Tuberculosis occupies 4th place among major causes of death, and the number of new cases is estimated at 7.25 million in 1997, and 99% of TB deaths and 95% of new TB cases are seen in developing countries. TB had been brought under control in developed countries by applying modern TB control programme including chemotherapy, as basic health infrastructure was already well developed, and their economy can afford cost of control programme including TB drugs. The rapid decline of TB due to the success of TB control in developed countries had lowered the concern on TB, thus bought about the reduction in research grant for TB and difficulty in bringing up successors engaging in TB control. Similar trend was seen also in developing countries, where TB still remains one of most improtant health problems due to poor quality of the programme caused by poorly developed health infrastructure including man-power, budget and institutions.
New obstacles which hinder the smooth implementation of TB control programme have appeared, and they are the rapid expansion of global population, the move of population, the impact of HIV epidemic on TB and the multi-drug-resistant TB (MDRTB). The growth of population automatically increases the number of TB cases and gives heavier burden for TB control. TB has moved from developing to developed countries with the move of the population, and currently approximately half of new TB cases in developed countries is occupied by foreign-born patients.
Among several opportunistic infections seen in AIDS cases, TB comes out first as the virulence of tubercle bacilli is much higher than the other germs causing opportunistic infections. The pathogenesis of TB changes markedly among HIV positives, and the incidence becomes much higher, and the time interval from the primary infection to the disease, and that from the detection of the disease to death without any effective treatment are shortened, and the fatality rate becomes much higher. Because of the atypical clinical picture, attenuated tuberculin sensitivity and high incidence of side-effects of TB drugs, in particular thiacetazone, clinical management of HIV positive TB is much more difficult than ordinary TB.
MDRTB is produce by the bad quality of TB control, and by improving treatment completion rate as well as the cure rate, decline in the prevalence of drug resistance, both primary and acquired, could be expected together with the decline of TB itself.
WHO has made a great challenge with TB after the nomination of Dr Kochi to chief medical officer, TUB in 1989. Currently, Global TB Programme (GTB) is promoting socalled DOTS strategy of TB control, consisting of the committment of the government to give high priority to TB control, passive case-finding with sputum smear examination by microscopy, directly observed treatment by standardized short-course regimen of chemotherapy, well-organized logistics for TB drugs, and the provision of reporting and monitoring system of TB including the evaluation of treatment outcome by cohort analysis. Marked achievements have been obtained in several countries introduced DOTS strategy.
Japan is asked to intensify its efforts in international cooperation in TB control.

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To indentify predictive parameters for the development of residual pleural thickening in tuberculous pleurisy, we investigated 58 tuberculous pleurisy patients retrospectively who could be followed up until their chest roentgenogram no longer changed. The patients were devided into the following three groups according to the final configuration of pleural space: group I costphrenic angle (C-P angle) of the affected side was completely or almost completely recovered (20 cases), group II C-P angle became dull (20 cases), group III pleural thickening of>2 mm remained in the lateral chest wall above the diaphragmatic dome level (18 cases). Differences of the clinical, chest roentgenographic and laboratory data were compared between these three groups. There were no differences between groups I and II in all of the parameters compared, while there were some differences between groups I and/or II and group III The mean age of group III (51.1±18.1 y. o.) was significantly higher than that of group I (40.7±18.6 y.o.) and group II (34.7±14.7 y.o.) (p<0.05 and p<0.005 respectively). Glucose level in pleural fluid of group III (32±31 mg/dl) was lower than that of group I (96±13mg/dl/) and group II (86±21mg/d/) (p<0.001, respectively), while the levels of LDH, TP and ADA in pleural fluid were not different significantly among three groups. BSR (blood sedimentation rate) and CRP (C-reactive protein) were higher in group III (77±30 mm/hr and 8.5±4.3mg/dl/) than those in group I (45±23 mm/hr and 4.1±5.4 mg/dl) (p<0.01 and p<0.05, respectively). The level of albumin in serum was lower and that of globulim was higher, and consequently that of A/G ratio in group M (0.78±0.17) was lower than that of group I (1.15±0.16) and group II (1.10±0.22) (p<0.001, respectively). It should be emphasized that the level of 7 γ-globulin was higher in group M irrespective of the presence or absence of accompanying pulmonary tuberculosis. Most patients more than 40 years old with serum A/G ratio less than 0.95 belonged to group III (13/15 (87%)) while most of those with serum A/G ratio more than 0.95 belonged to group I or II (10/11 (91%)). Thus hyper (γ-) globulinemia and the intensity of inflammatory reaction in the whole boby and in the pleural space are the predictive factors for the development of residual pleural thickening in tuberculous pleurisy.

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An Investigation by questionnaire was conducted in 1996 to know the tuberculosis (TB) status and living conditions of 50 homeless people registered as TB patients at one of Nagoya city's 16 health centers.
1. All patients had one or more symptoms of TB, 64% of them showed positive TB bacilli on smear, and 35.3% of them had a previous history of TB treatment. However, only 15.2% suspected they had TB at the onset of symptoms.
2. Main reasons of seeking medical treatment: 28.6% arrived by ambulance after falling down from exhaustion, 25.7% had consulted with welfare agencies after the onset of symptoms, and 20.0% had been diagnosed during the treatment of other diseases.
3. When they were admitted to the hospital they had many concerns 29.0% loss of income, 19.4% living expenses, 19.4% smoking prohibition, 12.9% admission fee, and 9.7% privacy.
4. They lived in the following: 42.9% construction camps, 20.0% parks or streets, 17.1% single room occupancy hotels, 17.1% daily or monthly paid apartments, and 11.4% sauna baths.
5. Past medical histories of the subjects included 40.6% injuries by labor accidents, and 25.0% stomach ulcers. Current diseases were 15.6% mental diseases, 15.6% liver diseases, 15.6% diabetes mellitus, and 9.4% alcoholic dependance. Seventy percent of them consumed alcohol daily (average pure ethanol 125m1 per day).
6. From the results outlined above, the following proposals relating to TB control of the homeless should be considered.
1) Educating the homeless as to the need for a health check when TB symptoms are present.
2) Opening a clinic for the homeless for easy access to consultation on TB.
3) Directly observed therapy, short-course, for TB in the homeless.
4) Health examination of the employees of single-room occupancy hotels and sauna baths which are used frequently by the homeless.
5) A fundamental countermeasure to deal with alcoholic dependancy among the homeless.

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Annual incidence of nontuberculous mycobacterial (NTM) disease has been gradually increasing in the last 10 years in Japan. It is likely to encounter this disease not only in hospitals specialized in mycobacterial diseases but also in general hospitals. NTM were isolated from 97 cases between January 1990 and June 1996 at our hospital. Out of them, 41 patients were diagnosed as NTM disease. Mycobacterium avium complex (MAC) was the most frequent pathogens (68.3%) and M. kansasii (22%) was the next. Other pathogens were M. chelonae (4.9%), M. fortuitum (2.4%) and M. szulgai (2.4%). Results obtained in our hospital were very similar to the rates which have been reported previously. Patients with MAC infection showed relatively poor prognosis (eight patients were died out of 28 patients with MAC) in this study compared with the cases reported in previous papers, and this result could be explained by the severity of illness when they were admitted to our hospital, the insufficiency of the initial treatment which should be stared with the combined use of three to four antibacterial drugs including clarithromycin, and to a low dosage of clarithromycin compared with conventionally adopted dosage. Unlike tuberculosis, human to human transmission is considered to be negligible in the case of NTM disease, and general hospitals are able to provide medical care to the patients with NTM disease. Rather, if general hospitals which are located in the region near to the patients residence can play more active role in the treatment of NTM disease, it would be more beneficial to patients requiring long-term follow-up observation. Based on the result that similar therapeutic results were obtained for infections with other NTM as reported in previous papers, it is indicated that general hospitals are able to provide medical care to patients with NTM disease if therapeutic regimens recommended by specialist are sufficiently understood and applied.

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The patient was a 76 year-old female with tuberculous tendonitis, treated with antituberculous drugs including rifampicin (RFP). About two weeks after the start of RFP, she noticed general malaise and started vomiting, and the laboratory data showed severe hyponatremia. Because of mild liver dysfunction, RFP was discontinued and her symptoms gradually improved. Abdominal X-ray and CT showed swellings and calcifications of adrenal glands bilaterally. Serum ACTH level was high and cortisole, 17-OHCS, and 17-KS levels were normal. Her responce to rapid ACTH stimulation was blunted significantly. After another trial of RFP, she started to vomit and complain general malaise again. We diagnosed her as partial Addison's disease and administered hydrocortisone with RFP. After this treatment her improvement was rapid.
It has been known that RFP causes induction of enzymes in hepatic microsomes which increase the catabolism of glucocorticoids. To avoid the risk of adrenal insufficiency, patients with insufficient adrenal hormone reserve should receive compensatory hydrocortisone while they are taking RFP.

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