Takashi Ogasawara

Development of anti-Sm and anti-DNA antibodies followed by clinical manifestation of systemic lupus erythematosus in an elderly woman with long-standing Sjögren's syndrome

A 69-year-old Japanese women who had been followed up for 10 years as a primary Sjögrens syndrome, is reported. She suddenly developed serological and clinical characteristics of systemic lupus erythematosus (SLE): anti-Sm and anti-dsDNA antibodies followed by nephrotic syndrome and pancytopenia. This case suggests that the diagnosis of primary Sjögrens syndrome should be considered as tentative in certain cases and that the development of serological characteristics precede and are associated with the development of clinical symptoms of SLE.

Procalcitonin-guided antibiotic therapy in aspiration pneumonia and an assessment of the continuation of oral intake

BACKGROUND Procalcitonin-guided antibiotic therapy for community-acquired pneumonia is effective and safe. However, the usefulness of procalcitonin for aspiration pneumonia and its nutrition-related outcomes are unknown. METHODS We conducted a noninferiority randomized controlled study in patients with aspiration pneumonia who were admitted to our hospital between September 2010 and January 2012. We randomly assigned 105 patients to groups with different durations of antibiotic therapy based on the procalcitonin levels upon admission (procalcitonin group) or according to the standard guidelines (control group). The primary endpoints were relapse of aspiration pneumonia and death within 30 days, with a predefined noninferiority boundary of 10%. Secondary endpoints included duration of antibiotic exposure. Furthermore, we conducted a retrospective analysis of the prognostic factors that determined continuation of oral nutritional intake, relapse of pneumonia, and in-hospital death. RESULTS The rate of relapse and death within 30 days were similar in the procalcitonin and control groups (25% versus 37.5%; difference, -12.5%; 95% confidence interval, -30.9% to 5.9%). Procalcitonin-guided antibiotic therapy significantly shortened the median duration of antibiotic exposure (5 versus 8 days; p<0.0001); however, the continuation of oral intake was not increased (56% versus 50%; p=0.54). A multivariable analysis showed a significant association between the continuation of oral nutritional intake and the body mass index upon admission. CONCLUSIONS Procalcitonin-guided antibiotic therapy for aspiration pneumonia can shorten the duration of antibiotic exposure, but it does not increase the continuation of oral intake (UMIN000004800).

Idiopathic bronchocentric granulomatosis in an asthmatic adolescent.

Bronchocentric granulomatosis in asthmatic patients has been generally considered to be associated with allergic bronchopulmonary aspergillosis and represent a histopathologic manifestation of fungal hypersensitivity. Here we report a case of an idiopathic bronchocentric granulomatosis in a 17-year-old man with a history of asthma. He was admitted to the hospital with a fever and cough, and a chest CT scan showed peribronchial consolidation in the pulmonary parenchyma, which was unresponsive to antibiotic therapy. The pathological findings obtained by video-assisted thoracoscopic lung biopsy revealed necrotizing granulomatous inflammation centered on bronchi and bronchioles and there was no evidence of fungal colonization, resulting in a diagnosis of idiopathic bronchocentric granulomatosis. Systemic corticosteroid therapy led to clinical and radiological recovery. Physicians should take into account the possibility of the idiopathic process in bronchocentric granulomatosis of asthmatic patients.

Bronchodilator Effect of Tiotropium via Respimat®Administered with a Spacer in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Objective Among elderly patients with chronic obstructive pulmonary disease (COPD), there are some patients who cannot inhale tiotropium via RespimatⓇ due to poor hand-lung coordination. This study aimed to examine whether or not tiotropium inhalation therapy using RespimatⓇ with a spacer increased the forced expiratory volume in 1 s (FEV1) in patients with COPD. Methods A randomized, crossover, single-center study was conducted in 18 patients with stable COPD. Tiotropium (5 μg) via RespimatⓇ with or without a spacer (AeroChamberⓇ) was administered for 2 weeks. Following a 2-week washout period using a transdermal tulobuterol patch (2 mg per day), participants were then crossed over to the other inhalation therapy with respect to spacer use. The trough FEV1 was measured at every visit using a spirometer. A questionnaire regarding inhalation therapy was administered to patients at the final visit. Results The administration of tiotropium via RespimatⓇ both with and without a spacer significantly increased the trough FEV1 from baseline during each treatment period, with mean differences of 115.0±169.6 mL and 92.8±128.1 mL, respectively. There was no significant difference in the change in the trough FEV1 between the 2 procedures (p=0.66). A total of 86% of patients reported that inhalation using a spacer was not difficult, and more than half also rated both the usage and maintenance of the AeroChamberⓇ as easy. Conclusion Tiotropium inhalation therapy administered via RespimatⓇ using a spacer exerted a bronchodilatory effect similar to that observed with tiotropium RespimatⓇ alone.

Aortic Valve Infective Endocarditis with an Annular Abscess

A 45-year old man was referred to our hospital because of a fever. His blood culture revealed a Streptococcus pneumoniae infection; ultrasound cardiography recorded vegetation at the aortic valve. Infective endocarditis was diagnosed, and antibiotic therapy was initiated. Although the infection and heart failure were controlled, at approximately two weeks after the antibiotic therapy initiation, a seconddegree atrioventricular block was observed. Transesophageal echocardiography revealed an annular abscess extending to the non-coronary cusp annulus (Picture 1, 2) that also communicated with the left atrium (Picture 3). We performed abscess debridement, annulus and defect reconstruction with a bovine pericardium patch, and aortic valve replacement using a mechanical valve. The patient recovered without any recurrent infective endocarditis or heart failure symptoms. Even today, annular abscesses are serious complications of infective endocarditis (1). It is important to select an appropriate treatment strategy, including surgical planning, in order to precisely diagnose the existence and extension of the abscess preoperatively.