A Prospective Multicenter Study of the Etiological Analysis in Adults with Community-Acquired Pneumonia: Legionella, Leptospira, Hantaan virus and Orientia tsutsugamushi / 감염

BACKGROUND: Despite rigorous investigations, the etiology of community-acquired pneumonia remains unknown in about 50% of hospitalized patients. The diagnosis of the etiological agent is becoming more challenging and more critical as number of newer pathogens have been recognized in recent years. In the 3-year period prospective study we investigated adult patients with community-acquired pneumonia for Legionella, Leptospira, Hantaan virus and Orientia tsutsugamushi as potential etiologic agents. METHODS: A prospective multicenter study was performed from May 1997 to April 2000. A total of 431 patients with community-acquired pneumonia under the inclusion criteria were examined for specific microbial diagnosis; sputum culture and PCR, and serologic teats including indirect immunofluorescence antibody (IFA) test for Legionella, and hemagglutination tests for Leptospira, Hantaan virus and O. tsutsugamushi. Etiologic diagnosis was determined on the basis of the review of case record forms and specific laboratory diagnostic criteria. RESULT: During the study period a total of 385 sputum and 283 serum samples were examined. Legionella pneumonia was diagnosed in 2.3% (10/431) of the cases examined: 1.4% cases with PCR-positive (5/ 367) and 2.1% with positive IFA test (6/283). Leptospirosis and scrub typhus were diagnosed in 0.4% (1/ 252) and 2.0% (5/252), respectively. All 5 cases diagnosed as scrub typhus occurred in late fall, and rash or eschar was not found. None of cases was Hantaan virus infection. CONCLUSION: The results suggest that Legionella, Leptospira, and O. tsutsugamushi should be considered in the etiologic diagnosis and in empirical antibiotic therapy of community-acquired pneumonia.

Spontaneous Rupture of the Esophagus (Boerhaave's Syndrome): A review of 10 cases

BACKGROUND: Boerhaave's syndrome is a spontaneous rupture of the esophagus. The classic symptom triad, vomiting, chest pain, and subcutaneous emphysema, rarely develop together. It is diagnosed by using plain chest film, an esophagogram with a water soluble contrast media, and computerized tomography, but it is somewhat difficult to make an early diagnosis. It is generally treated with a surgical procedure, but the most frequent complication is suture line leakage, which leads to a pyothorax, pneumonia, mediastinitis, and eventually an irreversible septic condition. METHODS: We retrospectively reviewed 10 cases of patients with spontaneous esophageal rupture treated by various surgical methods during the recent 6 years at the Department of Surgery and Internal Medicine, the Catholic University of Korea. RESULTS: The results of the clinical reviews are as follows: There were 9 males and 1 female, and the mean age was 53 years old. The main symptom was chest pain (70%), and that developed after severe vomiting in 6 cases (60%). Abnormal findings were revealed on the chest PA films of 6 cases. Esophagogram were used in 8 cases, and a combined chest CT in 5 cases. Seven (70%) received an operation in less than 24 hours after the attack and 3 cases after 72 hours. The lower one-third of the esophagus was perforated in 9 cases (90%), and the left side of the esophagus was perforated in 8 cases (80%). The methods of operation were primary repair (6 cases), an esophagectomy and esophagogastrostomy (3 cases), and a cardial ligation, proximal esophagostomy, gastrostomy, and feeding jejunostomy (1 case). Anastomosis leakage and empyema developed in each of 4 cases. The overall mortality rate was 20%; only two patients died due to a delayed hospital visit (surgery 72 hours after first attack of symptoms). CONCLUSIONS: We recommand that the most important factor affecting the prognosis for spontaneous rupture of the esophagus is early diagnosis and immediate surgical intervention.