[Efficacy and Safety of Gefitinib as First-Line Chemotherapy for Elderly Patients with Advanced Non-Small Cell Lung Cancer(NSCLC)].

Epidermalgrowth factor receptor tyrosine kinase inhibitor(EGFR-TKI)is the first choice for the treatment of EGFR mutation- positive advanced non-small cell lung cancer(NSCLC). There have been few reports on the efficacy and safety of gefitinib in elderly patients with EGFR mutation-positive advanced NSCLC. We retrospectively assessed the efficacy and safety of gefitinib as first-line chemotherapy in 22 patients with advanced NSCLC aged 75 years or older and who were treated with gefitinib. The response rate was 81.8%, and the disease controlrate was 95.5%. The median progression-free survivaltime was 14.2 months, and the median survivaltime was 30.7 months. The common adverse events were skin toxicities(50.0%), liver dysfunction(18.2%), and diarrhea(18.2%). The dose of gefitinib was reduced in 36.3% of the patients, and the treatment of gefitinib was discontinued in 18.2% of the patients. Gefitinib is effective and safe for elderly patients with advanced NSCLC.

Saddle nose with sarcoidosis: "A great imitator" of relapsing polychondritis.

Sarcoidosis is a systemic granulomatous disease that can affect any organ including the nose. Nasal crusting and congestion are common nasal symptoms of sarcoidosis, whereas cases of saddle-nose deformity are rarely reported. We describe here a case of sarcoidosis that presented with saddle nose resembling relapsing polychondritis. Since sarcoidosis shares clinical features with relapsing polychondritis, the differential diagnosis of saddle nose can be challenging without a clear pathology.

[A CASE OF SPINAL TUBERCULOSIS WITH NEUROPATHY AMELIORATED BY DRAINING A TUBERCULOUS ILIOPSOAS ABSCESS WITHOUT SPINAL SURGERY].

A 75-year-old woman was referred to our hospital after a health check-up disclosed abnormal shadows in the bilateral lungs. The patient was admitted to our hospital after being diagnosed with pulmonary tuberculosis. A physical examination showed a mass in the left inguinal area. Enhanced computed tomography revealed that the tuberculosis involved several regions including the lumber vertebrae, iliopsoas muscles, and left inguinal area. A therapeutic regimen consisting of INH, RFP, EB, and PZA was begun. Neuropathy in the lower extremities and dysuria indicated a spinal lesion, and spinal surgery was considered. However, the patient's history indicated that these symptoms were likely due to an iliopsoas abscess rather than a spinal lesion. This hypothesis was confirmed when the patient's symptoms improved with no sequelae after the abscess was drained. Our case demonstrates that spinal lesions as well as iliopsoas abscesses can cause neuropathy, and underscores the importance of obtaining a patient's history to correctly diagnose the disease and determine the appropriate treatment options.

[A case of antitubercular drug-induced toxic epidermal necrosis in a systemic lupus erythematosus patient during treatment for pulmonary tuberculosis].

A 48-year-old woman, who had been suffering from systemic lupus erythematosus for one year and receiving steroid therapy, was admitted to our hospital because of pulmonary tuberculosis. The tuberculosis was treated with INH, RFP, EB, and PZA after having doubled the dose of steroid, but terminated three weeks later due to the appearance of erythema exsudativum multiforme. Treatment was resumed with PZA, SM, and LVFX after resolution of the eruption. However, the addition of INH to the regimen provoked a recurrence of the eruption, which progressed rapidly to toxic epidermal necrolysis (TEN). Steroid pulse therapy stopped progression of the TEN, and treatment for tuberculosis was resumed. Although the choice of drug was rendered difficult by other adverse reactions, the patient was able to complete her tuberculosis treatment with RFP, EB, and TH. INH was most likely to be the offending agent in this case. Eruptions induced by antitubercular drugs are often seen, but there are few reports of severe toxic epidermal necrolysis.

Pseudo-mediastinal tumor: Brachiocephalic artery buckling.

Buckling of the brachiocephalic artery is an important cause of unusual chest x-ray findings which resemble those of a mediastinal tumor. The possibility of a vascular anomaly should be kept in mind whenever a chest x-ray demonstrates an abnormal mediastinal opacity, especially in elderly female patients with hypertension.

Bochdalek Hernia Causing Sigmoid Colon Strangulation in an Elderly Patient.

Diaphragmatic hernia with bowel strangulation is a fatal condition requiring a prompt diagnosis. Bochdalek hernia is a common type of diaphragmatic hernia that rarely but occasionally occurs in adults. We herein report a case of Bochdalek hernia causing sigmoid colon strangulation in an elderly patient whose condition was initially misdiagnosed as empyema. The early diagnosis of strangulated bowel stemming from diaphragmatic hernia can be challenging because of its rarity and the nonspecificity of its symptoms. However, tracing the mesenteric arteries on computed tomography can enable a quick diagnosis.

[A case of severe Legionella pneumonia in which survival was achieved without sequelae with the use of extracorporeal membrane oxygenation (ECMO)].

A 54-year-old man presented with fever and dyspnea about a week before his admission. We diagnosed Legionella pneumonia from his chest X-ray imaging which showed bilateral lobe consolidation excluding the left upper lobe, and his sputum culture yielded Legionella pneumophilla serogroup 1. Combination therapy with levofloxacin and rifampin was started on admission. However, the patient developed severe acute respiratory distress syndrome (ARDS) and then extracorporeal membrane oxygenation (ECMO) was initiated on the 2nd day. His respiratory status gradually improved after that and he was weaned from ECMO on the 7th day. He was discharged without sequelae on the 36th day. The outcome suggests that use of ECMO should be considered for patients with severe Legionella pneumonia.

C-reactive protein and the neutrophil-to-lymphocyte ratio on admission predicting bacteraemia with COVID-19.

BACKGROUND: Bacteraemia can co-occur with COVID-19. The present study aimed to determine the cut-off value for C-reactive protein (CRP) and the neutrophil-to-lymphocyte ratio (NLR) for predicting bacteraemia in patients with COVID-19. METHODS: Patients admitted to Tokyo Metropolitan Tama Medical Centre for COVID-19 treatment between 1 April 2020 and 30 October 2022 were included. Patients transferred from other hospitals and those whose CRP and/or neutrophil count was not measured at admission were excluded. Community-acquired bacteraemia was diagnosed if true bacteraemia was diagnosed in patients via a blood culture performed within 72 h of admission. The cut-off value for CRP and the NLR for community-acquired bacteraemia were determined using receiver operating characteristic analysis. RESULTS: Among 2989 patients hospitalized for COVID-19 treatment, 19 received the diagnosis of community-acquired bacteraemia, for which CRP ≥ 6.3 was determined to be the cut-off value. The sensitivity and specificity of the cut-off was 89.5% and 73.3%, respectively. The NLR cut-off value was ≥ 7.7, which had a sensitivity and specificity of 84.2% and 84.0%, respectively. CONCLUSIONS: Considering the possibility of the co-occurrence of bacteraemia with COVID-19, a blood culture should be performed when CRP is ≥ 6.3 or the NLR is ≥ 7.7.

Promoting coronavirus disease 2019 (COVID-19) vaccination among healthcare personnel: A multifaceted intervention at a tertiary-care center in Japan.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) vaccine may hold the key to ending the pandemic, but vaccine hesitancy is hindering the vaccination of healthcare personnel (HCP). We examined their perceptions of the COVID-19 vaccine and implemented an intervention to increase vaccination uptake. DESIGN: Before-and-after trial. PARTICIPANTS AND SETTING: Healthcare personnel at a 790-bed tertiary-care center in Tokyo, Japan. INTERVENTIONS: A prevaccination questionnaire was administered to HCP to examine their perceptions of the COVID-19 vaccine. A multifaceted intervention was then implemented involving (1) distribution of informational leaflets to all HCP, (2) hospital-wide announcements encouraging vaccination, (3) a mandatory lecture, (4) an educational session about the vaccine for pregnant or breastfeeding HCP, and (5) allergy testing for HCP at risk of allergic reactions to the vaccine. A postvaccination survey was also performed. RESULTS: Of 1,575 HCP eligible for enrollment, 1,224 (77.7%) responded to the questionnaire, 533 (43.5%) expressed willingness to be vaccinated, 593 (48.4%) were uncertain, and 98 (8.0%) expressed unwillingness to be vaccinated. The latter 2 groups were concerned about the vaccine's safety rather than its efficacy. After the intervention, the overall vaccination rate reached 89.7% (1,413 of 1,575), and 88.9% (614 of 691) of the prevaccination survey respondents answered "unwilling" to or "unsure" about eventually receiving a vaccination. In the postvaccination questionnaire, factors contributing to increased COVID-19 vaccination included information and endorsement of vaccination at the medical center (274 of 1,037, 26.4%). CONCLUSIONS: This multifaceted intervention increased COVID-19 vaccinations among HCP at a Japanese hospital. Frequent support and provision of information were crucial for increasing the vaccination rate and may be applicable to the general population as well.

Diagnosing Pollen-food Allergy Syndrome Allergologically in a Patient with Suspected Eosinophilic Gastroenteritis.

Pollen-food allergy syndrome (PFAS) consists of type I allergy to pollen and multiple food items that are cross-reactive to the pollen. PFAS typically occurs in the oral cavity and can co-occur with eosinophilic esophagitis. However, it is infrequently reported to present with symptoms of eosinophilic gastroenteritis (EGE), such as abdominal pain and eosinophilic infiltration of the gastrointestinal tract. We herein report a patient with a condition initially suspected of being EGE based on symptoms and pathological findings that was later diagnosed as PFAS associated with birch pollen. PFAS should be considered as a differential diagnosis in patients with EGE-like symptoms.

[A case of IgG4-positive inflammatory pseudotumor which rapidly resolved].

A 72-year-old man visited our hospital due to persistent cough, fever and weight loss. A chest X-ray film revealed a round tumor in the left lower lung field. A specimen obtained by transbronchial lung biopsy demonstrated histiocytic and lymphocytic infiltration in the alveolar space, with spindle myofibroblasts and plasmacytes in the interstitium, Those findings were consistent with inflammatory pseudotumor. Four weeks later, a chest X-ray film showed only scars of the primary lesion, and his symptoms resolved dramatically. He has had no recurrence of symptoms and pulmonary tumor since then. Although spontaneous remission is uncommon in inflammatory pseudotumor of the lung, there are several case reports about spontaneous remission of hepatic inflammatory pseudotumor and autoimmune pancreatitis, parts of IgG4-related sclerosing disease. Recently, inflammatory pseudotumor is thought to be IgG4-related sclerosing disease. We speculate that IgG4 may be associated with spontaneous remission of inflammatory pseudotumor of the lung, and we discuss this issue in relation to the pertinent literature.

Pleural effusion as a rare presentation of foreign body aspiration.

Unsuspected, non-asphyxiating, aspirated foreign body often masquerades as unresolved pneumonia, bronchiolitis or bronchial asthma. We report herein an 82-year-old, male patient with pleural effusion. Although the patient received the diagnosis of heart failure and treatment with diuretics, the pleural effusion remained, and a productive cough and a low-grade fever developed. Thoracentesis showed an exudative effusion, and chest computed tomography revealed a pill-like object in the right bronchus intermedius. The foreign body proved to be an iron pill, and the patient finally died from obstructive pneumonia due to severe mucosal damage caused by the pill. The present case emphasizes that foreign body aspiration may mimic not only respiratory but also cardiovascular diseases and should be suspected if the treatment of the initially diagnosed condition fails to ameliorate the patient's condition.

Evaluation of a novel urinary antigen test kit for diagnosing Legionella pneumonia.

OBJECTIVES: The aim of this study was to evaluate the diagnostic utility of a novel test kit that could theoretically detect all serogroups of Legionella pneumophila for diagnosing Legionella pneumonia, in comparison with existing kits. METHODS: This study was conducted in 16 hospitals in Japan from April 2016 to December 2018. Three urinary antigen test kits were used: the novel kit (LAC-116), BinaxNOW Legionella (Binax), and Q-line Kyokutou Legionella (Q-line). In addition, sputum culture and nucleic acid detection tests and serum antibody tests were performed where possible. The diagnostic accuracy and correlations of the novel kit with the two existing kits were analyzed. RESULTS: In total, 56 patients were diagnosed with Legionella pneumonia. The sensitivities of LAC-116, Binax, and Q-line were 79%, 84%, and 71%, respectively. The overall match rate between LAC-116 and Binax was 96.8% and between LAC-116 and Q-line was 96.4%. One patient had L. pneumophila serogroup 2, and only LAC-116 showed a positive result, whereas Binax and Q-line did not. CONCLUSIONS: The novel Legionella urinary antigen test kit was useful for diagnosing Legionella pneumonia. In addition, it could detect Legionella pneumonia caused by non-L. pneumophila serogroup 1.

Risk factors for post-bronchoscopy pneumonia: a case-control study.

The bronchoscopy, though usually safe, is occasionally associated with complications, such as pneumonia. However, the use of prophylactic antibiotics is not recommended by the guidelines of the British Thoracic Society. Thus far there are few reports of the risk factors for post-bronchoscopy pneumonia; the purpose of this study was to evaluate these risk factors. We retrospectively collected data on patients in whom post-bronchoscopy pneumonia developed from the medical records of 2,265 patients who received 2666 diagnostic bronchoscopies at our institution between April 2006 and November 2011. Twice as many patients were enrolled in the control group as in the pneumonia group. The patients were matched for age and sex. In total, 37 patients (1.4%) had post-bronchoscopy pneumonia. Univariate analysis showed that a significantly larger proportion of patients in the pneumonia group had tracheobronchial stenosis (75.7% vs 18.9%, p < 0.01) and a final diagnosis of primary lung cancer (75.7% vs 43.2%, p < 0.01) than in the control group. The pneumonia group tended to have more patients with a history of smoking (83.8% vs 67.1%, p = 0.06) or bronchoalveolar lavage (BAL) (4.3% vs 14.9%, p = 0.14) than the control group. In multivariate analysis, we found that tracheobronchial stenosis remained an independent risk factor for post-bronchoscopy pneumonia (odds ratio: 7.8, 95%CI: 2.5-24.2). In conclusion, tracheobronchial stenosis was identified as an independent risk factor for post-bronchoscopy pneumonia by multivariate analysis in this age- and sex- matched case control study.

Ultrasensitive enzyme-linked immunosorbent assay for the detection of MPT64 secretory antigen to evaluate Mycobacterium tuberculosis viability in sputum.

OBJECTIVES: This study examined Mycobacterium tuberculosis (MTB)-secreted MPT64 as a surrogate of bacterial viability for the diagnosis of active pulmonary TB (PTB) and for follow-up treatment. METHODS: In this proof-of-concept prospective study, 50 PTB patients in the Tokyo metropolitan region, between 2017 and 2018, were consecutively included and 30 healthy individuals were also included. Each PTB patient submitted sputum on days 0, 14 and 28 for diagnosis and follow-up, and each healthy individual submitted one sputum sample. The following were performed: smear microscopy, Xpert MTB/RIF, MGIT and solid culture, and MPT64 detection on the sputum samples. Ultrasensitive ELISA (usELISA) was used to detect MPT64. The receiver operating characteristic analyses for diagnosis and follow-up revealed the optimal cut-off value of MPT64 absorbance for detecting culture positivity at multiple intervals. RESULTS: The sensitivity of MPT64 for diagnosing PTB was 88.0% (95% CI 75.7-95.5) and the specificity was 96.7% (95% CI 82.8-99.9). The specificity of MPT64 for predicting negative culture results on day 14 was 89.5% (95% CI 66.9-98.7). The sensitivity of MPT64 for predicting positive culture results on day 28 was 81.0% (95% CI 58.1-94.6). CONCLUSIONS: This study revealed that MPT64 is useful for diagnosing active PTB in patients and predicting treatment efficacy at follow-up.

Novel method for sputum induction using the Lung Flute in patients with suspected pulmonary tuberculosis.

BACKGROUND AND OBJECTIVE: The Lung Flute is a small self-powered audio device that generates sound waves, which vibrate in tracheobronchial secretions. This was a preliminary trial to evaluate the usefulness of the Lung Flute for sputum sampling in patients suspected of pulmonary tuberculosis (TB). METHODS: Thirty-four patients who were not expectorating sputum, but for whom sputum examination was required for the differential diagnosis of TB or other diseases, were enrolled in the study. Patients were instructed to blow out fast and hard through the Lung Flute and to repeat this for a total 20 sets of two blows each. RESULTS: Using the Lung Flute, sputum samples were collected within 10 or 20 min from 30 of 34 patients (88%). The device permitted a rapid diagnosis of TB in seven of 15 confirmed TB cases. In three patients acid-fast bacillus smears were positive. In four patients acid-fast bacillus smears were negative, but PCR tests for TB were positive. Hyperventilation-related symptoms occurred in three patients. CONCLUSIONS: The application of the Lung Flute may represent a promising technique for the rapid diagnosis of pulmonary TB.

[A case of sternoclavicular joint tuberculosis with renal failure due to rifampicin].

A 79-year-old man was admitted to a previous hospital complaining of left precordial swelling. Chest CT scan showed destruction of left sternoclavicular joint and a mass of 5 cm in diameter. Needle biopsy was performed and the diagnosis of sternoclavicular joint tuberculosis was made on the basis of presence of M. tuberculosis in the specimen. The patient was treated with isoniazid, ethambutol, rifampicin, and pyrazinamid but he developed renal failure. Then, he was transferred to our hospital. All medications were suspended because of the possibility of the side effect of drugs. We performed renal biopsy and histopathological examination revealed interstitial nephritis and minimal-change glomerulonephritis. From the result of examination, we considered interstitial nephritis was due to rifamicin. The treatment with 50 mg/day of prednisolone and isoniazid, ethambutol, and levofloxacin was administrated and renal failure and precordial mass were improved. Tuberculous arthritis usually affect hip and knee joint and sternoclavicular joint involvement is very rare.

[A cluster of paragonimiasis westermani infections in Thai immigrants].

We report a cluster of infections in four female Thai immigrants aged between 35 and 49 years who developed paragonimiasis westermani within 16 months of ingesting freshwater crabs purchased from a market in Japan. Their symptoms included cough, bloody sputum, chest pain, and dyspnea. Radiographic and CT findings comprised pleural effusion, pneumothorax, air-space consolidation, and nodular opacities. Paragonimus eggs were identified in the feces of one patient, and in the pleural effusion and the bronchoalveolar lavage fluid (BALF) of another. All diagnoses of paragonimiasis westermani were established by enzyme-linked immunosorbent assay (ELISA) of their serum. Paragonimiasis is a re-emerging disease in Japan. Moreover, since the number of immigrant patients is increasing, it is necessary to pay attention to infectious diseases resulting from their eating habits as well as imported diseases.