A Clinical features of Severe Adenovirus Pneumonia among Members of the Korea Military: A Case Series / 감염과화학요법

BACKGROUND: Adenoviral diseases generally present as self-limiting upper respiratory illnesses. However, in some cases, adenovirus can cause fatal outcomes, even in healthy adults. Severe pneumonia caused by adenovirus in young soldiers at basic military training sites have been reported. MATERIALS AND METHODS: We conducted a retrospective review of the medical records of patients with pneumonia who were hospitalized in the Intensive Care Unit of the Armed Forces Capital Hospital between January 2011 and March 2012. RESULTS: Nine patients with pneumonia who required ventilator treatment were analyzed. Adenovirus was proved to be the causative agent of the illness in six out of nine patients, three of whom died due to severe adenoviral pneumonia or adenovirus-related illness. Among these six patients, three were military trainees. Clinical features were characterized by fever (100%) and cough (100%). Other important findings included thrombocytopenia (83.3%), leukopenia (66.6%), and radiologically lobar consolidation (66.7%). CONCLUSIONS: Adenovirus appeared to be the most important pathogen of young Korean soldiers, particularly among military trainees with severe pneumonia requiring mechanical ventilation. Outbreak surveillance for adenovirus associated illness is necessary.

Treatment Response and Long Term Follow-up Results of Nonspecific Interstitial Pneumonia

The purpose of this study was to investigate the long-term clinical course of non-specific interstitial pneumonia (NSIP) and to determine which factors are associated with a response to steroid therapy and relapse. Thirty-five patients with pathologically proven NSIP were included. Clinical, radiological, and laboratory data were reviewed retrospectively. The male-to-female ratio was 7:28 (median age, 52 yr). Thirty (86%) patients responded to steroid therapy, and the median follow-up was 55.2 months (range, 15.9-102.0 months). Five patients (14%) showed sustained disease progression and three died despite treatment. In the five with sustained disease progression, NSIP was associated with various systemic conditions, and the seropositivity of fluorescent antinuclear antibody was significantly associated with a poor response to steroids (P = 0.028). The rate of relapse was 25%, but all relapsed patients improved after re-treatment. The initial dose of steroids was significantly low in the relapse group (P = 0.020). In conclusion, progression is associated with various systemic conditions in patients who show progression. A low dose of initial steroids is significantly associated with relapse.

Incidence and Risk Factors of Steroid-induced Diabetes in Patients with Respiratory Disease

Glucocorticoids are effective for treating several respiratory diseases. However, they can cause hyperglycemia. This study determined the incidence and risk factors of steroidinduced diabetes mellitus (S-DM) in patients treated with glucocorticoid for respiratory diseases. A retrospective study examined patients with respiratory diseases treated with a prednisolone-equivalent glucocorticoid dose exceeding 20 mg/day for at least 4 weeks between January 2003 and December 2008. Patients whose initial random glucose level exceeded 200 mg/dL or who had pre-existing diabetes were excluded. S-DM was defined as a fasting glucose concentration exceeding 126 mg/dL or a random glucose concentration exceeding 200 mg/dL at least twice after beginning steroid treatment. A total of 231 patients with respiratory diseases met the inclusion criteria. Their median age was 55 yr, and 139 were female. The median cumulative prednisolone-equivalent glucocorticoid dose was 4,965 mg, and the median duration of steroid treatment was 193 days. S-DM was diagnosed in 34 (14.7%) of 231 patients. Multivariate logistic regression identified older age (odds ratio 1.05, 95% confidence interval 1.02-1.09) as a risk factor for S-DM. S-DM is frequent among patients with respiratory diseases treated with glucocorticoid. Clinicians should be aware of the possibility of S-DM, especially among elderly patients.

Impact of Parenchymal Tuberculosis Sequelae on Mediastinal Lymph Node Staging in Patients with Lung Cancer

Because tuberculous (TB) involvement of mediastinal lymph nodes (LN) could cause false positive results in nodal staging of lung cancer, we examined the accuracy of nodal staging in lung cancer patients with radiographic sequelae of healed TB. A total of 54 lung cancer patients with radiographic TB sequelae in the lung parenchyma ipsilateral to the resected lung, who had undergone at least ipsilateral 4- and 7-lymph node dissection after both chest computed tomography (CT) and fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT were included for the analysis. The median age of 54 subjects was 66 yr and 48 were males. Calcified nodules and fibrotic changes were the most common forms of healed parenchymal pulmonary TB. Enlarged mediastinal lymph nodes (short diameter > 1 cm) were identified in 21 patients and positive mediastinal lymph nodes were identified using FDG-PET/CT in 19 patients. The overall sensitivity and specificity for mediastinal node metastasis were 60.0% and 69.2% with CT and 46.7% and 69.2% with FDG-PET/CT, respectively. In conclusion, the accuracy of nodal staging using CT or FDG-PET/CT might be low in lung cancer patients with parenchymal TB sequelae, because of inactive TB lymph nodes without viable TB bacilli.

Impact of Parenchymal Tuberculosis Sequelae on Mediastinal Lymph Node Staging in Patients with Lung Cancer

Because tuberculous (TB) involvement of mediastinal lymph nodes (LN) could cause false positive results in nodal staging of lung cancer, we examined the accuracy of nodal staging in lung cancer patients with radiographic sequelae of healed TB. A total of 54 lung cancer patients with radiographic TB sequelae in the lung parenchyma ipsilateral to the resected lung, who had undergone at least ipsilateral 4- and 7-lymph node dissection after both chest computed tomography (CT) and fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT were included for the analysis. The median age of 54 subjects was 66 yr and 48 were males. Calcified nodules and fibrotic changes were the most common forms of healed parenchymal pulmonary TB. Enlarged mediastinal lymph nodes (short diameter > 1 cm) were identified in 21 patients and positive mediastinal lymph nodes were identified using FDG-PET/CT in 19 patients. The overall sensitivity and specificity for mediastinal node metastasis were 60.0% and 69.2% with CT and 46.7% and 69.2% with FDG-PET/CT, respectively. In conclusion, the accuracy of nodal staging using CT or FDG-PET/CT might be low in lung cancer patients with parenchymal TB sequelae, because of inactive TB lymph nodes without viable TB bacilli.

Endobronchial Metastasis of Epithelioid Sarcoma / 결핵및호흡기질환

Epithelioid sarcomas are rare soft tissue sarcomas with a high tumor grade and high local recurrence and metastasis rates. Although the lung is the most common site of metastasis, endobronchial metastasis hasn't been reported yet. We now report a case of epithelioid sarcoma with endobronchial metastasis. A 28-year-old man had recurrent pneumothorax and underwent wedge resection. He presented at our hospital with hemoptysis, dyspnea, and chest pain. Chest computed tomography revealed left pneumothorax, multiple lung nodules and endobronchial lesions at the right lower basal lobe. Bronchoscopy showed a hemorrhagic mass obstructing the bronchus of the right lower basal lobe. Magnetic resonance imaging revealed multiple nodular lesions in the left thigh muscles. The bronchoscopic biopsy of the endobronchial lesion and the muscle biopsy of the thigh showed the same feature epithelioid sarcoma. This is the first case report of an epithelioid sarcoma with endobronchial metastasis that was diagnosed by bronchoscopic biopsy.

Risk Factors of Postoperative Pneumonia after Lung Cancer Surgery

The purpose of this study was to investigate risk factors of postoperative pneumonia (POP) after lung cancer surgery. The 417 lung cancer patients who underwent surgical resection in a tertiary referral hospital were included. Clinical, radiological and laboratory data were reviewed retrospectively. Male and female ratio was 267:150 (median age, 65 yr). The incidence of POP was 6.2% (26 of 417) and in-hospital mortality was 27% among those patients. By univariate analysis, age > or = 70 yr (P or = 4.2 hr (P = 0.043), intraoperative red blood cells (RBC) transfusion (P = 0.004), presence of postoperative complications other than pneumonia (P = 0.020), forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) or = 0.15 mg/dL (P = 0.001) were related with risk of POP. Multivariate analysis showed that age > or = 70 yr (OR = 3.563, P = 0.014), intraoperative RBC transfusion (OR = 4.669, P = 0.033), the presence of postoperative complications other than pneumonia (OR = 3.032, P = 0.046), and FEV1/FVC < 70% (OR = 3.898, P = 0.011) were independent risk factors of POP. In conclusion, patients with advanced age, intraoperative RBC transfusion, postoperative complications other than pneumonia and a decreased FEV1/FVC ratio have a higher risk for pneumonia after lung cancer surgery.

Efficacy and Safety of Switching from Oral Cholinesterase Inhibitors to the Rivastigmine Transdermal Patch in Patients with Probable Alzheimer's Disease

BACKGROUND AND PURPOSE: The goal of this study was to estimate the efficacy and safety of the rivastigmine transdermal patch in patients with probable Alzheimer's disease (AD) who cannot tolerate or do not respond to oral cholinesterase inhibitors (ChEIs). METHODS: A 24-week, prospective, open-label, single-arm, multicenter study was conducted from June 2009 to June 2010 in patients with probable AD. The enrolled patients had either a poor response or a decline in global function after treatment with oral ChEIs, or they were not able to tolerate treatment with oral ChEIs due to adverse events such as nausea or vomiting. A poor response was defined as a decrease of at least 2 points on the Korean version of the Mini-Mental State Examination (K-MMSE) within the previous 6 months (the decline in global function was determined by the investigator or caregiver). The efficacy of treatment was assessed using a follow-up Clinical Global Impression of Change (CGIC) assessment and K-MMSE conducted after 24 weeks, and safety was measured by the occurrence of adverse events and patient disposition. RESULTS: In total, 164 patients aged 74.7+/-7.52 years (mean+/-SD) and with 5.12+/-3.64 years of education were included. The study was completed by 70% of the patients (n=116), with 12.2% discontinuing due to adverse events. The most frequently reported adverse events (11%) were skin lesions, such as erythema or itching, followed by gastrointestinal problems (1.2%). Either an improvement or no decline in CGIC scores was reported for 82% of the patients. CONCLUSIONS: The immediate switching of patients from an oral ChEI to the rivastigmine transdermal patch without a washout period was safe and well tolerated by the probable-AD patients in this study.

Influence of Additional Post-Bronchoscopy Visit on Patient Satisfaction after Flexible Bronchoscopy

BACKGROUND/AIMS: Many patients undergoing a flexible bronchoscopy (FB) experience anxiety and discomfort during the procedure. We assessed whether an additional patient visit after a FB would improve patient satisfaction. METHODS: The study patients were randomly assigned to a control and post-visit groups. The physicians who were scheduled to perform the FB visited the study patients. The control group had one visit before the FB and the post-visit group had a before and after FB visit. The post-visit group received additional information and support during the second visit. Twenty-four hours after the FB, the participants completed questionnaires about discomfort and satisfaction with the procedure. RESULTS: The control and post-visit groups included 151 and 153 patients, respectively. The post-visit group reported having more information after the FB than the control group. The additional post-bronchoscopy visit improved the general patient tolerability of the procedure. The willingness to return for another FB was not affected by the post-bronchoscopy patient visit. CONCLUSIONS: The post-bronchoscopy visit improved patient satisfaction and general tolerability to the procedure. Subjective patient tolerability with the FB may be improved through a post-bronchoscopy visit by providing more information and emotional support to patients.

Clinical Characteristics and Risk Factors for Nosocomial Candidemia in Medical Intensive Care Units: Experience in a Single Hospital in Korea for 6.6 Years

The aim of this study was to determine candidemia incidence among patients in a medical intensive-care unit (MICU) and the associated mortality rate and to identify risk factors associated with candidemia. We retrospectively performed a 1:3 matched case-control study of MICU patients with candidemia. Controls were matched for sex, age, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Candidemia incidence was 9.1 per 1,000 admissions. The most common pathogen was Candida albicans. Crude mortality was 96% among candidemia patients and 52% among controls (P<0.001). Mortality differed significantly between the groups according to Kaplan-Meier survival analysis (P=0.024). Multivariate analysis identified the following independent risk factors for candidemia: central venous catheterization (odds ratio [OR] = 3.2, 95% confidence interval [CI]=1.2-9.0), previous steroid therapy (OR=4.7, 95% CI=1.8-12.1), blood transfusion during the same admission period (OR=6.3, 95% CI=2.4-16.7), and hepatic failure upon MICU admission (OR=6.9, 95% CI=1.7-28.4). In conclusion, we identify an additional independent risk factor for candidemia, the presence of hepatic failure on MICU admission. Therefore, increased awareness of risk factors, including hepatic failure, is necessary for the management of candidemia.

Clinical Characteristics of Pulmonary Embolism with Underlying Malignancy

BACKGROUND/AIMS: The risk of venous thromboembolism (VTE), which encompasses deep vein thrombosis and pulmonary embolism (PE), increases in patients with cancer. Anticancer treatment is also associated with an increased risk for VTE. We conducted this study to investigate the clinical characteristics of patients with cancer and PE related to anticancer treatment in a tertiary care hospital in Korea. METHODS: We retrospectively reviewed the clinical data of patients with an underlying malignancy who were diagnosed with PE by chest computed tomography (CT) with or without lower extremity CT angiography between January 2006 and December 2007 at Seoul National University Hospital. RESULTS: Overall, 95 patients with malignancies among 168 with PE were analyzed. The median age was 64 years. The median time interval from the malignancy diagnosis to the PE diagnosis was 5.5 months. Lung cancer was the most common malignancy (23.0%), followed by pancreatobiliary cancer, stomach cancer, gynecological cancer, breast cancer, and hepatocellular carcinoma. Platinum-containing and pyrimidine analog-containing chemotherapeutic regimens were common. CONCLUSIONS: PE was diagnosed within 1 year after the cancer diagnosis in almost 70% of patients. Lung cancer was the most common underlying malignancy.

Role of Insulin in the Activation of NF-kappaB/IkappaB Pathway in Macrophage Cells / 결핵및호흡기질환

BACKGROUND: Sepsis still has a high mortality rate despite adequate supportive care. Newer therapeutic modalities have been developed but they have generally ended in failure. Recently, insulin was reported to have an anti-inflammatory effect by inhibiting the IkappaB/NF-kappaB pathway, and may have therapeutic potential in sepsis. However, the precise mechanism of the anti-inflammatory effect of insulin is unclear. This study examined the role of insulin in activating IkappaB/NF-kappaB in macrophage. METHODS: Raw 264.7 cells, a murine macrophage cell line, were used in this experiment. Western blotting using IkappaB Ab and phosphor-specific IkappaB Ab was performed to evaluate the degradation and phosphorylation of IkappaB cells. For the IkappaB Kinase (IKK) activity, an immune complex kinase assay was performed. The level of interleukin-6 (IL-6) was measured by ELISA to determine the level of proinflammatory cytokine. RESULTS: IkappaBalpha degradation began 30 min after lipopolysaccharide (LPS) treatment. However, an insulin pretreatment suppressed the IkappaBalpha degradation caused by the LPS treatment. The phosphorylation of IkappaBalpha and IKK activity was also inhibited by the insulin pretreatment. Finally, the insulin pretreatment showed a tendency to suppress the induction of IL-6 by LPS. CONCLUSION: Insulin might have an anti-inflammatory effect though partial inhibition of the IkappaB/NFkappaB pathway in macrophage cell lines.

Sequential Bilateral Lung Resection in a Patient with Mycobacterium Abscessus Lung Disease Refractory to Medical Treatment

Mycobacterium abscessus (M. abscessus) is the second most common nontuberculous mycobacteria (NTM) in South Korea. Nevertheless, the diagnosis and treatment of M. abscessus lung disease can be problematic. Surgical resection has been tried for patients with localized M. abscessus lung disease refractory to medical treatment. Here, we report on a 25-year-old woman with M. abscessus lung disease who had been diagnosed and treated three times for pulmonary tuberculosis. She was initially diagnosed as having M. intracellulare lung disease; however, M. abscessus was isolated after several months of medication. She had multiple bronchiectatic and cavitary lesions bilaterally, and M. abscessus was repeatedly isolated from her sputa despite prolonged treatment with clarithromycin, ethambutol, moxifloxacin, and amikacin. She improved only after sequential bilateral lung resection. Based on the experience with this patient, we suggest that, if medical treatment fails, surgical resection of a diseased lung should be considered even in patients with bilateral lesions.

Acute Respiratory Failure from Invasive Pulmonary Aspergillosis in an Immunocompetent Adult: A Case Report / 대한구급학회지

Invasive pulmonary aspergillosis has traditionally been known as a disease of an immunocompromised host. We report here on a case of an immunocompetent 73-year-old male who presented with dyspnea and he was finally diagnosed as suffering with invasive pulmonary aspergillosis. He died from progressive respiratory failure and secondary bacterial sepsis despite of voriconazole treatment. Invasive pulmonary aspergillosis should be considered as one of the differential diagnoses in patients with atypical pneumonia that does not respond to the usual antibiotics therapy, and even if the patient does not have an obvious history of an immunosuppressive status. An early suspicion with prompt treatment is important to improve the patient outcome.

Expression of COX-2 and IDO by Uteroglobin Transduction in NSCLC Cell Lines / 결핵및호흡기질환

BACKGROUND: Uteroglobin (UG) is a secretary protein that has strong immunomodulatory properties, and which is synthesized in most epithelia including lung tissue. Overexpression of UG is associated with decreased expression of cyclooxygenase (COX)-2 and suppression of cancer cell growth. Indoleamine 2,3-dioxygenase (IDO) catalyzes tryptophan along the kynurenine pathway, and both the reduction in local tryptophan and the production of tryptophan metabolites contribute to the immunosuppressive effects of IDO. METHODS: In this study, we investigated the pattern of expression of COX-2 and IDO, and the effect of UG transduction in the expression of COX-2 and IDO in several non-small cell lung cancer cell lines, especially A549. RESULTS: Both COX-2 and IDO were constitutionally expressed in A549 and H460 cells, and was reduced by UG transduction. In A549 cells, the slightly increased expression of COX-2 and IDO with the instillation of interferon-gamma (IFN-gamma) was reduced by UG transduction. However, the reduced expression of COX-2 and IDO by UG transduction was not increased with IFN-gamma instillation in A549 cells. In both the A549 COX-2 sense and the A549 COX-2 anti-sense small interfering RNA (siRNA)-transfected cells, IDO was expressed; expression was reduced by UG transduction, irrespective of the expression of COX-2. CONCLUSION: The results suggest that the anti-proliferative function of UG may be associated with the immune tolerance pathway of IDO, which is independent of the COX-2 pathway.

A Case of Severe Human Metapneumovirus Pneumonia Requiring Mechanical Ventilation in an Immunocompetent Adult / 결핵및호흡기질환

Human metapneumovirus (hMPV) is a recently recognized human respiratory pathogen, which is known to be associated with upper and lower respiratory tract infections mainly in children, immunocompromised patients, and the elderly. The clinical manifestations of hMPV infections are similar to those of the human respiratory syncytial virus infection, which range from mild upper respiratory tract infection to severe bronchiolitis and pneumonia. Recently, hMPV has come to be thought of as the cause a similar spectrum of disease in adults as that seen in children; however, most of the reports of hMPV infections have focused on infection in children. We report a case of severe hMPV pneumonia requiring mechanical ventilation in an immunocompetent adult in Korea.

A Case of Oral Tuberculosis Confirmed by Histopathology / 결핵및호흡기질환

Although tuberculosis is a chronic infectious disease that can occur in any section of the body, oral tuberculosis is rare. Here, we report a case of oral tuberculosis in which the patient sought treatment for a painful oral lesion. A histopathologic examination revealed the characteristics of tuberculosis and pulmonary lesions were detected on subsequent examination. The patient was treated with antituberculosis therapy, and his symptoms improved. This case emphasizes the importance of including oral tuberculosis as part of the differential diagnosis for mucosal lesions.

Prevalence and Its Predictors of Extrapulmonary Involvement in Patients with Pulmonary Tuberculosis

Extrapulmonary organ involvement in human immunodefiaency virus (HIV)-infected patients with pulmonary tuberculosis (TB) is reported to be 26%, however, the clinical predictors of extrapulmonary involvement in pulmonary TB patients has not been reported yet. We tried to determine the clinical predictors of presence of extrapulmonary involvement in patients with pulmonary TB. Cross-sectional study was performed including all adult patients with culture-proven pulmonary TB diagnosed between January 1, 2004 and July 30, 2006, at a tertiary referral hospital in South Korea. The presence of extra-pulmonary TB involvement was diagnosed based on bacteriological, pathological, or clinical evidence. Among 320 patients with a culture-proven pulmonary TB, 40 had extrapulmonary involvement. Patients with bilateral lung involvement were more likely to have extrapulmonary involvement, with an adjusted odds ratio (OR) of 4.21 (95% confidence interval [CI], 1.82-9.72), while patients older than 60 yr (adjusted OR, 0.27; 95% CI, 0.08-0.89), patients with cavitary lesions (adjusted OR, 0.37; 95% CI, 0.16-0.84), and with higher levels of serum albumin (adjusted OR, 0.45; 95% CI, 0.25-0.78) had less frequent involvement. Clinicians should be aware of the possibility of extrapulmonary involvement in TB patients with bilateral lung involvement without cavity formation or lower levels of serum albumin.

The Role of Whole-Body FDG PET/CT, Tc 99m MDP Bone Scintigraphy, and Serum Alkaline Phosphatase in Detecting Bone Metastasis in Patients with Newly Diagnosed Lung Cancer

Bone scan (BS) and serum alkaline phosphatase (ALP) concentration are used to detect bone metastasis in malignancy, although whole-body fluoro-D-glucose positron emission tomography computed tomography (FDG PET/CT) is being used increasingly. But BS is still used for the detection of metastatic bone lesion. So we compared the usefulness of PET/CT, BS, and serum ALP in detecting bone metastases in patients with newly diagnosed lung cancer. The medical record database was queried to identify all patients with a new diagnosis of lung cancer between January 2004 and December 2005, who had a PET/CT, BS, and serum ALP before treatment. We retrospectively reviewed all patients' records and radiological reports. One hundred eighty-two patients met the inclusion criteria. Bone metastases were confirmed in 30 patients. The sensitivity values were 93.3% for PET/CT, 93.3% for BS, 26.7% for serum ALP concentration, and 26.7% for BS complemented with serum ALP concentration. The respective specificity values were 94.1%, 44.1%, 94.1%, and 97.3%. The kappa statistic suggested a poor agreement among the three modalities. FDG PET/CT and BS had similar sensitivity, but PET/CT had better specificity and accuracy than BS. PET/CT is more useful than BS for evaluating bone metastasis. However, in the advanced stage, because of its high specificity, BS complemented with serum ALP is a cost-effective modality to avoid having to use PET/CT.

A case of granulomatous lung disease in a patient with Good's syndrome

Good's syndrome is extremely rare. This adult-onset condition is characterized by a thymoma with immunodeficiency, low B- and T-cell counts, and hypo-gammaglobulinemia. The initial clinical presentation is either a mass-lesion thymoma or a recurrent infection. Patients with Good's syndrome are very susceptible to infections; common respiratory and opportunistic infections can be life-threatening. There are no reports of granulomatous lung disease in patients with Good's syndrome, although it has been observed in patients with common variable immunodeficiency, of which Good's syndrome is a subset. We describe a 53-year-old male thymoma patient who presented with respiratory symptoms caused by granulomatous lung disease and an opportunistic infection. He died of uncontrolled fungal infection despite repeated intravenous immunoglobulin and supportive care. Clinicians should look for evidence of immunologic dysfunction in thymoma patients presenting with severe recurrent infections, especially opportunistic infections.