Whole Blood Interferon-gamma Release Assay Is Insufficient for the Diagnosis of Sputum Smear Negative Pulmonary Tuberculosis

PURPOSE: We investigated the value of an interferon-gamma release assay (IGRA) for the diagnosis of active pulmonary tuberculosis (PTB) among sputum smear negative PTB suspects in an environment with intermediate burden of PTB and high Bacillus Calmette-Guerin (BCG) vaccination rate. MATERIALS AND METHODS: We retrospectively reviewed IGRA, medical records, chest PA and CT scan of PTB suspects seen at Gangnam Severance Hospital, Seoul, Korea from Oct. 2007 to Apr. 2013. "Active PTB" was diagnosed when 1) M. tuberculosis culture positive, 2) confirmation by pathologic examination; or 3) clinical findings compatible with TB. RESULTS: Of 224 sputum smear negative PTB suspects, 94 were confirmed as having active PTB. There were no statistically significant differences in the diagnostic yield of IGRA between immunocompromised and immunocompetent sputum smear negative PTB suspects. IGRA did show superior sensitivity [81.9%, 95% confidence interval (CI); 74.13-89.70%] in the diagnosis of sputum smear negative PTB when compared with chest high-resolution computed tomography (HRCT), tuberculin skin test (TST), and chest X-ray (p<0.001). Also, IGRA showed highest negative predictive value (82.7%, 95% CI; 75.16-90.15%) when compared with HRCT, TST and chest X-ray (p=0.023). However, combining the results of IGRA with those of HRCT, TST, or both did not increase any diagnostic parameters. CONCLUSION: Failure to increase diagnostic yields by combination with other diagnostic modalities suggests that additional enforcement with IGRA may be insufficient to exclude other diagnoses in sputum smear negative PTB suspects and to screen active PTB in an environment with intermediate TB prevalence and a high BCG vaccination rate.

Stress Related Cardiomyopathy during Flexible Bronchoscopy / 대한구급학회지

Flexible bronchoscopy is a safe medical procedure, but the incidence rate of major complications is 0.08-0.3%. Here, we report 2 cases of stress induced cardiomyopathy, which developed immediately after flexible bronchoscopy. Stress related cardiomyopathy was confirmed by EKG, echocardiography, and coronary angiogram. The cardiac functions of these patients were fully recovered with conservative treatment. Although, the pathogenesis of stress related cardiomyopathy is not well understood, post-bronchoscopy tachycardia or arrhythmia is thought to be associated with hypoxemia or catecholamine excess. Because the clinical presentation is quite similar to acute myocardial infarction, discrete evaluations are required for appropriate treatment.

Late Respiratory Infection after Lung Transplantation / 결핵및호흡기질환

BACKGROUND: Aiming to improve outcome of lung transplantation (LTx) patients, we reviewed risk factors and treatment practices for the LTx recipients who experienced respiratory infection in the late post-LTx period (>1 month after LTx). METHODS: We analyzed the clinical data of 48 recipients and donors from 61 LTx, who experienced late respiratory infections. Late respiratory infections were classified according to the etiology, time of occurrence, and frequency of donor-to-host transmission or colonization of the recipient prior to transplantation. RESULTS: During the period of observation, 42 episodes of respiratory infections occurred. The organisms most frequently involved were gram (-) bacteria: Acinetobacter baumannii (n=13, 31.0%), Pseudomonas aeruginosa (n=7, 16.7%), and Klebsiella pneumoniae (n=4, 10.0%). Among the 42 episodes recorded, 14 occurred in the late post-LTx period. These were bacterial (n=6, 42.9%), fungal (n=2, 14.3%), viral (n=4, 28.5%), and mycobacterial (n=2, 14.3%) infections. Of 6 bacterial infections, 2 were from multidrug-resistant (MDR) A. baumannii and one from each of MDR P. aeruginosa, extended spectrum beta-lactamase (+) K. pneumoniae, methicillin-resistant Staphylococcus aureus and Streptococcus pneumoniae. Infection-related death occurred in 6 of the 14 episodes (43%). CONCLUSION: Although the frequency of respiratory infection decreased sharply in the late post-LTx period, respiratory infection was still a major cause of mortality. Gram (-) MDR bacteria were the agents most commonly identified in these infections.

Clinical Outcomes of Tigecycline in the Treatment of Multidrug-Resistant Acinetobacter baumannii Infection

PURPOSE: Acinetobacter baumannii (A. baumannii) has emerged as a major cause of nosocomial pneumonia and sepsis in seriously ill patients. Multidrug-resistant A. baumannii (MDRAB) is increasing in frequency, and the management of it's infections is consequently difficult. Therefore, tigecycline is considered to be the drug of choice for MDRAB treatment. The aim of our study was to evaluate the microbiological eradication and clinical effectiveness of tigecycline against MDRAB in seriously ill patients, including patients with ventilator-associated pneumonia (VAP). MATERIALS AND METHODS: We conducted a retrospective study including patients with A. baumannii infections who were treated with tigecycline between April 1, 2009 and March 31, 2010. We treated 27 patients with tigecycline for MDRAB infections. RESULTS: The mean age of patients was 66.2 years, and 20 (74.1%) patients were male. The median length of stay at hospital was 74.6 days. MDRAB was eradicated from the site of infection in 23 cases (85.2%), however, only 17 cases (63.0%) showed positive clinical responses. Overall, an in-hospital mortality rate of 51.9% was observed, and 4 cases of death were attributable to sepsis. The combination therapy showed better clinical and microbial success rates than the monotherapy without significant difference. CONCLUSION: We observed the relatively low clinical success rate although the microbial eradication rate was high, probably due to superinfections in VAP and bacteremia. We suggest that clinicians should limit tigecycline monotherapy for MDRAB infection in critically ill patients, until large controlled clinical trials should be conducted.

The Clinical and Pathologic Features according to Expression of Acyl Protein Thioesterase-1 (APT1) in Stage I Non-small Cell Lung Cancer / 결핵및호흡기질환

BACKGROUND: Acyl protein thioesterase-1 (APT1) is a cytosolic protein that may function in the depalmitoylation of numerous proteins, including the Ras family. However, the clinical role of depalmitoyl thioesterase in human cancer is not known. We evaluated the APT1 expression in lung cancer tissue and its clinicopathological findings according APT1 expression pattern. METHODS: APT1 expression was examined by immunohistochemistry in the tumor tissue from 79 patients, who had undergone curative surgical removal of the primary lesion; all patients had been diagnosed with stage I non-small cell lung cancer between 1993 and 2004, at Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. RESULTS: The APT1 expression was seen in 50 out of 79 (63.3%) cases. The positive APT1 expression was significantly related with histologic subtype and T stage, but was not influenced by differentiation. The positive APT1 expression was not significantly related to patient age, gender, or smoking history. The median follow-up duration was 10.0 years; the 5-year survival rate was 71.0%. The positive APT1 expression group showed significantly worse overall survival and worse disease-free survival without statistical significance. CONCLUSION: We conclude that positive APT1 expression in stage I lung cancer after surgery is closely associated with overall survival. To evaluate APT1 as a prognostic marker in lung cancer, comprehensive studies on advanced stage cases are needed.

A Case of Docetaxel Induced Subacute Cutaneous Lupus Erythematosus / 결핵및호흡기질환

Drug-induced subacute cutaneous lupus erythematosus (SCLE) is associated with use of the following classes of medications: anti-hypertensives, anti-cholesterolemia, anti-psychotics, and anti-inflammatory drugs. Docetaxel is an anti-neoplastic agent, which is widely used for treatment of non-small cell lung cancer. Few cases of docetaxel-induced SCLE have been reported in the medical literature. Here, we report the case of a 58-year-old female patient who developed drug-induced SCLE after administration of docetaxel. After 4 cycles of chemotherapy with docetaxel and cisplatin, erythematous skin eruptions developed on the patient's face. Skin biopsies of the eruptions were remarkable for interfacing dermatitis with basement membrane thickening. Immunofluorescent study revealed characteristic features of SCLE, including granular deposition of IgM, C3, and apoptotic bodies along the basement membrane. The skin eruptions resolved gradually after cessation of drug and with the use of topical corticosteroids.

Trial of Argon Plasma Coagulation in Patients with Heterotopic Gastric Mucosa Presenting with Laryngopharyngeal Symptoms / 대한소화기내시경학회지

Heterotopic gastric mucosa in the upper esophagus, in which the inlet patch is a salmon-colored valvet patch, is located mainly below the upper esophageal sphincter. The acid secretion and inflammation from heterotopic gastric mucosa causes laryngopharyngeal symptoms. Generally, the management of heterotopic gastric mucosa depends on the symptoms, and the condition is generally treated by proton pump inhibitor. Recently, it was reported that argon plasma coagulation (APC) is effective when medical treatment fails. A 49-year-old man and a 44-year-old woman with symptoms of globus sensation and hoarseness visited this clinic. An upper gastrointestinal endoscopy showed a flat salmon-colored patch located at the upper esophagus. The former patient failed medical treatment and the latter did not require long term medical treatment. Therefore, the patients were treated with APC, which resulted in an improvement in symptoms. APC treatment may improve the symptoms of patients with heterotopic gastric mucosa of the cervical esophagus.