Impact of immune-related adverse events on survival outcomes in extensive-stage small cell lung cancer patients treated with immune checkpoint inhibitors.

BACKGROUND: Immune checkpoint inhibitors have recently become the standard of care in the first-line treatment of extensive-stage small cell lung cancer. Although immune-related adverse events have been reported to influence prognosis in non-small cell lung cancer patients, few studies have investigated the prognostic value of immune-related adverse events in small cell lung cancer patients. In this study, we evaluated the prognosis of patients who developed immune-related adverse events after first-line treatment with immune checkpoint inhibitor-based chemotherapy for extensive-stage small cell lung cancer. METHODS: We enrolled 90 patients with extensive-stage small cell lung cancer who received immune checkpoint inhibitor-based chemotherapy as first-line treatment from September 2019 to December 2022 in six hospitals in Japan. The patients were categorized into groups with and without immune-related adverse events. RESULTS: There were 23 patients with and 67 without immune-related adverse events. Seventeen patients had grade 1-2 immune-related adverse events, and nine (including overlapping cases) had grade ≥3. The most frequent immune-related adverse event was a skin rash. The median survival time was 22 months in patients with immune-related adverse events and 9.3 months in patients without immune-related adverse events. The hazard ratio was 0.40 (95% confidence interval: 0.19-0.83, p = 0.013). CONCLUSIONS: The results of this study show that immune-related adverse events are associated with improved survival outcomes in patients with extensive-stage small cell lung cancer.

Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic respiratory failure: A randomized controlled trial.

BACKGROUND AND OBJECTIVE: The relative effectiveness of initial non-invasive respiratory strategies for acute respiratory failure using continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) is unclear. METHODS: We conducted a multicenter, open-label, parallel-group randomized controlled trial to compare the efficacy of CPAP and HFNC on reducing the risk of meeting the prespecified criteria for intubation and improving clinical outcomes of acute hypoxemic respiratory failure. The primary endpoint was the time taken to meet the prespecified criteria for intubation within 28 days. RESULTS: Eighty-five patients were randomly assigned to the CPAP or HFNC group. Eleven (28.9%) in the CPAP group and twenty (42.6%) in the HFNC group met the criteria for intubation within 28 days. Compared with HFNC, CPAP reduced the risk of meeting the intubation criteria (hazard ratio [HR], 0.327; 95% CI, 0.148-0.724; p = 0.006). There were no significant between-group differences in the intubation rates, in-hospital and 28-day mortality rates, ventilator-free days, duration of the need for respiratory support, or duration of hospitalization for respiratory illness. Pulmonary oxygenation was significantly better in the CPAP group, with significantly lower pH and higher partial pressure of carbon dioxide, but there were no differences in the respiratory rate between groups. CPAP and HFNC were associated with few possibly causal adverse events. CONCLUSION: CPAP is more effective than HFNC at reducing the risk of meeting the intubation criteria in patients with acute hypoxemic respiratory failure.

First case of Cutibacterium avidum-infected pelvic lymphocele post-lymphadenectomy for endometrial cancer: A case report.

Background: Pelvic lymphocele (lymphocyst) infection after lymphadenectomy is a rare complication that can cause the spread of inflammation to neighboring organs whose microbiology is not well known. Cutibacterium avidum causes various infections. However, no case reports of C. avidum pelvic lymphocele infection are available; therefore, its clinical characteristics in pelvic lymphocele infections remain unknown. Case presentation: A 38-year-old woman with obesity (body mass index: 38.1 kg/m2) and a history of pelvic lymphadenectomy and chemotherapy for endometrial cancer presented with worsening left lower quadrant (LLQ) pain with fever. Physical examination revealed decreased abdominal bowel sounds and tenderness on LLQ palpation with no signs of peritonitis. Computed tomography (CT) revealed an infected left pelvic lymphocele with inflammation spreading to the adjacent sigmoid colon. Following blood culture, ampicillin/sulbactam (2 g/1 g every 6 h) was administered intravenously. Anaerobic culture bottles revealed gram-positive rods on day 4 of incubation at 37 °C. No other disseminated foci were observed in enhanced whole-body CT and upon transthoracic echocardiography. The isolates grew aerobically and anaerobically on blood agar plates with strong hemolysis. The bacterium was identified as C. avidum using a combination of characteristic peak analysis with matrix-assisted laser desorption ionization (MALDI) and 16S rRNA gene sequencing. The patient was diagnosed with C. avidum pelvic lymphocele infection. Based on penicillin susceptibility, the patient was successfully treated with intravenous ampicillin/sulbactam and de-escalated with intravenous ampicillin (2 g every 6 h) for 10 days, followed by oral amoxicillin (2000 mg/day) for an additional 11 days without drainage. Conclusions: C. avidum should be considered a causative microorganism of pelvic lymphocele infection. Peak analysis using MALDI and distinctive growth on blood agar plates are suitable for identifying C. avidum. Mild pelvic lymphocele caused by C. avidum can be treated with a short course of appropriate antimicrobial treatment without surgical intervention.

Group A Streptococcus dysgalactiae subspecies equisimilis vertebral osteomyelitis accompanied by progressive atlantoaxial subluxation: A case report and literature review.

RATIONALE: Clinically, vertebral osteomyelitis commonly occurs in immunocompromised individuals, such as people with diabetes, immunosuppression, chronic liver disease, and malignancy. Microbiologically, vertebral osteomyelitis is commonly caused by Staphylococcus aureus; however, Streptococcus dysgalactiae subspecies equisimilis (SDSE) may also potentially cause vertebral osteomyelitis, albeit rarely. Since no case reports have documented the occurrence of SDSE cervical osteomyelitis accompanied by progressive atlantoaxial subluxation, its clinical characteristics remain uncertain. Herein, we report the first case of progressive atlantoaxial subluxation in addition to cervical osteomyelitis due to septic atlantoaxial arthritis caused by SDSE in an immunocompetent individual, and provide a review of the relevant literature. PATIENT CONCERNS: A 63-year-old man with hypertension but no history of trauma or musculoskeletal disorders presented with worsening neck pain for 1 month without fever. Physical examination revealed neck pain due to neck retroflexion and tenderness with swelling of the upper cervical spine. No neurological deficit was observed. Magnetic resonance imaging revealed low-intensity areas on a T1-weighted image and high-intensity areas on a short tau inversion recovery image at the C2, C5, and C6 vertebral bodies with atlantoaxial subluxation. Two sets of blood culture tests (aerobic and anaerobic) were performed. DIAGNOSES: The anaerobic blood culture bottle showed the presence of beta-hemolytic pyrrolidonyl arylamidase-negative SDSE expressing Lancefield group A antiserum. Hence, the patient was diagnosed with SDSE cervical osteomyelitis with atlantoaxial subluxation; intensive intravenous ampicillin (2 g every 6 hours) - which is effective against SDSE - was administered. INTERVENTIONS: Posterior fusion (occipital bone, C4) was performed on day 33 because a follow-up magnetic resonance imaging on day 31 revealed progression of atlantoaxial subluxation with thickened atlantodental soft tissue. OUTCOMES: The patient's neck pain was completely relieved after treatment with intravenous ampicillin for 6 weeks, followed by oral amoxicillin (1500 mg) daily for an additional 4 weeks. The patient did not experience recurrence or sequelae during the 2-year follow-up period. LESSONS: SDSE expressing Lancefield group A antiserum can cause afebrile vertebral osteomyelitis and progressive atlantoaxial subluxation due to the occurrence of septic atlantoaxial arthritis in immunocompetent individuals. Spinal instrumentation for vertebral osteomyelitis may be acceptable after 6 weeks of antimicrobial therapy.

Primary bacterial intercostal pyomyositis diagnosis: A case report.

RATIONALE: Pyomyositis is a microbial infection of the muscles and contributes to local abscess formation. Staphylococcus aureus frequently causes pyomyositis; however, transient bacteremia hinders positive blood cultures and needle aspiration does not yield pus, especially at the early disease stage. Therefore, identifying the pathogen is challenging, even if bacterial pyomyositis is suspected. Herein, we report a case of primary pyomyositis in an immunocompetent individual, with the identification of S aureus by repeated blood cultures. PATIENT CONCERNS: A 21-year-old healthy man presented with fever and pain from the left chest to the shoulder during motion. Physical examination revealed tenderness in the left chest wall that was focused on the subclavicular area. Ultrasonography showed soft tissue thickening around the intercostal muscles, and magnetic resonance imaging with short-tau inversion recovery showed hyperintensity at the same site. Oral nonsteroidal anti-inflammatory drugs for suspected virus-induced epidemic myalgia did not improve the patient's symptoms. Repeated blood cultures on days 0 and 8 were sterile. In contrast, inflammation of the soft tissue around the intercostal muscle was extended on ultrasonography. DIAGNOSES: The blood culture on day 15 was positive, revealing methicillin-susceptible S aureus JARB-OU2579 isolates, and the patient was treated with intravenous cefazolin. INTERVENTIONS: Computed tomography-guided needle aspiration from the soft tissue around the intercostal muscle without abscess formation was performed on day 17, and the culture revealed the same clone of S aureus. OUTCOMES: The patient was diagnosed with S aureus-induced primary intercostal pyomyositis and was successfully treated with intravenous cefazolin for 2 weeks followed by oral cephalexin for 6 weeks. LESSONS: The pyomyositis-causing pathogen can be identified by repeated blood cultures even when pyomyositis is non-purulent but suspected based on physical examination, ultrasonography, and magnetic resonance imaging findings.

Magnesium Oxide as an Unexpected Bronchial Foreign Body in an Elderly Patient.

As cases of magnesium oxide pill aspiration are rare, the associated airway proinflammatory properties and appropriate analytic strategies remain unclear. An 81-year-old woman presenting with dyspnea was diagnosed with magnesium oxide pill aspiration. Computed tomography, a "mixing test" with levodopa, and a magnesium content analysis revealed a similar density between the foreign body and her prescribed magnesium oxide pill. The patient recovered without airway complications after foreign body removal. Clinicians should be aware of magnesium oxide tablets as potential bronchial foreign bodies in elderly patients because they may not dissolve without exposure to gastric juices.

Vertebral osteomyelitis caused by Fusobacterium nucleatum with an associated asymptomatic liver abscess in an immunocompetent adult: A case report and literature review.

Fusobacterium nucleatum rarely causes vertebral osteomyelitis or liver abscesses, and no reports exist of it concurrently causing vertebral osteomyelitis and pyogenic liver abscess. A 58-year-old woman with a history of periodontitis presented with worsening lumbago, left lower leg pain, numbness, and fever for a week. Physical examination indicated knocking pain at the L2-L3 levels with a psoas sign on the left side. A magnetic resonance image showed L2-S1 vertebral osteomyelitis and intervertebral discitis, with a left psoas major muscle abscess. Vertebral osteomyelitis caused by Staphylococcus aureus was suspected; blood cultures were obtained, and intravenous cefazolin was administered. Computed tomography, which was performed to detect disseminated foci, revealed a multilocular liver abscess. On day 4 of incubation, the anaerobic blood culture bottles were positive for characteristic filamentous gram-negative rods. The empiric antimicrobial therapy was changed to ampicillin/sulbactam. The isolate was identified as F. nucleatum based on 16S rRNA gene sequencing. The liver abscess was drained on day 12. Based on the antimicrobial susceptibility test results, the patient was treated with intravenous ampicillin/sulbactam for 4 weeks followed by oral amoxicillin/clavulanate for an additional 8 weeks and remained disease-free at the 1-year follow-up. Clinicians should consider F. nucleatum as the causative organism for vertebral osteomyelitis presenting with asymptomatic pyogenic liver abscess. The gold standard for identifying and diagnosing F. nucleatum infections is 16S rRNA gene sequencing, and gram staining helps determine appropriate antimicrobials.

Efficacy and Safety of Amrubicin in Small Cell Carcinoma Previously Treated with Immune Checkpoint Inhibitors and Chemotherapy.

Adding an immune checkpoint inhibitor to chemotherapy to treat extensive-stage small cell lung cancer is effective. However, there are no reports of an effective second-line treatment in patients previously treated with chemotherapy and immune checkpoint inhibitors as a first-line treatment. Here, we assessed the efficacy and safety of amrubicin as a second-line treatment for extensive-stage small cell lung cancer after chemotherapy and immune checkpoint inhibitor combination therapy. The study enrolled 150 patients with extensive-stage small cell lung cancer. The efficacy and the incidence of adverse events were compared between patients previously treated with immune checkpoint inhibitors and patients without previous immune checkpoint inhibitor treatment. One hundred and twenty-three patients were eligible. There was no difference in objective response rate, time-to-treatment failure, progression-free survival, and overall survival between both groups. The incidence of adverse events was similar in both treatment groups. Pretreatment with immune checkpoint inhibitors was not associated with an increase in amrubicin-related adverse events. This study shows that the efficacy of amrubicin in extensive-stage small cell lung cancer remains unchanged irrespective of previous treatment with immune checkpoint inhibitors. Amrubicin-related adverse events did not increase in patients previously treated with immune checkpoint inhibitors.

Vertebral osteomyelitis caused by the novel pathogen Cutibacterium modestum: a case report.

BACKGROUND: Cutibacterium modestum is one of the five species of the genus Cutibacterium. While C. acnes has been reported as an important pathogen in bone and joint infections, the clinical characteristics of C. modestum infections remain unclear. Moreover, thus far, there has been no clinical case report regarding C. modestum infections. CASE PRESENTATION: An 82-year-old man with a history of repeated trigger point injections for lumbago at the L4 level presented with fever and an exacerbation of lumbago. Physical examination indicated knocking pain at the L4-L5 levels; magnetic resonance imaging showed irregular bone destruction of the L4 vertebral body, and low T1 and high T2 intensity lesions at the L4-L5 intervertebral disc. Two sets of blood cultures (two aerobic and two anaerobic) were performed. Intravenous cefazolin was administered, considering the common pathogens of vertebral osteomyelitis, such as Staphylococcus aureus. The patient's condition did not improve; thereafter, anaerobic culture bottles revealed Gram-positive rods on day 11 of incubation. There was no evidence of infective endocarditis upon transthoracic echocardiography. Needle aspiration from the L4-L5 intervertebral disc was performed on day 13 that also showed the presence of Gram-positive rods. The patient was diagnosed with vertebral osteomyelitis caused by C. modestum using a combination of characteristic peak analysis with matrix-assisted laser desorption ionization (MALDI), microbial biochemistry examinations, and 16S rRNA gene sequencing from the blood and pus cultures. He was successfully treated with alternative intravenous ampicillin, followed by oral amoxicillin for 10 weeks, according to the tests for ampicillin susceptibility, with a minimum inhibitory concentration of 0.016 µg/mL using E-test® under aerobic conditions. CONCLUSIONS: Cutibacterium modestum is a microorganism that is difficult to identify. A combination of characteristic peaks with MALDI, appropriate microbial biochemical examinations, and 16S rRNA gene sequencing may serve as an efficient guide for the identification of C. modestum.

Primary melanoma in the bronchus.

Primary malignant melanoma of the lung (PMML) is an extremely rare tumor with a dismal prognosis. Distinguishing PMML from metastatic melanoma of the lung can be difficult without an established treatment protocol for advanced PMML. We present a case of immunotherapy-treated PMML wherein the patient died 3 months after treatment.

Dry pleural dissemination of malignancy diagnosed by aggressive thoracoscopy.

Determination of pleural dissemination of lung cancer helps define the treatment strategy. Positron emission tomography-computed tomography imaging could be false-negative for dry pleural dissemination of lung cancer. Clinicians should consider preoperative thoracoscopy in affected patients showing limited pleural effusion, interlobar fine granular shadows, and no metastasis on high-resolution computed tomography.

Lactobacillus paragasseri as a novel causative pathogen of cavernosal abscess.

Most cases of cavernosal abscesses result from the progression of sexually transmitted diseases (STDs) commonly caused by Neisseria gonorrhoeae; however, cavernosal abscesses without STDs are rare events. Herein, we describe the first case report of a Lactobacillus paragasseri cavernosal abscess. A 63-year-old man with diabetes and a history of foreign object insertion into the urethra one year prior presented with high-grade fever and slight local pain. The patient was diagnosed with L. paragasseri cavernosal abscess based on computed tomography and microbial biochemical examinations in addition to matrix-assisted laser desorption ionization (MALDI) and 16S rRNA sequencing from blood and pus cultures. The patient was successfully treated with a surgical procedure and appropriate antimicrobials. Hence, L. paragasseri, a commensal bacterium of the gastrointestinal or genitourinary tract, can cause cavernosal abscesses. Notably, L. paragasseri is difficult to distinguish from L. gasseri using MALDI or 16S rRNA sequencing without microbial biochemical examinations owing to morphological similarities. Therefore, special attention should be paid, clinically and microbiologically, to the potential of L. paragasseri cavernosal abscess in clinical settings.

Asymptomatic endobronchial tuberculosis represented as a solitary airway stenosis without tree-in-bud appearance on computed tomography.

Bronchoscopy is a crucial tool for diagnosing endobronchial tuberculosis in patients with airway stenosis. Early diagnosis and treatment may reduce airway sequelae and prevent the spread of infection.

An unusual case of hemoptysis: Pulmonary artery pseudoaneurysm secondary to a lung abscess.

Massive hemoptysis may originate from injured pulmonary arteries, such as from pulmonary artery pseudoaneurysms (PAPs). A 93-year-old man, diagnosed with pneumonia, was hospitalized; he later developed a lung abscess (controlled with intravenous antibiotics). On post-hospitalization day 29, he suddenly developed hemoptysis. Multi-detector computed tomography angiography (MDCTA) showed an enhanced nodule, diagnosed as a PAP, inside the lung abscess. The hemoptysis resolved, without recurrence, following transcatheter arterial embolization (TAE) of the PAP and its feeding arteries. PAPs should be considered in patients with lung abscesses and delayed massive hemoptysis. In these patients, MDCTA and TAE are effective diagnostic and treatment modalities.

Non-bacterial thrombotic endocarditis with cryptogenic stroke.

Negative blood culture and pathological findings are helpful to diagnose non-bacterial thrombotic endocarditis. The treatment strategy, including lifelong anticoagulation or surgery, should be individualized based on patients' underlying diseases.

Successfully treated infected aneurysm caused by Listeria monocytogenes.

Infected aneurysms caused by Listeria monocytogenes are extremely rare. Therefore, there is no standard procedure for their diagnosis and treatment. A 76-year-old Japanese man with diabetes and hypertension was diagnosed with a left common iliac aneurysm caused by L. monocytogenes, using multidetector computed tomographic angiography and rapid diagnostic testing of the positive blood culture. He was successfully treated with a combination of ampicillin administration, timely surgical debridement, and in-situ Y-graft placement with revascularization and omental implantation. Vancomycin and third-generation cephalosporins, to which L. monocytogenes is resistant, are used as an empirical regimen for infected aneurysms. Therefore, the use of a rapid diagnostic testing is important as it identifies L. monocytogenes within 24 h from obtaining the blood cultures, and guides the administration of the appropriate antibiotics. In-situ Y-graft placement restores nearly normal blood flow, following the confirmation of negative conversion of blood culture in response to the intensive intravenous ampicillin therapy. Appropriate and timely microbiological examinations, in addition to radiographic examinations, can be the key for selecting the optimal therapeutic procedures for each patient and achieving the best possible outcomes.