Clinical characteristics of allergic bronchopulmonary mycosis caused by Schizophyllum commune.

BACKGROUND: Allergic bronchopulmonary mycosis (ABPM) is an allergic disease caused by type I and type III hypersensitivity to environmental fungi. Schizophyllum commune, a basidiomycete fungus, is one of the most common fungi that causes non-Aspergillus ABPM. OBJECTIVE: Herein, we attempted to clarify the clinical characteristics of ABPM caused by S. commune (ABPM-Sc) compared with those of allergic bronchopulmonary aspergillosis (ABPA). METHODS: Patients with ABPM-Sc or ABPA were recruited from a nationwide survey in Japan, a multicenter cohort, and a fungal database at the Medical Mycology Research Center of Chiba University. The definition of culture-positive ABPM-Sc/ABPA is as follows: (1) fulfills five or more of the 10 diagnostic criteria for ABPM proposed by Asano et al., and (2) positive culture of S. commune/Aspergillus spp. in sputum, bronchial lavage fluid, or mucus plugs in the bronchi. RESULTS: Thirty patients with ABPM-Sc and 46 with ABPA were recruited. Patients with ABPM-Sc exhibited less severe asthma and presented with better pulmonary function than those with ABPA (p = 0.008-0.03). Central bronchiectasis was more common in ABPM-Sc than that in ABPA, whereas peripheral lung lesions, including infiltrates/ground-glass opacities or fibrotic/cystic changes, were less frequent in ABPM-Sc. Aspergillus fumigatus-specific immunoglobulin (Ig)E was negative in 10 patients (34%) with ABPM-Sc, who demonstrated a lower prevalence of asthma and levels of total serum IgE than those with ABPM-Sc positive for A. fumigatus-specific IgE or ABPA. CONCLUSIONS: Clinical characteristics of ABPM-Sc, especially those negative for A. fumigatus-specific IgE, differed from those of ABPA.

Antigen avoidance and environmental inhalation challenge for successful diagnosis of fibrotic hypersensitivity pneumonitis mimicking idiopathic pulmonary fibrosis.

A 77-year-old man was initially diagnosed with idiopathic pulmonary fibrosis (IPF) and treated with anti-fibrotic nintedanib. Despite undergoing anti-fibrotic treatment for one year, his condition remained unstable. The patient was admitted to our hospital for exertional dyspnea. We performed an exposure assessment, including 2-week antigen avoidance and an environmental inhalation challenge, and successfully re-diagnosed him with fibrotic hypersensitivity pneumonitis (HP), known as chronic farmer's lung. Adding oral glucocorticoids to the nintedanib treatment improved his condition. Although antigen avoidance and environmental inhalation challenge tests are not standardized, they may be useful for diagnosing fibrotic HP when properly applied.

Macrolide resistant Mycobacterium avium complex pulmonary disease following clarithromycin and ethambutol combination therapy.

RATIONALE: Whether two-drug therapy (clarithromycin and ethambutol) for Mycobacterium avium complex (MAC) pulmonary disease contributes to the development of macrolide-resistant MAC is unclear. OBJECTIVE: To compare the incidence of macrolide-resistant MAC between patients treated with two-drug therapy (clarithromycin and ethambutol) and the standard three-drug therapy (clarithromycin, ethambutol, and rifampicin) for MAC pulmonary disease. METHODS: We retrospectively reviewed 147 patients with treatment-naive MAC pulmonary disease who had received two-drug therapy (n = 47) or three-drug therapy (n = 100) between 1997 and 2016 at National Hospital Organization, Tenryu Hospital, Hamamatsu, Japan. The risk of development of macrolide-resistant MAC was evaluated by calculating the cumulative incidence rate using Gray's test. RESULTS: The median follow-up period was 74.5 months. During the follow-up period, one of the 47 patients (2.1%) in the two-drug group developed macrolide-resistant MAC, compared to 12 of the 100 patients (12.0%) in the three-drug group. The cumulative incidence rate of macrolide-resistant MAC was lower in the two-drug group than in the three-drug group (0.0023; 95% confidence interval, 0.002 to 0.107 versus 0.200; 95% confidence interval, 0.100 to 0.324, p = 0.0593). CONCLUSIONS: These results suggest that two-drug treatment with clarithromycin and ethambutol for MAC pulmonary disease does not lead to a higher incidence of resistance acquisition to clarithromycin than the standard three-drug treatment.

Low-dose Fluticasone Propionate in Combination With Salmeterol in Patients With Chronic Obstructive Pulmonary Disease.

Inhaled corticosteroids are widely used in the treatment of chronic obstructive pulmonary disease (COPD). However, their use has been questioned for appropriate dose and a possible increased risk of pneumonia. Here, we reviewed patients with COPD who had received fluticasone-salmeterol combination treatment using data from a linked electronic medical record database. A total of 180 patients received salmeterol with 250 µg fluticasone propionate twice daily and 78 received salmeterol and 100 µg fluticasone propionate twice daily. In both groups, there was no difference in the improved forced expiratory volume in 1 second and COPD assessment test score and the proportion of patients with exacerbations. Although the incidence of common toxicity was approximately equal, that of pneumonia was much higher in the 250 µg group (8.9% vs 1.3%, P=.01). The beneficial effects of inhaled corticosteroids might be obtained at lower doses.

Clinical characteristics and prognosis of chronic pulmonary aspergillosis.

BACKGROUND: The details of the clinical characteristics of patients with chronic pulmonary aspergillosis (CPA) have not been fully understood. METHOD: One hundred twenty-nine consecutive patients with isolation of Aspergillus species by culture from respiratory specimens who attended our hospital between October 2001 and September 2009 were enrolled. Patients diagnosed with chronic pulmonary aspergillosis (CPA) were retrospectively reviewed for clinical characteristics and prognosis, compared with patients with Aspergillus species colonization. RESULTS: Forty-two (32.6%) were diagnosed with CPA, whereas 87 (67.4%) with colonization. Aspergillus fumigatus was significantly more frequently detected in the CPA group than in the colonization group. Regarding underlying diseases, CPA patients had a significantly higher prevalence of a history of pulmonary tuberculosis and diabetes mellitus than colonization patients. There were no significant differences between the CPA and colonization group in Aspergillus antigen titers. Positivity for Aspergillus precipitating antibody was 74.3% in CPA and 15.8% in colonization, respectively. Sensitivity and specificity of Aspergillus precipitating antibody for the determination of CPA was 74.4% and 84.1%, respectively.Patients with CPA had significantly shorter survival than patients with colonization (mortality rate 50.0% vs. 13.8%, observation periods: 28.7 ± 26.6 months) (p < 0.0001). Multivariable analysis revealed that BMI was an independent predictor of prognosis (Odds Ratio, 1.973; p = 0.0223). CONCLUSIONS: CPA is a disease with a poor prognosis, which shows distinct clinical characteristics from colonization.

[A case of relapsing sarcoidosis with pleurisy 14 years after spontaneous remission].

An 83-year-old woman was referred to our hospital with dyspnea on exertion and right pleural effusion. At the age of 69, she had been given a clinical diagnosis of sarcoidosis due to uveitis, bilateral hilar lymphadenopathy, bilateral multiple nodular shadows on chest images, and serum angiotensin-converting enzyme (SACE) level elevation. Remission was spontaneous. The pleural effusion was exudative lymphocyte-rich. On thoracoscopy, the macroscopic appearance of the parietal pleura was telangiectasia without nodular lesions and the pleural biopsy specimens revealed non-caseating epitheloid cell granulomas whose cultures were negative for acid-fast bacilli and fungi. A tuberculin skin test and QFT-2G were negative, thus we diagnosed sarcoidsis pleurisy.

[A case of antiphospholipid syndrome associated with acute respiratory distress syndrome].

A 52-year old woman admitted to our hospital because of productive cough and dyspnea. Breathing room air arterial blood gases, revealed severe hypoxemia (P/F ratio 185 mmHg) and Chest CT showed diffuse ground glass opacities in both lung fields. Respiratory failure gradually improved after steroid pulse therapy, sivelestat sodium hydrate and antibiotics. However, a mosaic pattern attenuation in the lung parenchyma on Chest CT remained and ultrasonic cardiography showed dilation of right ventricle. Since the presence of V/Q mismatch in pulmonary perfusion and ventilation scintigrams and lupus anticoagulant were detected, we finally diagnosed acute respiratory distress syndrome (ARDS) and pulmonary thromboembolism (PTE) associated with antiphospholipid syndrome (APS). Therefore, this case reminded us that PTE and APS could cause ARDS.

Drug lymphocyte stimulation test in the diagnosis of adverse reactions to antituberculosis drugs.

BACKGROUND: Tuberculosis (TB) is a worldwide infectious disease. Recently, standard therapy has become very effective for treating patients with TB; however, as a result of this powerful regimen, serious side effects have become an important problem. The aim of this prospective study was to evaluate the usefulness of the drug lymphocyte stimulation test (DLST) to determine anti-TB drugs causing side effects. METHOD: Four hundred thirty-six patients with TB were admitted to our hospital for treatment between January 2002 and August 2007. DLST was performed in patients who had certain adverse drug reactions during TB treatment. The causative drug was identified by the drug provocation test (DPT). The tested drugs were mainly isoniazid (INH), rifampin (RIF), ethambutol (EMB) and pyrazinamide (PZA). RESULTS: Of 436 patients, 69 patients (15.8%) had certain adverse drug reactions to anti-TB drugs. Of the 261 agents that underwent the DLST and DPT, 28 agents (10.7%) in 20 patients (28.9%) were positive by DLST, and 67 agents (25.7%) in 46 patients (66.6%) were identified as causative drugs by DPT. The sensitivity of DLST was only 14.9% for all drugs (INH, 14.3%; RIF, 13.6%; EMB, 14.3%; PZA, 0%). CONCLUSIONS: DLST offers little contribution to the detection of causative agents in patients with adverse anti-TB drug reactions.