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Lee YM, Kim SW, Kwack WG. Tracheitis Caused by Coinfection with Cytomegalovirus and Herpes Simplex Virus. Medicina (B Aires) 2021; 57:medicina57111162. [PMID: 34833380 PMCID: PMC8624308 DOI: 10.3390/medicina57111162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022] Open
Abstract
Clinically significant isolated viral tracheitis is scarce in adults, and upper airway obstruction caused by viral tracheitis is even more infrequent. A 74-year-old woman, who was administered low-dose steroids for two months for chronic obstructive pulmonary disease (COPD), developed dyspnea with stridor and required mechanical ventilation for respiratory failure. Chest computed tomography showed a diffuse tracheal wall thickening with luminal narrowing and peribronchial consolidation in the right upper lobe. Bronchoscopy revealed a proximal tracheal narrowing with multiple ulcerations of the tracheal mucosa surrounded by an erythematous margin. Pathologic examinations of the tracheal mucosal tissue, including immunohistochemistry, revealed a cytomegalovirus (CMV) and herpes simplex virus (HSV) infection. Furthermore, the bronchial alveolar lavage fluid was positive on the CMV real-time polymerase chain reaction. The patient was treated with intravenous ganciclovir for 44 days. The follow-up bronchoscopy 49 days after the initiation of ganciclovir revealed improved multiple ulcerations with scars. We report a rare case of tracheitis caused by coinfection with CMV and HSV in a patient with COPD who had been taking low-dose steroids for months. The case showed that CMV and HSV are potential causes of serious tracheitis and respiratory failure.
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Affiliation(s)
- Yu-Mi Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul 02447, Korea;
| | - So-Woon Kim
- Department of Pathology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul 02447, Korea;
| | - Won-Gun Kwack
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kyung Hee University Hospital, Seoul 02447, Korea
- Correspondence: ; Tel.: +82-2-958-8194
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Restrepo MI, Sibila O, Anzueto A. Pneumonia in Patients with Chronic Obstructive Pulmonary Disease. Tuberc Respir Dis (Seoul) 2018; 81:187-197. [PMID: 29962118 PMCID: PMC6030662 DOI: 10.4046/trd.2018.0030] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 11/24/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a frequent comorbid condition associated with increased morbidity and mortality. Pneumonia is the most common infectious disease condition. The purpose of this review is to evaluate the impact of pneumonia in patients with COPD. We will evaluate the epidemiology and factors associated with pneumonia. We are discussing the clinical characteristics of COPD that may favor the development of infections conditions such as pneumonia. Over the last 10 years, there is an increased evidence that COPD patients treated with inhaled corticosteroids are at increased risk to develp pneumonia. We will review the avaialbe information as well as the possible mechanism for this events. We also discuss the impact of influenza and pneumococcal vaccination in the prevention of pneumonia in COPD patients.
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Affiliation(s)
- Marcos I Restrepo
- South Texas Veterans Health Care System, San Antonio, TX, USA
- Veterans Evidence Based Research Dissemination and Implementation Center (VERDICT) (MR), San Antonio, TX, USA
| | - Oriol Sibila
- Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Anzueto
- South Texas Veterans Health Care System, San Antonio, TX, USA
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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3
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Abstract
Herpes esophagitis due to infection with herpes simplex virus typically occurs in immunocompromised patients such as those with human immunodeficiency virus, malignancy, and those undergoing immunosuppressive therapy. Albeit rare, herpes esophagitis can occur in immunocompetent patients as a primary infection. We present a case of herpes esophagitis after corticosteroid treatment for back pain including epidural steroid injections. Corticosteroids, especially local injections, are a common treatment for chronic back pain, but they are not without risk. Epidural steroid injections can have systemic effects, which may go unrecognized and underappreciated. Although local infections have been reported after administering these injections, systemic immune suppression may allow for unexpected infections such as herpes esophagitis. Given the widespread use of epidural steroid injections, physicians should reevaluate the potential for harm when considering this treatment.
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Wessolossky M, Welch VL, Sen A, Babu TM, Luke DR. Invasive Aspergillus infections in hospitalized patients with chronic lung disease. Infect Drug Resist 2013; 6:33-9. [PMID: 23761976 PMCID: PMC3674018 DOI: 10.2147/idr.s43069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Although invasive pulmonary aspergillosis (IPA) is more prevalent in immunocompromised patients, critical care clinicians need to be aware of the occurrence of IPA in the nontraditional host, such as a patient with chronic lung disease. The purpose of this study was to describe the IPA patient with chronic lung disease and compare the data with that of immunocompromised patients. METHODS The records of 351 patients with Aspergillus were evaluated in this single-center, retrospective study for evidence and outcomes of IPA. The outcomes of 57 patients with chronic lung disease and 56 immunocompromised patients were compared. Patients with chronic lung disease were defined by one of the following descriptive terms: emphysema, asthma, idiopathic lung disease, bronchitis, bronchiectasis, sarcoid, or pulmonary leukostasis. RESULTS Baseline demographics were similar between the two groups. Patients with chronic lung disease were primarily defined by emphysema (61%) and asthma (18%), and immunocompromised patients primarily had malignancies (27%) and bone marrow transplants (14%). A higher proportion of patients with chronic lung disease had a diagnosis of IPA by bronchoalveolar lavage versus the immunocompromised group (P < 0.03). The major risk factors for IPA were found to be steroid use in the chronic lung disease group and neutropenia and prior surgical procedures in the immunocompromised group. Overall, 53% and 69% of chronic lung disease and immunocompromised patients were cured (P = 0.14); 55% of chronic lung patients and 47% of immunocompromised patients survived one month (P = 0.75). CONCLUSION Nontraditional patients with IPA, such as those with chronic lung disease, have outcomes and mortality similar to that in the more traditional immunocompromised population.
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Affiliation(s)
- Mireya Wessolossky
- Division of Infectious Diseases, University of Massachusetts Medical School, Worcester, MA, USA
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Malave A, Laserna E, Sibila O, Mortensen EM, Anzueto A, Restrepo MI. Impact of prior systemic corticosteroid use in patients admitted with community-acquired pneumonia. Ther Adv Respir Dis 2012. [PMID: 23179232 DOI: 10.1177/1753465812458985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Limited information is available regarding the impact of prior outpatient use of systemic corticosteroids (SCS) in patients subsequently developing community-acquired pneumonia (CAP). We investigate the effects of prior SCS on severity of illness, microbiology and clinical outcomes for patients hospitalized with CAP. METHODS A retrospective cohort study of subjects with CAP (according to International Classification of Diseases, 9th edition codes) was conducted over a 3-year period at two tertiary teaching hospitals. Subjects were considered to be SCS users if they received oral corticosteroids prior to admission. Primary outcomes were severity of illness, microbiology and 30-day mortality. RESULTS Data were abstracted on 698 patients [prior SCS users, 75 (10.7%) versus prior non-SCS users 623 (89.3%)]. Prior SCS users were more likely to have chronic obstructive pulmonary disease. No differences were found in severity of disease at admission, microbiological etiology including opportunistic and drug-resistant pathogens and clinical outcomes, including 30-day mortality, intensive care unit admission, length of hospital stay, need for mechanical ventilation and need for vasopressors. CONCLUSION Prior SCS use is not associated with increased 30-day mortality for patients hospitalized with CAP. In addition, no differences were found in either the severity of the disease at the time of presentation or in the presence of the resistant or opportunistic pathogens among groups.
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Affiliation(s)
- Adriel Malave
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX, USA
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6
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Pulmonary infectious diseases in patients with primary immunodeficiency and those treated with biologic immunomodulating agents. Curr Opin Pulm Med 2011; 17:172-9. [DOI: 10.1097/mcp.0b013e3283455c0b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Snell NJC. HOST DEFENSES AGAINST RESPIRATORY TRACT INFECTION—IMPLICATIONS FOR ANTI-INFLAMMATORY DRUG DEVELOPMENT AND TREATMENT. Exp Lung Res 2009; 33:529-36. [DOI: 10.1080/01902140701756661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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8
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Severe cytomegalovirus-associated esophagitis in an immunocompetent patient after short-term steroid therapy. J Clin Microbiol 2009; 47:3031-3. [PMID: 19571016 DOI: 10.1128/jcm.00143-09] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A case of severe human cytomegalovirus esophagitis after short-term corticosteroid therapy in a patient with no other apparent cause of immunodeficiency, such as human immunodeficiency virus infection, neoplasia, or previous organ transplantation, is described herein. The cytomegalovirus esophagus infection was successfully treated with ganciclovir.
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Osawa R, Singh N. Cytomegalovirus infection in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R68. [PMID: 19442306 PMCID: PMC2717427 DOI: 10.1186/cc7875] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 03/25/2009] [Accepted: 05/14/2009] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined. METHODS Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed. RESULTS CMV infection occurs in 0 to 36% of critically ill patients, mostly between 4 and 12 days after ICU admission. Potential risk factors for CMV infection include sepsis, requirement of mechanical ventilation, and transfusions. Prolonged mechanical ventilation (21 to 39 days vs. 13 to 24 days) and duration of ICU stay (33 to 69 days vs. 22 to 48 days) correlated significantly with a higher risk of CMV infection. Mortality rates in patients with CMV infection were higher in some but not all studies. Whether CMV produces febrile syndrome or end-organ disease directly in these patients is not known. CONCLUSIONS CMV infection frequently occurs in critically ill immunocompetent patients and may be associated with poor outcomes. Further studies are warranted to identify subsets of patients who are likely to develop CMV infection and to determine the impact of antiviral agents on clinically meaningful outcomes in these patients.
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Affiliation(s)
- Ryosuke Osawa
- Infectious Diseases Section, VA Medical Center, University Drive C, Pittsburgh, PA 15420 USA.
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Samarakoon P, Soubani AO. Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature. Chron Respir Dis 2008; 5:19-27. [PMID: 18303098 DOI: 10.1177/1479972307085637] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND There are increasing reports describing invasive pulmonary aspergillosis (IPA) in patients with chronic obstructive pulmonary disease (COPD) without the classic risk factors for this severe infection. The available literature on this association is based on case reports or small case series. The aim of this review is to systematically review these cases and describe the clinical features, diagnostic studies and outcome. METHODS We identified all the cases of IPA and COPD reported in the literature and had enough clinical information. We also included five cases of IPA in patients with COPD identified by the authors. These cases were systematically reviewed for clinical features, diagnostic studies and outcome. RESULTS There were 60 cases of IPA in patients with COPD identified from the literature. The total number of cases reviewed was 65. The mean age was 65.1 years, the mean FEV1 was 39% of predicted (n = 17, range 19-56%). Forty-nine patients were documented to be on systemic corticosteroids. The mean dose was 24 mg/day (range 15-65 mg/day). Five patients were only on inhaled corticosteroids and in 11 patients there was no documentation of corticosteroid therapy. The clinical and radiological findings were nonspecific. Thirteen patients had documented evidence of disseminated IPA. Sputum examination was positive for Aspergillus in 76% and bronchoscopy with bronchoalveolar lavage that was positive in 70%. The diagnosis of IPA was definite in 43 patients and probable in 22 patients. Forty-six patients were treated with anti-fungal therapy. Fifty-nine patients (91%) died with IPA. CONCLUSION Invasive pulmonary aspergillosis is an emerging serious infection in patients with COPD. The majority of these patients have advanced COPD and/or on corticosteroid therapy. The clinical and radiological presentation is nonspecific. High index of suspicion is necessary for the timely treatment of these patients.
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Affiliation(s)
- P Samarakoon
- Division of Pulmonary, Allergy, Critical Care and Sleep, Wayne State University School of Medicine, Harper University Hospital, Detroit, MI 48201, USA
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Dussauze H, Bourgault I, Doleris LM, Prinseau J, Baglin A, Hanslik T. Corticothérapie systémique et risque infectieux. Rev Med Interne 2007; 28:841-51. [PMID: 17629359 DOI: 10.1016/j.revmed.2007.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Revised: 05/20/2007] [Accepted: 05/26/2007] [Indexed: 11/24/2022]
Abstract
PURPOSE It was shown that corticosteroids alter the inflammatory and immune responses. Many publications report on serious infections occurring in patients receiving corticosteroids or presenting with Cushing's syndrome. This information is synthesized in this article. CURRENT KNOWLEDGE AND KEY POINTS The demonstration of the infectious risk associated with corticosteroids relies on observational data and on biological plausibility. However, this risk remains difficult to quantify, because of many confusing factors such as the patients' associated conditions and immunosuppressive treatments, and the highly variable dose and duration of the corticosteroid treatment. Taking into account the published data, the screening for a chronic infection seems licit among patients receiving a systemic corticosteroid treatment, in particular for those who will receive more than 10 mg of prednisone per day. FUTURE PROSPECTS Although no clinical trials of prevention of infections in corticosteroid treated patients has been published, a strategy aiming at minimizing the infectious risk of corticosteroid treated patients is proposed, based on the analysis of the literature presented in this article.
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Affiliation(s)
- H Dussauze
- Service de médecine interne, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, université Versailles-Saint-Quentin-en-Yvelines, 92100 Boulogne-Billancourt, France
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Dalhoff K, Kothe H. Antibiotikatherapie bei Exazerbation. Internist (Berl) 2006; 47:908, 910-2, 914-6. [PMID: 16855849 DOI: 10.1007/s00108-006-1687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Bacterial infections are involved in approximately 50% of acute exacerbations of chronic bronchitis (AECB). Pneumococci, Haemophilus influenzae and Moraxella catarrhalis are the main pathogens. Studies using quantitative cultures and molecular typing suggest a causal relationship between bacterial infection and exacerbation. Furthermore, an association between infection and bronchial inflammation has been demonstrated. In contrast to steroid therapy and non-invasive ventilation, the benefits of antibiotic treatment are not well established. Current guidelines recommend antimicrobial therapy for AECB in type I exacerbations, for patients needing ventilatory support and for patients with cardiac comorbidity. Bacterial eradication is able to prolong the infection free interval.
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Affiliation(s)
- K Dalhoff
- Medizinische Klinik III, Universitätsklinikum Schleswig-Holstein - Campus Lübeck.
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Menéndez Calderón MJ, Nuño Mateo J, Seguí Riesco ME, Fonseca Aizpuru E. Infiltrados pulmonares en paciente en tratamiento con glucocorticoides. Rev Clin Esp 2006; 206:195-6. [PMID: 16750092 DOI: 10.1157/13086802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Agustí C, Rañó A, Aldabó I, Torres A. Fungal pneumonia, chronic respiratory diseases and glucocorticoids. Med Mycol 2006; 44:S207-S211. [PMID: 30408905 DOI: 10.1080/13693780600857348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) usually occurs in severely immunocompromised patients. The expanded use of glucocorticoids (GC) in clinical practice accounts for the increasing number of fungal infections reported in mildly or non-immunocompromised hosts. We report a series of 8 patients with fungal pneumonia in whom long term high dose GC treatment was the only risk factor for opportunistic infections. All patients except one had chronic underlying disorders (asthma, idiopathic fibrosis, chronic obstructive pulmonary disease, COPD). Seven patients were diagnosed with pulmonary aspergillosis. Etiological suspicion of fungal infection was obtained during lifetime in six cases and in one case was confirmed only in the post-mortem examination. In most cases bronchoscopic techniques allowed identification of the microorganism. However, delay in establishing the diagnosis (mean 20 days) precluded a prompt initiation of a specific treatment. The course of the fungal infection was ominous. All but one patient experienced progressive respiratory failure requiring ICU admission and mechanical ventilation support. Despite this, all of them died. The only survivor was a patient receiving early empirical antifungal treatment due to a high clinical suspicion of fungal infection. Based on the present and previous findings, antifungal treatment should be considered in chronic respiratory patients requiring high or repetitive doses of GC when there is clinical evidence of pneumonia and isolation of Aspergillus spp. from respiratory secretions.
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Affiliation(s)
- Carlos Agustí
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Ana Rañó
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Ivet Aldabó
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Antoni Torres
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
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Gea-Banacloche JC, Opal SM, Jorgensen J, Carcillo JA, Sepkowitz KA, Cordonnier C. Sepsis associated with immunosuppressive medications: an evidence-based review. Crit Care Med 2005; 32:S578-90. [PMID: 15542967 DOI: 10.1097/01.ccm.0000143020.27340.ff] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for sepsis associated with immunosuppressive medications that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis. DESIGN The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. METHODS The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591. CONCLUSION Immunosuppressed patients, by definition, are susceptible to a wider spectrum of infectious agents than immunologically normal patients and, thus, require a broader spectrum antimicrobial regimen when they present with sepsis or septic shock. Special expertise managing immunosuppressed patient populations is needed to predict and establish the correct diagnosis and to choose appropriate empiric and specific agents and maximize the likelihood that patients will survive these microbial challenges.
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Niewoehner DE. The role of systemic corticosteroids in acute exacerbation of chronic obstructive pulmonary disease. ACTA ACUST UNITED AC 2004; 1:243-8. [PMID: 14720044 DOI: 10.1007/bf03256615] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The administration of systemic corticosteroids for patients with exacerbations of chronic obstructive pulmonary disease (COPD) has become common practice over the past 25 years. This practice remained somewhat controversial because corticosteroids can have serious adverse effects and initial clinical trials provided inconclusive evidence concerning their efficacy. Results from recent clinical trials indicate that systemic corticosteroids are modestly effective in shortening the duration of severe exacerbations of COPD. Systemic corticosteroids administered intravenously or orally to hospitalized patients with exacerbations of COPD reduced the absolute treatment failure rate by about 10%, increased the forced expiratory volume in 1 second (FEV1) by about 100 ml, and shortened the hospital stay by 1 to 2 days. Oral corticosteroids probably confer similar benefits when used for treating moderately severe COPD exacerbations in an out-patient setting. The optimal starting dose of corticosteroids is not known, but the duration of treatment should not extend longer than 2 weeks. Hyperglycemia is the most common adverse event, but secondary infections, mental disturbances, and myopathies may also occur.
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Affiliation(s)
- Dennis E Niewoehner
- Pulmonary Section, Veterans Affairs Medical Center, and University of Minnesota, Minneapolis, Minnesota 55417, USA.
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Mulhall BP, Wong RKH. Infectious Esophagitis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2003; 6:55-70. [PMID: 12521573 DOI: 10.1007/s11938-003-0034-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Infectious esophagitis can have significant implications in an impaired host. Described most commonly in immunocompromised patients, infectious esophagitis can also occasionally be discovered in immunocompetent individuals in several unique clinical settings. Evaluation of the typical presenting complaints, such as dysphagia or odynophagia, are especially important in immunocompetent patients, and therapy should be directed at the appropriate predisposing condition and resultant infectious agent. In immunocompromised patients, however, clinical experience supports the use of empiric therapy in patients without concomitant systemic complaints. Especially in AIDS patients or those with lymphoma or leukemia, the initial approach to infectious esophagitis complaints (ie, dysphagia or odynophagia) is to begin an empiric trial of oral systemic fluconazole for presumed candidal esophagitis. If the individual remains symptomatic after 3 to 7 days or has any associated systemic complaints or concerning clinical findings (eg, hematemesis), then upper endoscopy with biopsies is indicated. If an etiologic agent other than Candida is defined by histologic, immunohistochemical, or culture methods, then appropriate therapy can be initiated. There are many important and pathologic agents implicated in infectious esophagitis. Thus, directed therapy needs to be administered appropriately and in a timely fashion to avoid poor short-term problems or long-term sequelae.
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Affiliation(s)
- Brian P. Mulhall
- Gastroenterology Service, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5000, USA.
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Agustí C, Rañó A, Filella X, González J, Moreno A, Xaubet A, Torres A. Pulmonary infiltrates in patients receiving long-term glucocorticoid treatment: etiology, prognostic factors, and associated inflammatory response. Chest 2003; 123:488-98. [PMID: 12576371 DOI: 10.1378/chest.123.2.488] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Glucocorticoid treatment alters immunoregulatory defense mechanisms and may therefore favor the development of different pulmonary infections. METHODS The etiology, prognostic factors, and associated inflammatory response of pulmonary infiltrates in 33 patients receiving long-term glucocorticoid treatment (LTGCT) were prospectively evaluated. RESULTS Aspergillus spp (n = 9, 31%) and Staphylococcus spp (n = 6, 21%) were the most common causative agents. Using different diagnostic techniques, we obtained a specific diagnosis in 28 of 33 episodes (85%) of pulmonary infiltrates. Bronchoscopic techniques provided the diagnosis in 64% of the cases. Crude mortality was 45%. Variables associated with mortality were as follows: age > 64 years, bilateral radiographic involvement, delay in diagnosis, inappropriate empirical treatment, Simplified Acute Physiology Score (SAPS) II > or = 25, and requirement for mechanical ventilation (MV). SAPS II > or = 25 (odds ratio [OR], 16; 95% confidence interval, 1 to 260) and MV requirement (OR, 50; 95% confidence interval, 2 to 360) were also significant on multivariate analysis. Pulmonary infections were associated with an increase in the concentration of relevant inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6 both in serum and BAL. This local and systemic inflammatory response was attenuated when compared with the response observed in patients with pulmonary infections but without glucocorticoid treatment or receiving glucocorticoids for a short period of time (< 9 days). CONCLUSIONS Pulmonary infiltrates in patients receiving LTGCT are often caused by fungi and Gram-positive cocci, and are associated with attenuated local and systemic inflammatory response. Although in most cases, sputum cultures and bronchoscopic techniques are diagnostic, the associated mortality is high, particularly in those requiring MV.
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Affiliation(s)
- Carlos Agustí
- Servei de Pneumologia, Institut Clínic de Pneumologia i Cirurgía Toràcica, Barcelona, Spain
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Dimopoulos G, Piagnerelli M, Berré J, Eddafali B, Salmon I, Vincent JL. Disseminated aspergillosis in intensive care unit patients: an autopsy study. J Chemother 2003; 15:71-5. [PMID: 12678418 DOI: 10.1179/joc.2003.15.1.71] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Disseminated aspergillosis is an uncommon but frequently fatal disease in critically ill populations. With studies suggesting that the incidence of this disease is increasing, and with relatively few epidemiological data available in this population, we evaluated cases of disseminated aspergillosis identified at autopsy over a one-year period on a 31-bed mixed medico-surgical intensive care unit (ICU) of an academic university hospital. In 1999, there were 489 deaths out of 2984 ICU admissions, and 222 autopsies were performed. Post-mortem examination demonstrated disseminated aspergillosis involving non-contiguous organs in 6 (2.7%) autopsies and, of these, five patients (2.3% of total) had had chronic obstructive pulmonary disease (COPD) and had been treated with corticosteroids and mechanical ventilation for pulmonary infection. One patient also had granulocytopenia. In each patient, sputum and bronchoalveolar lavage (BAL) cultures had been positive for Aspergillus fumigatus after ICU admission but this was considered as colonization and the patients were given fluconazole for suspected candidal infection. In conclusion, COPD patients treated with corticosteroids and presenting with pulmonary infection should be considered at risk for disseminated aspergillosis. The rapidly fatal outcome after ICU admission suggests that colonization with Aspergillus can occur before ICU admission.
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Affiliation(s)
- G Dimopoulos
- Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium
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Carrascosa Porras M, Herreras Martínez R, Corral Mones J, Ares Ares M, Zabaleta Murguiondo M, Rüchel R. Fatal Aspergillus myocarditis following short-term corticosteroid therapy for chronic obstructive pulmonary disease. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2002; 34:224-7. [PMID: 12035764 DOI: 10.1080/00365540110077407] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A 58-y-old man with chronic obstructive pulmonary disease (COPD) was admitted for treatment of an acute exacerbation of his illness. The patient's condition initially improved after therapy with oxygen, bronchodilators, antibiotic and methylprednisolone (40 mg every 8 h) was started. Soon afterwards, however, the patient's clinical status deteriorated and he died on the fifth hospital day. Post-mortem examination revealed unsuspected, isolated fungal myocarditis. The fungus was later identified as Aspergillus by indirect immunofluorescence. To our knowledge, this is the first case of fatal Aspergillus myocarditis related to short-term (< 1 week) steroid therapy in a COPD patient. We believe that this case provides further evidence to support the possibility of life-threatening infections in COPD patients who receive even a short course of corticosteroid treatment.
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Tárrega J, Jerez FR, Plaza V, Franquet T, Sánchez F, Gurguí M. [The prognostic factors of invasive pulmonary aspergillosis in patients with chronic pneumopathy]. Arch Bronconeumol 2000; 36:29-33. [PMID: 10726182 DOI: 10.1016/s0300-2896(15)30230-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES a) To determine in patients with chronic respiratory disease the risk factors for death due to semi-invasive and invasive pulmonary aspergillosis (SIPA), and b) to describe the clinical features of SIPA in such patients. METHOD Twenty-one patients with chronic respiratory disease were enrolled (9 with chronic obstructive pulmonary disease, 2 asthmatics and 3 with bronchiectasis, 5 with post-tubercular sequelae and 2 mixed cases). A diagnosis of SIPA was established in our hospital when, in a patient with a clinical picture consistent with such a diagnosis, the fungus was isolated in bronchial secretions or parenchymal pulmonary specimens were obtained during autopsy. RESULTS The most common symptoms were dyspnea (81%), cough (67%) and expectoration (62%) increasing over the levels usual for patients with chronic respiratory disease. Hemoptysis was present in only 14%. Eight patients (38%) died as a result of SIPA. A comparison of those surviving and non-surviving patients revealed that the latter had significantly higher LDH levels and white cell counts, and significantly lower total plasma protein and platelet counts. CONCLUSIONS a) Low protein levels and high LDH levels and white cell counts with thrombopenia are indicators of poor prognosis in chronic respiratory disease patients with SIPA, and b) such patients do not usually present signs or symptoms that lead to a suspicion of SIPA given that such signs are typical of failing compensatory mechanisms in the disease itself.
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Affiliation(s)
- J Tárrega
- Departamento de Neumología, Hospital de la Santa Creu i de Sant Pau, Barcelona
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23
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Weiner P, Weiner M, Rabner M, Waizman J, Magadle R, Zamir D. The response to inhaled and oral steroids in patients with stable chronic obstructive pulmonary disease. J Intern Med 1999; 245:83-9. [PMID: 10095821 DOI: 10.1046/j.1365-2796.1999.00412.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A significant minority of patients with COPD have favourable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side-effects. Long-term administration of inhaled steroids is a safe means of treatment. However, only a few studies have addressed the role of inhaled steroids in patients with COPD, with conflicting results. METHODS Forty-four patients with stable COPD were defined as 'responders to bronchodilators' (increase in FEV1 > or = 20% following administration of beta 2-agonist) (group A), and 124 as 'non-responders to bronchodilators' (group B). All patients were randomized to receive a 6-week course of either a daily dose of 800 micrograms of inhaled budesonide or placebo, separated by 4 weeks when no medication was taken; were randomized again to receive a 6-week course of either 1600 micrograms day-1 of inhaled budesonide, or 800 micrograms day-1 of inhaled budesonide plus placebo; and were randomized once again to receive a 6-week course of either 40 mg day-1 of prednisone or placebo. All stages were performed in a double-blind cross-over design. RESULTS Following administration of 800 micrograms day-1 of inhaled budesonide, there was an increase in the mean FEV1 from 1.40 +/- 0.20 to 1.92 +/- 0.22 L (P < 0.001) and a significant decrease in inhaled beta 2 agonist consumption in group A. These changes remained almost stable during the increased dose of inhaled budesonide or during prednisone treatment. The mean FEV1 did not change during the placebo period, or in group B in either treatments. CONCLUSIONS Treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about one-quarter of patients with stable COPD, and this rate increased to about three-quarters in patients who responded to beta 2-agonist inhalation. There was no additional benefit in using a higher dose of inhaled budesonide or prednisone.
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Affiliation(s)
- P Weiner
- Department of Medicine A, Hillel-Yaffe Medical Center, Hadera, Israel
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Hettlich C, Küpper TH, Wehle K, Pfitzer P. Aspergillus in the Papanicolaou stain: morphology, fluorescence and diagnostic feasibility. Cytopathology 1998; 9:381-8. [PMID: 9861530 DOI: 10.1046/j.1365-2303.1998.00123.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Aspergillus species exhibit a distinct and clear fluorescence in Papanicolaou-stained cytological samples. The Papanicolaou (PAP) stain enhances the autofluorescence of cultured aspergilli and allows better cytological recognition of the fungus by fluorescence microscopy when it is not easily discerned from its surroundings by light microscopy. Morphological properties can be better distinguished and facilitate the differentiation of aspergillus organisms from other filamentous fungi. Neither light nor fluorescence microscopy, the cytological quality nor the presence of phagocytosed hyphae in alveolar macrophages allow distinction between infection and contamination with Aspergillus species. Only the presence of eosinophilic inflammation permits a tentative diagnosis of an Aspergillus infection. In conclusion, PAP fluorescence reduces the need for special stains, is superior to and quicker than other investigative techniques and enhances the sensitivity and specificity of cytological investigation when a rapid and reliable identification of Aspergillus is needed.
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25
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Tratamiento esteroide: factor de riesgo para aspergilosis pulmonar invasiva. Arch Bronconeumol 1998. [DOI: 10.1016/s0300-2896(15)30473-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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26
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Cahill BC, Hibbs JR, Savik K, Juni BA, Dosland BM, Edin-Stibbe C, Hertz MI. Aspergillus airway colonization and invasive disease after lung transplantation. Chest 1997; 112:1160-4. [PMID: 9367451 DOI: 10.1378/chest.112.5.1160] [Citation(s) in RCA: 159] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Invasive Aspergillus is an important cause of morbidity and mortality among lung transplant recipients. The diagnosis can be difficult and treatment is often unsuccessful so many centers preemptively treat all Aspergillus airway isolates to prevent invasive disease. This approach is untested as little is known about the relationship between Aspergillus airway colonization and invasive disease. This study was undertaken to evaluate the incidence of Aspergillus airway colonization after lung transplantation and the risk of invasive disease after colonization. DESIGN All cultures and histologic specimens obtained from a consecutive series of 151 lung transplant cases were reviewed for the presence of Aspergillus and compared with clinical data. RESULTS Aspergillus was isolated from the airway in 69 (46%) of 151 transplant recipients. Invasive disease occurred in five cases and was uniformly fatal, accounting for 13% of all posttransplant deaths. Results of cytologic examination of BAL fluid were normal in all cases of invasive disease and cultures were positive in only one of five patients prior to invasion. Invasive disease occurred exclusively in patients who died or were colonized with Aspergillus fumigatus within the first 6 months posttransplant. Patients growing A. fumigatus from the airway during the first 6 months were 11 times more likely to develop invasive disease relative to those not colonized. CONCLUSION Aspergillus airway colonization after lung transplantation is common and in most cases, transient. In contrast, invasive Aspergillus disease is less common, but fatal. Bronchoscopy with cytologic examination and fungal culture are not sensitive or timely predictors of invasive disease. Invasive Aspergillus occurred only in patients initially colonized with A. fumigatus within the first 6 months posttransplant. A trial of empiric anti-Aspergillus therapy limited to the first 6 months posttransplant may be warranted.
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Affiliation(s)
- B C Cahill
- Thoracic Transplant Program, University of Minnesota, Minneapolis, USA
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van Wijk CA, Mearin ML, van de Sluys Veer A, Hoogerbrugge PM, Weiland HT, Vossen JM. Cytomegalovirus colitis and immunotherapy. J Pediatr Gastroenterol Nutr 1997; 24:608-11. [PMID: 9161960 DOI: 10.1097/00005176-199705000-00021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- C A van Wijk
- Department of Pediatrics, Leiden University Hospital, The Netherlands
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28
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Liebau P, Kuse E, Winkler M, Schlitt HJ, Oldhafer K, Verhagen W, Flik J, Pichlmayr R. Management of herpes simplex virus type 1 pneumonia following liver transplantation. Infection 1996; 24:130-5. [PMID: 8740105 DOI: 10.1007/bf01713317] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Interstitial pneumonia caused by Herpes simplex virus type 1 (HSV-1) is a severe complication of orthotopic liver transplantation (LTX). The records of patients were reviewed who had an LTX at the age of 16 years or older between 1991 and 1994 with a mean follow-up of 21 months (range, 10 to 44 months). Six patients were included who had fever of > 38 degrees C, deterioration of arterial blood gases, radiological evidence of interstitial pneumonia and proof of HSV-1 in bronchoalveolar lavage fluid. All patients were anti-HSV-IgG positive before LTX. All patients were successfully treated with intravenous acyclovir, mechanical ventilation and reduced immunosuppression. Three patients who received cyclosporin A had a rejection which was successfully treated by switching to FK 506. Four patients were discharged in good health. One patient died 36 months after LTX of an unrelated cause. One patient died of urosepsis on postoperative day 139. Acyclovir together with mechanical ventilation and reduced immunosuppression proved to be an effective treatment for HSV-1 pneumonia following LTX.
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Affiliation(s)
- P Liebau
- Abt. Anästhesiologie IV, Medizinische Hochschule Hannover, Germany
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29
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Pseudomonas aeruginosa blepharitis in a patient with vancomycin induced neutropenia. Can J Infect Dis 1996; 7:63-5. [PMID: 22514419 DOI: 10.1155/1996/301396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/1994] [Accepted: 05/18/1995] [Indexed: 11/18/2022] Open
Abstract
A patient who developed a necrotizing pseudomonas blepharitis as a complication of drug induced neutropenia is reported. Although the patient's neutrophil count recovered and he survived his infection, radical reconstructive surgery of his eyelids was required. Clinicians should keep in mind that in patients with predisposing risk factors, even commonly encountered infections such as blepharoconjunctivitis may be caused by atypical pathogens.
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Abstract
A significant minority of patients with COPD have favorable response to corticosteroid treatment. In addition, the benefit of corticosteroid treatment may be outweighed by the side effects. Long-term administration of inhaled steroids is a safe means of treatment. We hypothesized that treatment with high-dose inhaled budesonide would improve clinical symptoms and pulmonary function in subjects with COPD, and that the response to inhaled beta 2-agonist will serve to individualize steroid responders. We compared a 6-week course of 800 micrograms/d inhaled budesonide with placebo, separated by 4 weeks when no medication was taken, in a double-blind crossover trial, in 8 patients responding to inhaled beta 2-agonist, and in 22 nonresponders with stable COPD. In six of eight "responders to beta 2-agonist," there was a significant improvement in the FEV1 (defined as > or = 20%) following inhaled budesonide, as compared with placebo. In the 22 "nonresponders to beta 2-agonist," there was no significant improvement in the mean FEV1 (1.41 +/- 0.1 L before, and 1.61 +/- 0.1 L after treatment) with inhaled budesonide or placebo. Over the 6-week course of treatment by either budesonide or placebo, the nonresponders reported similar beta 2-agonist consumption (4.8 +/- 0.2 and 5.0 +/- 0.1 puffs per patient per day, respectively). However, there was a significant difference between the two periods of treatment in the responders as for the mean daily number of beta 2-agonist inhalations (2.4 +/- 0.1 in the budesonide period as compared with 5.3 +/- 0.1 in the placebo period; p < 0.005). We conclude that treatment with inhaled steroids improved spirometry data and inhaled beta 2-agonist consumption in about 25% of patients with stable COPD, and this rate is increased to about 75% in patients who respond to beta 2-agonist inhalation.
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Affiliation(s)
- P Weiner
- Department of Medicine A, Hillel-Yaffe Medical Center, Hadera, Israel
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Conesa D, Rello J, Vallés J, Mariscal D, Ferreres JC. Invasive aspergillosis: a life-threatening complication of short-term steroid treatment. Ann Pharmacother 1995; 29:1235-7. [PMID: 8672828 DOI: 10.1177/106002809502901209] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To describe a patient with invasive pulmonary aspergillosis related to short-term steroid treatment. CASE SUMMARY A 78-year-old man with chronic obstructive pulmonary disease (COPD) developed an invasive pulmonary aspergillosis after short-term (less than 1 week) intravenous steroid therapy. The diagnosis was established by recovering Aspergillus fumigatus from a bronchoalveolar lavage and was confirmed by autopsy, with the additional finding of an aspergilloma. DISCUSSION This case is of interest for 3 reasons: (1) it illustrates that invasive aspergillosis may be followed by a rapidly progressive respiratory failure, even in the absence of a fever; (2) this patient had simultaneously an aspergilloma and an invasive aspergillosis; and (3) it confirms reports indicating that short-term steroid therapy for COPD represents a significant risk factor for opportunistic lung infections. CONCLUSIONS In patients with COPD who receive even short-term steroid therapy and who have progressive respiratory failure caused by pneumonia, invasive aspergillosis should be suspected early and acted upon accordingly.
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Affiliation(s)
- D Conesa
- Internal Medicine Department, Hospital de Sabadell, Barcelona, Spain
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Hedlund JU, Ortqvist AB, Kalin ME, Granath F. Factors of importance for the long term prognosis after hospital treated pneumonia. Thorax 1993; 48:785-9. [PMID: 8211867 PMCID: PMC464701 DOI: 10.1136/thx.48.8.785] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Elderly patients admitted to hospital for community acquired pneumonia have a high risk of recurrence of pneumonia and of death during the years after discharge. In this study potential factors of importance for the long term prognosis after hospital treated pneumonia were retrospectively investigated. METHODS A total of 241 patients (103 men) with a mean age of 60 (range 18-102) years discharged from hospital after treatment for community acquired pneumonia were studied. After an average follow up period of 31 months, 18 independent variables present during hospital treatment of the initial pneumonia were examined for association with the following end points: recurrence of pneumonia, death from any cause, and death from pneumonia. RESULTS Age adjusted analysis showed that systemic treatment with corticosteroids correlated significantly with recurrence of pneumonia and with death. The presence of low serum albumin levels on admission or colonisation of the respiratory tract with Gram negative enteric bacteria seemed to be important negative prognostic factors for the outcome during pneumonia recurrences after discharge. CONCLUSIONS Patients who are admitted to hospital with pneumonia are at risk of subsequent pneumonia and death after discharge. This risk seems to be even higher in patients who are treated with corticosteroids systemically, who have a low serum albumin level on admission, or who become colonised in the respiratory tract with Gram negative enteric bacteria during their hospital stay.
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Affiliation(s)
- J U Hedlund
- Department of Infectious Diseases, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
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Rodrigues J, Niederman MS, Fein AM, Pai PB. Nonresolving pneumonia in steroid-treated patients with obstructive lung disease. Am J Med 1992; 93:29-34. [PMID: 1626569 DOI: 10.1016/0002-9343(92)90676-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE To review autopsy-proven cases of opportunistic pneumonia and determine how many of these patients had received corticosteroid therapy for obstructive lung disease in order to define whether this therapy was the major risk factor predisposing to infection. PATIENTS AND METHODS All autopsies performed at Winthrop-University Hospital over a 5-year period were reviewed, and 30 cases of opportunistic pneumonia were identified. In eight of 30 cases, corticosteroid therapy for chronic obstructive pulmonary disease (COPD) was the only identifiable risk factor for opportunistic infection. The other 22 patients had other well-defined risk factors for infection. Chart review of the eight patients with COPD was undertaken to define the clinical features of their infections. RESULTS All eight patients had a progressive multilobar pneumonia that failed to resolve, either clinically or radiographically, despite the use of multiple broad-spectrum antibiotics. In four cases, the infection was community-acquired, while in the other four cases, it was nosocomial in origin. Despite the presence of a nonresolving pneumonia, opportunistic infection was generally not considered as a diagnostic possibility, with only one case being correctly diagnosed antemortem. Autopsy examination documented Aspergillus species as being responsible for six episodes of pneumonia, Candida albicans accounting for one episode, and cytomegalovirus accounting for one episode. CONCLUSION Based on this experience, it is clear that corticosteroid therapy of COPD can lead to opportunistic pulmonary infection, in or out of the hospital. This diagnosis should be considered when patients receiving this therapy develop a pneumonia that fails to respond to broad-spectrum antibiotics.
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Affiliation(s)
- J Rodrigues
- Department of Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, New York 11501
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Palmer LB, Greenberg HE, Schiff MJ. Corticosteroid treatment as a risk factor for invasive aspergillosis in patients with lung disease. Thorax 1991; 46:15-20. [PMID: 1871691 PMCID: PMC1020907 DOI: 10.1136/thx.46.1.15] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Invasive pulmonary aspergillosis usually occurs in severely immunocompromised or neutropenic patients. Six patients with invasive aspergillosis are described whose only defence impairment was underlying lung disease and corticosteroid treatment. Cough, fever, and sputum production were the usual reasons for presentation and four patients developed the sepsis syndrome. Radiographic findings included de novo cavitation in three patients and rapid radiographic progression in four. Aspergillus species were isolated from respiratory secretions of all patients early in the course of the disease. Treatment was effective in only two patients and the subsequent progress of the others was consistent with a chronic necrotising process. Invasive pulmonary aspergillosis is uncommon in patients with respiratory diseases receiving corticosteroids, but should be considered when pneumonia and cavitary infiltrates occur.
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Affiliation(s)
- L B Palmer
- Department of Medicine, North Shore University Hospital, Cornell University Medical Center, Manhasset, New York 11030
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Hudson LD, Monti CM. Rationale and use of corticosteroids in chronic obstructive pulmonary disease. Med Clin North Am 1990; 74:661-90. [PMID: 2186237 DOI: 10.1016/s0025-7125(16)30544-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Several studies of corticosteroid efficacy in patients with COPD performed in the last decade have had stronger study designs and larger patient populations than most of the previously reported investigations. These studies have provided evidence of the objective benefit of corticosteroid therapy on pulmonary function in clinically stable COPD patients. These positive results are due to a relatively marked beneficial effect of corticosteroids in a minority of the subjects studied rather than a modest effect in the majority of subjects. A controlled randomized trial of intravenous corticosteroid administration in patients with COPD and acute respiratory failure admitted to the hospital showed improvement in pulmonary function from 12 hours following initial administration through the remainder of the 3 days of the study in the treatment group as compared to the control group. A greater percentage of patients showed a beneficial response to corticosteroids in this study of patients with acute exacerbations as compared to most of the studies of clinically stable COPD patients with beneficial effects. This suggests the possibility that some patients may show a beneficial response to corticosteroids during an acute exacerbation although they have not shown a response when clinically stable. The response to inhaled corticosteroids in patients with COPD has not been studied as extensively as the response to oral corticosteroids. However, some studies have shown a beneficial response to inhaled corticosteroids, primarily but not exclusively, in individuals who have also shown a positive response to oral agents. Generally, the response in terms of improved pulmonary function has been less striking with the inhaled agent as compared to the oral drug, although higher relative doses of the oral drugs usually were studied. Several limitations of the currently available studies are evident. Most of the studies deal with the effects in clinically stable outpatients with COPD and no studies have dealt with maintenance therapy in patients who have responded to a 1 to 2 week course of 30 mg of prednisone or greater. Data on the efficacy of inhaled corticosteroids in COPD patients are limited. No studies have investigated the role of corticosteroids in acute exacerbations in outpatients with COPD. Recommendations are given regarding use of corticosteroids in patients with COPD. A trial of corticosteroids is recommended at some point during a patient's course, while clinically stable. If a beneficial response is obtained in terms of improvement in airflow obstruction, then clinical judgment must be used regarding whether maintenance therapy is continued and, if so, at what dose and by what route.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- L D Hudson
- Department of Medicine, University of Washington, Seattle
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