Akikatsu Nakashima

Endotoxin Adsorption Therapy for a Patient With Severe Pneumonia Resulting From Novel Influenza A (H1N1) Virus Infection

Dear Editor, A 44-year-old man was admitted to our hospital with a one-week history of high fever and increasing dyspnea in January 2010. He did not have a history of any diseases and was not vaccinated against the novel influenza A (H1N1) virus during 2009–2010. On physical examination, his body temperature was 40.4°C, pulse rate was 140 beats/min, respiratory rate was 36 breaths/min, and peripheral oxygen saturation was 66% while breathing room air. Fine crackles were audible throughout both lungs. Laboratory data were as follows: white blood cell count, 5.1 ¥ 10/L; platelet count, 99 ¥ 10/L; serum C-reactive protein, 8.6 mg/dL; aspartate aminotransferase, 502 U/L; alanine aminotransferase, 242 U/L; lactate dehydrogenase, 1887 U/L; and creatine kinase, 4731 U/L. A rapid test of a nasal mucus specimen was negative for influenza A and B antigens. A chest CT revealed patchy areas of consolidation and ground-glass opacity, mainly in the peripheral subpleural regions in both lungs (Fig. 1). The patient was endotracheally intubated and mechanically ventilated with 100% oxygen; intravenous administration of piperacillin, ciprofloxacin, methylprednisolone, and sivelestat was started immediately after admission; however, the fever and hypoxemia persisted, and chest radiography revealed progressive consolidation. We strongly suspected the patient to be infected with an influenza virus (1) and an endotracheal aspirate specimen was examined on the seventh hospital day. The result of a nucleic acid test was positive for H1N1 virus, and the patient was diagnosed with severe pneumonia resulting from H1N1 virus infection. A neuraminidase inhibitor oseltamivir was administered and, in addition, endotoxin adsorption therapy using a polymyxin B-immobilized fiber column was performed for 4 h on the eighth hospital day; this therapy may alleviate a “cytokine storm”. Arterial blood gas analysis under mechanical ventilation with 90% oxygen revealed that the partial pressure of oxygen dramatically

Fatal cytomegalovirus infection with CD4+ T-lymphocytopenia during corticosteroid therapy for bronchial asthma

An 80-year-old woman was admitted with dyspnea. She had been treated with oral prednisolone for bronchial asthma. She was intravenously treated with dexamethasone. On the 9th day, she presented oliguria and thrombocytopenia. She was diagnosed as dehydration and disseminated intravascular coagulation, and was treated with hydration and heparin infusion. On the 12th day, she presented macroscopic hematuria and melena. Cystoscopy revealed hemorrhagic cystitis. Bone marrow aspiration showed hemophagocytosis. Serum antigen of cytomegalovirus (CMV) was positive. CD4+ T cell count was very low (40/μL). She was diagnosed as disseminated CMV infection, and was treated with gancyclovir and immunoglobulin infusion. On the 14th day, she died of pneumonia. This is the first report of fatal CMV infection during corticosteroid therapy for bronchial asthma.

Changes in serum interleukin-6 levels as possible predictor of efficacy of tocilizumab treatment in rheumatoid arthritis

Abstract Objectives: We aimed to evaluate the association between the change in serum IL-6 during the clinical course of tocilizumab (TCZ) therapy and rheumatoid arthritis (RA) disease activity or occurrence of adverse events. Methods: General laboratory data including serum IL-6 levels and physical findings were obtained every 4 weeks, and, in addition, at the time when any adverse events occurred. Results: The proportion achieving Clinical Disease Activity Index (CDAI) remission at 52 weeks was significantly lower in 20 patients with serum IL-6 ≥ 30 pg/ml at 12 weeks than 24 patients with serum IL-6 < 30 pg/ml. In 17 patients with serum IL-6 ≥ 30 pg/ml at 24 weeks, the proportion achieving CDAI remission was also significantly lower than 27 patients with serum IL-6 < 30 pg/ml then. In these 17 patients, Disease Activity Score (DAS) 28-ESR and CDAI at 52 weeks were significantly higher than those with serum IL-6 < 30 pg/ml. Age- and sex-adjusted logistic regression analysis showed logIL-6 at 12 weeks to be a predictive factor for DAS28-ESR remission at 52 weeks. Conclusion: Serum IL-6 levels from 12 to 24 weeks after TCZ initiation better reflect the efficacy of TCZ at 52 weeks.