Is ß-Lactam Plus Macrolide More Effective than ß-Lactam Plus Fluoroquinolone among Patients with Severe Community-Acquired Pneumonia?: a Systemic Review and Meta-Analysis.

Adding either macrolide or fluoroquinolone (FQ) to ß-lactam has been recommended for patients with severe community-acquired pneumonia (CAP). However, due to the limited evidence available, there is a question as to the superiority of the two combination therapies. The MEDLINE, EMBASE, Cochrane Central Register, Scopus, and Web of Science databases were searched for systematic review and meta-analysis. A total of eight trials were analyzed. The total number of patients in the ß-lactam plus macrolide (BL-M) and ß-lactam plus fluoroquinolone (BL-F) groups was 2,273 and 1,600, respectively. Overall mortality of the BL-M group was lower than that of the BL-F group (19.4% vs. 26.8%), which showed statistical significance (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.49 to 0.94; P = 0.02). Length of hospital stay was reduced in the BL-M group compared to the BL-F group (mean difference, -3.05 days; 95% CI, -6.01 to -0.09; P = 0.04). However, there was no significant difference in length of intensive care unit (ICU) stay between the two groups. Among patients with severe CAP, BL-M therapy may better reduce overall mortality and length of hospital stay than BL-F therapy. However, we could not elicit strong conclusions from the available trials due to high risk of bias and methodological limitations.

Case report of meningiomatosis with aspiration of a dental bridge improved by comprehensive rehabilitation therapy.

[Purpose] The aim of this study was to ascertain the effect of comprehensive rehabilitation therapy on a quadriplegic patient with meningiomatosis and severe dysphagia. [Subject and Methods] Meningiomatosis is defined as multiple meningiomas involved in several intracranial regions, which occurs more frequently in elderly patients. The prognosis of meningiomatosis is mostly reported as benign, but the prognosis for some malignant cases can be poor. Furthermore, dysphagia in elderly patients with brain lesions may lead to foreign body aspiration, which can be fatal. The removable type of dental prosthesis is a common cause of aspiration, but aspiration is rare with the fixed type. [Results] This report presents a rare case of bronchial aspiration involving a fixed dental prosthesis in an elderly meningiomatosis patient that was improved following comprehensive rehabilitation therapy. [Conclusion] Thorough evaluation and individualized assessment of rehabilitation goals is recommended for the care of severe comorbid elderly patients.

The Effectiveness of Anti-leukotriene Agents in Patients with COPD: A Systemic Review and Meta-analysis.

BACKGROUND: Anti-leukotriene (anti-LT) agents have been not yet established for effectiveness in patients with chronic obstructive pulmonary disease (COPD). We performed a systematic review and meta-analysis to assess whether anti-LT agents have the responsiveness for COPD patients. METHODS: MEDLINE, EMBASE, Cochrane Central Register, and Korea Med were searched for relevant clinical trials to review. RESULTS: Seven studies involving 342 patients were finally analyzed. Pooled estimation from three randomized controlled studies did not demonstrate that anti-LT agents increased forced expiratory volume in 1 s [overall effect: 0.09 L, 95 % confidence interval (CI) -0.04 to 0.21; P = 0.17; I (2)  = 41.0 %] or forced vital capacity (overall effect: 0.04 L, 95 % CI -0.04 to 0.11; P = 0.64; I (2) = 0.0 %). As for inflammatory markers, anti-LT agents did not affect the level of myeloperoxidase (standardized mean difference, -0.15; 95 % CI -0.65 to 0.36) or LTB4 (standardized mean difference, -0.41; 95 % CI -0.96 to 0.13). They reduced the frequency of dyspnea [relative risk (RR) 0.43; 95 % CI 0.29 to 0.64] and sputum (RR 0.37; 95 % CI 0.22 to 0.63), based on overall estimation from two non-randomized studies. However, our review revealed that there are few well-designed, randomized controlled studies with large sample sizes and long treatment durations. CONCLUSION: Although symptomatic improvements were demonstrated in some studies, there is a lack of evidence to support the therapeutic efficacy of anti-LT agents in patients with COPD. Further large-scale, long-term studies are needed to identify predictive factors for COPD patients who may benefit from anti-LT agents.

Identification and Antimicrobial Susceptibilities for Patients with Non-tuberculous Mycobacteria Infection in Jeju Island: Single-Center Retrospective Study.

BACKGROUND: The distribution of species and characteristics of non-tuberculous mycobacteria (NTM) differ, and surveillance data for changes in antimicrobial susceptibilities of NTM is insufficient. This study analyzed the changes in antimicrobial susceptibility trends across NTM species and assessed the appropriateness of empirical antimicrobial drugs for NTM. MATERIALS AND METHODS: We retrospectively analyzed the clinical characteristics, including demographics, distribution of NTM species, antimicrobial drug susceptibilities, and outcomes, at a teaching hospital in Jeju Island from 2009 - 2022. RESULTS: Overall, 342 patients were included in the analysis; 93.0% were classified into the pulmonary group (PG) and 7.0% into the extrapulmonary group (EPG). The isolation rate of Mycobacterium avium was significantly higher in PG (36.8% vs. 0%, P = 0.001), while that of Mycobacterium fortuitum was significantly higher in EPG (4.5% vs. 31.3%, P = 0.001). The antimicrobial susceptibility rate is higher against clarithromycin (89.9%) and amikacin (83.3%) and lower against rifampin (54.7%) and ethambutol (28.1%). The susceptibility rate to clarithromycin was over 80%, but those to rifampin and ethambutol showed decreasing annual trends. Of the 162 patients who received empirical antimicrobial therapy, actual antimicrobial susceptibility rates were high (90.1%) using empirical macrolide, and relatively low using ethambutol and rifampin (28.0% and 58.8%, respectively). CONCLUSION: This is the first study of analysis of the distribution, baseline characteristics, and antimicrobial susceptibility of isolated NTM species in pulmonary and extrapulmonary patients in Jeju Island over 10 years. Policies that continuously monitor changes in susceptibility rate are required to ensure effective treatment strategies.

Substantiating the Therapeutic Effects of Simultaneous Heat Massage Combined with Conventional Physical Therapy for Treatment of Lower Back Pain: A Randomized Controlled Feasibility Trial.

BACKGROUND: There are various therapeutic options for the conservative management of lower back pain (LBP). A combination of two or more treatment options may be more effective in the clinical management of non-specific LBP. In this study, we compared the effects of simultaneous heat massage with conventional physical therapy in patients with subacute LBP. METHODS: A single-center randomized controlled trial in which 40 participants with LBP were allocated to one of two groups: a heat massage group (HMG) and physical therapy group (PTG). The HMG received simultaneous heat massage therapy using a mechanical device (CGM MB-1401, Ceragem, Republic of Korea). The PTG received conventional physical therapy. Both groups received 40 min of therapy once daily, five times a week, for a total of four weeks. Changes in serum cortisol, epinephrine (EP), and norepinephrine (NE) were assessed. The outcomes were measured using the pain numeric rating scale (PNRS), the Oswestry disability index (ODI), the Roland-Morris disability questionnaire (RMDQ), the short-form McGill pain questionnaire (SF-MPQ), the multidimensional fatigue inventory (MFI-20), the Beck depression inventory (BDI), surface EMG (sEMG), and sympathetic skin response (SSR) at baseline (PRE), at 2 (2 W) and 4 weeks (4 W) following the intervention. RESULTS: The serum EP and NE levels in the HMG decreased after treatment. The PNRS, ODI, RMDQ, and SF-MPQ scores improved without significance in both groups. The BDI score showed improvement in the HMG before the PTG. The MFI-20 score improved in both groups, but the results were better in the HMG than in the PTG at 4 W. All the activities of sEMG were significantly decreased in both groups. However, the improvement of the %MVIC in the HMG was better than that in the PTG at 4 W. The SSR latency on sEMG decreased while the amplitude increased in the HMG at 2 W and 4 W, respectively. CONCLUSIONS: Following 4 weeks of combined therapies, heat massage was not superior to conventional physical therapy alone. Both treatments were shown to be effective in improving LBP and pain-related disability. However, heat massage was shown to have a better effect on the control of autonomic nerve function and underlying moods.

Mechanical Changes of the Lumbar Intervertebral Space and Lordotic Angle Caused by Posterior-to-Anterior Traction Using a Spinal Thermal Massage Device in Healthy People.

BACKGROUND: The axial (horizontal) traction approach has been traditionally used for treatment of low back pain-related spinal disorders such as nuclear protrusion, primary posterolateral root pain, and lower thoracic disc herniation; however, it is known to have some technical limitations due to reductions of the spinal curve. Lumbar lordosis plays a pivotal function in maintaining sagittal balance. Recently, vertical traction and combination traction have been attracting attention due to improving therapeutic outcomes, although evidence of their clinical application is rare; therefore, this study was conducted to investigate the mechanical changes of lumbar intervertebral space, lordotic angle, and the central spinal canal area through vertical traction treatment using a spinal massage device in healthy participants. METHODS: In total, 10 healthy subjects with no musculoskeletal disorders and no physical activity restrictions participated. The participants lay on the experimental device (CGM MB-1901) in supine extended posture and vertical traction force was applied in a posterior-to-anterior direction on the L3-4 and L4-5 lumbar sections at level 1 (baseline) and level 9 (traction mode). Magnetic resonance (MR) images were recorded directly under traction mode using the MRI scanner. The height values of the intervertebral space (anterior, center, and posterior parts) and lordosis angle of the L3-4 and L4-5 sections were measured using Image J software and the central spinal canal area (L4-5) was observed through superimposition method using the MR images. All measurement and image analyses were conducted by 2 experienced radiologists under a single-blinded method. RESULTS: The average height values of the intervertebral space under traction mode were significantly increased in both L3-4 and L4-5 sections compared to baseline, particularly in the anterior and central parts but not in the posterior part. Cobb's angle also showed significant increases in both L3-4 and L4-5 sections compared to baseline (p < 0.001). The central spinal canal area showed a slightly expanded feature in traction mode. CONCLUSIONS: In this pilot experiment, posterior-to-anterior vertical traction on L3-4 and L4-5 sections using a spinal massage device caused positive and significant changes based on increases of the intervertebral space height, lumbar lordosis angle, and central spinal canal area compared to the baseline condition. Our results are expected to be useful as underlying data for the clinical application of vertical traction.

Predictive Factors of Methicillin-Resistant Staphylococcus aureus Infection in Elderly Patients with Community-Onset Pneumonia.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infection is a severe and life-threatening disease in patients with community-onset (CO) pneumonia. However, the current guidelines lack specificity for a screening test for MRSA infection. METHODS: This study was retrospectively conducted in elderly patients aged ≥65 years, who had contracted CO-pneumonia during hospitalization at the Jeju National University Hospital, between January 2012 and December 2014. We analyzed the risk factors of MRSA in these patients and developed a scoring system to predict MRSA infection. RESULTS: A total of 762 patients were enrolled in this study, including 19 (2.4%) with MRSA infection. Healthcare-associated pneumonia (HCAP) showed more frequent MRSA infection compared to community-acquired pneumonia (4.4% vs. 1.5%, respectively; p=0.016). In a multivariate logistic regression analysis, admissions during the influenza season (odds ratio [OR], 2.896; 95% confidence interval [CI], 1.022-8.202; p=0.045), chronic kidney disease (OR, 3.555; 95% CI, 1.157-10.926; p=0.027), and intensive care unit admission (OR, 3.385; 95% CI, 1.035-11.075; p=0.044) were identified as predictive factors for MRSA infection. However, the presence of HCAP was not significantly associated with MRSA infection (OR, 1.991; 95% CI, 0.720-5.505; p=0.185). The scoring system consisted of three variables based on the multivariate analysis, and showed moderately accurate diagnostic prediction (area under curve, 0.790; 95% CI, 0.680-0.899; p<0.001). CONCLUSION: MRSA infection would be considered in elderly CO-pneumonia patients, with three risk factors identified herein. When managing elderly patients with pneumonia, clinicians might keep in mind that these risk factors are associated with MRSA infection, which may help in selecting appropriate antibiotics.

A New Instrument for Measuring Tibial Torsion in Pediatric Patients.

OBJECTIVE: To develop and test the validity and reliability of a new instrument for measuring the thigh-foot angle (TFA) for the patients with in-toeing and out-toeing gait. METHODS: The new instrument (Thigh-Foot Supporter [TFS]) was developed by measuring the TFA during regular examination of the tibial torsional status. The study included 40 children who presented with in-toeing and out-toeing gaits. We took a picture of each case to measure photographic-TFA (P-TFA) in the proper position and to establish a criterion. Study participants were examined by three independent physicians (A, B, and C) who had one, three and ten years of experience in the field, respectively. Each examiner conducted a separate classical physical examination (CPE) of every participant using a gait goniometer followed by a TFA assessment of each pediatric patient with or without the TFS. Thirty minutes later, repeated in the same way was measured. RESULTS: Less experienced examiner A showed significant differences between the TFA values depending on whether TFS used (left p=0.003 and right p=0.008). However, experienced examiners B and C did not show significant differences. Using TFS, less experienced examiner A showed a high validity and all examiner's inter-test and the inter-personal reliabilities increased. CONCLUSION: TFS may increase validity and reliability in measuring tibial torsion in patients who has a rotational problem in lower extremities. It would be more useful in less experienced examiners.

[A case of idiopathic colitis developed after barium enema].

It has been reported that colitis may be associated with intrarectally administered drugs or chemicals. Colonotoxicity may results from conventional medical therapy, herbal or other illicit drugs, contrast materials, and detergents. Clues that a colitis may be due to an intrarectally administered agent include perianal excoriation, segmental distal colitis due to a concentration gradient from enema administration, and recent diagnostic or therapeutic administration of high risk solutions such as hypertonic contrast agents or detergent enemas. Barium is a highly viscous contrast agent that is insoluble in water. Barium enemas are usually very safe. Also, no case report of barium-induced chemical colitis has been reported yet. We report a case of chemical colitis with colonic stricture occurring after the barium enema for diagnostic purpose.

Clinical characteristics of patients with hemodialysis-associated pneumonia compared to patients with non-hemodialysis community-onset pneumonia.

BACKGROUND: The 2005 ATS/IDSA guidelines included hemodialysis-associated pneumonia (HDAP) as a category of healthcare-associated pneumonia (HCAP). However, the clinical epidemiology of HDAP has been not well established. This study aimed to evaluate the clinical and microbiological characteristics of HDAP patients compared to community-acquired pneumonia (CAP) or other HCAP except HDAP (O-HCAP). METHODS: We conducted a retrospective observational study on HDAP patients who were admitted between January 2012 and December 2014. We compared clinical features, distribution of microorganisms, antibiotic regimens, and clinical outcomes among the three groups. RESULTS: A total of 914 patients, comprised of 595 patients with CAP, 24 with HDAP, and 295 with O-HCAP, were evaluated. The median PSI score of the HDAP group was higher than that of the CAP group and similar to that of the O-HCAP group. The major pathogens of the HDAP group were Staphylococcus aureus and Klebsiella pneumoniae. The isolation rate of multidrug-resistant (MDR) pathogens and total in-hospital mortality of the HDAP group was similar to those of the CAP group (8.3% vs. 6.8%, p = 1.000 and 4.1% vs. 7.5%, p = 0.821, respectively). Otherwise, the isolation rate of MDR pathogens and total in-hospital mortality rate in the O-HCAP group were at 15.2% and 16.9%, respectively, and were the highest among the three groups. CONCLUSIONS: Based on microorganisms and clinical outcomes, the HDAP group was clinically more similar to the CAP group than the O-HCAP group. Therefore, the 2005 ATS/IDSA guidelines that include HDAP as a category of HCAP might be reassessed.

Predictive factors of true bacteremia and the clinical utility of blood cultures as a prognostic tool in patients with community-onset pneumonia.

Although blood cultures (BCs) are an important component of diagnostic practice for antibiotic management in patients with pneumonia, several studies have questioned whether they should be performed. The objective of this study was to evaluate the predictive factors of bacteremia and the role of BCs in patients with community-onset pneumonia (community-acquired pneumonia and healthcare-associated pneumonia).This study was retrospectively conducted in patients with community-onset pneumonia who were hospitalized at Jeju National University Hospital between January 2012 and December 2014. A true bacteremia (TB) group and a contaminants or negative bacteremia (CNB) group were classified according to the bacterial growth on the BC media and were investigated for the clinical relevance of the BCs.We enrolled 785 patients; the TB group and the CNB group contained 36 patients (4.5%) and 749 (95.4%) patients, respectively. Only 10 patients (1.2%) required a change in antibiotic therapy based on the BC results (3 patients with an escalation, 7 with a de-escalation). There was no significant difference between the community-acquired pneumonia and the healthcare-associated pneumonia groups with regard to the rate of antibiotic change due to the BC results (1.1% vs 1.4%; P = 0.751). Chronic liver disease (odds ratio [OR] 2.973, 95% confidence interval [CI] 1.099-8.037), a confusion, urea, respiratory rate, blood pressure, age ≥65 (CURB-65) score of 4 to 5 points (OR 3.484, 95% CI 1.304-9.307), and Pneumonia Severity Index (PSI) class V (OR 2.405, 95% CI 1.007-5.743) were independently associated with TB. In patients with PSI class V and a CURB-65 score of 4 to 5 points, the TB group tended to show a higher inhospital mortality rate than the CNB group (50.0% vs 29.4%; P = 0.060, 60.0% vs 42.5%; P = 0.480). The areas under the curve for PSI score and CURB-65 score for predicting TB revealed an increased tendency compared with that of C-reactive protein (0.72, 95% CI 0.630-0.809; and 0.72, 95% CI 0.622-0.819 vs 0.629, 95% CI 0.522-0.735, respectively).It seemed reasonable to selectively conduct BC in patients hospitalized with severe community-onset pneumonia based upon its low overall positive rate, its effects on antimicrobial modification, and the associations of TB with the severity indices of pneumonia.

A Case of Pulmonary Mycobacterium kansasii Disease Complicated with Tension Pneumothorax.

Pneumothorax is an extremely rare complication of non-tuberculous mycobacterial infection. A 52-year-old man presenting with difficulty breathing and chest pain was admitted to our hospital. A right-sided pneumothorax was observed on chest radiography and chest computed tomography showed multiple cavitating and non-cavitating nodules with consolidation in the upper to middle lung zones bilaterally. Serial sputum cultures were positive for Mycobacterium kansasii, and he was diagnosed with pulmonary M. kansasii disease complicated by tension pneumothorax. After initiation of treatment including decortications and pleurodesis, the patient made a full recovery. We herein describe this patient's course in detail and review the current relevant literature.

Clinical characteristics of nursing home-acquired pneumonia in elderly patients admitted to a Korean teaching hospital.

BACKGROUND/AIMS: Nursing home-acquired pneumonia (NHAP) is included under healthcare-associated pneumonia. However, the optimal treatment strategy for NHAP has been controversial in several studies. We evaluated the clinical features of NHAP compared to community-acquired pneumonia (CAP) in elderly patients admitted with pneumonia. METHODS: This was a retrospective study in elderly patients aged ≥ 65 years with NHAP or CAP who were hospitalized at Jeju National University Hospital between January 2012 and April 2013. RESULTS: A total of 209 patients were enrolled, and 58 (27.7%) had NHAP. The patients with NHAP were older, had more frequent central nervous system disorders, and showed worse clinical parameters. Potential drug-resistant pathogens were more frequently detected in the NHAP group (22.4% vs. 9.9%, p = 0.018), and the incidences of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were 8.6% and 10.3%, respectively. In-hospital mortality occurred in 13 patients (22.4%) with NHAP and 17 patients (11.2%) with CAP (p = 0.039). In multivariate analyses, only higher pneumonia severity index (PSI) score was associated with increased mortality (p < 0.001), and the PSI score was higher in the NHAP group than that in the CAP group. CONCLUSIONS: Elderly patients admitted with NHAP showed more severe pneumonia at onset, higher rates of potentially drug-resistant pathogens, and worse clinical outcomes than those with CAP. However, higher in-hospital mortality in those with NHAP seemed to be related to the PSI score reflecting host factors and severity of pneumonia rather than the type of pneumonia or the presence of drug-resistant pathogens.

Successful Treatment of Phantom Limb Pain by 1 Hz Repetitive Transcranial Magnetic Stimulation Over Affected Supplementary Motor Complex: A Case Report.

A 37-year-old man with a right transfemoral amputation suffered from severe phantom limb pain (PLP). After targeting the affected supplementary motor complex (SMC) or primary motor cortex (PMC) using a neuro-navigation system with 800 stimuli of 1 Hz repetitive transcranial magnetic stimulation (rTMS) at 85% of resting motor threshold, the 1 Hz rTMS over SMC dramatically reduced his visual analog scale (VAS) of PLP from 7 to 0. However, the 1 Hz rTMS over PMC failed to reduce pain. To our knowledge, this is the first case report of a successfully treated severe PLP with a low frequency rTMS over SMC in affected hemisphere.

A Case of Posterior Mediastinal Plasmacytoma Confounded by Community-Acquired Pneumonia.

Plasmacytomas are extramedullary accumulations of plasma cells originating from soft tissue. Mediastinal plasmacytoma is a rare presentation. A 67-year-old man recovered after antibiotic treatment for community-acquired pneumonia. However, on convalescent chest radiography after 3 months, mass like lesion at the right lower lung field was newly detected. Follow-up chest computed tomography (CT) revealed an increase in the extent of the right posterior mediastinal mass that we had considered to be pneumonic consolidations on previous CT scans. Through percutaneous needle biopsy, we diagnosed IgG kappa type extramedullary plasmacytoma of the posterior mediastinum.

Genetic alterations of the HCCS1 gene in Korean hepatocellular carcinoma.

We analyzed the gene mutations and loss of heterozygosity (LOH) of the HCCS1 gene using intragenic polymorphic markers in a series of 88 primary HCCs. We found two sequence variations at exon 5 and 14 in both normal and tumor DNAs of case 50 and 51, respectively. The variation in case 50 led to a reading frameshift and a premature stop (TGA) at codon 125 and case 51 showed amino acid change at codon 448 (Val-->Ala, GTG-->GCG). Interestingly, these variations were not found in peripheral lymphocytes of 69 normal individuals and 227 cancer patients (86 HCC, 75 unselected gastric cancer, and 66 breast cancer), suggesting that these two variations are mutation, not polymorphism. In addition, we found 14 novel intragenic polymorphic sites in the HCCS1 gene. Thirty-two (47%) of sixty-eight informative cases showed allelic loss at at least one or more intragenic polymorphic sites, but there was no significant relationship between the frequency of LOH and clinicopathologic parameters. These results suggest that mutation of the HCCS1 gene might not be a main inactivation mechanism in the development of Korean HCC and that the HCCS1 gene might be involved in acceleration of the tumorigenic process in Korean HCC.

[A case of non-traumatic hemobilia due to warfarin therapy].

Hemobilia is a hemorrhage into the biliary tract that may follow surgical trauma, liver biopsy, aneurysms, extra- or intra-hepatic tumors of the biliary tract, gallstones, and inflammatory lesion of liver, especially helminthic or pyogenic. Sometimes, it is associated with primary liver cancer. An 84 year-old woman was admitted because of continuous right upper quadrant pain 4 days before admission. Physical examination revealed decreased skin turgor, icteric sclerae and severe tenderness on right upper quadrant abdomen. She had no hepatosplenomegaly, and no rebound tenderness. She has been taking warfarin for 3 weeks before admission because of atrial fibrillation. On admission, serum bilirubin and transaminase were elevated. The level of hemoglobin and hematocrit were 11.3 g/dL and 37.4%, respectively. HBsAg was negative, but IgG anti-HBc and anti-HBs were positive and anti-HCV was negative. Parasite skin test and stool ova count demonstrated non-specific findings. Stool occult blood was strongly positive, and prothrombin time was markedly prolonged. According to endoscopic retrograde cholangiopancreatography, common bile duct was dilated, and filled with blood clot but there was no stone in bile tree. After two weeks, serum transaminase, bilirubin, hemoglobin, hematocrit, and CA19-9 were normalized. We report a case of hemobilia, occurring in a patient with continuous warfarin use.

Case of invasive mucinous adenocarcinoma mimicking chronic eosinophilic pneumonia.

Invasive mucinous carcinoma is difficult to distinguish from other lung diseases; therefore, confirmation of the diagnosis may be delayed. A 64-year-old woman was admitted with a six-month history of cough, febrile sensation, and shortness of breath, with worsening symptoms. A computed tomography scan of the chest revealed bilateral homogenous ground-glass opacities and consolidation with subpleural predominance. The percentage of eosinophils in the serum and induced sputum was elevated and a diagnosis of chronic eosinophilic pneumonia was established. Despite administration of a systemic steroid, she did not rapidly respond. We performed a percutaneous needle biopsy and finally confirmed invasive mucinous adenocarcinoma.

Churg-strauss syndrome presented with hearing impairment and facial palsy.

Churg-Strauss syndrome (CSS) is a rare systemic necrotizing vasculitis. Cranial nerve involvement is very rare in CSS. A 59-year-old woman had complained of both hearing impairments for eight months and left facial palsy for three months. Left facial and cochlear neuropathies were detected in electrodiagnostic studies. Paranasal sinus computed tomography (CT) showed chronic pansinusitis. Chest CT revealed eosinophilic infiltration in the right upper lobe. Tissue biopsy of the right inferior turbinate displayed necrotizing vasculitis with eosinophilic infiltration. She was diagnosed as CSS, based on the presence of eosinophilia, pulmonary infiltration, paranasal sinusitis, and biopsy containing blood vessels with extravascular eosinophils. She was treated with intravenous and oral steroids and azathioprine, showing relatively good prognosis on facial palsy and hearing impairment. We report a very rare case of CSS presented with hearing impairment and facial palsy.

Usefulness of sputum induction with hypertonic saline in a real clinical practice for bacteriological yields of active pulmonary tuberculosis.

BACKGROUND: Mycobacterial identification in active pulmonary tuberculosis (APTB) is confirmative, even though successful rates using self-expectorated sputum are limited. Sputum specimens collected by hypertonic saline nebulization showed higher bacteriologic diagnostic sensitivities over those of self-expectoration, mostly studied in smear-negative or sputum-scarce patients. The efficacy of induced sputum was rarely assessed in real clinical settings. METHODS: A prospective randomized case-control study was performed in one hospital. The subjects highly suspicious of APTB were asked to provide 3 pairs of sputum specimens in 3 consecutive days. The first pairs of the specimens were obtained either by self-expectoration (ES) from the next day of the visit or sputum induction with 7% saline nebulization in clinic (SI), and the other specimens were collected in the same way. The samples were tested in microscopy, culture, and polymerase chain reaction (PCR). The outcomes of the bacteriological diagnosis were compared. RESULTS: Seventy six patients were assigned to either ES (38 subjects, median age of 51, 65.8% male) or SI (38 subjects, median age of 55, 52.6% male). APTB was clinically confirmed in 51 patients (70.8%), 27 in ES and 24 in SI. Among the APTB, more adequate specimens were collected from SI (41/65, 63.1%) than ES (34/80, 42.5%) (p=0.01). Bacteriological confirmation was achieved in 14 (58.3%) patients in SI, and 13 (48.1%) in ES (p=0.46). In the same-day bacteriological diagnosis with microscopy and PCR, there were positive results for 9 patients (37.5%) in SI and 7 patients (25.9%) in ES (p=0.37). CONCLUSION: Sputum induction improves sputum specimen adequacy. It may be useful for the same-day bacteriological diagnosis with microscopic examination and PCR.