Saori Takata

High-resolution CT findings of patients with pulmonary nocardiosis

BACKGROUND Opportunistic pulmonary infection with Nocardia species is rare in humans, and only a few studies have radiologically analyzed patients with pulmonary nocardiosis using high-resolution computed tomography (HRCT). METHODS We retrospectively reviewed the medical records of patients with pulmonary nocardiosis at our hospital between April 2006 and December 2011 to assess HRCT and clinical findings. We also searched the medical literature for pulmonary nocardiosis reported in Japan between 2002 and 2011 for comparison. RESULTS We identified seven patients at our institution and 33 reported infections in Japan. Four of our patients were immunocompetent, whereas the other three had impaired cellular immunity due to type 2 diabetes mellitus or having been inappropriately treated with steroid. Thoracic HRCT revealed no zonal predominance, but tropism for distribution from the middle to the peripheral area, and radiological findings of nodules, cavitation, mass, consolidations, bronchial wall thickening, septal line thickening and ground glass opacity (GGO) were evident. The main HRCT finding in our study comprised nodules (n=5, 71.4%) <30 mm and four patients had multiple nodules as described in other reports. Furthermore, we discovered a crazy paving appearance (CPA) around nodules, cavities, masses or consolidations in five patients (71.4%). CONCLUSIONS Multiple nodules distributed from the middle to the peripheral area on HRCT might reflect pulmonary nocardiosis, and CPA seemed to be a worth paying attention to the diagnosis.

Kinetics of c-reactive protein (CRP) and serum amyloid A protein (SAA) in patients with community-acquired pneumonia (CAP), as presented with biologic half-life times.

Context: In management of community-acquired pneumonia (CAP), excellent biomarkers for inflammation would be helpful in our practice. Objectives: Kinetics of c-reactive protein (CRP) and serum amyloid A (SAA) was characterized, using their biologic half-life times. Materials and methods: Time course of CRP and SAA levels in the successfully treated 36 CAP patients were investigated and their half-life times were determined and compared. Results & Discussions: SAA and CRP declined in an exponential mean and the biologic half-life times of SAA levels was 34.9 ± 28.7 h, significantly shorter than that of CRP, 46.4 ± 21.7 h (p = 0.0014). Conclusion: The kinetic evidence, presented as biologic half-life times of CRP and SAA, helps us make a clinical assessment of CAP patients.

Pathological Evidence of Rhabdomyolysis-induced Acute Tubulointerstitial Nephritis Accompanying Legionella pneumophila Pneumonia

A case of Legionella pneumophila pneumonia with rhabdomyolysis-induced acute tubulointerstitial nephritis (ATIN) and prolonged renal dysfunction is presented. The patient was a 54-year-old man, admitted with high-grade fever, ataxia and muscle dysfunction; chest roentgenogram showed multilobular infiltrations. L pneumophila was detected in his sputum and urine, by PCR and by culture, and L pneumophila pneumonia was diagnosed. Despite antimicrobial treatment, he developed renal failure and rhabdomyolysis. Renal biopsy showed the presence of myoglobin casts that occluded the distal tubuli and tubulointerstitial nephritis, leading to the diagnosis of rhabdomyolysis-induced ATIN. Renal function subsequently normalised, and he was discharged. This is believed to be the first pathological evidence of involvement of rhabdomyolysis in legionellosis-associated ATIN.

Breakthrough Invasive Candida glabrata in Patients on Micafungin: a Novel FKS Gene Conversion Correlated with Sequential Elevation of MIC

ABSTRACT Candida glabrata strains sequentially isolated from blood developed resistance to micafungin (MICs from <0.015 to 4 μg/ml). A novel mutation identified in micafungin-resistant strains at bp 262 of FKS2 (containing a deletion of F659 [F659del]) was inserted into the homologous region in FKS1.

Mechanic's hands revisited: is this sign still useful for diagnosis in patients with lung involvement of collagen vascular diseases?

BackgroundThe presence of “mechanic’s hands” is one of the clinical clues for collagen vascular diseases. However, the exact relevance of “mechanic’s hands” in collagen vascular diseases has not been well documented. The aim of this study was to clarify the relevance of “mechanic’s hands” to collagen vascular diseases including various skin lesions and interstitial pneumonia.MethodsA retrospective review of the medical records of patients with “mechanic’s hands” at our hospital between April 2011 and December 2012 was conducted. A PubMed search was also conducted using the term “mechanic’s hands”.ResultsFour patients in our institution and 40 patients obtained from PubMed who had “mechanic’s hands” were identified. The most frequent diseases were DM/amyopathic DM (n = 24, 54.5%) and anti-ARS syndrome (n = 17, 38.6%). In these patients, the major skin lesions associated with “mechanic’s hands” were periungual erythema (n = 23, 52.3%), Gottron’s sign (n = 17, 38.6%), heliotrope rash (n = 10, 22.7%), Raynaud’s phenomenon (n = 9, 20.5%), and anti-ARS syndrome (n = 17, 38.6%). Six cases (2 DM, 4 anti-ARS syndrome) had only “mechanic’s hands”. Antibodies to anti-ARS (n = 24) were Jo-1 (n = 19), PL-7 (n = 3), OJ (n = 1), and PL-12 (n = 1).ConclusionThe presence of “mechanic’s hands” together with diverse skin lesions could be a clinical clue to the diagnosis of lung involvement associated with collagen vascular diseases, especially in anti-ARS syndrome or DM/amyopathic DM.

IL-17A synergistically stimulates TNF-α-induced IL-8 production in human airway epithelial cells: A potential role in amplifying airway inflammation

ABSTRACT Background: Recent reports have suggested an involvement of neutrophilic inflammation driven by interleukin (IL)-17 from Th17 cells, especially in severe, refractory asthma. It remains unknown about the possible interactions of this cytokine and other proinflammatory cytokines to direct neutrophilic airway inflammation. Materials and Methods: We evaluated the effects of IL-17A, IL-17E, and IL-17F in combination with other stimuli such as tumor necrosis factor (TNF) –α on the production and expression of IL-8 in human bronchial epithelial cells. We also studied their effects on other cytokine production. The possible role of mitogen-activated protein kinase (MAPK) and nuclear factor-kappa B (NF-κB) signaling pathways was evaluated by specific inhibitors. We examined the effects of anti-asthma drugs, such as steroids or salmeterol. Results: IL-17A alone induced only a minimal effect on IL-8 expression. IL-17A, but not IL-17E or IL-17F, in combination with TNF-α showed a synergistic effect on IL-8 expression. Similar findings were found when combination with IL-1β and IL-17A were used, but such was not the case with lipopolysaccharide (LPS). In addition, we further found such synergy on GM-CSF production. The synergy with TNF-α and IL-17A was significantly inhibited by MAPKs inhibitors. Corticosteroids such as fluticasone propionate and dexamethasone, but not salmeterol, partially suppressed the IL-17A and TNF-α-induced IL-8 production. Conclusions: IL-17A in the combination with TNF-α or IL-1β showed a synergistic augmenting effect on IL-8 and GM-CSF production in human airway epithelial cells.

Clarithromycin ameliorates pulmonary inflammation induced by short term cigarette smoke exposure in mice

BACKGROUND Cigarette smoking is considered to be one of major causes of acute worsening of asthma as well as chronic obstructive pulmonary disease (COPD). Macrolide antibiotics have been reported to reduce the risk of exacerbations of COPD, and possibly neutrophilic asthma. However, the effect of clarithromycin (CAM) on pulmonary inflammation caused by short term exposure to cigarette smoke still remains to be investigated. METHODS C57BL/6J female mice were daily exposed to tobacco smoke using a tobacco smoke exposure system, or clean air for 8 days, while simultaneously treated with either oral CAM or vehicles. Twenty four hours after the last exposure, mice were anaesthetized and sacrificed, and bronchoalveolar lavage (BAL) fluids were collected. Cellular responses in BAL fluids were evaluated. Levels of cytokine mRNA in the lung tissues were measured by quantitative RT-PCR. Paraffin-embedded lung tissues were evaluated to quantitate degree of neutrophil infiltration. RESULTS The numbers of total cells, macrophages and neutrophils in the BAL fluid of smoke-exposed mice were significantly increased as compared to clean air group. These changes were significantly ameliorated in CAM-treated mice. The lung morphological analysis confirmed decrease of neutrophils by CAM treatment. Studies by quantitative PCR demonstrated CAM treatment significantly reduced lung expression levels of IL-17A, keratinocyte-derived chemokine (KC), granulocyte-macrophage colony stimulating factor (GM-CSF) and MMP-9 induced by cigarette smoke. CONCLUSION We demonstrate that CAM administration resolves enhanced pulmonary inflammation induced by short term cigarette smoke exposure in mice.

The saw-tooth sign as a clinical clue for intrathoracic central airway obstruction

BackgroundThe saw-tooth sign was first described by Sanders et al in patients with obstructive sleep apnea syndrome as one cause of extrathoracic central airway obstruction. The mechanism of the saw-tooth sign has not been conclusively clarified. The sign has also been described in various extrathoracic central airway diseases, such as in burn victims with thermal injury to the upper airways, Parkinson’s disease, tracheobronchomalacia, laryngeal dyskinesia, and pedunculated tumors of the upper airway.Case presentationA 61-year-old man was referred to our hospital with a two-month history of persistent dry cough and dyspnea. He was diagnosed with lung cancer located in an intrathoracic central airway, which was accompanied by the saw-tooth sign on flow-volume loops. This peculiar sign repeatedly improved and deteriorated, in accordance with the waxing and waning of central airway stenosis by anti-cancer treatments.ConclusionThis report suggests that the so-called saw-tooth sign may be found even in intrathoracic central airway obstruction due to lung cancer.

The Role of Vital Signs in Predicting Cardiac Tamponade in Asymptomatic Patients with Malignancy: Associated Pericardial Effusion

Background: Cardiac tamponade is a potentially life-threatening complication in patients with advanced lung cancer or other metastatic malignant diseases. However, few reports described how to assess the risk for developing cardiac tamponade in asymptomatic patients with pericardial effusion. Methods: The medical records of all patients with malignancy-associated cardiac tamponade diagnosed between April 2006 and June 2012 at Kyorin Hospital were retrospectively reviewed. This study mainly focused on the correlation between the duration between the first recognition of pericardial effusion on computed tomography and cardiac tamponade diagnosis and the vital signs at each point. Results: We identified 17 patients with malignancy-associated cardiac tamponade, mainly due to lung cancer (n=11, adenocarcinoma; n=1, non-small cell carcinoma; n=1, large cell neuroendocrine carcinoma; n=1, small cell carcinoma; and n=1, squamous cell carcinoma) followed by malignant mesothelioma (n=1), and an unknown cause (n=1). Among 17 patients with cardiac tamponade, the systolic blood pressure at the time of malignancy diagnosis was significantly higher than that at the onset of cardiac tamponade (average±SD, 115±13 vs 95±25 mm Hg; p=0.014), whereas heart rate (HR) and cardiothoracic ratio (CTR) determined on chest radiography were significantly higher at the onset of cardiac tamponade (HR, 84±15 bpm vs 111±30; p<0.001) (CTR, 49±7% vs 71±4.9; p=0.001). The correlation coefficient between the days from the first recognition of pericardial effusion on thoracic computed tomography to cardiac tamponade diagnosis and the gap of vital signs at each point such as ΔHR (r=−0.422, p=0.345) and ΔCTR (r=−0.212, p=0.647) was not statistically significant. Conclusion: This preliminary study demonstrated that increased HR and CTR are essential signs for predicting malignancy-associated cardiac tamponade.

Renal Salt Wasting Syndrome due to Carboplatin in a Patient with Lung Cancer

A 40-year-old woman with lung cancer had multiple episodes of hyponatremia when- ever she had chemotherapy with cisplatin plus etoposide and/or carboplatin plus etoposide over the last year. Although she had been diagnosed as having Syndrome of Inappropriate Secre- tion of Antidiuretic Hormone (SIADH), based on a multidisciplinary assessment, a diagnosis of Renal Salt Wasting Syndrome (RSWS) possibly due to carboplatin was made, and after completion of intravenous treatment with isotonic saline, hyponatremia resolved, and she was discharged uneventfully. Cisplatin is well known for causing renal toxicity via proximal tubu- lar damage, some cases of which present as RSWS. However, RSWS is extremely rare with carboplatin. The differential diagnosis between RSWS and SIADH for hyponatremic patients is sometimes difficult because of similarities in their clinical features, but careful consideration is needed to make the correct diagnosis because their treatments are diametrically opposed.