Traction bronchiectasis on high-resolution computed tomography may predict fatal acute eosinophilic pneumonia.

BACKGROUND: Most patients with acute eosinophilic pneumonia (AEP) show rapid improvement. However, some cases of AEP prove fatal. The aims of this study were to determine the clinical, radiographic, and pathologic characteristics of patients in whom AEP has a fatal outcome and to identify predictors of a poor prognosis. METHODS: We retrospectively identified the medical records of all patients diagnosed with AEP at our institution in Japan from July 2005 to July 2013. RESULTS: There were four deaths among 41 patients diagnosed to have AEP during the study period. All the patients who died were male; three cases were idiopathic and one was medication-related. The median bronchoalveolar lavage eosinophil differential count was 59%. An autopsy was performed on the patient with medication-related AEP who died and the pathologic finding was diffuse alveolar damage with eosinophilic infiltration. Diffuse ground-glass attenuation and traction bronchiectasis (TBE) were identified on high-resolution computed tomography in the four patients with fatal AEP. TBE was observed in six patients (five with idiopathic AEP, one with medication-related AEP), and 67% of these patients died. None of the patients with smoking-related AEP had TBE; all these patients had better responses to treatment and survived. CONCLUSIONS: We observed the characteristics of patients with fatal AEP who did not respond to treatment. TBE was observed in all fatal cases and may be associated with a poor prognosis.

A Case of Community-Acquired Pneumonia Due to Legionella pneumophila Serogroup 9 Wherein Initial Treatment with Single-Dose Oral Azithromycin Appeared Useful.

Legionella species are important causative pathogens for severe community-acquired pneumonia (CAP). Most cases of Legionella pneumonia are due to Legionella pneumophila serogroup 1, and CAP due to L. pneumophila serogroup 9 is rare. A fourth case of CAP due to L. pneumophila serogroup 9 has been reported, and initial treatment using single-dose oral azithromycin appeared useful. Azithromycin or fluoroquinolone injection is usually recommended for the treatment of Legionella pneumonia, and no previous reports have shown the effectiveness of single-dose oral azithromycin. This case report is therefore valuable from the perspective of possible treatment for mild to moderate Legionella pneumonia using single-dose oral azithromycin.

18 Cases of pulmonary Mycobacterium abscessus: Clinical difference depending on the presence or absence of Mycobacterium avium complex.

BACKGROUND AND OBJECTIVES: It can be difficult to treat respiratory tract infections caused by Mycobacterium abscessus (M. abscessus) as there is no established treatment strategy. Complications involving other nontuberculous mycobacterial infections such as Mycobacterium avium complex (MAC) are also commonly observed. METHODS: We investigated the clinical background and course of 18 cases of pulmonary M. abscessus infection treated over 8 years at Kurashiki Central Hospital. Radiological evaluation was performed using NICE scoring system, a method of semi-quantitative evaluation of imaging findings of pulmonary MAC infection. RESULTS: The mean age of the 18 patients (males, 6; females, 12) was 74.7 years. The median follow-up period was 1316 days (95% confidence interval; 720-1675 days), and 11 patients were concomitantly infected with pulmonary MAC. Among the patients that underwent antibacterial treatment for M. abscessus, there was one MAC-complication case and one non-MAC-complication case. All MAC-complication cases underwent antibacterial treatment including clarithromycin. Chest X-ray NICE scores for all cases were 8.50 ± 5.45 and 10.94 ± 6.03 at baseline and follow-up, respectively (p = 0.0063). For MAC-complication cases, scores were 8.36 ± 4.74 and 12.00 ± 6.02 at baseline and follow-up, respectively (p = 0.00818), and for non-MAC-complication cases, scores were 8.71 ± 6.82 and 9.29 ± 6.13 at baseline and follow-up, respectively (p = 0.356). MAC-complication cases were significantly further exacerbated than non-MAC-complication cases (p = 0.027). CONCLUSIONS: Some cases of pulmonary M. abscessus infection progressed well without undergoing antibacterial treatment. In particular, results suggested that the clinical course of MAC-complication and non-MAC-complication cases differs.

Serial procalcitonin levels for predicting prognosis in community-acquired pneumonia.

BACKGROUND AND OBJECTIVE: This study aimed to investigate the usefulness of addition of serial measurements of procalcitonin (PCT) to C-reactive protein (CRP) values and pneumonia severity scores, such as CURB-65 (confusion, urea > 7 mmol/L, respiratory rate ≥ 30 breaths/min, low blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg) and age ≥ 65 years) and the Pneumonia Severity Index, and attempted to create and evaluate a new scoring system for predicting mortality risk using the biomarkers and pneumonia severity scores. METHODS: A total of 365 hospitalized community-acquired pneumonia (CAP) patients in an observational cohort study in which PCT was measured serially from admission to 2-3 days after admission between December 2010 and December 2014 were reviewed retrospectively. PCT and CRP were measured on admission (PCT D1 and CRP D1) and within 48-72 h after admission (PCT D3 and CRP D3). RESULTS: Twenty-one patients died (5.8%), and 52 patients (14.2%) did not respond to initial therapy. On multivariate analysis, CRP D1 ≥ 100 mg/L (P = 0.002), CURB-65 ≥ 3 (P < 0.001) and PCT D3/D1 ≥ 1 (P < 0.001) were significant predictors of 30-day mortality. Peak CRP (P = 0.02) and PCT D3/D1 ≥ 1 (P = 0.03) were significant predictors of initial treatment failure. Using the new scoring system that defines CRP D1 ≥ 100 mg/L as 2 points, CURB-65 ≥ 3 as 1 point and PCT D3/D1 ≥ 1 as 1 point, in CAP patients with both CRP D1 ≥ 100 mg/L and CURB-65 ≥ 3 on admission, the 30-day mortality rate was 21.8%, and with PCT D3/D1 ≥ 1, it increased to 50.0%. CONCLUSION: It is useful to add serial measurements of PCT to CRP measurement and assessment of CURB-65 on admission of CAP patients to predict prognosis and initial treatment failure.

Composite Physiologic Index, Percent Forced Vital Capacity and Percent Diffusing Capacity for Carbon Monoxide Could Be Predictors of Pirfenidone Tolerability in Patients with Idiopathic Pulmonary Fibrosis.

OBJECTIVE: The goals of this study were to assess the efficacy and tolerability of pirfenidone in patients with idiopathic pulmonary fibrosis (IPF) and to identify predictors of tolerability to pirfenidone. METHODS: We conducted a retrospective observational study. When the patient showed deterioration in the percent forced vital capacity (%FVC) or experienced acute exacerbations or severe adverse events, treatment of the patient with pirfenidone was discontinued. We classified the patients who did not display progression following six months of pirfenidone treatment as the tolerant group and the patients who did display progression as the intolerant group. We retrospectively analyzed differences between the two groups in terms of baseline characteristics. The efficacy of pirfenidone was evaluated by the changes in vital capacity (VC) and %FVC before and after the start of treatment in the tolerant group. Patients A total of 20 patients who had been diagnosed with IPF were treated with pirfenidone. RESULTS: In the tolerant group, the baseline %FVC (p=0.01) and the percentage diffusing capacity of the lungs for carbon monoxide (DLCO, p=0.02) were significantly higher, and the baseline composite physiologic index (CPI) was significantly lower (p=0.009) than in the intolerant group. In the tolerant group, pirfenidone significantly reduced the decline in VC and %FVC of the patients after treatment. In the intolerant group, five patients discontinued pirfenidone treatment because of anorexia. CONCLUSION: We found that pirfenidone was better tolerated in patients with milder disease symptoms, as indicated by their baseline CPI, %FVC and %DLCO, and that patients in the tolerant group could benefit from the use of pirfenidone.

Identifying the Cause of the "Saturation Gap": Two Cases of Dapsone-induced Methemoglobinemia.

Diaphenylsulfone (DDS: Dapsone) is used for Pneumocystis pneumonia (PCP) prophylaxis, and methemoglobinemia has rarely been reported as a side effect of DDS. We herein report two cases of DDS-related methemoglobinemia in an 81-year-old man with organizing pneumonia and an 84-year-old woman with eosinophilic pneumonia under treatment with prednisolone. Both patients initially received trimethoprim/sulfamethoxazole for PCP prophylaxis and were switched to DDS due to side effects and subsequently exhibited a clinically unexplainable decrease in SpO2. Methemoglobinemia was diagnosed based on the findings of arterial blood gas analyses. In both cases, the methemoglobinemia improved after discontinuing DDS.

Incidence and impact of interstitial lung disease and malignancy in patients with polymyositis, dermatomyositis, and clinically amyopathic dermatomyositis: a retrospective cohort study.

The aims of this study were to retrospectively review Japanese consecutive cases of polymyositis (PM), dermatomyositis (DM), and clinically amyopathic dermatomyositis (CADM), focusing on interstital lung disease (ILD) and malignancy, and to document any differences in the incidence, clinical features, and impact on prognosis among patients with PM, DM, and CADM. We retrospectively reviewed 62 consecutive patients diagnosed with PM, DM, and CADM according to Bohan and Peter's criteria (PM/DM) and Sontheimer's criteria and Gerami's criteria (CADM), focusing on ILD and malignancy. ILD occurrence rates were 48 % (11/23) in patients with PM, 46 % (11/24) in DM, and 100 % (15/15) in CADM. Malignancy occurred during diagnosis or the observation period in 14 patients; 86 % were without ILD, and 64 % were DM without ILD. Multivariate logistic regression analysis showed that the risk of newly diagnosed malignancy was significantly lower in patients with ILD [odds ratio, 0.0688; 95 % confidence interval (CI), 0.00127-0.372; p = 0.00190] and significantly higher in patients with DM (odds ratio, 5.21; 95 % CI, 1.17-23.1; p = 0.0299) than in other patients. Patients with malignancies had shorter survival than those without malignancies; no clinically meaningful difference in survival was observed among the different myositis types and for presence of ILD. In CADM-ILD, 80 % fatal cases died from refractory ILD ≤90 days from the first visit; neither death nor recurrence occurred subsequently. In conclusion, a positive association between DM and malignancy and a negative association between ILD and malignancy were noted. In the present study, malignancy was a predictor of poor long-term prognosis, but ILD were not. ILD associated with CADM contributed greatly to poor short-term prognosis, but neither death nor recurrence occurred subsequently.

Successful treatment of non-small cell lung cancer with gefitinib after severe erlotinib-related hepatotoxicity.

Gefitinib and erlotinib are first-generation small molecular inhibitors of EGFR tyrosine kinase activity. To the best of our knowledge, to date, two reports have stated that patients with NSCLC who develop severe hepatotoxicity secondary to gefitinib treatment can be safely switched to erlotinib. However, the reverse situation has not been reported. Here, we present the first case with non-small cell lung cancer harboring EGFR mutation who developed grade 3/4 hepatotoxicity after initiation of erlotinib, which resolved when therapy was changed to gefitinib. As far as we know, this is the first report showing the efficacy of gefitinib for a non-small cell lung cancer patient who developed severe hepatotoxicity while under erlotinib therapy.