Predictors and impact of time to clinical stability in community-acquired pneumococcal pneumonia.

BACKGROUND: A clinical stability (CS) evaluation is thought to be important in community-acquired pneumonia (CAP) treatment, but evidence concerning the time to CS (TCS) remains lacking. METHODS: Among consecutive patients hospitalized with pneumococcal pneumonia, relationships between TCS and other clinical outcomes were examined, and predictors and a predictive TCS score were derived from patient characteristics on admission. RESULTS: A total of 144 patients were enrolled, including 46% and 27% with moderate and severe pneumonia, respectively, defined by the pneumonia severity index (PSI). The median TCS was 2 days, and was significantly correlated with the length of hospital stay (r = 0.595); a longer TCS was significantly associated with the more presence of poor clinical outcomes and ICU stays (adjusted odds ratios: 1.359 and 1.366, respectively). A multivariate Cox proportional hazard model revealed an absence of bilateral pneumonia (hazard rate (HR): 2.107) or bacteremia (HR: 2.520), and mild or moderate pneumonia (HR: 2.798 and 2.515, respectively, versus severe) as predictors of CS. A predictive score had moderate discriminating power for the prolonged TCS (area under the curve: 0.76), and provided similar predictive values for poor clinical outcomes and ICU stays. A score of 3 or more points indicated the prolonged TCS, with a sensitivity and specificity of 73.3% and 70.9%, respectively. CONCLUSIONS: Because TCS has a significant relationship with other clinical outcomes of pneumococcal CAP, the prediction of TCS might lead to the prevention of complications or an earlier transition to oral therapy. Future studies are warranted to validate these results.

Diagnostic management of patients with suspected ocular sarcoidosis.

BACKGROUND: Ophthalmologists often refer patients with suspected ocular sarcoidosis to pulmonologists for diagnostic examination of sarcoidosis. However, no recommendation has been proposed for managing such patients. This study aims to prospectively evaluate the diagnostic values of examinations and propose the management of patients with suspected ocular sarcoidosis. METHODS: Consecutive patients with suspected ocular sarcoidosis were prospectively investigated according to type of ocular lesions, measurement of serum ACE, and findings of chest radiography, chest CT, bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). Diagnostic values were calculated on the basis of pathological results. RESULTS: Forty-two patients were included (female, 71.4%; mean age, 56.2±14.8 years), of whom 64.3% was diagnosed with sarcoidosis. Patient characteristics and ocular lesions did not differ significantly, regardless of the presence of sarcoidosis. Chest CT had low specificity and very high sensitivity for detecting sarcoidosis; in contrast, chest radiography and direct findings of bronchofiberscopy had high specificity and low sensitivity. Serum ACE and BAL did not have high diagnostic value. A flow chart was proposed to diagnose sarcoidosis, and this chart reduced the requirement of TBLB to 50% in our population. During the median follow-up of 51 months, 7 patients in the sarcoidosis group (25.9%) developed new lesions. CONCLUSIONS: Application of our flow chart appears to detect avoidable TBLB. Development of a more comprehensive flow chart including survey of ocular findings is warranted.

Re-expansion pulmonary edema: evaluation of risk factors in 173 episodes of spontaneous pneumothorax.

BACKGROUND: The precise incidence and clinical features of re-expansion pulmonary edema (RPE) are unclear, and they vary among reports. In this study, we assessed the incidence, risk factors, and outcomes of patients with RPE over a 3-yr period in a general hospital, with the goal of proposing a primary intervention for pneumothorax. METHODS: We retrospectively reviewed records of inpatients with spontaneous pneumothorax treated by tube thoracostomy between October 2007 and December 2010. RESULTS: A total of 173 episodes of spontaneous pneumothorax occurred in 156 patients. The incidence of RPE was 27/173 (15.6%). Symptom duration and pneumothorax size were significant risk factors for RPE, and the occurrence of RPE was independent of primary treatment of spontaneous pneumothorax. Among the patients with RPE, 18 (67%) were symptomatic. Five patients (18.5%) were treated with temporary oxygen, however, 21 patients (78%) did not need any treatment. All patients survived and none required mechanical ventilation. The occurrence of RPE did not influence the clinical outcome. CONCLUSIONS: The risk of developing RPE increases with an increased duration or size of pneumothorax. Our results suggest that the methods of primary intervention, including prompt suction, do not affect the onset of RPE. Close observation is always required regardless of the intervention because of the potentially fatal complications.

Paradoxical infarct in tuberculous meningitis: a case report.

We describe a case of 78-year-old woman with a 1-week history of fever and left hemiparesis. Head magnetic resonance imaging showed a small infarct. After admission, she showed altered consciousness and another small infarct. She finally had diagnoses of miliary tuberculosis (miliary-TB) and tuberculous meningitis (TBM). She recovered after receiving anti-tuberculous therapy (ATT) with prednisolone. However, 5 weeks later, we found another infarct. This is a rare case of TBM with recurrent infarcts in atypical lesions in spite of ATT. We suggest the possibility that the new infarct after ATT was due to a paradoxical reaction.

Prospective evaluation of the relationship between acute exacerbations of COPD and gastroesophageal reflux disease diagnosed by questionnaire.

BACKGROUND: Little is known about the relationship between acute exacerbations of COPD (AECOPD) and gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects on AECOPD of GERD diagnosed by a questionnaire. METHODS: The subjects were 221 consecutive patients with stable COPD who were evaluated using the Frequency Scale for Symptoms of GERD (FSSG) and a prospective survey of AECOPD for one year. Patients taking drugs for acid suppression were excluded. The association between the frequency of AECOPD and the presence of GERD or FSSG score was examined. RESULTS: Based on the FSSG, the prevalence of GERD was 26.7%. AECOPD and hospitalization due to AECOPD were significantly more frequent in patients with GERD than in those without GERD, with crude relative risks of 3.42 and 3.66, respectively. Multivariate analyses showed that GERD and COPD stage IV were significant predictors of hospitalization due to AECOPD, independent of respiratory therapies or patient characteristics. The severity of GERD symptoms, as measured by the FSSG score, was significantly correlated with the frequencies of AECOPD and hospitalization due to AECOPD. Similar correlations were seen for the FSSG subscores for acid reflux and gastric dysmotility. CONCLUSIONS: This prospective cohort study showed that GERD appears to be a predictive factor for hospitalization due to AECOPD and that severer GERD symptoms may be associated with more frequent AECOPD. Thus, further studies are warranted to evaluate the preventive effect of the therapy for GERD on AECOPD.

[A case of fulminant community-acquired Acinetobacter pneumonia in a healthy woman].

We describe a case of fulminant community-acquired Acinetobacter baumannii pneumonia. A 68-year-old woman, who had no past medical history, was admitted with septic shock and pneumonia of left lower lobe. Despite intensive treatment she died on day 3 after admission. To the best of our knowledge, this is the 4th report of community-acquired Acinetobacter pneumonia in Japan and the 1st report in a healthy patient. We report a case of Acinetobacter pneumonia and discuss the clinical characteristics of the community-acquired type compared with the hospital-acquired type.

[Relationship between chronic obstructive pulmonary disease and gastroesophageal reflux disease defined by the Frequency Scale for the Symptoms of gastroesophageal reflux disease].

Little is known about gastroesophageal reflux disease (GERD) in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to investigate the prevalence, clinical characteristics and risk factors for GERD in COPD patients, based on the Frequency Scale for the Symptoms of GERD (FSSG). In 228 COPD patients, the prevalence of GERD was 26.7%, independent of COPD stage. Logistic regression multivariate analysis revealed significant risk factors for accompanying GERD were age (p = 0.009; odds ratio (OR), 0.933; 95% confidence interval (CI) 0.885 to 0.983) and number of COPD exacerbation within one year (p = 0.043; OR, 1.675; 95% CI, 1.075 to 2.764). The risk factors of COPD exacerbation were total FSSG score (p = 0.031; OR, 1.079; 95% CI, 1.007 to 1.156) and inhaled corticosteroid use (p = 0.003; OR, 3.238; 95% CI, 1.482 to 7.076). Moreover, the Spearman rank correlation test showed that FSSG score was weakly but significantly correlated with the number of COPD exacerbations (rs = 0.317, p < 0.001). In conclusion, the incidence of GERD in COPD patients is high, and the incidence of GERD is closely related to COPD exacerbation.

Spontaneous pneumomediastinum: an algorithm for diagnosis and management.

Spontaneous pneumomediastinum (SPM) is a rare disorder most often affecting young males which is generally self-limiting. Despite the benign prognosis with few complications and little morbidity, it frequently confuses clinicians in primary settings, who may have difficulty differentiating SPM from other serious organ ruptures, especially oesophageal rupture (the so-called Boerhaave syndrome), which may lead to mediastinitis and may be fatal, even with appropriate interventions. An overview of adult SPM is provided, reviewing 17 studies (414 patients), including our clinical experience, and finally an algorithm for diagnosis and management of SPM is proposed, based on the characteristics of SPM.

[Predictors of survival in patients with chronic hypercapnic respiratory failure receiving domiciliary NPPV].

Fifty-four cases (36 men) with chronic hypercapnic respiratory failure were prescribed domiciliary NPPV during 9 years. COPD (26 patients) and sequelae of tuberclosis (16 patients) were the major primary diseases. At the initiation of NPPV, the age was 71.2 +/- 7.3 years-old (mean +/- standard deviation) and PaCO2 was 76.7 +/- 16.2Torr. Overall, the 1-year and 5-year survival rates were 63.8% and 26.0%, respectively. Multivariate analysis identified BMI (body mass index) (hazzard ratio : 0.837, p = 0.020) and the number of days of hospitalization during 1 year before NPPV (hazzard ratio: 1.013, p = 0.016) as predictors of survival. Patients with frequent hospitalization for exacerbation or with malnutrition had poor prognosis, so comprehensive supports aimed to improve general status are needed for patients with chronic respiratory failure received domiciliary NPPV.

Management of spontaneous pneumomediastinum based on clinical experience of 25 cases.

STUDY OBJECTIVES: Spontaneous pneumomediastinum (SPM) is a rare disorder that usually occurs in young individuals and has a self-limiting course and no recurrence in most cases. But actually in many cases, patients are undergo some examinations or some limitations. The purpose of this study was to evaluate the clinical characteristics and recommend appropriate management of SPM. DESIGN: Retrospective research of clinical records of a single institution. RESULTS: Over 11 years, we diagnosed 25 patients (18 males) with SPM. Their average age was 20.1 years (range 13-28 years). Chest pain or neck symptoms were most frequent, and 17 patients (68%) had subcutaneous emphysema. In all cases, blood counts and C-reactive protein (CRP) were measured, and their mean values were 10,100+/-4600/mm(3) and 1.0+/-1.5 mg/dL, respectively. In 20 patients (80%), either leucocytosis or elevated CRP was observed. Twenty-four patients (96%) were admitted (average 7.8+/-4.1 days) and 20 of them were prescribed antibiotics or limited oral intake. The symptoms were self-limiting in all cases and disappeared on average 1.8+/-0.9 days after diagnosis. No recurrence was noted in the approximately 2 years follow-up period. CONCLUSION: SPM is a self-limiting disease with mild inflammatory signs. For patients suspicious of SPM, shortened hospitalization for about 2 days with observation alone may be feasible, if their symptoms improve gradually. Otherwise, less invasive procedures, such as esophagram, should be performed immediately. Long-term follow-up is usually unnecessary. We propose a new algorithm for management of SPM based on clinical experience.

[Purpura fulminans due to pneumococcal pneumonia in a healthy adult: a case report].

We report a case of infectious purpura fulminans due to pneumococcal pneumonia in a 61-year-old man presenting multiple organ failure and pneumococcal bacteremia secondary to pneumonia on admission. His lower limbs showed rapidly progressive purpura and symmetrical dry gangrene. He had no history of or apparent immunodeficiency, including asplenia, in abdominal ultrasonography. Despite of therapy, he died on day 15 after admission. Infectious purpura fulminans involves skin lesions with severe infection often accompanied by disseminated intravascular coagulation and septic shock. Although it occurs mainly in childhood, especially as a complication of Neisseria meningitis or Varicella virus infection, it has also been reported in adult, as a rare complication of invasive pneumococcal infection. Most had immunodeficiency such as asplenia or postsplenectomy. Purpura fulminans in a previously healthy adult is very rare and this is insofar as we know, the first report in Japan detailing the development from pneumococcal pneumonia.