Abstract [Objective] Recently, the effectiveness of closed wound drainage has been evaluated for various types of orthopedic surgery. Some studies showed insufﬁcient evidence to support the routine use of a drain. In the current analysis, the efﬁcacy of closed suction drainage in anterior spinal fusion for lumbar spinal tuber- culosis was retrospectively evaluated. [Patients and Methods] Ninety-one consecutive patients treated from January 1997 to January 2016 were included. Before 2006, a closed suction drainage system was placed immediately before wound closure (31 patients). From 2007, no drain was used (60 patients). The two groups of patients were compared regarding postoperative laboratory data (hemoglobin, albumin, and C-reactive protein [CRP]), postoperative complications (deep hematoma, paralysis, wound infection, wound healing, and wound discharge), and healing of the tuberculous lesion. [Results] There were no signiﬁcant differences in decrease of hemoglobin and albumin between the second and seventh postoperative day. On the other hand, CRP showed a signiﬁcantly smaller decrease in patients treated with a drain. Deep hematoma and postopera- tive paralysis were not detected in either group. Surgical site infection was detected in two patients with a drain. Delayed wound healing was noted in three patients with a drain and one patient without a drain. Persistent discharge was noted in nine patients with a drain. All patients showed excellent healing of the tuberculous lesion. [Conclusion] Comparison between patients with and without a suction drain did not show any deﬁnite advantage of drainage. Therefore, the routine use of a drain in anterior spinal fusion for lumbar spinal tuberculosis is not recommended.
Key words : Spinal tuberculosis, Drainage, Postoperative complication
Department of Orthopaedic Surgery, National Hospital Organization
Toneyama National Hospital Correspondence to : Kazutaka Izawa, Department of Orthopaedic Surgery, National Hospital Organization Toneyama National Hospital, 5_1_1, Toneyama, Toyonaka-shi, Osaka 560_8552 Japan.
(Received 14 Nov. 2016/Accepted 4 Feb. 2017) Kekkaku Vol. 92, No. 4 : 409_412, 2017
EFFICACY OF CLOSED SUCTION DRAINAGE
IN ANTERIOR SPINAL FUSION
FOR LUMBAR SPINAL TUBERCULOSIS
Closed wound suction drainage is commonly used in poste- rior spinal surgery to prevent postoperative hematoma, which can result in paralysis or wound infection. It is also used in anterior spinal fusion for spinal tuberculosis for the same reasons, as well as for the purpose of pus drainage. How- ever, it is questionable whether drainage placement for re- moving pus from the surgical site is necessary after thorough debridement with anti-tuberculous drug treatment. Recently, the efﬁcacy of closed wound drainage has been evaluated for various types of orthopedic surgery, due to its potential adverse effects, including wound contamination via the drain- age tube or excessive bleeding. Some of these studies showed insufﬁcient evidence to support the routine use of postopera- tive drainage1) 2). From 2007, we stopped using closed suction drainage in anterior spinal fusion surgery for lumbar spinal tuberculosis in order to avoid the risk of postoperative infec- tion. In the current study, we retrospectively evaluated the
efﬁcacy of closed suction drainage in anterior spinal fusion for lumbar spinal tuberculosis by comparing patients with versus without drain placement.
Patients and Methods
We retrospectively reviewed 91 consecutive patients under- went anterior spinal fusion for lumbar spinal tuberculosis from January 1997 to January 2016. The surgery was performed with the patient under general anesthesia. Debridement and tricortical iliac bone grafting were performed using the stan- dard retroperitoneal approach. Before 2006, closed suction drainage systems (a 28FG catheter connected with an under water sealed drain system) were placed immediately before wound closure. Postoperatively, the drains were removed when the daily amount of drainage decreased to little or none. The drain insertion site was sutured after the removal. After 2007, no drain was used. Patients who underwent anterior and posterior fusion were excluded from the analysis. All patients received antibiotics using a standard anti-tuberculous drug
A Case of Mycobacterium intracellulare Pleurisy/A.Shinzato et al. 417
Abstract A case of pleurisy from Mycobacterium intra- cellulare is rare, and there have been no reports on the details
of thoracoscopic ﬁndings. Here, we report a case of pleurisy caused by M.intracellulare in an 84-year-old woman, with
a history of acute hepatitis B virus infection. Following her treatment of acute hepatitis B with steroid pulse and maintenance therapy, she visited the emergency department complaining of high fever and chest pain on her left side. She was diagnosed with pneumonia and parapneumonic effusion due to a chest X-ray showing left-sided pleural effusion, and admitted to our department for treatment. The analysis of pleural effusion revealed an increasing level of adenosine deaminase, therefore, tuberculous pleurisy was the tentative diagnosis. However, chest computed tomography ﬁndings on the lingular segment of the left lung suggested a nontuber- culous mycobacteria pulmonary infection. Thoracoscopy was performed under local anesthesia. The ﬁndings of thoracoscopy showed multiple nodules and small clusters of ﬁbrinous mem- brane adhesion in both the visceral and parietal pleurae. After pleural biopsy was performed, M.intracellulare was identiﬁed
using polymerase chain reaction and bacterial culture. There- after, this case was diagnosed as M.intracellulare pleuritis.
After combination therapy with clarithromycin, rifampicin, ethambutol and streptomycin for M.intracellulare pulmonary
disease, the patient improved and clinical symptoms subsided. Key words: Nontuberculous mycobactria, Pleurisy, Thora- coscope, Adenosine deaminase
Department of Infectious, Respiratory, and Digestive Medi- cine, Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus
Correspondence to: Shusaku Haranaga, Department of Infec- tious, Respiratory, and Digestive Medicine, Control and Prevention of Infectious Diseases, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa 903_0215 Japan.
(E-mail: email@example.com) −−−−−−−−Case Report−−−−−−−−
A CASE OF
MYCOBACTERIUM INTRACELLULARE PLEURISY
DIAGNOSED BY PLEURAL BIOPSY
Akira SHINZATO, Shusaku HARANAGA, Kazuya MIYAGI, Masao TATEYAMA, and Jiro FUJITA
complex による胸膜炎の 2 例. 日呼吸会誌. 2010 ; 48 : 151‒156. 5 ） 市木 拓, 植田聖也, 渡邊 彰, 他：胸膜炎を合併し た肺非結核性抗酸菌症の検討. 日呼吸会誌. 2011 ; 49 : 885‒889. 6 ） 萩原恵里, 関根朗雅, 佐藤友英, 他：気胸を合併した 肺Mycobacterium fortuitum感染症の1例. 感染症学会誌. 2008 ; 82 : 73‒76.
7 ） Gribetz AR, Damsker B, Marchevsky A, et al.: Nontuber- culous mycobacteria in pleural ﬂuid. Chest. 1985 ; 87 : 495‒498.
8 ） 杉山昌裕, 立川壮一, 堀口高彦, 他：結核性胸膜炎に対 する局所麻酔下胸腔鏡検査の有用性. 気管支学. 2001 ; 23 : 336‒340.
9 ） Kotani K, Hirose Y, Endo S, et al.: Surgical treatment
of atypical Mycobacterium intracellulare infection with
chronic empyema : a case report. J Thoracic Cardiovasc Surg. 2005 ; 130 : 907‒908.
10） 水谷尚雄, 萱野公一：肺末梢孤立性のMycobacterium avium intracellulare complex感染症による続発性自然気
胸の1例. 日呼外会誌. 2008 ; 22 : 943‒947.
11） Namkoong H, Kurashima A, Morimoto K, et al.: Epi-demiology of pulmonary nontuberculous mycobacterial disease, Japan. Emerg Infect Dis. 2016 ; 22 : 1116‒1117. 12） 荻原恵理, 椎原 淳, 榎本崇宏, 他：気胸を合併した非
結核性抗酸菌症16例の臨床的検討. 日呼吸会誌. 2010 ; 48 : 104‒107
13） 高橋伸政, 星 永進, 鍵山奈保, 他：気胸を合併した抗 酸菌症症例の検討. 結核. 2012 ; 87 : 649‒653.
結核 第92巻 第 4 号 2017年 4 月 422 稿を終えるに当たり，胸部 CT の読影をされた新潟大 学医歯学総合病院放射線診断科の先生方，結核患者を受 け入れて下さった長岡赤十字病院結核病棟のスタッフの 方々に謝辞を述べたい。 本報告の内容は，第 54 回日本呼吸器学会学術講演会 （2014年 5 月，大阪）で発表した。 著者の COI（Conﬂicts of interest）開示：本論文発表内 容に関して特に申告なし。 文 献
1 ） Sørensen JB, Klee M, Palshof T, et al.: Performance status assessment in cancer patients. An inter-observer variability study. Br J Cancer. 1993 ; 67 : 773‒775. 2 ） 高原 誠, 三吉政道, 小澤哲夫, 他：一般病院入院後活 動性肺結核と判明した 2 症例の臨床的検討. 日胸. 2009 ; 68 : 234‒244. 3 ） 日本結核病学会予防委員会：インターフェロンγ遊離 試験使用指針. 結核. 2014 ; 89 : 717‒725. 4 ） 赤川志のぶ：高齢者の結核の現状と治療の実際. 日老 医誌. 2010 ; 47 : 165‒173.
5 ） Im JG, Itoh H, Shim YS, et al.: Pulmonary Tuberculosis : CT ﬁndings—Early Active Disease and Sequential Change with Antituberculous Therapy. Radiology. 1993 ; 186 : 653‒ 660.
6 ） Hatipoğlu ON, Osma E, Manisali M, et al.: High resolution computed tomographic ﬁndings in pulmonary tuberculosis. Thorax. 1996 ; 51 : 397‒402.
7 ） Murata K, Itoh H, Todo G, et al.: Centrilobular Lesions of the Lung: Demonstration by High-Resolution CT and Patho- logic Correlation. Radiology. 1986 ; 161 : 641‒645. 8 ） 藤田次郎：粟粒結核. 呼吸. 2013 ; 32 : 1064‒1071.
Abstract Between January 2010 and June 2013, three hos- pitalized patients developed pulmonary tuberculosis during decreased performance status. They consisted of two men and one woman, and were over 60 years old. All of them developed repeated aspiration pneumonia frequently several months before the onset. Chest computed tomography (CT) scan demonstrated ﬁbrotic changes, pleural thickness, and calci- ﬁcation of lung parenchyma or pleura before the onset. One case had previous history of tuberculous pleuritis. Two cases without previous history of tuberculosis underwent interferon-gamma release assay (IGRA) before the onset. One case was indeterminant and one case was positive. After they developed tuberculosis, consolidation, tree-in-bud appearance, centri- lobular nodoles, miliary nodules, and cavitary lesions were shown by chest CT scan. If elder patients with decreased performance status repeat aspiration pneumonia, chest com-
puted tomography and multiple sputum mycobacterium culture are necessary for excluding pulmonary tuberculosis diagnosis.
Key words : Performance status (PS), Chest computed to- mography (CT), Interferon-gamma release assay (IGRA), Aspiration pneumonia
Department of Internal Medicine, National Hospital Orga- nization Niigata National Hospital
Correspondence to: Makoto Takahara, Department of Internal Medicine, National Hospital Organization Niigata National Hospital, 3_52, Akasaka-cho, Kashiwazaki-shi, Niigata 945_ 8585 Japan. (E-mail: firstname.lastname@example.org)
CLINICAL EVALUATION OF THREE PATIENTS WHO DEVELOPED
PULMONARY TUBERCULOSIS DURING DECREASED PERFORMANCE STATUS
Miliary Tuberculosis with Involvement / K. Kureya et al. 427
Abstract An 86-year-old woman had been treated with oral prednisolone at 3 mg/day for rheumatoid arthritis. In the beginning of June, 201X, she was admitted to the hospital because of fever and left ophthalmalgia. The left eye showed a red-colored nodule on the left bulbar conjunctiva, and the ophthalmological examinations revealed snow ball vitreous opacity. She was diagnosed with endophthalmitis, and admin- istered antimicrobial and antimycotic drugs. However, her eye manifestation was not improved. Her chest X-ray images showed bilateral miliary shadows, and TB-LAMP of the sputum was positive. In addition, TB-PCR of the left eye aqueous humor was positive. Therefore, we diagnosed miliary tuberculosis with intraocular tuberculosis. After diagnosis, anti-tuberculous combination chemotherapy consisting of isoniazid, rifampicin, and ethambutol was immediately ini- tiated. After 1 month of therapy, the inﬂammatory reaction was improved, and after 2 months of therapy, her eyesight
The time-delay in the diagnosis of intraocular tuberculosis lead to loss of eyesight. In advanced tuberculosis cases with eye manifestation, such as ophthalmalgia or eyesight decrease, it is necessary to consider intraocular tuberculosis as the differential diagnosis of eye manifestation in patients with tuberculosis. Therefore, early-stage cooperation with ophthal- mology is important.
Key words : Intraocular tuberculosis, Miliary tuberculosis, Steroid
Osaka City Juso Hospital
Correspondence to : Keisuke Kureya, Osaka City Juso Hospital, 2_12_27, Nonaka-kita, Yodogawa-ku, Osaka-shi, Osaka 532_0034 Japan. (E-mail: email@example.com) −−−−−−−−Case Report−−−−−−−−