Incidence of metachronous gastric cancer in patients whose primary gastric neoplasms were discovered after Helicobacter pylori eradication.

BACKGROUND AND AIMS: The incidence of metachronous gastric cancer (MGC) in patients whose primary gastric neoplasm is discovered after Helicobacter pylori eradication remains unclear. Here, we evaluated the long-term effect of previous H pylori eradication on development of MGC after endoscopic submucosal dissection (ESD). METHODS: We analyzed prospectively collected data of consecutive patients with successful H pylori eradication more than 1 year before (eradicated group, 180 patients) or after (control group, 602 patients) initial curative ESD. These patients were also followed by endoscopy for over 2 years. Propensity score matching and inverse probability of treatment weighting (IPTW) were used to adjust for confounding variables during data analysis. The main outcome was the incidence of MGC after initial ESD. RESULTS: In a propensity-matched analysis of 174 pairs, the incidence of MGC was similar in the 2 cohorts (33.9 per 1000 person-years vs 40.8 per 1000 person-years in the control group, P = .454) at a median follow-up of 4.1 years (interquartile range, 3.0-5.6). Incidences were also similar in the 2 groups when data were analyzed using IPTW, even after exclusion of 123 patients with successful H pylori eradication <5 years before initial ESD. Multiple Cox regression analysis revealed age, differentiated-type histology, and initial multiplicity were predictors of MGC in patients after initial curative ESD. CONCLUSIONS: The frequency of follow-up surveillance after initial curative ESD should be kept constant, irrespective of whether H pylori eradication is performed before or after initial curative ESD.

Clinical factors on cavitary and nodular bronchiectatic types in pulmonary Mycobacterium avium complex disease.

BACKGROUND AND OBJECTIVE: Pulmonary Mycobacterium avium complex (MAC) disease is the most common pulmonary non-tuberculous mycobacteriosis (NTM). The clinical and radiological findings were similar to those of pulmonary tuberculosis, both of which are characterized by upper lobe cavities. On the other hand, the presence of middle and lower field lesions with centrilobular nodules and bronchiectasis has been noted. We analyzed the clinical feature of these two radiologically different types and identified their prognostic factors. METHODS: The clinical, laboratory and radiological findings of 273 cases of MAC disease, newly diagnosed during the recent 7 years periods, were investigated. They were radiologically classified into cavitary (Cav) and nodular bronchiectasis (NB) types at the time of diagnosis. The findings of 44 fatal cases were compared with those of the newly diagnosed cases. RESULTS: A prominent increase in the number of cases was recently found only in females. Low body mass index (BMI) and moderately reduced serum albumin were found at the time of first hospital visit in both newly diagnosed and fatal cases. In the latter, peripheral blood lymphocyte count was slightly decreased, and tuberculin skin test was negative in 57.7% of the cases. Radiologically, Cav type was prevalent in males and NB type in females in the newly diagnosed cases, while in the fatal cases Cav type was frequently found in both males and females. The two radiological patterns did not change during the entire disease course. CONCLUSION: Cav type in females was one of the pathogenetic factors. Deterioration of cell-mediated immunity may underlie MAC disease.

[Case of multi-drug resistant pulmonary tuberculosis with bilateral cavitary lesions successfully treated by surgical treatment].

A case was 38 years old male. He was pointed out abnormal shadow on chest X-ray and complained respiratory infection symptoms. He had not past history of tuberculosis. He was diagnosed as multi-drug resistant tuberculosis (MDR-TB) in a certain hospital and was referred to our hospital to undergo treatment. His drug sensitivity test by Ogawa medium was resistant to all anti-tuberculosis drugs except for kanamycin (KM) and enviomycin (EVM). His chest X-ray revealed large cavities in the right upper field and infiltrations in the right lower field and small cavitary lesions in the left lower field. The right pneumonectomy was done because he took anti-tuberculosis drugs but his sputum examinations continued to be smear and culture positive without improvement of the lesions. After the surgical treatment (right pneumonectomy), he continued anti-tuberculosis drugs therapy and the chest X-ray improved including the collapse of left lower cavitary lesions. This case was a difficult case to treat because of bilateral cavitary lesions. However he was successfully treated by the surgical treatment.

[Pneumocystis carinii pneumonia in a patient with hyper-IgE syndrome].

A 15-year-old girl with abnormal findings detected on a medical check-up chest x-ray film was admitted to our center. High-resolution computed tomography, performed upon hospitalization, demonstrated panlobular nodular darkening in left lung fields, and an expanding, blended, map-like darkening near the pleura. Since a Grocott stain-positive cyst was confirmed histopathologically by transbronchial lung biopsy, the patient was given a diagnosis of Pneumocystis carinii pneumonia. Drug therapy was initiated with sulfamethoxaxole trimethoprim (Baktar), and on the 58th day, chest CT confirmed that the darkening observed at admission had virtually disappeared. Underlying diseases, such as AIDS, malignant lymphoma and secondary immunodeficiency caused by immunosuppressive agents or adrenocorticosteroids, were excluded as the cause of P. carinii pneumonia based on clinical/laboratory findings. Under the suspicion of the possibility of primary immunodeficiency, various immunological competence tests were performed. However, no abnormal findings indicating cell-mediated immunity, humoral immunity, complement immune function, neutrophil phagocytic capacity, or bactericidal capacity were recognized. Since significant increase of serum IgE suggested hyper-IgE syndrome, IgE antibody specific to Staphylococcal enterotoxin A and B, and the exotoxins of Staphylococcus aureus were measured with positive results. Since all three diagnostic criteria for hyper-IgE syndrome (i.e., high serum IgE values, positive IgE antibody specific to Staphylococcal enterotoxin and recurrent infection) were fulfilled, hyper-IgE syndrome was diagnosed. This is a rare case of hyper-IgE syndrome as a result of P. carinii pneumonia.

[Clinical study of 90 cases of Mycoplasma pneumoniae pneumonia].

We investigated 90 patients with Mycoplasma pneumoniae (M. pneumoniae) pneumonia. Forty-four patients were men, 46 were women and the mean age was 43.1 years old. Twenty-nine patients were smokers and 28 had underlying diseases. As for diagnostic method, 16 were culture positive, 71 had a fourfold increase in antibody titer to M. pneumoniae, and 3 were both culture positive and had a fourfold increase in antibody titer. Regarding the degree of severity, 21 patients were classified as severe according to Japanese Respiratory Society diagnostic criteria, 11 patients were diagnosed as severe according to American Thoracic Society diagnostic criteria. Partial pressure of arterial oxygen (PaO2) of 18 patients were <60mmHg, 5 patients were under mechanical ventilation, and 3 patients died. Three of 16 patients treated with only beta-lactum antibiotics recovered. The 3 patients who died were M. pneumoniae culture-positive and two patients had polymicrobial infections. Severe pneumonia associated with Mycoplasma pneumoniae infection is not unusual. If a rapid diagnosis kit or culture method of M. pneumoniae pneumonia is not introduced, the pathogen might be unknown in cases of rapid death due to M. pneumoniae pneumonia. These data suggest that the mortality rate of M. pneumoniae pneumonia might be underestimated without these detection tests.

[Pulmonary tuberculosis with cerebellar lesion in a patient after anti-TNF-alpha (infliximab) treatment for rheumatoid arthritis].

We report a case of pulmonary tuberculosis in a 51-year-old Japanese woman, who received treatment with infliximab for active rheumatoid arthritis. She had cough and sputum after the second infusion of the drug, small nodular lesions of right lung field and left lower lobe on her chest CT and a small nodular lesion of right cerebellar lobe on her cranial MRI were identified. Mycobacterium tuberculosis was cultured from her sputum. Therefore, we diagnosed her illness as pulmonary tuberculosis with a cerebellar lesion. The patient was treated with anti-tuberculosis drugs and showed marked improvement in lesions of the lung and brain. We considered this case a tuberculosis reactivation after infliximab treatment because of the short interval between the administration of infliximab and the occurrence of tuberculosis, and the complication of extrapulmonary lesion that suggested brain tuberculoma.

[Community-acquired pneumonia with rhabdomyolysis].

We assessed the frequency and etiology of rhabdomyolysis in patients with community-acquired pneumonia. In 594 patients with community-acquired pneumonia whose serum CPK were measured, 25 patients (2.4%) were found to have rhabdomyolysis. Including 4 patients with mixed infections, the etiologies in 25 patients with community-acquired pneumonia with rhabdomyolysis were as follows: Legionella species, 11 patients (44%); Influenza virus, 6 (24%); Streptococcus pneumoniae, 4 (16%); Chlamydia psittaci, 3 (12%); Mycoplasma pneumoniae, 2 (8%); unknown 3 patients (12%). The rates of rhabdomyolysis for each etiologic category were as follows: Legionella species, 26.8% (11/41); Chlamydia psittaci, 21.4% (3/14); Influenza virus, 9.5% (6/63) ; Streptococcus pneumoniae, 4.7% (4/85);Mycoplasma pneumoniae, 3.1% (2/65). Renal dysfunction with a serum creatinine concentration greater than 1.5 mg/dl occurred in 6 patients (24%). Our experience illustrates that 5 pathogens can cause rhabdomyolysis in patients with community-acquired pneumonia. Legionella species are the most common organisms followed by Influenza virus, Streptococcus pneumoniae, Chlamydia psittaci, Mycoplasma pneumoniae.