Association between loss of hypercoagulable phenotype, clinical features and complement pathway consumption in COVID-19.

Background: Coronavirus disease 2019 (COVID-19) features a hypercoagulable state, but therapeutic anticoagulation effectiveness varies with disease severity. We aimed to evaluate the dynamics of the coagulation profile and its association with COVID-19 severity, outcomes, and biomarker trajectories. Methods: This multicenter, prospective, observational study included patients with COVID-19 requiring respiratory support. Rotational thromboelastometry findings were evaluated for coagulation and fibrinolysis status. Hypercoagulable status was defined as supranormal range of maximum clot elasticity in an external pathway. Longitudinal laboratory parameters were collected to characterize the coagulation phenotype. Results: Of 166 patients, 90 (54%) were severely ill at inclusion (invasive mechanical ventilation, 84; extracorporeal membrane oxygenation, 6). Higher maximum elasticity (P=0.02) and lower maximum lysis in the external pathway (P=0.03) were observed in severely ill patients compared with the corresponding values in patients on non-invasive oxygen supplementation. Hypercoagulability components correlated with platelet and fibrinogen levels. Hypercoagulable phenotype was associated with favorable outcomes in severely ill patients, while normocoagulable phenotype was not (median time to recovery, 15 days vs. 27 days, P=0.002), but no significant association was observed in moderately ill patients. In patients with severe COVID-19, lower initial C3, minimum C3, CH50, and greater changes in CH50 were associated with the normocoagulable phenotype. Changes in complement components correlated with dynamics of coagulation markers, hematocrit, and alveolar injury markers. Conclusions: While hypercoagulable states become more evident with increasing severity of respiratory disease in patients with COVID-19, normocoagulable phenotype is associated with triggered by alternative pathway activation and poor outcomes.

Disseminated Mycobacterium genavense Infection Mimicking Sarcoidosis: A Case Report and Review of Literature on Japanese Patients.

Sarcoidosis is a systemic inflammatory disease characterized by noncaseating epithelioid cell granulomas. However, certain infections can exhibit similar histological findings. We present a case of a 69-year-old man who was initially diagnosed with sarcoidosis and later was confirmed, through 16S rRNA sequencing, to have disseminated Mycobacterium genavense infection. Acid-fast bacteria were detected in the bone marrow biopsy using Ziehl-Neelsen staining, but routine clinical tests did not provide a definitive diagnosis. The patient tested negative for HIV, anti-interferon-gamma antibodies, and genetic immunodeficiency disorders. He was treated with multiple drugs, including aminoglycosides and macrolides, but showed no improvement in fever and pancytopenia. However, these clinical signs responded favorably to steroid therapy. We reviewed 17 Japanese cases of M. genavense infection. All cases were in males; 7/17 (41%) were HIV-negative; and 12/17 (71%) had a decreased CD4 count. Genetic analysis confirmed M. genavense isolation, and macrolides were used universally. Mycobacterium genavense infection is challenging to identify and mimics other systemic inflammatory diseases such as sarcoidosis. There are no standard treatment protocols. Our case report and Japanese case review contribute to understanding this rare disease.

A case of pancreatic endocrine carcinoma with a different clinical diagnosis before chemotherapy and pathological autopsy.

We encountered a case of pancreatic neuroendocrine carcinoma (pNEC) diagnosed via pathological autopsy that was initially diagnosed clinically as G3 pancreatic neuroendocrine tumor (G3 pNET) and discussed the differences between these entities in the literature. A 76-year-old man was admitted to our department because of jaundice. Computed tomography revealed multiple round nodules in both lung fields, suggesting metastasis, and a mass lesion was detected in the head of the pancreas with poor contrast in the arterial phase and slight contrast enhancement in the equilibrium phase. Biopsy of the lungs and pancreas led to a diagnosis of multiple pulmonary metastases of G3 pNET. Because the lesions were unresectable, chemotherapy was administered. Treatment was started with everolimus for 5 weeks. However, the patient experienced severe loss of appetite and malaise, and the lung lesions progressed, prompting treatment discontinuation. Subsequently, the patient's disease progressed rapidly, and he died 99 days after the start of chemotherapy. We performed a pathological autopsy with the consent of the family because of the rapid tumor growth. A pathological autopsy revealed a final diagnosis of pNEC, which differed from the clinical diagnosis.

Direct regulation of transforming growth factor ß-induced epithelial-mesenchymal transition by the protein phosphatase activity of unphosphorylated PTEN in lung cancer cells.

Transforming growth factor ß (TGFß) causes the acquisition of epithelial-mesenchymal transition (EMT). Although the tumor suppressor gene PTEN (phosphatase and tensin homologue deleted from chromosome 10) can negatively regulate many signaling pathways activated by TGFß, hyperactivation of these signaling pathways is observed in lung cancer cells. We recently showed that PTEN might be subject to TGFß-induced phosphorylation of its C-terminus, resulting in a loss of its enzyme activities; PTEN with an unphosphorylated C-terminus (PTEN4A), but not PTEN wild, inhibits TGFß-induced EMT. Nevertheless, whether or not the blockade of TGFß-induced EMT by the PTEN phosphatase activity might be attributed to the unphosphorylated PTEN C-terminus itself has not been fully determined. Furthermore, the lipid phosphatase activity of PTEN is well characterized, whereas the protein phosphatase activity has not been determined. By using lung cancer cells carrying PTEN domain deletions or point mutants, we investigated the role of PTEN protein phosphatase activities on TGFß-induced EMT in lung cancer cells. The unphosphorylated PTEN C-terminus might not directly retain the phosphatase activities and repress TGFß-induced EMT; the modification that keeps the PTEN C-terminus not phosphorylated might enable PTEN to retain the phosphatase activity. PTEN4A with G129E mutation, which lacks lipid phosphatase activity but retains protein phosphatase activity, repressed TGFß-induced EMT. Furthermore, the protein phosphatase activity of PTEN4A depended on an essential association between the C2 and phosphatase domains. These data suggest that the protein phosphatase activity of PTEN with an unphosphorylated C-terminus might be a therapeutic target to negatively regulate TGFß-induced EMT in lung cancer cells.

Diffuse alveolar hemorrhage as a fatal adverse effect of bevacizumab: an autopsy case.

A 71-year-old female with Stage IIIB primary adenocarcinoma was administered a three-drug combination therapy consisting of docetaxel, cisplatin and bevacizumab as a first-line treatment based on the Phase II clinical trial. On the 32nd day after the fourth course of chemotherapy, the patient developed bloody sputum. She was found dead at home on the 34th day. Autopsy revealed a diffuse alveolar hemorrhage without diffuse alveolar damage. Endothelial cells of the small arteries and capillaries were swollen and desquamated, indicating that alveolar capillaries were injured. The similar pathological changes in blood vessels were also observed in the kidney and the digestive tract. Because diffuse alveolar hemorrhage caused by cisplatin and docetaxel has never been reported apart from interstitial pneumonitis, bevacizumab is the most suspicious drug for diffuse alveolar hemorrhage in our case. Chest physicians and oncologists should be aware that although it is very rare, diffuse alveolar hemorrhage can develop during any course of chemotherapy with bevacizumab.

Involvement of TGFß-induced phosphorylation of the PTEN C-terminus on TGFß-induced acquisition of malignant phenotypes in lung cancer cells.

Transforming growth factor ß (TGFß) derived from the tumor microenvironment induces malignant phenotypes such as epithelial-mesenchymal transition (EMT) and aberrant cell motility in lung cancers. TGFß-induced translocation of ß-catenin from E-cadherin complexes into the cytoplasm is involved in the transcription of EMT target genes. PTEN (phosphatase and tensin homologue deleted from chromosome 10) is known to exert phosphatase activity by binding to E-cadherin complexes via ß-catenin, and recent studies suggest that phosphorylation of the PTEN C-terminus tail might cause loss of this PTEN phosphatase activity. However, whether TGFß can modulate both ß-catenin translocation and PTEN phosphatase activity via phosphorylation of the PTEN C-terminus remains elusive. Furthermore, the role of phosphorylation of the PTEN C-terminus in TGFß-induced malignant phenotypes has not been evaluated. To investigate whether modulation of phosphorylation of the PTEN C-terminus can regulate malignant phenotypes, here we established lung cancer cells expressing PTEN protein with mutation of phosphorylation sites in the PTEN C-terminus (PTEN4A). We found that TGFß stimulation yielded a two-fold increase in the phosphorylated -PTEN/PTEN ratio. Expression of PTEN4A repressed TGFß-induced EMT and cell motility even after snail expression. Our data showed that PTEN4A might repress EMT through complete blockade of ß-catenin translocation into the cytoplasm, besides the inhibitory effect of PTEN4A on TGFß-induced activation of smad-independent signaling pathways. In a xenograft model, the tumor growth ratio was repressed in cells expressing PTEN4A. Taken together, these data suggest that phosphorylation sites in the PTEN C-terminus might be a therapeutic target for TGFß-induced malignant phenotypes in lung cancer cells.

[A case of lung scedosporiosis successfully treated with monitoring of plasma voriconazole concentration level].

A 71-year-old man was referred because of fever and productive cough. His chest radiograph showed a large cavitary mass with an intracavitary mycetoma-like lesion in the left middle lung field. We undertook bronchoscopy and CT-guided biopsy, and both bronchial lavage fluid culture and CT-guided biopsy culture revealed Scedosporium apiospermum. On a diagnosis of lung scedosporiosis, he was treated with 200 mg/day voriconazole for 2 months, but his symptoms did not improve. Measurement of the plasma voriconazole level showed low plasma concentration levels (peak level: 2.15 microg/ml, trough level: 0.72 microg/ml). We then increased the voriconazole dosage from 200 mg/day to 400 mg/day. After that, his symptoms and chest radiograph findings improved immediately, accompanied by an elevated plasma voriconazole level (peak level: 5.13 microg/ml, trough level: 3.13 microg/ml). We believe that measurement of plasma voriconazole levels is useful to determine its dosage in lung scedosporiosis.

[Retrospective analysis of immediate cause of death in lung cancer-two case reports of lung cancer deaths due to bowel necrosis].

The immediate cause of death of 313 patients who died of lung cancer during 5 years in this center was analyzed. The specific, immediate causes of the 313 deaths were respiratory failure 34. 8%, pneumonia 19. 0%, cachexia 12. 0%, and brain metastasis 8. 3%. Digestive organ disease deaths were 7. 0%(22 patients), being the 5th-ranking immediate cause of death. Of these 22 cases, hepatic insufficiency death by liver metastasis was in 10 out of 22 cases, and gastrointestinal bleeding was in 8 cases. Two patients died of intestinal tract necrosis, but the direct causal relationship between the cause of death and the tumor was unconfirmed from the autopsy result. However, we speculated that an elderly, tumor-bearing condition combined with chemotherapy led to prolonged immobility, a poor nutritional state, and rapid weight loss, which could be influential on the bowel necrosis.