Prediction of an increase in oxygen requirement of SARS-CoV-2 pneumonia using three different scoring systems.

INTRODUCTION: In patients with severe coronavirus disease 2019 (COVID-19), respiratory failure is a major complication and its symptoms occur around one week after onset. The CURB-65, A-DROP and expanded CURB-65 tools are known to predict the risk of mortality in patients with community-acquired pneumonia. In this retrospective single-center retrospective study, we aimed to assess the correlations of the A-DROP, CURB-65, and expanded CURB-65 scores on admission with an increase in oxygen requirement in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. METHODS: We retrospectively analyzed 207 patients who were hospitalized with SARS-CoV-2 pneumonia at the Self-Defense Forces Central Hospital in Tokyo, Japan. Performance of A-DROP, CURB-65, and the expanded CURB-65 scores were validated. In addition, we assessed whether there were any associations between an increase in oxygen requirement and known risk factors for critical illness in COVID-19, including elevation of liver enzymes and C-reactive protein (CRP), lymphocytopenia, high D-dimer levels and the chest computed tomography (CT) score. RESULTS: The areas under the curve for the ability of CURB-65, A-DROP, and the expanded CURB-65 scores to predict an increase in oxygen requirement were 0.6961, 0.6980 and 0.8327, respectively, and the differences between the three groups were statistically significant (p < 0.001). Comorbid cardiovascular disease, lymphocytopenia, elevated CRP, liver enzyme and D-dimer levels, and higher chest CT score were significantly associated with an increase in oxygen requirement CONCLUSIONS: The expanded CURB-65 score can be a better predictor of an increase in oxygen requirement in patients with SARS-CoV-2 pneumonia.

Case Report: Eosinophilic Bronchiolitis With Eosinophil ETosis in Mucus Plugs Successfully Treated With Benralizumab.

Eosinophilic bronchiolitis is a rare allergic disorder caused by eosinophilic inflammation in the bronchioles of the lungs. An effective treatment strategy is needed in cases resistant to steroids. However, its pathophysiology remains unclear owing to the limited number of cases. We herein present the case of a 31-year-old man who experienced eosinophilic bronchiolitis with eosinophil ETosis (EETosis) in the mucus plugs. The patient was diagnosed with asthma. His respiratory symptoms worsened with eosinophilia when treated with the standard asthma regimen, including inhaled corticosteroids, long-acting ß2-agonist, long-acting muscarinic antagonist, and leukotriene receptor antagonist. Chest computed tomography revealed bronchial wall thickening and centrilobular nodules in the lower lobes of both lungs. Bronchoscopy showed obstruction of the subsegmental bronchus with mucus plugs. Histological analysis demonstrated abundant eosinophils in the mucus plugs. Cytolytic eosinophils together with Charcot-Leyden crystal formations and deposition of major basic proteins were also observed, indicating the occurrence of EETosis. Introduction of benralizumab, an anti-interleukin-5 receptor α antibody, successfully controlled the patient's condition and reduced the amount of systemic corticosteroids administered. Our findings confirm that this antibody strongly decreases airway eosinophils in patients with severe asthma. Thus, benralizumab might be an optimal therapeutic agent for the treatment of mucus plug-forming and/or EETosis-occurring eosinophilic lung diseases, including eosinophilic bronchiolitis.

Serial serum SARS-CoV-2 RNA results in two COVID-19 cases with severe respiratory failure.

Coronavirus disease 2019 (COVID-19) is spreading worldwide and poses an imminent threat to public health. We encountered 2 cases of COVID-19 with progression resulting in severe respiratory failure and improvement without any specific treatment. To examine the course of infection, we performed reverse-transcription (RT) polymerase chain reaction assay with serum specimens, and serum SARS-CoV-2 RNA was detected in both cases when body temperature increased and respiratory status deteriorated. We, then examined, retrospectively and prospectively, the clinical course during hospitalization by performing serial examinations of serum SARS-CoV-2 RNA status. The findings from our cases suggest that not only is detection of viremia useful as a predictive marker of severity, but also serial serum SARS-CoV-2 RNA results can be helpful for predicting the clinical course.

Single nucleotide polymorphisms in genes encoding penicillin-binding proteins in ß-lactamase-negative ampicillin-resistant Haemophilus influenzae in Japan.

OBJECTIVE: ß-Lactamase-negative ampicillin-resistant Haemophilus influenzae is a common opportunistic pathogen of hospital- and community-acquired infections, harboring multiple single nucleotide polymorphisms in the ftsI gene, which codes for penicillin-binding protein-3. The objectives of this study were to perform comprehensive genetic analyses of whole regions of the penicillin-binding proteins in H. influenzae and to identify additional single nucleotide polymorphisms related to antibiotic resistance, especially to ampicillin and other cephalosporins. RESULTS: In this genome analysis of the ftsI gene in 27 strains of H. influenzae, 10 of 23 (43.5%) specimens of group III genotype ß-lactamase-negative ampicillin-resistant H. influenzae were paradoxically classified as ampicillin-sensitive phenotypes. Unfortunately, we could not identify any novel mutations that were significantly associated with ampicillin minimum inhibitory concentrations in other regions of the penicillin-binding proteins, and we reconfirmed that susceptibility to ß-lactam antibiotics was mainly defined by previously reported SNPs in the ftsI gene. We should also consider detailed changes in expression that lead to antibiotic resistance in the future because the acquisition of resistance to antimicrobials can be predicted by the expression levels of a small number of genes.

A Case of Bacillus Calmette-Guérin Cystitis Diagnosed with a Novel Loop-mediated Isothermal Amplification Method.

Intravesical bacillus Calmette-Guérin (BCG) instillation is broadly used to prevent bladder cancer recurrence or to treat carcinoma in situ. BCG infection is rare but can cause serious problems because this strain has intrinsic resistance to pyrazinamide, a first-line anti-tuberculosis drug. Furthermore, there had been no specific and easy procedure accurately diagnosing BCG infection. In this case report we present the first case of BCG cystitis diagnosed with a newly developed easy-to-use diagnostic procedure using the loop-mediated isothermal amplification method.

Mucus de alta atenuación en aspergilosis broncopulmonar alérgica / High-Attenuation Mucus in Allergic Bronchopulmonary Aspergillosis

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A Simple and Rapid Identification Method for Mycobacterium bovis BCG with Loop-Mediated Isothermal Amplification.

Bacillus Calmette-Guérin (BCG) is widely used as a live attenuated vaccine against Mycobacterium tuberculosis and is an agent for standard prophylaxis against the recurrence of bladder cancer. Unfortunately, it can cause severe infectious diseases, especially in immunocompromised patients, and the ability to immediately distinguish BCG from other M. tuberculosis complexes is therefore important. In this study, we developed a simple and easy-to-perform identification procedure using loop-mediated amplification (LAMP) to detect deletions within the region of difference, which is deleted specifically in all M. bovis BCG strains. Reactions were performed at 64 °C for 30 min and successful targeted gene amplifications were detected by real-time turbidity using a turbidimeter and visual inspection of color change. The assay had an equivalent detection limit of 1.0 pg of genomic DNA using a turbidimeter whereas it was 10 pg with visual inspection, and it showed specificity against 49 strains of 44 pathogens, including M. tuberculosis complex. The expected LAMP products were confirmed through identical melting curves in real-time LAMP procedures. We employed the Procedure for Ultra Rapid Extraction (PURE) kit to isolate mycobacterial DNA and found that the highest sensitivity limit with a minimum total cell count of mycobacterium (including DNA purification with PURE) was up to 1 × 10(3) cells/reaction, based on color changes under natural light with FDA reagents. The detection limit of this procedure when applied to artificial serum, urine, cerebrospinal fluid, and bronchoalveolar lavage fluid samples was also about 1 × 10(3) cells/reaction. Therefore, this substitute method using conventional culture or clinical specimens followed by LAMP combined with PURE could be a powerful tool to enable the rapid identification of M. bovis BCG as point-of-care testing. It is suitable for practical use not only in resource-limited situations, but also in any clinical situation involving immunocompromised patients because of its convenience, rapidity, and cost effectiveness.

PURE-LAMP Procedure for the Diagnosis of Extrapulmonary Tuberculosis: A Case Series.

Although the polymerase chain reaction is effective for the diagnosis of extrapulmonary tuberculosis (EPTB), it is typically unavailable in resource-limited situations. In contrast, the loop-mediated isothermal amplification (LAMP) assay is a relatively cost-effective and accessible method. Additionally, when combined with the procedure for ultra-rapid extraction (PURE) kit, which enables simple DNA extraction, LAMP can detect Mycobacterium tuberculosis in sputum within 1.5 hours using a simple procedure. In this study, we investigated the utility of the PURE-LAMP technique to diagnose three cases of EPTB and showed that it may potentially be a valuable tool for the diagnosis of EPTB.

Mortality and severity evaluation by routine pneumonia prediction models among Japanese patients with 2009 pandemic influenza A (H1N1) pneumonia.

BACKGROUND: Influenza-related pneumonia, referred to as influenza pneumonia, was reported relatively more frequently during a recent influenza pandemic in 2009. The validity of adapting routine pneumonia severity prediction models for various types of pneumonia is unclear. METHODS: We conducted a nationwide survey to evaluate influenza pneumonia among adult patients in Japan. Questionnaires were sent to physicians working in departments of respiratory medicine at 2491 hospitals. Both the outcome and pneumonia severity, using invasive positive pressure ventilation (IPPV) as an indicator, were evaluated by routine pneumonia severity index (PSI), CURB-65 (confusion, urea, respiratory rate, blood pressure, and age ≥ 65 years), and A-DROP (age, dehydration, respiration, disorientation, and blood pressure). RESULTS: Data collected from 320 patients with influenza pneumonia, including 25 cases (7.8%) of death and 43 (13.4%) of IPPV, were analyzed. Although all routine prediction models showed that higher mortality tended to be associated with a higher risk class/grade, the actual mortality rates were higher than predicted. The risk class of mortality calculated by the PSI was influenced by pneumonia patterns. Although pneumonia severity was similarly predicted, the types of pneumonia also affected severity in all prediction models. A-DROP showed the highest accuracy on receiver operating characteristic analysis for both mortality and severity. CONCLUSIONS: CURB-65 and A-DROP are fair predictors of mortality regardless of pneumonia patterns. However, the current pneumonia prediction models may underestimate the severity and appropriate site of care for patients with influenza pneumonia.

The (H1N1) 2009 pandemic influenza pneumonia among adult patients in Japan.

The recent H1N1 influenza pandemic involved several cases of influenza pneumonia. Although influenza pneumonia may have occurred more frequently in fatal cases, the clinical characteristics of influenza pneumonia in Japan remain unclear. We conducted a retrospective cohort study of adult patients with influenza pneumonia, for which questionnaires were sent to respiratory physicians working in 2,491 hospitals across Japan. Questionnaires were returned by 994 physicians (39.9%), providing data on 346 influenza pneumonia cases. The case-fatality ratio was 8.2% (27 cases). Pure influenza viral pneumonia was observed in 94 cases, which were most frequently young adults with chief complaints of non-productive cough and dyspnea. Radiological imaging showed diffuse ground-glass opacity. Corticosteroid therapy and mechanical ventilation were more frequently used for pure influenza viral pneumonia, but these modalities were not correlated with poor treatment outcomes. Anti-influenza antiviral drugs were prescribed in 335 cases (96.8%). In the recent pandemic in Japan, several pure influenza viral pneumonia cases were observed, but we found no variances in mortality between the different types of pneumonia. Almost all cases were treated with anti-influenza antiviral drugs, which may have contributed to its relatively low mortality rate.

Pleuroparenchymal fibroelastosis as a series of airway complications associated with chronic graft-versus-host disease following allogeneic bone marrow transplantation.

We herein report the case of a 31-year-old woman who presented with bilateral upper lobe volume loss and pleural irregularities with hilar retraction. She had undergone allogeneic bone marrow transplantation (BMT) for the treatment of acute lymphoblastic leukemia nine years earlier. A surgical lung biopsy showed pleural thickening and subpleural alveolar collapse and fibrosis, consistent with a diagnosis of pleuroparenchymal fibroelastosis (PPFE). Antecedent sicca syndrome and the absence of other causes of fibroelastosis suggested that these abnormalities were associated with chronic graft-versus-host disease (cGVHD). PPFE as a late, noninfectious complication is rare; however, the present case suggests a new class of BMT-related pulmonary complications associated with cGVHD.

A case of Nocardia asteroides infection in a patient with HIV/AIDS diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

We report a 45-year-old man with HIV/AIDS who developed mediastinal lymphadenopathy caused by Nocardia asteroides infection that was diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). He was an untreated HIV-infected man who was admitted to our hospital because of Pneumocystis pneumonia and Cytomegalovirus pneumonia. After treatment for pneumonia, cough and fever recurred and chest computed tomography revealed subcarinal lymphadenopathy with rim enhancement. To identify the etiology, we performed EBUS-TBNA and obtained purulent exudates which contained N. asteroides. EBUS-TBNA is a useful and safe technique for the diagnosis of mediastinal infectious lymphadenopathy of unknown origin.

[Clinical characteristics of pandemic (H1N1) 2009 influenza and preventive/therapeutic strategies].

Majority of cases of pandemic (H1N1) 2009 influenza were observed in young generation, but the severe cases were more frequently observed in elder generation in Japan during 2009-10 period. The people with certain underlying medical conditions appear to be at higher risk of severe illness, but over 60% of patients had healthy background. Signs of the influenza are seasonal-flu-like. The virus is spread from person to person, similar to seasonal influenza viruses. It is transmitted to other people by exposure to infected droplets or contaminated hands. To prevent spread, certain infection control measures should be performed. We also mentioned the treatment guidelines of IDSA, WHO and the Japanese association for infectious diseases.