Delayed iliopsoas abscess following COVID-19 pneumonia.

Bacterial co-infection has been reported to contribute to a poor prognosis in patients with COVID-19. However, iliopsoas abscess (IPA) has not been previously reported as a comorbidity during the course of COVID-19. We report two cases of IPA in patients with COVID-19 pneumonia. Both patients required prolonged immunosuppressive therapy for COVID-19 pneumonia and developed bacteremia due to Serratia marcescens in one and Staphylococcus aureus in the other. Although immunosuppressive therapy is commonly used for COVID-19 pneumonia with hypoxemia, the comorbidity of IPA may have been underestimated in these cases.

Acute asthma exacerbation due to the SARS-CoV-2 vaccine (Pfizer-BioNTech BNT162b2 messenger RNA COVID-19 vaccine [ComirnatyⓇ]).

The messenger RNA vaccine against SARS-CoV-2 is effective at preventing COVID-19-associated hospitalization, and the Centers for Disease Control and Prevention has recommended vaccination for all eligible individuals. We demonstrate a case involving a patient who developed a life-threatening acute asthma exacerbation after receiving their third dose of the BNT16b2 vaccine. Because eosinophilia was observed after the second inoculation, it was considered likely that the patient had been sensitized to the BNT16b2 vaccine. Theoretically, the SARS-CoV-2 vaccine could trigger the exacerbation of asthma. It should be recognized that repeated SARS-CoV-2 vaccination may be a risk factor for the acute exacerbation of asthma.

[Successful treatment of HHV8-negative effusion-based lymphoma with drainage of pleural effusion].

Two cases of human herpesvirus 8 (HHV8)-negative effusion-based lymphoma (EBL) involving unilateral pleural effusion that regressed only after drainage are reported. Cases 1 and 2 were 91- and 81-year-old men with right and left pleural effusion, respectively. No chemotherapy was administered to either patient because of their advanced age and the presence of cardiac comorbidities. They completely recovered after effusion drainage alone without relapse till the last observation. Thus, this study suggests that some patients with HHV8-negative EBL can be safely managed with effusion drainage alone.

Comparison of chest computed tomography features between pulmonary tuberculosis patients with culture-positive and culture-negative sputum for non-mycobacteria: A retrospective observational study.

ABSTRACT: Although complication with non-mycobacterial pneumonia among patients with pulmonary tuberculosis (TB) may lead to poor prognosis, discrimination between TB complicated with and without non-mycobacterial pneumonia using radiological imaging has not been fully elucidated. We aimed to clarify the differences in chest computed tomography (CT) features between pulmonary TB patients with culture-positive and culture-negative sputum for non-mycobacteria.We retrospectively included consecutive patients admitted to our hospital from January 2013 to December 2015 for bacteriologically-confirmed pulmonary TB, who were tested by sputum culture for non-mycobacteria, and who underwent chest CT within 2 weeks before or after admission. Chest CT features were compared between pulmonary TB patients who had positive non-mycobacterial cultures and in those who had not.Of 202 patients with pulmonary TB, 186 (92%) were tested by sputum culture for non-mycobacteria and underwent chest CT. Among these, non-mycobacteria were isolated in 118 patients (63%), while 68 patients (37%) had negative cultures. Patients with a positive culture for non-mycobacteria were significantly older and had lower levels of physical activity and albumin, higher levels of C-reactive protein, and a greater number of respiratory failures. By CT, emphysematous lesions, ground-glass opacities, airspace consolidation, air-bronchogram, interlobular septal thickening, bronchiectasis, pleural effusion, pleural thickening, and lymph node enlargement were more frequently in patients with a positive culture for non-mycobacteria. These chest CT features could be helpful for detecting complication with non-mycobacterial pneumonia in patients with pulmonary TB.

Efficacy and safety of fluoroquinolone-containing regimens in treating pulmonary Mycobacterium avium complex disease: A propensity score analysis.

BACKGROUND: Although combination therapy using clarithromycin, rifampicin, and ethambutol is recommended for patients with pulmonary Mycobacterium avium complex (MAC) disease, some patients do not tolerate it because of adverse effects or underlying diseases. The efficacy and safety of fluoroquinolone-containing combination regimens as an alternative remain uncertain. This study aimed to compare the efficacy and safety of fluoroquinolone-containing regimens with those of the standard regimens for treating pulmonary MAC disease. METHODS: We retrospectively included consecutive MAC patients who were treated in our hospital between January 2011 and May 2019. Patients treated with fluoroquinolone-containing regimens who had relapsed after treatment with standard regimens were excluded. A propensity score analysis was conducted to reduce selection bias, and the proportions of clinical improvement, defined by chest imaging findings and sputum conversion, were compared between the fluoroquinolone-containing regimen and standard regimen groups. RESULTS: We analyzed 28 patients who received fluoroquinolone-containing regimens and 46 who received the standard regimen. Fluoroquinolone-containing regimens were more likely selected for patients with cavitary lesions, diabetes mellitus, culture negativity, a low daily physical activity level, a decreased lymphocyte count and an increased CRP level. The propensity score was calculated using these variables (C-statistic of the area under the receiver operating characteristic curve of the propensity score: 0.807, p < 0.0001). The fluoroquinolone-containing regimens were significantly inferior to the standard regimen in clinical improvements (p = 0.002, Log-rank test) in the univariate analysis, but the significance was lost after adjusting for the propensity score (HR 0.553, 95% CI 0.285-1.074, p = 0.080). Six (21%) patients in the fluoroquinolone-containing regimen group and ten (22%) patients in the standard regimen group experienced low-grade adverse effects. CONCLUSIONS: There was no significant difference in clinical improvement between these regimens after propensity score adjustment. A large-scale prospective study is required to validate these results.

The impact of performance status on tuberculosis-related death among elderly patients with lung tuberculosis: A competing risk regression analysis.

While advanced age is a main prognostic factor in patients with tuberculosis, the factors that specifically affect tuberculosis-related death are unclear because elderly people are at a risk for other age-related lethal diseases. We aimed to assess the impact of performance status on tuberculosis-related death among elderly patients with lung tuberculosis. Elderly patients (≥65 years of age) admitted to our hospital for bacteriologically-diagnosed lung tuberculosis were included, and analyzed the influence of performance status on tuberculosis-related in-hospital death, with non-tuberculosis-related death as a competing risk. Forty and 19 of the 275 patients died from tuberculosis-related causes and non-tuberculosis-related causes, respectively. The tuberculosis-related death group had a greater number of patients with a poor performance status (defined as category 3 and 4 [HR 21.022; 95%CI 2.881-153.414; p = 0.003]), a lower serum albumin level (HR 0.179; 95%CI 0.090-0.359; p < 0.001) and a higher C-reactive protein level (HR1.076; 95%CI 1.026-1.127; p = 0.002). A multivariate competing risk regression analysis showed that a poor performance status (HR 7.311; 95%CI 1.005-53.181; p = 0.049) and low albumin level (HR 0.228; 95%CI 0.099-0.524); p = 0.001) significantly predicted tuberculosis-related death. Performance status can be a useful scale for predicting tuberculosis-related death among elderly patients with pulmonary tuberculosis.

A high C-reactive protein level and poor performance status are associated with delayed sputum conversion in elderly patients with pulmonary tuberculosis in Japan.

INTRODUCTION: Although the aging population had been increasing in many countries, the factors associated with sputum conversion in elderly patients with pulmonary tuberculosis have not been fully elucidated. OBJECTIVES: We aimed to identify the predictors of delayed sputum conversion and to assess the impact of non-conversion on mortality during tuberculosis treatment in elderly patients. METHODS: Elderly patients (>65 years) admitted at our hospital in Japan for sputum smear-positive pulmonary tuberculosis were included. The risk factors for sputum non-conversion after 2 months of treatment were determined using multiple logistic regression. Cox hazard regression was used to assess the influence of non-conversion on mortality. RESULTS: We included 185 patients, with median age of 82 years (IQR, 79-88 years). The median time to conversion was 47 (95% CI 43-51) days, and 62 (34%) were identified as non-converters. Multivariate analysis showed that high pretreatment smear grade, high C-reactive protein level and poor performance status were associated with non-conversion. Non-conversion did not contribute to death during treatment. CONCLUSIONS: In elderly patients, inflammation level and physical activity level, along with initial smear grade may have a significant impact on delayed sputum conversion. Non-conversion after two months of treatment might not be related with mortality.

Factors associated with atypical radiological findings of pulmonary tuberculosis.

BACKGROUND: Unusual radiological images may delay diagnosis of pulmonary tuberculosis. This study aimed to analyze the risk factors for an atypical radiological image in patients with pulmonary tuberculosis. METHODS: We retrospectively analyzed data from patients admitted to one hospital from January 2013 to December 2016 for sputum smear-positive lung tuberculosis who underwent chest computed tomography (CT) on admission. Patients whose sputum cultures were positive for general bacteria were excluded. Patient characteristics and laboratory data were compared between patients with cavity and those without and between patients with upper predominant lung involvement and those without. RESULTS: This study included 94 (93%) of 101 patients who underwent chest CT. The non-cavity group was older, had a greater number of females, had a lower C-reactive protein (CRP) level, and had a lower glomerular filtration rate. Multivariate analysis showed that a low CRP level (OR 0.808; 95% CI 0.674-0.967; p = 0.020) significantly predicted non-cavity pulmonary tuberculosis. The non-upper predominant lung involvement group was older and had a greater number of females, poorer performance status, a higher CRP level, and a lower serum albumin level. A poor performance status (OR 2.155; 95% CI 1.257-3.693; p = 0.005) was found to significantly predict pulmonary tuberculosis with non-upper predominant lung distributions. CONCLUSIONS: A low CRP level and poor performance status were associated with non-cavity and non-upper predominant lung distribution, respectively, in patients with pulmonary tuberculosis. Tuberculosis patients with these characteristics may present unusual chest images.

Asthma Exacerbation Coincident with Saddle Pulmonary Embolism and Paradoxical Embolism.

Saddle pulmonary embolism (PE) and paradoxical embolism (PDE) are life-threatening disorders carrying a risk of sudden death, and their prompt diagnosis is extremely important. Saddle PE is a radiologic definition and refers to a thrombus that straddles the bifurcation of the pulmonary artery trunk, carrying a risk of sudden hemodynamic collapse. PDE is defined as a systemic arterial embolus due to the passage of a venous thrombus though a right-to-left shunt, such as patent foramen ovale (PFO). We herein present the rare case of asthma exacerbation coincident with saddle PE and PDE. A 69-year-old woman with asthma was suffering from dyspnea, pulse attenuation of the left radial artery and left upper limb pain. An arterial blood gas analysis revealed hypoxemia, and a pulmonary function test demonstrated an obstructive pattern. Enhanced computed tomography (CT) revealed saddle PE, right popliteal venous thrombosis, and left brachial artery occlusion. After the treatment with edoxaban, an anticoagulant, and aspirin, the PE was significantly alleviated, and the brachial artery occlusion was recanalized. Subsequently, the right-to-left shunt through PFO was confirmed, and PDE was suspected of inducting her brachial artery embolism. In the present case, the pulse attenuation of the radial artery and upper limb pain prompted us to consider peripheral vascular disease or coagulation disorders. Physicians should keep in mind that patients with asthma are at considerable risk of PE, and it is important to be aware of possible PFO in patients presenting with the coexistence of PE and systemic arterial embolism.

Impact of additional antibiotics on in-hospital mortality in tuberculosis isolated general bacteria: A propensity score analysis.

Whether or not additional antibiotics with anti-tuberculosis agents are required to treat bacterial co-infection with pulmonary tuberculosis is unclear. We aimed to assess the impact of additional antibiotics on mortality in pulmonary tuberculosis patients whose sputum cultures were positive for general bacteria as a surrogate definition of bacterial pneumonia. This study was a single-center retrospective cohort using a propensity score analysis. We included patients who were admitted for pulmonary tuberculosis and whose sputum cultures were positive for general bacteria. The mortality of patients who received additional antibiotics was analyzed after adjusting for other variables, including the propensity score predicting treatment with additional antibiotics. We assessed 68 and 55 tuberculosis patients treated with and without general antibiotics, respectively. Additional antibiotics tended to be administered to patients with a high level of C-reactive protein and neutrophil count, poor performance status, hypoxemia and hypoalbuminemia (C-statistics of area under receiver operating characteristic curve to the propensity score; 0.884, p < 0.001). In the multivariate analysis, advanced age and not the use of additional antibiotics was associated with in-hospital mortality. Additional antibiotics with anti-tuberculosis agents may not improve the prognosis of pulmonary tuberculosis patients whose sputum cultures were positive for general bacteria. Isolation of general bacteria does not equate to complication with bacterial pneumonia, so physicians should not administer general antibiotics to TB patients based solely on the results of sputum culture for general bacteria. A prospective study is needed to verify these results using a more accurate definition of pulmonary tuberculosis complicated with bacterial pneumonia.

Elevated Serum Anti-GM-CSF Antibodies before the Onset of Autoimmune Pulmonary Alveolar Proteinosis in a Patient with Sarcoidosis and Systemic Sclerosis.

Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of periodic acid-schiff stain-positive lipoproteinaceous materials in the alveolar space due to impaired surfactant clearance by alveolar macrophage. Autoimmune PAP is the most common form of PAP, but rarely accompanies collagen disease or sarcoidosis. We report here a rare case of autoimmune PAP preceded by systemic sclerosis and sarcoidosis. A 64-year-old woman was admitted to our hospital for blurred vision, muscle weakness of extremities, Raynaud's phenomenon, and exertional dyspnea. We diagnosed her as having systemic sclerosis complicated with sarcoidosis. Chest computed tomography (CT) and transbronchial lung biopsy showed the findings of pulmonary fibrosis without PAP. We treated her with corticosteroid and intravenous cyclophosphamide therapy, followed by tacrolimus therapy. Thereafter, her symptoms improved except for exertional dyspnea, and she began to complain of productive cough thirteen months after corticosteroid and immunosuppressant therapy. On the second admission, a chest CT scan detected the emergence of crazy-paving pattern in bilateral upper lobes. Bronchoalveolar lavage (BAL) fluid with milky appearance and a lung biopsy specimen revealed acellular periodic acid-schiff stain-positive bodies. The serum titer of anti-granulocyte macrophage colony stimulating factor (GM-CSF) antibodies was elevated on first admission and remained high on second admission. We thus diagnosed her as having autoimmune PAP. Reducing the dose of immunosuppressive agents and repeating the segmental BAL resulted in the improvement of her symptoms and radiological findings. Immunosuppressant therapy may trigger the onset of autoimmune PAP in a subset of patients with systemic sclerosis and/or sarcoidosis.

Corticosteroid Therapy for a Patient with Relapsing Polychondritis Complicated by IgG4-Related Disease.

Relapsing polychondritis (RP) is a rare systemic disorder characterized by recurrent, widespread chondritis of the auricular, nasal, and tracheal cartilages. IgG4-related disease (IgG4-RD) is a systemic immune-mediated disease characterized by the infiltration of IgG4-bearing plasma cells into systemic organs. Although 25% to 35% of patients with RP have a concurrent autoimmune disease, coexistence of RP and IgG4-RD is rare. We herein report a case of RP complicated by IgG4-RD. A 63-year-old man developed recurrent bilateral ear pain and swelling, recurrent blurred and decreased vision, and migratory multiple joint pain, sequentially within one year. Fourteen months after the first symptom, he experienced dry cough and dyspnea with exertion. A computed tomography (CT) scan detected interstitial pneumonia, swelling of bilateral submandibular glands, bilateral hilar and mediastinal lymphadenopathy, and several nodules in bilateral kidneys. His serum levels of IgG and IgG4 were elevated. The biopsy specimen of auricular cartilage showed infiltrations of inflammatory cells and fibrosis consistent with RP. The IgG4-positive cells were not observed in auricular cartilage. The patient met the diagnostic criteria of RP, including bilateral auricular chondritis, conjunctivitis, iritis and polyarthritis. The biopsy specimens of lung and kidney revealed the significant infiltrations of IgG4-positive plasma cells and fibrosis. We also diagnosed him as having IgG4-RD, affecting bilateral submandibular glands, hilar and mediastinal lymph nodes, lungs, and kidneys. Thus, RP preceded the onset of IgG4-RD. Corticosteroid therapy improved the symptoms and CT scan findings. In conclusion, RP and IgG4-RD do coexist; however, the pathogenesis of their coexistence is unknown.