, and how important it is to perform bacteriological examinations of sputum.

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We have studied clinically 42 cases of chronic empyema, admitted to our hospital during the past 5 years (1978-1982). Operative procedures applied were decortication for 17 cases, thoracoplasty for 13 cases, open treatment for 2 cases, closed tube drainage for 7 cases, and 2 cases were treated with chemotherapy alone.
In our cases, we have several cases of chronic empyema with interesting healing processes by surgical treatments.
The results of the study are summarized as follows:
1) There is a case of p.aerginosa empyema after pneumonectomy of right lung healed by the treatment with CTD+50% iodine tincture.
2) Two cases of total fistulous empyema were healed by “CTD+fistulo-obstruction thoracoplasty” alone.
3) Calcified fistulous empyema was subjected to radical operation after open treatment and removal of calcified tissue.
4) Cases excreting resistant bacteria or aspergillus were treated with opening of thorax to reduce amount of bacteria in thorax cavity.
5) Six cases under treatment are kept on O2-inhalation.
6) There are 2 cases surgically healed by air plombage against fistulous chronic empyema.
7) There were 2 cases excreting resistant bacteria with fistulous empyema after left upper lobe lobectomy healed by “roll-method pneumonectomy” which is operated against strong adhesion between V¹⁺², V³, V⁴⁺⁵ and fistulous bronchus wall. The procedure is follows; at first, the left main bronchus is resected 3 cm, second, the left lower lobe lobectomy is done, and last, the remaining fistulous bronchus roll is lengthwise opened, sliced off mucous membrane and bronchial cartillages, and then the remaining bronchus wall is sutured.
8) Results of treatment were surgically healed in 80.9%, under treatment in 7.2% and died in 11.9 %.

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Since the establishment of the tuberculosis registration system in early 1960's, only slight changes have been given to the system of the case management that is principally based on the ideas from the early chemotherapy era.
Therefore it is considered as an urgent matter to revise it to well conform to the recent situation with modern philosophy of tuberculosis control, especially with the powerful short course chemotherapy.
In the symposium, five reports were presented by experts in public health or in clinical service, and discussions were held from wide viewpoint, which are summarised as follows:
1) Relapse after completion of chemotherapy was observed by Ueda and Higa in the routine service in Osaka and in Okinawa, respectively. About 4-5% of relapse rate during the first three years' follow-up period was seen in their study, in which bacteriologically confirmed relapses occupied 20-50% out of all. Sugita reported a lower rate of 1.5% as a relapse rate from the experience of a tuberculosis hospital's routine service. In Okinawa the follow-up X-ray examination of the inactive cases detected only 20% of the whole relapses, while others were detected by the clinical service for the symtomatics. Cases having some particular characteristics were found to run a higher risk of relapse and these included male sex, the aged, initial positive bacteriology, initial presence of cavity, and presence of known risk factors. The follow-up examination was considered to have rather limited value for the efficient detection of relapses and its efforts should be concentrated on these special risk groups. Also the diagnostic standard of “relapse” should be reviewed more strictly so as rely not too much on X-ray findings.
2) Fujioka made close observations of the deaths and occurrences of chronic excretors among newly registered cases and of the incidence of tuberculosis or infections among contacts. He found that the initially smear positive cases had the poorest prognosis in terms of deaths and treatment failures, and he also confiremed that the contacts of the smear positive cases had the highest probability to develop the disease and to get infected.
Current system of “Activity Classification” where either bacillary-positive on smear and/or culture-or cavitary cases grouped under the same category “infectious” should be altered so as to give greater importance to smear positive cases and to chronic exretors from a view point of infection-source control.
3) Some prefectures have their own standards for the indication of chemoprophylaxis as were reported by Higa and Ueda, but medical characteristics of subjects for chemoprophylaxis were shown to vary quite widely. Several cases, though very small in rate, have developed among those having completed prescribed chemoprophylaxis, and almost all of them were from contacts of heavily positive sources of infection. Special emphasis should be put on the chemoprophylaxis cases from contacts-convertors, separately from those diagnosed on mass basis without definite contact
4) In Japan medically prescribed restriction on daily life and on working condition is still considerable, depriving an average of 122 working days, hospitalizing about sixty percent of newly detected cases (including non-infectious ones) and confining them on the average for 5.4 months to hospital or home beds during the first year, as was revealed by Nobutomo's study. Unequality produced by this classical practice supported by “Standards for guiding daily life and work in tuberculosis cases” among areas and medical institutions was also noted.

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