Fulminant Type 1 Diabetes Mellitus Complicated with a Life-threatening Electrolyte Abnormality and Abnormal Electrocardiogram Findings.

Fulminant type 1 diabetes mellitus (T1DM) is idiopathic T1DM with the rapid destruction of pancreatic ß-cells. We herein report a 48-year-old man who developed fulminant T1DM complicated with a life-threatening electrolyte abnormality and abnormal electrocardiogram findings. He had no remarkable medical history, but one day, he developed general fatigue. His blood glucose level and HbA1c were 806 mg/dL and 6.3%, and his insulin secretion was markedly suppressed. He had ketoacidosis, hyponatremia and hyperkalemia. Furthermore, a life-threatening abnormality was noted on electrocardiogram. After fluid infusion and insulin therapy, the abnormality disappeared. In conclusion, we should bear in mind the possibility of fulminant T1DM in patients complaining of general malaise.

[USE OF QuantiFERON-TB Gold in Tube AND T-SPOT.TB FOR DIAGNOSING PATIENTS WITH SUSPECTED PULMONARY TUBERCULOSIS].

OBJECTIVE: We analyzed the use of QFT-TB Gold in Tube and T-SPOT.TB in diagnosing patients with suspected pulmonary tuberculosis. SUBJECTS AND METHODS: We evaluated 122 patients with suspected pulmonary tuberculosis (where chest X-ray showed consolidation or. tumor shadow in predilection sites of pulmonary tuberculosis and through contact investigation). QFT-TB Gold and T-SPOT.TB were performed for all the patients. The positive response rate and history of pulmonary tuberculosis in patients who showed positive results for the tests were evaluated. RESULTS: Ninteen patients showed positive results for QFT-TB Gold, and 9, for T-SPOT.TB. Four patients showed positive results for QFT-TB Gold, and 3, for T-SPOT.TB in 4 patients with active tuberculosis. The patients without active tuberculosis whose IGRAs were positive (old pulmonary tuberculosis, Mycobacterium avium cmplex, pneumonia, lung cancer, pulmonary sequestration, bronchiectasis) had a past history of pulmonary tuberculosis. CONCLUSION: The positive result rate of QFT?-TB Gold was higher than that of T-SPOT.TB in the subjects with suspected pulmonary tuberculosis. We think that QFT-TB Gold reflected the past history of pulmonary tuberculosis.

Clinical effect of biapenem on nursing and healthcare-associated pneumonia (NHCAP).

The clinical effect of Biapenem (BIPM) on Nursing and Healthcare-associated pneumonia (NHCAP) was evaluated. One hundred and three NHCAP patients (Group B: 52 patients, Group C: 51 patients) to whom BIPM was administered were included in this study. Clinical effect, bacteriological effect, and adverse events were examined. Results revealed efficacy in 45 of 52 patients (efficacy rate: 86.5%) of NHCAP Group B, and 43 of 51 patients (efficacy rate: 84.3%) of NHCAP Group C, 88 of 103 patients (efficacy rate: 85.4%) as a whole. As for bacteriological effect, 10 (76.9%) of 13 Pseudomonas aeruginosa strains, 9 (90.0%) of 10 Klebsiella pneumoniae strains, 7 (87.5%) of 8 methicillin-sensitive Staphlococcus aureus strains, and 7 (100%) of 7 Streptococcus pneumonia strains were eradicated. As a whole, 38 (80.9%) of 47 strains were eradicated. Adverse events included drug fever and drug eruption in one patient each, and abnormal laboratory findings, including mild hepatic dysfunction in 18 patients and mild renal dysfunction in 5 patients. Based on the above, it was concluded that BIPM shows excellent clinical effect on NHCAP with fewer adverse events.

[The positive response rate with QuantiFERON-TB GOLD In-Tube in patients with Mycobacterium avium complex].

OBJECTIVE: We studied the positive response rate with QuantiFERON-TB GOLD In-Tube in patients with Mycobacterium avium complex disease. MATERIALS AND METHODS: We evaluated 62 subjects with M. avium complex disease. QuantiFERON-TB GOLD In-Tube was performed for all the subjects. The positive response rate with QuantiFERON-TB GOLD In-Tube and the history of pulmonary tuberculosis in patients who showed a positive response were evaluated. RESULTS: Seven patients (11.3%) showed a positive response with QuantiFERON-TB GOLD In-Tube. These patients were elderly (age, 72-87 years) and had a history of pulmonary tuberculosis. Eleven other patients with a history of pulmonary tuberculosis showed a negative response with QuantiFERON-TB GOLD In-Tube. CONCLUSION: Half or less than half of the elderly patients with M. avium complex disease and a history of pulmonary tuberculosis showed a positive response with QuantiFERON-TB GOLD In-Tube.

Macrolide-resistant Mycoplasma pneumoniae in adolescents with community-acquired pneumonia.

BACKGROUND: Although the prevalence of macrolide-resistant Mycoplasma pneumoniae isolates in Japanese pediatric patients has increased rapidly, there have been no reports concerning macrolide-resistant M. pneumoniae infection in adolescents aged 16 to 19 years old. The purpose of this study was to clarify the prevalence and clinical characteristics of macrolide-resistant M. pneumoniae in adolescent patients with community-acquired pneumonia. METHODS: A total of 99 cases with M. pneumoniae pneumonia confirmed by polymerase chain reaction (PCR) and culture were analyzed. Forty-five cases were pediatric patients less than 16 years old, 26 cases were 16 to 19-year-old adolescent patients and 28 cases were adult patients. Primers for domain V of 23S rRNA were used and DNA sequences of the PCR products were compared with the sequence of an M. pneumoniae reference strain. RESULTS: Thirty of 45 pediatric patients (66%), 12 of 26 adolescent patients (46%) and seven of 28 adult patients (25%) with M. pneumoniae pneumonia were found to be infected with macrolide-resistant M. pneumoniae (MR patients). Although the prevalence of resistant strains was similar in pediatric patients between 2008 and 2011, an increase in the prevalence of resistant strains was observed in adolescent patients. Among 30 pediatric MR patients, 26 had an A-to-G transition at position 2063 (A2063G) and four had an A-to-G transition at position 2064 (A2064G). In 12 adolescent MR patients, 10 showed an A2063G transition and two showed an A2064G transition, and in seven adult MR patients, six showed an A2063G transition and one showed an A2064G transition. CONCLUSIONS: The prevalence of macrolide-resistant M. pneumoniae is high among adolescent patients as well as pediatric patients less than 16-years old. To prevent outbreaks of M. pneumoniae infection, especially macrolide-resistant M. pneumoniae, in closed populations including among families, in schools and in university students, physicians should pay close attention to macrolide-resistant M. pneumoniae.

Influence of age on the clinical differentiation of atypical pneumonia in adults.

BACKGROUND AND OBJECTIVE: The Japanese Respiratory Society (JRS) scoring system is a useful tool for the early and simple presumptive diagnosis of atypical pneumonia (Mycoplasma pneumoniae and Chlamydia pneumoniae pneumonia). However, it has been suggested that it is difficult to diagnose atypical pneumonia in the elderly using this system. In the present study, we evaluated the accuracy and usefulness of the JRS scoring system for diagnosing atypical pneumonia in different age groups. METHODS: Cases of M. pneumoniae (n = 262), C. pneumoniae (n = 98) and common bacterial pneumonia (n = 364) were analysed. RESULTS: For both atypical pneumonias, the frequency of comorbid illnesses and being in a higher risk category were significantly greater in elderly (age ≥60 years) than in non-elderly patients (age <60 years). One or more additional aetiological factors were more frequently present in elderly than in non-elderly patients. The diagnostic sensitivity and specificity for atypical pneumonia were 39% and 88%, respectively, in the elderly group, and 86% and 88%, respectively, in the non-elderly group. When the patients were stratified into 10-year age groups, the diagnostic sensitivity was highest in the 18- to 29-year age group and decreased from the youngest to the oldest age group. CONCLUSIONS: These results indicate that it is difficult to distinguish between atypical pneumonia and bacterial pneumonia in the elderly using the JRS scoring system. When treating patients aged ≥60 years, physicians should use fluoroquinolones or ß-lactam antibiotics + macrolides as empirical first-choice drugs so as to always provide antibiotic protection against potential atypical pathogens.

Clinical features and the role of atypical pathogens in nursing and healthcare-associated pneumonia (NHCAP): differences between a teaching university hospital and a community hospital.

OBJECTIVE: The Japan Respiratory Society documented a new category of guidelines for nursing and healthcare-associated pneumonia (NHCAP), which is distinct from community acquired pneumonia (CAP). The objective of this study was to determine the epidemiological differences between NHCAP patients in a teaching university hospital and a community hospital. In addition, to clarify the strategy for treatment of NHCAP, we investigated the role of atypical pathogens. METHODS: We analyzed 250 NHCAP and 421 CAP cases in a university hospital and 349 NHCAP and 374 CAP cases in a community hospital. RESULTS: Patient age and the incidences of poor general condition were significantly higher in the community hospital compared with those in the university hospital. The distribution and frequency of pathogens, especially multidrug-resistant (MDR) pathogens, were significantly different between the two hospitals. Central nervous system disorders, dementia and poor performance status, which was possibility related to aspiration pneumonia, were significantly more frequent in patients with NHCAP compared with those with CAP in both hospitals. Atypical pathogens were detected in a few cases in patients with NHCAP. CONCLUSION: There were many differences in the clinical characteristics between NHCAP patients in a university hospital and a community hospital even for hospitals located in the same area. Aspiration pneumonia was thought to be the main characteristic of NHCAP in both hospitals. Thus, all NHCAP patients did not need the same empiric therapy with a multidrug regimen directed against MDR pathogens. In addition, physicians rarely need to consider atypical pathogens in NHCAP treatment.

Clinical features of Proteus mirabilis pneumonia.

In this study, we clinically reviewed 13 patients with Proteus mirabilis pneumonia who were admitted for treatment to Kawasaki Medical School Kawasaki Hospital, Okayama, Japan, between April 2006 and July 2009. Clinical features were retrospectively reviewed. Results showed that: (1) hospital-acquired pneumonia occurred in elderly patients with underlying diseases such as cerebrovascular disease; (2) some patients had complications of urinary tract infection due to P. mirabilis; (3) preadministration of antibacterial agents did not become a risk factor; (4) resistance for levofloxacin (LVFX) was observed; (5) prognosis was comparatively good (effective rate 84.7%).

Clinical features of Escherichia coli pneumonia.

Escherichia coli pneumonia was clinically reviewed. Twenty-two patients with E. coli pneumonia were admitted for treatment to Kawasaki Medical School Kawasaki Hospital, between January 2006 and December 2008. Clinical features were retrospectively reviewed. Results showed that: (1) hospital-acquired pneumonia occurred in elderly patients with underlying diseases, such as cerebrovascular disease, diabetes mellitus, or chronic obstructive pulmonary disease; (2) more patients had complications of urinary-tract infection or alimentary infection due to E. coli; (3) previous administration of antibacterial agents did not become a risk factor; (4) resistance to ampicillin (ABPC) and levofloxacin (LVFX) was observed; and (5) mortality was 22.7%.

[A case of miliary tuberculosis difficult to distinguish from metastatic lung cancer].

We report a case of the coexistence of pulmonary tuberculosis and lung cancer maked a wrong diagnosis of lung cancer and metastatic lung carcinoma. The patient was a 80-years-old woman who had ascites and anorexia and decreased weight. Chest CT film showed a mass shadow in the right S, and infiltrative shadows on bilateral lung fields. FDG-PET revealed the tumor in the right lower lung field and many infiltrative shadows in all lung fields, and showed that FDG accumulated diffusely along the peritoneum. We made a diagnosis of lung cancer and metastatic lung carcinoma. However we obtained a diagnosis of coexisting of pulmonary tuberclosis and lung cancer autopsy. When the patient has a shadow suggestive of lung tumor shadow with many infiltrative shadows, we tend to make a diagnosis of lung cancer and metastatic lung carcinoma. We saw the importance of a postmortem examination in a new light.

Procalcitonin and severity of community-acquired pneumonia.

The purpose of this study was to clarify the relationship between procalcitonin and the severity and prognosis of community-acquired pneumonia. The subjects were 162 patients with community-acquired pneumonia (disease severity, mild, 39 patients; moderate, 81 patients; severe, 37 patients; and super severe, 5 patients) in whom we examined the serum procalcitonin concentration at the start of treatment; we determined the relationship of procalcitonin status with disease severity and prognosis. The results showed that procalcitonin was positive in 12.8% of the patients with mild disease, 27.1% of the patients with moderate disease, 59.5% of the patients with severe disease, and 80.0% of the patients with super severe disease. The mortality of procalcitonin-positive patients was 37.7%, whereas that of the procalcitonin-negative patients was 12.8%. Based on the above findings, it is concluded that the more severe the community-acquired pneumonia, the higher is the positivity rate for procalcitonin, and the prognosis in procalcitonin-positive patients is worse than that in procalcitonin-negative patients.

[Clinical effects of continuous infusion and intermittent infusion of meropenem on bacterial pneumonia in the elderly].

We compared the clinical effects of continuous infusion and intermittent infusion of meropenem (MEPM) on bacterial pneumonia in the elderly. The subjects were elderly patients (over 65) with moderate community-acquired bacterial pneumonia whose performance status was 3 or 4. They were randomly divided into an intermittent group (0.5 g MEPM was infused morning and evening) and a continuous infusion group (1.0 g/day over 24 hours was infused continuously), and the clinical effects were reviewed prospectively. Clinical efficacy on the third day was 64.0% in the intermittent infusion group and 72.0% in the continuous infusion group, and the overall clinical efficacy was 76.0% in the intermittent infusion group and 80.0% in the continuous infusion group. Administration periods were 13.2 +/- 5.7 days in the intermittent infusion group and 12.1 +/- 4.5 days in the continuous infusion group. These results show no statistically significant difference, and suggest that continuous infusion of MEPM did not have better clinical effect than intermittent administration twice a day in the treatment of elderly patients with moderate community-acquired bacterial pneumonia.

[Q fever in hospital-acquired pneumonia].

We studied the effects of Q fever in hospital-acquired pneumonia. The subjects consisted of 121 cases with hospital-acquired pneumonia treated during the period from December 2004 till June 2007. Q fever was diagnosed using a PanBio Coxiella burnetii ELISA test kit. There were no patients with acute infection by Coxiella burnetii. It is concluded that C. burnetii cannot induce onset of hospital-acquired pneumonia.

[Clinical effects of intravenous ciprofloxacin on community-acquired pneumonia with positive Immunocard Mycoplasma test results].

We studied the clinical effects of intravenous ciprofloxacin (CPFX) on community-acquired pneumonia in patients with positive Immunocard Mycoplasma test results. The subjects were 35 patients (59.4 +/- 24.8 years old) with community-acquired pneumonia with positive Immunocard Mycoplasma test results. We infused CPFX 300mg copy intravenously twice daily for 3-14 days. It was effective in 33 of 35 patients, with an efficacy rate of 94.3%. Adverse reactions consisted of itching in 2 patients, malaise in 2 patients, drug eruption in 1 patient, elevation of GPT in 1 patient and elevation of BUN in 1 patient, but all were mild. We conclude that intravenous CPFX is useful for community-acquired pneumonia in case with positive Immunocard Mycoplasma test results.

[Study of the cases with multidrug-resistant Pseudomonas aeruginosa by sputum culture].

We evaluated the clinical features of multidrug-resistant Pseudomonas aeruginosa cases determined by sputum culture between April, 2005 and December, 2006. The clinical features of most cases were: (1) pneumonia in the elderly with cerebrovascular diseases, (2) previous administration of carbapenems and antipseudomonal cephems, (3) PIPC, CAZ and ISP sensitve MDRP, (4) MRSA was isolated concurrently, (5) not necessary of therapy against MDRP, (6) good outcome.

[Positive phase periods of ImmunoCard Mycoplasma tests].

We evaluated the positive phase period of ImmunoCard Mycoplasma tests. The subjects were 74 penumonia patients (male : 38, female : 36, 17-94 years old) with positive ImmunoCard Mycoplasma tests. ImmunoCard Mycoplasma tests were performed every week for 8 weeks later, then every 4 weeks until negative conversion. The positive phase period was within a week in 30 of 74 patients (40.5%) and within 4 weeks in 52 patients (70.3%). In each generation the positive phase period of the most patients was within a week. The positive phase period of the elderly had no tendency to be longer than that of the young patients. These results indicated that about half of the patients with positive ImmunoCard Mycoplasma tests showed Mycoplasma infection which occurred within the past 1 week.

Coxiella burnetii and acute exacerbations/infections in patients with chronic lung disease.

The aim of the present study was to determine the incidence of Q fever in patients with an acute exacerbation of a chronic lower respiratory tract infection. Eighty patients treated for acute exacerbation of chronic lower respiratory tract infections during a 30-month period were studied. Q fever was diagnosed by ELISA. Two elderly woman with pre-existing bronchiectasis (2.5%) were diagnosed as having an acute infection by Coxiella burnetii. The acute illness was considered to be a result of mixed infection with Pseudomonas aeruginosa and Haemophilus influenzae with C. burnetii. Co-infection with C. burnetii can occur during a bacterial exacerbation of a chronic lower respiratory tract infection.

[Testing for Mycoplasma pneumonia using the ImmunoCard Mycoplasma rapid test].

We evaluated the effectiveness of ImmunoCard Mycoplasma rapid tests in all patients admitted with community-acquired pneumonia (CAP) between January, 2004 and December, 2005. ImmunoCard Mycoplasma rapid tests were performed on the 1st day of admission and we analyzed the frequency of positive cases among CAP cases according to month and age. A total of 82 of 270 (33.7%) and 41 of 257 (16.0%) were positive among CAP cases in 2004 and 2005, respectively. More positive cases were seen between spring and early summer and in cases aged 70 years or more, especially those over 80 years old. These results indicated that further evaluation is required among positive cases in elder group.

[Clinical effect of continuous infusion of meropenem on bacterial pneumonia in the elderly].

We studied the clinical effect of continuous infusion over 24 hours of meropenem (MEPM) on bacterial pneumonia in the elderly (over 65). The subjects were 26 patients (community-acquired pneumonia: moderate, n = 9; severe, n= 4; hospital-acquired pneumonia: group III, n = 13) whose performance status was 3 or 4. MEPM 1.0g/day was infused continuously for 7-14 days, and its clinical efficacy, bacteriological efficacy, and side effects were examined prospectively. It was effective in 23 of the 26 patients (community-acquired pneumonia: moderate, 8/9; severe, 3/4; hospital-acquired pneumonia: group III, 12/13; efficacy rate: 88.5%). Bactericidal effects were obtained in 3 strains of Klebsiella pneumoniae, 2 strains of Streptococcus pneumoniae, 2 strains of methicillin-sensitive Staphlococcus aureus, 1 strain of Streptococcus agalactiae and 1 strain of Proteus mirabilis, but not in 2 strains of methicillin-resistant S. aureus, 1 strain of Pseudomonas aeruginosa and 1 strain of Serratia marcescens. Mild abnormal laboratory findings were observed in 2 patients: elevation of GPT, gamma-GTP, BUN and elevation of ALP. Based on the above, continuous infusion of MEPM on bacterial pneumonia in the elderly obtained excellent clinical effects. Further study is needed to compare the efficacy of continuous versus intermittent administration of MEPM.

Clinical predictors for the detection of community-acquired pneumonia in adults as a guide to ordering chest radiographs.

OBJECTIVE: To identify sensitive clinical predictors for the detection of community-acquired pneumonia in adults as a guide to when to order a CXR. METHODS: In total, 79 outpatients presenting with at least one of the following clinical features of pneumonia: fever, cough, sputum, chest pain, dyspnoea and coarse crackles and who underwent CXR to detect pneumonia were examined retrospectively. The relationship between these clinical features and the presence of pneumonia on CXR was determined. RESULTS: A total of 24 patients (30.4%) had radiological evidence of pneumonia. In total, 22 presented with four clinical signs: fever, cough, sputum and coarse crackles. The sensitivity and the specificity of detecting pneumonia based on these four clinical signs mentioned was 91.7% and 92.7%, respectively. CONCLUSIONS: As a diagnostic strategy, the ordering of CXR to confirm a diagnosis of community-acquired pneumonia in adults is recommended when patients have the following four clinical signs: fever, cough, sputum and coarse crackles.