[Purpose] This study was conducted to assess clinically whether intervention with instruction applying respiratory rehabilitation method for expectorating sputum was useful or not to obtain more suitable sputum for smear examination of acid-fast bacilli.
[Subject] All specimens examined were sputa obtained from 163 patients without the instruction group and 161 patients with the instruction group, who visited our outpatients clinic during one year from September 1, 2000 to August 31, 2001 and the following one year, respectively.
[Method] Gross appearance of the sputum according to Miller & Jones' classification (Ml, M2, P1-P3) and smear positive rate by fluorescence staining method after N-AcetylL-cysteine-NaOH treatment and centrifugation were compared between the two groups.
[Results] M1 and P1 sputa were 21.5% and 21.5% in the no instruction group, while those were 8.1%, 36.6% in the instruction group. Difference in M2, P2 and P3 sputa were not significant between the groups. Smear positive rate was 10.4% in the no instruction group, while it was 21.1% in the instruction group. According to gross appearance of M2, P1 and P2, positive rate was 11.1%, 11.4% and 30.8% in the no instruction group, and 17.7%, 28.8%, and 26.3% in the instruction group. Chest roentogenographic findings judged by type (cavitary and non-cavitary) and extent of the pulmonary lesions of these smear positive cases (17 in the no instruction group and 34 with the instruction group), revealed that the no instruction group consisted of more predominantly severer disease with cavity and moderately or far advanced lesions as compared with the instruction group.
[Consideration] We could exclude that the difference in gross appearance and smear-positive rate of the sputum specimen between groups without and with the instruction might be due to differences in disease severity between the two groups with and without the instruction.
[Conclusion] The instruction for sputum expectoration seems to be useful to increase positive rate in the smear examination of acid-fast bacilli.

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[Introduction] The epidemiology of Mycobacterium avium-intracellulare (MAC) infections has not been completely defined. Recently some reports presented polyclonal MAC infections. The purpose of this study was to reveal the clonal diversity of Mycobacterium avium isolates and the relation between clinical subtype of lung disease and polyclonal infection.
[Methods] We categorized pulmonary Mycobacterium avium infection to three clinical subtypes, tuberculosis like type, bronchiectasis with preexisting tuberculosis type and nodular bronchiectasis type. Mycobacterium avium isolates of 11 patients were studied for their heterogeneity using 1S1245 based RFLP analysis. The insertion sequence 1S1245 is repetitive element identified only in Mycobacterium avium. Standard method of IS1245 based RFLP analysis has been proposed as a suitable technique for typing of Mycobacterium avium isolates for epidemiological and taxonomic studies. At least three distinct colonies were subcultured to single clone. The subclones of the isolates were analyzed by IS1245 based RFLP technique and some subclones were also examined by antimicrobial susceptibility test.
[Results] Two of three patients of tuberculosis like type were considered to be monoclonal infection because only a single genotype was identified. And only one of four patients of bronchiectasis with preexisting tuberculosis type was considered to be polyclonal infection despite of long-term observation. Although isolates were collected in two or more occasions in clinical course over one year period, only a single genotype was observed in two patients. In contrast, three of four patients of nodular bronchiectasis type had multiple genotypes. Isolates recovered from patients with monoclonal infection pattern following long-term treatment with clarithromycin monotherapy became resistant to clarithromycin. In contrast, three strains derived from one nodular bronchiectasis patient were susceptible to clarithromycin despite of long-term chemotherapy including clarithromycin. The susceptibility patterns of the other drugs were also apparently different. Strain conversion due to repeated polyclonal infection was considered. These results of the antimicrobial susceptibility test supported clonal diversity of the Mycobacterium avium infection.
[Discussion] IS1245 based RFLP analysis possesses a discriminatory power between the isolates on clonal level. This study demonstrates that polyclonal infections are common in nodular bronchiectasis type and monoclonal infections are common in tuberculosis like type and bronchiectasis with preexisting tuberculosis type. And not only simultaneous polyclonal infection but also repeated polyclonal infection were observed in a nodular bronchiectasis type patient.
Drug susceptibility test showed long-term chemotherapy including clarithromycin could change the susceptibility of clarithromycin to resistant in patients with monoclonal infection. In contrast patients with repeated polyclonal infection pattern would avoid drug resistance because of strain conversion. This multiple susceptibility patterns identified in this study would not have been detected by the standard susceptibility test without subculture. And we also need the treatment strategy considering the polyclonal infection.
[Conclusions] Polyclonal infections are considered to be common in pulmonary Mycobacterium avium infection, especially nodular bronchiectasis type. Clonal diversity of Mycobacterium avium infection is an important factor to perform chemotherapy and drug susceptibility test.

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[Objective] The purpose of this study is to investigate the distribution of Mycobacterium tuberculosis genotypes, such as Beijing family and other genotypes in Okayama district, and to examine the relation between these genotype strains and prevalent strains.
[Methods] The 142 M. tuberculosis strains isolated in Okayama City from January 2000 to December 2002 were subjected to IS6110-RFLP and spoligotyping for the population-based study. In addition, 13 strains having 1 to 5 IS6110 copies isolated in Okayama Prefecture excluding Okayama City were also subjected to spoligotyping.
[Results] A total of 103 (72.5%) of 142 strains belonged to Beijing family. Furthermore, 3 of 4 groups of prevalent strains belonged to the family. Twenty one strains out of 39 rest strains could be classified into 10 shared types (STs) of 259 STs in the worldwide spoligotype database. In addition, 15 out of 26 strains from inside and outside of Okayama City having 1 to 5 IS6110 copies showed common unique spoligotype. Moreover, the age of majority patients who were infected with M.tuberculosis of the Beijing family or other genotypes were older than 60 years.
[Conclusion] It was suggested that Beijing family had been the main infection source, and the spread of strains of Beijing family and other genotypes occurred considerably in old times, and the unique genotype strains remained for a long time as peculiar strains.

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1. Epidemiological trend of TB and its diagnosis among the elderly: Masako OHMORI (Research Institute of Tuberculosis, JATA)
It is estimated that over 10, 000 TB patients will occur among the elderly aged over 75 years of age during 2010 and 2020. Though the new TB patients among the elderly over 65 years of age decreased in number from 1987 to 2001, sputum smear positive patients, which are highly infectious increased by 1.3 times for the same age group, and 2.3 times for that of over 80 years of age. 17.6% of those elderly patients were detected in institutions, either hospitals or nursing homes. These indicate that the elderly will become higher risk of TB for causing early death and infection to others during their admission in the hospitals or nursing homes.
2. Clinical characteristics of TB among the elderly: Nobuhiko NAGATA (Department of Internal Medicine, National Ohmuta Hospital)
Analysis of the 93 elderly TB patients shows that TB diagnosis was delayed among the elderly. For TB diagnosis, 43.2% took over 1 month, and 27.3% over 2 months among the patients over 75 years of age, compared to 22.9% and 9.7% respectively for the patients under 65 years. The prognosis was also poor. Of all who died in the hospital during TB treatment, 40.9% (mostly complicated with other diseases) was among the elderly over 75 years, while it was 6.5% among those under 65 years. Complication of dementia delayed the diagnosis. 79.4% of the smear positive patients over 75 years were diagnosed while admitted in a general ward, and 40% had been admitted 2 weeks or more before diagnosis.
3. Use of serological tests for the diagnosis of TB among the elderly: Atsuyuki KURASHIMA (Department of Clinical Research, National Tokyo Hospital)
As TB diagnosis is difficult for the elderly due to nonspecific appearances of signs/symptoms, X-ray shadows or negative tuberculin reaction, some serological tests, which have been recently developed, can be useful as a supplementary diagnostic tool. One of them is anti-lipoarabinomannan antibody. 74.3% was positive to this among 148 bacteriologically confirmed TB cases ; 77.8% for those aged 65 years and above, and 71.1% for those under 65 years. To and TBGL antibody, 78% of 170 confirmed TB cases were positive ; 75 % for those aged 65 years and above, 79.8% for those less than 65 years. Multi-lipo antibody developed by Japan BCG Laboratory showed higher sensitivity of 91.5%. GPL-core antibody may increase the sensitivity.
4. Mode of TB detection in nursing homes: Shinji SHISHIDO (Research Institute of Tuberculosis, JATA)

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