Severe Liver Dysfunction after Donor Lymphocyte Infusion for Relapsed Multiple Myeloma.

Donor lymphocyte infusion (DLI) is performed to augment an anti-tumor immune response or ensure donor stem cells remain engrafted following allogeneic stem cell transplantation but may induce graft-versus-host disease (GVHD) involving skin, intestine, and liver. Although hepatic involvement of GVHD can manifest as mild to severe hepatitis, few reports have mentioned acute severe liver dysfunction with encephalopathy. We experienced a case of acute severe liver dysfunction with semicoma after DLI in a patient with relapsed multiple myeloma following allogeneic stem cell transplantation, in whom chronic viral hepatitis B had been suppressed by antiviral treatment. The patient recovered after high-dose glucocorticoid administration based on an assessment of hepatic GVHD. Clinicians should be aware of the possibility of this catastrophic hepatic complication after DLI in hematologic disorders.

The clinical efficacy of a mixture of ivy leaf extract and coptidis rhizome in patients with idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with poor prognosis and cough is the one of most common and major symptoms in IPF. The aim of this study was to evaluate the clinical efficacy of a Mixture of Ivy Leaf Extract and Coptidis rhizome (Synatura®) in patients with IPF. This was a prospective, open-label, single-center, and single-arm study in Korea from October 2019 to September 2020. IPF patients with chronic bronchitis were enrolled. Between baseline and eight weeks after use of Synatura®, clinical measures regarding cough and health-related quality of life, and the systemic inflammatory markers was prospectively collected. Thirty patients were enrolled. Median age was 73 years and 86.7% were men. The median gender-age-pulmonary function stage of IPF was 3. Baseline total score of Leicester cough questionnaire (LCQ) and St. George respiratory questionnaire (SGRQ) were 104.5 and 30.59 respectively. After eight weeks, there was no significant improvement in LCQ (16.8 [15.6-19.1] vs 17.5 [15.2-18.9], P = .772) and SGRQ (30.6 [19.4-37.8] vs 29.9 [19.6-41.8], P = .194) scores. Also, there was no significant difference of systemic inflammatory markers. In analysis of minimal clinically important differences (MCID), one third (33.3%) patients fulfilled the criteria of MCID (1.3) in LCQ scores and median differences was 14 (range: 10-18). In terms of SGRQ, 6 patients (20%) reached MCID (4.0) without significant predictive factors. In our study, use of Synatura® during 8 weeks improved cough-specific life quality in one third patients with IPF. Large-scale, randomized, double-blind, and placebo-controlled clinical trials are needed.

Clinical usefulness of biomarkers for diagnosis and prediction of prognosis in sepsis and septic shock.

Sepsis is a life-threatening condition and remains a major cause of mortality. The aim of this study was to evaluate the role of biomarkers in the diagnosis of sepsis and septic shock in patients admitted to the emergency department (ED). Medical records of patients who underwent measurement of serum biomarkers including lactic acid, C-reactive protein, procalcitonin (PCT), and presepsin in the ED between May 2019 and May 2020 were retrospectively reviewed. Patients were subdivided into 3 groups; non-sepsis, sepsis, and septic shock according to the new definition using the sequential organ failure assessment score. The mean age was 69.3 years, and 55.8% of the study population was female. Of 249 subjects, 98 patients confined to sepsis group, and 35.7% of them were septic shock. In the multivariable analysis, a high level of PCT was an independent predictor of sepsis (odds ratio [OR], 1.028; 95% confidence interval [CI], 1.006-1.051; P = .011) along with a simplified acute physiology score III (SAPS III) (OR, 1.082; 95% CI, 1.062-1.103, P < .001). PCT was also an independent risk factor for septic shock (OR, 1.043; 95% CI, 1.016-1.071, P = .02). In the receiver operating characteristic curve analysis, the area under the curve of PCT to predict sepsis and septic shock were 0.691 (P < .001) and 0.734 (P < .001), respectively. The overall 30-days mortality rate was 8.8%, and the mortality rate was significantly higher in the sepsis group (sepsis vs non-sepsis, 15.3% vs 4.6%; P = .004). In the multivariate Cox analysis, a higher level of lactic acid (hazard ratio [HR], 1.328; 95% CI, 1.061-1.663, P = .013), predisposing chronic pulmonary diseases (HR, 7.035; 95% CI, 1.687-29.341, P = .007), and a high SAPSIII value (HR, 1.046; 95% CI, 1.015-1.078, P = .003) were independent risk factors for mortality in sepsis patients. PCT was a useful biomarker for predicting sepsis and septic shock in the ED. A higher level of lactic acid, predisposing chronic pulmonary diseases, and a high SAPS III score were associated with a greater mortality risk in patients with sepsis.

Pharmacokinetics and Monte Carlo Simulation of Meropenem in Critically Ill Adult Patients Receiving Extracorporeal Membrane Oxygenation.

Objectives: There have been few clinical studies of ECMO-related alterations of the PK of meropenem and conflicting results were reported. This study investigated the pharmacokinetics (PK) of meropenem in critically ill adult patients receiving extracorporeal membrane oxygenation (ECMO) and used Monte Carlo simulations to determine appropriate dosage regimens. Methods: After a single 0.5 or 1 g dose of meropenem, 7 blood samples were drawn. A population PK model was developed using nonlinear mixed-effects modeling. The probability of target attainment was evaluated using Monte Carlo simulation. The following treatment targets were evaluated: the cumulative percentage of time during which the free drug concentration exceeds the minimum inhibitory concentration of at least 40% (40% fT>MIC), 100% fT>MIC, and 100% fT>4xMIC. Results: Meropenem PK were adequately described by a two-compartment model, in which creatinine clearance and ECMO flow rate were significant covariates of total clearance and central volume of distribution, respectively. The Monte Carlo simulation predicted appropriate meropenem dosage regimens. For a patient with a creatinine clearance of 50-130 ml/min, standard regimen of 1 g q8h by i. v. infusion over 0.5 h was optimal when a MIC was 4 mg/L and a target was 40% fT>MIC. However, the standard regimen did not attain more aggressive target of 100% fT>MIC or 100% fT>4xMIC. Conclusion: The population PK model of meropenem for patients on ECMO was successfully developed with a two-compartment model. ECMO patients exhibit similar PK with patients without ECMO. If more aggressive targets than 40% fT>MIC are adopted, dose increase may be needed.

Acute respiratory distress syndrome caused by carbon monoxide poisoning and inhalation injury recovered after extracorporeal membrane oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column: a case report.

BACKGROUND: Inhalation injury from smoke or chemical products and carbon monoxide poisoning are major causes of death in burn patients from fire accidents. Respiratory tract injuries from inhalation injury and carbon monoxide poisoning can lead to acute respiratory distress syndrome and cytokine storm syndrome. In the case of acute respiratory failure needing mechanical ventilation accompanied by cytokine storm, mortality is high and immediate adequate treatment at the emergency department is very important. CASE PRESENTATION: This report describes a case of acute respiratory distress syndrome and cytokine storm followed by carbon monoxide poisoning in a 34-year-old Korean male patient who was in a house fire, and was successfully treated by extracorporeal membrane oxygenation and direct hemoperfusion with polymyxin B-immobilized fiber column at emergency department. CONCLUSIONS: To prevent mortality in acute respiratory distress syndrome with cytokine storm from inhalation injury and to promote a better prognosis, we suggest that early implication of extracorporeal membranous oxygenation along with direct hemoperfusion with polymyxin B-immobilized fiber column even at the emergency department should be considered.

Coxsackievirus A6-induced Hand-Foot-and-Mouth Disease Mimicking Stevens-Johnson Syndrome in an Immunocompetent Adult.

Hand-foot-and-mouth disease, a highly contagious viral infection, occurs more common in children than in adults. However, there was a recent outbreak of Coxsackievirus A6-induced infection with an atypical presentation among the adult population. Stevens-Johnson syndrome is a severe mucocutaneous disease characterized by extensive necrosis and detachment of the epidermis, and this condition is commonly caused by medications. Herein, we describe a 30-year-old male patient taking allopurinol for the management of gout. The patient presented with numerous erythematous papules, vesicles, and patches with mucosal eruptions on the whole body, oral mucositis, and fever, and he was finally diagnosed with hand-foot-and-mouth disease.

Huge idiopathic pulmonary artery aneurysm.

A pulmonary artery aneurysm is an uncommon anomaly. The clinical manifestations are mostly nonspecific, and management is controversial. We report a case of a 67-year-old woman with a main pulmonary artery aneurysm who did not take surgical intervention. Subsequently, there was no increase in size for 3 years.

Benign Mature Teratoma in Anterior Mediastinum.

Teratoma of mediastinum is rare germ cell tumor. Anterior mediastinum is the most common extragonadal site. Benign mediastinal teratoma accounts for 60% of all mediastinal germ cell tumors. Benign mature teratoma has excellent prognosis after surgical excision. We present a case of 20-year-old woman diagnosed as benign mature teratoma which compressed main pulmonary trunk. The patient underwent surgical excision.

Congenital partial defect of the left pericardium presenting as chest pain.

Congenital pericardial defect is a rare cardiac defect with variable clinical presentations. It is usually an unexpected finding during cardiac surgery or autopsy. The clinical detection of congenital absence of pericardium is important because of its life-threatening complications such as fatal myocardial strangulation, myocardial ischaemia and sudden death. We present a patient with the incidental finding of left-sided partial defect of the pericardium during evaluation of chest pain.