A fatal case report of invasive pulmonary aspergillosis and mucormycosis coinfection in an immunocompetent patient with coronavirus disease 2019 in Korea.

Systemic glucocorticoid treatment is highly recommended in critically ill coronavirus disease 2019 (COVID-19) patients. However, secondary fungal infections are of concern in such patients. Here, we describe the first case of COVID-19-associated invasive pulmonary aspergillosis (CAPA) and COVID-19-associated mucormycosis (CAM) coinfection in a COVID-19 positive immunocompetent patient in Korea. A 69-year-old man was admitted to our hospital with COVID-19 pneumonia. He had no underlying comorbidities and was not taking medications. He received remdesivir, dexamethasone, and antibiotic therapy under mechanical ventilation. Although his condition improved temporarily, multiple cavities were observed on chest computed tomography, and Aspergillus fumigatus was cultured from tracheal aspiration culture. He was diagnosed with probable CAPA and received voriconazole therapy. However, his condition was not significantly improved despite having received voriconazole therapy for 4 weeks. After release from COVID-19 quarantine, he underwent bronchoscopy examination and was then finally diagnosed with CAPA and CAM coinfection on bronchoscopic biopsy. Antifungal treatment was changed to liposomal amphotericin B. However, his progress deteriorated, and he died 4 months after admission. This case highlights that clinical suspicion and active checkups are required to diagnose secondary fungal infections in immunocompetent COVID-19 patients who receive concurrent glucocorticoid therapy.

A physician-led medical emergency team increases the rate of medical interventions: A multicenter study in Korea.

BACKGROUND: According to the rapid response system's team composition, responding teams were named as rapid response team (RRT), medical emergency team (MET), and critical care outreach. A RRT is often a nurse-led team, whereas a MET is a physician-led team that mainly plays the role of an efferent limb. As few multicenter studies have focused on physician-led METs, we comprehensively analyzed cases for which physician-led METs were activated. METHODS: We retrospectively analyzed cases for which METs were activated. The study population consisted of subjects over 18 years of age who were admitted in the general ward from January 2016 to December 2017 in 9 tertiary teaching hospitals in Korea. The data on subjects' characteristics, activation causes, activation methods, performed interventions, in-hospital mortality, and intensive care unit (ICU) transfer after MET activation were collected and analyzed. RESULTS: In this study, 12,767 cases were analyzed, excluding those without in-hospital mortality data. The subjects' median age was 67 years, and 70.4% of them were admitted to the medical department. The most common cause of MET activation was respiratory distress (35.1%), followed by shock (11.8%), and the most common underlying disease was solid cancer (39%). In 7,561 subjects (59.2%), the MET was activated using the screening system. The commonly performed procedures were arterial line insertion (17.9%), intubation (13.3%), and portable ultrasonography (13.0%). Subsequently, 29.4% of the subjects were transferred to the ICU, and 27.2% died during hospitalization. CONCLUSIONS: This physician-led MET cohort showed relatively high rates of intervention, including arterial line insertion and portable ultrasonography, and low ICU transfer rates. We presume that MET detects deteriorating patients earlier using a screening system and begins ICU-level management at the patient's bedside without delay, eventually preventing the patient's condition from worsening and transfer to the ICU.

Intramuscular and Intermuscular Abdominal Fat Infiltration in COPD: A Propensity Score Matched Study.

Purpose: Low-attenuation muscle area (LAMA) and normal-attenuation muscle area (NAMA) indicate lipid-rich and lipid-poor skeletal muscle areas, respectively. Additionally, intermuscular adipose tissue (IMAT) indicates localized fat between muscle groups. In this study, we aimed to evaluate the intramuscular and intermuscular fat infiltration in individuals with chronic obstructive pulmonary disease (COPD) by performing quantitative assessment of the LAMA, NAMA, and IMAT observed on abdominopelvic computed tomography (APCT) images. Patients and Methods: We performed a cross-sectional study using data of subjects who underwent a general health examination with APCT at Ulsan University Hospital between March 2014 and June 2019. We classified the subjects into control and COPD groups based on age, smoking history, and pulmonary function results. We compared the attenuation and body mass index adjusted area of intra-abdominal components between the two groups using propensity score matching. We also evaluated these outcomes in COPD subgroups (mild and moderate stage subjects). Results: Overall, 6,965 subjects were initially enrolled, and 250 pairs of control and COPD subjects were selected after propensity score matching. The NAMA attenuation (unstandardized ß=-1.168, P<0.001) was lower, and the IMAT (unstandardized ß=0.042, P=0.006) and LAMA (unstandardized ß=0.120, P<0.001) indexes were greater in the COPD group than in the control group. In subgroup analysis, those with mild and moderate COPD also had high IMAT (unstandardized ß=0.037, P=0.009 and unstandardized ß=0.045, P<0.001) and LAMA (unstandardized ß=0.089, P=0.002 and unstandardized ß=0.147, P<0.001) indexes compared to the control subjects. However, the NAMA attenuation (unstandardized ß=-1.075, P<0.001) and NAMA index (unstandardized ß=-0.133, P=0.015) were significantly lower in moderate COPD subjects only. Conclusion: Our study showed that intramuscular and intermuscular abdominal fat infiltration could be present in subjects with mild COPD, and it might be exacerbated in those with moderate COPD.

Histiocytic pleural effusion: the strong clue to malignancy.

BACKGROUND: There have been many studies on the clinical characteristics of neutrophilic, lymphocytic, and/or eosinophilic pleural effusion. While caring for patients with pleural effusion, we found that histiocytic pleural effusion (HisPE) was not uncommon. However, few studies have explored HisPE. The purpose of the present study was to determine the clinical characteristics and etiologies of HisPE. METHODS: In this retrospective study, HisPE was defined as pleural fluid white blood cells comprised of ≥ 50% histiocytes. Using a clinical data warehouse, patients with HisPE among all patients aged >18 years who underwent thoracentesis and pleural fluid analysis between January 2010 and December 2019 at Ulsan University Hospital were enrolled. A total of 295 (9.0%) of 3279 patients who underwent thoracentesis were identified as HisPE patients. Among them, 201 with exudative HisPE were included. Clinical characteristics and etiologies were extracted from medical records and analyzed. RESULTS: Among the 201 patients with exudative HisPE, the major causes were malignant pleural effusion (n = 102 [50.7%]), parapneumonic effusion (n = 9 [4.5%]), and tuberculous pleurisy (n = 9 [4.5%]). In the 102 patients with malignant pleural effusion, the main types of cancer were lung (n = 42 [41.2%]), breast (n = 16 [15.7%]), and stomach cancer (n = 11 [10.8%]). Among lung cancers, adenocarcinoma (n = 34 [81.0%]) was the most common histology. CONCLUSIONS: The leading cause of exudative HisPE was malignancy, particularly lung cancer. Physicians should consider the possibility of malignant disease if histiocytes are predominantly present in pleural effusion.

The association between hospital length of stay before rapid response system activation and clinical outcomes: a retrospective multicenter cohort study.

BACKGROUND: Rapid response system (RRS) is being increasingly adopted to improve patient safety in hospitals worldwide. However, predictors of survival outcome after RRS activation because of unexpected clinical deterioration are not well defined. We investigated whether hospital length of stay (LOS) before RRS activation can predict the clinical outcomes. METHODS: Using a nationwide multicenter RRS database, we identified patients for whom RRS was activated during hospitalization at 9 tertiary referral hospitals in South Korea between January 1, 2016, and December 31, 2017. All information on patient characteristics, RRS activation, and clinical outcomes were retrospectively collected by reviewing patient medical records at each center. Patients were categorized into two groups according to their hospital LOS before RRS activation: early deterioration (LOS < 5 days) and late deterioration (LOS ≥ 5 days). The primary outcome was 28-day mortality and multivariable logistic regression was used to compare the two groups. In addition, propensity score-matched analysis was used to minimize the effects of confounding factors. RESULTS: Among 11,612 patients, 5779 and 5883 patients belonged to the early and late deterioration groups, respectively. Patients in the late deterioration group were more likely to have malignant disease and to be more severely ill at the time of RRS activation. After adjusting for confounding factors, the late deterioration group had higher 28-day mortality (aOR 1.60, 95% CI 1.44-1.77). Other clinical outcomes (in-hospital mortality and hospital LOS after RRS activation) were worse in the late deterioration group as well, and similar results were found in the propensity score-matched analysis (aOR for 28-day mortality 1.66, 95% CI 1.45-1.91). CONCLUSIONS: Patients who stayed longer in the hospital before RRS activation had worse clinical outcomes. During the RRS team review of patients, hospital LOS before RRS activation should be considered as a predictor of future outcome.

Diagnosing peripheral lung lesions using endobronchial ultrasonography with guide sheath: A prospective registry study to assess the effect of virtual bronchoscopic navigation using a computed tomography workstation.

Bronchoscopy has a lower diagnostic yield for peripheral lung lesions (PLL). Endobronchial ultrasound guide sheath transbronchial lung biopsy (EBUS GS TBLB) has been used to overcome such limitation. Recent studies revealed that combined methods (e.g., EBUS GS TBLB plus electromagnetic navigation [EMN] or virtual bronchoscopic navigation [VBN]) further improve the diagnostic yield. However, those systems are associated with a high cost burden. Accordingly, we attempted to use VBN by computed tomography (CT) workstation (Aquarius iNtuition, TeraRecon) not dedicated only for VBN as an adjunctive tool for EBUS GS TBLB. We performed a prospective registry study to investigate whether VBN by CT workstation could improve the diagnostic yield of PLL.Between February 2017 and February 2018, 128 patients with PLL were divided into 2 groups (VBN and non-VBN [NVBN]). In NVBN group (n = 64), EBUS GS TBLB was performed using a hand-drawn bronchial map based on CT images. VBN group (n = 64) underwent EBUS GS TBLB using VBN images.VBN using CT workstation did not improve the diagnostic yield of EBUS GS TBLB for PLL (VBN vs NVBN, 72% vs 80%, P = .284). VBN slightly reduced procedure time (minute [mean ±â€ŠSD], 25.31 ±â€Š10.33 vs 25.81 ±â€Š9.22), navigation time (time to find the lesion) (9.10 ±â€Š7.88 vs 9.50 ±â€Š7.14), and fluoroscopy time (2.23 ±â€Š2.39 vs 2.86 ±â€Š4.61), while these differences were not statistically significant.The diagnostic yield of EBUS GS TBLB was not improved with VBN (compared with using a hand-drawn bronchial map). Although VBN slightly shortened the procedure-related times, which were not significantly different.

Circulating Tumor Cell Number Is Associated with Primary Tumor Volume in Patients with Lung Adenocarcinoma.

BACKGROUND: Circulating tumor cells (CTCs) are frequently detected in patients with advanced-stage malignant tumors and could act as a predictor of poor prognosis. However, there is a paucity of data on the relationship between CTC number and primary tumor volume in patients with lung cancer. Therefore, our study aimed to evaluate the relationship between CTC number and primary tumor volume in patients with lung adenocarcinoma. METHODS: We collected blood samples from 21 patients with treatment-naive lung adenocarcinoma and 73 healthy individuals. To count CTCs, we used a CTC enrichment method based on fluid-assisted separation technology. We compared CTC numbers between lung adenocarcinoma patients and healthy individuals using propensity score matching, and performed linear regression analysis to analyze the relationship between CTC number and primary tumor volume in lung adenocarcinoma patients. RESULTS: CTC positivity was significantly more common in lung adenocarcinoma patients than in healthy individuals (p<0.001). The median primary tumor volume in CTC-negative and CTC-positive patients was 10.0 cm³ and 64.8 cm³, respectively. Multiple linear regression analysis showed that the number of CTCs correlated with primary tumor volume in lung adenocarcinoma patients (ß=0.903, p=0.002). Further subgroup analysis showed a correlation between CTC number and primary tumor volume in patients with distant (p=0.024) and extra-thoracic (p=0.033) metastasis (not in patients with distant metastasis). CONCLUSION: Our study showed that CTC numbers may be associated with primary tumor volume in lung adenocarcinomas patients, especially in those with distant metastasis.

Clinical outcomes of immunocompromised patients on extracorporeal membrane oxygenation support for severe acute respiratory failure.

OBJECTIVES: There are limited data regarding extracorporeal membrane oxygenation (ECMO) support in immunocompromised patients, despite an increase in ECMO use in patients with respiratory failure. The aim of this study was to investigate the clinical characteristics and outcomes of immunocompromised patients requiring ECMO support for severe acute respiratory failure. METHODS: Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into 2 groups based on the immunocompromised status at the time of ECMO initiation. In-hospital and 6-month mortalities were compared between the 2 groups. In addition, association of immunocompromised status with 6-month mortality was evaluated with logistic regression analysis. RESULTS: Among 461 patients, 118 (25.6%) were immunocompromised. Immunocompromised patients were younger and had lower haemoglobin and platelet counts than immunocompetent patients. Ventilatory parameters and the use of adjunctive/rescue therapies were similar between the 2 groups, but prone positioning was more commonly used in immunocompetent patients. Successful weaning rates from ECMO (46.6% vs 58.9%; P = 0.021) was lower and hospital mortality (66.1% vs 59.8%; P = 0.22) was higher in immunocompromised patients. In addition, immunocompromised status was associated with higher 6-month mortality (74.6% vs 64.7%, adjusted odds ratio 2.10, 95% confidence interval 1.02-4.35; P = 0.045). CONCLUSIONS: Immunocompromised patients treated with ECMO support for severe acute respiratory failure had poorer short- and long-term prognoses than did immunocompetent patients.

Lung Compliance and Outcomes in Patients With Acute Respiratory Distress Syndrome Receiving ECMO.

BACKGROUND: Limited data are available regarding mechanical ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation (ECMO). METHODS: A retrospective analysis of acute respiratory distress syndrome patients on ECMO was conducted in 9 hospitals in Korea. Data on ventilator settings (pre-ECMO and 0, 4, 24, and 48 hours after ECMO) were collected. Based on the effect of the duration and intensity of mechanical ventilator on outcomes, time-weighted average values were calculated for ventilator parameters. RESULTS: The 56 patients included in the study had a mean age of 55.5 years. The hospital and 6-month mortality rates were 48.1% and 54.0%, respectively, with a median ECMO duration of 9.4 days. After initiation of ECMO, peak inspiratory pressure, above positive end-expiratory pressure, tidal volume, and respiration rate were reduced, while lung compliance did not change significantly. Before and during ECMO support, tidal volume and lung compliance were higher in 6-month survivors than in nonsurvivors. In Cox proportional models, both lung compliance (odds ratio, 0.961; 95% confidence interval, 0.928 to 0.995) and time-weighted average-lung compliance (odds ratio, 0.943; 95% confidence interval, 0.903 to 0.986) were significantly associated with 6-month mortality. Kaplan-Meier curves revealed that patients with higher lung compliance before ECMO had a longer survival time at the 6-month follow-up than did those with lower lung compliance. CONCLUSIONS: Lung compliance, whether before or during ECMO, may be an important predictor of outcome in acute respiratory distress syndrome patients receiving ECMO. However, this result requires confirmation in larger clinical studies.

Gynecomastia induced by H1-antihistamine (ebastine) in a patient with idiopathic anaphylaxis.

H1-antihistamine is generally a well-tolerated and safe drug. However, in resemblance with all other drugs, H1-antihistamines can also prompt adverse drug reactions (ADRs). We recently encountered the very unusual ADR of H1-antihistamine-induced gynecomastia. A 21-year-old man with idiopathic anaphylaxis was treated with ebastine (Ebastel), a second-generation H1-antihistamine, for the prevention of anaphylaxis. Three months later, the patient remained well without anaphylaxis, but had newly developed gynecomastia. Because anaphylaxis recurred after the cessation of H1-antihistamine, the preventive medication was changed to omalizumab. A few months later, his gynecomastia had entirely disappeared. Physicians should be aware of this exceptional ADR of H1-antihistamine.

Massive hemoptysis due to pulmonary vein stenosis following catheter ablation for atrial fibrillation.

Pulmonary vein stenosis, which is one of the rare complications of radiofrequency catheter ablation for atrial fibrillation, has various symptoms. Here, we report a rare case of massive hemoptysis due to pulmonary vein stenosis following radiofrequency catheter ablation, which was successfully managed with pneumonectomy.

Clinical characteristics and survival of Korean idiopathic pulmonary arterial hypertension patients based on vasoreactivity.

We aimed to identify a vasoreactive subset of patients with idiopathic pulmonary arterial hypertension (IPAH) in Korea and to show their clinical characteristics and prognosis. Data on patients who were diagnosed with IPAH at Asan Medical Center between January 1994 and March 2013 were retrospectively collected. Acute vasodilator testing was performed with inhaled nitric oxide during diagnostic right heart catheterization. A positive acute response was defined as a reduction in mean pulmonary arterial pressure (PAP) ≥10 mmHg to an absolute level of mean PAP <40 mmHg without a decrease in cardiac output. Among a total of 60 IPAH patients included for analysis, 9 (15%) showed a positive acute response to acute vasodilator testing. Acute responders showed significantly lower peak velocity of a tricuspid regurgitation jet on echocardiography (4.1±0.3 m/s vs. 4.6±0.6 m/s; P=0.01) and significantly lower mean PAP hemodynamically (47±10 mmHg vs. 63±17 mmHg; P=0.003) than non-responders at baseline. The survival rate of acute responders was 88% at 1, 3, 5, and 10 yr, respectively, which was significantly higher than that of non-responders (85%, 71%, 55%, and 40%, respectively; P=0.029). In conclusion, Korean IPAH patients with vasoreactivity showed better baseline hemodynamic features and survival than those without vasoreactivity.

Disseminated Mycobacterium intracellulare Infection in an Immunocompetent Host.

Disseminated Mycobacterium avium complex (MAC) infection can occur in immunocompromised patients, and rarely in immunocompetent subjects. Due to the extensive distribution of the disease, clinical presentation of disseminated MAC may mimic malignancies, and thorough examinations are required in order to make accurate diagnosis. We report a case of disseminated Mycobacterium intracellulare disease in an immunocompetent patient, which involved the lung, lymph nodes, spleen, and multiple bones. F-18 fluorodeoxyglucose positron-emission tomography imaging showed multiple hypermetabolic lesions, which are suggestive of typical hematogenous metastasis. However, there was no evidence of malignancy in serial biopsies, and M. intracellulare was repeatedly cultured from respiratory specimens and bones. Herein, we should know that disseminated infection can occur in the immunocompetent subjects, and it can mimic malignancies.