Clinical outcomes of and risk factors for secondary infection in patients with severe COVID-19: a multicenter cohort study in South Korea

Background/Aims@#Secondary infection with influenza virus occurs in critically ill patients and is associated with substantial morbidity and mortality; however, there is limited information about it in patients with severe coronavirus disease 2019 (COVID-19). Thus, we investigated the clinical outcomes of and risk factors for secondary infections in patients with severe COVID-19. @*Methods@#This study included patients with severe COVID-19 who were admitted to seven hospitals in South Korea between February 2020 to February 2021. Multivariate logistic regression analyses were performed to assess factors associated with the risk of secondary infections. @*Results@#Of the 348 included patients, 104 (29.9%) had at least one infection. There was no statistically significant difference in the 28-day mortality (17.3% vs. 12.3%, p = 0.214), but in-hospital mortality was higher (29.8% vs. 15.2%, p = 0.002) in the infected group than in the non-infected group. The risk factors for secondary infection were a high frailty scale (odds ratio [OR], 1.314; 95% confidence interval [CI], 1.123 to 1.538; p = 0.001), steroid use (OR, 3.110; 95% CI, 1.164 to 8.309; p = 0.024), and the application of mechanical ventilation (OR, 4.653; 95% CI, 2.533 to 8.547; p < 0.001). @*Conclusions@#In-hospital mortality was more than doubled in patients with severe COVID-19 and secondary infections. A high frailty scale, the use of steroids and application of mechanical ventilation were risk factors for secondary infection.

Corticosteroid outcome may be dependent of duration of use in severe COVID-19

Background/Aims@#For patients hospitalized with coronavirus disease 2019 (COVID-19) who require supplemental oxygen, the evidence of the optimal duration of corticosteroid is limited. This study aims to identify whether long-term use of corticosteroids is associated with decreased mortality. @*Methods@#Between February 10, 2020 and October 31, 2021, we analyzed consecutive hospitalized patients with COVID-19 with severe hypoxemia. The patients were divided into short-term (≤ 14 days) and long-term (> 14 days) corticosteroid users. The primary outcome was 60-day mortality. We performed propensity score (PS) analysis to mitigate the effect of confounders and conducted Kaplan-Meier curve analysis. @*Results@#There were 141 (52%) short-term users and 130 (48%) long-term corticosteroid users. The median age was 68 years and the median PaO2/FiO2 at admission was 158. Of the patients, 40.6% required high-flow nasal cannula, 48.3% required mechanical ventilation, and 11.1% required extracorporeal membrane oxygenation. The overall 60-day mortality rate was 23.2%, and that of patients with hospital-acquired pneumonia (HAP) was 22.9%. The Kaplan-Meier curve for 60- day survival in the PS-matched cohort showed that corticosteroid for > 14 days was associated with decreased mortality (p = 0.0033). There were no significant differences in bacteremia and HAP between the groups. An adjusted odds ratio for the risk of 60-day mortality in short-term users was 5.53 (95% confidence interval, 1.90–18.26; p = 0.003). @*Conclusions@#For patients with severe COVID-19, long-term use of corticosteroids was associated with decreased mortality, with no increase in nosocomial complications. Corticosteroid use for > 14 days can benefit patients with severe COVID-19.

Prevalence of Low Back Pain and Associated Risk Factors among Farmers in Jeju

Background@#We aimed to investigate the prevalence of low back pain (LBP) and its associated agricultural work-related, biomechanical factors among this population. @*Methods@#We analyzed initial survey data from the Safety for Agricultural Injury of Farmers cohort study involving adult farmers in Jeju Island. The prevalence of LBP was calculated with associated factors. @*Results@#In total, 1,209 participants were included in the analysis. The overall prevalence of LBP was 23.7%. Significant associations for LBP were the type of farming activity, length of farming career, prior agricultural injury within 1 year, and stress levels. Multivariate logistic regression analysis revealed three biomechanical factors significantly related to LBP: repetitive use of particular body parts; the inappropriate posture of the lower back and neck. @*Conclusions@#Some occupational, and biomechanical risk factors contribute to LBP. Therefore, postural education, injury prevention education, and psychological support will be needed to prevent LBP.

Relationship Between Sleep Duration and Suicidal Ideation Among Farmers: Safety for Agricultural Injuries of Farmers Cohort Study of Jeju, Korea

Background@#This study was conducted to identify the association between sleep duration and suicidal ideation among farmers in Korea. @*Methods@#We used Safety for Agricultural Injuries of Farmers cohort data collected from September 2015 to June 2018, which was an agricultural survey on the health and behaviors of adult farmers in Jeju island, Korea. @*Results@#A total of 964 participants were included in the analysis, and 3.7% of them were identified with having suicidal ideation. The frequencies of average daily sleep duration of 8 h (long sleep) were 24.4%, 70%, and 5.6%, respectively. Multivariate analyses revealed that short sleep duration was significantly associated with suicidal ideation compared with normal sleep duration (odds ratio = 2.49, 95% confidence interval = 1.07–5.77). @*Conclusion@#Our findings suggest that short sleep duration in farmers result in higher suicidal ideation. Because individuals who have suicidal ideation often commit suicide, careful monitoring is required to prevent suicide in farmers with short sleep duration.

Relationship Between Sleep Duration and Suicidal Ideation Among Farmers: Safety for Agricultural Injuries of Farmers Cohort Study of Jeju, Korea

Background@#This study was conducted to identify the association between sleep duration and suicidal ideation among farmers in Korea. @*Methods@#We used Safety for Agricultural Injuries of Farmers cohort data collected from September 2015 to June 2018, which was an agricultural survey on the health and behaviors of adult farmers in Jeju island, Korea. @*Results@#A total of 964 participants were included in the analysis, and 3.7% of them were identified with having suicidal ideation. The frequencies of average daily sleep duration of 8 h (long sleep) were 24.4%, 70%, and 5.6%, respectively. Multivariate analyses revealed that short sleep duration was significantly associated with suicidal ideation compared with normal sleep duration (odds ratio = 2.49, 95% confidence interval = 1.07–5.77). @*Conclusion@#Our findings suggest that short sleep duration in farmers result in higher suicidal ideation. Because individuals who have suicidal ideation often commit suicide, careful monitoring is required to prevent suicide in farmers with short sleep duration.

A Fatal Pulmonary Event during Plasma Exchange in a Patient with Severe Fever with Thrombocytopenia Syndrome / 대한내과학회지

Severe fever with thrombocytopenia syndrome (SFTS) caused by the SFTS virus (SFTSV), a novel Phlebovirus, is endemic to South Korea, central and northeastern China, and western Japan. SFTS poses a threat to public health because of its high mortality and secondary transmission. Ticks and domestic animals are hosts for SFTSV in endemic areas. There is no specific treatment for SFTS, and avoiding tick bites is the best way to prevent infection. Early therapeutic plasma exchange (TPE) is a rescue therapy in patients with rapidly progressive SFTS. Here, we present a patient with SFTS who was improving on TPE but died suddenly due to acute lung injury after TPE.

Exogenous lipoid pneumonia presented by acute eosinophilic pneumonia

Exogenous lipoid pneumonia is an uncommon medical condition resulting from aspiration or inhalation of oily material. Generally, lipoid pneumonia has nonspecific clinical and radiological presentations, and may be misdiagnosed as bacterial pneumonia or lung cancer. We describe an unusual case of exogenous lipoid pneumonia accompanied by peripheral blood and pulmonary eosinophilia. A 63-year-old man was admitted with progressively worsening exertional dyspnea and productive cough for 5 days. A chest radiograph showed abnormalities in the lower lobe of the right lung, and a diagnosis of community-acquired pneumonia was made; intravenous antibiotics were administered. However, dyspnea and hypoxia gradually worsened and peripheral blood eosinophilia developed. A bronchoscopy was performed and bronchoalveolar lavage fluid analysis showed markedly increased numbers of eosinophils (40%). Subsequently, a comprehensive review of history revealed that he fell asleep with camellia oil in his mouth for 2 weeks to relieve foreign body sensation of the throat. Sputum and bronchoalveolar lavage fluid cytology showed the presence of lipid-laden macrophages. He was diagnosed with lipoid pneumonia and acute eosinophilic pneumonia. Chest radiograph and symptom were rapidly improved after treatment with intravenous methylprednisolone.

Iatrogenic pleural empyema caused by Propionibacterium acnes

Propionibacterium acnes is one of the commensals living on the human skin and glands, implicated mainly in acnes, but seldom in deep infection. Pleural empyema is rarely complicated with closed thoracostomy. We experienced 1 case of empyema caused by P. acnes after pleural biopsy and closed thoracostomy through a percutaneous pigtail catheter. A 79-year-old man was admitted for cough, purulent sputum and shortness of breath. Three weeks ago, closed thoracostomy and pleural biopsy were performed to confirm a diagnosis for his recurrent pleural effusion. He had increased amount of right pleural effusion. Through the pigtail catheter, pleural effusion was removed. Gram-positive rods were observed in Gram stain, but not cultured. By 16S rRNA analysis, P. acnes was confirmed as the pathogen. His empyema was repeatedly treated with antibiotics, fibrolysis and irrigation. Pleural decortication was recommended. We report the first case of empyema with P. acnes in Korea, possibly complicated with closed thoracostomy procedures.

Migration of Peripherally Inserted Central Catheter after Contrast-Enhanced Computed Tomography / 전남의대학술지

No abstract available.

Usefulness of Sputum Induction with Hypertonic Saline in a Real Clinical Practice for Bacteriological Yields of Active Pulmonary Tuberculosis / 결핵및호흡기질환

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.

Serum Vitamin D Status and Its Relationship to Metabolic Parameters in Patients with Type 2 Diabetes Mellitus / 전남의대학술지

The potential relationship between vitamin D (VitD) status and metabolic control in patients with type 2 diabetes mellitus (T2DM) warrants further study. We aimed to evaluate the relationship between the serum 25-hydroxyvitamin D [25(OH)D] level and various parameters in patients with T2DM. We analyzed retrospectively data from 276 Korean patients with T2DM whose serum 25(OH)D level was measured in our hospital. Nondiabetic healthy subjects who visited the hospital for health screening were selected as the control group (Non-DM, n=160). Compared with control subjects, patients with T2DM had a lower serum 25(OH)D level (15.4+/-0.5 vs. 12.9+/-0.4 ng/ml, p<0.01). Eleven percent of T2DM patients were VitD "insufficient" (20-29 ng/ml) and 87% of the patients were VitD "deficient" (<20 ng/ml). The serum 25(OH)D level was significantly related to serum fibrinogen, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), ferritin, the urine albumin creatinine ratio, and hemoglobin A1C (HbA1C). In a multivariate logistic regression analysis, high levels of HbA1C, TG, and LDL-C were independently associated with VitD deficiency in T2DM patients. The results of the present study show that the majority of Koreans with T2DM are VitD deficient, and the serum 25(OH)D level in patients with T2DM is related to lipid and glucose parameters. Further studies are required of the relationship of VitD with fibrinogen and other related parameters.

An Atypical Case of Plasmodium vivax Malaria after Initiating Adalimumab Therapy

We report an unusual case of Plasmodium vivax malaria that occurred in a 22-year-old ankylosing spondylitis patient after initiating adalimumab therapy. P. falciparum malaria was initially included as a possible differential diagnosis due to hyperparasitemia and similar features in the peripheral blood smear. The patient was successfully treated with conventional therapy for P. vivax malaria.

Serum Vitamin D Status and Its Relationship to Metabolic Parameters in Patients with Type 2 Diabetes Mellitus / 전남의대학술지

The potential relationship between vitamin D (VitD) status and metabolic control in patients with type 2 diabetes mellitus (T2DM) warrants further study. We aimed to evaluate the relationship between the serum 25-hydroxyvitamin D [25(OH)D] level and various parameters in patients with T2DM. We analyzed retrospectively data from 276 Korean patients with T2DM whose serum 25(OH)D level was measured in our hospital. Nondiabetic healthy subjects who visited the hospital for health screening were selected as the control group (Non-DM, n=160). Compared with control subjects, patients with T2DM had a lower serum 25(OH)D level (15.4+/-0.5 vs. 12.9+/-0.4 ng/ml, p<0.01). Eleven percent of T2DM patients were VitD "insufficient" (20-29 ng/ml) and 87% of the patients were VitD "deficient" (<20 ng/ml). The serum 25(OH)D level was significantly related to serum fibrinogen, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), ferritin, the urine albumin creatinine ratio, and hemoglobin A1C (HbA1C). In a multivariate logistic regression analysis, high levels of HbA1C, TG, and LDL-C were independently associated with VitD deficiency in T2DM patients. The results of the present study show that the majority of Koreans with T2DM are VitD deficient, and the serum 25(OH)D level in patients with T2DM is related to lipid and glucose parameters. Further studies are required of the relationship of VitD with fibrinogen and other related parameters.

Digitalis (Cardiac Glycoside) Poisoning after Foxglove Ingestion: Case Report

Digoxin, also known as digitalis, is a purified cardiac glycoside extracted from the foxglove plant, Digitalis purpurea. Digoxin-mediated cardiac glycoside toxicity due to accidental plant ingestion can occur. Presently, a 69-year-old woman visited our emergency department with epigastric pain, nausea and vomiting after ingestion of a plant. Physical examination and initial laboratory blood test results were within normal limits. An electrocardiogram (ECG) showed sinus bradycardia with first degree AV block and diffuse ST-segment depressions in a "scooping" pattern. The plant was identified as D. purpurea, and the patient's serum digoxin level was 2.89 ng/mL. The patient was treated conservatively in the absence of any life-threatening event. Recovery was uneventful.

A Case of Massive Pulmonary Thromboembolism Associated with Ramsay Hunt Syndrome: A Case Report / 대한구급학회지

Ramsay Hunt syndrome associated with the Varicella zoster virus (VZV) infection is characterized by vesicles on the pinna, otalgia, facial nerve palsy and sensorineural hearing loss. Although significant complications from VZV infection are increasing, thrombosis associated with VZV infection is one of the rare complications in adults. The VZV itself could cause endothelial damage in the various organs. Subsequently, the thrombosis might be complicated. A previously healthy 84 year-old female patient was diagnosed with Ramsay Hunt syndrome. On the 7th day of antiviral treatment, she complained of sudden breathlessness. She was hypoxemic with an elevated alveolar-arterial oxygen difference and needed to be supported by mechanical ventilation. Massive pulmonary thrombosis was documented by computerized tomography and she successfully underwent thrombolytic therapy. We report a case of massive pulmonary thromboembolism associated with VZV infection, treated with thrombolytic therapy.

A Case of Salmonella Psoas Abscess Presenting as Low Back Pain and Subacute Renal Failure / 대한내과학회지

Salmonella is a rare cause of psoas abscess and infectious spondylitis. We report a case of a 62-year-old male patient with Salmonella group D psoas abscess and infectious spondylitis as low back pain and subacute renal failure. The patient who had a previous operation history of abdominal aortic aneurysm rupture was admitted to evaluate low back pain and abnormal renal function. Bilateral psoas abscess and infectious spondylitis of lumbar vertebrae was detected by spine MRI and Salmonella group D was isolated in aspirated fluid of psoas abscess. After long term antibiotics treatment (ceftriazxone and ciprofloxacin), psoas abscess and spondylitis was markedly improved, however, his renal function was not recovered to progress to end stage renal disease.

A Case of Kikuchi Disease Accompanied with Bilateral Retinal Vasculitis

Kikuchi disease, also called histiocytic necrotizing lymphadenitis, is an uncommon, idiopathic and generally self-limited disease, characterized by cervical lymphadenopathy. It can present systemic symptoms and signs, but ocular involvement is unusual. We report a 35-year-old woman who presented sudden decreased visual acuity and a swollen lymph node on the left side of her neck. On laboratory findings, there were no evidences of infection, autoimmune disease and systemic vasculitis. She was diagnosed with Kikuchi disease and bilateral retinal vasculitis by histologic analysis of lymph node, fundoscopy and fluorescein angiography.