Effect of the inoculum size on carbapenem susceptibilities of beta-lactamase-negative, ampicillin-resistant Haemophilus influenzae.

A higher inoculum size of beta-lactamase-positive Haemophilus influenzae is reported to increase minimum inhibitory concentrations (MICs) for beta-lactams. However, the effect of inoculum size of beta-lactamase-negative, ampicillin-resistant H. influenzae (BLNAR) on MICs for carbapenems has not been investigated. This study evaluated the effect of inoculum size on MICs for carbapenems and other beta-lactams in nine clinical isolates of BLNAR. The MICs were determined by both the standard method described by the Clinical and Laboratory Standards Institute (final inoculum size of 5 x 10(5) colony-forming units [CFU]/ml) and a modified method (final inoculum size of 5 x 10(6) CFU/ml) using viable cell counts. The findings showed that the higher inoculum size increased MICs for imipenem, meropenem, panipenem, biapenem, ampicillin, ceftazidime, and ceftriaxone. The inoculum effect (4 log(2) dilution or a greater increase in the MIC) with imipenem, meropenem, panipenem, and biapenem was found in three, five, two, and two isolates, respectively. The magnitude of the inoculum effect for panipenem significantly increased with the levels of MICs, but correlation between them for the others was not statistically significant. The mutations of penicillin-binding protein genes had little relevance to the reduced susceptibility to carbapenems or to the magnitude of the inoculum effect. These results suggest that MIC determination using turbidity can produce interpretive errors in the antimicrobial susceptibility testing of BLNAR for carbapenems because of their inoculum effect. Thus, accurate adjustment of inoculum size, such as viable cell count, is helpful for confirming the true MICs when the isolates are interpreted as "resistant" by turbidity-based MIC determination.

Tiotropium does not affect lower urinary tract functions in COPD patients with benign prostatic hyperplasia.

BACKGROUND: Tiotropium is widely used for the treatment of chronic obstructive pulmonary disease (COPD), but it is not usually prescribed for patients with micturition disorder, such as benign prostatic hyperplasia (BPH), because of the potential to increase the risk of acute urinary retention through its anticholinergic effects. However, no data are available to prove a true causal relationship between tiotropium and lower urinary tract dysfunction (LUTD) using quantitative symptomatic scoring or objective parameters evaluated by uroflowmetry. OBJECTIVE: To clarify the effect of tiotropium on lower urinary tract functions in COPD patients with BPH. METHODS: This prospective pilot study comprised 25 male COPD patients with BPH as defined by the International Prostate Symptom Score (IPSS), the quality of life (QOL) index, maximum flow rate (Q-max) in uroflowmetry, and prostate volume. Patients were given tiotropium once a day for 3 months. At baseline and after treatment, lower urinary tract functions were assessed symptomatically by the IPSS and the QOL index, and objectively by urinary parameters, including Q-max, average flow rate (Q-ave), postvoid residual urine volume (PVR), and bladder voiding efficiency (BVE). RESULTS: Acute urinary retention was not observed in any patients. Subjectively, no significant difference was found in the IPSS or the QOL index between baseline and after tiotropium treatment. Additionally, tiotropium treatment did not change Q-max, Q-ave, time to Q-max, or overall flow time compared to baseline (Q-max (mL/s), 9.66+/-3.63, 9.11+/-3.68 and 10.51+/-3.88, P=0.15; Q-ave (mL/s), 4.20+/-1.76, 4.14+/-1.55, and 4.71+/-1.81, P=0.31; time to Q-max (s), 12.1+/-8.0, 16.2+/-11.4, and 13.0+/-11.3, P=0.10; flow time (s), 39.4+/-19.6, 40.4+/-20.1, and 38.3+/-19.1; baseline, 1 month after treatment and 3 months after treatment, respectively). No significant increase was found in PVR or BVE (PVR (mL), 57.9+/-51.2, 55.4+/-47.2 and 66.1+/-52.7, P=0.36; BVE (%), 75.8+/-18.4, 73.3+/-19.1 and 73.9+/-17.3, P=0.67; baseline, 1 month after treatment, and 3 months after treatment, respectively). CONCLUSION: In our preliminary study, tiotropium did not adversely affect lower urinary tract functions in COPD patients with BPH, suggesting the possibility that tiotropium can be safely given to those patients. This warrants future studies in a larger series of COPD patients to validate our observations.

[Thyroid involvement of sarcoidosis].

A 54-year-old woman was found to have abnormal shadows on her chest radiograph taken on an annual medical examination. The chest radiograph showed multiple nodules in the bilateral middle and lower lung fields accompanied with bilateral hilar lymphadenopathy. A computed tomography of the neck and chest revealed nodules in her right middle lobe and bilateral lower lobes with an enlarged thyroid. A metastatic malignant disease involving both thyroid and lungs was suspected, therefore thyroid and lung biopsies were performed. The histological examination of the thyroid and the lung specimens revealed non-caseating epithelioid cell granulomas which were compatible with sarcoidosis. Although the thyroid involvement of sarcoidosis is rare, it should be included in the differential diagnosis with patients with thyroid swelling.

Possible therapeutic effect of direct haemoperfusion with a polymyxin B immobilized fibre column (PMX-DHP) on pulmonary oxygenation in acute exacerbations of interstitial pneumonia.

BACKGROUND AND OBJECTIVE: Acute exacerbations of interstitial pneumonias (IP) can occasionally occur, and have an extremely poor prognosis. Recently, direct haemoperfusion with a polymyxin B immobilized fibre column (PMX-DHP) was shown to have a beneficial effect in acute exacerbations of IPF. However, little is known about the efficacy of PMX-DHP in acute exacerbations of other IP. This study investigated the effectiveness and safety of PMX-DHP in acute exacerbations of IP. METHODS: The study subjects consisted of five patients with an acute exacerbation of IP, including three with IPF, one with idiopathic interstitial pneumonia (IIP) with atypical radiological findings of IPF, and one with myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-related IP. The patients were treated with two courses of 3-12 h each of PMX-DHP, concurrently with corticosteroids alone or plus cyclophosphamide. RESULTS: After two courses of PMX-DHP, the PaO(2)/fraction of inspired oxygen (FiO(2)) (P/F) ratio increased rapidly from an average of 93 to 260 mm Hg, and there was radiological improvement in all patients. However, one patient treated for 3 h each time eventually died of respiratory failure, and two patients treated for 6 h each time died from respiratory infections. The other two patients were treated for 12 h each time, and the therapeutic effects lasted longer, with both surviving longer than 48 days. No adverse effects were detected apart from thrombocytopaenia. CONCLUSION: PMX-DHP therapy was safe and effective in improving oxygenation in acute exacerbations of IPs, either with corticosteroids alone or plus cyclophosphamide, and may be beneficial for the treatment of this condition.

[A case of hypersensitivity pneumonitis caused by zinc fume].

A 55-year-old man with a 3-year occupational history of welding was admitted for repeated episodes of fever, cough and dyspnea after inhalation of smoke while welding galvanized steel. A computed tomography (CT) showed diffuse centrilobular nodules, panlobular ground-glass opacity and interlobular septal thickening in both lung fields, and he suffered from hypoxemia (PaO2 = 55.3Torr) while breathing room air. Percentage of lymphocytes in bronchoalveolar lavage fluid increased, and lung biopsy specimens at thoracoscopy revealed lymphocytic alveolitis and organization in air spaces. His symptoms and signs disappeared spontaneously only when he ceased welding. Panlobular ground-glass opacity and interlobular septal thickening improved immediately with oral corticosteroids. Patch tests using metal series gave positive reactions to zinc. We diagnosed this case as hypersensitivity pneumonitis caused by zinc fumes.

[An adult case of asymptomatic congenital tracheal stenosis].

A 42-year-old woman was admitted with abnormal chest radiographs. Though interstitial pneumonia associated with dermatomyositis was diagnosed, her chest radiograph also revealed a narrowed trachea about 6 mm in diameter. Bronchoscopy showed that her trachea lacked a membranous posterior segment and O-shaped complete tracheal rings were present throughout the trachea, indicating congenital tracheal stenosis. Congenital tracheal stenosis is a rare disorder and is usually recognized in the first few weeks of life, but the patient had no history of dyspnea or recurrent pneumonia. This case suggests that among healthy people there are a very few who have asymptomatic congenital tracheal stenosis.

[Placement of an ultraflex nitinol stent for severe tracheobronchial obstruction in a case of relapsing polychondritis].

A 59-year-old man, who had been treated for bronchial asthma since 2000, was hospitalized with high fever and productive cough in November 2003. Chest radiography on admission showed consolidations in both lower lung fields, and computed tomography demonstrated anteroposterior narrowing of both main bronchi. A physical examination revealed deformity of auricular cartilage and saddle nose, and we diagnosed him relapsing polychondritis (RP). When he was readmitted 4 months later because of severe tracheobronchial stenosis and respiratory failure he required mechanical ventilation, but it was difficult to wean him from the ventilator. Self-expandable metallic stents were placed in the left main bronchus and the trachea. After the procedure, he was successfully weared from mechanical ventilation. Since airway complications of RP can be fatal, stent implantation should be considered in the management of RP with airway manifestations.

[Hypersensitivity pneumonitis induced by Aspergillus niger--a case report].

A 52-year-old woman was hospitalized because of severe cough in August 1994. She had engaged in culturing roses in greenhouses since 1968, and had developed a cough during the summer of 1990. Chest radiography showed diffuse ground-glass opacity in both lung fields, and she suffered from hypoxemia (PaO2 = 45.6 torr) while breathing room air. The lymphocyte count in the bronchoalveolar lavage fluid was increased, and transbronchial lung biopsy specimens showed lymphocyte alveolitis in the alveolar spaces. After admission, the patient's symptoms improved rapidly without medication. However, on her return to work, the cough and hypoxemia reappeared. In her rose culture, she had used Rockwool, and Aspergillus niger was detected predominantly in the Rockwool. Precipitins against the extracts of Aspergillus niger were detected with the double immunodiffusion test and the inhalation provocation test yielded clinical symptoms. Our diagnosis was hypersensitivity pneumonitis caused by Aspergillus niger.

[Two cases of intralobar pulmonary sequestration associated with nontuberculous mycobacterial infection in a young patient].

We report two cases of intralobar pulmonary sequestration associated with nontuberculous mycobacterial infection. Case 1: A 28-year-old woman was hospitalized because of cough. Chest CT demonstrated multi-cystic lesions with an air-fluid level in the right lower lobe. Case 2: A 25-year-old woman was hospitalized because of fever. Chest CT demonstrated homogeneous consolidation in the right lower lobe. In both cases, aortography showed an anomalous artery supplying the right basal segment, and pulmonary sequestration was diagnosed. Furthermore, Mycobacterium avium was detected in the bronchial lavage, and a right lower lung lobectomy was performed after chemotherapy. Mycobacterium avium was cultured from the fluid in the sequestrated lung, and histological findings of the resected lobe showed epithelioid cell granulomas. We diagnosed these cases as having pulmonary sequestrations associated with nontuberculous mycobacterial infection. We concluded that pulmonary sequestration should be considered an underlying disease of secondary nontuberculous mycobacterial infections in young patients.

[Hypersensitivity pneumonitis induced by Pleurotus eryngii spores--a case report].

A 52-year-old man was hospitalized because of recurrent fever, dyspnea and cough in February 2002. He had worked in a Eringi (Pleurotus eryngii) mushroom factory since 1996. Chest radiography showed diffuse fine nodular shadows. Chest computed tomography demonstrated centrilobular nodules and increased attenuation in both lungs. The patient suffered from hypoxemia (PaO2 = 65 torr) while breathing room air. The lymphocyte count in the bronchoalveolar lavage fluid was increased, and transbronchial lung biopsy specimens showed lymphocyte alveolitis with epithelioid cell granulomas in the alveolar spaces. After admission, the patient's symptoms improved rapidly without medication. However, on his return to work, fever and hypoxemia appeared again. The lymphocyte stimulating test was positive against extracts of Eringi spores. Precipitins against the extracts of Eringi spores were detected by the double immunodiffusion test. Our diagnosis was hypersensitivity pneumonitis (HP) caused by Eringi spores. In Japan, more than 30 cases of HP induced by mushroom spores have been reported. It is a matter of great urgency to prevent the occurrence of occupational HP in mushroom factories.