Pulmonary cryptococcosis suspected due to inhalation of swallow excreta presenting with multiple infiltrative shadows.

A 70-year-old woman had been treated with methotrexate for rheumatoid arthritis by a rheumatologist who opened a clinic near our hospital. In January of a certain year, she had respiratory symptoms of cough, sputum, and fever. Laboratory test results showed a white blood cell count of 8600/µL (neutrophil count of 5330/µL, lymphocyte count of 2490 µ/L), C-reactive protein (CRP) of 3.30 mg/dL. Chest radiography showed multiple infiltrative shadows in the right middle and lower lobes. Bronchoalveolar lavage fluid (BAL) lymphocyte count was increased (65.1%), and histopathological findings were consistent with numerous bowl-shaped cryptococcus cells stained black by Grocott staining. Added measurement of serum cryptococcal antigen titers was 4096-fold. Treatment with fluconazole 400 mg/day was initiated, and her symptoms resolved; the shadows of the lung fields improved. When asked in detail, the cryptococcus infection route was suspected from swallow excreta. There have been no reported cases of pulmonary cryptococcosis suspected due to inhalation of swallow excreta presenting with multiple infiltrative shadows.

Eosinophilic pneumonia developed after dupilumab administration in a patient with atopic dermatitis.

A 63-year-old woman with refractory atopic dermatitis started treatment with dupilumab. She developed a cough 4 days later, sputum, and a slight fever 2 weeks later. Laboratory test results showed a blood eosinophil count of 7360/µL. Chest x-ray and computed tomography scan showed infiltrative shadows with surrounding consolidation of both upper lobes. Bronchoalveolar lavage fluid eosinophil count was increased (50.0%), and histopathological findings were consistent with numerous eosinophilic infiltrations. Treatment with prednisolone 30 mg/day (0.5 mg/kg/day) was initiated. Her symptom resolved, and the shadow of the lung fields improved. There have been no reported cases of eosinophilic pneumonia diagnosed 7 weeks after the administration of dupilumab for atopic dermatitis.

Impact of early inflammatory cytokine elevation after commencement of PD-1 inhibitors to predict efficacy in patients with non-small cell lung cancer.

Early elevation of inflammatory cytokines, such as IL-6 or TNF-α, or CRP, which is a surrogate marker for IL-6, following commencement of PD-1/L1 inhibitors (PD1-I) may represent early activation of immune-cells. Serum IL-6 and TNF-α were measured in 10 non-small cell lung cancer patients who were evaluable within the 7 days before and after commencement of PD1-I. For CRP, medical records were reviewed and 34 patients with measured CRP within the 7 days before and after the treatment were evaluated. In the 10 patients analyzed for IL-6/TNF-α, the serum levels of IL-6/TNF-α were not significantly different between pre- and post-initial PD1-I [IL-6 20.3 (2.6-49.9) and 22.9 (3.6-96.1) pg/mL, p = 0.453; TNF-α 1.6 (0.7-6.3) and 3.3 (0.7-9.6) pg/mL, p = 0.329]; however, all four responses were observed among the 7 IL-6-elevated cases, resulting in a response rate of 57%. In the 34 patients analyzed for CRP, CRP was significantly increased after initial PD1-I [1.8 (0.1-17.8) mg/dL, 2.4 (0.0-27.8), p = 0.001]. Notably, in the 31 evaluable cases, all responses were again observed in either the IL-6 or CRP elevated groups and the response rate was 46% (11 of 24). The median overall survival time was not reached in the elevated group and was 112 days in the non-elevated group (p = 0.069). The early increase in inflammatory cytokines with PD1-I was indicated to be predictive for the efficacy in patients with non-small cell lung cancer.

Efficacy and Tolerability of High-Flow Nasal Cannula Oxygen Therapy for Hypoxemic Respiratory Failure in Patients with Interstitial Lung Disease with Do-Not-Intubate Orders: A Retrospective Single-Center Study.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy may provide effective respiratory management of hypoxemic respiratory failure in patients with interstitial lung disease (ILD) with a do-not-intubate (DNI) order. OBJECTIVES: The aim was to assess the efficacy and tolerability of HFNC for these patients. METHODS: We retrospectively reviewed the records of patients requesting a DNI order for hypoxemic respiratory failure associated with ILD, comparing treatment with HFNC and noninvasive positive pressure ventilation (NPPV). Outcomes measured were 30-day survival, in-hospital mortality, temporary interruption and discontinuation of the treatment at the patient's request, adverse events, oral intake, and communication ability at the end of life. RESULTS: A total of 84 patients (HFNC, n = 54; NPPV, n = 30) were analyzed. Neither 30-day survival (HFNC 31.5% vs. NPPV 30.0%; p = 0.86) nor in-hospital mortality (HFNC 79.6% vs. NPPV 83.3%; p = 0.78) differed significantly. The temporary interruption and discontinuation rates were significantly lower in the HFNC group than in the NPPV group (3.7 vs. 23.3%; p = 0.009 and 0 vs. 10%; p = 0.043, respectively), and that group had significantly fewer adverse events. Among patients who died in the hospital, those treated with HFNC had significantly better oral intake and ability to converse until just before death. CONCLUSION: HFNC had a survival rate equivalent to that of NPPV and was better tolerated by patients with hypoxemic respiratory failure associated with ILD who had a DNI order. HFNC allowed patients to eat and converse until just before death, suggesting that HFNC in these patients is a reasonable palliative treatment.