A 73-Year-Old Man With Refractory Hemoptysis.

CASE PRESENTATION: A 73-year-old man with fever and fatigue presented to his doctor. He had a history of smoking (52 pack-years) and COPD on home oxygen therapy. The patient had no significant family medical history, illicit drug-use history, or recent alcohol use. Chest CT scan showed a slight infiltrative shadow of the left lower lobe on a background of emphysema. Broad-spectrum antibiotics were administered for community-acquired pneumonia without any clinical or radiologic improvement after 2 weeks of therapy. Additional tests showed rapid deterioration of renal function (creatinine level, which was 0.68 mg/dL 2 years earlier, had worsened to 2.08 mg/dL), BUN level of 49.8 mg/dL (reference range, 8- to 20 mg/dL), myeloperoxidase-anti-neutrophil cytoplasmic antibodies 484.0 units/mL (range, 0.0 to 3.4 units/mL), C-reactive protein level of 11.1 mg/dL (range, 0.0 to 0.14 mg/dL), hemoglobin level of 9.0 g/dL (range, 13.7 to 16.8 g/dL), and urinalysis protein 1+ and occult blood 3+. On physical examination, multiple lesions of purpura were observed on the body surface, and hemoptysis was present. No sputum, urine, or blood cultures were done. Based on the examination, the previous doctors suspected microscopic polyangiitis (MPA) rather than an atypical/resistant infectious disease. The patient was treated with high-dose methylprednisolone (500 mg for 2 days and 125 mg for 13 days), but hemoptysis reappeared, and the patient was subsequently transported to our hospital.

Case Report of Primary Lung Abscesses Due to Hypervirulent Klebsiella pneumoniae (Serotype K2, Sequence Type 375): an Emerging Isolate in Okinawa, Japan.

Hypervirulent Klebsiella pneumoniae (HV-KP) is typically associated with community-acquired liver abscess and bacteremia with metastatic infection; however, primary lung abscess (PLA) caused by HV-KP is rare, with only one such case report to date. A 69-year-old man with a history of diabetes mellitus (DM) was admitted to hospital complaining of slight bloody sputum. Chest imaging showed multiple consolidations with cavities in both lung fields. A culture of bronchoalveolar lavage fluid confirmed the presence of K. pneumoniae. Genetic analyses identified the isolate as serotype K2 and sequence type 375 (K2-ST375), and that it harbored the rmpA gene. The patient was an Asian middle-aged male with DM, all of which are risk factors for HV-KP infection. Although complicating DM and the presence of the rmpA gene are more likely to induce disseminated infection, metastatic infections were not found in this patient. The clinical and microbiological characteristics of our patient were different from those of a previous reported case, although in both cases the patient was from Asia and had DM. Therefore, DM appears to be one of the predisposing factors for HV-KP lung abscesses and physicians should pay attention to emerging HV-KP lung abscess infection, particularly in Asian countries. Previous studies have also revealed that K2-ST375 is one of the major clones causing HV-KP infection, and that it is mainly isolated from patients with liver abscess. Interestingly, including the present case, most of the infectious cases caused by K2-ST375 have been reported from Okinawa Prefecture in Japan. Therefore, the trend of the K2-ST375 strain should be carefully monitored, particularly in Okinawa, Japan. The serotype of HV-KP that causes PLA is still unknown and further study is needed to elucidate the etiology of PLA due to HV-KP and the relationship between the strain K2-ST375 and PLA.

Clinical characteristics of dermatomyosits/polymyositis associated interstitial lung disease according to the autoantibody.

BACKGROUND: Dermatomyositis (DM) and polymyositis (PM) often have association with interstitial lung disease (ILD) which have disease specific autoantibody. METHODOLOGY: We reviewed medical records of DM/PM associated ILD from January 2000 to December 2017 according to the autoantibody. RESULT: We identified 52 patients, of whom 30 were antibody negative, 18 had anti aminoacyl-tRNA synthetases (ARS) antibodies and 4 had anti melanoma differentiation-associated gene (MDA)-5 antibody. In high resolution computed tomography (HRCT) of the chest, area of ground glass opacity (GGO), consolidation, and lung tip consolidation were more extensive in anti MDA-5 antibody positive patients (p=0.051, p=0.026, and p=0.027, respectively). Among laboratory findings, GOT had strong correlations with CPK (r=0.889, p < 0.001), and LDH (r=0.910, p < 0.001). Among roentgenographic findings, there were moderate correlations between GGO and consolidation (r=0.668, p < 0.001), and between reticular shadow and traction bronchiectasis (p=0.633, p < 0.001). ILD patients with anti MDA-5 antibodies had decreased survival (1.00 vs 84.3, 22.9 months, p < 0.001). CONCLUSION: ILD patients with anti ARS antibody had intense inflammation, but reversible fibrosis and good prognosis. On the other hand, anti MDA-5 antibody positive ILD patients had shorter survival. Extent of parenchymal shadow and serum GOT were useful indicator of disease activity of PM/DM associated ILD patients in our cohort. J. Med. Invest. 65:251-257, August, 2018.

Clinical Characteristics Based on the New Criteria of Acute Exacerbation in Patients with Idiopathic Pulmonary Fibrosis.

OBJECTIVE: Idiopathic pulmonary fibrosis (IPF) is the most common parenchymal lung disease. Patients with IPF sometimes develop acute exacerbation (AE), which predicts a poor prognosis. To evaluate the predictors of 90-day mortality of AE in patients with IPF based on the new 2016 criteria. MATERIALS AND METHODS: Sixty-five patients with AE were studied retrospectively between January 2001 and December 2016 at Okinawa Chubu Hospital. RESULTS: The mean age of the patients was 74 years, with 40 (61.5%) men and 25 (38.5%) women. Among our cohort, 37 were current or ex-smokers, with a mean exposure of 32.4 pack-years. The mean grade of the modified Medical Research Council breathlessness scale was 2.8, and the mean duration of dyspnea prior to admission was 6.5 days. Clubbed fingernails were present in 29% of patients. Triggered AE occurred in 12 (18%) of patients. Patients with triggered AE had more extensive ground-glass opacity and higher consolidation scores than the idiopathic AE group (7.3 vs. 4.2, p=0.01). The triggered group had shorter survival than the idiopathic group (1.4 vs. 11.4 months, p=0.094). Serum lactate dehydrogenase (LDH), ΔLDH, and the ratio of partial pressure of oxygen to the fraction of inspiratory oxygen ratio were strong predictors of 90-day mortality. Hazard ratios were 1.003 (p=0.004), 1.004 (p=0.02), and 0.994 (p=0.010), respectively. CONCLUSION: Compared with idiopathic AE, triggered AE in patients with IPF had more extensive infiltration and tended toward shorter survival. Serial trends of serum LDH >2 weeks can help predict prognosis of AE in patients with IPF.