Beyond Symptoms: Radiologic identification of asymptomatic Mycobacterium avium complex pulmonary infections.

BACKGROUND: Although international nontuberculous mycobacterial pulmonary disease (NTM-PD) guidelines highlight symptom presence at diagnosis, the clinical characteristics of asymptomatic Mycobacterium avium complex pulmonary infection (MAC-PI) patients remain understudied. We clarified the clinical characteristics and course of asymptomatic MAC-PI patients. METHODS: We retrospectively analyzed 200 consecutive patients with MAC-PIs and adequate available data who newly met the microbiological and radiological criteria for NTM-PD at Fukujuji Hospital from January 2018 to June 2020. We compared the clinical characteristics and course of asymptomatic patients with symptomatic patients and evaluated factors influencing treatment initiation through multivariate analysis. RESULTS: 111 patients were symptomatic and 89 were asymptomatic at diagnosis. While the proportion was significantly lower than that in the symptomatic group (28.8 %), 15.7 % of asymptomatic group patients had cavitary lesions (P = 0.042). In the asymptomatic group, treatments were initiated in 38 (42.7 %) patients, and cavitary lesions, a positive acid-fast bacilli smear, and younger age were independent risk factors for treatment initiation. Among 22 (57.9 %) patients who experienced disease progression necessitating treatment during follow-up, 13 (34.2 %) displayed radiological progression without any worsening of symptoms. Agents used for treatment were consistent across the groups, with no significant differences in culture conversion, microbiological recurrence rates, or spontaneous culture conversion rates. CONCLUSION: Routine health checkups and radiological examinations can detect clinically important MAC-PIs even in the absence of symptoms. Considering that the clinical course of asymptomatic MAC-PI patients is largely similar to that of symptomatic patients, timely and appropriate management and intervention are essential for all MAC-PI patients.

Activities of Daily Living, Hypoxemia, and Lymphocytes Score for Predicting Mortality Risk in Patients With Pulmonary TB.

BACKGROUND: A clinically applicable mortality risk prediction system for pulmonary TB may improve treatment outcomes, but no easy-to-calculate and accurate score has yet been reported. The aim of this study was to construct a simple and objective disease severity score for patients with pulmonary TB. RESEARCH QUESTION: Does a clinical score consisting of simple objective factors predict the mortality risk of patients with pulmonary TB? STUDY DESIGN AND METHODS: The data set from our previous prospective study that recruited patients newly diagnosed with pulmonary TB was used for the development cohort. Patients for the validation cohort were prospectively recruited between March 2021 and September 2022. The primary end point was all-cause in-hospital mortality. Using Cox proportional hazards regression, a mortality risk prediction model was optimized in the development cohort. The disease severity score was developed by assigning integral points to each variate. RESULTS: The data from 252 patients in the development cohort and 165 patients in the validation cohort were analyzed, of whom 39 (15.5%) and 17 (10.3%), respectively, died in the hospital. The disease severity score (named the AHL score) included three clinical parameters: activities of daily living (semi-dependent, 1 point; totally dependent, 2 points); hypoxemia (1 point), and lymphocytes (< 720/µL, 1 point). This score showed good discrimination with a C statistic of 0.902 in the development cohort and 0.842 in the validation cohort. We stratified the score into three groups (scores of 0, 1-2, and 3-4), which clearly corresponded to low (0% and 1.3%), intermediate (13.5% and 8.9%), and high (55.8% and 39.3%) mortality risk in the development and validation cohorts. INTERPRETATION: The easy-to-calculate AHL disease severity score for patients with pulmonary TB was able to categorize patients into three mortality risk groups with great accuracy. CLINICAL TRIAL REGISTRATION: University Hospital Medical Information Network Center; No. UMIN000012727 and No. UMIN000043849; URL: www.umin.ac.jp.

Multiple bacterial culture positivity reflects the severity and prognosis as bronchiectasis in Mycobacterium avium complex pulmonary disease.

BACKGROUND: Bacterial coinfections are observed in 19-66% of patients with Mycobacterium avium complex pulmonary disease (MAC-PD) during the entire duration of the disease. The impact of bacterial coinfection at diagnosis on the clinical course of MAC-PD has not been reported. METHODS: Among 558 patients diagnosed with MAC-PD between January 2016 and December 2020, 218 patients who underwent sputum culture tests twice or more within one year before and after diagnosis were included. We compared the patient characteristics and disease courses between the patients who had the same bacterial species detected twice or more (bacterial culture positive group: BCP group) and those who never had bacteria cultured (bacterial culture negative group: BCN group). RESULTS: We included 70 patients in the BCP group and 74 in the BCN group. The radiological findings showed that BCP at diagnosis correlated with a high modified Reiff score. During the median follow-up period of 42 months, the patients in the BCP group were more likely to accomplish spontaneous sputum conversion of MAC. The treatment initiation rate for MAC-PD in the BCP group was lower than that in the BCN group (41.4% vs. 67.6%, P = 0.003). In contrast, the time to the first bronchiectasis exacerbation in the BCP group was shorter than that in the BCN group, and the frequency of bronchiectasis exacerbations was higher in the BCP group. CONCLUSIONS: Patients with BCP at diagnosis are less likely to initiate treatment for MAC-PD and more likely to develop bronchiectasis exacerbation.

Relationship between the thickness of erector spinae muscles and mortality in patients with pulmonary tuberculosis.

BACKGROUND: Skeletal muscle mass is a known predictor of mortality in older patients. However, its relationship with tuberculosis is unclear. Skeletal muscle mass is determined by the cross-sectional area of erector spinae muscle (ESMCSA). Additionally, the erector spinae muscle thickness (ESMT) is an easier measurement than ESMCSA. This study investigated the relationship of ESMT and ESMCSA with mortality in tuberculosis patients. METHODS: We retrospectively collected the data of 267 older patients (age ≥65 years) who were hospitalized due to tuberculosis at the Fukujuji Hospital from January 2019 to July 2021. This included 40 patients with 60-day mortality (the death group) and 227 patients with 60-day survival (the alive group). Here, we assessed the correlations between ESMCSA and ESMT, and the data were compared between the two groups. RESULTS: ESMT had a strong proportional relationship with ESMCSA (r = 0.991, p < 0.001). ESMCSA (median 670.2 mm2 [interquartile range (IQR): 585.1-760.9] vs. 914.3 mm2 [717.6-1141.6], p < 0.001) and ESMT (median 16.7 mm [15.4-18.6] vs. 21.1 mm [18.0-25.5], p < 0.001) were significantly lower in the patients in the death group than those of patients in the alive group. A multivariable Cox proportional hazard model for 60-day mortality showed significantly independent differences in ESMT (hazard ratio [HR] 0.870 [95% confidence interval (Cl): 0.795-0.952], p = 0.003) and ESMCSA (HR 0.998 [95% Cl: 0.996-0.999], p = 0.009). CONCLUSIONS: This study demonstrated a strong correlation between ESMCSA and ESMT, which were risk factors for mortality in patients with tuberculosis. Therefore, using ESMT is easier to predict mortality than ESMCSA.

Characteristics of pleural effusion due to paradoxical response in patients with pulmonary tuberculosis.

BACKGROUND: Patients with pulmonary tuberculosis may present with deterioration of pleural effusion during anti-tuberculosis therapy, referred to as a paradoxical response (PR), with some patients requiring additional intervention. However, PR may be confused with other differential diagnoses, and the predictive factors for recommending additional therapies are unknown. Therefore, this study aimed to reveal useful information for the diagnosis and intervention of PR. METHODS: Data from human immunodeficiency virus-negative patients with tuberculous pleurisy (n = 210), including 184 patients with pre-existing pleural effusion and 26 patients with PR at Fukujuji Hospital, were retrospectively collected from January 2012 to December 2022 and compared. Furthermore, patients with PR were divided into the intervention group (n = 9) and the no intervention group (n = 17) and were compared. RESULTS: Patients in the PR group had lower pleural lactate dehydrogenase (LDH) (median 177 IU/L vs. 383 IU/L, p < 0.001) and higher pleural glucose (median 122 mg/dL vs. 93 mg/dL, p < 0.001) levels than those in the preexisting pleural effusion group. Other pleural fluid data were not significantly different. Patients in the intervention group had a shorter duration from the initiation of anti-tuberculosis therapy to the development of PR than patients in the no intervention group (median 19.0 days [interquartile range (IQR): 18.0-22.0] vs. median 37.0 days [IQR: 28.0-58.0], p = 0.012). CONCLUSION: This study demonstrates that, apart from lower pleural LDH and elevated pleural glucose levels, PR presents with similar features to preexisting pleural effusion and that patients who develop PR faster tend to require intervention.

Usefulness of SMART-COP score in prognosis of aspiration pneumonia / Utilidad de la puntuación en la escala SMART-COP para el pronóstico de la neumonía por aspiración

Introduction: Aspiration pneumonia is becoming a common syndrome in the elderly in aging societies such as Japan. Although a number of tools have been validated for prediction of mortality in patients with community-acquired pneumonia, none have been established for aspiration pneumonia. The purpose of this study was to access the correlations of the A-DROP, CURB-65 and SMART-COP scores at the emergency visit with the 30-day mortality risk in patients with aspiration pneumonia.MethodsWe Titleretrospectively investigated 210 patients who presented to the emergency department at Mishuku Hospital in Tokyo, Japan.ResultsThe areas under the curve for the ability of A-DROP, Curb-65 and SMART-COP scores to predict the 30-day mortality risk were 0.6359, 0.6468 and 0.7594, respectively. Among the parameters of SMART-COP, involvement of multiple lobes on chest radiographs is the best predictor of the mortality.ConclusionsThe SMART-COP score can be a better predictor of the 30-day mortality risk. (AU)

Introducción: La neumonía por aspiración se está convirtiendo en un síndrome frecuente entre las personas de la tercera edad en sociedades envejecidas como Japón. A pesar de que se han aprobado diversas herramientas para la predicción de la mortalidad en pacientes con neumonía adquirida en la comunidad, no se ha logrado ninguna para la neumonía por aspiración. El objetivo de este estudio fue obtener correlaciones entre las puntuaciones en las escalas A-DROP, CURB-65 y SMART-COP en las visitas al servicio de urgencias y el riesgo de mortalidad a 30 días en pacientes con neumonía por aspiración.MétodosInvestigamos de forma retroactiva 210 pacientes que acudieron al servicio de urgencias del Hospital Mishuku en Tokio, Japón, y que fueron hospitalizados con neumonía por aspiración.ResultadosLas áreas bajo la curva de capacidad de las puntuaciones en las escalas A-DROP, CURB-65 y SMART-COP para predecir el riesgo de mortalidad a 30 días fueron 0,6359; 0,6468 y 0,7594, respectivamente. Entre los parámetros de la escala SMART-COP, la afectación de múltiples lóbulos en las radiografías de tórax es el mejor indicador de la mortalidad.ConclusionesLa puntuación en la escala SMART-COP puede ser un mejor indicador del riesgo de mortalidad a 30 días. (AU)

Usefulness of SMART-COP score in prognosis of aspiration pneumonia.

INTRODUCTION: Aspiration pneumonia is becoming a common syndrome in the elderly in aging societies such as Japan. Although a number of tools have been validated for prediction of mortality in patients with community-acquired pneumonia, none have been established for aspiration pneumonia. The purpose of this study was to access the correlations of the A-DROP, CURB-65 and SMART-COP scores at the emergency visit with the 30-day mortality risk in patients with aspiration pneumonia. METHODS: We Titleretrospectively investigated 210 patients who presented to the emergency department at Mishuku Hospital in Tokyo, Japan. RESULTS: The areas under the curve for the ability of A-DROP, Curb-65 and SMART-COP scores to predict the 30-day mortality risk were 0.6359, 0.6468 and 0.7594, respectively. Among the parameters of SMART-COP, involvement of multiple lobes on chest radiographs is the best predictor of the mortality. CONCLUSIONS: The SMART-COP score can be a better predictor of the 30-day mortality risk.

Cilia-Mediated Insulin/Akt and ST2/JNK Signaling Pathways Regulate the Recovery of Muscle Injury.

Following injury, skeletal muscle regenerates but fatty tissue accumulation is seen in aged muscle or muscular dystrophies. Fibro/adipogenic progenitors (FAPs) are key players in these events; however, the effect of primary cilia on FAPs remains unclear. Here, it is reported that genetic ablation of trichoplein (TCHP), a ciliary regulator, induces ciliary elongation on FAPs after injury, which promotes muscle regeneration while inhibiting adipogenesis. The defective adipogenic differentiation of FAPs is attributed to dysfunction of cilia-dependent lipid raft dynamics, which is critical for insulin/Akt signaling. It is also found that interleukin (IL) 13 is substantially produced by intramuscular FAPs, which are upregulated by ciliary elongation and contribute to regeneration. Mechanistically, upon injury, long cilia excessively activate the IL33/ST2/JNK axis to enhance IL13 production, facilitating myoblast proliferation and M2 macrophage polarization. The results indicate that FAPs organize the regenerative responses to skeletal muscle injury via cilia-mediated insulin/Akt and ST2/JNK signaling pathways.

Allergic Bronchopulmonary Mycosis Due to Schizophyllum commune Presented as a Lung Mass

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Transition metals doped effects for the crystal stabilization of the cerium oxides with the first principle calculation.

In recent years, hydrogen energy has been attracting attention, and the hydrogen gas production using solar thermal energy has been conducted. The studies of Kodama et al. were reported that the cyclic reaction can efficiently produce the hydrogen gas through a two-step thermal redox reaction with the cerium oxide. The transition metal doping into the cerium oxide improved the reaction efficiency. We considered the doping effect on the thermal two-step redox reaction. As a result of the calculation by the DV-Xα method, it was clarified that the doped cerium oxide becomes a strong bond, the large BOP value without changing the ceria crystal structure in the two-step thermal redox reaction. The theoretical calculation results corresponded to the reaction efficiency improvement of the thermal reaction in experimental results.

Acute eosinophilic pneumonia following aromatherapy with essential oil.

Essential oils are liquid extracts of various plants with potential health benefits and are often used in aromatherapy. Contact allergy, including skin irritation, is a well-known side effects of these extracts. A Japanese woman visited our emergency department complaining of dyspnea, cough, and fever. Two weeks earlier, she had started aromatherapy using a humidifier and essential oil. Based on clinical and imaging findings, and the results of bronchoalveolar lavage, we diagnosed acute eosinophilic pneumonia due to inhalation of essential oil. Her symptoms resolved after steroid therapy. This case makes the clinicians aware the possibility of acute eosinophilic pneumonia induced by aromatherapy using essential oil.

Efficacy of Chest Radiography as a Primary Care Triage Tool in Severe Coronavirus Disease.

Objective Severe acute respiratory syndrome coronavirus 2 has spread globally, and it is important to utilize medical resources properly, especially in critically ill patients. We investigated the validity of chest radiography as a tool for predicting aggravation in coronavirus disease (COVID-19) cases. Methods A total of 104 laboratory-confirmed COVID-19 cases were referred from the cruise ship "Diamond Princess" to the Self-Defense Forces Central Hospital in Japan from February 11 to 25, 2020. Fifty-nine symptomatic patients were selected. Chest radiography was performed upon hospitalization; subsequently, patients were categorized into the positive radiograph (Group A) and negative radiograph (Group B) groups. Radiographic findings were analyzed with a six-point semiquantitative score. Group A was further classified into two additional subgroups: patients who required oxygen therapy during their clinical courses (Group C) and patients who did not (Group D). Clinical records, laboratory data, and radiological findings were collected for an analysis. Results Among 59 patients, 34 were men with a median age of 60 years old. Groups A, B, C, and D consisted of 33, 26, 12, and 21 patients, respectively. The number of patients requiring oxygen administration was significantly larger in Group A than in Group B. The consolidation score on chest radiographs was significantly higher in Group C than in Group D. When chest radiographs showed consolidation in more than two lung fields, the positive likelihood ratio of deterioration was 10.6. Conclusions Chest radiography is a simple and easy-to-use clinic-level triage tool for predicting the severity of COVID-19 and may contribute to the allocation of medical resources.

A rare case of atypical bone marrow sarcoidosis without pulmonary involvement in a Japanese woman.

Sarcoidosis is a systemic granulomatous disease of unknown origin characterised by the presence of non-caseating granulomatous lesions. Extrapulmonary sarcoidosis with bone marrow involvement is rare and even more so without pulmonary involvement. Here, we describe a case of 69-year-old woman diagnosed as having bone marrow and hepatic sarcoidosis without pulmonary involvement based on 18F-fluorodeoxyglucose positron emission tomography findings. She was successfully treated with systemic glucocorticoid therapy.

Multiple infected lung bullae associated with Mycobacterium intracellulare in a Japanese man.

Mycobacterium avium complex (MAC)-infected lung bulla was a rare type of pulmonary non-tuberculous mycobacterial (NTM) infection. A 29-year-old man with a history of tetralogy of Fallot was admitted to our hospital because of a high fever and left chest pain. Chest computed tomography showed two bullae with intrabullous fluid in both the lower lobes and centrilobular small nodular shadow in the right upper lobe and the left lower lobe. Culture of bronchoscopic washing specimen from the right upper lobe bronchus and left lower lobe one and purulent fluid drained from the bulla in the left lower lobe revealed Mycobacterium intracellulare. Percutaneous drainage from the left bulla and anti-NTM treatment were performed. Afterwards, symptoms improved and two intrabullous fluid disappeared. Therefore, a diagnosis of multiple infected lung bullae associated with M. intracellulare was made. This is the first documented case of multiple infected lung bullae associated with MAC.

Prediction of an increase in oxygen requirement of SARS-CoV-2 pneumonia using three different scoring systems.

INTRODUCTION: In patients with severe coronavirus disease 2019 (COVID-19), respiratory failure is a major complication and its symptoms occur around one week after onset. The CURB-65, A-DROP and expanded CURB-65 tools are known to predict the risk of mortality in patients with community-acquired pneumonia. In this retrospective single-center retrospective study, we aimed to assess the correlations of the A-DROP, CURB-65, and expanded CURB-65 scores on admission with an increase in oxygen requirement in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia. METHODS: We retrospectively analyzed 207 patients who were hospitalized with SARS-CoV-2 pneumonia at the Self-Defense Forces Central Hospital in Tokyo, Japan. Performance of A-DROP, CURB-65, and the expanded CURB-65 scores were validated. In addition, we assessed whether there were any associations between an increase in oxygen requirement and known risk factors for critical illness in COVID-19, including elevation of liver enzymes and C-reactive protein (CRP), lymphocytopenia, high D-dimer levels and the chest computed tomography (CT) score. RESULTS: The areas under the curve for the ability of CURB-65, A-DROP, and the expanded CURB-65 scores to predict an increase in oxygen requirement were 0.6961, 0.6980 and 0.8327, respectively, and the differences between the three groups were statistically significant (p < 0.001). Comorbid cardiovascular disease, lymphocytopenia, elevated CRP, liver enzyme and D-dimer levels, and higher chest CT score were significantly associated with an increase in oxygen requirement CONCLUSIONS: The expanded CURB-65 score can be a better predictor of an increase in oxygen requirement in patients with SARS-CoV-2 pneumonia.

Serial serum SARS-CoV-2 RNA results in two COVID-19 cases with severe respiratory failure.

Coronavirus disease 2019 (COVID-19) is spreading worldwide and poses an imminent threat to public health. We encountered 2 cases of COVID-19 with progression resulting in severe respiratory failure and improvement without any specific treatment. To examine the course of infection, we performed reverse-transcription (RT) polymerase chain reaction assay with serum specimens, and serum SARS-CoV-2 RNA was detected in both cases when body temperature increased and respiratory status deteriorated. We, then examined, retrospectively and prospectively, the clinical course during hospitalization by performing serial examinations of serum SARS-CoV-2 RNA status. The findings from our cases suggest that not only is detection of viremia useful as a predictive marker of severity, but also serial serum SARS-CoV-2 RNA results can be helpful for predicting the clinical course.

Clinical characteristics of COVID-19 in 104 people with SARS-CoV-2 infection on the Diamond Princess cruise ship: a retrospective analysis.

BACKGROUND: The ongoing COVID-19 pandemic is a global threat. Identification of markers for symptom onset and disease progression is a pressing issue. We described the clinical features of people infected on board the Diamond Princess cruise ship who were diagnosed with asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or mild or severe COVID-19, on admission to the Self-Defense Forces Central Hospital (Tokyo, Japan) and at the end of observation. METHODS: This retrospective, single-centre study included participants with laboratory-detected SARS-CoV-2 infection who were admitted to the Self-Defense Forces Central Hospital from Feb 11 to Feb 25, 2020. Clinical records, laboratory data, and radiological findings were analysed. Clinical outcomes were followed up until discharge or Feb 26, 2020, whichever came first. We defined asymptomatic infection as SARS-CoV-2 infection with no history of clinical signs and symptoms, severe COVID-19 as clinical symptoms of pneumonia (dyspnoea, tachypnoea, peripheral capillary oxygen saturation <93%, and need for oxygen therapy), and mild COVID-19 as all other symptoms. Clinical features on admission were compared among patients with different disease severity, including asymptomatic infection, at the end of observation. We used univariable analysis to identify factors associated with symptomatic illness among asymptomatic people infected with SARS-CoV-2 and disease progression in patients with COVID-19. FINDINGS: Among the 104 participants included in the final analysis, the median age was 68 years (IQR 47-75) and 54 (52%) were male. On admission, 43 (41%) participants were classified as asymptomatic, 41 (39%) as having mild COVID-10, and 20 (19%) as having severe COVID-19. At the end of observation, 33 (32%) participants were confirmed as being asymptomatic, 43 (41%) as having mild COVID-19, and 28 (27%) as having severe COVID-19. Serum lactate hydrogenase concentrations were significantly higher in the ten participants who were asymptomatic on admission but developed symptomatic COVID-19 compared with the 33 participants who remained asymptomatic throughout the observation period (five [50%] vs four [12%] participants; odds ratio 7·25, 95% CI 1·43-36·70; p=0·020). Compared with patients with mild disease at the end of observation, patients with severe COVID-19 were older (median age 73 years [IQR 55-77] vs 60 years [40-71]; p=0·028) and had more frequent consolidation on chest CT (13 [46%] of 28 vs nine [21%] of 43; p=0·035) and lymphopenia (16 [57%] vs ten [23%]; p=0·0055) on admission. INTERPRETATION: Older age, consolidation on chest CT images, and lymphopenia might be risk factors for disease progression of COVID-19 and contribute to improved clinical management. FUNDING: None.

Neuro-Sweet disease in a Japanese woman with Sjögren's syndrome.

Sweet disease (SD) is a multisystem inflammatory disorder characterised by fever, cutaneous erythematous plaques and aseptic neutrophilic infiltration of various organs. Neuro-Sweet disease (NSD) is a known rare central nervous system complication of SD. We describe a case of a 39-year-old Japanese woman who was diagnosed as NSD associated with Sjögren's syndrome. She was successfully treated with systemic corticosteroid therapy.