Two hundred eighty one cases of the lung disease due to mycobacteria other than tubercle bacilli (atypical mycobacteria) were found at the seven National Chest Hospitals in Japan during the past ...several years. Eighteen of 281 cases were the disease due to M. kansasii, 3 due to M. scrofulaceuni, 247 due to M. intracellulare, 11 due to M. chelonei, and 2 due to M fortuitum. The first chest radiograms were observed, and the radiographic features of the disease due to various species of atypical mycobacteria were compared. The results were summerized as follows: (I) Minimal cases and cases without any previous pathological changes in the respiratory organs (primary infection cases) were found more f requently among persons of middle age and younger than among the older persons in the disease due to all the species of atypical mycobacteria. (II) There was no statistically significant difference in the ratio of cavitary cases to the total cases among the various species (83 to 100%). (III) The difference in the radiographic features among various species were as follows. i) In the case of the disease due to group IV organisms (M. chelonei and M. fortuitum), single solitary cavity was found in the lung field, and its shape was round, thin-walled and less than 40mm in diameter in almost all cases. In the case of the disease due to M. kansasii, round, thin-walled cavitary lesions were observed which were similar to that of the disease due to group IV organisms, however, the proportion of cases with multiple (3 and more) cavitations amounted to 16.6% of the total cases, and giant cavity (over 40mm in diameter) was found occasionally. ii) In the case of the disease due to M. intracellulare, subpleural cavitary lesions were found in many cases, while in the case of the disease due to M. kansasii, M. scrofulaceum and M. chelonei, cavitary lesions were found in the lung field in the majority of the cases. iii) In the cases with the lesions localized in one lobe, the lesions were found more frequently (2.7 times) in the right lung than in the left, and the number of cases with the lesions localized in the upper lobes amounted to approximately 90% of the total cases. The number of cases with the lesions localized in the middle lobe was only 2% in the case of M. intracellulare infections. iv) The majority of non-cavitary lesions were infiltrative. Only in the case of the disease due to M. intracellulare, various lesions (diffuse nodular lesions, bronchiectasis and pleural empyema, etc.) were observed. In the case of the disease due to group IV organisms, non-cavitary lesions were not found in most of cases (61.5%). v) The previous pathological changes in the respiratory organs were found in many cases of M. intracellulare infection, but they were found in a few cases of M. kansasii and group IV organisms infection. In the case of the disease due to M. scrofulaceum, pneumoconiosis was found in 2 of 3 cases. (IV) Even among the disease due to the same species of atypical mycobacteria (111. intrace llulare), the radiographic findings differed in different hospitals.
Sixty seven cases with pulmonary atypical mycobacteriosis (2 by M. kansasii, 62 by M. intracellulare, 2 by M. fortuitum and 1 by a possible new pathogen of group III mycobacteria) died in 9 Japanese ...national sanatoria up to October 1976. Of these 67 cases, 40 died of atypical mycobacterial disease, and the remaining 27 cases died of other diseases. Roentgenological aggravation was found in 44 cases (1 by M. kansasii, 1 by M. fortuitum and 42 by M. intracellulare). There were various types of roentgenological aggravation. Spread of non-cavitary foci, infiltrate and pneumonia were found most frequently (40/44, 90.9%). Enlargement of cavity was found in 12 cases (27.2%), appearance of pleural effusion in 5 cases (11.4%), and spontaneous pneumothorax in 3 cases. Infection of bulla was found in 11 out of 22 cases with bullae as the underlying disease. The first roentgenological aggravation was found in 20 (45.5%) out of 44 cases within 12 months; 13 cases (29.5%) between 13 to 24 months; and 11 cases (25%) over 2 years after the discovery of the disease. From the results mentioned above, in the fatal cases, progression of the disease was predicted by the appearance of the roentgenological aggravation within 2 years after the discovery of the disease. There were various courses of the progression of the lesions as shown in Figures 2a and 2b. One of the typical course of the progression was devided into the following 5 stages: The first stage: localized cavitary lesion. The second stage: spread of foci around cavity. The third stage: spread of foci in contralateral lung. The fourth stage: enlargement of cavity (appearance of giant cavity). The fifth stage: extensive pneumonia in the lower lung field. Another typical course of the progression was the repeated infections of bullae. Roentgenological aggravation found in patients with atypical mycobacterial disease was not rarely due to the mixed infection with various organisms (gram-negative bacilli, fungi and also human type tubercle bacilli). The majority of the patients with underlying pulmonary disease (extensive emphysema, chronic bronchitis and bronchiectasis) died of pulmonary insufficiency in the relatively early stage of atypical mycobacteriosis. The patients with the mixed infection have died, in spite of the negative conversion or the dicrease of the excretion of atypical mycobacteria. There were two cases (M. intracellulare infection) complicated with pulmonary tuberculosis.
The incidence of lung disease due to mycobacteria other than Mycobacterium tuberculosis (atypical mycobacteria) in Japan was estimated to be 0.9-1.9 per 10⁵ population per year in 1971-1979. Although ...the incidence of lung tuberculosis is steadily decreasing, the incidence of lung disease due to atypical mycobacteria has remained at almost the same level. The number of patients newly infected per year in recent years was calculated to be ∼2,000. The ratio of the number of patients with lung disease due to atypical mycobacteria to the number of patients with lung disease due to all species of mycobacteria was highest in hospitals on the southwest coast of the Pacific. The atypical mycobacteria that caused disease most frequently belonged to the Mycobacterium avium-intracellulare complex. Of the 537 cases of disease due to atypical mycobacteria, 491 (89.6%) were due to these organisms; 43 (8.0%), to Mycobacterium kansasii; and 7 (1.3%), to Mycobacterium fortuitum. The disease due to M. kansasii appeared most frequently in hospitals in the Tokyo and Kanagawa prefectures. Patients with lung tuberculosis had a high risk of lung infection due to M. avium-intracellulare. The incidence of such disease in tuberculous patients was estimated to be 18.7 per 10⁵ population per year, a rate that is ∼10 times that found in the general population.
A case of intralobar sequestration of 53-year-old woman was reported. Chest roentgenogram at the mass survey revealed a round, circumscribed tumor-like shadow in the right lower lobe. At operation, ...an egg-sized soft cystic mass was found in the right lower lobe. An abnormal vessel, 8mm in diameter, originating from the thoracic aorta, was entering into the cystic mass. After ligation of this abnormal vessel, right lower lobectomy was carried out. Gross pathologic examination revealed that the mass was a multilocular cyst which contained dark red material. Microscopically, the wall was lined by the ciliated columnar epithelium, resting upon loose connective tissue. Smooth muscle and cartilage were also noted.
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.
The present study reports results of the study in 1979, which covered the period from April 1979 to March 1980. The study was restricted to patients hospitalized during this period, and out-patients ...were not subjected to the study. All patients who were considered to have lung disease due to myco-bacteria (including Mycobacterium tuberculosis) were studied for their sputum and clinical findings. All acid-fast organisms isolated were screened for atypical mycobacteria (mycobacteria other than M. tuberculosis) by p-nitrobenzoic acid-Ogawa egg medium. All mycobacterial strains other than M. tuberculosis were identified for their species in the National Chubu Hospital according to the methods previously described. For diagnosing lung disease due to atypical mycobacteria, modified criterion) of the criteria recently proposed by Tsukamura were used. 1) Frequency of atypical mycobacteria among all mycobacteria (M. tuberculosis plus atypical mycobacteria) was estimated on patients hospitalized in June, September and December 1979 and March 1980 by monthly examinations. Ratio of atypical mycobacteria among all mycobacteria was estimated at 12.0% (Table 1). This ratio was 6.0%, 5.8%, 7.8% and 9.5% in 1971, 1974, 1975 and 1977, respectively. The increase in the ratio is considered as probably due to a relative increase of patients with disease due to atypical mycobacteria among hospitalized patients. The kind of species of atypical mycobacteria are shown in Tables 2 and 3. It was noticed that the ratio of M. nonchromo-genicum complex, which occur as casual isolates, decreased from 4.4% in 1971 to 0.4% in 1979. 2) Number of patients with lung disease due to atypical mycobacteria found in this study year was 141. The kind of species which have caused disease are shown in Table 4. Although the disease due to M. kansasii appeared almost restrictively in Tokyo area until 1978, it has been shown in the pre-sent study that the disease has appeared also in Fukuoka and Osaka area (Fukuoka and Kinki Hos-pitals) (Table 4). Sex and age of patients are shown in Table 5. The ratio, (number of patients with lung disease due to atypical mycobacteria) / (average number of patients hospitalized in tuber-culosis departments per day), is increasing annually (Table 6). 3) Prevalence rate of lung disease due to atypical mycobacteria was estimated using the data of statistics of tuberculosis of the Ministry of Health and Welfare, Japan, and the ratio, (number of patients with lung disease due to atypical mycobacteria found among newly hospitalized patients) / (number of patients newly hospitalized into tuberculosis departments), which was estimated during a period of the 1st January to the 31st December of every year (Tables 7 and 8). Prevalence rate of the disease appeared to be different from prefecture to prefecture. The prefectures locating in the South coast of the Pacific ocean, Tokyo, Aichi, Osaka and Kochi, showed a high prevalence rate, and those locating in North Japan a lower rate (Table 9; Fig.1). The prevalence rate in 1979 has been estimated at 1.6 per 105 population per year (Table 10). In a previous paper13), we have reported that the prevalence rate is slightly increasing or almost the same, but the result of the present study suggested that the prevalence rate is probably the same since several years (Table 10). Increase of the ratio of patients with disease due to atypical mycobacteria among all hospitalized patients as ob-served in Table 6 is considered to be due to decrease of the prevalence rate of tuberculosis. The kind of species, which caused lung disease in 537 patients, who were found among 32, 293 newly hospitalized patients during period of January 1971 to December 1979 (9 years), are shown in Table 11.
Nine cases (8 pulmonary disease and I pleural empyema) of the respiratory disease due to Mycobacterium fortuitum were found in 5 of 13 National sanatoria in Japan during the period from January 1967 ...to August 1980. It was supposed that the respiratory disease due to M. fortuitum occupied about 1 per cent of whole atypical mycobacteriosis and the patients were found all over the country. The patients previously reported in Japan were all over 40-year-old and the patients found in National sanatoria were all over 50-year-old, while patients under 20 years of age have been found not rarely in Europe and America. There were no difierence in the number of patient by sex (5 men and 4 women). Subjective symptoms such as fever, cough, sputum and hemoptysis were observed at the onset of the illness in the majority of the patients. The disease was divided into two types; i.e., the primary infection type without underlying respiratory disease and the secondary infection type with preexisting disease. Three of 9 cases belong to the primary infection type. In the remaining 6 cases which belong to the secondary infection type, plumonary tuberculosis, pleurisy and pneumoconiosis was observed as the underlying disease, but there was no association of achalasia which was found frequently in European and American patients. In the primary infection type sputum culture negative conversion occurred in all cases by antituberculous drug therapy alone and the appearance of their chest X-ray improved, although all strains isolated from the patient were completely resistant to all antituberculous drugs. On the contrary, in the majority of the secondary infection cases the excretion of organisms from sputum continued for extended periods. No patient underwent any surgical treatment. Two patients have died during this period, but both patients died of the disease other than atypical mycobacteriosis.
