肺非結核性抗酸菌症の診断と治療 : 肺結核との相違点と非典型例を中心に

(1)

&#'$

Îd£Æ*National Hospital Organization : NHO+ V JA ÃÿMLOÂGd°JP"¿%OÛ#¥uP bDBU7<=PM6UOOd;ÎT;N#<A[ I9Y"'Î¥uOî¹©Và»Jê~Mw\8G I6Z!SNÎd£ÆJPýÓKC´BFîÜ» \äÛBI"õ²^xqu_xfOwcixÉýMLN Ê¸BI<F!VqN9>Z EBM ùøOFTOî¹ ©V.kOmjlw&c¹©UIBI9Y"ZÅÖ ïNBIU4úO¬P¹©;øÉBI6Z;"®W P´WYUa´üÅÖï\6ðKBF¹©O`ê ;-BI6Z! VqN9>ZZa´üÅÖïNCZ@ÐP ªÎì*½Îd£Æ+O¬P¹©^\=ôN äÛA[I<F;"O-N\6"½ÒJP_ Ù=dUÕBF'Î@ÐKMGI6Z!ÎTJOZ a´üÅÖïOP¡NüZ´\ñY" ç~M%øÎO=JÑUË="-±Ä;26I6Z! Za´üÅÖïOH²GMî³V,ìºPZ ´KP{MZ;"´öO³»;pB6îO-NWY"æOî,;ÏPA[IBR7@KUíM =M6! qÈJP"Z´KO}6NêJ\<<M;XZa´ üÅÖïOö9KàNH6I$CZ!AXN" NHO Ë:dJOâ»\EáB"VòöJ+¯B 7ZaH²9WQpjlq`&uNH6IU¾§CZ! :;.*5/1-4%)< .# (¹© ÅÖ&ïOS>KBI"5;B¢"óA[ Frcvq]&hNRYÿü\mßCZ@K;« ?X[Z!Ohä»JP"ÅÖNWZrcvq]&h OüNP.S{ü;5Y"Zorcvq]&hT NÅÖ;32CZK"COX'/OeN\BITh. ];B¢NLGI|ßA[Z@K;áA[I6Z!Å ÖNWZrcvq]&hOüP"EOÁOÍjï *OsÇML+N|BI6ZXüUÚFA[I6 Z.'1+_! Ë1g&c_xe&NWZ'dns"\}6FZa ´üÅÖïO/ØO·ÔJP"dû*-y²( zD²+"&³*¤Q(?+"9WQd²*Z& ²('÷Yè²+O{MZïN9>Z¦O [ O}6N;tX:NA[HH5Y"{Á{0NUÜS X[I6Z!ëç/ØNH6IU"SNP "Vr^ cvekt^l"MLNWGI"Za´üÅÖï Oãéü~KØOt;øTX[I6Z!AXN" µþ microRNA \o^ar&b&KBFãOüO cUÜSX[I6Z! /# a´üÅÖïOP/-.1WNP.1#4(.-rK MY"üZ´O\A8F!ç~M%øÎO =JPÑUË="-±Ä;26I6Z2"3+_!´K{ MYxhnJOàyPUB="ùDzdP../(.-r KaòNË6!Za´üÅÖïO;kP!

7 6!,238+90("

Za´üÅÖïOö9Kà ,Z´KO)}JKaH²\=ôN,

å ¼

l

RM77Þx¹©g;À¨$*ÍTiv *0W0¶.2Véf+*0W1¶/2Vé+ ×ÎÝ 44."/Ì 12)23 APRIL/2"/-/.*0+ 12

(2)

ÒQJN:a?"É>ZS£Tk!RJ@"X SâTfDM;Q;7,_{!k¼(Îà²Ss"} °TMycobacterium aviumOMycobacterium intracellu-laredÓcGIMycobacterium avium complex+MAC, ?9¡þOQKM;a?"üMRbk¼(Îà² ýS%Bªôd~IE¡ÓT3¡LPN:a!y"

Mycobacterium Kansasii _]Mycobacterium abscessus

complexSsýNT"4¡LP?%Bªôd~ID M=`"oÃ(?^`Ò;8,_{!oÃ(R¨EaâO} D M T"m 5 Ð : S1L N : a u t m q S å é +glycopeptidolipid ; GPL,QPS¨?xÔCbM; a!MAC S\|R=AaspT"M. avium T{QqN" M. intracellulare _T,[qNj?Ò;8,_{!NHO ÒCo} NS¿TN\"HS j T1?1#48N : K I+2013) 2016%142¿>,!IJD"È¼.¶T,[qN\M.

avium ?í>N"NHO ÒCoN2009)2014R¹ÂD

I7ýT3MM. avium _R^a\SN:KI!

3#K%B 1,%Bªô bk¼(Îà²ýSÅÜS%BªôT"2008^R\ |¼o k¼(Îà²ý?ßRR^`Ý) CbI!BSÚR"®ÕöÀg?emDIkK ¶Îà²ý+b¤0ý,S%Bªô+1985^,>_- üý":`.?ÞùCb7«%B?ÒQKI?"% Bªôd~IDM\èáç«TÆ'SýS£ìa ¸dÑDMfBEal?:a9,_!k¼(Îà²T ¼²OTQ`¥¯!Ü²N:aI["hRK% BRTU²îN2þSc(d]Eal ?:a?"ûQ@O\5LPSÙdEa!' S¿ÖRYKM;aKý?=@"¿dº<E aBO?ñN:a!»ýNT>cDS%BË? Ç·cD+ú/z,^`Ò@"NHO ÒCoNSb MAC_{ý+2013)2016%243,S34#}_9/?>cDSZ (N:KI10,_! 2,Îà²S¿ò$UK=^Vw÷%B ³^"Îà²S¿ò$UKR¨DMî'S¿Öyz? eCbI!¼²à9rzR=Aa¤PTO}( ¿>NWX100/"O}(¿>N50)70/OQKM=`" O}(¿>N¼²à9rz?(N:bU"¼ TWXiKCba11,_{!LAMP+Loop-mediated isothermal} amplification,zT"YN&;R¿Ö?êä`N: `"TRC+Transcription Reverse Transcription Concerted Amplification,z+KPN&;Rl(inp RNA d9rEayz,NT"¼²R<MM. intracellulare =^VM. avium SUK\ÒQKM;a!ÏRé s-z+MALDI-TOF-MS,NS-?ÒQ`"} wk(zAdédl(inpOD"Îà²c¢S²î d2õE\©[1ç§LPNrÍ@UKEaBO?` OQKI+170*200²î,!½*%BODMT"ÎMAC Î>+g|r}e!_MAC_{Î> ELISA&Î GPL core IgA} Î>,?vÁNOQKM=`"XP?90/OÒ@ eýìN(OQbU MAC ýS`(?k!RÒ;! (T1´W¶OjD"¼.¬¦ãH¶NÒ; µÌR:a!±$;B OR"¾ ! ì N S IgG ¶ Î MACÎ>S-NT"FÒ^ø(S(?RÒ ;\SS"bk¼(Îà²ýSÊâOCbM;a BMIOS8¨TQ@"¤0S}jhODM(v~{ SÄûQP?6KCbM;a12,_! 3,Û¤ï(æÂ k¼(Îà²R=AaÛ¤ï(æÂS¼Tü ËOS?:`"-@(.N\tzNüMR T4ËEaÿÓ\:a?"HSÃTðsRTCb M ; Q ;! O D M ¼ ² Û ¤ ï ( ¿ Ö N S Rifampicin+RFP,R?EaM. kansasii S¤ï(=^V

k¼ ( Î à ² Û ¤ ï ( ¿ Ö N S Clarithromycin +CAM,R?Ea MAC S¤ï(T"#(?]C bM;a!+¢?Î¼R¤ï(S:a¼²NT" sfhxfpojp?`N:a?"k¼(Îà ²R=Aa¤ï(æÂTKMn?lN:aI[" MIC_{+Øúe_P,NnCba!} hR;_bM;ak¼(Îà²Û¤ï(¿Ö T"cDÐ)>_&;e²S¤ï(æÂRT×Å(? J@;_bF"M. abscessus complexSV@(+Ê ó,SfKTI_@G¿ÖNTÙCbM;Q>KI! D>D"àhypzd;I&;eÎà²UK ë Ã u 46

(3)

dmq;§@\"M. abscessus complex_O~úOpg K®qS<O§;y05¾J¬{KMHE! /#Ê Î«<ÙèÄ-PøNO0ÊNÁ@\[! ,(ÎC»³ìª`Ê']³DÆÊ( ]Þ}O¾(<NQ="ò¾ z;M6/ßV" PÍ£$J^ÈZAM;Y7ÝC[!¸®O ië¡?NXZ"ã±E^ÈZAI6[-ÂV¬{ @\I6[!Å}OÎ«<ÙèÄ-OJP"?O ÊNX[&;U<6! -(GÇrÊ'Î«ÁïÊ( ÞÃY<O¾öNQ="ÚLO¢^7N wñ<NPC[?K;hJ5[!7Ý;N="¯ ×¿KM[-Â;Q6! .(ÕºÎCÊ Î«NX[ÕºÎCKMZ"ç<W@¥P S\J5[!¹$OX7NáuJOàPM. avium N X[VO;øRJ5[;"NHO ÞZJOÐmJP Ù MAC ÙRµ<ÂP{UM:HE!NP·;½ ]\IA)^ü>[?K;Q6;"MAC -J5\Q DAVÙèÄ-KAIO'¾¡P´AM6,.(_! /(Hot Tub Lung 'hypersensitivity-like disease(

Î«<ÙèÄ^¶_Fb`|j{OÌ»shÀzN XZ"Á<M6A~Á<N|WÔÀâv^fC[x û<ô°J5[!Machine Operators Lung9XR Lifeguard Lung_{VpBTKÛ8Y\[!<K} ÁïO+³]4<½1W GGO"½^fA"UÀ& cºOÄW>ÐJOÙèÄOÐ#PhJPM6! 0(I6úÊ =8N96IP"HIV ±E-°ö"LÏ¯å¢2 ×9XRK¸2×MLOå¢<¨IÂN{UY\ [TJ5[;"Ù IFN-γ ]ÈóÖÙRµ<öJO-Â;à@\"hMM©:Y^«@\I6[,/(_! y¤JP" HIV ±EöN>BEú<Î«<Ùè

Ä-Â'0+Â(N96I"¹ZO¨I^AM6-Â'.2Â(O3,*'.,Â(;Ù IFN-γ óÖÙRµ<ÂJ 5HEKà@\I6[,0(_{!vòÂJP"IFN-γ Oþ} WÙ CD-+ÙR'zndhxv(Ol°;îTY\I6 [!ÙèÄ¨Nµ°C[©úWõN0^<ECy }p{iÊxafreoz`±E-'Mendelian susceptibility to mycobacterial disease : MSMG(JV" p±OT^fC[EUOÄOaù;!´KM[,1(_! ú< MAC -'4+*.;M. avium_(Oø´M±EÌ

ÇP»sJPM="b³¥:YOÌb±EJ5[,2(_! Î«P HIV ±E-O%º:YßAI=[;"MAC -Pº;7ÝAI:YßC[?K;Q="å¢<¨ NX[xûË=;ÿJÊ#<KMZ=" Ù MAC ÙROµ<¹Ve6,3(_!5XNPÏ¶;! ´J"OØ»¶wq{JV9NÄPÐ#@\ [/ßV5[;"MAC OÐ#NP BACTECTM _Myco_& F Lytic Culture Vials_{Oé²;£SA6!Î«<Ùè} Ä;co%o{µÆÏ»±E-OÒKM[?KNV^ ;´J5[,4(_! 0#¨ Î«<ÙèÄ-O¨K¨Î«OTP" DAVpJPM6!Î«ÄJPtq;¬O"øJ5 Z"hNPÎ«Ä;ÔÀ¸¨OK¸N¨¦:Yd B3zC[?KPM6!Î«JP%±Eð"Î«¨; ÿNÚ\@\M67GN"OÄ;:YÏÝ<5 [6Pz}sÝ<Nç@\[!¨Î«NP"çd ×N-C[/ß'÷}öOÃ¥W½Î«(K" åMxû<NF_J6E¿íÄ:YOu<ã~ ;5[!JPz}sC;äVQ6;"y¤JP Ã¥Oj;khNÞ6! J"Î«<ÙèÄ P²Â0æÄJ5[EU"RWh¨*:YdBÄ; 3zC[/ß;5[!¹$O±N"ú<Î«<Ùè Ä±E-KAI¨;#ÓC[/ßV5[! Î«ÄO%±EN<P6I¼?[Ã¥JP"ÃÜ NVAE,ÀOÄRNAIå¢<¨NXZxû ;Ë=@\[;"pðN[Ê;¼?Z"# @\[©úgaqca}NXHIÃ¥ªåÏ³On< ;É7AIÃ:_¼^<EC!óHÍ£At[;"§ò Î«<ÙèÄ-O5XKò¾ /2

(4)

®²Vx3WúiT¦f4tÇ _tÇ RDPßu Fc!&-V½}ÒWY¸4RCd"ÔÇ ¡ Vd¦fø@P8T8*Û=F8="uð±=¡ T&²U;8PW PET'CT =¦f4U¢¨Q7 c/-*_{!"~Ç 4ÔèÁU`c½W"¯]U} t<aVX:0_U`MPµBb"ñ®\Ô4Q ¥Ð¯Q7c/.*_{!tfveT8½=¾]P} [dT«£RDP"~Ç 4ÔèÁ=©º,äÁQ7c K]Í¨åfø@P;b"y=6EU?8BR= ×:adc! 3#ñ® .*jñ® t~Ç 4ÔèÁ&V9LQü]T¤®=Eä Fc^VWt MAC &Q7c="IV±#ÆWFàQ" ÁD©Uû÷D©)COPD"t®"67ãé ¨´"Z BMI e*_©º©)c+YVÚµ"c+ 5"28¥Ûe*V¦^L>?"ñ®êVwP WkD8!z]UWÈ·$¶È=7c&²"³ªì U=ÚbQ7c<V{=DtV.'0fV: c*Û";`X=ÂhÄWñ®^RCdP8c! "@V{=¼?ó¢&-^D8a4&²_ 42á(VÚ³öQWÆ«çRTcBR=F8//*_! t MAC &UGFcü¤®W"¯]UÜQ V HIV ¨<&§öQV±#ïËU¯O8P;bÜjQ V±#ïËVr&pWF?T8="RFP.-mg'kg)3--mg [ Q*'m).*"Ethambutol)EB*.2V±#ïËVr&pWF?T8="RFP.-mg'kg)3--mg/kg)42- Q*'m).*"Ethambutol)EB*.2mg/kg)42-mg [Q*'m).*"CAM3--(5--Q*'m).*"Ethambutol)EB*.2mg/kg)42-mg'm).2(/-Q*'m).*"Ethambutol)EB*.2mg/kg)42-mg' kg*).[KW/)5--mg W/RF c**V0ã U"©UEP Streptomycin)SM*[KW Kanamycin )KM*V%.2mg/kg ).---mg [Q*VÀ S f ù/[KW0¨FcBRRCdP8c/0*_!D<D" ñ®)ÁV4"QOL VÓ(7c8W¥ÐV W*=¡Qd¦±¬UN8PV¡T¯üWT?" Ç ñ®RTbñ®gnðU¡Tñ®±¬=;[C dT8BRYV§öV^MRTc!kñ4Q7c BR<a"d¦±¬VW_¡®V»=æCd P8c="ô±#QWå¨QVNª²^F8!T;" mQôíCdK~ HIV ¨<§öfG'RDK CAM" EB"RFP V0ãñ®ÃR SM ¨ÃRV>Ó>|£ï ËQW"SM ¨ÃU;8Pþ±VÁ4=¢U (%DK="±#&-_BÿÊV?;`XßsÁ U¢ÞWo]P8T8/1*_! t~Ç 4ÔèÁ&UGFc¡®U;@cj&$ s{qlW CAM Q7c="ÜjQ¬CdK MAC U ;@c CAM V MIC W"M. avium RM. intracellulare

QWTc^VV"d^H4fyDl4f òDK5*_{!MAC V CAM H4²ÖW"/0S rRNA Uwk} {hsÅÔÁ¡=ÇÛFcâUú©T]¯U;@ c point mutation Q7c="CAM+RFP"CAM+tz& juÅÔÁ¡7c8W CAM OãTSVýj§= C.V÷Kc©RTMP8c!CAM H4&²U1! Cdcñ®~nyWT?"2p6EW 4-,QFã H4Ç )"T?R^ INH R RFP UH4*R¢Þ= T8!CAM Oãñ®W3ù¬Q CAM H4f¤gFc *Û^7b"MAC &²UW¿°RTMP8c!¡[ &²V\TaG³ªìU&Q^"rTaé¨fÕ: cZ>Q7c!T;"CAM R AZM WÑÞH4fo] c="CAM R Erythromycin)EM*RVÑÞH4WT 8RCdP;b"üñ®VKJ:®RD EM Oã d¦=ÙedP8c²^F8/2*_! ü®Qé¨Cdc RFP W¡AÏå¨Q CAM VÈRqbfZCHcBR=QadP;b"mU; 8P CAM"EB"RFP V0ãñ®ÃR CAM"EB V/ ãñ®ÃV>Ó>|£ïË=ôíCdK=".pÐVÁ 4WIdJd1-#3,)/1'26*;`X22,)00'3-* R¢ÞWo]adP8T8/3*_{!BVÉ·QW"0ãñ} ®RV CAM VÈRqb=/ãñ®RR|£DP¾]P Z8BR=òCdP;b"4ØTSUGFc CAM VOã"°d¦Q^"~Ç 4ÔèÁVH4f ¤gFcr4=òÝCdP8c!t MAC &VW±Æ W".-pÐQ 4-,Ufo]"CëRDP" Z BMI"Âh;`Xwk{hsH4=¹Aad P8c/4*_{!/´ñ®RDP±ICdP8c^VV.N} =|vo&w}gxim¶n®Q7b"QV5 9QWü®YV()HQ"Á4VTT? fo]P8c="Îð`QÜj$oUWîMP8T8/5*_! õ Ì 15

(5)

-(¢òÅ ¨L6;Z¢òÅé@HNqO"I/]6IK Z¸ÈSBOüS8±X7H"7E©Å¦N°Ï ÊSBOÝ¸Ê"~òSBOÝu8Ô3ºzF SV´ê¥j^4S"aÇ¸HEN¶WK? Ò82ZÊ"=XLÌÃ"¼Y£@´{¬M"_jv{ f{jÚÖ¬Mw^Ö @Z5ÊI=[G3Z-1(_!¥ H"Ùò^³é@¢pòÅHOJNouSHR³HN þ'8[v7"Eh~o|%{³pN8ÖJNo uSHNI/8þ';#LÆÖ4N7"·ÌÆ æ'AW¸"wg|z`p^F¸"²½DÅ¦K J(^¶@Z«ûL6;Zþ'qNew"$LÅ x=[G3K3bUZ3! 0#BCG }gl~IÂ¦FÐã¸5 BCG }gl~OÂ¦¬M7XQN?r^½D@ Z<I8fX[G3B8"Â¦,¬MN·§ÏU¶@ Z<I8¤×=[B.+(_{!¨O¯CÂ¦N)h®Ø*} H2Y"BCG }gl~NJÿ8ÀX=[G3Z8" 0ðNÂ¦Î«ÁO+#.&,+«IC HÞUl3!ÿF BCG ¬M5N5ÎI>ÄÂ¦¸N¢8&É@ Z<I82Z8"çNymemowHOso½¸I¹ ¡H9K3!K6"ÑÐ²L]@Z BCG Å¦ÌLU !F¢V·©8&É@Z<I8fX[G3Z8" aO¬MHOK:"BCG NdGL]@Z 8IÑ5X[G3Z.,(_! jab%n~Vuz~jHO"BCG }gl~NQÊ JÿhìÌL"0ðL6;ZÂ¦FÐã¸5NÎ«Á N748¤×=[G6Y"BCG }gl~OÂ¦¸C; HK:"0ð³NÂ¦FÐã¸5N5L]@Z½D Ï8óÛ=[G3Z! 5127%3/$"(6408#'&,*+-)!. Â¦FÐã¸5N¤Â^(RG9B8"9>Å HO¯¿Ç2Z3O¤×ÊNK3_LT»@Z8ÖV è]Mtmouc%{L±Z<IU1K:K3!>7U" Â¦FÐã¸58¨p®.L?Ò@Z¬F÷«H 2Z8ËL"qIK¿8Ò][G3K3<IL´F7 A"PIòÅ8ÀX=[G3Z5ÊNYâUmH9 K3! <<7XO"ôÇÊ^nó>G°Ë@ZÃîÓLE 3GK@Z! ,#,³>e^ÍZº ,(Â¦¸IÂ¦FÐã¸NÚâ 5Ênó 0+ß`-F!öF£Í"7´=*"ÌÏtª» F'due%.Õ(6WP LAMP ¦»FHÂ¦I> e=["ÐÂ¦µ/áHN)òÅ8¡å=[B!ÌL \gHN»F8§=["Àª8 INH"RFP L 5GfluoroquinoloneIiùáLU^FI±>"kZá ^FÂ¦I>GsIKDB!-ÄONòÅ¡åñW Y=*NU^TG3B8"sÌNÌÏ.ËÅO QGtªFH2DB! ,òÅH2DB<II")òÅH¸Ç8l>G 3B<I7X¬"FíÇNÂLµ8H?"¢iLH 2DBaþÅÜúLä¹>B¸ªNym^¾>BI <\M. intracellulare I±>B!sÌN¼ªHN ÝÅHO"Â¦¸OQµáL¬"FH2DB!sñL TBNUO,³Ie=[B! K

Ê¾gHOpL"Â¦¸O R ½'rough morpho-type("Â¦FÐã¸O S ½'smooth morphotype(N h|q%^¾G@Z8"\gHOh|q%N¾G8 K3BT"¸ÇVBN¸ÿNÚâOH9A"\ gHNU:WuOÂ¦¸WY MAC 8W3.-(_!Ø}H OpLO\g8»FIKDB8Ö"uÊ¾ gH¼>h|q%^Nc>+¸>G7X¬"F^V m>G3Z8"Nc>B¸ªNÝymOøë=[G3K 3! ¨5ÊHOÌÏLÚâ>G3BM. intracellulare N Á8\¼hLU>"+¸NàLÊ¾gLÚâ >G3B S ½H2DBOANy¸^ÍDGNc>BI Ñ5X[Z!ÅÜõHNg|j$h~kxr%iy~V Å\NýY¯3KJHU"ÉïNÂ^39|Z!Z á^FÂ¦NÍ>O¶ÏKµáNhìLÁ8ZBT"< %LÈ2¿^@Zº82Z..(_! Â¦FÐã¸5N>eIòÅ /1

(6)

,(Å¹â>K7<Y®+ !¢Uî 0*ÞGþ+!N&2ºóDLxÅ+Ñâ¹!L¯ 5HPªÂ£à>ZG5D9"'S0(K»a +{9úÌ?>H½Ð\iSDDS"sÅL×\ ¯[Z«¢å·ÈÜ9Ô[ZD!«¢å4$H`o a%/Ö<\"TRC HÅ¹+IJX"íW HYIJFD!¥§ÈÜHM`oa%/ÖH4FD9 PCR_{ÈÜHMÅ¹"MAC ITK+H4FD!} [+ÈDK7<Y PCR HLÅ¹+K6" -É´ýHñæ?G5YÅ¹cmqL¾ÈÜ 'VNTR (HTwR}mIJX"d%b_ve. HMycobacteriun shinjukuense _Iw?D!

1

M. shinjukuense_{Mß^WKVFG",*++jKgØd}

ML1¢LÍ±¨ÈD8W'DKÈú>ZDxÅ+ Ñâ¹H4X"Runyon ¡HM MAC I_@x¼¹K @AY!-W$W+%MÅ¹¼I}JY9" +0S rRNA L~Zä©t¤9M. tuberculosis H-1RvT IÕ5<_+'32#0)(\î?+0S rRNA \g%ch jI?DÅ¹_RahjH4YTRCRapid M.TB assay HM+\îA=I9LWZG5Y-."-/(_{!_L®} +M"CLBLÅ¹â>I¹õK75GT¬= XcY! -(xX¾W=ýÊ !¢Uî'+( .*ÞGK+!-*ÞGVXè³DÒ!HptklvL d\ÃA?G5D!7+Lï+¦":sLz \iS"}:\rÁI?DzÅ9¯[Zh IJFD!¥§[+'G3Ö(HQEKzüí9 ã>ZD9"PCR ÈÜHÅ¹MÈú>ZB"í `hÎT%L9MiSJ8FD!CLÎ"u +IJX"DDH 7VNd%b_ve.HØdLx Å+Ñâ¹L*#+)\3SYMycobacterium xenopi I_R>ZD! 1

HIV_{¡5!{Loõ+xÅ+Ñâ¹UHot Tub Lung} LH"z\iSY=I94Y!!¢HMs

{MiSB"QD_]ufsL±h£MJ;"í Î.ø¥Mq¹9ëA?DDS"Hot Tub Lung I?G X¾WHMJ;zL¿,KÂ«bá~9¦?G 5Ym+9îÚ>ZD-0(_! !¢Uî',( .*ÞGþ+'°£J?(!¶È(HÛsS KÀ0cm HLC+Lö©\iSD!«¢å·ÈÜ \ñæAYTR(JKéWB"PET&CT T+H4F DDS"C+kl6§L¯5H¶Ó·K/ÿû \æÔ?D!*?(JHMç;&Ifö+{9ó DH4FD9/ÿMÙeHÛ/ÿû\æÔ?D! ;&WKM"C+{Ml%KO?D«¢åL ù«H4X"rvn0KTfö\iSD!ôûìL nHLÑâ¹u9+IJX"DDHHM. kansasii I_R>ZD! 1 Å0«¢åO¾LsxÅ+Ñâ¹!HM%K A5G]%L«¢åO9úÌAY9"sM. kansasii !HT-*)K«¢åO=\iSY!l%L«¢å OMsxÅ+Ñâ¹!HMQZHM4Y9"l+ sö¨IL¤9yIJY-1(_! =ZWL!¢LK"sxÅ+Ñâ¹!L¿FM¸ SGCÝH4X"=ýÊLRHÍ±¨ð L¤ð 8WÿAP:HMJ5! ,#PªÂK7<Y{FL +(¹ÏGÌ" !¢Uî 0*ÞGK+!s§KE?G#/ÿû\÷<DÎ" Æ+|Æ\v!?Geiu^k9`h>ZD! -wÇÎKNLs MAC !I(J>ZH¹ +IJFD9"jKMM. abscessuscomplexOL¹Ï G9w?D!íTÑ+H»a{9>H?"«bL p9)Ô?D9ôûL_|McWZJ8FD!M. abscessus complexÈú.jÎK²ÄJ>y\iS" ¶ÓKµHJ«Ó9úÌ?D!dê·ÈÜH#«¢ åJIª9i>Z"±M`oa%3Ö<\H4F D!s:Vû\R?D9"8gKH ¥Æ\:D?

ò Ë

(7)

ªBaJ! K Ð§AßòÅ3R9?`ÅAÙSë3¿S W=;"sõÊSQ`ÅR]`ë®MN5_(£¥ NT20*)"ü¼e[³ZÅ&Së©;µN5`! -+,/SiéNT"M. abscessus _3SÂº;2N 0R52CM9_(Ç)'NW6)"MAC :^S ÅÛ^;Oá8^aM6`0)_!

M. abscessus complex_T"M. abscessus ssp.abscessus_" M. abscessus ssp.massilience _9]VM. abscessus ssp.

bolletii _R¾Ba`;"M. abscessus ssp.abscessus _O M. abscessus ssp. bolletii NT"wi}yeqÌßÅ°

N±zBa`erm(/,)_{sõR]_"-.S rRNA Sq}

µ;xn{Ba"qR CAM [AOQ`!M. abscessus ssp. abscessus _S ¬9]VM. abscessus

ssp.massilience NT"erm(/,)sõ;¸GF CAM

®(AOQ`;"ü¼eR¨|[AÅOQ`AO[5 `.3".4)_! babaRT"©3¿R96M¹{S¢R]_¹¯ ÷baRÆÞ;DD`zlic²ÔN<M6Q:KJ! H0-ÙSÐ§AßòÅ3NT·baÆS,× R»E`µ;5_" NTM 3þ<RZE`-ÿO CMT"ÈH05S ¦ªqH0-cã6"H¹ baWS¹{ñ Sóc§>AO;+µN5`/+)_! -)½IS´WS=r 3¿oý 1+ì^/A!çkNÆCË¥9]Vc( ;C"Âçj MRI ÓéNèê1O;bBaZ3¼£N SÍ°ðOQKJ!-ÒÙROTÂk; b_vc(;CJ!ÂO;bC"ÂâÃÂâ QÃ-c#øC"HSÙRÂâq|r%kOßÅ°u³ c2±ÎUC]OQKJ!TíÅ·AN 5KJ;"ÙRßòÅ·;¶AOQ_j%ih~l FR]_M. abscessus ssp. abscessus _O«CJ!

¯ TQ="Ð§AßòÅ3S;bRû^Q:KJ ;",ÒÙSÂ CT N9JRTSÄO Th2/3 jYS¢9]V¥jY'ÅcZJ!Í:^M. abscessus ssp. abscessus _R]`AGj:^Â

Rû_Ä[UCJOá8âJ! K ßòÅR]`GjSzlitdim%OCM~q¥ 1;¡æBaM9_"ÅYcÇ8CJ¤wi}td% k;¥1WxCÅYc¢,EÀ;öpBa M6`/,)_{!X¨S¶RL6MSÀh%;µN5`} ;"~q¥1cZ`3¿TFC[W=TQ6!7 uqf¾ÅR]ÀGj:^"XaNT5`;Â >g»RûÀO;câM6`;"Ð§AßòÅN [y´S\cmC|`/-)_! .#ü¼ÝncÚ`\

Æ"¬ëàd3ÜÉ(Immune reconstitution in-flammatory syndrome : IRIS)OCMS®M3S3$ R;fBaM6`!IRIS T"¬¸;½ÏRë àd5`6T«AEÀOR]_"$OCMÖYR ZE`¬3;RÀC"ÁÔ®M3;3 (Unmasking IRIS)$R(Paradoxical IRIS)CM" DYR+}Q4¦c<JE\N5`!¬ëàd3Ü Éc3E`^qQclinical settingOCMT"AIDSR ZE`ß HIV ¼£S¤ô(Á»S IRIS c3)"Dª qEî\¬¸@°S½ÏQeù"¬ngoive~ pP¦°S¤ô"Ö"RZE`ü¼R]`¬¸S ¡$RÀw;¿@â`!ßòÅ3R96M["Ha IaS\R9?`3¿S¡æ;RCM6`! ß HIV ¼£R]`¬ëàd3ÜÉNT"ß HIV ¼ £z-&/*RLãE`Ð§ SRcZ` AO;W6;"e?:Íc³YVS´R9JQ ;Õ ïE`6å[5`!Ð§AßòÅ3T Unmasking IRIS_{OCM.ZM!BaÀO;W="ïAz~} sJSt;ä6!&AÐ§AßòÅ3OQ_" ;ÄïEÀO[5_"Ñ·S¶AºTl 6/.)_! ²JzfwnQPSþØ¬A"R TNF P¦°c u³CJ6å"XaR«xAÐ§\Ð§AßòÅ3c 3EÀO;câM6`;"TNF P¦°ceùS 78NßòÅ3ü¼cÎUCM[¼KqRcZÀ O;5`!ºÅS°î®(A\ TNF P¦°SOA R®_;Q?aU TNF P¦°SÎU[N`úOB_| Ð§AßòÅ3S;bOü¼ 0,

(8)

X,,&_! f`gbm^shD¤Mg§L63HS·M x%8Õ»=Y"TNF D¤h©Lg§BM IGRA M ëÞSÉ±=YX!£{0N%(M4EL"Ãz_ bM CT Ix»=YX!w·3Æ×®%LG3H S"f`gbm^shD¤Mg§LUXGu%¸ 8Ík7V¢G7Ì=YH3X,-&_! CíM·L6;Xä´imÀMþ¤u N"l'-´Ib´¼@X<JMK3OI2W" |}bLNþ¤Mä´Ã8o=YCÀLGu\oR X!·ä´LUXøîM¥sM8«}J=Y H3X8"QYIN2X8·3Æ×®%L63HS h©MO8Ì=YH3X,.&_! <YVL5"|}LNÒÈW%Á°J>Hõ LNoè=YH3K38"Ö¿¤L6;X@%Sh© MOJÉ5VYX!·3Æ×®%IMæ¼¸NK 38"`;MïúúE@L6;X¦}®J>H"

M. abscessus complex MÌ8Õ»=YX! %¸aå%·%¸& %¸%)& *(Q!3!5')t¸À7Vxp8ãI>"¬ M-TI+óMÆ®¤g§\ñ;Hp>C!x %+t¸ÀLN¬/S$é>C8"xp8Òr> S[WÒm~JKFC!wM+üJÿ »\oR"º½6UO/7V·®8¹ù=Y",Ô IMûä´8im=YC!>7>"ä´Û)óÀ LN£JMGuJMH¬/Mù¾82W"+óã I>C! %¸%*& *(Q!3!`;*óÀ7VÎv]\æ>C8 7Ñ\ñ;A"ùÖ-t¸ÀL¼]MGuJ¿§%( Mù¾\oRm~JKFC!t3:\JYÎt¾ \oR"²wL+ü\yFH3C!t¾MAÚ7V ·®8¹ù=Y",ÔIMûä´\imM45t¾ Mirj$d8Û=YC!>7>"BMÀ/óLf WwNGu>C! *%¸JS¤ÔN3NoRA"þ¤uJzT>ä´ k¨MÇNÊ[A´\µI>CJ<Z"ä¥LàF C! = Ö¿¤N"n*XL6;XPâª>\@XCRM Ó3M¬2(O7V¨¶L@XCR"Ò ÈW%Á°M«}J4WjX!Ö¿¤MÒÈW%Á °J>HQbK@%N"·"bpkhcgae% 6UO_^qe3I2X!Ö¿¤·M1Nw \¦>H6W"4E/LX1,´\oR"ß ¯N+0'JË:),'LÀy%\Ø@,/&_! æ¼¸MÖ¿¤·MYS8ä´imL¹I>Hþ ¤u\^>C<JN"Ö¿¤·Jþ¤u8h? ÒÈW%Á°MelbhonL2X<J\|>H3 XJÝ[YX,0&_! !$#" w·3Æ×®%N"7GHN¿§?¡zM| 8-´L²[XêI2FC8"¯qM»¯MGT ¬2´M.6UO68ÔMÅ~Kµ{L6; XÙªLUW"K0M-´8«¶>H[¤\Ê4 P9êJKFC!|Iw·3Æ×®%M@© çTx6UO.dM¥"NDKe8K:"· 3Æ×®C}LË3FÃ¯\å@¤ÔMxS.]I 3K3!öFH"w·3Æ×®%M-TJä´L6 3HN"'L·#´JÓ®bK¹Ñ·MLý 8K37\o>"«L?¹LMÒaùT£Já³ MÒ¹\Ê3"5K®ð\uv>HÊ:<J8÷«I 2X!QC"ív³J>HM¥sTBMò)}Ü Lõ°w@X«82X!c±¸I2FHS"ë L¦}®\®#h_>U»\ô9>HÊ:<J8Q YX! w·3Æ×®%MONK¡L[CWV{ÐSR 93CR"BMÜZÑT·#º©\S|MÞ<I ëÞ@X<JNA>S¨xINK:"Âb~°8 C@P9¢NR93JÝ[YX!ÏÀS¶K8V" w·3Æ×®%L@X-´MÄ&LS §>HÊ 9C3! ì ½ -*

(9)

.

-,*Shinohara, T., Pantuso, T., Shinohara, S., Kogiso, M., et al . : Persistent inactivation of macrophage cyclo-oxygenase'-in mycobacterial pulmonary inflamma-tion. Am J Respir Cell Mol Biol.!'$$,/1',0/!-++4 -*Yamashita, M., Shinohara, T., Tsuji, S., Myrvik, Q. N.,

et al . : Catalytically inactive cyclooxygenase 2 and absence of prostaglandin E- biosynthesis in murine peritoneal macrophages followingin vivophagocytosis of heat-killed Mycobacterium bovis bacillus Calme-tte-Guérin. J Immunol._!_{$*,$2+2-'2+23!}_-++2 .*Kogiso, M., Shinohara, T., Dorey, C. K., Shibata, Y. :

Role of PPARγ in COX'-activation in mycobacterial pulmonary inflammation. Inflammation.!&($,130' ,140!

-+,-/*Shibata, Y., Ohata, H., Yamashita, M., Tsuji, S., et al . : Immunologic response enhances atherosclerosis-type, helper T cell)Th,*-to-type - helper T cell )Th-*shift and calcified atherosclerosis in Bacillus Calmette-Guerin)BCG*-treated apolipoprotein E-knockout_{)apo E'('*mice. Transl Res.!}_$',$1-'14! -++2

0*Namkoong, H., Kurashima, A., Morimoto, K., Hoshino, Y.,et al . : Epidemiology of Pulmonary Nontubercu-lous Mycobacterial Disease, Japan. Emerg Infect Dis._!_{%%$,,,1',,,2!}_-+,1

1*Prevots, D. R., Marras, T. K.:Epidemiology of human pulmonary infection with nontuberculous mycobac-teria : a review. Clin Chest Med.!&)$,.'./!-+,0 2*Izumi, K., Morimoto, K., Hasegawa, N., Uchimura, K.,

et al . : Epidemiology of Adults and Children Treated for Nontuberculous Mycobacterial Pulmonary Di-sease in Japan. Ann Am Thorac Soc.!$)$./,' ./2!-+,4

3*Morimoto, K., Hasegawa, N., Izumi, K., Namkoong, H.,_{et al . : A Laboratory-based Analysis of} Nontuber-culous Mycobacterial Lung Disease in Japan from 2012 to 2013. Ann Am Thorac Soc.!$'$/4'01!-+,2

4*§bV¡WUbVip^mNQU, § g][WUY#bVW|¢U$bVip ^?Z9Fr&-++3. Kekkaku.!+&$0-0' 0-1!-++3 ,+*o, xf¤!_£®$MAC ?68 FR@ª«!6DAR@B¬Xy @°~?;5<@d"jeOt!%&$,4-' ,44!-+,3 ,,*\q!}¨fcP!³© !Sf¦h $ bV±?68FbV^`Vpd{dk@:C@ LAMP¥)Direct TB-LAMP*@ª« @ d " Kekkaku.!++$2-2'2..!-+,.

,-*Nishimura, T., Fujita-Suzuki, Y., Mori, M., Carpenter S. M.,et al . : Middle-aged to elderly women have a higher asymptomatic infection rate with Mycobac-terium avium complex, regardless of body habitus. Respirology._!_%$$00.'000!_-+,1

,.*Ose, N., Maeda, H., Takeuchi, Y., Susaki, Y., et al . : Solitary pulmonary nodules due to non-tuberculous mycobacteriosis among -3 resected cases. Int J Tuberc Lung Dis.!%#$,,-0',,-4!-+,1

,/*Browne, S. K., Burbelo, P. D., Chetchotisakd, P., Suputtamongkol, Y.,et al . : Adult-onset immunodefi-ciency in Thailand and Taiwan. N Engl J Med.!&)*$ 2-0'2./!

-+,-,0*Aoki, A., Sakagami, T., Yoshizawa, K., Shima, K., et al . : Clinical Significance of Interferon-γ Neutralizing Autoantibodies Against Disseminated Nontubercu-lous Mycobacterial Disease. Clin Infect Dis.!))$ ,-.4',-/0!-+,3

,1*Wu, U. I., Holland, S. M. : Host susceptibility to non-tuberculous mycobacterial infections. Lancet Infect Dis.!$($413'43+!-+,0

,2*Horsburgh, C. R. Jr. : The pathophysiology of disse-minatedMycobacterium avium complex disease in AIDS. J Infect Dis.!$*,!Suppl&"$S/1,'/10!,444 ,3*u²$bVip^@l>°~#¡

Tza@s7E"§IMHGL%JK/ TzwXWUnt!&,$,,',2!-+,4

(10)

*2(Tagashira, Y., Kozai, Y., Yamasa, H., Sakurada, M., et al . : A cluster of central line-associated bloodstream infections due to rapidly growing nontuberculous mycobacteria in patients with hematologic disorders at a Japanese tertiary care center : an outbreak investigation and review of the literature. Infect Control Hosp Epidemiol.!&)$0/&1)!+)*.

+)(Shinohara, T., Shiota, N., Kume, M., Hamada, N., et al . : Asymptomatic primary tuberculous pleurisy with intense*1&fluorodeoxyglucose uptake mimick-ing malignant mesothelioma. BMC Infect Dis.!$&$ *+!+)*, doi :*).**1//*-0*-+,,--*,-*+

+*(Ando, T., Kawashima, M., Matsui, H., Takeda, K., et al . : Clinical Features and Prognosis of Nontubercu-lous Mycobacterial Pleuritis. Respiration.!,)$.)0& .*,!+)*1 ++(`dOs$MAC aT|87n"Kekkaku.!+,$ /*&/.! +)*-+,(tLDzE@xLDcSXKahU;<@, t QJHE@Fea#LDE_{@$wxLDcSX Ka>E6G49NA%+)*+uBm"LD!+*$ 1,&1/!+)*+

+-(Kobashi, Y., Matsushima, T., Oka, M. : A double-blind randomized study of aminoglycoside infusion with combined therapy for pulmonary Mycobacte-rium aviumcomplex disease. Respir Med.!$#$$*,)& *,1!+))0

+.(Hosono, Y., Kitada, S., Yano, Y., Mori, M., et al . : The association between erythromycin monotherapy for

Mycobacterium avium complex lung disease and cross-resistance to clarithromycin : A retrospective case-series study. J Infect Chemother.!%'$,.,&,.0! +)*1

+/(Miwa, S., Shirai, M., Toyoshima, M., Shirai, T., et al . : Efficacy of clarithromycin and ethambutol for My-cobacterium avium complex pulmonary disease. A preliminary study. Ann Am Thorac Soc.!$$$+,&+2!

+)*-+0(Kitada, S., Uenami, T., Yoshimura, K., Tateishi, Y., et

al . : Long-term radiographic outcome of nodular bro-nchiectaticMycobacterium aviumcomplex pulmona-ry disease. Int J Tuberc Lung Dis.!$)$//)&//-!+)*+ +1(Griffith, D. E., Eagle, G., Thomson, R., Aksamit, T. R., et al . : Amikacin Liposome Inhalation Suspension for Treatment-Refractory Lung Disease Caused by

Mycobacterium avium Complex'CONVERT(. A Prospective, Open-Label, Randomized Study. Am J Respir Crit Care Med._!_{$,+$*..2&*./2!}_+)*1 +2(tLDzE@xLDcSXKahU;<@$wx

LDcSXKa6h49C?[7~b"LD!+&$ .+0&.+1!+))1

,)(Roy, A., Eisenhut, M., Harris, R. J., Rodrigues, L. C., et al . : Effect of BCG vaccination against Mycobacte-rium tuberculosis infection in children : systematic review and meta-analysis. BMJ.!&',$g-/-,! +)*-doi :_{*).**,//bmj.g-/-,}

,*(Tobiume, M., Shinohara, T., Kuno, T., Mukai, S., et al . : BCG-induced pneumonitis with lymphocytic pleurisy in the absence of elevated KL&/. BMC Pulm Med.!$'$,.!+)*- doi :*).**1//*-0*-+-//-*--,. ,+(`rI!Roi!`W=Y!ljdy g$

Mycobacteria Growth Indicator Tube'MGIT(: 35\qSXKM^fk7M^v6G49Mp. FeaEVZ!*&$*0+&*01!*222

,,(Ohji, R., Shinohara, T., Ohji, H., Hatakeyama, N., et al . : Pulmonary tuberculosis misdiagnosed as exten-sively drug-resistant tuberculosis due to selection of a nontuberculous mycobacterial colony from a pre-culture dish used for a drug-susceptibility test. Respir Investig.!(+$+*/&+*2!+)+)

,-(Saito, H., Iwamoto, T., Ohkusu, K., Otsuka, Y., et al . :

Mycobacterium shinjukuensesp. nov., a slowly grow-ing, non-chromogenic species isolated from human clinical specimens. Int J Syst Evol Microbiol.!)$!Pt +"$*2+0&*2,+!+)**

,.(Taoka, T., Shinohara, T., Hatakeyama, N., Iwamura, S.,_{et al . :}Mycobacterium Shinjukuense pulmonary disease progressed to pleuritis after iatrogenic

pneu-] P }

(11)

.-mothorax : a case report. J Clin Tuberc Other Myco-bact Dis.!"*"&%%&+%!'%'% doi:&%.&%&+/j.jctube. '%'%.&%%&+%.eCollection

(+$Okano, Y., Shinohara, T., Imanishi, S., Takahashi, N., et al . : Miliary pulmonary nodules due to Mycobacte-rium xenopi in a steroid-induced immunocompromi-sed patient successfully treated with chemothera-py : a case report. BMC Pulm Med.!"'".'!'%&+ doi :_{&%.&&-+/s&'-.%-%&+-%'*'-y}

(,$Kadota, N., Shinohara, T., Naruse, K., Hino, H., et al . : A lobulated mass in the left lower lobe : not what it seems. Thorax.!(%"*&.#*'%!'%&.

(-$Choi, G. E., Shin, S. J., Won, C. J., Min, K. N., et al . : Macrolide treatment forMycobacterium abscessus

andMycobacterium massiliense infection and indu-cible resistance. Am J Respir Crit Care Med.!")'" .&,#.'*!'%&'

(.$Koh, W. J., Jeong, B. H., Kim, S. Y., Jeon, K., et al . : Mycobacterial characteristics and treatment outco-mes inMycobacterium abscessus lung disease. Clin Infect Dis.!'%"(%.#(&+!'%&,

)%$Inayama, M., Shinohara, T., Yoshida, M., Hino, H., et al . : Bronchopleural fistula following M. abscessus

infection&& years after lobectomy for lung cancer. Springerplus.!#"*+-!'%&( doi :&%.&&-+/'&.(-&-%&-

'-*+-)&$Chan, E. D., Kong, P. M., Fennelly, K., Dwyer, A. P., et al . : Vertebral osteomyelitis due to infection with nontuberculous mycobacterium species after blunt trauma to the back_{"( examples of the principle of} locus minoris resistentiae. Clin Infect Dis.!$#" &*%+#&*&%!'%%&

)'$Kadota, N., Shinohara, T., Hino, H., Goda, Y., et al . :

Mycobacterium abscessus ssp. abscessus infection progressing to empyema from vertebral osteomye-litis in an immunocompetent patient without pulmo-nary disease : a case report. BMC Pulm Med._!_"*" &%%!'%&. doi :&%.&&-+/s&'-.%-%&.-%-+%-)

)($Lawn, S. D., Bekker, L. G., Miller, R. F. : Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving an-tiretrovirals. Lancet Infect Dis.!&"(+&#(,(!'%%* ))$Takazono, T., Nakamura, S., Imamura, Y., Miyazaki,

T.,et al . : Paradoxical response to disseminated non-tuberculosis mycobacteriosis treatment in a patient receiving tumor necrosis factor-α inhibitor : a case report. BMC Infect Dis.!"%"&&),'%&) doi:&%.&&-+/ &),&-'(()-&)-&&)

)*$Fujita, K., Yamamoto, Y., Kanai, O., Okamura, M., et al . :Development ofMycobacterium aviumComplex Lung Disease in Patients With Lung Cancer on Immune Checkpoint Inhibitors. Open Forum Infect Dis.!("ofaa%+,!'%'% doi :&%.&%.(/ofid/ofaa%+, )+$Yano, S., Kobayashi, K., Kato, K., Tokuda, Y., et al . :

Paradoxical worsening of pulmonaryMycobacterium abscessus. Respir Med.!"!""-+-#-,%!'%%, ),$Singh, N., Perfect, J. R. : Immune reconstitution

syn-drome and exacerbation of infections after preg-nancy. Clin Infect Dis.!%&"&&.'#&&..!'%%,

)-$Shinohara, T., Kagawa, K., Okano, Y., Sawada, T., et al . : Disseminated tuberculosis after pregnancy pro-gressed to paradoxical response to the treatment : report of two cases. BMC Infect Dis.!"'"'-)!'%&+ doi :&%.&&-+/s&'-,.-%&+-&+')-x

(12)

Diagnosis and Treatment of Pulmonary Nontuberculous Mycobacterial Disease

−Focusing on Differences from Pulmonary Tuberculosis and Atypical Cases−

Tsutomu Shinohara

Department of Community Medicine for Respirology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan

SUMMARY

In public hospital peer groups such as the National Hospital Organization!NHO"and JA Welfare Federation, hospitals are set up in various places around Japan and play an important role in clinical researches including clinical trials on a nationwide scale. In particular, NHO has contributed to po-licies such as vaccination against new viruses by conducting clinical studies that are directly linked to medical administration. NHO is also conducting clinical researches to promote EBM in Japan and organ-specific network researches. Many multi-institutional joint studies on pulmonary mycobacterial disease are also underway, and in recent years the weight of research on pulmonary nontuberculous mycobacterial disease!PNTMD"has increased rather than pulmonary tuberculosis!PTB".

Epidemiological studies of PNTMD in Japan have been conducted mainly by joint research groups of the former National Sanatorium_{!now NHO",but with the increase in prevalence, they are} now a national survey with the additional participation of community hospitals. The incidence rate of PNTMD in Japan is exceeding that of culture-positive PTB and the highest among major indus-trialized nations. Although the typical clinical course and radiological manifestations of PNTMD differ from those of PTB, physicians with little experience in treating tuberculosis patients some-times confuse these mycobacterial diseases.

This review describes the diagnosis and treatment of PNTMD, with an emphasis on differences from pulmonary tuberculosis. In addition, I present our own cases of PNTMD at NHO Kochi Hos-pital and explain the atypical cases and pitfalls that may be encountered in daily practice.

Key words :pulmonary nontuberculous mycobacterial disease, pulmonary tuberculosis, atypical cases, pitfalls

& % '