The frequency and seasonal distribution of viral infection in patients with community-acquired pneumonia and its impact on the prognosis.

BACKGROUND: Studies on the effects of viral coinfection on bacterial pneumonia are still scarce in South Korea. This study investigates the frequency and seasonal distribution of virus infection and its impact on the prognosis in patients with community-acquired pneumonia (CAP). METHODS: The medical records of CAP patients with definite etiology, such as viruses and bacteria, were retrospectively reviewed. Their epidemiologic and clinical characteristics, microbiologic test results, the severity of illness, and 30-day mortality were analyzed. RESULTS: Among 150 study subjects, 68 patients (45.3%) had viral infection alone, 47 (31.3%) had bacterial infection alone, and 35 (23.3%) had viral-bacterial coinfection, respectively. Among 103 patients with viral infections, Influenza A virus (44%) was the most common virus, followed by rhinovirus (19%), influenza B (13%), and adenovirus (6%). The confusion-urea-respiratory rateblood pressure-age of 65 (CURB-65) score of the viral-bacterial coinfection was higher than that of the viral infection (median [interquartile range]: 2.0 [1.0-4.0] vs. 2.0 [0.3-3.0], P=0.029). The 30-day mortality of the viral infection alone group (2.9%) was significantly lower than that of bacterial infection alone (19.1%) and viral-bacterial coinfection (25.7%) groups (Bonferroni-corrected P<0.05). Viral-bacterial coinfection was the stronger predictor of 30-day mortality in CAP (odds ratio [OR], 18.9; 95% confidence interval [CI], 3.0-118.3; P=0.002) than bacterial infection alone (OR, 6.3; 95% CI, 1.1-36.4; P=0.041), compared to viral infection alone on the multivariate analysis. CONCLUSIONS: The etiology of viral infection in CAP is different according to regional characteristics. Viral-bacterial coinfection showed a worse prognosis than bacterial infection alone in patients with CAP.

Clinical characteristics and treatment outcomes of patients with pneumonia caused by Raoultella planticola.

BACKGROUND: Raoultella planticola, considered to be an environmental organism, is a rare cause of human infections. Although in recent years the frequency of R. planticola infections reported in the literature has increased, few cases of pneumonia caused by R. planticola have been described. Here, we investigate the clinical characteristics, management, and clinical outcomes of pneumonia caused by R. planticola. METHODS: Consecutive patients with pneumonia caused by R. planticola were included. The medical records of patients with R. planticola pneumonia treated at Dankook University Hospital from January 2011 to December 2017 were collected. RESULTS: A total of 11 adult patients with R. planticola pneumonia were diagnosed and treated [10 males and 1 female; median age, 70 years (range: 51-79 years)]; 5 patients had underlying malignant conditions (45.5%). Antibacterial susceptibility testing showed that all isolates of R. planticola were susceptible to cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and beta-lactams/beta-lactamase inhibitors. Chest imaging revealed consolidation (8/11, 72.7%), ground-glass opacity (5/11, 45.5%), pleural effusion (5/11, 45.5%), and micronodules (3/11, 27.3%). Four patients (36.4%) required mechanical ventilation; three survived but one died of multiple organ dysfunction syndrome (principally pneumonia and septic shock). CONCLUSIONS: R. planticola pneumonia occurred mainly in patients with underlying risk factors such as malignant disease, cerebral infarction or hemorrhage, and chronic obstructive pulmonary disease. The organism was sensitive to most antibiotics, and the clinical outcomes were favorable after empirical antibiotic therapy.

Empyema caused by transdiaphragmatic extension of pyogenic liver abscess.

Empyema caused by transdiaphragmatic extension of pyogenic liver abscess is a very rare complication of liver abscess. Empyema patients with unclear respiratory symptoms should be evaluated for the presence of underlying liver abscess. Effective drainage with appropriate antibiotic use is an essential part of successful treatment.

The role of FGF-2 in smoke-induced emphysema and the therapeutic potential of recombinant FGF-2 in patients with COPD.

Although the positive effects of recombinant fibroblast growth factor-2 (rFGF-2) in chronic obstructive pulmonary disease (COPD) have been implicated in previous studies, knowledge of its role in COPD remains limited. The mechanism of FGF2 in a COPD mouse model and the therapeutic potential of rFGF-2 were investigated in COPD. The mechanism and protective effects of rFGF-2 were evaluated in cigarette smoke-exposed or elastase-induced COPD animal models. Inflammation was assessed in alveolar cells and lung tissues from mice. FGF-2 was decreased in the lungs of cigarette smoke-exposed mice. Intranasal use of rFGF-2 significantly reduced macrophage-dominant inflammation and alveolar destruction in the lungs. In the elastase-induced emphysema model, rFGF-2 improved regeneration of the lungs. In humans, plasma FGF-2 was decreased significantly in COPD compared with normal subjects (10 subjects, P = 0.037). The safety and efficacy of inhaled rFGF-2 use was examined in COPD patients, along with changes in respiratory symptoms and pulmonary function. A 2-week treatment with inhaled rFGF-2 in COPD (n = 6) resulted in significantly improved respiratory symptoms compared with baseline levels (P < 0.05); however, the results were not significant compared with the placebo. The pulmonary function test results of COPD improved numerically compared with those in the placebo, but the difference was not statistically significant. No serious adverse events occurred during treatment with inhaled rFGF-2. The loss of FGF-2 production is an important mechanism in the development of COPD. Inhaling rFGF-2 may be a new therapeutic option for patients with COPD because rFGF-2 decreases inflammation in lungs exposed to cigarette smoke.

Hepatic Failure by Spontaneous Reactivation of Hepatitis B Virus without a Trigger Factor in a Patient with Anti-HBs.

A patient who has achieved resolution of acute hepatitis B and acquired anti-HBs would get protective immunity against hepatitis B virus (HBV). However, reactivation of HBV could happen if the patient was exposed to an immunocompromised state by using immunosuppressive drugs or chemotherapeutic agents. That is because cccDNA could reside within hepatocytes after recovery of acute hepatitis B. Therefore, guidelines for hepatitis B recommend the use of prophylactic antiviral agents such as entecavir or tenofovir in patients with anti-HBc IgG. The reactivation of hepatitis B without exposure to an immunocompromised state is very rare and only 1 case has been reported in the world to date. An 82-year-old male patient visited Dankook University Hospital because of high aspartate transaminase, alanine aminotransferase, and total bilirubin. He had shown HBsAg negative/anti-HBs positive when he had blood test examinations 1 year previously. However, the present blood test revealed HBsAg positive/anti-HBs negative and a high titer of HBV DNA (814,815 copies/mL). He had undergone vertebroplasty 5 years previously and had no other medical history. Other blood and radiological examinations failed to show other diseases that could affect host immunity. He started antiviral treatment with entecavir. However, he passed away because of deteriorated hepatic function and hepatorenal syndrome 20 days after admission. It is very rare that a patient with anti-HBs would develop hepatic failure and pass away without trigger factors. Here, we report the case with a literature review.

Successful treatment of acute respiratory failure in a patient with pulmonary Mycobacterium abscessus infection accompanied by organizing pneumonia.

Organizing pneumonia (OP) is an inflammatory lung disease characterized pathologically by the presence of buds of granulation tissue in the distal air spaces. There are numerous causes of OP including acute respiratory infections such as viral and bacterial infections. However, Mycobacterium abscessus (M. abscessus) has rarely been reported as a causative pathogen of OP. Here, we report a 67-year-old woman with rapidly progressive pulmonary M. abscessus infection who developed OP and acute respiratory failure (ARF). She was treated successfully with a corticosteroid and anti-mycobacterial therapy. Our observations suggest that pulmonary M. abscessus infection should be added to the list of infectious conditions associated with OP.

An unusual case of superior vena cava syndrome caused by the intravascular invasion of an invasive thymoma.

Superior vena cava syndrome (SVCS) is usually caused by extrinsic compression or invasion of the superior vena cava (SVC) by malignant tumors involving mediastinal structures. Although thymomas are well-known causes of SVCS, cases of SVCS caused by malignant thymomas protruding into adjacent vessels draining the SVC with thrombosis have been very rarely reported worldwide. We experienced a 39-year-old female patient with SVCS that developed after the direct invasion of the left brachiocephalic vein (LBCV) and SVC by an anterior mediastinal mass with a high maximum standardized uptake value on the chest computed tomography (CT) and positron emission tomography-CT. Based on these results, she underwent en bloc resection of the tumor, including removal of the involved vessels, and was eventually diagnosed as having a type B2 thymoma permeating into the LBCV and SVC. We present this case as a very rare form of SVCS caused by an invasive thymoma.

Endobronchial stent insertion to manage hemoptysis caused by lung cancer.

Hemoptysis in patients with lung cancer is not uncommon and sometimes have dangerous consequences. Hemoptysis has been managed with various treatment options other than surgery and medicine, such as endobronchial tamponade, transcatheter arterial embolization and radiation therapy. However, these methods can sometimes be used only temporarily or are not suitable for a patient's condition. We present a case in which uncontrollable hemoptysis caused by central lung cancer was successfully treated by inserting a covered self-expanding bronchial stent. The patient could be extubated and was able to undergo further palliative therapy. No recurrent episodes of hemoptysis occurred for the following three months. As our case, airway stenting is a considerable option for the tamponade of a bleeding lesion that cannot be successfully managed with other treatment methods and could be used to preserve airway patency in a select group of patients.

Treatment outcomes and survival based on drug resistance patterns in multidrug-resistant tuberculosis.

RATIONALE: Few large-scale studies have investigated multidrug-resistant tuberculosis (MDR-TB) treatment outcomes relative to drug-resistance patterns. OBJECTIVES: To assess the impact of additional drug resistances on treatment outcomes and long-term survival in a large HIV-negative MDR-TB cohort. METHODS: Treatment outcomes and long-term survival of patients with MDR-TB newly diagnosed or retreated in 2000 to 2002 were retrospectively analyzed based on drug-resistance patterns after 5-8 years of follow-up. MEASUREMENTS AND MAIN RESULTS: Of 1,407 patients with MDR-TB, 75 (5.3%) had extensively drug-resistant TB (XDR-TB(re)) by the revised definition; 159 (11.3%) had ofloxacin-resistant pre-XDR-TB (pre-XDR-TB(o)); and 117 (8.3%) had second-line injectable drug (SLID)-resistant pre-XDR-TB (pre-XDR-TB(s)). Patients with XDR-TB(re) showed the lowest treatment success rate (29.3%) and the poorest long-term survival, and XDR-TB(re) was more strongly associated with long-term mortality than XDR-TB as originally defined (hazards ratio [HR], 3.15; 95% confidence interval [CI], 2.06-4.83; P < 0.001 vs. HR, 2.15; 95% CI, 1.49-3.09; P < 0.001). Patients with either form of pre-XDR-TB showed poorer cumulative survival than those with ofloxacin-susceptible/SLID-susceptible MDR-TB (P < 0.05 for each comparison). Although streptomycin susceptibility did not affect the treatment outcomes of patients with pre-XDR-TB, streptomycin-resistant pre-XDR-TB was more strongly associated with long-term mortality than ofloxacin-susceptible/SLID-susceptible MDR-TB (HR, 2.17; 95% CI, 1.22-3.84; P < 0.008 for pre-XDR-TB(o); and HR, 2.69; 95% CI, 1.40-5.16; P = 0.003 for pre-XDR-TB(s)). CONCLUSIONS: The revised XDR-TB definition is appropriate for defining patients with MDR-TB with the poorest outcomes. Both pre-XDR-TB(o) and pre-XDR-TB(s) were independently associated with poor long-term survival in patients with MDR-TB. SM susceptibility was linked to better survival in patients with pre-XDR-TB.

Repression of TNF-alpha-induced IL-8 expression by the glucocorticoid receptor-beta involves inhibition of histone H4 acetylation.

Increased expression of a number of proinflammatory genes, including IL-8, is associated with inflammatory conditions such as asthma. Glucocorticoid receptor (GR)beta, one of the GR isoforms, has been suggested to be upregulated in asthma associated with glucocorticoid insensitivity and to work as a dominant negative inhibitor of wild type GRalpha. However, recent data suggest that GRbeta is not a dominant negative inhibitor of GRalpha in the transrepressive process and has its own functional role. We investigated the functional role of GRbeta expression in the suppressive effect of glucocorticoids on tumor necrosis factor (TNF)-alpha-induced IL-8 release in an airway epithelial cell line. GRbeta expression was induced by treatment of epithelial cells with either dexamethasone or TNF-alpha. GRbeta was able to inhibit glucocorticoid-induced transcriptional activation mediated by binding to glucocorticoid response elements (GREs). The suppressive effect of dexamethasone on TNF-alpha-induced IL-8 transcription was not affected by GRbeta overexpression, rather GRbeta had its own weak suppressive activity on TNF-alpha-induced IL-8 expression. Overall histone deacetylase activity and histone acetyltransferase activity were not changed by GRbeta overexpression, but TNF-alpha-induced histone H4 acetylation at the IL-8 promoter was decreased with GRbeta overexpression. This study suggests that GRbeta overexpression does not affect glucocorticoid-induced suppression of IL-8 expression in airway epithelial cells and GRbeta induces its own histone deacetylase activity around IL-8 promoter site.

Treatment outcomes and long-term survival in patients with extensively drug-resistant tuberculosis.

RATIONALE: The increasing worldwide incidence of extensively drug-resistant tuberculosis (XDR-TB) has emerged as a threat to public health and tuberculosis (TB) control. Treatment outcomes have varied among studies, and data on long-term survival are still scarce. OBJECTIVES: To retrospectively assess the burden, clinical characteristics, treatment outcomes, and long-term survival rate of patients with XDR-TB in a cohort of patients with HIV-negative multidrug-resistant tuberculosis (MDR-TB) in South Korea. METHODS: Medical records were reviewed of patients newly diagnosed with or retreated for MDR-TB from 2000 to 2002. The cohort was monitored for 3 to 7 years after the initiation of treatment. Initial treatment outcomes and cumulative survival rates were analyzed, and predictors of treatment success and survival were defined. MEASUREMENTS AND MAIN RESULTS: Of 1,407 patients with MDR-TB 75 (5.3%) had XDR-TB at treatment initiation. The default rate was high (453/1,407; 32%), and patients with XDR-TB had lower treatment success (29.3 vs. 46.2%; P = 0.004) and higher all-cause (49.3 vs. 19.4%; P < 0.001) and TB-related disease mortality (41.3 vs. 11.8%; P < 0.001) than other patients with MDR-TB. The presence of XDR-TB significantly affected treatment success (odds ratio, 0.23; 95% confidence interval [CI], 0.08-0.64; P = 0.005), all-cause mortality (hazards ratio, 3.25; 95% CI, 1.91-5.53; P < 0.001), and TB-related mortality (hazards ratio, 4.45; 95% CI, 2.48-8.00; P < 0.001) on multivariate analyses. CONCLUSIONS: XDR-TB occurred in a substantial proportion of patients with MDR-TB in South Korea, and was the strongest predictor of treatment outcomes and long-term survival in patients with MDR-TB. Adequate TB control policies should be implemented to prevent the further development and spread of drug resistance.

The effects of on-site measured ozone concentration on pulmonary function and symptoms of asthmatics.

Most studies on the effects of ambient ozone on asthmatics have been based on ozone concentration measurements taken by air monitors in downtown areas. Using a passive ozone sampler, we investigated the effects of on-site ozone concentrations on the pulmonary function and symptoms of asthmatics. Twenty moderate to severe asthmatics who had been managed for at least 2 months without changes of their medication were enrolled from 3 June to 18 July 2005. Respiratory, nasal and ocular symptoms, peak expiratory flow (PEF), which was measured twice a day, and medication use were recorded on a daily basis during the study period. Data for 17 subjects were analyzed. The average ozone exposure level was 28.2+/-23.6 ppb (3.4-315.3 ppb). There was no significant correlation between PEF and ozone concentration (p>0.05) on the same day or 1-, 2-, or 3-day lags. Interestingly, the degree of asthma symptoms was influenced by the ozone concentration (rho=0.303, p<0.001), even at concentrations less than 80 ppb (p=0.298, p<0.001), but the correlation between ozone exposure and the frequency of reliever medication use was not statistically significant (p=0.99). Our results suggest that exposure to relatively low concentrations of ozone influences the symptoms of moderate to severe asthmatics regardless of changes in pulmonary function or medication use.

First male case of lymphocytic hypophysitis in Korea.

Lymphocytic hypophysitis is a rare inflammatory disorder which is caused by autoimmune destruction of the pituitary gland. Almost all reported cases have been in women and the disease is often associated with pregnancy. We describe here the first male case of lymphocytic hypophysitis in Korea. The patient presented with headache, impotence, decreased libido, and deteriorated vision. Endocrinologic studies showed panhypopituitarism, and pituitary MRI imaging revealed a homogeneously enhanced pituitary mass with a thickened stalk. Treatment with prednisolone and thyroid hormone for five months was ineffective. Transsphenoidal resection of the pituitary mass was performed successfully with normalization of the visual field defect. Histologic examination revealed diffuse lymphocytic infiltration with dense collagenous fibrosis, consistent with lymphocytic hypophysitis. Lymphocytic hypophysitis should be considered in differential diagnosis even in men with hypopituitarism and an enlarged pituitary gland.

Chronic necrotizing bronchopulmonary aspergillosis with elements of bronchocentric granulomatosis.

Chronic necrotizing pulmonary aspergillosis (CNPA) is an unusual form of pulmonary aspergillosis arising in the setting of mildly immune compromised state or altered local defense system. CNPA rarely shows histological findings mimicking bronchocentric granulomatosis (BCG), which is characterized by peribronchiolar granulomatous destruction. We describe a case representing CNPA with elements of BCG. A-64 year-old woman was admitted because of atypical pneumonia with multi-focal variable sized consolidations and cavitary lesions on high-resolution computed tomography (HRCT). The open lung biopsy specimen showed large areas of necrotizing pneumonia with some scattered aspergillus hyphae within the lung parenchyma. Some terminal bronchioles were found to be destroyed and were replaced by peribronchiolar granulomatous inflammation. There was no evidence of angioinvasion by aspergillus or aspergillous emboli. Despite vigorous antifungal agent and steroid treatment, she died of acute airway obstruction by bronchial casts on the thirty-fourth hospital day.