Ryota Sato

Recurrence of chronic pulmonary aspergillosis after discontinuation of maintenance treatment by antifungal triazoles.

OBJECTIVE To assess the prevalence and risk factors of recurrence of chronic pulmonary aspergillosis (CPA) after discontinuation of antifungal triazoles. METHOD We reviewed the medical records of CPA patients who achieved resolution of clinical and radiographic manifestations and stopped taking antifungal triazoles between June 2006 and June 2012 at Tokyo National Hospital. We evaluated whether there was CPA recurrence within 1 year after treatment cessation and investigated risk factors for relapse. The association of anti-Aspergillus antibody conversion with CPA recurrence was also reviewed. RESULTS A total of 39 patients were included in this study and there was CPA recurrence in 14 patients. Compared with the Non-recurrence group, the Recurrence group exhibited 1) younger age (p = 0.017), 2) more than one lung lobe affected by CPA more frequently (p = 0.008), 3) longer duration needed to remit manifestations of chest radiograph (p = 0.031), 4) longer antifungal treatment duration (p = 0.042). The present study did not reveal an association between negative conversion of serum anti-Aspergillus antibody and recurrence risk. Multivariate logistic regression analysis revealed that patients with CPA with affected area of more than one lung lobe had increased risk (odds ratio, 10.20; 95% confidence interval, 1.49-69.77; p = 0.018). CONCLUSION CPA recurrence can be seen in about one-third of cases after discontinuing azole treatment. We should make decisions about treatment duration and follow up depending on the severity of each case, particularly on the expansion of CPA-affected area.

Prevalence and risk factors of sepsis-induced cardiomyopathy: A retrospective cohort study.

AbstractThe aim of the study is to evaluate the epidemiology and clinical features of sepsis-induced cardiomyopathy (SICM).A retrospective cohort study was conducted.A total of 210 adult patients with sepsis or septic shock admitted to a Japanese tertiary care hospital from January 1, 2013, to December 31, 2015, who underwent transthoracic echocardiography (TTE) on admission.The definition of SICM was ejection fraction (EF) < 50% and a ≥10% decrease compared to the baseline EF which recovered within 2 weeks, in sepsis or septic shock patients.Our primary outcome was the incidence rate of SICM. Our secondary outcomes were the in-hospital mortality rate and length of intensive care unit (ICU) stay according to the presence or absence of SICM. In total, 29 patients (13.8%) were diagnosed with SICM. The prevalence rate of SICM was significantly higher in male than in female (P = 0.02). Multivariate logistic regression analyses revealed that the incidence of SICM was associated with younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–0.99), higher lactate level on admission (OR, 1.18; 95% CI, 1.05–1.32) and history of heart failure (HF) (OR, 3.77; 95% CI, 1.37–10.40). There were no significant differences in the in-hospital and 30-day mortality between patients with and without SICM (24.1% vs 12.7%, P = 0.15; 20.7% vs 12.1%, P = 0.23). Lengths of hospital and ICU stay were significantly longer in patients with SICM than in those without SICM (median, 43 vs 26 days, P = 0.04; 9 vs 5 days, P < 0.01).SICM developed in 13.8% of patients with sepsis and septic shock. A younger age, higher lactate levels on admission and history of HF were risk factors.

Can We Rule Out Meningitis from Negative Jolt Accentuation? A Retrospective Cohort Study

Jolt accentuation has been considered to be the most sensitive physical finding to predict meningitis. However, there are only a few studies assessing the diagnostic accuracy of jolt accentuation. Therefore, we aimed to evaluate the diagnostic accuracy of jolt accentuation and investigate whether it can be extended to patients with mild altered mental status.

Streptococcus pneumoniae meningitis without pleocytosis of the cerebrospinal fluid.

Pleocytosis of the cerebrospinal fluid is a key finding for the diagnosis of bacterial meningitis. Bacterial meningitis presenting in normal cerebrospinal fluid is rare in adult patients. We describe the case of a patient with pneumococcal meningitis without cerebrospinal fluid pleocytosis. This case suggests that immediate antibiotic therapy should be started when meningitis is suspected, even with normal cerebrospinal fluid findings. (See Figure.)

Rat-bite fever complicated by vertebral osteomyelitis: A case report.

Rat-bite fever (RBF) is a challenging diagnosis transmitted by the bite of the rats. We present the first reported case of RBF complicated by vertebral osteomyelitis. It is important to consider performing the MRI to differentiate vertebral osteomyelitis from simple back pain to determine the appropriate duration of antibiotic therapy.

Blood pressure and acute kidney injury

Maintaining the optimal blood pressure is an important aspect of preventing acute kidney injury (AKI), especially for vasopressor-dependent patients. Although mean arterial pressure (MAP) has played an important role in previous trials for prevention of AKI, there is little evidence that MAP actually reflects organ perfusion. In fact, several studies have suggested that perfusion pressure, including diastolic perfusion pressure and mean perfusion pressure (MPP) and calculated with central venous pressure (CVP), may be more useful than the widely used MAP to help prevent AKI. This emphasizes the importance of maintaining diastolic arterial pressure and avoiding elevation of CVP to prevent AKI in patients with sepsis or invasive surgery. To achieve this, further investigation regarding titrated fluid therapy and vasopressors is warranted.

Focus Instead on Determining Lower Limit of Continuous Renal Replacement Therapy

To the Editor: Several studies have established that if the effluent volume for continuous renal replacement therapy is greater than 20 to 25 mL/ kg/h, there is no difference in patient prognosis. The recent randomized controlled trial by Park et al showed no difference in mortality between the conventional (40 mL/kg/h) and high-dose (80 mL/kg/h) groups. A number of prior studies addressed the same set of issues related to dialysis dose in continuous dialysis therapy. Ronco et al reported in 2000 that the dose should reach 35 mL/kg/h. However, the Acute Renal Failure Trial Network (ATN) Study and the RENAL (Randomized Evaluation of Normal Versus Augmented Level) Replacement Therapy Study revealed no difference in mortality between an effluent volume of 25 and 35 mL/kg/h, followed by the KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guideline for acute kidney injury (AKI) recommending a dose of 20 to 25 mL/kg/h. Further, the systematic review and meta-analysis of Clark et al concluded that there was no significant benefit on mortality between standard and high-volume hemofiltration . 50 mL/kg/h for septic AKI. Although the average dose in Japan is 14.3 mL/ kg/h, lower than the standard, Uchino et al reported no significant difference in mortality compared with other countries. Additionally, Mc Causland et al reported that intensive renal replacement therapy (35 mL/kg/h) was associated with decreased urine output compared to less intensive therapy (20 mL/kg/h). These studies suggest that a lower dose of dialysis could be beneficial. In addition, it is important to avoid unnecessary medical costs. Therefore, future studies should shift their focus to determining the lower limit of effective effluent volume for the treatment of AKI.

Cerebral edema induced by hyperammonemia: a case report

Severe hyperammonemia may have an extremely high risk of leading to intracranial hypertension and cerebral edema development; however, there is no current standard strategy for severe hyperammonemia treatment. We describe a case of hyperammonemia complicated with cerebral edema and show that in severe hyperammonemia, particularly when the ammonia level is >200 mol/L or when enriched branched-chain amino acid and lactulose are ineffective, it is important for physicians to immediately consider hemodiafiltration to prevent cerebral edema.

Clinical Features and Prognosis of Nontuberculous Mycobacterial Pleuritis

Background: While nontuberculous mycobacterial (NTM) pleuritis rarely complicates pulmonary NTM infection, high mortality has been reported in case reports and small studies. Objectives: The purpose of this study was to clarify the clinical features and treatment outcomes of pulmonary NTM infection cases accompanied by NTM pleuritis. Methods: Medical records of 1,044 patients with pulmonary NTM disease were retrospectively reviewed to select patients complicated by NTM-proven pleuritis. We investigated clinical characteristics, pathogens, pleural effusion examinations, radiographic findings, treatments, and clinical course of the NTM pleuritis patients. Results: Among 1,044 cases with pulmonary NTM, NTM pleuritis occurred in 15 cases (1.4%). The mean age was 69 years with a performance status of mostly 2 or better (80.0%), and 6 cases (40.0%) were complicated by pneumothorax. Subpleural cavities were radiologically detected in 11 cases (73.3%), and extrapulmonary air-fluid level was detected in 14 cases (93.3%). Eleven patients were treated with combinations of 2–4 antimycobacterial drugs, including clarithromycin, and 2 patients were treated with isoniazid, rifampicin, and ethambutol. Chest tube drainage was performed in 11 cases, and surgical approach was added in 6 cases. The pleural effusion of 2 patients treated with only antimycobacterial medications gradually deteriorated. Two patients died from NTM pleuritis, and 1 patient died from pneumonitis during a mean of 1.8 years of follow-up. Conclusions: Comorbid NTM pleuritis was difficult to treat by medical therapy alone and resulted in a poor prognosis. In addition to antimycobacterial agents, chest tube drainage and surgical procedures in the early stages should be considered to treat NTM pleuritis.

Cecal Perforation Associated with Clostridium difficile Infection: A Case Report

BACKGROUND Various complications are reported with Clostridium difficile infection (CDI), including fulminant CDI. Fulminant CDI is an underappreciated life-threatening condition associated with complications such as toxic megacolon and bowel perforation. CASE REPORT A 79-year-old woman presented to the Emergency Department with altered mental status. She was admitted and conservatively treated for a left thalamic hemorrhage. While hospitalized, she developed watery diarrhea due to Clostridium difficile. Although metronidazole was initiated, she developed altered mental status and septic shock. Abdominal x-ray study and computed tomography revealed a significantly dilatated colon and a massive pneumoperitoneum. She underwent subtotal colectomy with a 14-day course of intravenous meropenem. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case suggests that we must be aware of the complications that CDI may present and adequately consider surgical management because early diagnosis and surgical treatment is critical to reduce the mortality of fulminant CDI.