Rapid Detection of Severe Fever with Thrombocytopenia Syndrome Virus in the Acute Phase of Infection by Direct Real-Time Reverse Transcription without RNA Extraction.

No specific treatment has been developed for severe fever with thrombocytopenia syndrome (SFTS). However, the prognosis can improve with early plasma exchange. Therefore, rapid and accurate detection of SFTS virus is important for diagnosis and prognosis. Direct real-time reverse transcription polymerase chain reaction (RT-PCR) testing is easier and more time-efficient than conventional real-time RT-PCR. Our study compared direct real-time RT-PCR efficiency without the RNA extraction and purification of conventional real-time RT-PCR. Samples were collected from 18 patients with SFTS and five without SFTS. A strong correlation (r = 0.774, 95% CI: 0.652-0.857, P <0.01) was found between conventional and direct real-time RT-PCR assays. Direct real-time RT-PCR showed 84.4% sensitivity and 92.0% specificity for viral detection. Direct real-time RT-PCR is an effective diagnostic tool for patients with acute phase SFTS, but further optimization is required for viral detection.

Real-time monitoring of vitamin C levels in trauma patients by electron-spin resonance spectrometry.

BACKGROUND: In critically ill patients, healthy vitamin C levels are important to avoid an imbalance in reactive oxygen species. To achieve this, oxidative stress levels in emergency patients need to be accurately measured in real-time. However, normally, reactive oxygen/nitrogen species are short-lived, rendering measurement difficult; moreover, measurement of relatively stable antioxidants and other oxidative stress markers in real-time is challenging. Therefore, we used electron-spin resonance spectrometry (ESR) to assess vitamin C levels, clarify their relationship with patients' severity, and establish more effective vitamin C therapy in critically ill patients. METHODS: We studied 103 severely ill emergency patients and 15 healthy volunteers. Vitamin C radical (VCR/dimethyl sulfoxide [DMSO]) values were analyzed in arterial blood samples by ESR at admission and once daily thereafter during the acute recovery phase. Severity scores were calculated. The relationship between these scores and VCR/DMSO values and chronological changes in VCR/DMSO values were analyzed. RESULTS: Serum VCR/DMSO values were significantly lower in critically ill patients than in healthy volunteers (0.264 ± 0.014 vs. 0.935 ± 0.052, p < 0.05), particularly in the severe trauma group and the cardiopulmonary arrest/post-cardiac arrest syndrome group. VCR/DMSO values and various severity scores did not correlate at admission; however, they correlated with SOFA scores from days 2-6. VCR/DMSO values remained low from the first measurement day through Day 6 of illness. CONCLUSIONS: Vitamin C levels were low at admission, remained low with conventional nutritional support, and did not correlate with the initial patient's severity; however, they correlated with patients' severity after admission. Some patients had normal vitamin C levels. Therefore, vitamin C levels should be measured in real-time and supplemented if they are below normal levels. TRIAL REGISTRATION: Retrospectively registered.

Septic shock due to Yersinia pseudotuberculosis infection in an adult immunocompetent patient: a case report and literature review.

BACKGROUND: Yersinia pseudotuberculosis infection can occur in an immunocompromised host. Although rare, bacteremia due to Y. pseudotuberculosis may also occur in immunocompetent hosts. The prognosis and therapeutic strategy, especially for immunocompetent patients with Y. pseudotuberculosis bacteremia, however, remains unknown. CASE PRESENTATION: A 38-year-old Japanese man with a mood disorder presented to our hospital with fever and diarrhea. Chest computed tomography revealed consolidation in the right upper lobe with air bronchograms. He was diagnosed with pneumonia, and treatment with intravenous ceftriaxone and azithromycin was initiated. The ceftriaxone was replaced with doripenem and the azithromycin was discontinued following the detection of Gram-negative rod bacteria in 2 sets of blood culture tests. The isolated Gram-negative rod bacteria were confirmed to be Y. pseudotuberculosis. Thereafter, he developed septic shock. Doripenem was switched to cefmetazole, which was continued for 14 days. He recovered without relapse. CONCLUSIONS: We herein report a case of septic shock due to Y. pseudotuberculosis infection in an adult immunocompetent patient. The appropriate microorganism tests and antibiotic therapy are necessary to treat patients with Y. pseudotuberculosis bacteremia.

Successful treatment of left subclavian artery penetration due to ingestion of a safety pin by an elderly person.

BACKGROUND: Ingestion cases are increasing in elderly persons. Herein, we report a rare case of ingestion of a safety pin by an elderly person. CASE PRESENTATION: The patient was an 87-year-old bedridden woman who had fever with left pleural effusion. Chest X-ray revealed a foreign body, confirmed to be a safety pin, in the cervical esophagus. A contrast multidetector row computed tomography scan revealed that the opened safety pin penetrated the left subclavian artery, leading to the diagnosis of an esophageal foreign body penetrating the left subclavian artery. The safety pin was removed, and the subclavian artery aneurysm caused by the penetration was embolized by interventional radiology. After treatment, she was returned to the nursing home on postoperative day 8. CONCLUSION: Penetration by ingestion of a safety pin is rare; in this case, safe treatment was possible due to a team of certified specialist physicians and surgeons.

Veno-Venous Extracorporeal Membrane Oxygenation for Severe Pneumocystis jirovecii Pneumonia in an Immunocompromised Patient without HIV Infection.

Pneumocystis jirovecii pneumonia (PJP) occurs in immunocompromised hosts and is classified as PJP with human immunodeficiency virus (HIV) infection (HIV-PJP) and PJP without HIV infection (non-HIV PJP). Non-HIV PJP rapidly progresses to respiratory failure compared with HIV-PJP possibly due to the difference in immune conditions; namely, the prognosis of non-HIV PJP is worse than that of HIV PJP. However, the diagnosis of non-HIV PJP at the early stage is difficult. Herein, we report a case of severe non-HIV PJP successfully managed with veno-venous extracorporeal membrane oxygenation (V-V ECMO). A 54-year-old woman with neuromyelitis optica was treated with oral corticosteroid, azathioprine, and methotrexate. She admitted to our hospital for fever, dry cough, and dyspnea which developed a week ago. On admission, she required endotracheal intubation and invasive ventilation for hypoxia. A chest computed tomography (CT) scan revealed ground-glass opacity and consolidation in the both lungs. Grocott staining and PCR analysis of bronchoalveolar lavage fluid indicated the presence of fungi and Pneumocystis jirovecii, respectively, whereas serum HIV-antibody was negative. The patient was thus diagnosed with non-HIV PJP and was treated with intravenous pentamidine and corticosteroid pulse therapy for PJP. However, hypoxia was worsened; consequently, V-V ECMO assistance was initiated on day 7. The abnormal chest CT findings and hypoxia were gradually improved. The V-V ECMO support was successfully discontinued on day 14 and mechanical ventilation was discontinued on day 15. V-V ECMO could be a useful choice for respiratory assistance in severe cases of PJP among patients without HIV infection.

Naturally absorbed polyunsaturated fatty acids, lithium, and suicide-related behaviors: A case-controlled study.

OBJECTIVE: Previous studies have investigated the effects of omega-3, omega-6 and lithium on suicide-related behaviors separately. This study was performed to comprehensively investigate the effects of naturally absorbed EPA, DHA, arachidonic acid and lithium in relation to suicide attempt and deliberate self-harm, with adjustment for each other. METHODS: We analyzed plasma EPA, DHA, arachidonic acid levels and serum lithium levels of 197 patients including 33 patients with suicide attempts, 18 patients with deliberate self-harm, and 146 control patients. RESULTS: Multivariate logistic regression analysis with adjustment for age, gender, EPA, DHA, arachidonic acid and log-transformed lithium levels revealed that the negative associations with EPA levels (adjusted OR 0.972, 95% CI 0.947-0.997, p = 0.031) and log-transformed lithium levels (adjusted OR 0.156, 95% CI 0.038-0.644, p = 0.01) and the positive association with DHA levels (adjusted OR 1.026, 95% CI 1.010-1.043, p = 0.002) were significant in patients with suicide attempts than in control patients. The analysis also demonstrated that the positive association with arachidonic acid levels (adjusted OR 1.015, 95% CI 1.005-1.025, p = 0.004) was significant in patients with deliberate self-harm than in control patients. LIMITATIONS: The limitations are relatively small number of patients and the effects of demographics of individual patients could not be adjusted for the analyses. CONCLUSIONS: The present findings suggest that, as naturally absorbed nutrients, higher EPA and lithium levels may be associated with less suicide attempt, and that higher arachidonic acid levels may be associated with more deliberate self-harm.

Serum lithium levels and suicide attempts: a case-controlled comparison in lithium therapy-naive individuals.

BACKGROUND: Several epidemiological studies have shown the inverse association of lithium levels in drinking water and suicide rates; however, it is necessary to perform a clinical study dealing with individual patients. METHODS: We analyzed 199 patients including 31 patients with suicide attempts, 21 patients with self-harm, and 147 control patients. All were transferred to a university emergency department suffering from intoxication or injury, were aged 20 or more years, and were alive at the start of the study. The exclusion criteria consisted of suffering from schizophrenia and a past or present history of lithium therapy. These exclusions were applied because it is difficult to determine whether their suicide attempt was induced by the intent to end their life or by psychotic symptoms such as auditory hallucinations, and if the patient had received lithium therapy, the association between the small amount of lithium taken from drinking water and food and serum lithium levels cannot be detected. RESULTS: There was a significant difference (p = 0.043) between the three groups whereby patients with suicide attempts had significantly lower lithium levels than control patients (p = 0.012) in males but not females. Multivariate logistic regression analysis with adjustment for age and gender revealed that patients with suicide attempts had significantly lower lithium levels than control patients (p = 0.032, odds ratio 0.228, 95% CI 0.059-0.883). LIMITATIONS: The limitations of the present study are the nature of observational research which cannot reveal a causal relationship and the relatively small number of subjects. CONCLUSIONS: The present findings suggest that higher serum lithium levels may be protective against suicide attempts in lithium therapy-naive individuals.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis.

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).

Comparative analysis of mamushi (Gloydius blomhoffii) bite patients indicates that creatinine kinase levels/white blood cell count trends reflect severity.

Aim: There has been no indicator that allows an early quantitative evaluation of the severity of a mamushi snake (Gloydius blomhoffii) bite. Because the number of severe mamushi bite cases is much fewer than non-severe cases, a formal case-control study is difficult. Therefore, we tried to generate a preliminary quantitative, real-time index for its severity by referring to published reports of severe mamushi bite cases. Methods: We enrolled patients who presented with a mamushi bite and visited our outpatient clinic. Severe cases were collected from published works. Creatinine kinase levels and white blood cell counts of non-severe and severe cases were compared and analyzed. Results: There was a lag time of 10 h before the creatinine kinase level began to rise. The speed of the increase was higher in severe cases than in non-severe cases, and severe cases were recognized as those showing speeds of above 250 IU/L/h. White blood cell counts increased earlier than creatinine kinase levels without any lag time. Severe cases were recognized as those with the counts of over 1,000 × (h) + 6,000 [/µL] before 5 h and 300 × (h) + 10,000 [/µL] after 5 h. Conclusion: We herein present the creatinine kinase level and white blood cell count trends and demonstrate preliminary cut-off equations. The trends for both parameters serve as quantitative indicators of the severity of a mamushi bite until a large scale case-control study is achieved.

Chromobacterium haemolyticum Pneumonia Possibly Due to the Aspiration of Runoff Water.

Here, we report a case of pneumonia possibly caused by the aspiration of runoff water containing Chromobacterium haemolyticum. A 69-year-old man became intoxicated with alcohol, fell into a ditch, and lost consciousness after suffering a blow to the head. The lower half of his body was completely paralyzed because of damage to his spinal cord, and he aspirated runoff water from the ditch. Chest computed tomography scans revealed consolidation in the right upper lobe and bilateral lower lobes. A sputum culture detected gram-negative bacteria that was identified as C. haemolyticum. Antibacterial chemotherapy was initiated, and the clinical course was favorable. To the best of our knowledge, this is the first report of C. haemolyticum pneumonia in the literature.

Successful treatment with tacrolimus of progressive interstitial pneumonia associated with amyopathic dermatomyositis refractory to cyclosporine.

A 58-year-old male was admitted to our hospital because of periungual nailfold an erythema and erythematous rash on the dorsal joints of his hands and feet, but no muscle weakness. He was thus diagnosed to have amyopathic dermatomyositis. He had moderate hypoxemia and his chest computed tomography scans demonstrated bilateral ground-glass opacities, implicating complication with interstitial pneumonia. Therapy was initiated with pulsed methylprednisolone followed by high-dose corticosteroids, pulsed cyclophosphamide, and cyclosporine. The skin manifestations improved; however, the pulmonary infiltrates and hypoxemia deteriorated during the 2-month period of the treatment. The treatment was switched from cyclosporine to tacrolimus because of an inadequate clinical response to the therapy, and this resulted in the resolution of interstitial pneumonia. This case indicates that tacrolimus administration should be considered for patients with this life-threatening disorder when it is judged to be refractory to cyclosporine.

Significance of serum vascular endothelial growth factor level in patients with idiopathic pulmonary fibrosis.

Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis, which has been implicated in the pathogenesis of fibrotic lung diseases, including idiopathic pulmonary fibrosis (IPF). The aim of this study was to examine the clinical significance of the serum VEGF level for evaluating disease severity and progression. The levels of VEGF in serum were measured in 41 patients with IPF, 14 patients with lung cancer, and 43 healthy volunteers. We measured the serum levels of CRP, LDH, KL-6, SP-D, and the parameters obtained from arterial blood gas analysis and pulmonary function tests. High-resolution computed tomography (HRCT) was performed to determine the extent of the interstitial and the alveolar opacities. The ability of each biomarker to predict disease severity was estimated by measuring the area under the receiver operating characteristic curve (AUC). The VEGF levels of IPF patients with high alveolar-arterial difference of oxygen (AaDO(2)) levels were significantly elevated than those with low AaDO(2) levels and those of healthy volunteers. When examined within the IPF group, a significant positive correlation was found between the VEGF levels and the HRCT interstitial score (p = 0.027) and the KL-6 levels (p = 0.037). Among several serum biomarkers, VEGF showed the largest AUC for predicting disease severity as defined by a high AaDO(2) value. There was an inverse correlation between the baseline VEGF level and the monthly change in percent predicted vital capacity. The serum VEGF level may reflect the severity of IPF and offer clinical benefits to predict the disease's progression.

Increased serum ADAM8 concentration in patients with drug-induced eosinophilic pneumonia-ADAM8 expression depends on a the allergen route of entry.

BACKGROUND: ADAM8 (a disintegrin and a metalloprotease 8) has been linked to asthma and eosinophilic pneumonia (EP). ADAM8 cleaves a variety of substrates and is a sheddase for CD23, the low affinity IgE receptor. The concentration of soluble ADAM8 (sADAM8) is increased in bronchoalveolar lavage fluid (BALF) from patients with smoking-induced acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP), but not drug-induced EP (Drug-EP). In AEP, the BALF sADAM8 concentration significantly correlates with the soluble CD23 concentration (sCD23). METHODS: To evaluate the involvement of ADAM8 in the pathogenesis of eosinophilic pneumonia, we measured the concentrations of sADAM8 and its substrate, soluble CD23 (sCD23), in serum from patients with AEP, CEP, and Drug-EP. We also measured the change in the sADAM8 concentration after a provocation test. RESULTS: In contrast to the BALF findings, serum sADAM8 concentrations were increased in Drug-EP (mean+/-SEM; 639.6+/-49.15) and serum ADAM8 levels correlated positively with the serum sCD23 levels in patients with Drug-EP (P=0.0080, R(2)=0.8465). Serum sADAM8 concentrations were also increased in AEP (409+/-76.91) and CEP (644.7+/-87.03). Serum ADAM8 concentrations were also elevated after the provocation test. CONCLUSION: Serum ADAM8 concentrations were elevated in Drug-EP, although the sADAM8 concentrations were not increased in the BALF in Drug-EP. Thus, the pathogenesis of AEP and Drug-EP may be distinct with regard to allergen exposure; AEP may be caused by the inhalation of antigens, whereas Drug-EP may be caused by bloodstream antigens. These findings indicate that ADAM8 levels reflect the route of eosinophilic inflammation in EP.

Elevated concentrations of liver-expressed chemokine/CC chemokine ligand 16 in bronchoalveolar lavage fluid from patients with eosinophilic pneumonia.

BACKGROUND: Eosinophilic pneumonia is characterized by the prominent accumulation of eosinophils and lymphocytes in the lung parenchyma. Liver-expressed chemokine (LEC)/CC chemokine ligand 16 (CCL16) is a novel functional ligand for H4 which is expressed on eosinophils and also an affinity ligand for CCR1, CCR2, CCR5 and CCR8 which are expressed on T lymphocytes and monocytes. The purpose of this study is to clarify the role of LEC/CCL16 in eosinophilic pneumonia. METHODS: The LEC/CCL16 level was measured using an enzyme-linked immunosorbent assay in the bronchoalveolar lavage fluid (BALF) of 33 patients with eosinophilic pneumonia, 26 patients with sarcoidosis and 10 healthy volunteers. The cell sources of LEC/CCL16 in BALF were evaluated by immunocytochemistry. RESULTS: The LEC/CCL16 levels in BALF from patients with eosinophilic pneumonia were significantly higher than those from patients with sarcoidosis and healthy volunteers. The BALF LEC/CCL16 levels correlated with the numbers of BALF eosinophils and lymphocytes, respectively. The BALF LEC/CCL16 levels were significantly decreased after remission in eosinophilic pneumonia. In immunocytochemistry, the LEC/CCL16 expression was clearly observed in CD1a-positive dendritic cells as well as in CD68-positive macrophages harvested from patients with eosinophilic pneumonia, but not from the controls. CONCLUSIONS: These results suggest that LEC/CCL16 produced by dendritic cells as well as by alveolar macrophages contributes to the accumulation of eosinophils and lymphocytes into the inflamed lungs of patients with eosinophilic pneumonia.

[A case of pulmonary sarcoidosis demonstrating panlobular ground-glass opacity with mosaic distribution].

A 68-year-old woman presenting dyspnea on exertion was admitted. Hypoxemia and a considerably elevated level of serum KL-6 were noted. Chest high-resolution computed tomography (HRCT) scans demonstrated panlobular ground-glass opacities with a mosaic distribution and hilar and mediastinal lymphadenopathy. Bronchoalveolar lavage revealed an increased percentage of lymphocytes and an elevated CD4/CD8 ratio, implicating a diagnosis of sarcoidosis. However, as we could not exclude other diffuse lung diseases because of unusual HRCT pattern in sarcoidosis, video-assisted thoracoscopic lung biopsy was performed. The histology of epithelioid cell granulomas in the specimens of the lung and the lymph nodes confirmed a diagnosis of sarcoidosis. The lung specimens corresponding to areas of increased opacity demonstrated diffuse alveolitis with minimal fibrosis between individual granulomas. Immunohistochemistry for KL-6 provided positive results on alveolar lining cells in areas of alveolitis but not on granulomas. After steroid treatment, the ground-glass opacities disappeared and the serum KL-6 level normalized. We discuss this rare case of pulmonary sarcoidosis presenting panlobular ground-glass opacities with mosaic distribution.

Influence of age on symptoms and laboratory findings at presentation in patients with influenza-associated pneumonia.

Influenza virus infection is a major respiratory infectious disease that generally induces pneumonia. The clinical manifestations of influenza virus infection and community-acquired pneumonia (CAP) differ between elderly persons and younger adults. To determine the clinical features of influenza-associated pneumonia, we studied 21 adult patients with influenza-associated pneumonia, as indicated by positive test results for influenza virus antigen. At presentation, the higher-age patients (> or =75 years; n=12) with influenza-associated pneumonia had lower body temperature than did the lower-age (<75 years) patients (n=9). Conversely, the laboratory data indicated significantly higher C-reactive protein (CRP) concentration in higher-age patients than that in lower-age patients. None of the 18 patients undergoing neuraminidase inhibitor therapy died, but two of three patients who did not receive this therapy died from complications of advanced pneumonia. In this study, vaccination did not appear to be an important factor for prevention of pneumonia. High-age patients with CAP have lower body temperature, raising the possibility that diagnosis and treatment may be delayed in these patients. Increased CRP levels in these patients at presentation, however, could contribute to early detection of this serious pulmonary complication.

Asthma and sinusitis: association and implication.

BACKGROUND: Sinusitis occurs frequently in asthmatic patients. Epidemiologic data on sinusitis and lower airway disease must be evaluated with caution because they are based mostly on symptoms and do not include nasal endoscopic or computed tomography (CT) findings. Clinical support and evidence for this association are lacking. We evaluated the impact of sinusitis on lower airway disease in patients with well-characterized asthma. METHODS: Subjects (n = 188) completed a questionnaire designed to provide information about their signs and symptoms related to asthma, allergic rhinitis (AR) and sinus disease. Patients (n = 104) were divided into four groups based on the presence or absence of sinusitis and/or AR. Clinical findings were compared in asthma patients with and without diagnosed sinusitis, by an otorhinolaryngologist or based on sinus CT findings. RESULTS: The prevalence of sinusitis in patients with asthma was 36.7%. Sinus CT scan abnormalities were detected in 66.3% of patients with asthma. The scans revealed abnormal opacity in 17.9% of asthmatic patients without a history of sinusitis. There was a significant correlation between the rate of asthma severity and sinus morphologic abnormalities in patients with and without sinusitis. In adult-onset asthma (>or=16 years old), sinusitis frequently preceded asthma, whereas in non-adult-onset asthma (<16 years old) it preceded sinusitis. The complication rate of sinusitis in asthmatic patients was significantly higher in adult-onset asthma than in non-adult-onset asthma. CONCLUSIONS: Our findings suggest that bronchial asthma is closely related to sinusitis and the onset age of asthma is important when considering allergic disease frequency. Whether sinus disease directly affects the intensity of bronchial inflammation remains to be elucidated.

Reduced IgG levels found during acute eosinophilic pneumonia, which normalize during recovery from disease.

Clinically there are several different types of eosinophilic pneumonia (EP), but other than for tropical pulmonary eosinophilia, the humoral immune response between different types of EP, such as acute eosinophilic pneumonia (AEP), chronic EP, drug-induced EP, allergic bronchopulmonary aspergillosis, and Churg-Strauss syndrome, has not been examined. Immunoglobulin G (IgG) and E (IgE) serum concentrations were analyzed in patients with EP, or bacterial pneumonia, and in age-matched controls. Patients with AEP had lower IgG levels than the age-matched controls. Serum IgG levels in patients with AEP were significantly lower than in patients with other types EP or bacterial pneumonia. IgG2 and IgG4 were also significantly decreased in AEP, compared to age-matched controls. In AEP, the serum IgG levels were significantly decreased during active disease and increased during remission, but the serum IgE levels did not change significantly, indicating a decrease in serum IgG is a common feature of AEP. Low IgG levels were significantly correlated with serum surfactant protein D and absolute eosinophil counts in the bronchoalveolar lavage fluid of patients with AEP. This is the first reported study of immunoglobulin levels in AEP. The pathogenesis of AEP might negatively affect serum IgG levels, but not IgE levels. The present findings might indicate that serum IgG reflects the inflammatory response in AEP.

Amoxapine-associated acute respiratory distress.

A 37-year-old woman was admitted to our hospital because of acute respiratory distress. Two weeks previously, amoxapine (75 mg/day) had been administered for the first time. Ten days later she developed a high fever, severe hypoxaemia and pulmonary infiltrates on chest CT, including patchy areas of ground-glass opacity, thickening of the interlobular septae and bronchial walls and pleural effusions. BAL showed a predominance of neutrophils, lymphocytes and erythrocytes but not eosinophils. Amoxapine was stopped, resulting in complete resolution of the pulmonary infiltrates. When the patient was re-exposed to amoxapine (52.5 mg total dose), high fever, reduced SaO(2) and pulmonary infiltrates reappeared. We concluded that acute respiratory distress may be associated with amoxapine treatment.