• Tuberculosis and Respiratory Diseases
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• v.62 no.6
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• pp.536-539
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• 2007

Lymphadenitis is a common manifestation in tuberculous diseases. However, papulonecrotic tuberculid is an uncommon cutaneous manifestation, and is considered an allergic reaction against tuberculous bacilli in tuberculous lesions other than the lymph nodes. A wide great variety of cutaneous manifestations arise over a period of a few weeks - i.e., papules, necrosis, crusted and atrophic scars. We described a 27-year-old woman with right cervical tuberculous lymphadenitis and skin lesions involving her arms, legs and both fingers. Histopathologically, a leukocytoclastic vasculitis with V-shaped epidermal necrosis was observed in the upper and deep dermis, including the good response to anti-tuberculosis therapy support the diagnosis of papulonecrotic tuberculid.

• Journal of Chest Surgery
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• v.33 no.8
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• pp.669-675
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• 2000

Background: Tuberculous pleurisy is the leading cause of pleural effusion in Korea. And differential diagnosis of tuberculous pleurisy with other cause is clinically very important. Traditional diagnostic methods such as routine analysis of pleural fluid, staining for acid-fast bacilli or pleural biopsy have major inherent limitaion. This study was designed to evaluate the significance of pleural fluid polymerase chain reaction(PCR) and adenosine deaminase (ADA) activity in early diagnosis of tuberculous pleurisy. Material and Method: Between March 1996 and July 1997, 198 patients with pleural effusion reviewed retrospectively. The study group included 112 cases with tuberculous effusion and 86 cases with non-tuberculous effusions, whose diagnoses were confirmed by pleural biopsy, microbiological methods, or cytology. We compared the results of PCR and pleural fluid levels of ADA between tuberculous and non-tuberculous effusions. Result: Mean age was 47.54$\pm$19.52 years(range 2 to 85 years). The positive rate of PCR was significantly higher in tuberculous group than non-tuberculous group(p<0.05). The sensitivty, specificity, positive predictive value(PPV), and negative predictive value(NPV) for PCR were 31.7, 90.9, 83.0, and 48.8%, respectively. Mean ADA activity was significantly higher in tuberculous group than non-tuberculous group(83.2 U/L vs 49.8 U/L)(p<0.05). With diagnostic thresholds of 40 U/L, the sensitivity, specificity, PPV, and NPV of ADA for tuberculosis were 75.9, 70.9, 77.3, and 69.3% respectively. At a level of 70 U/L, the sensitivity, specificity, PPV, and NPV of ADA for tuberculosis were 70.1, 75.9, 82.9, and 60.3% respectively. Conclusion: PCR is very highly specific, but less sensitive methods in diagnosis of tuberculous pleurisy. But ADA level of pleural fluid has acceptable sensitivity and specificity in diagnosis of tuberculous pleurisy. ADA activity is more useful test in the evaluation of pleural effusions.

• Tuberculosis and Respiratory Diseases
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• v.59 no.3
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• pp.257-265
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• 2005

Background : Rifabutin (ansamycin) is a spiro-piperidyl rifamycin, which is highly active against Mycobacterium tuberculosis. It has been found that some clinical isolates of tubercle bacilli that are resistant to rifampicin are susceptible to rifabutin, with some patients with multi-drug resistant pulmonary tuberculosis having shown favorable clinical and bacteriological responses to the rifabutin. This study was conducted to find the proportion of rifabutin-susceptible strains among rifampicin-resistant isolates from Korean MDR-TB patients, and investigate the presence of specific rpoB mutations, which may confer resistance to rifampicin, but not to rifabutin. Methods : 201 rifampicin-resistant and 50 pan-susceptible M. tuberculosis isolates were randomly selected for this study. The isolates were retested at rifampicin and rifabutin concentrations of 0, 20, 40 and $80{\mu}g/ml$, respectively. The isolates that grew at and/or over a rifabutin concentration of $20{\mu}g/ml$ were judged rifabutin-resistant. The rpoB gene was extracted from the isolates, and then amplified for direct sequencing to investigate specific rpoB mutations that conferred rifabutin- susceptibility but rifampicin-resistance. Results : Out of the 201 rifampicin-resistant M. tuberculosis, 41 strains (20.4%) were susceptible to rifabutin using the absolute concentration method on Lowenstein-Jensen media. The rpoB mutation types that showed susceptibility to rifabutin were Leu511Pro, Ser512Arg, Gln513Glu, Asp516Ala, Asp516Gly, Asp516Val, Asp516Tyr, Ser522Leu, His526Asn, His526Leu, His526Cys, Arg529Pro and Leu533Pro. A reverse hybridization technique was able to detect 92.5% of the rifabutin-susceptible isolates, with a specificity of 96.1% among 195 M. tuberculosis isolates with the rpoB mutation. Conclusions : Around 20% of the rifampicin-resistant isolates in Korea showed susceptibility to rifabutin, which was associated with some specific mutations of rpoB. Rifabutin could be used for the treatment of MDR-TB patients, especially when drug susceptibility testing reveals susceptibility to rifabutin.

• 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.56 no.3
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• pp.268-279
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• 2004

Background : The tuberculin skin test has been used to diagnose latent tuberculosis infection, but is not widely used to diagnose or exclude pulmonary tuberculosis. The objective of this study was to evaluate the diagnostic utility of the tuberculin test in diagnosing and excluding pulmonary tuberculosis, and differentiating pulmonary tuberculosis from nontuberculous mycobacteria (NTM) pulmonary disease, when a sputum acid-fast bacilli (AFB) smear was positive. Material and Methods : From October 2002 to August 2003, among all the inpatients of the Division of Pulmonary and Critical Care Medicine at Samsung Medical Center, 258 patients with clinical suspicion of pulmonary tuberculosis were enrolled and underwent a tuberculin test. Results : 156 males and 102 females were included, with a mean age of 57.5 years. The final diagnoses included lung cancer in 89 cases (34.5%), pulmonary tuberculosis in 59 cases (22.9%), bacterial pneumonia in 33 cases (12.8%) and NTM pulmonary disease in 24 cases (9.3%). The positive tuberculin test rate was higher in the tuberculosis than non-tuberculosis group; 81.4 (48/59) vs. 42.4% (81/199). (p<0.001). In 208 patients with a negative sputum AFB smear, the result of the tuberculin test was positive in 69.4% (25/36) of the tuberculosis group and in 44.8% (77/172) of the non-tuberculosis group (p=0.007), so a positive result of the tuberculin test could predict pulmonary tuberculosis with 69.4% sensitivity, 55.2% specificity, a 24.5% positive predictive value and a 89.6% negative predictive value. In 50 patients with a positive sputum AFB smear, the positive rates of the tuberculin test were 83.9% (26/31) in tuberculosis group and 21.1% (4/19) in NTM pulmonary disease group (p<0.001), so a positive result of the tuberculin skin test could predict pulmonary tuberculosis with 83.9% sensitivity, 78.9% specificity, a 86.7% positive predictive value and a 75.0% negative predictive value. Conclusion : The tuberculin test could be useful in excluding pulmonary tuberculosis when the sputum AFB smear is negative, and to differentiate pulmonary tuberculosis from NTM pulmonary disease when the sputum AFB smear is positive.

• Tuberculosis and Respiratory Diseases
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• v.70 no.4
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• pp.347-351
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• 2011

We report here an unusual case of pericardial tuberculoma that was misdiagnosed as thymic carcinoma on an imaging study. A 48-year-old woman was referred for evaluation of an anterior mediastinal mass. Computed tomography (CT) scans of the chest displayed cystic masses mimicking thymic carcinoma at the anterior mediastinum. Pericardiotomy and surgical drainage of the cystic masses were done, and pathologic examination of the excised pericardial specimen showed a chronic granulomatous inflammation with necrosis, compatible with tuberculosis. Acid-fast bacilli were also identified in the specimen. After treatment with anti-tuberculosis drugs and steroids, the patient showed clinical improvement. Although tuberculous pericarditis usually presents as pericardial effusion or constrictive pericarditis, it can also present as a pericardial mass mimicking thymic carcinoma on CT. Therefore, we suggest that tuberculous pericardial abscess should be included in the differential diagnosis of a mediastinal mass in Korea, with intermediate tuberculosis prevalence.

• Tuberculosis and Respiratory Diseases
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• v.44 no.6
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• pp.1256-1262
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• 1997

Background : Leukocyte-endothelial adhesion molecules have been implicated in the pathogenesis of inflammatory disease. ICAM-1, VCAM-1 and E-selectin are cell surface adhesion molecule on vascular endothelial cells. They are up-regulated by inflammatory cytokines and regulate the adhesion and migration of leukocytes across the endothelium. Tuberculosis, a granulomatous disorder is an infection caused by Mycobacterium tuberculosis. The clinical manifestations of tuberculosis are dependent on the cellular immune response to tubercule bacilli. Circulating adhesion molecules are probably formed by cleavage and release into the circulation of the extracellular domain of the membrane bound form. The elevated levels of circulating adhesion molecules have been reported in numerous disease state. To evaluate their role as markers of disease activity in tuberculosis, we measured a sE-selectin, sVCAM-1 and sICAM-1 levels in the serum with severities of mild, moderate and far advanced pulmonary tuberculosis. Methods : The control and test groups were divided as follows. Group I : control(n=5), Group II : patients with mild pulmonary tuberculosis(n=12), Group III : pateints with moderate pulmonary tuberculosis(n=20), Group IV : patients with far advanced pulmonary tuberculosis(n=19). Serum sICAM-1, sVCAM-1 and sE-selectin were measured by ELISA kit Results : Serum soluble adhesion molecules are elevated in patients with pulmonary tuberculosis, Circulating ICAM-1 levels were significantly elevated in patients with moderate and far advanced pulmonary tuberculosis when compared with control group. When compared with control group, serum sVCAM-1 levels showed significant elevation in patients with mild, moderate and far advanced pulmonary tuberculosis. Serum sE-selectin levels were significantly elevated in patients with far advanced pulmonary tuberculosis when compared with control group. Conclusion : These results suggest that sICAM-1, sVCAM-1, and sE-selectin may be invloved in the pathogenesis of tuberculosis. And, particularly, sICAM-1 and sVCAM-1 may be useful markers of the disease activity.

• Tuberculosis and Respiratory Diseases
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• v.65 no.5
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• pp.379-384
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• 2008

Background: Sputum decontamination with NALC-NaOH (N-acetyl-L-cysteine-sodium hydroxide) is known to better detect Mycobacterium tuberculosis (M. tb) by culture than that with using NaOH, which is widely used in Korean hospitals. In this report, sputum samples collected from pulmonary tuberculosis (TB) patients were treated with either NaOH or NALC-NaOH, and we compared the results of smear and culture positivity to determine whether the NALC-NaOH treatment method improves culture positivity in the sputum samples, and especially for those sputum samples that are smear negative and scanty. Methods: For each decontamination method, 436 sputum samples from pulmonary TB patients in the National Masan Tuberculosis Hospital were collected for this study. Sputum from a patient was collected two times for the first and second day of sampling time, and these samples were employed for the decontamination process by performing the 4% NaOH and NALC-2% NaOH treatment methods, respectively, for detecting M. tb by an AFB (Acid Fast Bacilli) smear and also by culture in solid Ogawa medium. Results: The NaOH and NALC-NaOH treatment methods did not significantly affect the AFB smear positivity of the sputum samples (33.0% vs 39.0%, respectively, p=0.078). However, the culture positive percents of M. tb in the Ogawa medium treated with NALC-NaOH and NaOH were 39.7% and 28.0%, respectively, which was a significantly different (p=0.0003). This difference in culture was more prominent in the sputum samples that were smear negative (the positive percents with NALC-NaOH and NaOH were 15.8% and 7.2%, respectively, p=0.0017) and scanty (NALC-NaOH and NaOH were 60.8% and 42.9%, respectively, p=0.036), but not for a smear that was 1+ or higher (p>0.05). Conclusion: NALC-NaOH treatment is better than NaOH treatment for the detection of M. tb by culture, but not by smear, and especially when the AFB smear is negative and scanty.

• Tuberculosis and Respiratory Diseases
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• v.41 no.2
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• pp.144-151
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• 1994

Background: Miliary tuberculosis almost always results from the discharge of infected caseous material into the blood stream, usually from a well hidden lymph node in the presentation of this disease in the past four decades, and although it is seen less frequent1y today than previously, its presentation and manifestation may require greater suspicion and diligence by the physician. We investigated the clinical characteristics, predisposing factors and accompanying diseases of miliary tuberculosis and tried to acquire the early diagnosis and treatment of this disease. Methods: A retrospective clinical study was done on 40 cases of miliary tuberculosis admitted to Hanyang University Hospital from Mar. 1989 to Dec.1992. The study investigated age and sex distribution, seasonal distribution, duration of symptoms before admission, pre-disposing factors, clinical symptoms, biochemical findings, chest X-ray findings, extrapulmonary tuberculosis associated with miliary tuberculosis, prognosis and mortality rate. Results: 1) The patients were most common in the age group between 20 and 29(23%) and the ratio of male to female was 1.4:1(male 23 : female 17). 2) Sputum smears for tubercle bacilli were positive in 5 cases(13%). 3) The most common clinical symptoms were fever with chilling(47.5%), coughing(47.5%), second most common symptom was dyspnea(32.5%), and the physical findings on admission were tachycardia(30%), weight loss(27.5%), meningeal signs(17.5%) in order. 4) The predisposing factors were heavy alcohol drinking(6 cases), steroid use(3 cases), pregnancy(2 cases) etc. 5) The chest X-ray findings on admission were miliary shadow only(40%), in addition pneumonic infiltration, pleurisy, and calcification in order. 6) The extrapulmonary tuberculosis associated with miliary tuberculosis were tuberculous meningitis(30%), bone and joint tuberculosis(17.5%), intestinal tuberculosis(15%) in order. 7) Biochemical findings were increased SGOT/SGPT(32.5%), increased alkaline phosphatase(32.5%), hypoalbuminemia(15%), hyponatremia(15%) etc. 8) About 4-6 weeks later after treatment(INH, RFP, PZA, EMB), 26 cases(65%) were improved on clinical symptoms or chest X-ray, 12 cases(30%) were stationary or aggravated, and 2 cases(5%) were died. Conclusion: For the early diagnosis and treatment of miliary tuberculosis, we must see its presentation and manifestation with greater interest and suspicion and investigate its predisposing factors and accompanying diseases.

• Tuberculosis and Respiratory Diseases
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• v.39 no.6
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• pp.526-535
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• 1992

Background: The oxygen radicals released by alveolar macrophages contribute to killing of microorganisms including M. tuberculosis. Macrophages are "primrd" for enhanced oxygen radical release by macrophage activator like IFN-$\gamma$ and LPS, which do not themselves cause release of oxygen radicals. Actural production of oxygen radicals is "triggered" by phagocytosis or by exposure to chemical stimuli like PMA or FMLP. There has been debates about the priming effect of alveolar macro phages because they are exposed to usual environmental particles unlike blood monocytes. Therefore we examined priming effect of IFN-$\gamma$ in human alveolar macrophages comparing with that in blood monocytes and rat alveolar macrophages. And we observed the alterations of superoxide production in both human and rat alveolar macrophages after exposure to M. tuberculosis H37Ra bacilli itself and its lysate. Methods: Bronchoalveolar lavage fluid was processed to isolate alveolar macrophages by adherence and the adherent cells were removed by cold shock method. After exposure to M. tuberculosis H37Ra strain, alveolar macrophages were incubated for 24 hours with IFN-$\gamma$. The amount of superoxide production stimulated with PMA was measured by ferricytochrome C reduction method. Results: 1) The priming effect in human alveolar macrophages was not observed even with high concentration of IFN-$\gamma$ while it was observed in blood monocytes and rat alveolar macrophages. 2) Both human and rat alveolar macrophages exposed to avirulent H37Ra strain showed triggering of superoxide release and similar results were shown with the exposure to H37Ra lysate. Conclusion: The priming effect in human alveolar macrophages is not observed because of its usual exposure to environmental particles and avirulent H37Ra strain does not inhibit the activation of alveolar macrophages.