Atezolizumab-related sclerosing cholangitis with multiple liver abscesses in a patient with lung squamous cell carcinoma: A case report.

A 76-year-old man underwent an operation for lung squamous cell carcinoma in the right lower lobe, followed by initial adjuvant therapy with atezolizumab, an antibody against anti-programmed death-ligand 1 (PD-L1). On day 4 after atezolizumab treatment, the patient developed general malaise and fatigue. He was diagnosed with atezolizumab-induced sclerosing cholangitis. Steroid treatment was started, and patient's condition, including symptoms, laboratory data and imaging findings, improved. Antibiotic treatments were ended on day 40, and the steroid dose was gradually reduced. Multiple liver abscesses were observed on day 106, and another treatment with antibiotics became necessary. The patient eventually recovered from liver abscesses. Sclerosing cholangitis induced by immune checkpoint inhibitor is rare, and the long-term clinical data about this adverse effect is limited. Hence, we think it is important to raise an alarm over sclerosing cholangitis coupled with liver abscesses after immunosuppressive therapy.

Comparison of sputum specimens and nasopharyngeal swab specimens for diagnosis of acute human metapneumovirus-related lower respiratory tract infections in adults.

BACKGROUND: To detect human metapneumovirus, tests besides reverse transcription-polymerase chain reaction (RT-PCR) on nasopharyngeal swab specimens are less accessible. Immunochromatography assays are rapid and simple without the need of any special equipment but sometimes are insufficiently sensitive. This study describes the usefulness of immunochromatography assays to detect human metapneumovirus in adult patients with human metapneumovirus-related acute lower respiratory tract infection using sputum specimens. METHODS: This prospective single-center study enrolled adults and adolescents aged ≥16 years with signs and symptoms of an acute respiratory illness who were diagnosed with acute lower respiratory tract infection. The presence of human metapneumovirus infection was confirmed by seroconversion. Immunochromatography assays and real-time RT-PCR were performed to compare the efficacy of nasopharyngeal swab specimens and sputum specimens. Comparative results were obtained via McNemar's test. RESULTS: Overall, 337 patients were recruited in this study; 63 (18.7%) patients were seroconverted. Sputum specimens showed significantly higher positivity rates than nasopharyngeal swab specimens with both immunochromatography assays (p = 0.0008) and real-time RT-PCR (p = 0.014). Among 29 patients with pneumonia who had concordant positive real-time RT-PCR results for both nasopharyngeal swab specimens and sputum specimens, 21 (72.4%) had a higher viral load in the sputum specimens. CONCLUSIONS: Sputum specimens are more useful in detecting human metapneumovirus than nasopharyngeal swab specimens in adult patients with acute lower respiratory tract infection.

Legionella pneumonia immediately after recovery from COVID-19.

We experienced a patient with Legionella pneumonia developing immediately after discharge from COVID-19 recovery. Antibiotic treatment was successful. The source of Legiolella infection was proven to be bathtub water in this case. It is very important to accurately detect pathogens, particularly in the time of pandemics such as COVID-19.

A useful and safe method for retrieving a round metallic object from an airway.

The endoscopic net forceps with the support of a laryngeal mask airway are a dependable choice for retrieving a round metallic object from an airway.

Efficacy and Usefulness of New Single-Needle Intensive Granulocyte and Monocyte Adsorptive Apheresis in Active Ulcerative Colitis Patients Without Corticosteroids and Biologics.

Intensive granulocyte and monocyte adsorptive apheresis (GMA) twice weekly is effective and safe for patients with active ulcerative colitis (UC), but the requirement for maintaining two blood access routes is problematic. Here we compared the efficacy and safety of one-route blood access intensive GMA using a single-needle (SN) and conventional two-route blood access intensive GMA using a double-needle (DN) in patients with active UC not undergoing corticosteroid therapy. Among 80 active UC patients, 38 patients received SN intensive GMA and 42 patients received DN intensive GMA. The clinical remission ratio and mucosal healing ratio at 6 weeks, and the cumulative non-relapse ratio at 52 weeks did not differ significantly between groups. In addition, no serious or mild adverse effects were observed in SN intensive GMA. SN intensive GMA may be an adequate and novel therapeutic option for active UC as an alternative therapy before using corticosteroids.

[Clinical Characteristics of Adult Onset RSV Infection During Two Consecutive Winter Seasons].

We performed a retrospective study examining adult patients with RSV infection who were diagnosed at our hospital during two consecutive winter seasons, 2011-2012 and 2012-2013; these patients were compared with, adult patients who had been diagnosed as having influenza during the same periods. RSV infection was confirmed by a 4-fold increase in the CF antibody titer, while influenza was diagnosed based on a rapid antigen test. Forty-three patients with RSV infection and pneumonia patients (39 inpatients and 4 outpatients) and 25 patients with influenza and pneumonia (23 inpatients and 2 outpatients) were detected. Overall, 54 patients with RSV infection and 42 patients with influenza, were hospitalized during the two seasons. A history of the influenza vaccination was verified for 48% of the influenza patients with pneumonia and 35% of the non-pneumonia influenza patients who were hospitalized, and neuraminidase inhibitors were used for the treatment of all the influenza patients and 88% of the non-pneumonia influenza patients who were hospitalized. Overall, 5.3% of the adult cases with pneumonia (43/817) during the two seasons were diagnosed as having RSV related illness, and within the peak period, in particular, 14.6% were judged as having RSV pneumonia. Furthermore, 63% of the patients with RSV infection and pneumonia had mixed infections with other common respiratory pathogen, such as Streptococcus pneumoniae, and within the peak period, almost 15% of the patients with pneumonococcal pneumonia were confirmed to have mixed infections that included RSV. In both groups, one-fourth of the patients had been living in nursing homes or had been receibing home medical care. Up to 20% of the RSV pneumonia patients were initially diagnosed as having aspiration pneumonia. We suspect that some of these elderly patients might have developed pneumonia as a result of preceding viral infection or following vomiting or aspiration. The overall clinical picture, such as the mean age, maximum body temperature, hypoxemia, CRP, and WBC, did not differ significantly between the two groups. The 30-day mortality and overall hospital mortality rates were similar in both groups, but the lengths of the hospital stay were significantly longer, and several patients survived but continued to have a reduced activities of daily living score at the time of their discharge in the RSV pneumonia group.

[[TUBERCULOSIS DIAGNOSIS FOLLOWING A VISIT TO THE EMERGENCY ROOM].]

We aimed to evaluate the clinical char- acteristics of patients admitted to the emergency room (ER) and diagnosed with tuberculosis. [Method] We conducted a retrospective study of patients aged ; 16 years admitted to the hospital between April 1980 and March 2015 and diagnosed with tuberculosis. We com- pared patient clinical characteristics and type of tuberculosis between ER and non-ER patients. We also compared the incidence of delayed diagnosis of tuberculosis between ER patients with and without respiratory symptoms. We compared the tuberculosis encounter rate and the time to diagnosis of tuberculosis in ER and non-ER patients. [Results] A total of 255 patients, including 54 ER and 201 non-ER patients were enrolled in this study. The average age J was higher in ER patients than in non-ER patients (71.7? 16.3 vs. 63.3 ?20.3 years, p=0.006). The reasons for visiting the ER included acute conditions such as fracture of the lumbar spine, acute myocardial infarction, hemorrhagic gastric ulcer, brain infarction, and carbon monoxide intoxication, requiring immediate treatment. The time to diagnosis of tuberculosis in ER patients without respiratory symptoms (n=21) was approximately three times longer than that in patients with respiratory symptoms (n=33) as urgent treatment is priori- tized. The tuberculosis encounter rate was 1/1,800 for pa- tients transported by ambulance and 1/22,000 for emergency outpatients. The time to diagnosis of tuberculosis for patients transported by ambulance was approximately 4-6 days lon- ger than that for emergency outpatients or non-ER patients. [Conclusion] Physicians should seek to rule out the possi- bility of tuberculosis in all patients admitted to the ER, even where more urgent clinical conditions are prioritized.

Efficacy of recombinant human soluble thrombomodulin in preventing walled-off necrosis in severe acute pancreatitis patients.

OBJECTIVE: To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) in preventing the development of walled-off necrosis (WON) in severe acute pancreatitis (SAP) patients. METHODS: We retrospectively analyzed 54 SAP patients divided into two groups: SAP patients treated by rTM (rTM group, 24 patients) and not treated by rTM (control group, 30 patients). rTM was administered to patients with disseminated intravascular coagulation (DIC). Initially, on the admission day, we recorded patient severity and pancreatic necrosis/ischemia positive or negative. Then we investigated development of WON using 4 weeks later CT/MRI. Finally we compared the proportions of patients developing WON in the rTM group and the control group. RESULTS: On the admission day, the condition of patients treated by rTM was significantly worse than patients in the control group; rTM group vs. CONTROL: 71.8 ± 13.9 vs. 59.8 ± 15.3 years for age, 10.7 ± 3.5 vs. 8.0 ± 4.4 for Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and 3.3 ± 1.8 vs. 2.2 ± 1.8 for sequential organ failure assessment (SOFA) score (p < 0.05). We found no significant differences on the admission day in rate of pancreatic necrosis/ischemia between patients treated by rTM and controls (58.3% vs. 63.3%, p = 0.71). Nevertheless, the proportion of patients developing WON was significantly lower among those administered rTM than in those not administered rTM {29.2% (7/24 patients) vs. 56.7% (17/30 patients), p < 0.05}. CONCLUSION: Treatment of SAP patients treated by rTM may prevent progression from pancreatic necrosis/ischemia to WON.

Novel Prokinetic Acotiamide Reduces Transient Lower Esophageal Sphincter Relaxation in Healthy Subjects.

BACKGROUND/AIMS: Currently, there is no study evaluating the effect of acotiamide on transient lower esophageal sphincter relaxations (TLESRs). The aim of this study was to evaluate the effect of acotiamide on TLESRs using simultaneous high-resolution manometry (HRM) and impedance-pH monitoring. METHODS: Ten healthy subjects were enrolled. On day 1, subjects underwent HRM and impedance-pH recordings as a baseline. Subjects ate a 750-kcal liquid meal; recording was continued for 2 h while the subjects were in a sitting position. After the administration of acotiamide 100 mg three times a day for 1 week, subjects underwent HRM and impedance-pH recording under the same protocol. RESULTS: A total of 208 TLESRs were identified at baseline. Acotiamide decreased the total number of TLESRs from 208 to 143 (p < 0.05). The rate of reflux events during TLESRs after acotiamide administration was similar to that at baseline (57% after acotiamide vs. 58% at baseline). Bolus clearance time was significantly reduced by acotiamide. CONCLUSIONS: Acotiamide was believed to have the potential for reducing TLESRs and for enhancing esophageal bolus clearance in healthy volunteers. Future research is needed to determine whether the effects of acotiamide that reduce TLESRs and enhance esophageal motility could improve symptoms in patients with refractory gastroesophageal reflux disease.

[Occurrence and clinical characteristics of tuberculosis among home medical care patients].

OBJECTIVE: To clarify the occurrence and clinical characteristics of tuberculosis among home medical care patients, we conducted a retrospective study of patients who received home medical care from our hospital. SUBJECTS AND METHODS: We investigated 502 patients (mean age, 79.5 years) who received home medical care from our hospital between January 2003 and December 2012. The newly notified tuberculosis cases aged > or = 70 years in the general population in Miyagi were defined as the control group. Among the patients receiving home medical care, we evaluated the clinical characteristics of the patients with tuberculosis. RESULTS: Four of the 502 patients (0.8%) developed tuberculosis. Using the person-years method, the case rate of tuberculosis was calculated as 298.3 per 100,000 among home medical care patients. Compared with the control group, home medical care patients had a greater incidence of tuberculosis (298.3 vs. 36.06; rate ratio, 8.27; 95% confidence interval, 3.06-22.3; p < 0.001). When home medical care patients visited the hospital or were transported there by ambulance, they were initially often diagnosed with aspiration pneumonia. Moreover, the time interval to the onset of disease from the introduction of home medical care varied among cases (3-192 months). CONCLUSION: Patients receiving home medical care are at high risk of contracting tuberculosis. Therefore, for the medical staff involved in treating home medical care patients, the onset of tuberculosis should be carefully considered in daily medical practice.

Therapeutic effect of intensive granulocyte and monocyte adsorption apheresis combined with thiopurines for steroid- and biologics-naïve Japanese patients with early-diagnosed Crohn's disease.

BACKGROUND: Early induction with biologics can reduce complications in patients with Crohn's disease (CD) and improve their quality of life. The safety of biologics, however, is uncertain. Granulocyte and monocyte adsorptive apheresis (GMAA) is a natural biologic therapy that selectively removes granulocytes and monocytes/macrophages and has few severe adverse effects. The effects of GMAA on patients with early-diagnosed CD are unclear. We investigated the effects of GMAA combined with thiopurines on patients with early-diagnosed CD. METHODS: Twenty-two corticosteroid- and biologic-naïve patients with active early-diagnosed CD were treated with intensive GMAA (twice per week) combined with thiopurines administration. Active early-diagnosed CD was defined as follows: (i) within 2years after diagnosis of CD, (ii) with no history of both surgical treatment and endoscopic dilation therapy, and (iii) Crohn's Disease Activity Index (CDAI) was higher than 200. We investigated the ratios of clinical remission defined as CDAI was less than or equal to 150 at 2, 4, 6 and 52weeks and mucosal healing defined as a Simplified Endoscopic Activity Score for Crohn's Disease (SES-CD) as 0 at 6 and 52weeks. Adverse events were recorded at each visit. RESULTS: The ratios of clinical remission at 2, 4, and 6 weeks were 6 of 22 (27.2%), 12 of 22 (54.5%), and 17 of 22 (77.2%), respectively. At 52 weeks, 18 of 21 patients (81.8%) were in clinical remission. The ratios of mucosal healing at 6 and 52 weeks were 5 of 22 (22.7%) and 11 of 22 (50%), respectively. The difference in the mucosal healing ratio was significant between 6 and 52 weeks (p = 0.044). No serious adverse effects were observed during this study. CONCLUSIONS: Combination therapy with intensive GMAA and thiopurines administration rapidly induced high remission in patients with active early-diagnosed CD without serious adverse effect. Mucosal healing was observed in 50.0% of enrolled patients. This combination therapy might be a rational option for patients with early-diagnosed CD.

Predictive factors associated with the success of pneumatic dilatation in Japanese patients with primary achalasia: a study using high-resolution manometry.

BACKGROUND/AIMS: A new classification of achalasia using high-resolution manometry (HRM) has recently been suggested. Pneumatic dilatation (PD) is a common treatment for primary achalasia. The usefulness of the new classification and HRM for the treatment and follow-up of patients after PD is unknown. The aim of this study was to evaluate the PD effectiveness and the predictive factors of success in Japanese patients with achalasia using HRM and the new classification of achalasia. METHODS: Twenty-five patients were diagnosed with primary achalasia using HRM and treated by PD in our hospital. We evaluated symptom scores and esophageal manometry 6 and 12 months after the first PD. RESULTS: After the first PD treatment, remission occurred in 24 out of 25 (96.0%) patients at 6 months and in 19 out of 25 (76.0%) patients at 12 months. With the new classification of achalasia, the success rates were 83.3, 80.0 and 50% for types I, II and III, respectively, 12 months after PD. The median age of the successful group was significantly greater than that of the failure group (47.1 vs. 37.0 years, p < 0.05). The median residual lower esophageal sphincter (LES) pressure 6 months after PD in the successful group was significantly lower than that of the failure group (9.0 vs. 15.5 mm Hg, p < 0.05). CONCLUSION: Good predictors of PD success were old age (>40 years) and residual LES pressures less than 15 mm Hg 6 months after PD.

Effect of intensive granulocyte and monocyte adsorptive apheresis in patients with ulcerative colitis positive for cytomegalovirus.

BACKGROUND AND AIM: Cytomegalovirus (CMV) exacerbates ulcerative colitis (UC) refractory to immunosuppressive therapies. The conditions under which CMV reactivation occurs in patients with UC, however, is unclear. In addition, the diagnostic and treatment strategies for UC positive for CMV have not been established. Granulocyte and monocyte adsorptive apheresis (GMAA) is natural biological therapy for UC in which the granulocytes/macrophages producing inflammatory cytokines are removed. We investigated the rate of colonic CMV reactivation and the efficacy of GMAA in active UC patients positive for CMV without concomitant corticosteroid (CS) therapy. METHODS: Fifty-one active UC patients without concomitant CS therapy were enrolled. Colonic CMV reactivation was examined by real-time polymerase chain reaction (PCR) using biopsy specimen and/or histological examination. All patients were treated with intensive GMAA (twice per week). Rates of clinical remission and mucosal healing were compared between UC patients positive and negative for CMV. RESULTS: Of 51 patients, 15 (29.4%) were diagnosed as CMV positive. The clinical remission rates following intensive GMAA did not differ between UC patients positive and negative for CMV (73.3% vs 69.4%, p=0.781). Proportion of patients achieving mucosal healing was also similar between these two groups. CMV-DNA became negative in all UC patients positive for CMV who achieved clinical remission 1 week after completion of intensive GMAA. CONCLUSIONS: Intestinal inflammation might trigger CMV reactivation in a subpopulation of active UC patients without CS treatment. GMAA could be a promising option for active UC positive for CMV.

[A case of septic pulmonary embolism due to Peptostreptococcus micros with multiple infection of the head and neck].

A 46-year-old man with no underlying diseases visited our hospital with otorrhea, ocular motility disorder of the left eye, dizziness and loss of appetite which had lasted for two months. Chest radiography and computed tomography (CT) showed bilateral multiple pulmonary nodules and cavities. Furthermore, CT of the head and neck revealed bilateral mastoiditis, a left orbital abscess and a deep neck abscess. Peptostreptococcus micros was cultured from blood and otorrhea specimens. In addition, P. micros DNA was detected with the polymerase chain reaction (PCR) method in the specimens from the site of culture-negative lesions (i.e. sputum, bronchoalveolar lavage, neck abscess). Thus, we diagnosed the lung lesions as septic pulmonary embolisms (SPEs). The clinical findings of the head and neck had improved following antibiotics treatment for five weeks, and follow-up chest radiography and CT showed that all lesions almost disappeared. Since some SPE patients demonstrate a slow progression, SPE should be included in the differential diagnosis of multiple pulmonary nodules such as Wegener's glanulomatosis or neoplasm.

The clinical characteristics of two anti-OJ (anti-isoleucyl-tRNA synthetase) autoantibody-positive interstitial lung disease patients with polymyositis/dermatomyositis.

We herein report the clinical and laboratory characteristics of two anti-OJ (anti-isoleucyl-tRNA synthetase) autoantibody-positive interstitial lung disease patients with polymyositis/dermatomyositis (PM/DM). We compared these characteristics with previously published findings. Previous reports and our present cases show that anti-OJ autoantibody-positive interstitial lung disease (ILD) patients with PM/DM lack the manifestations of Raynaud's phenomenon and sclerodactyly and show good prognoses and responses to glucocorticoid therapy. These results indicate that the presence of anti-OJ autoantibodies may be useful for predicting the prognosis of ILD and its clinical course in PM/DM patients.

Combined pH-impedance monitoring and high-resolution manometry of Japanese patients treated with proton-pump inhibitors for persistent symptoms of non-erosive reflux disease.

BACKGROUND: Data on acid and non-acid reflux patterns and esophageal function in Japanese patients with non-erosive reflux disease (NERD) are limited. The aim of this study was to use combined multichannel intraluminal impedance pH monitoring (MII-pH) and high-resolution manometry (HRM) to investigate the characteristics of Japanese patients who were treated with a "double-dose" (20 mg) of rabeprazol (a proton-pump inhibitor; PPI) for persistent symptoms of NERD. METHODS: Twenty-five patients who complained of typical gastroesophageal reflux disease symptoms, which had occurred more than twice a week despite treatment with rabeprazol, were enrolled in the study. All patients underwent upper endoscopy, esophageal HRM, and 24-h MII-pH monitoring while double-dose PPI therapy was continued. RESULTS: Twelve (48.0%) of the patients had a positive symptom index (SI) with 234 recorded symptoms, 127 (54.3%) of which were related to reflux episodes. Of those with reflux episodes, 29 (22.8%) were related to acid reflux, while 98 (77.2%) were the result of a weaker acidic reflux. In acid reflux and in mixed (liquid-gas) reflux, the proximal esophageal region was involved to a significantly greater degree (P<0.002 and P=0.005, respectively) than the distal region. In liquid reflux, there was no difference between the distal and proximal regions. HRM showed that proximal motility parameters were significantly more defective than in those of healthy volunteers. CONCLUSIONS: MII-pH monitoring indicated that weakly acidic reflux and mixed refluxate in the proximal esophagus is the major cause of persistent symptoms in patients with NERD who are being treated with PPI. HRM showed that proximal esophageal dysfunction might be a key condition that facilitates reflux.

[Four cases of respiratory infections caused by Legionella pneumophila serogroup 3].

Legionella pneumonia tends to be severe and is known to be fatal. Introduction of the urinary Legionella antigen test and changes in the Infectious Disease Law have led to increased numbers of reports, and milder cases are now occasionally seen. We experienced three cases demonstrating mild respiratory infections and one case demonstrating nosocomial pneumonia associated by Legionella pneumophila serogroup 3. Case 1 showed multiple ground-glass opacities on HRCT and productive cough. Cases 2 and 3 showed abnormal findings on chest X-ray, and chest CT findings in both cases suggested chronic respiratory infection. Case 4 experienced fever and hypoxia, and pulmonary edema was noted on X-ray. All of them four cases were diagnosed with respiratory infections isolated L. pneumophila serogroup 3 by culture results, and three of them cases were treated in the outpatient clinic. Thus, milder cases of Legionella pneumonia may be encountered during routine care, and tests for Legionella should be performed in such cases.