Antibody titers among healthcare workers for coronavirus disease 2019 at 6 months after BNT162b2 vaccination

BACKGROUND

Antibody levels decrease substantially at 6 months after the BNT162b2 vaccine. The factors influencing titer of antibodies against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) among healthcare workers for coronavirus disease 2019 (COVID-19) is unclear.

METHODS

We conducted a 6-month longitudinal prospective study in Japanese healthcare workers in a tertiary care hospital for COVID-19. Participants in the study were tested for the presence of anti-spike protein (SP) IgG antibodies before and at 1 and 6 months after the last vaccination dose.

RESULTS

Among 1076 healthcare workers, 794 received the vaccine, and 469 entered the study. Five were infected with SARS-CoV-2 (none among COVID-19 section workers) by the end of the study and 451 participants were finally analyzed (mean age, 42.5 years; 27.3 % male; 18.8 % COVID-19 section workers). Median SP IgG index values were 0.0, 44.4, and 5.5 before and at 1 and 6 months after the last dose, respectively. Regression analysis revealed a negative correlation of SP IgG antibody levels with age (P < 0.0001), and higher levels in COVID-19 section workers (P = 0.0185) and in females (P = 0.0201).

CONCLUSION

In healthcare workers at a COVID-19 hospital, IgG antibody titer was substantially lower at 6 months after receipt of the last dose of the BNT162b2 vaccine compared with that 1 month after the last dose, but was better preserved among younger participants, COVID-19 section workers and females.

Clinical Features of Fibrosing Mediastinitis in Japanese Patients: Two Case Reports and a Literature Review

Fibrosing mediastinitis (FM) is a rare fibroinflammatory disease of the mediastinum with an etiology and clinical features that vary by world region. The characteristics of FM in Japan are still unknown. We herein report two Japanese patients with FM who were treated with corticosteroids and responded well. We also reviewed the Japanese literature on PubMed® and summarized the characteristics of 27 Japanese FM patients, including our two patients. In Japan, the predominant cases were those without a specific cause, were diffusely distributed, and responded well to corticosteroid therapy.

Efficacy and Safety of Favipiravir in Moderate COVID-19 Pneumonia Patients without Oxygen Therapy: A Randomized, Phase III Clinical Trial

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), is an enveloped, single-stranded RNA virus. Favipiravir is an orally administrable antiviral drug whose mechanism of action is to selectively inhibit RNA-dependent RNA polymerase. A preliminary trial in COVID-19 patients reported significant improvements across a multitude of clinical parameters, but these findings have not been confirmed in an adequate well-controlled trial. We conducted a randomized, single-blind, placebo-controlled Phase III trial assessing the efficacy and safety of favipiravir in patients with moderate pneumonia not requiring oxygen therapy.

Methods

COVID-19 patients with moderate pneumonia (SpO₂ ≥ 94%) within 10 days of onset of fever (temperature ≥ 37.5 °C) were assigned to receive either placebo or favipiravir (1800 mg twice a day on Day 1, followed by 800 mg twice a day for up to 13 days) in a ratio of 1:2. An adaptive design was used to re-estimate the sample size. The primary endpoint was a composite outcome defined as the time to improvement in temperature, oxygen saturation levels (SpO₂), and findings on chest imaging, and recovery to SARS-CoV-2-negative. This endpoint was re-examined by the Central Committee under blinded conditions.

Results

A total of 156 patients were randomized. The median time of the primary endpoint was 11.9 days in the favipiravir group and 14.7 days in the placebo group, with a significant difference (p = 0.0136). Favipiravir-treated patients with known risk factors such as obesity or coexisting conditions provided better effects. Furthermore, patients with early-onset in the favipiravir group showed higher odds ratio. No deaths were documented. Although adverse events in the favipiravir group were predominantly transient, the incidence was significantly higher.

Conclusions

The results suggested favipiravir may be one of options for moderate COVID-19 pneumonia treatment. However, the risk of adverse events, including hyperuricemia, should be carefully considered.

Trial registration

Clinicaltrials.jp number: JapicCTI-205238.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00517-4.

A retrospective analysis of pembrolizumab plus chemotherapy versus pembrolizumab monotherapy for advanced or recurrent non-small cell lung cancer

Background

Although clinical trials have investigated the addition of pembrolizumab to chemotherapy for non‐small cell lung cancer, none have investigated the addition of chemotherapy to pembrolizumab.

Methods

We conducted a retrospective study of 71 NSCLC patients including 33 treated with pembrolizumab plus chemotherapy (combination therapy group) and 38 treated with pembrolizumab monotherapy (monotherapy group) from 1 May 2016 to 31 August 2020.

Results

Eleven of 33 (33.3%) patients in the combination therapy group and 37 of 38 (97.4%) patients in the monotherapy group had programmed cell death ligand‐1 (PD‐L1) tumor proportion score (TPS) ≥50%. Objective response rate (ORR) and median overall survival (OS) were not significantly different between the combination therapy group and monotherapy group (54.5% vs. 47.4, p = 0.637 and 16.6 vs. 27.0 months, p = 0.463). In patients with PD‐L1 TPS ≥50%, ORR and median OS were not different between the combination therapy group and the monotherapy group (63.6% vs. 48.6%, p = 0.499 and not reached vs. 27.0 months, p = 0.976). Thirty‐three (100%) patients experienced adverse events (AEs) in the combination therapy group and 32 (84.2%) in the monotherapy group. Treatment discontinuation at 1 year due to AEs occurred more frequently in the combination therapy group (45.2%) than in the monotherapy group (21.1%).

Conclusion

There was no significant difference in ORR and OS between the two groups, and treatment discontinuation was more frequent in the combination group. A randomized controlled trial is needed to evaluate the addition of chemotherapy to pembrolizumab for first‐line treatment in patients with PD‐L1 TPS ≥50%.

Outcome and risk factor of immune-related adverse events and pneumonitis in patients with advanced or postoperative recurrent non-small cell lung cancer treated with immune checkpoint inhibitors

BACKGROUND

Non-small cell lung cancer (NSCLC) patients with pre-existing respiratory diseases have been excluded in clinical trials of immune checkpoint inhibitor (ICI) therapy, and it is unknown whether the same degree of response can be expected as that in patients without pre-existing respiratory diseases and if they are associated with increased risk for various immune-related adverse events (irAEs) and ICI pneumonitis. This study aimed to evaluate predictive factors of clinical response, prognostic factors, risk factors of irAEs, and ICI pneumonitis in NSCLC patients with or without pre-existing respiratory diseases.

METHODS

We conducted a retrospective study of 180 NSCLC patients who received ICI monotherapy of nivolumab, pembrolizumab, or atezolizumab from 1 January 2016 to 31 March 2019.

RESULTS

A total of 119 patients had pre-existing respiratory diseases, including 20 with pre-existing idiopathic interstitial pneumonias (IIPs). A total of 85 patients experienced irAEs, of which ICI pneumonitis was the most frequent adverse event, occurring in 27 patients. Of the three patients who died from irAEs, all from ICI pneumonitis, two had pulmonary emphysema and one had pre-existing IIP. In multivariate analyses, irAEs were associated with objective response rate (ORR) and favorable OS, and IIPs were associated with increased risk for ICI pneumonitis. However, IIPs were not associated with low ORR or poor OS.

CONCLUSIONS

Pre-existing IIPs were a risk factor for ICI pneumonitis. However, this study showed that ICI therapy can be offered to patients with pre-existing respiratory diseases with the expectation of the same degree of response as that in patients without pre-existing respiratory diseases.

KEY POINTS

Significant findings of the study: Pre-existing IIPs were a risk factor for ICI pneumonitis, but objective response rate and prognosis of patients with IIPs were similar to those of other patients.

WHAT THIS STUDY ADDS

In patients with pre-existing IIPs, ICI pneumonitis should be noted. However, ICI therapy can be offered to patients with pre-existing respiratory diseases with the expectation of the same degree of response as that in patients without pre-existing respiratory diseases.

Prognostic significance of 2019 Asian Working Group for Sarcopenia update on definition of sarcopenia

Background/Introduction

Sarcopenia plays a major role in the pathophysiology of frailty and is associated with worse outcome in the elderly population including patients with heart failure. A recent update of the most common definition of sarcopenia in Asia, Asian Working Group for Sarcopenia (AWGS2019), included significant changes in the diagnostic algorithm with newly dividing sarcopenia into severe and “non-severe” sarcopenia.

Purpose

The objective of this study was to evaluate the differences between AWGS2014 and AWGS2019 in patients with heart failure.

Methods

In the multicenter prospective FRAGILE-HF registry, which included elderly (≥65 years old) patients who were hospitalized with heart failure, we studied 865 patients (80±8 years old, 42% female). All-cause death in 1-year follow-up was tracked.

Results

Based on the original version of AWGS (AWGS2014), 183 patients (21%) were diagnosed with sarcopenia, which was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p&lt;0.001) as well as higher rate of all-cause death (HR 1.90, p=0.004 after adjustment by multivariable regression). Those patients with sarcopenia by AWGS2014 were reclassified mainly to severe sarcopenia (155, 84.7%) by AWGS2019, and 25 (13.7%) and 2 (1.1%) were classified into sarcopenia and non-sarcopenia. Meanwhile, 24 (3.5%) and 4 (0.6%) of patients without sarcopenia by AWGS2014 were reclassified into sarcopenia and severe sarcopenia, respectively. Although severe sarcopenia by AWGS2019 was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p&lt;0.001), patients with “non-severe” sarcopenia was rather younger (p&lt;0.001) and had better physical performance (p=0.021) despite less muscle mass (p&lt;0.001) than those without sarcopenia. Multivariate Cox analysis demonstrated severe sarcopenia by AWGS2019 was an independent prognostic factor (HR 1.77, p=0.014), but “non-severe” sarcopenia was not (HR 1.52, p=0.37). The prognosis of patients who were reclassified from non-sarcopenia to sarcopenia or severe sarcopenia were comparable to those remained non-sarcopenia. When added to other risk factors, the prognostic predictability of AWGS2019 was significantly lower than AWGS2014 (net reclassification improvement −0.26, p=0.025).

Conclusions

About a half of “non-severe” sarcopenia in AWGS2019 were patients without sarcopenia in AWGS2014. The prognosis of such patients who were newly diagnosed as sarcopenia was good, resulting in low overall prognostic predictability of AWGS2019. A further consideration for diagnostic algorithms of sarcopenia may be warranted in patients with heart failure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Japan Heart Foundation

Negative impact of skeletal muscle impairment in older patients with heart failure with reduced versus preserved ejection fraction

Background/Introduction

Reduced functional capacity is an important phenotype of heart failure (HF), even though it may be considered multifactorial, especially in HF with preserved ejection fraction (HFpEF). Impairment in skeletal muscle may be one of extra-cardiac factors for reduced functional capacity and subsequent poor outcome.

Purpose

We sought to investigate the impact of the impairment in skeletal muscle, defined by the cut-offs proposed by the international consensus, on functional capacity and clinical outcome, in HF patients with preserved and reduced EF (HFrEF).

Methods

This is a multicenter prospective study including 1317 consecutive older (≥65 years) hospitalized patients with HF [HFpEF (ejection fraction ≥45%, n=675, 82±7 years, 46.4% male) and HFrEF (ejection fraction &lt;45%, n=642, 78±8 years, 68.4% male)].

Results

HFrEF patients were more likely to have low skeletal muscle mass measured by bioelectrical impedance analysis (30.9% vs 22.1%, p=0.003) whereas less likely to have low muscle strength (handgrip strength; 62.9% vs 73.8%, p&lt;0.001) than HFpEF, resulting in similar prevalence of sarcopenia between the two groups (21.6% vs 18.1%, p=0.19). In HFrEF, presence of sarcopenia was an independent predictor of reduced functional capacity assessed by a 6-minute walk distance (standardized beta=−0.093, p=0.039 in multivariate linear regression analysis) and 1-year mortality (adjusted hazard ratio (aHR) and 95% CI; 2.14 (1.22–3.70), p=0.009 in multivariate Cox-regression analysis). In patients with HFpEF, sarcopenia could predict mortality (aHR and 95% CI; 2.23 (1.23–3.91), p=0.009), though its association with reduced functional capacity was not significant after multivariate adjustment (standardized beta=−0.059, p=0.20). Kaplan-Meier survival curves in HFpEF and HFrEF are shown (Figure).

Conclusion(s)

In older patients with HF, sarcopenia was similarly contributed to mortality in HFpEF and HFrEF whereas its influence on functional capacity was pronounced in HFrEF.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Japan Heart Foundation Research Grant

Social frailty provides additive prognostic impact on one-year outcome in aged patients with congestive heart failure

Background

Frailty is associated with multisystem declines in physiologic reserve and increased vulnerability to stressors, resulting in increased risks of adverse clinical outcomes in patients with heart failure (HF). Although frailty is conceptualized as an accumulation of deficits in multiple areas, most of the studies have focused mainly on physical frailty, and the social domains is one of the least investigated area.

Objectives

We prospectively evaluated the incidence and prognostic implication of social frailty (SF) in older patients with HF.

Methods

The FRAGILE-HF is a multicenter, prospective cohort study including patients hospitalized for HF and aged ≥65 years old. We defined SF by Makizako's 5 items, which are 5 questions proposed and validated to be associated with future disability. The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF. The impact of SF on all-cause mortality alone was also evaluated.

Results

Among 1,240 hospitalized HF patients, 5 simple questions revealed that 825 (66.5%) were in SF. During 1-year observation period after the discharge, the combined endpoint was observed in 399 (32.2%) patients, and 145 (11.7%) patients died. Kaplan-Meier analysis showed that SF patients had significantly higher rates of both the combined endpoint and all-cause mortality than those without SF (Log-rank test: p&lt;0.05 for both, Figures). Moreover, SF remained independently associated with higher event rate of the combined endpoint (hazard ratio: 1.30; 95% confidence interval: 1.02 to 1.66; p=0.038) and all-cause mortality (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.30; p=0.044), even after adjusting for other covariates. Significant incremental prognostic value was shown when information on social frailty was added to known risk factors for combined endpoint (NRI: 0.189, 95% confidence interval: 0.063–0.316, p=0.003) and all-cause mortality (NRI: 0.234, 95% confidence interval: 0.073–0.395, p=0.004).

Conclusions

Among older hospitalized patients with heart failure, two-thirds of the population was with SF. Evaluating SF provides additive prognostic information in elderly patients with heart failure.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Pharma Research Grants, Japan Heart Foundation Research Grant

Impact of radial compression protocols on the compression time and radial artery occlusion

Background

Trans-radial access (TRA) has been established as a safe and established approach for invasive coronary catheter procedures. However, protocols for post-procedural hemostasis varies depending on institutes and an evidence-based protocol is lacking.

Purpose

The objective of this study was to investigate the clinical implications of procedural hemostasis.

Methods

Consecutive patients who were referred to outpatient catheter examination before and after April 2018 were treated with an old and a new protocol, respectively. In both protocols, we used the same commercially available hemostasis band with injecting an air of 16 ml for hemostasis. In the old protocol, the amount and timing of deflation were fixed, whereas the air was removed as much as possible for every 30 minutes in the new protocol. Time to complete hemostasis, the rate of major bleeding, and the rate of radial artery occlusion (RAO) at 6 months after the catheter examination were compared between the protocols.

Results

Total of 1,843 (71±10 years old, 77% male) patients was included in the study. Between patients in the old and the new protocol group (n=1,000 and 843, respectively), there was no significant difference in age, gender, body size, or systolic blood pressure. The new group had significantly higher prevalence of diabetes (47% vs 39%, p=0.002), slightly larger sheath size (4.1±0.3 vs 4.0±0.2 Fr, p&lt;0.001), and lower rate of dual antiplatelet therapy (DAPT: 24% vs. 35%, p&lt;0.001). Time for complete hemostasis was about one-third with the new protocol compared with the old protocol (65±32 vs. 190±16 min, p&lt;0.001) and there was no major bleeding in either group. The rate of radial artery occlusion was 0.7% and 9.8% in the old and the new group (p&lt;0.001). Multivariate analysis showed that the significant predictor of prolonged hemostasis time were the old protocol (odds ratio: OR 80.5, p&lt;0.001) and the prescription of DAPT (OR 2.9, p&lt;0.001), while the factors associated with higher risk of radial occlusion were the old protocol (OR 13.9, p&lt;0.001), the number of previous TRA (OR 1.1, p&lt;0.001), and smaller body size (OR 0.127 per 1 m2 increase p=0.005).

Conclusions

Our new protocol for hemostasis after TRA was strongly associated with shorter hemostasis time and a lower rate of radial artery occlusion. This approach will decrease the post-procedural hospital time with even fewer complication rates.

Study outline

Funding Acknowledgement

Type of funding source: None

Clinical course and findings of 14 patients with COVID-19 compared with 5 patients with conventional human coronavirus pneumonia

OBJECTIVE

To clarify what future problems must be resolved and how clinical findings of SARS-CoV-2 infection differ from those of cHCoV infection.

METHODS

Patients and Methods Clinical characteristics of 14 patients with laboratory-confirmed Coronavirus disease 2019 (COVID-19) and 5 patients with cHCoV pneumonia admitted to our institution and treated up to March 8, 2020, were retrospectively analyzed.

RESULTS

On admission, 10 patients had pneumonia, 5 of whom had pulmonary shadows detectable only via computed tomography (CT). During hospitalization, another patient with no pulmonary shadows on admission developed pneumonia. In total, 11 (78.6%) of the 14 patients developed pneumonia, indicating its high prevalence in COVID-19. During hospitalization, the patients' symptoms spontaneously relapsed and resolved, and gastrointestinal symptoms were frequently found. C-reactive protein values showed correlation with the patients' clinical courses. Ritonavir/lopinavir were administered to 5 patients whose respiratory conditions worsened during admission, all of whom improved. However, the pneumonia in the 6 other patients improved without antivirals. None of the 14 patients died, whereas 5 other patients with cHCoV pneumonia were in respiratory failure on admission, and one patient (20%) died.

CONCLUSION

Both SARS-CoV-2 and cHCoV can cause severe pneumonia. Problems for future resolution include whether antiviral agents administered in cases of mild or moderate severity can reduce the number of severe cases, and whether antivirals administered in severe cases can reduce mortality.

Incidence and etiology of chronic pulmonary infections in patients with idiopathic pulmonary fibrosis

BACKGROUND

The incidence and etiologies of chronic pulmonary infection (CPI) in patients with idiopathic pulmonary fibrosis (IPF) have been poorly investigated.

METHODS

We conducted a retrospective study of 659 patients with IPF to assess the incidence, etiologies, and risk factors of CPI development. CPI was defined if the etiology of infection was diagnosed one or more months after the onset of symptoms or upon the appearance of new shadows on pulmonary radiological images.

RESULTS

At IPF diagnosis, 36 (5.5%) patients had CPI, and 46 (7.0%) patients without CPI at IPF diagnosis developed CPI over a median follow-up period of 6.1 years. The incidence density of CPI development was 18.90 cases per 1000 person-years. Detected organisms from these 46 patients were Mycobacterium avium complex in 20 patients, other nontuberculous mycobacteria in 4, M. tuberculosis in 7, Aspergillus spp. in 22, and Nocardia sp. in one. In a multivariate Cox regression hazard model, PaO2 <70 Torr and KL-6 ≥2000 U/mL were associated with CPI development.

CONCLUSIONS

Nontuberculous mycobacteria, M. tuberculosis, and Aspergillus and Nocardia spp. were the four most frequent etiologies of CPI in patients with IPF. During follow-up of IPF, clinicians should pay attention to the development of CPI, especially in patients with PaO2 <70 Torr or KL-6 ≥2000 U/mL.

Allergic Bronchopulmonary Mycosis Caused by Schizophyllum commune: A Special Interest in Positive Culture of Other Basidiomycetes Fungi

A 42-year-old man with asthma presented in 2007 with chest infiltration and productive cough. Pycnoporus sanguineus and Perenniporia tephropora were repeatedly isolated from sputum and bronchial washing fluids. Because we lacked immunologic evidence, we could not diagnose him with allergic bronchopulmonary mycosis (ABPM) due to these basidiomycetous fungi. At that time, serum-specific IgE and IgG against Schizophyllum commune findings were negative. Inhaled beclomethasone/salmeterol improved his condition. Seven years later, mucous plugs obtained via bronchoscopy at a relapse were compatible with allergic mucin. Because S. commune was isolated from mucous plugs and serum-specific IgG against S. commune turned positive, we diagnosed the patient with ABPM due to S. commune.

P2437Screening for cardiac relaxation abnormalities using surface ECG wavelets for identifying high-risk cardiac phenotypic abnormalities

Background

The impairment of myocardial relaxation is a strong predictor of all-cause mortality and has been proposed to be a potential tool for cardiovascular (CV) risk stratification. We investigated a novel signal-processed electrocardiography (spECG) technique to extract the features of abnormal myocardial relaxation as a screening tool to identify high-risk CV patients.

Methods

Time–frequency-energy features extracted from continuous wavelet-transformed spECG (Fig. A) were obtained in 1,006 cases. A machine learning model was trained for predicting abnormal myocardial relaxation as a screening tool for detecting high-risk CV patients. High-risk CV phenotype was defined as presence of LV hypertrophy, advanced LV diastolic dysfunction (grade 2 or 3), LV ejection fraction <50%, and/or significant valvular heart disease.

Results

After training with 5-fold cross validation using data from 810 patients, the machine learning model when tested in an independent hold-out validation set of 180 cases, showed an area under receiver-operating characteristic curve (AUC) of 0.83 (p<0.001) for prediction of myocardial relaxation impairment (Fig. B). A prediction of abnormal relaxation was associated with older patients (64±11 vs. 45±16 years old, p<0.001) with a higher prevalence of coronary artery disease (23% vs. 7%, p=0.004), hypertension (70% vs. 40%, p<0.001), and diabetes (30% vs. 9%, p=0.001). Furthermore, a prediction of abnormal myocardial relaxation was associated with increased likelihood of high-risk CV phenotypes (Odds ratio: 3.93, p<0.001) including LV hypertrophy (Odds ratio: 2.62, p=0.028), advanced LV diastolic dysfunction (Odds ratio: 11.4, p=0.020), and LV ejection fraction <50% (Odds ratio 10.5, p=0.025). Age and gender modified the prediction of abnormal relaxation with higher diagnostic value seen for patients under 60 years (Fig C, AUC: 0.88, p<0.001) and in male patients (Fig D, AUC: 0.87, p<0.001). The algorithm for abnormal relaxation also showed robust prediction of LV ejection fraction <50% (Fig E, AUC: 0.91, p<0.001) in male patients. spECG showed significant net reclassification improvement (0.47, p<0.001) and integrated discrimination improvement (0.16, p<0.001) over traditional surface ECG interpretation using Glasgow score for predicting abnormal relaxation and other high-risk phenotypic presentations.

ROC curves

Conclusion

The spECG provided a robust prediction of abnormal myocardial relaxation and may be a valuable screening strategy for early detection of high-risk cardiac structural and functional abnormalities.

Diffuse alveolar hemorrhage caused by IgA deposition associated with multiple myeloma

We report a man with diffuse alveolar hemorrhage caused by multiple myeloma who was diagnosed with the aid of bronchoalveolar lavage and transbronchial lung biopsy. Multiple myeloma should be considered as an important differential diagnosis in patients with diffuse alveolar hemorrhage, and bronchoscopy may help to differentiate the cause.

Restrictive ventilatory impairment improved by laminoplasty for ossification of the posterior longitudinal ligament

We report a woman with severe restrictive ventilatory impairment because of respiratory muscle paralysis caused by ossification of the posterior longitudinal ligament (OPLL). Laminoplasty improved her respiratory function and quality of life. Cervical myelopathy including OPLL should be considered as an important differential diagnosis in patients with respiratory dysfunction.

Viral Pneumonia Requiring Differentiation from Acute and Progressive Diffuse Interstitial Lung Diseases

Objective The clinical characteristics and chest imaging findings of viral pneumonia and several interstitial lung diseases (ILDs) overlap, and viral pneumonia may be underrecognized and misdiagnosed as certain ILDs. To clarify the frequency of viral pneumonia among patients with acute progressive clinical courses that required a differential diagnosis between ILDs and pneumonia, and to determine the most frequent ILDs misdiagnosed in cases of viral pneumonia. Patients and Methods We retrospectively analyzed patients hospitalized from 2010 to 2017 with an acute clinical course (≤30 days) who underwent bronchoalveolar lavage (BAL) for the differential diagnosis of infection and ILDs. We performed a multiplex PCR for respiratory viruses using the patients' preserved BAL fluid. The final diagnosis was made by a multidisciplinary approach and after considering the PCR results. The diagnosis at discharge was compared to the final diagnosis. Results Among the 109 patients, 53 were diagnosed with viral pneumonia. Viral pneumonia and other diseases showed some differences in symptoms and laboratory data; however, the differences were small or overlapped. Viral pneumonia was misdiagnosed on discharge as acute fibrinous organizing pneumonia, cryptogenic organizing pneumonia, or chronic eosinophilic pneumonia (AFOP/COP/CEP) (n=22), acute interstitial pneumonia (n=5), connective tissue disease-related ILDs (n=3), unclassifiable interstitial pneumonia (n=2), drug-induced ILD (n=1), and pneumonia (n=20). Conclusion Approximately half of the patients who underwent BAL had viral pneumonia. The most common ILD-related misdiagnoses were AFOP/COP/CEP. Differences in symptoms and laboratory findings between viral pneumonia and other diseases were small, and viral pneumonia should be included in the differential diagnosis when physicians encounter cases in which the abovementioned ILDs are suspected.

Allergic bronchopulmonary aspergillosis successfully treated with mepolizumab: Case report and review of the literature

A 56-year-old woman was referred to our hospital for recurrent asthma of 20 years duration. She was diagnosed as having allergic bronchopulmonary aspergillosis on the basis of clinical symptoms, peripheral blood eosinophilia, elevated total serum immunoglobulin E value, positive results of specific IgE and precipitating antibodies against Aspergillus sp., central bronchiectasis, and mucoid impaction. Systemic corticosteroids and anti-fungal therapy improved her symptoms, but the cessation of these treatments led to frequent exacerbations. Omalizumab improved her asthmatic symptoms to the point that corticosteroids could be stopped; however, radiological findings were not improved, and coexisting eosinophilic sinusitis and otitis media worsened. After her treatment was changed from omalizumab to mepolizumab, not only her asthmatic symptoms but also her sinusitis and otitis media became well controlled, and chest radiological findings improved.

Allergic Bronchopulmonary Mycosis Due to Schizophyllum commune Treated Effectively with Voriconazole

A 63-year-old woman presented to our hospital for cough, sputum, and abnormal shadows on chest X-ray. Schizophyllum commune was isolated from mucous plugs. Positive specific IgE and IgG against the fungi, elevated serum IgE, and mucous plugs with typical histologic findings of allergic bronchopulmonary mycosis (ABPM) led to the diagnosis of ABPM due to S. commune. We initially administered itraconazole unsuccessfully. Changing the antifungal agent to voriconazole resulted in improvement of the symptoms and chest imaging findings. Her ABPM has not relapsed for two years since the cessation of voriconazole, which was administered for one year.

Clinical characteristics and prognostic factors of pneumonia in patients with and without rheumatoid arthritis

Background

To elucidate the characteristics of pneumonia in rheumatoid arthritis (RA) patients and to assess whether pneumonia in RA patients differs from that in non-RA patients.

Methods

We retrospectively divided pneumonia patients into two groups, those with RA and those without RA, and compared the two groups. We evaluated the risk factors for mortality with univariate and multivariate logistic regression analysis.

Results

Among 1549 patients, 71 had RA. The RA patients with pneumonia were 71.0±8.9 years old, 54.9% were female, 40.9% had a smoking history, and 71.8% had underlying respiratory disease. Female sex, non-smoker, and respiratory comorbidities were statistically more frequent in the RA patients than non-RA patients. The most frequent causative microbial agents of pneumonia in the RA patients were Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Mycoplasma pneumoniae, and influenza virus, whereas those of pneumonia in non-RA patients were S. pneumoniae, influenza virus, M. pneumoniae, Legionella spp., P. aeruginosa, H. influenzae, and Moraxella catarrhalis. Polymicrobial infection were identified as etiologies more frequently in the RA patients than non-RA patients. Although the severity of pneumonia did not differ between the two groups, mortality was statistically higher in the RA patients than non-RA patients. Multivariate analysis showed RA to be an independent risk factor for mortality.

Conclusions

P. aeruginosa, H. influenzae, M. catarrhalis, and polymicrobial infection were statistically more frequent etiologies of pneumonia in the RA patients than non-RA patients. RA itself was found to be an independent risk factor for mortality from pneumonia.

Incidence and predictive factors of lung cancer in patients with idiopathic pulmonary fibrosis

The incidence and risk factors of lung cancer in patients with idiopathic pulmonary fibrosis (IPF) have been poorly investigated.

We conducted a retrospective study of 632 patients with IPF to assess the incidence and risk factors of lung cancer development.

Seventy patients developed lung cancer over a median follow-up period of 3.8 years. The incidence density of lung cancer development was 25.2 cases per 1000 person-years. The most frequent type was squamous cell carcinoma (30%), the majority developed lung cancer in the peripheral lung (82.9%) and adjacent to usual interstitial pneumonia (75.7%). In a multivariate Cox regression hazard model, pack-years of smoking ≥35 and coexisting emphysema were associated with lung cancer development. The 1-, 3- and 5-year all-cause mortality rates after lung cancer diagnosis were 53.5%, 78.6% and 92.9%, respectively.

The incidence density of lung cancer is high in IPF patients and occurs more frequently in patients with smoking history of pack-years of smoking ≥35 and with coexisting emphysema. The majority of lung cancers develop adjacent to usual interstitial pneumonia. Knowledge of these factors may help direct efforts for early detection of lung cancer and disease management.

In patients with IPF, lung cancer will develop in 25.2 cases per 1000 person-years. Clinicians should pay attention to the development of lung cancer, especially in patients with ≥35 pack-years of smoking and coexisting emphysema.http://ow.ly/KLjx30hObFu

Clinical Characteristics of Influenza-Associated Pneumonia of Adults: Clinical Features and Factors Contributing to Severity and Mortality

Background: Pneumonia is a major complication of influenza that contributes to mortality. Clinical characteristics and factors of influenza virus contributing to the severity and mortality of pneumonia have not been fully elucidated. Objective: The objective was to clarify clinical characteristics and factors contributing to the severity and mortality of influenza-associated pneumonia (flu-p). Methods: We retrospectively analyzed patients with flu-p. Results: From December 1999 to March 2016, 210 patients with a median age of 69 (range, 17 to 92) years with flu-p based on positive rapid antigen tests, increased antibody titers of paired sera, or positive results of reverse transcription polymerase chain reaction were admitted to our institution. A multivariate analysis found that advanced age (≥ 65 years), pneumonia subtypes (unclassified), diabetes mellitus, and acute kidney injury complicated with flu-p were independent factors associated with disease severity, whereas pneumonia subtypes (mixed viral and bacterial pneumonia and unclassified), healthcare-associated pneumonia, acute kidney injury complicated with flu-p, and severity on admission (severe) were independent factors associated with non-survival. Conclusion: The clinical characteristics of flu-p are varied, and the contribution of several factors to the severity and mortality of flu-p suggest their importance in either preventing flu-p or managing flu-p after it develops.

How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease?

In the treatment of asthma and chronic obstructive pulmonary disease (COPD), errors in handling and wrong techniques in using inhalation devices are associated with poor disease control. The aim of this study was to evaluate the number of instructions that are necessary to minimize errors in using pressurized metered-dose inhaler (pMDI), soft mist inhaler (SMI), and dry powder inhaler (DPI). Among 216 patients with asthma (n = 135) and COPD (n = 81), we studied 245 cases that used different types of inhalation devices. After initial guidance, 145 of 245 cases (59%) made at least one error that could affect efficacy. For every device, at least three instructions were required to achieve entirely no errors or less than 10% errors in total. The most common error on the use of pMDI was device handling, whereas that of DPI was inhalation manner. Both errors were associated with low peak flow rate. In both patients with asthma and in patients with COPD, the most common error was inhalation manner. We concluded that it is necessary to repeat at least three times of instructions to achieve effective inhalation skills in both asthma and COPD patients.

Development of myasthenia gravis 8 years after interstitial lung disease associated with antisynthetase (anti-EJ antibody) syndrome

Patients with antisynthetase-positive interstitial lung disease (ILD) alone sometimes develop myositis during follow-up, but myasthenia gravis (MG) overlapping on antisynthetase syndrome is unusual. A 56-year-old woman with ILD and anti-EJ antibody treated for 8 years developed MG. Physicians should consider myositis and MG when patients develop muscle symptoms during follow-up.

Diagnostic criteria that can most accurately differentiate allergic bronchopulmonary mycosis from other eosinophilic lung diseases: A retrospective, single-center study

BACKGROUND

Several diagnostic criteria have been proposed to differentiate allergic bronchopulmonary mycosis (ABPM) from asthma, but there have been no studies to establish diagnostic criteria to classify ABPM differently from other eosinophilic lung diseases.

METHODS

We retrospectively investigated both patients with ABPM (n=42) diagnosed by clinical (Rosenberg-Patterson criteria modified to apply to fungi other than Aspergillus spp., with consideration of computed tomography and bronchoscopy findings) or pathological criteria and those with other eosinophilic lung diseases (n=118) to establish elaborate diagnostic criteria for ABPM.

RESULTS

Etiologies of ABPM included fungi other than Aspergillus spp. or unidentified pathogens in 16 patients. Fourteen patients (33.3%) did not have asthma. When the diagnostic cutoff line was set to satisfy six or more primary plus secondary modified Rosenberg-Patterson criteria, ABPM could be diagnosed with good sensitivity, specificity, and positive/negative predictive values (97.6%, 98.3%, 95.3%, and 99.1%, respectively). When the diagnostic criteria were combined with pathological criteria, the values further improved to 100%, 98.3%, 95.5%, and 100%, respectively.

CONCLUSIONS

Our results suggest that these novel criteria offer good sensitivity, specificity, and positive/negative predictive values for the diagnosis and classification of ABPM.

Pulmonary Nontuberculous Mycobacteriosis and Chronic Lower Respiratory Tract Infections in Patients with Allergic Bronchopulmonary Mycosis without Cystic Fibrosis

Objective The frequency of pulmonary nontuberculous mycobacteriosis (pNTM), chronic lower respiratory tract infections (cLRTIs), and pneumonia in patients with allergic bronchopulmonary mycosis (ABPM) without cystic fibrosis has not yet been fully investigated. Methods We retrospectively analyzed 42 patients with ABPM focusing on the frequency of pNTM and cLRTIs, acute exacerbation of cLRTIs, and pneumonia. Results During a median follow-up period of 2,299 days (range, 118-6,138 days), 7 patients developed pNTM (mainly Mycobacterium avium complex), and 21 patients developed cLRTI (mostly from Staphylococcus aureus followed by Pseudomonas aeruginosa). Twelve patients developed 21 episodes of acute exacerbation of cLRTIs, and 4 patients developed pneumonia. Conclusion Patients with ABPM can have concomitant NTM infection and, not uncommonly, cLRTI, and they can also sometimes develop pneumonia or an acute exacerbation of cLRTI.

Combined Allergic Bronchopulmonary Aspergillosis and Eosinophilic Granulomatosis with Polyangiitis: Three Cases and a Review of the Literature

Previous reports of combined allergic bronchopulmonary mycosis (ABPM) and eosinophilic granulomatosis with polyangiitis (EGPA) are limited; however, among 41 cases of ABPM and 18 cases of EGPA treated at our hospital, we experienced three cases of combined ABPM and EGPA. In two of these cases, the diagnosis of EGPA preceded that of ABPM, however, one of the two cases had already shown findings suggestive of ABPM, such as mucous plugs and central bronchiectasis, at the time of the diagnosis of EGPA. In six previously reported cases of combined ABPM and EGPA, ABPM preceded EGPA in four cases. In the other two cases in which EGPA was diagnosed before or simultaneously with ABPM, findings suggestive of ABPM had been detected when EGPA was diagnosed, which suggests that sensitization to fungi resulting in ABPM may play an important role in the development of EGPA. Careful attention should therefore be paid to the possibility that these diseases may coexist during the course of either disease.

The Long-term Clinical Course of Chronic Eosinophilic Pneumonia

Objective The long-term clinical course and prognosis of patients with chronic eosinophilic pneumonia (CEP) including factors predictive of the relapse of CEP have not been fully investigated. The aim of the present study was to investigate these issues. Methods We retrospectively investigated the rate of relapse and prognosis in 73 patients diagnosed as having CEP. Results Systemic corticosteroid therapy was administered at a prednisolone dose of 29.4±7.6 mg/day. During a median follow-up period of 1,939 days, 27 patients suffered from relapse of CEP. Two patients developed steroid-induced diabetes mellitus, and 1 patient developed pulmonary nontuberculous mycobacteriosis. Five patients died; however, none died of CEP. A history of smoking was the only independent negative risk factor for relapse of CEP [hazard ratio, 0.37 (0.14-0.98)]. Conclusion Patients with CEP frequently relapse. During the follow-up, metabolic and infectious complications under prolonged corticosteroid therapy are problematic. A history of smoking was a negative factor for predicting the risk of CEP relapse.

Case Series of Pulmonary Tumor Embolism and Intravascular Lymphoma: Evaluation of the Usefulness of Pulmonary Microvascular Cytology

Pulmonary tumor embolism (PTE) and intravascular lymphoma cause rapidly progressive deterioration and an antemortem diagnosis is difficult. The usefulness of pulmonary microvascular cytology (PMC) in the diagnosis of these disorders has been reported in sporadic case reports. We retrospectively evaluated the records of 7 patients with tumor cells in the pulmonary microvasculature (4 with PTE and 3 with malignant lymphoma) who underwent pulmonary microvascular cytology. Two of the 4 patients with PTE and 2 of the 3 patients with malignant lymphoma (all 3 had intravascular metastasis) had positive PMC results. These findings suggested that PMC may be useful in the diagnosis of these disorders.

Clinical and Radiographic Comparison of Influenza Virus-associated Pneumonia among Three Viral Subtypes

OBJECTIVE

Presently, the predominant subtypes of influenza viruses in the world, except for those in local epidemics, include influenza pandemic H1N1 2009 (pH1N1), H3N2, and B viruses. There are few reports on the differences in the clinical features, radiographic findings, treatment, and outcomes of influenza virus-associated pneumonia among these three viral subtypes. The purpose of this study was to investigate whether the clinical features, radiographic findings, treatment, and outcomes differ among the viral subtypes.

METHODS

We retrospectively analyzed 96 patients with influenza virus-associated pneumonia whose viral subtypes were clarified.

RESULTS

Patients with pH1N1 virus-associated pneumonia tended to be young. The frequency of primary viral pneumonia differed among the virus-associated pneumonia subtypes (pH1N1, 80%; H3N2, 26.5%; and B, 31%). Patients with pH1N1 virus-associated pneumonia more frequently showed bilateral ground-glass opacities (GGOs), which affected more lobes than in patients with H3N2 and B virus-associated pneumonia. However, patients with H3N2 virus-associated pneumonia showed a higher frequency of consolidation and diffuse bronchial wall thickening than did the patients with pH1N1 virus-associated pneumonia. The severity and mortality did not differ among the three pneumonia subtypes.

CONCLUSION

In the patients who developed influenza virus-associated pneumonia, those with pH1N1 virus-associated pneumonia frequently developed primary viral pneumonia resulting in bilateral and broad areas of GGOs on imaging, whereas patients with H3N2 virus-associated pneumonia frequently showed consolidation and diffuse bronchial wall thickening on pulmonary imaging.

Antineutrophil cytoplasmic antibody-positive conversion and microscopic polyangiitis development in patients with idiopathic pulmonary fibrosis

Background

Increasing evidence indicates that antineutrophil cytoplasmic antibody (ANCA)-positive conversion occurs in patients initially diagnosed with idiopathic pulmonary fibrosis (IPF) and as a result, some of these patients develop microscopic polyangiitis (MPA). However, the incidence density of these patients is not well known.

Objectives

To explore the incidence of ANCA-positive conversion and development of MPA during the disease course in patients with IPF and to evaluate whether corticosteroid therapy reduces MPA development in patients with IPF with myeloperoxidase (MPO)-ANCA positivity at diagnosis or who later acquire MPO-ANCA positivity.

Methods

We retrospectively analysed the medical records of 504 Asian patients with IPF treated at our institution in Saitama, Japan.

Results

Of the 504 patients with IPF, 20 (4.0%) had MPO-ANCA and 16 (3.2%) had PR-3-ANCA when first evaluated. In 264 of 504 patients with IPF, ANCA was measured repeatedly and seroconversion to MPO-ANCA and PR3-ANCA occurred in 15 (5.7%) and 14 (5.3%) patients, respectively, and 9 of 35 patients who were either MPO-ANCA positive at IPF diagnosis or who subsequently seroconverted developed MPA. None of the nine patients who developed MPA had been previously treated with steroids. The incidence of MPA tended to be lower in patients treated than not treated with corticosteroids although this was not statistically significant.

Conclusions

Some patients with IPF with MPO-ANCA positivity at IPF diagnosis or with MPO-ANCA-positive conversion during follow-up developed MPA. Clinical trials to determine whether corticosteroid therapy can reduce MPA development and prolong survival in MPO-ANCA-positive patients with IPF should be considered.

Characteristics of tuberculosis in patients with rheumatoid arthritis: a retrospective single-center study

OBJECTIVE

The objective of this study was to assess the characteristics of hospitalized patients suffering from tuberculosis with rheumatoid arthritis (RA), focusing specifically on those treated without anti-tumor necrosis factor (TNF) therapy.

METHODS

We conducted a retrospective review to assess the characteristics of 1,022 hospitalized Japanese patients suffering from tuberculosis with and without RA between 2002 and 2011.

RESULTS

Compared with the 995 non-RA patients with tuberculosis, the 24 RA patients with tuberculosis treated without anti-TNF therapy were older and predominantly female. They less frequently had a history of smoking, with a higher rate of underlying respiratory diseases, an impaired performance status and side effects. The three RA patients receiving anti-TNF therapy had extrapulmonary tuberculosis; however, the rate of extrapulmonary tuberculosis in the other RA patients treated without anti-TNF therapy did not differ from that observed in the non-RA patients. Five patients died during hospitalization. The in-hospital mortality of the RA patients did not differ significantly from that of the non-RA patients. Independent factors contributing to in-hospital mortality did not include RA.

CONCLUSION

In this study, the RA patients treated without anti-TNF therapy did not differ from the non-RA patients in terms of the rate of extrapulmonary tuberculosis or bilateral pulmonary lesions, although they did exhibit a higher frequency of side effects of antituberculosis treatment. RA was not found to be an independent factor contributing to in-hospital mortality.

Development of multi-organ involvement including a left atrial myxoma-like lesion in a patient with granulomatosis with polyangiitis

A 76-year-old woman suffering from granulomatosis with polyangitis (GPA) developed organizing pneumonia with positive antineutrophil cytoplasmic antibodies and microscopic hematuria. Prednisolone improved the hematuria and radiological findings; however, after tapering the dose of prednisolone, a posterior left atrial wall mass was detected in association with a fever. Both regressed spontaneously, although secretory otitis media and sinusitis were noted; the resected sinusitis specimen exhibited vasculitis highly suggestive of GPA. The clinical picture of GPA with multi-organ involvement can vary. Recognizing the various manifestations of GPA is therefore necessary in order to provide an appropriate diagnosis and disease management.

IgG4-related pleuritis with chylothorax

Presently, 6 cases of IgG4-related pleuritis have been reported. We encountered a patient who developed chylothorax due to IgG4-related disease. To our knowledge, such patients have not been reported. This patient developed right-sided chylothorax and left-sided non-chylothorax lymphocyte-predominant pleuritis. Elevated serum and pleural IgG4 concentrations and histopathological analysis of pleural biopsy confirmed the diagnosis of IgG4-related pleuritis. Left-sided pleuritis improved with corticosteroid therapy, but right-sided chylothorax persists. IgG4-related disease can be one cause of chylothorax.

Clinical characteristics of biopsy-proven allergic bronchopulmonary mycosis: variety in causative fungi and laboratory findings

OBJECTIVE

The diagnosis of allergic bronchopulmonary mycosis (ABPM) has traditionally relied widely on Rosenberg's criteria, which emphasize immunologic responses while overlooking the investigation of mucous plugs as a primary criterion. Therefore, the characteristics of biopsy-proven ABPM require further elucidation. The aim of this study was to analyze the clinical characteristics of biopsy-proven ABPM and address whether full compliance with clinical criteria, such as the presence of asthma, and certain laboratory findings is necessary to establish a diagnosis of ABPM.

METHODS

We retrospectively analyzed 17 patients with biopsy-proven ABPM focusing on causative fungi and laboratory findings.

RESULTS

Causative fungi included Aspergillus sp. in seven patients, Schizophyllum commune in four patients, Penicillium sp. in two patients and unknown in five patients. Bronchial asthma was observed in 10 patients, eosinophilia was observed in 10 patients and an increased serum immunoglobulin (Ig) E level was observed in 14 of the 17 patients. IgG for Aspergillus sp. was positive in six of the seven patients with ABPM due to Aspergillus and turned positive in the remaining patient during follow-up. Technological limitations prevented the measurement of specific IgE for S. commune and IgG for S. commune and Penicillium sp. in most patients. Computed tomography revealed central bronchiectasis, pulmonary infiltration and mucous plugs in all patients.

CONCLUSION

Causative fungi other than Aspergillus sp. are not uncommon, and immunological tests for other fungi should be popularized. Asthma and characteristic laboratory findings, such as peripheral blood eosinophilia, increased serum IgE and precipitating antibodies, may not always be required to diagnose ABPM. The importance of typical pathologic findings of mucous plugs for diagnosing ABPM requires reevaluation. Further studies are needed to establish more elaborate diagnostic criteria for ABPM.

A patient who survived primary seasonal influenza viral pneumonia: histologic findings obtained via bronchoscopy

The histological findings and clinical course of primary seasonal influenza viral pneumonia have not been fully elucidated. We herein report the case of a 65-year-old man with primary seasonal influenza viral pneumonia. The patient presented with fever, myalgia, general fatigue and dyspnea of seven days duration. Chest computed tomography showed bilateral ground-glass opacity and consolidation. A rapid influenza virus antigen test was positive for influenza A virus. We diagnosed him as having community-acquired influenza pneumonia and started therapy with antibiotics plus oseltamivir; however, his symptoms, respiratory condition and radiological findings deteriorated. Polymerase chain reaction following bronchoscopy showed the bronchoalveolar lavage fluid to be positive for the influenza A virus. A right lower lobe transbronchial lung biopsy revealed type II pneumocyte metaplasia, acute and chronic interstitial infiltrates and alveolar organization without hyaline membranes or fibrin thrombi in the vascular lumen. Treatment with prednisolone at a dose of 60 mg/day (1 mg/kg) resulted in an improvement. The patient was discharged on hospital day 15. Two weeks after admission, the serum antibody titer for influenza A (H3N2) had increased significantly. No other pathogens were found either serologically or in the respiratory samples, and we diagnosed the patient to therefore have primary influenza viral pneumonia.

Allergic bronchopulmonary aspergillosis with repeated isolation of nontuberculous mycobacteria

A 68-year-old woman without asthma presented with a cough and abnormal shadows on a chest X-ray. Computed tomography showed right middle lobe atelectasis and centrilobular nodules with a tree-in-bud appearance in the other lobes. The patient's sputum repeatedly yielded positive cultures of nontuberculous mycobacteria (NTM); however, no fungi were detected. A transbronchial biopsy showed allergic mucin with eosinophils, although the findings were not diagnostic. We suspected that the patient had pulmonary mycobacteriosis; however, treatment for this condition failed. We then performed thoracoscopy for further evaluation and treatment of the NTM infection. The resected specimen obtained from the right middle lobe exhibited the characteristic findings of allergic bronchopulmonary mycosis without evidence of mycobacterial infection. The administration of corticosteroids and itraconazole resulted in improvement of the patient's condition. The NTM appeared to be simply a coincidental colonization of the resected middle lobe bronchus. The absence of asthma, the inability to isolate fungi and the repeated isolation of NTM made it difficult to differentiate allergic bronchopulmonary aspergillosis from NTM infection.

A favorable response to cisplatin, pemetrexed and bevacizumab in two cases of invasive mucinous adenocarcinoma formerly known as pneumonic-type mucinous bronchioloalveolar carcinoma

The leading subtype of lung cancer, adenocarcinoma, received a new classification in 2011 when multifocal, pneumonic-type mucinous tumors, formerly called mucinous bronchioloalveolar carcinomas, were reclassified as "invasive mucinous adenocarcinomas." These tumors appear to be less sensitive to chemotherapy than other non-small cell lung cancers. We herein report two cases of invasive mucinous adenocarcinoma that showed a dramatic radiologic response to combination therapy with cisplatin, pemetrexed and bevacizumab. Recent data suggest that the use of paclitaxel-based chemotherapy is an acceptable therapeutic strategy in cases of invasive mucinous adenocarcinoma. The cases reported here and preclinical findings suggest the therapeutic efficacy of cisplatin, pemetrexed and bevacizumab in treating such tumors.

Etiology and factors contributing to the severity and mortality of community-acquired pneumonia

OBJECTIVE

Community-acquired pneumonia (CAP) remains a major cause of death. No studies have reported the use of rapid influenza diagnostic tests (RIDT) for the etiological diagnosis, and the factors contributing to severity and mortality have not yet been fully investigated. The aim of this study was to review the etiologies of CAP using RIDT and to identify risk factors related to the severity and mortality of the disease.

METHODS

This retrospective study assessed these factors in hospitalized patients, with special emphasis on microbial etiology.

RESULTS

A total of 1,032 patients aged 63.9±18.3 years were studied, 66.2% of whom were men. Microbial identification was obtained in 57.0% of the cases. The most frequent causative microbial agents were Streptococcus pneumoniae, Mycoplasma pneumoniae and the influenza virus, and the second most frequent pathogens in the patients with severe CAP and the non-survivors were S. pneumoniae and the influenza virus. Age (≥65 years), chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, dementia and Legionella spp. infection and polymicrobial infection were each found to be independent factors related to severity in the multivariate analysis, whereas "unidentified pathogen" was found to be an independent factor for non-severe CAP. Age (≥65 years), chronic pulmonary aspergillosis, post-lung cancer surgery and severe CAP were found to be independent factors for non-survival according to a multivariate analysis.

CONCLUSION

In addition to S. pneumoniae, the influenza virus was a frequent cause of CAP overall and a frequent causative pathogen in both severe cases of CAP and non-survivors. Legionella spp. infection and polymicrobial infection were found to be an independent factor for the severity of CAP along with advanced age and certain comorbidities. An advanced age, certain respiratory comorbidities and severe CAP were found to be important independent factors for the mortality of CAP.

[Clinical analysis of mycobacteriosis patients with pneumothorax]

BACKGROUND

Secondary pneumothorax caused by mycobacteriosis is rare. The frequency of incidence of pneumothorax in tuberculosis patients is reported to be only 1.5%, and that in nontuberculous mycobacteriosis patients may be very low. It is important to detect mycobacteriosis at an earlier stage in patients hospitalized for pneumothorax, in general wards so that nosocomial infections such as tuberculosis can be prevented.

OBJECTIVE

Chart review of mycobacteriosis patients with secondary pneumothorax admitted to the isolation ward, and that of the mycobacteriosis patients with pneumothorax admitted in the general wards of our hospital.

METHODS

We reviewed records of 555 mycobacteriosis patients admitted to the isolation ward of our hospital from January 2006 to December 2008. We analyzed the reasons for admission and cause, treatment, and outcome of pneumothorax.

RESULTS

Of the 555 mycobacteriosis patients, 11 (2.0%) had complications of pneumothorax. Among these 11 patients, 9 had tuberculosis, and 2 had nontuberculous mycobacteriosis. Of the 11, 5 were discharged, but 6 (54.5%) died during hospitalization, while among the remaining 544 mycobacteriosis patients without pneumothorax, 49 (9%) died during hospitalization. The hospital death rate of mycobacteriosis patients with pneumothorax was significantly higher than that of mycobacteriosis patients without pneumothorax (p < 0.0001). Among the 9 tuberculosis patients, 4 in whom pneumothorax was caused by rupturing of bullae showed improvement except one patient, but 5 in whom pneumothorax was caused by tuberculosis died. Excluding the 555 patients admitted to the isolation ward, 388 pneumothorax patients were admitted to the general ward during the same period, among which 3 (0.8%) had mycobacteriosis.

CONCLUSION

Tuberculosis-induced pneumothorax has a poor prognosis because the occurrence of tuberculosis impairs the mechanism of recovery from pneumothorax.

Airway dimensions and pulmonary function in chronic obstructive pulmonary disease and bronchial asthma

BACKGROUND AND OBJECTIVE

COPD and bronchial asthma are chronic airway diseases with a different pathogenesis. Comparisons of differences in airway calibre by bronchial generation between these diseases and their importance to pulmonary function have not been fully studied. We investigated airway calibre and wall thickness in relation to pulmonary function in patients with asthma, COPD, asthma plus emphysema and normal subjects using CT.

METHODS

Sixty-three asthmatic patients, 46 COPD, 23 patients with asthma plus emphysema and 61 control subjects were studied cross-sectionally. We used a software with curved multiplanar reconstruction to measure airway dimensions from 3rd- to 6th-generation bronchi of the right lower posterior bronchus.

RESULTS

Patients with COPD had increased wall thickness, but the airway was not narrow from the 3rd-(subsegmental) to 6th-generation bronchi. Mean bronchial inner diameter (Di) of 3rd- to 6th-generation bronchi in patients with asthma or asthma plus emphysema was smaller than that of COPD patients and normal subjects. Airway luminal area (Ai) of 5th-generation bronchi most closely correlated with pulmonary function in patients with stable asthma. Although Di was similar in patients with asthma and asthma plus emphysema, the Ai of 6th-generation bronchi correlated significantly with pulmonary function in patients with asthma plus emphysema.

CONCLUSIONS

Airway calibre in asthma may be smaller than in COPD. Airflow limitations correlated more closely with peripheral Ai in patients with asthma plus emphysema than in patients with asthma alone.

Comparison of high-dose salmeterol/fluticasone and moderate-dose salmeterol/fluticasone plus low-dose mometasone in patients with severe persistent asthma

BACKGROUND AND OBJECTIVE

The effects of adding a second inhaled corticosteroid with a different particle size, compared with using an increased dose of a single inhaled corticosteroid, were assessed in patients with persistent asthma.

METHODS

This was an open-label study of Japanese asthma patients over 20 years of age. After a 1-month run-in period, 36 patients with inadequate control while using salmeterol/fluticasone propionate 50/250 µg (SFC50/250) bd, were randomized to receive SFC50/500 bd or SFC50/250 plus mometasone 100 µg bd (SFC50/250/MF100) for 2 months.

RESULTS

Both treatments resulted in improvements in morning and evening PEF. There were no significant changes in FEV(1) , maximum mid-expiratory flow, maximum expiratory flow rate at 50%, maximum expiratory flow rate at 25% or exhaled NO (FENO) in the SFC50/500 group. On the other hand, there were significant improvements in FEV(1) % (+12.2%, P = 0.0142), %maximum mid-expiratory flow (+28.9%, P = 0.0181), %MEF50 (+32.4%, P = 0.0206) and %MEF25 (+30.3%, P = 0.0113) in the SFC50/250/MF100 group. The changes in FENO (-23.2% (P = 0.0157) in the SFC50/250/MF100 group and -14.5% (not significant) in the SFC50/500 group) did not differ significantly between the groups.

CONCLUSIONS

In patients with severe persistent asthma, addition of low-dose mometasone to SFC50/250 improved spirometric parameters, FENO and PEF, while an increase in dose from SFC50/250 to SFC50/ 500 only improved PEF.

Etiology and outcome of community-acquired lung abscess

BACKGROUND

Anaerobes are the first and Streptococcus species the second most common cause of community-acquired lung abscess (CALA) in the West. The etiologic pathogens of this disease have changed in Taiwan, with Klebsiella pneumoniae being reported as the most common cause of CALA.

OBJECTIVE

To determine the etiologies of community-acquired lung abscess.

METHODS

We retrospectively reviewed the records of 205 Japanese adult patients with CALA to evaluate etiologies and outcomes. We used not only traditional microbiological investigations but also percutaneous ultrasonography-guided transthoracic needle aspiration and protected specimen brushes.

RESULTS

Of these 205 patients, 122 had documented bacteriological results, with 189 bacterial species isolated. Pure aerobic, mixed aerobic and anaerobic, and pure anaerobic bacteria were isolated in 90 (73.8%), 17 (13.9%), and 15 (12.3%) patients, respectively. The four most common etiologic pathogens were Streptococcus species (59.8%), anaerobes (26.2%), Gemella species (9.8%), and K. pneumoniae (8.2%). Streptococcus mitis was the most common among the Streptococcus species. Mean duration of antibiotic administration was 26 days. Six patients (2.9%, 3 with actinomycosis and 3 with nocardiosis) were treated with antibiotics for 76-189 days. Two patients with anaerobic lung abscess died.

CONCLUSIONS

The first and second most common etiologic pathogens of CALA in our hospital were Streptococcus species and anaerobes, respectively. The etiologies in our study differ from those in Taiwan and are similar to those in the West with the exception that Streptococcus species were the most common etiologic pathogens in our study whereas anaerobes are the most frequent etiologic pathogens in Western countries. S. mitis and Gemella species are important etiologic pathogens as well. The identification of Actinomyces and Nocardia is important in order to define the adequate duration of antibiotic administration.

[A surgical case of extramedullary plasmacytoma in the left main bronchus]

A 69-year-old woman complaining of cough and wheezing of 2-months duration was admitted for diagnosis and treatment. She had been treated for bronchial asthma. Chest computed tomography showed an endobronchial tumor in the left main bronchus. Bronchoscopic biopsy yielded a diagnosis of plasmacytoma. We confirmed the absence of M-protein in the serum and urine, bone lesions in bone scintigraphy, and other organ dysfunction. In addition bone marrow biopsy and revealed normal findings. We diagnosed extramedullary plasmacytoma in the left main bronchus. We performed a sleeve resection of the left main bronchus including the tumor and reconstructed the bronchus with primary end-to-end anastomoses. We achieved complete excision and were able to maintain lung function. One year after the operation, the patient remains well, with no evidence of recurrence, or conversion to multiple myeloma. When a patient complains of wheezing, a bronchial tumor should always be considered.

[Severe complications and their outcomes in 65 patients with Legionella pneumonia]

The aim of the current study was to investigate the lethal complications of Legionella pneumonia. Severe complications and their outcomes in 65 patients with Legionella pneumonia were studied. All patients who eventually had a fatal outcome or who had severe complications received antimicrobial agents active against Legionella on the admission day. Many patients in the severe complication category had multiple severe complications. Six deaths occurred (mortality rate 9.2%), 4 of which were due to septic shock/multiple organ dysfunction syndrome (MODS) (2 patients) or interstitial pneumonia/pulmonary fibrosis after Legionella pneumonia (2 patients), whereas the other 2 deaths were due to causes unrelated to Legionella pneumonia. Mortality rates for each severe complication were as follows: acute respiratory distress syndrome 27.3% (3 of 11); renal failure 33.3% (2 of 6); disseminated intravascular coagulation 33.3% (2 of 6); severe sepsis 0% (0 of 1); septic shock/MODS 66.7% (2 of 3); interstitial pneumonia/pulmonary fibrosis 50% (2 of 4). Despite prompt diagnosis and appropriate treatment with antimicrobial agents active against Legionella, the lethal complications of Legionella pneumonia are septic shock/MODS and interstitial pneumonia/pulmonary fibrosis.

[Mucoid impaction of the bronchi caused by Schizophyllum commune which developed after discontinuation of itraconazole administration]

We report the case of a 75-year-old woman with mucoid impaction of the bronchi (MIB) due to Schizophyllum commune who improved with itraconazole (ITCZ) administration and relapsed after discontinuation of the drug. She improved again after readministration of ITCZ, and MIB has not recurred. This patient was not suffering from asthma and has been well without steroid administration. Reports of respiratory disorders due to S. commune have been increasing, and cases of allergic bronchopulmonary mycosis (ABPM), fungus ball, lung abscess, and pneumonia have been reported. Including this report, 12 cases of ABPM and MIB due to S. commune have been reported by Japanese authors. Treatment in these 12 cases included anti-fungal agent in 6, single steroid therapy in 3, combination therapy in 2, and bronchial toilet in 1 case. S. commune is not well recognized; however, one should suspect this fungus to be the causative pathogen when Aspergillus species are not detected or anti-Aspergillus antibody is negative.

[Primary ciliary dyskinesia. A case report and comparison with 4 previous cases]

We encountered a 59-year-old man, whose chief complaints were sputum and dyspnea on effort. He had suffered from sinusitis since childhood, and chest computed tomography showed bronchiectasis. Electron microscopic examination of bronchial mucosa biopsied by bronchoscopy showed defect of the inner dynein arm in most of his cilia. We diagnosed primary ciliary dyskinesia. Seminal analysis showed no abnormalities, and the etiology of infertility remains unclear. The present case is the fifth case treated at our hospital. In this paper, we compared this case with 4 cases (2 cases of Kartagener's syndrome and 2 cases of primary ciliary dyskinesia without situs invertus) of our hospital, and findings of previous reports. Primary ciliary dyskinesia should be included in the differential diagnosis even in cases of mild bronchiectasis or normal mobility of sperm. Primary ciliary dyskinesia has more variety in radiological and clinical findings than has been recognized.