• Tuberculosis and Respiratory Diseases
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• v.43 no.2
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• pp.138-146
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• 1996

Background : Known as a kind of complication or a specific form of pulmonary tuberculosis, endobronchial tuberculosis caused several kinds of problems in diagnosis and managements. But the frequency of this disease are is widely variable, generally reported from as low as 10 - 20 % to as high as 40 - 50 %. We prospectively performed bronchoscopy in patients diagnosed as pulmonary tuberculosis to evaluate the frequency of endobronchial tuberculosis and its related findings. Method : From March, 1995 to February, 1996, we prospectively performed bronchoscopy in patients newly diagnosed as pulmonary tuberculosis and evaluated the frequency of endobronchial tuberculosis, its clinical features and laboratory findings including raiologic, microbiologic and physiologic aspects. Results : Number of patients diagnosed as pulmonary tuberculosis was 103 and 55 patients(53.4%) were found to have endobronchial tuberculosis. But the frequency were 43.8% in male and 76.7% in female, respectively. Frequently noted symptoms were nonspecific including cough, sputum, fever, weight loss in the order of frequency but cough was more frequent than in pulmonary tuberculosis. Physical examination showed rale, decreased breathing sound and wheezing and wheezing was more frequent than in pulmonary tuberculosis. All 7 subtypes were noted bronchoscopically and edema-hyperemia (stenotic without fibrosis) type was most frequently(32.7%) noted, and followed by chronic nonspecific bronchitis type, stenotic with fibrosis type and actively caseating type in the order of frequency. The relationship between subtypes of endobronchial tuberculosis and radiologic findings was insignificant. Right lung was involved more frequently than left lung and left upper lobe was most commonly involved site, and followed by right upper lobe and trachea. Acid-fast bacilli(AFB) positivity in sputum and / or bronchial washing fluid was 73% and suggested high risk of infectivity. Conclusion : The frequency of endobronchial tuberculosis in patients with pulmonary tuberculosis was higher than known and also suggested bronchoscopic examination to detect endobronchial involvement should be recommanded and careful management is also needed to prevent complications.

• Tuberculosis and Respiratory Diseases
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• v.54 no.1
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• pp.33-44
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• 2003

Background : Mycobacterium avium complex(MAC) is the most common respiratory pathogen in nontuberculous mycobacterial pulmonary disease. This study described the clinical characteristics of the patients with pulmonary disease caused by MAC. Materials and Methods : The clinical characteristics of 24 patients with pulmonary disease caused by the MAC, who fulfilled the 1997 American Thoracic Society diagnostic criteria for nontuberculous mycobacterial pulmonary disease, were retrospectively analyzed. Results : Fourteen patients(58%) were male and the median age at diagnosis was 61 years(range 46-75). Of the 24 patients, 16(67%) had a M. intracellulare infection, 7(29%) had a M. avium infection and one patient was not identified. Coughing (92%) and sputum (88%) were most frequently observed symptoms. The sputum smear for acid-fast bacilli was positive in 17(71%) patients. Fourteen(58%) patients had the upper lobe cavitary form and 10(42%) patients had the nodular bronchiectatic form. In a comparison between the patients with the upper lobe cavitary form and those with the nodular bronchiectatic form, significant differences were found according to sex(male 86% vs. 20%, p=0.003), smoking history(79% vs. 10%, p=0.008), the presence of an underlying disease(64% vs. 20%, p=0.036), the pulmonary function(% forced vital capacity, median 71% vs. 88%, p=0.022; % forced expiratory volume in one second, median 69% vs. 89%, p=0.051) and bilateral disease at chest radiography(29% vs. 90%, p=0.005). The time from the onset of symptoms to diagnosis was longer in those with the nodular bronchiectatic form(median 72 months, range 8-132) than those with the upper lobe cavitary form(median 22 months, range 6-60) Conclusions : MAC pulmonary disease occurs in two distinct populations with two distinct clinical presentations. For a correct diagnosis of MAC pulmonary disease, knowledge of the diverse clinical and radiological findings is essential.

• Tuberculosis and Respiratory Diseases
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• v.43 no.6
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• pp.945-953
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• 1996

Background : Many acute and chronic lung diseases including pneumoconiosis are characterized by the presence of increased numbers of activated macrophages. These macrophages generate several inflammatory cell chemoattractants, by which neutrophil migrate from vascular compartment to the alveolar space. Recruited neutrophils secrete toxic oxygen radicals or proteolytic enzymes and induce inflammatory response. Continuing inflammatory response results in alteration of the pulmonary structure and irreversible fibrosis. Recently, a polypeptide with specific neutrophil chemotactic activity, interleukin-8(IL-8), has been cloned and isolated from a number of cells including : monocytes, macrophages and fibroblasts. IL-1 and/or TNF-${\alpha}$ preceded for the synthesis of IL-8, and we already observed high level of IL-1 and TNF-${\alpha}$ in the pneumoconioses. So we hypothesized that IL-8 may be a central role in the pathogenesis of pneumoconiosis. In order to evaluate the clinical utility of IL-8 as a biomarker in the early diagnosis of pneumoconiosis, we investigated the increase of IL-8 in the pneumoconiotic patient and the correlation between IL-8 level and progression of pneumoconiosis. Method : We measured IL-8 in the serum of 48 patients with pneumoconiosis and 16 persons without dust exposure history as a control group. Pneumoconiotic cases were divided into 3 groups according to ILO Classification : suspicious group(n=16), small opacity group(n=16) and large opacity group(n=16). IL-8 was measured by a sandwich enzytne immunoassay technique. All data were expressed as the $mean{\pm}standard$ deviation. Results: 1) The mean value of age was higher in the small opacity and large opacity group than comparison group, but smoking history was even. Duration of dust exposure was not different among 3 pneumoconiosis groups. 2) IL-8 level was $70.50{\pm}53.63pg/m{\ell}$ in the suspicious group, $107.50{\pm}45.88pg/m{\ell}$ in the small opacity group, $132.50{\pm}73.47pg/m{\ell}$ in the large opacity group and $17.85{\pm}33.85pg/m{\ell}$ in the comparison group. IL-8 concentration in all pneumoconiosis group was significant higher than that in the comparison group(p<0.001). 3) IL-8 level tended to increase with the progression of pneumoconiosis. Multiple comparison test using Anova/Scheffe analysis showed a significant difference between suspicious group and large opacity group(p<0.05). 4) The level of IL-8 was correlated with the progression of pneumoconiosis(r=0.4199, p<0.05). Conclusion : IL-8 is thought to be a good biomarker for the early diagnosis of pneumoconiosis.

• Tuberculosis and Respiratory Diseases
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• v.43 no.6
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• pp.916-924
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• 1996

Bacground : Percutaneous needle aspiration biopsy (PCNA) is one of the most frequently used diagnostic methcxJs for intrathoracic lesions. Previous studies have reponed wide range of diagnostic yield from 28 to 98%. However, diagnostic yield has been increased by accumulation of experience, improvement of needle and the image guiding systems. We analysed the results of PCNA performed for one year to evaluate the diagnostic yield, the rate and severity of complications and factors affecting the diagnostic yield. Method : 287 PCNAs undergone in 236 patients from January, 1994 to December, 1994 were analysed retrospectively. The intrathoracic lesions was targeted and aspirated with 21 - 23 G Chiba needle under fluoroscopic guiding system. Occasionally, 19 - 20 G Biopsy gun was used for core tissue specimen. The specimen was requested for microbiologic, cytologic and histopathologic examination in the case of obtained core tissue. Diagnostic yields and complication rate of benign and malignant lesions were ca1culaled based on patients' chans. The comparison for the diagnostic yields according to size and shape of the lesions was analysed with chi square test (p<0.05). Results : There are 19.9% of consolidative lesion and 80.1% of nodular or mass lesion, and the lesion is located at the right upper lobe in 26.3% of cases, the right middle lobe in 6.4%, the right lower lobe 21.2%, the left upper lobe in 16.8%, the left lower lobe in 10.6%, and mediastinum in 1.3%. The lesion distributed over 2 lobes is as many as 17.4% of cases. There are 74 patients with benign lesions, 142 patients with malignant lesions in final diagnosis and confirmative diagnosis was not made in 22 patients despite of all available diagnostic methods. 2 patients have lung cancer and pulmonary tuberculosis concomittantly. Experience with 236 patients showed that PCNA can diagnose benign lesions in 62.2% (42 patients) of patients with such lesions and malignant lesions in 82.4% (117 patients) of patients. For the patients in whom the first PCNA failed to make diagnosis, the procedure was repeated and the cumulative diagnostic yield was increased as 44.6%, 60.8%, 62.2% in benign lesions and as 73.4%, 81.7%, 82.4% in malignant lesions through serial PCNA. Thoracotomy was performed in 9 patients with benign lesions and in 43 patients with malignant lesions. PCNA and thoracotomy showed the same pathologic result in 44.4% (4 patients) of benign lesions and 58.1% (25 patients) of malignant lesions. Thoracotomy confirmed 4 patients with malignat lesions against benign result of PCNA and 2 patients with benign lesions against malignant result of PCNA. There are 1.0% (3 cases) of hemoptysis, 19.2% (55 cases) of blood tinged sputum, 12.5% (36 cases) of pneumothorax and 1.0% (3 cases) of fever through 287 times of PCNA. Hemoptysis and blood tinged sputum didn't need therapy. 8 cases of pneumothorax needed insertion of classical chest tube or pig-tail catheter. Fever subsided within 48 hours in all cases. There was no difference between size and shape of lesion with diagnostic yield. Conclusion: PCNA shows relatively high diagnostic yield and mild degree complications but the accuracy of histologic diagnosis has to be improved.

• Tuberculosis and Respiratory Diseases
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• v.53 no.1
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• pp.17-26
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• 2002

Background : The detection and early elimination of the causes for acute respiratory distress syndrome(ARDS) at the initial stage can result in a more favorable prognosis. Miliary tuberculosis as a cause of the ARDS is quite rare. A diagnosis of miliary tuberculosis is difficult due to the diversity of radiological patterns and non-specific clinical finfings, and low sensitivity of sputum examinations for acid-fast bacilli(AFBs). An analysis of the clinical data is the first step in diagnosing these unusual, rare cases. Materials and Methods : In this study the clinical features, laboratory data, radiological findings and diagnostic methods were analyzed in 9 cases with an initial presentation of ARDS due to miliary tuberculosis. The ARDS was defined by the definition of the American-Europian consensus conference 1992. Results : The mean age of the patients was $67{\pm}18$ years (F:M=7:2). The chief complaints were dyspnea(5/9), coughing (3/9) and fever(5/9). On a physical examination, fine or coarse crackles were noted(6/9). The ARDS developed on average 6.7 days after the initial respiratory symptoms. The mean $PaO_2/FiO_2$ of the patients was $133.5{\pm}53.4$, the number of cases with a WBC<5000/$mm^3$ was 4 out of 9 cases. A platelet count<70,000/$mm^3$ was observed in 2 out of 9 cases, and the serum albumin level was $2.6{\pm}0.6$ g/dL. The initial simple chest PA showed ground glass appearances and consolidation in all cases, However, the miliary nodular densities were observed in only 4 out of the 9 cases. HRCT revealed alveolar densities and a consolidation in 5 out of 6 cases, and miliary nodules in 5 out of 6 cases, The diagnosis of tuberculosis was made by a liver biopsy (4/4, 100% sensitivity), a bone marrow biopsy (1/2, 50% sensitivity), and an open lung biopsy (1/1), the sputum AFB was positive in only 2 out of 9 cases. The patient was treated with INH, RFP, EMB, PZA, and steroids. The survival rate was 55.5%. Conclusion : Miliary tuberculosis should be considered as one of the causes for ARDS in areas where there is a high prevalence of tuberculosis. The chief complaints of the patients on admission are dyspnea, fever and coughing without any specific riskfactors. A liver biopsy is particularly useful in ARDS patients with mechanical ventilation to determine the causes of the ARDS if miliary tuberculosis is suspected as being the underlying disease.

• Tuberculosis and Respiratory Diseases
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• v.59 no.1
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• pp.77-85
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• 2005

Background : According to the 2002 consensus report of the American Thoracic Society/European Respiratory Society (ATS/ERS), idiopathic pulmonary fibrosis (IPF) was classified as biopsy proven or probable IPF. Probable IPF is defined as those with distinctive features that allow for a confident diagnosis of IPF/usual interstitial pneumonia (UIP) within an appropriate clinical setting. The determination of the clinical course of probable IPF, as diagnosed by the ATS/ERS criteria, was studied. Methods : Between March 1995 and August 2002, 36 patients with probable IPF, from two tertiary referral hospitals, were enrolled in this study. The clinical characteristics, prognostic factors and treatment efficacy of these patients were retrospectively evaluated. Results : The mean age of the subjects was $65{\pm}6$ years. The one and 3 year survival rates were 82.4 and 50.3%, respectively, and a median survival period of 42.0 months. The total cell count of bronchoalveolar lavage was higher in the death than the survival group (p<0.05). No survival benefits were found in the cytoxan and steroid treatment groups compared with other treatment groups. Conclusion : These results suggest that the clinical course of probable IPF may be similar to that of biopsy-proven UIP. However, atypical patients must undergo an open lung biopsy for confirmation of the diagnosis.

• Tuberculosis and Respiratory Diseases
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• v.56 no.2
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• pp.159-168
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• 2004

Background : In recent years, numerous human tumor specific antigens such as melanoma antigen gene(MAGE) that is recognized by autologous cytotoxic T lymphocytes have been identified. MAGE is expressed in many human malignancies in various organs, such as lung, breast, stomach, esophagus and leukemia. Therefore MAGE has been studied widely for tumor diagnosis and immunotherapy. But, so far there were no clinical studies evaluating the role of MAGE in pleural effusion. We investigated the expression of MAGE in the patients with exudative pleural effusion for it's diagnostic utility and the results were compared with those of cytologic examinations. Methods : Diagnostic thoracentesis was performed in 44 consecutive patients with exudative pleural effusion during 6 months. We examined the expression of MAGE and cytology with the obtained pleural effusion. Expression of MAGE was interpreted by means of a commercial kit using RT-PCR method. Enrolled patients were divided into two groups such as malignant and benign and we analyzed its' sensitivity and specificity. Results : There were no significant differences between two groups in age, sex, white blood cell counts in pleural fluid, pleural fluid/serum protein ratio and pleural fluid/serum LDH ratio. The sensitivity and specificity of MAGE were 72.2% and 96.2% respectively and the positive predictive value and negative predictive value of MAGE were also 92.9% and 83.3% respectively. The sensitivity and negative predictive value of cytologic examinations were 66.7% and 81.3% respectively. There were no significant differences between sensitivities of MAGE and cytologic examinations but false positive result of MAGE was found in 1 case of tuberculous pleurisy. Conclusion : MAGE is a sensitive and specific marker for the differential diagnosis between benign and malignant effusion in patients with exudative pleural effusion. And MAGE would provide the equal sensitivity compared with that of cytologic examination in patients with malignant pleural effusion if 5mL of the pleural fluid is examined.

• Tuberculosis and Respiratory Diseases
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• v.50 no.2
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• pp.213-221
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• 2001

Background : There is a well recognized interlaboratory variation in the results using the polymerase chain reaction(PCR) to detect the IS6110 sequence. The clinical utility of a commercially developed PCR test(Amplicor) in bronchial washings for detecting pulmonary tuberculosis in smear negative patients was evaluated. The sensitivity and specificity of Amplicor was compared with that of an in-house PCR test used for detecting the IS6110 sequence of Mycobacterium tuberculosis(M.tbc) in the bronchial washing fluid. Methods : 66 patients whose sputum smear for M. tbc were negative or who could not produce any sputum were recruited from January 1999 to July 1999. They all had a bronchoscopy performed to determine if there were signs of hemoptysis, patients who could not cough up sputum, lung lesion that exclude pulmonary tuberculosis. Pulmonary tuberculosis was diagnosed on the basis of a positive culture or a response to anti-tuberculosis therapy. Results : 19 patients with tuberculosis were identified and samples from 16 patients were later confirmed by culture. Bronchial washing for Amplicor PCR revealed a sensitivity, specificity, positive and negative predictive values of 94.7%, 97.9%, 94.7%, 97.9%, respectively. Using IS6110 based PCR, the sensitivity, specificity, positive and negative predictive values were of 73.7%, 87.2%, 70%, 89.1% respectively. Conclusion : Bronchial washing for Amplicor PCR proved to be more useful than IS6110 based PCR in rapidly diagnosing smear negative pulmonary pulmoary tuberculosis in patients where tuberculosis was likely to be differential and rapid diagnosis was essential for optimal treatment.

• Tuberculosis and Respiratory Diseases
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• v.46 no.1
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• pp.17-24
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• 1999

Background : A sizable percentage of tuberculous pleurisy patients are known to have residual pleural thickening(RPT) despite adequate anti-tuberculous chemotherapy. But, the predictive factors related to the development of RPT is not well known. Therefore, we studied to determine which factors are related to the development of RPT after completion of therapy. Methods: By retrospective review of medical records, fifty-eight patients initially diagnosed as having tuberculous pleurisy between March 1995 and January 1998 were separated into two groups : 27 patients in group 1 had RPT on simple chest radiography, while 31 patients in group 2 had no RPT after 6 month of anti-tuberculous chemotherapy. The clinical characteristics, radiologic findings and pleural fluid findings of the two group were compared at the time of diagnosis and during the course of therapy. Results: 47% of patients had RPT after 6 month of chemotherapy, and RPT was more common in man than in women(54% vs 29%, p=0.092). In group 2 patients, complete resorption of pleural lesion occurred rather late stage of therapy(1-2 month: 26%, 3-4 month: 29%, 5-6 month: 45%). Group 1 patients had increased percentage of loculated pleural lesion(26 % vs 19%) and increased white blood cell and lymphocyte count, lactate dehydrogenase level in pleural fluid ($3527\pm5652$ vs $2467\pm2201$/ml, $2066\pm2022$ vs $1698\pm1835$/ml and $1636\pm1143$ vs $1441\pm923$IU/mL respectively) than group 2 at the time of diagnosis, but statistically insignificant. Duration of symptom prior to treatment, size of pleural effusion, presence of parenchymal lung lesion, level of total protein, glucose and adenosine deaminase(ADA)activity in pleural fluid were similar in both group. Conclusion: 53% of tuberculous pleurisy patients showed slow but complete resorption of pleural lesion after 6 month of chemotherapy. But, no clinical, radiological and pleural fluid findings are predictive for the development of RPT.

• Tuberculosis and Respiratory Diseases
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• v.47 no.4
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• pp.498-506
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• 1999

Background : The causes of solitary pulmonary nodule are many, but the main concern is whether the nodule is benign or malignant. Because a solitary pulmonary nodule is the initial manifestation of the majority of lung cancer, accurate clinical and radiologic interpretation is important. Bayes' theorem is a simple method of combining clinical and radiologic findings to estimate the probability that a nodule in an individual patients is malignant. We estimated the probability of malignancy of solitary pulmonary nodules with a specific combination of features by Bayesian approach. Method : One hundred and eighty patients with solitary pulmonary nodules were identified from multi-center analysis. The hospital records of these patients were reviewed and patient age, smoking history, original radiologic findings, and diagnosis of the solitary pulmonary nodules were recorded. The diagnosis of solitary pulmonary nodule was established pathologically in all patients. We used to Bayes' theorem to devise a simple scheme for estimating the likelihood that a solitary pulmonary nodule is malignant based on radiological and clinical characteristics. Results : In patients characteristics, the probability of malignancy increases with advancing age, peaking in patients older than 66 year of age(LR : 3.64), and higher in patients with smoking history more than 46 pack years(LR : 8.38). In radiological features, the likelihood ratios were increased with increasing size of the nodule and nodule with lobulated or spiculated margin. Conclusion : In conclusion, the likelihood ratios of malignancy may improve the accuracy of the probability of malignancy, and can be a guide of management of solitary pulmonary nodule.