Spinal epidural abscess caused by Pasteurella multocida mimicking aortic dissection: a case report.

BACKGROUND: Pasteurella multocida (P. multocida) forms part of the normal flora of many animals. Although it is a common causative agent of skin and soft tissue infection after an animal bite or scratch, in rare cases it can cause spinal infections in humans. CASE PRESENTATION: A 68-year-old immunocompetent woman presented with fever and sudden onset of severe back pain mimicking aortic dissection. No findings related to the pain were revealed on enhanced computed tomography or initial magnetic resonance imaging (MRI) of the spine. The patient was found to be bacteremic with P. multocida, although she had no apparent injury related to animal contact. Repeated evaluation by MRI with gadolinium-contrast established the diagnosis of spinal epidural abscess. The patient was cured by the rapid initiation of antimicrobial therapy without surgery. CONCLUSIONS: We describe the successful treatment of an individual with a spinal epidural abscess due to P. multocida without surgery. P. multocida infections may occur as sudden presentations. Obtaining the patient history of recent animal contact is essential. Repeated MRI evaluation may be required when spinal infections are suspected. To the best of our knowledge, this is the first report which describes a case of spinal epidural abscess due to this organism.

Putting things in and taking them out of containers: a young child's interaction with objects.

Introduction: How does the behavior of putting things away (putting them in) in a container and using them again (taking them out) develop in young children? Though object interaction is one of the most examined topics in child development, research on organized behavior with various objects and containers at home is lacking. Rather than conducting experiments on young children's interactions with objects, this study focused on natural child-object interaction in the home. Methods: We conducted a case study on a young child's natural interaction with objects at home, focusing on when the child puts them in or takes them out of a container (the shelf, the cabinet, or the box). The study took place over 2½ years. Results: The behaviors of putting many objects in a container and taking them out appeared at 9 months old. After acquiring the skill of walking, the child carried the objects using bags. Putting objects in and taking them out was embedded in the locomotion, and the child prepared the containers of toys before play. Pulling as many objects out as possible became rare after 19 months of age. Taking objects out became more appropriate in that context. The child brought out the container before the activity and put things away afterward. Discussion: Based on these findings, the development of organized object interaction as well as the anticipation and significance of the naturalistic longitudinal observations are discussed.

Clarithromycin-induced eosinophilic granulomatosis with polyangiitis: A case report.

A 75-year-old man presented to our hospital with chronic sinusitis, bronchiectasis, and chronic lower respiratory tract infections. He began taking erythromycin in August, X-2. The chronic lower respiratory tract infection gradually worsened, and clarithromycin was started on May 11, X. He became aware of fever and numbness in his lower legs on June 4, X. The sign occurred soon after oral clarithromycin and blood tests showed an elevated eosinophil count and C-reactive protein (CRP) levels, positive MPO-ANCA antibodies, and positive for drug-induced lymphocyte stimulation test (DLST); we diagnosed eosinophilic granulomatosis with polyangiitis (EGPA) associated with clarithromycin administration.

[Pneumonitis induced by rifampicin].

An 86-year-old male with pulmonary tuberculosis developed fever, rash, and interstitial pneumonia 3 weeks after the beginning of treatment with isoniazid (INH), rifampicin (RFP), and ethambutol (EB). Chest CT showed new infiltration shadows that were diffuse bilateral ground-glass opacities mixed with dense consolidation and septal thickening, accompanied by a small amount of pleural effusion. Drug-induced pneumonitis was suspected, and therefore the antituberculous regimen was discontinued. The radiologic findings and symptoms improved promptly. A provocation trial with RFP lead to fever, diarrhea, and rash. Therefore, RFP was considered to be the causative drug. INH and EB were reintroduced without any recurrence of the symptoms. Clinicians should be aware not only of paradoxical reactions but also of drug-induced pneumonitis, when a new pulmonary infiltrate develops in the course of tuberculosis treatment.

[Qualitative analysis of interns' decision-making process of selecting respiratory medicine as their specialty].

BACKGROUND: Because there is a shortage of pulmonologists in Japan, it is crucial to understand interns' decision-making process of selecting respiratory medicine as their specialty. OBJECTIVE: The objectives of the study were to illustrate the process in which residents pursue the specialty of respiratory medicine and to establish a strategic springboard that may encourage more residents to select respiratory medicine as their specialty. METHODS: A qualitative study using semi-structured interviews was performed. Eleven doctors who had selected respiratory medicine were recruited. We measured categories which constitute the process of career choice. RESULTS: The present analysis of 11 interviews produced three main categories that influenced residents' career decision. Those were "ambiguous preference for respiratory medicine", "triggers for interests on respiratory medicine", and "comparisons and contemplations among specialties". "Triggers for interests" were as follows: experiencing effectual mentorship in respiratory medicine, being impressed with pulmonologists' daily practice, taking an interest in anatomy and physiology, and exposing themselves to clinical practice repeatedly. Through "comparisons and contemplations among specialties", the interviewees recognized respiratory medicine as attractive, because of its close association with other internal medicine disciplines, the comprehensive diagnostic process, and the diversity of respiratory diseases. CONCLUSION: Experiencing enthusiastic mentorship, being impressed with pulmonologists' daily practice, and realizing profoundness of respiratory medicine influenced the decision-making process.

[Long-term follow up study of four cases of pulmonary Langerhans' cell histiocytosis].

We reported the clinical features of 4 cases with pulmonary Langerhans' cell histiocytosis. All of them were men who had a history of smoking. They ranged in age from 23 to 46 years. Cases 1 and 3 did not stop smoking, while Cases 2 and 4 did stop smoking. All of the chest CTs revealed small nodules and cysts, and during the follow-up period of 8 to 13 years, the numbers of nodules decreased and the walls of the cysts became thin in all of the cases. Their pulmonary function tests revealed restrictive impairment in 3 cases and reduced diffusion capacity in 2 cases, but none showed obstructive impairment. FEV1% and DL(CO) deteriorated during the follow-up period. Case 1 died of respiratory failure after 8 years. Cases 2 and 4 were both alive with home oxygen therapy after 11 and 12 years, respectively. Case 3 was alive but complained of dyspnea on exertion after 13 years. In conclusion, all of the 4 cases showed deterioration of pulmonary function, and one of them died due to respiratory failure. The prognosis of patients with pulmonary Langerhans' cell histiocytosis appears to be poor.

Ten-year experience of smoking cessation in a single center in Japan.

BACKGROUND: Long-term, real-world data, as opposed to academic or research data, on outcomes of smoking cessation clinics are scarce. We assessed patient outcomes over a 10-year period at a smoking cessation clinic in a community teaching hospital in Japan and explored predictors of successful smoking cessation. METHODS: We used data from a prospective registry of cigarette smokers who participated in a 3-month smoking cessation program comprising combined pharmacological treatment and cognitive behavioral therapy and explored factors associated with program execution and successful smoking cessation. The primary outcome was smoking cessation, defined by quitting completely between the 8-week and 12-week sessions, with verification according to exhaled carbon monoxide (CO) level of ≤10 ppm. RESULTS: Between August 2007 and December 2017, 813 patients with nicotine dependence participated in the program. The number of participants decreased after Japan׳s 2010 tobacco tax increase. Among participants, 433 (53.3%) completed the program. In multivariate analysis, the number of cigarettes smoked daily (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.96, 0.99), cardiovascular disease (OR 1.75, 95% CI 1.16, 2.68), chronic obstructive pulmonary disease (OR 1.74, 95% CI 1.10, 2.78), and gastric/duodenal ulcer (OR 1.77, 95% CI 1.04, 3.08) were significantly associated with program completion. Among program completers, 288 (66.5%) achieved smoking cessation. Exhaled CO level (OR 0.94, 95% CI 0.93, 0.97) and mental disorders (OR 0.53, 95% CI 0.33, 0.85) were negatively associated with successful smoking cessation. CONCLUSIONS: Baseline exhaled CO level and mental disorders were significantly associated with either success or failure of smoking cessation.

[A case of ANCA-associated vasculitis with diffuse alveolar hemorrhage successfully treated by plasmapheresis].

A 65-year-old man was admitted due to rapidly progressing dyspnea experienced over a 3-day period. Chest radiography and computed tomography conducted upon admission showed diffuse bilateral interstitial infiltrate. Bronchoalveolar lavage fluid contained blood and siderophores, which suggested pulmonary alveolar hemorrhage. Laboratory data showed that the serum MPO-ANCA level was elevated, and so ANCA-associated pulmonary hemorrhage was diagnosed. Although aggressive immunosuppressive agents were administered, including steroids and cyclophosphamides, the patient's condition worsened. Plasmapheresis using fresh frozen plasma was performed on day 5, after which his symptoms improved dramatically. Plasmapheresis was done 6 times, and the pulmonary lesions resolved. The patient was discharged 6 months later. This case report suggests that plasmapheresis may be an effective treatment for ANCA-associated vasculitis with diffuse alveolar hemorrhage that is resistant to aggressive immunosuppressive therapy.

[A case of pulmonary aspergillosis accompanied with eosinophilic pneumonia].

An infiltrative shadow was observed in the upper lobe of the left of a 60-year-old man lung during the course of paroxysmal tachycardia. Fever and coughing occurred one month later, and ground-glass opacities (GGOs) were found extensively in the lower left lung field. Although his condition strongly suggested allergic bronchopulmonary aspergillosis (ABPA) due to significantly increased eosinophil count in the peripheral blood and bronchoalveolar lavage fluid of the lower lobe of the left lung, anti-aspergillus antibody precipitation, and positive immediate intradermal test, the Rosenberg diagnostic criteria for ABPA were not satisfied. He was given a diagnosis of eosinophilic pneumonia, and GGO disappeared when itraconazole and prednisolone were administered. However, since the shadow in the upper lobe of the left lung later increased and percutaneous thoracocentesis revealed the presence of Aspergillus fumigatus, prednisolone treatment was discontinued and micafungin was administered. Nonetheless, the shadow spread into both lungs and regardless of treatment with amphotericin-B, the patient died. Although the present case is different from a typical ABPA, it indicates that allergic reaction can be induced by Aspergillus infection in the lung field, apart from the central airway. In addition, the development of an appropriate therapeutic strategy against both infection and allergy in such cases is essential.

[A case of myelodysplastic syndrome complicated with organizing pneumonia].

A 74-year-old man had been given a diagnosis of myelodysplastic syndrome (MDS), and had been treated with granulocyte-colony stimulating factor (G-CSF). 1 year later, he suffered from fever and his chest X-ray lung biopsy did not provide a diagnosis, video-assisted thoracoscopic lung biopsy was performed, which yielded a histological diagnosis of organizing pneumonia. His pulmonary disease was diagnosed as secondary organizing pneumonia due to MDS, and was treated successfully with steroids. Vigorous efforts to establish a histological diagnosis is needed for the antibiotics-resistant pneumonia in the case of MDS.

Impact of smoking cessation therapy on health-related quality of life.

BACKGROUND: Smoking is associated with poor health-related quality of life (HRQL); however, there are few data regarding effects of smoking cessation treatment on HRQL. The purpose of this study was to describe changes in HRQL after smoking cessation treatment and to elucidate factors influencing this improvement in HRQL. SETTING: Smoking cessation clinic at a 358-bed community teaching hospital in Japan. METHODS: We conducted a prospective cohort study of cigarette smokers who participated in a 3-month smoking cessation programme. HRQL was assessed at baseline and at the end of the programme using the St. George's Respiratory Questionnaire (SGRQ). The abstinence was subjected to verification by an exhaled CO level of ≤10 ppm. RESULTS: Of 570 participants in the programme, 277 (mean age: 60.9±12.2 y, male/female=180/97) were eligible; excluded were 277 participants who dropped out of the programme and 16 for whom SGRQs were not available or were incomplete. Initial prescribed pharmacotherapy was transdermal nicotine patches in 160 participants and varenicline in 117. At 12 weeks, SGRQ scores improved significantly as follows (mean±SD): Δ symptoms score, -5.7±16.0; Δ activity score, -4.4±18.3; Δ impact score, -5.3±13.5 and Δ total score, -5.1±12.2 (p<0.0001 in all cases). There were no significant differences in changes in SGRQ scores between quitters (n=183) and continuous smokers (n=94). In a multivariate analysis, only the average nicotine addiction level according to the Tobacco Dependence Screener test was associated with a clinically significant improvement in the SGRQ (OR 1.35 (95% CI 1.15 to 1.59)). Marked reduction in number of cigarettes smoked with a corresponding low median exhaled CO level of 7 ppm in continuous smokers following therapy was observed. CONCLUSIONS: Smoking cessation treatment improved HRQL regardless of quit status. Baseline nicotine addiction level was predictive of that improvement.

Reversed halo sign in pulmonary infarction with tumor emboli: a case report.

We describe the case of a 79-year-old woman with pulmonary infarction due to tumor emboli whose high-resolution CT (HRCT) scan demonstrated the reversed halo sign. The patient had gastric cancer and died because of cancer-related cerebral infarction. On autopsy, the central ground-glass area of the reversed halo sign on HRCT corresponded to pulmonary edema associated with alveolar septal capillary metastasis, whereas the peripheral ring-like consolidation consisted of a hemorrhagic infarct with tumor emboli. The present case is important because a detailed pathologic correlation with this unique HRCT appearance was revealed.

Association of hyperglycemia on admission and during hospitalization with mortality in diabetic patients admitted for pneumonia.

OBJECTIVE: Information available on the clinical features and outcomes of pneumonia in diabetic patients is limited. There are no data on the association between glycemic control during hospitalization and mortality in this population. The objective of this study is to examine whether the presence of hyperglycemia on admission and during hospitalization is associated with mortality in diabetic patients admitted to the hospital for pneumonia. METHODS: This study is a retrospective observational cohort study of diabetic adults hospitalized for the first time for pneumonia between 2005 and 2011 in a 358-bed community hospital. Univariate and multivariate analyses were performed for 30-day all-cause hospital mortality adjusted for sex, age, type of pneumonia (community-acquired pneumonia or nursing and health care-associated pneumonia), severity of pneumonia according to the A-DROP score and various comorbidities in consideration of the serum glucose and hemoglobin A1c levels on admission and the mean plasma glucose level during hospitalization. RESULTS: Of the 1,499 pneumonia patients evaluated, 185 (12.3%) (mean age 75 years) had diabetes mellitus. Fourteen (7.6%) of the 185 diabetic patients died within 30 days after admission. According to the univariate analysis, 30-day mortality was significantly associated with the A-DROP score (p<0.0001), the admission glucose level (p=0.01) and the mean plasma glucose level during hospitalization (p<0.0001). Even after adjusting for factors related to the severity of pneumonia, the mean plasma glucose level during hospitalization remained significantly associated with 30-day mortality (p=0.004). CONCLUSION: Hyperglycemia determined according to the mean plasma glucose level during hospitalization is independently associated with 30-day all-cause hospital mortality in diabetic patients admitted for pneumonia.