Monocytes predict prognosis and successful treatment in older patients with miliary tuberculosis.

Background: The increasing number of patients with miliary tuberculosis (MTB) is a concern in an aging society because of its high mortality rate. Several prognostic biomarkers for MTB have been identified; however, the predictive ability of monocytes as biomarkers remains unknown. This study demonstrates the usefulness of monocytes as prognostic biomarkers for MTB. Materials and methods: We retrospectively compared the clinical findings of 52 patients with MTB hospitalized between April 2013 and October 2021. The predictive ability of biomarkers for 3-month prognosis and their cutoff values were calculated. Survival times and longitudinal changes in monocytes after initiating treatment were compared. Results: A smaller number of monocytes (#M), higher lymphocyte-monocyte ratio (LMR), higher neutrophil-monocyte ratio, and poorer performance status were associated with death within 3 months. #M was an independent prognostic factor. #M and LMR exhibited the highest predictive performance compared to others using receiver operating characteristic curve analysis (area under the curve = 0.86 and 0.85, respectively). Survival time was shorter in patients with #M ≤ 200 cells/µL and LMR > 2.5. Rapidly increasing #M after treatment was related to better prognosis in patients with #M ≤ 200 cells/µL at diagnosis. Conclusions: #M at diagnosis and longitudinal changes in monocytes are related to MTB prognosis.

A unique case of bilateral ventricular infiltration by lung adenocarcinoma with paraneoplastic hypereosinophilia.

Existence of poorly differentiated tumour cells or paraneoplastic hypereosinophilia indicates extensive disease progression and poor prognosis in patients with malignancy. When these conditions are present, it is necessary to consider the possibility of intracardiac metastasis even in cases of lung adenocarcinoma.

[ACUTE MYELOID LEUKEMIA COMPLICATED BY DISSEMINATED TUBERCULOSIS AT DIAGNOSIS].

A 58-year-old man was admitted to our hospital because of fever and night sweating. Laboratory examinations showed pancytopenia on admission. Examination of bone marrow smear specimens revealed many myeloblasts, thus the diagnosis of acute myeloid leukemia (AML) was made. In contrast, many central necrotic epithelioid granulomas were found in clot specimens prepared from the same bone marrow sample. Computed tomography showed small lymphadenopathies and hepatosplenomegaly. Mycobacterium tuberculosis was isolated only from the urine culture. These findings of the bone marrow and the urine culture led to the diagnosis of disseminated tuberculosis. Therefore, these results mentioned above led to the diagnosis of AML complicated with disseminated tuberculosis. After disseminated tuberculosis treatment with anti-tuberculosis drugs, induction chemotherapy for AML helped the patient to achieve complete remission (CR). During treatment and CR, he showed a paradoxical reaction with lymph node enlargement without worsening of disseminated tuberculosis. This is a rare case of AML complicated by disseminated tuberculosis.

Lung transplantation for pleuroparenchymal fibroelastosis after chemotherapy.

We report the youngest patient ever reported in the literature to exhibit pleuroparenchymal fibroelastosis (PPFE) as a late-onset pulmonary toxicity after treatment with anticancer chemotherapy. The patient was diagnosed with mature B-cell leukemia at age 14. He was successfully treated with intensive chemotherapy; however, 7 years later, he experienced recurrent pneumothoraces. He was clinically diagnosed with upper lobe pulmonary fibrosis. At age 28, he underwent single left lung transplantation. Histologic examination of the resected lung revealed PPFE in the upper lobe and constrictive bronchiolitis obliterans in the lower lobe, which implied a close relationship between PPFE and constrictive bronchiolitis obliterans.

Nasopharyngeal tuberculosis.

Today, the opportunity to see tuberculosis is decreasing. Nasopharyngeal tuberculosis is a rare entity, even in endemic tuberculosis areas. A case of nasopharyngeal tuberculosis is described. A 28-year-old woman presented with a sore throat. Irregular mucosal thickening was seen in the nasopharynx. Staining for acid-fast bacilli was positive (Gaffky 1), and the PCR test was positive for Mycobacterium tuberculosis from pharyngeal mucus. Computed tomography showed mucosal thickening in the pharynx and old pulmonary tuberculosis in the right upper lobe. Multiple anti-tuberculosis drug therapy was performed for 6 months. A few days after the initiation of therapy, the pharyngeal pain subsided. The irregular mucosal thickening was quite thin after 1 month of multidrug therapy and was no longer observed after 2 months. A case of nasopharyngeal tuberculosis is reported. A good result was obtained with multiple anti-tuberculous drug therapy for 6 months. Nasopharyngeal tuberculosis should be considered in the differential diagnosis of a white nasopharyngeal coating, especially in a patient with a history of pulmonary tuberculosis.

Necrotizing pneumonia in the community.

A 62-year-old man presented with general fatigue. He was diagnosed with septic shock and severe pneumonia. The sputum at admission yielded methicillin-sensitive Staphylococcus aureus (MSSA) strain and methicillin-resistant S. aureus (MRSA) strain. Despite antibiotic treatment, he did not improve. A chest computed tomography (CT) revealed multilobar cavity lesions. Only MRSA strain was confirmed at that time. We diagnosed him with necrotizing pneumonia. Despite treatment with vancomycin, his pneumonia worsened and he died. At autopsy, many gram-positive cocci were observed in the lungs. The clinical presentation of our patient was different from typical CA-MRSA-mediated necrotizing pneumonia.

Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall.

The tubercular abscess of the chest wall remains one of the differential diagnoses of a chest wall tumour, and the management strategy is controversial. We reviewed the medical records of 22 patients treated at our institution. Two patients were managed by antitubercular medications alone; eight patients were managed by medication and open drainage. Five patients underwent open drainage with subsequent radical surgery at a constant interval of time, and the mean duration between open drainage and radical surgery was 9.8 weeks (range, 3-12). Seven patients underwent radical surgery without prior open drainage. Five patients required rib resections, and curettage of infected pleural peel was necessary in 5 patients. Antitubercular drugs were administered basically for more than 6 months regardless of surgical management, including for more than 1 month prior to radical surgery. Postoperative empyema was seen in 1 patient after radical surgery. The mean follow-up duration was 32.8 months (range, 3-100), and there was no recurrence. Complete resection of the tubercular abscess with sufficient antitubercular therapy resulted in a satisfactory outcome. Antitubercular therapy with or without open drainage can be a viable choice.

Hypersensitivity pneumonitis associated with inhalation of catechin-rich green tea extracts.

A 51-year-old man presented with fever and fatigue after 3.5 months of antituberculosis therapy. High-resolution computed tomography of his chest revealed new ground-glass opacities and poorly defined centrilobular nodules. He had undergone catechin inhalation for 1 month. We diagnosed hypersensitivity pneumonitis (HP) based on the clinical course, bronchoscopy and a challenge test. Cases of HP due to inhalation of extracted catechin powder are rare. Although it has many known positive attributes, it is necessary to be aware that catechin can cause HP.

[Analysis of usefulness of a whole blood interferon gamma assay (QuantiFERON TB-2G) for diagnosing active tuberculosis in immunocompromised patients].

PURPOSE: Recently, there have been many reports that QuantiFERON TB-2G (QFT-2G) is useful for diagnosing active tuberculosis. However, it remains controversial whether QFT-2G is useful for diagnosing active tuberculosis in immunocompromised patients as well as immunocompetent ones. Therefore, we analyzed whether QFT-2G sensitivity is decreased in immunocompromised patients compared with that in immunocompetent patients and what factors affect the QFT-2G sensitivity. SUBJECTS AND METHODS: The subjects consisted of 159 patients (105 males, 54 females; age 64.0 years [14-91]) who were diagnosed with active tuberculosis and underwent the QFT-2G test in Nishi Kobe Medical Center between July, 2006 and December, 2008. We analyzed these patients with regard to age, sex, white blood cell count in peripheral blood (WBC), lymphocyte count in peripheral blood (Lym), serum total protein, serum albumin, and QFT-2G sensitivity, and compared the findings between immunocompetent and immunocompromised patients. Immunocompromised patients consisted of those with diabetes mellitus, malignant disease, chronic renal failure, systemic steroid administration and AIDS. To test significance of differences, we used Mann-Whitney test for categorical variables, and t test for continuous variables. RESULTS: One hundred fifty one patients had pulmonary tuberculosis (including 8 with bronchial tuberculosis), 11 tuberculous pleurisy, 2 miliary tuberculosis, 2 intestinal tuberculosis, 1 tuberculous lymphadenitis, 1 tuberculosis of the hip joint, and 1 tuberculosis of the vertebra (there was some overlap among cases). In the entire patient group, positive QFT-2G results were detected in 125 (78.6%). In the immunocompetent and immunocompromised patients, positive results were seen in 82 (78.8%) and 43 (78.2%), respectively; these proportions were not significantly different (p = 1.00). In all patients, Lym was significantly lower in patients with intermediate, negative or indeterminate QFT-2G results than in QFT-2G-positive patients (p < 0.001). CONCLUSION: In our analysis, QFT-2G sensitivity did not significantly differ between immunocompetent and immunocompromised patients. Therefore, it is considered that QFT-2G is useful for diagnosing active tuberculosis in immunocompromised as well as immunocompetent patients.

[An open, noncomparative multicenter study of the efficacy and safety of itraconazole injections and high dose capsules in chronic pulmonary aspergillosis].

BACKGROUND: Itraconazole (ITCZ) is a novel triazole antifungal with a broad spectrum including Aspergillus species. We conducted a three-month open, noncomparative multicenter study of the efficacy and safety of ITCZ injections and high dose capsules in chronic pulmonary aspergillosis. METHODS: Patients with chronic pulmonary aspergillosis received intravenous injection of ITCZ (200mg) (twice a day for the first two days, then once a day for the following 3-12 days) prior to the oral administration of ITCZ capsules (200mg) twice a day. Radiologic findings by chest CT and clinical symptoms were evaluated at baseline and 12 weeks later. We also measured ITCZ plasma trough concentrations after two weeks and four weeks of the study. RESULTS: Twenty patients were included in the study, among which 14 patients presented with chronic necrotizing pulmonary aspergillosis (CNPA) and 6 presented with pulmonary aspergilloma. The efficacy evaluation was available in 17 patients (CNPA, 12 patients; aspergilloma, 5 patients). Radiological improvement was observed in nine (52.9%, 95%CI: 31.0%-73.8%) patients (CNPA, 7 patients; aspergilloma, 2 patients). One patient with aspergilloma showed deterioration. The clinical symptoms showed significant improvement on expectoration, bloody sputum, and pyrexia. Two patients had to stop treatment with ITCZ because of congestive heart failure. Other adverse effects were reported but did not lead to the discontinuation of treatment, as follows: hepatic dysfunction, two patients; hypokalemia, nine patients. In two patients who combined pulmonary Mycobacterium avium complex disease coadministration of ITCZ and rifampicin was done. Their ITCZ plasma concentrations were extremely low, and one of them was the only deterioration case in the primarily radiologic evaluation. CONCLUSION: Itraconazole injections and high dose capsules maintenance therapy is effective in treating chronic pulmonary aspergillosis.

Reversed halo sign in pneumocystis pneumonia: a case report.

BACKGROUND: The reversed halo sign may sometimes be seen in patients with cryptogenic organizing pneumonia, but is rarely associated with other diseases. CASE PRESENTATION: We present a case study of a 32-year-old male patient with acquired immunodeficiency syndrome, who had previously been treated with chemotherapy for non-Hodgkin's lymphoma. A chest X-ray showed bilateral patchy infiltrates. High-resolution computed tomography revealed the reversed halo sign in both upper lobes. The patient was diagnosed with pneumocystis pneumonia, which was successfully treated with sulfamethoxazole trimethoprim; the reversed halo sign disappeared, leaving cystic lesions. Cases such as this one are rare, but show that the reversed halo sign may occur in patients who do not have cryptogenic organizing pneumonia. CONCLUSION: Physicians can avoid making an incorrect diagnosis and prescribing the wrong treatment by carefully evaluating all clinical criteria rather than assuming that the reversed halo sign only occurs with cryptogenic organizing pneumonia.

[Successful telithromycin therapy of Legionella pneumonia --report of three cases].

Legionella species have been widely recognized as among the important causative organisms of community-acquired pneumonia in Japan. A delay in the start of adequate treatment has a negative influence on the outcome of the disease. Telithromycin, the first oral ketolide antibacterial, was developed for the treatment of community-acquired pneumonia, including Legionella pneumonia. However, few reports have indicated the efficacy of telithromycin in community-acquired pneumonia caused by Legionella species. We report three cases of Legionella pneumonia, that were improved by early telithromycin therapy. The first patient (67-year-old man) had bronchiectasis as an underlying disease, and the second patient (73-year-old man) had diabetes mellitus and chronic renal failure. The third patient (62-year-old man) developed pneumonia after a spa tour. The diagnosis of Legionella pneumonia was made on the basis of the presence of a single IgG titer of 1/256 in case 1 and positive antigenuria in cases 2 and 3. The patients were classified into a mild group (case 1) and a moderate group (cases 2 and 3) based on the severity of the community-acquired pneumonia according to the 2005 Japanese Respiratory Society Guidelines. The results support the efficacy of telithromycin in mild to moderate Legionella pneumonia.

A pilot study of aerosolized N-acetylcysteine for idiopathic pulmonary fibrosis.

OBJECTIVE: Idiopathic pulmonary fibrosis poses a significant therapeutic challenge because of its progressive course. Since oxidative stress plays an important role in the pathogenesis of idiopathic pulmonary fibrosis, an open, randomized trial of long-term inhalation therapy with the antioxidant, N-acetylcysteine was conducted. METHODOLOGY: A total of 30 patients with idiopathic pulmonary fibrosis were randomly assigned to one of the following inhalation therapies: N-acetylcysteine (352 mg per day) or bromhexine hydrochloride (4 mg per day) as the control. Efficacy was assessed by analysing changes occurring from baseline to 12 months in pulmonary function, the 6-min walking test, high-resolution CT, health-related quality of life, and serum KL-6-values. RESULTS: Four patients (n=2 in each group) died within 12 months due to progression of idiopathic pulmonary fibrosis. A total of 22 patients (control, n=12; N-acetylcysteine, n=10) completed the study. At 12 months there were significant differences between the N-acetylcysteine and control groups in terms of mean changes in lowest SaO(2) during the 6-min walking test (-0.3+/- 2.1% vs -6.8+/-1.8%, P<0.05), serum KL--6 (-482+/-220 U/mL vs 176+/-204 U/mL, P<0.05), and the ground-glass score on high-resolution CT (-1.3+/-1.6 vs 6.7+/-1.5, P<0.01). No significant differences were observed in pulmonary function, 6-min walking distance or quality of life. CONCLUSIONS: These data suggest that although long-term aerosolized N-acetylcysteine administration did not influence pulmonary function or quality of life, it may delay disease progression as evidenced by exercise desaturation, high-resolution CT, and serum KL-6.

[Clinical analysis of 10 cases of chest wall tuberculosis].

AIM/METHODS: A series of 10 cases of chest wall tuberculosis (man/woman=7/3, average age 62 +/- 17 years old) during past seven years were reviewed. RESULTS: Acid-fast bacillus was detected from an abscess in 60% by smear, 30% by culture, and 75% by polymerase chain reaction (PCR). It was characteristic that enhanced CT of abscess revealed a low density mass with peripheral enhancement, 'rim enhancement findings', in all cases. CT also showed ipsilateral pleural thickening in all cases, suggesting lymphogenous pathogenesis of chest wall lesions from tuberculous pleurisy. As for the treatment, antituberculosis chemotherapies were done in all cases. In addition, open drainage was done in 8 cases and curettage of abscess was performed in 5 cases. None of these ten cases had relapsed during the follow-up periods for 12 to 77 months. CONCLUSIONS: Chest wall tuberculosis is still important as a disorder of a chest wall mass requiring differential diagnosis. Contrasting CT is thought to be useful for the diagnosis. It should be emphasized that 50% of the cases had good outcome without curettage.

[Problems about the management of active pulmonary tuberculosis patients undergoing haemodialysis--our experiences and nation-wide questionnaire survey].

UNLABELLED: End-stage renal failure patients on chronic dialysis are high risk groups of tuberculosis due to attenuated cellular immunity. Patients receiving haemodialysis stay prolonged time inside the health-care facilities, thereby increased risk of tuberculosis transmission if a patient has active disease. So management of active pulmonary tuberculosis undergoing haemodialysis is important, however, the number of hospitals which are capable of taking care of such patients is estimated to be few in Japan. METHODS: From August 1994 through July 2002, 1059 active pulmonary tuberculosis patients (mean age; 57 +/- 19, male/female = 773/286) were admitted to Nishi-Kobe Medical Center, a 500-bed teaching hospital. Out of them, patients undergoing haemodialysis were retrospectively studied to describe the clinical characteristics of such cases. Then we conducted a questionnaire survey regarding the management of active pulmonary tuberculosis patients undergoing haemodialysis for 86 self-governing bodies in Japan. RESULTS: (1) Clinical characteristics of active pulmonary tuberculosis undergoing haemodialysis. We encountered 14 cases (mean age; 65 +/- 11, male/female = 7/7) of pulmonary tuberculosis undergoing haemodialysis during 8 years. In addition to pulmonary involvement, 3 pleural, one knee joint and one lymph node involvement was detected. Primary renal disease included diabetic nephropathy (n = 3), chronic glomerulonephritis (n = 3), congenital anomaly (n = 1), and unknown (n = 7). Nine cases were referred to our hospital from health-care facilities located out of city or prefecture. In five cases it took more than three months from the onset or detection of abnormal chest X-ray findings to the admission to our hospital. Five cases developed pulmonary tuberculosis within the first year after the initiation of dialysis. None of the patients had a past history of tuberculosis. Cavitary lesion on chest X-ray was observed in only one case. Triple antituberculosis therapy was used in 9 patients, and 4 antituberculosis drugs were used in 5 patients. Antituberculosis therapy was successfully done in all cases except two patients who died of apoplexy and cerebral infarction. (2) The nation-wide questionnaire survey. Of the 86 self-governing bodies we mailed, 66 self-governing bodies replied. Of them, 31% reported that they have experienced difficulties in the management of active pulmonary tuberculosis patients undergoing haemodialysis, and 25% reported the lack of health-care facilities to take care of such cases in their territory. They have referred such patients to hospitals located in the nearby prefectures or they have recommended antituberculosis therapy visiting a local haemodialysis facility. CONCLUSION: There are sometimes difficulties to manage active pulmonary tuberculosis patients undergoing haemodialysis in Japan. Health-care facilities to take care of such patients should be arranged and the formation of the network is necessarily.

[A case of Japanese summer-type hypersensitivity pneumonitis: monitoring with serum KL-6 and examination of the phenotype of HLA].

A 55-year-old woman was admitted with a cough and fever in August. A diagnosis of Japanese summer-type hypersensitivity pneumonitis was made on the basis of radiological, serological and pathological findings, in addition to positive returning home provocation. Serum KL-6 was monitored during the clinical course. Although KL-6 fluctuated slowly in comparison with the clinical symptoms and HRCT findings, it was considered useful for confirming the effects of treatment. Serum anti-Trichosporon antibody and the phenotype of HLA were studied in both the patient and her asymptomatic roommate, with whom she had no blood relationship. Though both were sensitized immunologically, HLA-DQ 3, which was reported to be associated with Japanese summer-type hypersensitivity pneumonitis, was detected in the patient but not in her roommate. It was suggested that HLA plays a role in the development of this disease.