Sunao Mikura

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.

Clinical significance of respiratory virus detection in patients with acute exacerbation of interstitial lung diseases

Abstract Background The impact of viral infections on acute exacerbations in idiopathic pulmonary fibrosis (IPF) and/or non-IPF interstitial lung disease (ILDs) has been scarcely described. Objectives To elucidate the frequency of virus infections in patients with IPF or non-IPF ILDs including idiopathic interstitial pneumonia (IIP) or connective tissue disease (CTD)-associated pneumonia, and its influence on their short-term mortality. Methods We prospectively enrolled adult patients with acute exacerbation of IPF and non-IPF ILDs who were admitted to the hospital during the last 3 years, and examined the respiratory samples obtained from nasopharyngeal, sputum, and bronchoalveolar lavage fluid. Results A total of 78 patients were identified, consisting of 27 patients with acute exacerbation of IPF and 51 patients with non-IPF ILDs (IIP: n = 27, CTD-associated IP: n = 24). Of all patients, 15 (19.2%) had viruses detected in their respiratory samples including the human herpesvirus 7 (HHV7; n = 4) and cytomegalovirus (CMV) plus HHV7 (n = 3). The proportion of virus infections in the IPF and non-IPF ILDs groups was comparable. The Kaplan-Meier survival curves over 60 days revealed a lower survival probability in the virus positive group (n = 15, 60%) than in the virus negative group (n = 60, 83.3%, p < 0.05). However, the virus infection itself could not predict the 60-day survival probability using simple logistic regression analysis. Conclusions Viral infections, mostly CMV or HHV7, were identified in both patients with acute exacerbation of IPF and non-IPF ILDs, but the clinical significance on short-term mortality or isolation itself from respiratory samples remains to be determined.

Diagnostic Value of Vascular Endothelial Growth Factor, Transforming Growth Factor-β, Interleukin-8, and the Ratio of Lactate Dehydrogenase to Adenosine Deaminase in Pleural Effusion

PurposeWe studied the diagnostic value of cytokines, including vascular endothelial growth factor (VEGF), transforming growth factor-β (TGF-β), and interleukin-8 (IL-8), and the ratio of lactate dehydrogenase (LDH) to adenosine deaminase (ADA) in pleural fluid.MethodsProspective analysis of 44 inpatients or outpatients with pleural fluid, from December 2016 to March 2017 was conducted.ResultsWe enrolled patients with malignant pleural effusion (MPE, N = 15), empyema (N = 11), parapneumonic effusion (PPE, N = 7), chronic renal failure (CRF)/chronic heart failure (CHF) (N = 7), and tuberculous pleural effusion (TBPE, N = 4). The pleural fluid values of IL-8 and VEGF were significantly higher in empyema patients than in CRF/CHF or PPE patients. In all patients, the pleural fluid VEGF and IL-8 values were significantly positively correlated (r = 0.405, p = 0.006; r = 0.474, p = 0.047, respectively). TGF-β was elevated in patients with empyema, PPE, TBPE, and MPE. The pleural LDH-to-ADA ratio in patients with MPE or empyema/PPE was significantly higher than in patients with CRF/CHF or TBPE. LDH and ADA levels correlated significantly only in patients with MPE (r = 0.648, p = 0.009) and empyema/PPE (r = 0.978, p < 0.001).ConclusionsVEGF and IL-8 production in the pleural cavity appear to accelerate the progression of PPE to empyema, by enhancing vascular permeability associated with inflammation. Sequential sampling would be needed to confirm this. The pleural LDH/ADA ratio may be a useful diagnostic tool for discriminating between various pleural effusion etiologies.

A Diagnostic Tool Yet Simple and Strong: Inspection of the Jugular Veins

1Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan 2Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA 3Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0) 422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Diaphragm Ultrasonography as an Important Aid to Diagnose Spinal Cord Injury

1Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan 2Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA 3Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0) 422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Cheyne-Stokes Respiration Revisited: Clinical Clue to the Diagnosis for Acute Exacerbation of Congestive Heart Failure

1Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan 2Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA 3Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Diaphragmatic Dysfunction without Paradoxical Breathing: A Case of Nemaline Myopathy

1Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan 2Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan 3Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0) 422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Diaphragm Ultrasonography as a Tool To Assess the Respiratory Issues of a Patient With Amyotrophic Lateral Sclerosis (ALS)

1Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan 2Department of Cardiology, Kyorin University School of Medicine, Tokyo, Japan 3Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0) 422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Diaphragm Ultrasonography as a Tool to Assess Paradoxical Breathing in a Patient With Asthma Attack

1Department of Respiratory Medicine, Kyorin University School of Medicine, Miatka City, Tokyo, Japan 2Divisions of Pulmonary, Critical Care and Sleep Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Pawtucket, RI, USA 3Department of Cardiology, Kyorin University School of Medicine, Miatka City, Tokyo, Japan 4Departments of Component Technology, Engineering Operation, Automotive OEM Business Division, JVC Kenwood Corporation, Tokyo 192-8525, Japan 5Departments of Development, Engineering Operation, Media Business Division, JVC Kenwood Corporation, Tokyo 192-8525, Japan 6Department of Respiratory Medicine, Hirosaki University School of Medicine, Hirosaki 0368562, Japan 7Department of Pulmonology, Nagano Red Cross Hospital, Nagano 380-8582, Japan *Corresponding authors Takeshi Saraya, MD, PhD Assistant Professor Department of Respiratory Medicine Kyorin University School of Medicine 6-20-2 Shinkawa, Mitaka City Tokyo 181-8611, Japan Tel. +81 (0) 422 44 0671 Fax: +81 (0)422 44 0671 E-mail: sara@yd5.so-net.ne.jp

Huge Mycotic Abdominal Aneurysm with Nerve Irritation

A 101-year-old woman was transferred to our hospital with exaggerated left hip pain that had developed over the previous two months. Non-enhanced abdominal computed tomography (CT) (Picture A) taken on admission showed a tortuous abdominal aortic aneurysm (AAA) together with the isolation of Klebsiella oxytoca from two sets of blood cultures and a urine culture. On the 10th hospital day, she suddenly complained of severe abdominal pain. Urgent thoracoabdominal enhanced CT showed an enlarged aorta with enhanced thickening of the outer membrane accompanied by a blurred inner membrane (Picture B-D, arrows) generating the inner (Picture B-D, asterisk) and the outer fluid space (Picture B-D, star), which implicated a thrombus and exudative effusion, respectively. She was thus diagnosed with an abdominal mycotic aneurysm caused by K. oxytoca which was located at the level of L2 to L5 with an irritation of the posterior cutaneous nerve of the thigh or sciatic nerve (1, 2).