Masayuki Kikawada

Aspiration and infection in the elderly : epidemiology, diagnosis and management.

Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. However, elderly persons may have diminished production of saliva as a result of medications and oral/dental disease, leading to poor oral hygiene and oropharyngeal colonisation with pathogenic organisms. When dysphagic patients aspirate pathogenic bacteria while swallowing food or liquids, they must also have decreased defences, such as impaired immunity or pulmonary clearance, in order to develop aspiration pneumonia.Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration. It was previously reported that patients with silent cerebral infarction affecting the basal ganglia were more likely to experience subclinical aspiration and an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and, as a consequence, a decrease of substance P in the glossopharyngeal nerve and sensory vagal nerves. Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction.The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.

Sarcoidosis induced by interferon therapy for chronic myelogenous leukaemia

A 31‐year‐old male was diagnosed as having chronic myelogenous leukaemia and has been treated with hydroxyurea and interferon‐α since February 1995. After 16 months, he complained of low‐grade fever and a cough. Bilateral hilar lymph node enlargement was detected on the chest X‐ray film and multiple subcutaneous erythematous nodules appeared. A skin biopsy revealed subcutaneous sarcoid granuloma. Two months after the cessation of interferon therapy, the subcutaneous nodules and the hilar lymph node enlargement resolved. It is possible that continuous interferon administration can promote granuloma formation in sarcoidosis by activating T cells and macrophages.

Peripheral T‐cell lymphoma presenting as myelofibrosis with the expression of basic fibroblast growth factor

Myelofibrosis is often observed in chronic myeloproliferative disorders (CMPD), but non‐Hodgkins lymphoma with diffuse myelofibrosis is rare. We describe an elderly case with peripheral T‐cell lymphoma‐unspecified (PTCL) presenting as diffuse myelofibrosis. Bone marrow biopsy revealed infiltration of atypical lymphocytes and diffuse myelofibrosis without any increase in megakaryocytes. To discuss the pathogenesis of fibrosis, we examined cytokines relative to fibrosis using immunostaining. The expression of basic fibroblast growth factor (bFGF) was diffusely detected in the area of extracellular matrix of bone marrow. In addition, in situ hybridization revealed that infiltrating lymphoma cells expressed bFGF mRNA. Basic FGF, originally identified based on its mitogenicity for fibroblasts, has multiple potential, influencing neoangiogenesis, bone marrow fibrosis and the proliferation of tumor cells. Basic FGF might play an important role in the pathogenesis of myelofibrosis in the present case.

A Study of Peripheral Airway Findings Using an Ultrathin Bronchofiberscope and Bronchoalveolar Lavage Fluid with Diffuse Panbronchiolitis

We investigated the peripheral airways using an ultrathin bronchofiberscope and analyzed bronchoalveolar lavage fluid (BALF) in 10 patients with diffuse panbronchiolitis (DPB; refractory and responsive to treatment with macrolide antibiotics) and 10 healthy volunteers. Refractory DPB patients had obstruction at the 11th or 12th level of bronchial branches and secretion from the 5th to 6th order bronchi to the 11th–12th level of bronchial branches. In responsive DPB patients, there was no obstruction of peripheral airways, but secretion in the bronchial lumens still remained in nearly all observed bronchial branches. Despite macrolide therapy, BALF from patients with refractory DPB contained a high percentage of neutrophils and had a lower CD4/CD8 ratio. Two-color analysis of T cell subsets in BALF revealed a high percentage and number of CD8+S6F1+ cells (activated cytotoxic T cells) in refractory DPB patients. Our findings suggest that obstruction around the terminal bronchioles may be correlated with BALF abnormalities and may be irreversible despite macrolide therapy in progressive DPB.

Successful treatment using cyclosporine A plus corticosteroid therapy in an elderly patient with severe idiopathic interstitial pneumonia

An 81‐year‐old woman was referred to our hospital due to acute progressive respiratory failure. Her chest X‐ray film showed bilateral interstitial changes and computed tomography revealed a diffuse ground‐glass appearance. Histological examination of transbronchial lung biopsy specimens did not provide a final diagnosis. The patient was diagnosed as having idiopathic interstitial pneumonia (IIP) and was treated with corticosteroid therapy. The chest X‐ray appearance improved temporarily after corticosteroid therapy, but the interstitial changes did not resolve and subsequently became worse again, so administration of cyclosporine A was added. After commencement of cyclosporine A, corticosteroid therapy could be gradually tapered over 10 months. This case suggests that a combination of steroid therapy with cyclosporine A is effective for severe IIP of unknown pathological diagnosis.

人工呼吸器管理を要し, ステロイドの投与が有効であった高齢者重症 Chlamydia pneumoniae 肺炎の1例

A 75-year-old man first developed dyspnea and low-grade fever in late March. A chest X-ray film showed infiltration in the right lower lung field and blood gas analysis revealed severe hypoxemia. Accordingly, he was diagnosed as having pneumonia and was admitted to our hospital on March 11, 2003. Mechanical ventilation for progressive respiratory failure was started immediately after admission, and he was treated with antibiotics. Chlamydia pneumoniae pneumonia was diagnosed due to an increase of the Chlamydia pneumoniae antibody titer. He had prolonged respiratory failure despite antibiotic therapy. Therefore, steroid therapy was started on day 15 for respiratory failure. At 21 days after admission, the infiltration was found to be decreased on chest X-ray films and improvement of hypoxemia allowed extubation. In conclusion, when severe community-acquired pneumonia occurs in elderly patients, we should remember the possibility of atypical pneumonia such as that due to Chlamydia pneumoniae infection.

Elevation of neutrophils and interleukin-8 in bronchoalveolar lavage fluid from old-old patients with cerebrovascular disease.

had orthopedic injuries, 17 gait disorders related to cerebrovascular disease, 13 hemiparesis from a recent stroke, 11 gait disorders related to arthritis, and two peripheral vascular diseases. The rehabilitative procedures were analyzed with an index (Rehabilitative Procedure Index, RPI) created to evaluate the level of intensity and complexity of rehabilitative procedures in the hospital. Previously, a chart list was defined, including all the rehabilitative procedures adopted during the rehabilitation of geriatric inpatients. The list graded three levels of complexity for each rehabilitative procedure (low, medium, and high), based on the degree of coordination and the emotional participation requested of the patient. The total number of the rehabilitative procedures performed by the single patient during the hospital stay was recorded. The index was obtained by multiplying the total number of rehabilitative procedures by complexity level and dividing the result by the length of hospital stay (days). Table 1 shows the characteristics of the patients stratified in four groups, according to the comorbidity level (first group, Charlson Index 0–3; second group, Charlson Index 4) and the Tinetti score2 on admission (first subgroup, Tinetti 0–12; second subgroup, Tinetti 13– 28; cutoff at 50th percentile). We found that the change in functional performances from admission to discharge (delta Tinetti), the total number of rehabilitative procedures, and the RPI (the intensity and the complexity of rehabilitative procedures) were significantly different in the four groups. Furthermore, the interactive effect of Tinetti and comorbidity (analysis of variance) was greater in subjects with low comorbidity and smaller in subjects with high comorbidity, suggesting that comorbidity represents a barrier to intensive rehabilitative programs. These data also suggest that the effect of comorbidity on the functional outcomes is not direct but is mediated by the different levels of complexity and intensity of the rehabilitative procedures. Comorbidity influences the physical therapists in determining a patient’s ability to sustain rehabilitative training of various intensity and complexity levels. It would be of extreme importance to individualize the different rehabilitative procedures, allowing better functional outcomes under the same clinical conditions, and to standardize the selection criteria of patients for the different levels of the rehabilitative programs.

Bedside swallowing assessments and brain computerized tomography findings in patients with chronic cerebral infarction and their outcomes

With the aims of evaluating the predictive value of the Smithard method of bedside swallowing assessment, and of elucidating the brain computed tomography (CT scan) findings characteristic of dysphagia, we studied the outcome and brain CT findings over a 2.2‐year follow‐up period after swallowing assessment in 102 patients with chronic cerebral infarction was performed. The subjects were 61 elderly men, average age 75.1 years, and 41 women, average age 78.1 years. They were divided into a positive group (n = 33), who displayed some difficulty swallowing water, and a negative group (n = 69). Outcomes were compared between the two groups in terms of survival, cause of death, recurrent stroke and onset of pneumonia. Brain CT findings were compared for the type, number and laterality of infarcts, the grade of periventricular lucency (PVL), presence of ventricular dilatation (VD), and degree of cortical atrophy (CA). The time elapsed since stroke till assessment tended to be longer for the positive group (mean 7.1 years) than the negative group (4.4 years), and dementia, impaired consciousness and dependent ADL status were all more common. During the observation period, 18 subjects died, 15 in the positive group as opposed to three in the negative group, resulting in a significantly higher annual death rate (29.9%vs 2.2%, χ2 = 28.3, P < 0.0001). Aspiration pneumonia was thought to be the cause of death in all 15 cases in the positive group, whereas the single case of death from pneumonia in the negative group was thought to have been due to a relapse of Wallenbergs syndrome. The sensitivity and specificity of a positive swallowing assessment as a predictor of pneumonia were estimated as 0.55 and 0.94, respectively. CT findings of multiple infarction, bilateral cerebral hemispheric lesion, high grade PVL, VD and severe CA were more common in the positive group. Multiple regression analysis showed that bilateral infarction, PVL, CA and VD contributed significantly to dysphagia. From the above, aspiration pneumonia was frequently seen in the positive group, and this method showed high sensitivity and specificity in predicting this complication. The Smithard method of bedside swallowing assessment is therefore a useful screening method for identifying patients at high risk of developing pneumonia. The CT findings indicated that dysphagia is more likely with high grade PVL, VD and CA, as well as multiple infarcts. These results suggest that the etiology of dysphagia involves not only the pyramidal tracts, but a combination of factors including extrapyramidal tracts, impaired consciousness, reduced cognitive function and impairment of ADL.

Elderly case of non-mucinous bronchioloalveolar carcinoma showing diffuse ground-glass changes on chest computed tomography

An 83‐year‐old man was diagnosed as having recurrent spinal canal stenosis and was admitted to his local hospital on 13 July 2001. Because interstitial changes were detected on the chest X‐ray, he was transferred to our hospital after 3 days. Chest computed tomography showed diffuse ground‐glass attenuation and a right pleural effusion. To make a diagnosis, transbronchial lung biopsy of right B3, B4 and B8 was performed. Histological examination of specimens from B4 and B8 revealed non‐mucinous bronchioloalveolar carcinoma. It seems that a bilateral diffuse ground‐glass appearance is one of the radiographic features of progressive bronchioloalveolar carcinoma.