Tark Kim

Paradoxical responses in non-HIV-infected patients with peripheral lymph node tuberculosis

OBJECTIVES We evaluated the clinical characteristics and risk factors for the paradoxical response (PR) in non-HIV-infected patients with peripheral lymph node tuberculosis (TB). METHODS Medical records of non-HIV-infected patients aged > or =16 years with peripheral lymph node TB treated in a tertiary hospital between January 1997 and August 2007 were analysed. PR was defined as clinical or radiological worsening of pre-existing TB lesions, or development of new lesions in a patient who had received anti-TB therapy for at least 2 weeks. RESULTS Three hundred patients with lymph node TB were included. Of these, 235 patients (78%) had confirmed TB; the remaining 65 (22%) had probable TB and were excluded from the final analysis. Among the 235 study patients, their mean age (+/-standard deviation) was 37.6 (+/-13.9) years and 175 (75%) were female. PR occurred in 54 (23%; 95% confidence interval 18-28%) patients, at a median onset time of 8 weeks (interquartile range, 4-14 weeks) after starting anti-TB medication. In multivariate analysis, younger age (OR 0.96), male gender (OR 2.60), and the presence of local tenderness at the time of diagnosis (OR 2.90) were independently associated with PR. CONCLUSION PR was relatively common, occurring in one-fifth of non-HIV-infected patients with peripheral lymph node TB, and was associated with younger age, male gender, and the presence of local tenderness.

Outcomes of Moderate-to-Severe Pneumocystis Pneumonia Treated with Adjunctive Steroid in Non-HIV-Infected Patients

ABSTRACT While it is well-known that adjunctive corticosteroid use improves the outcome of moderate-to-severe Pneumocystis jirovecii pneumonia (PcP) in patients with human immunodeficiency virus (HIV), there are limited data on its efficacy in non-HIV-infected patients with PcP. Patients undergoing fiber-optic bronchoscopy with bronchoalveolar lavage for suspected PcP from January 2007 through December 2010 were reviewed retrospectively. We compared demographics, clinical characteristics, and outcomes in 88 non-HIV-infected patients with moderate-to-severe PcP with (n = 59) and without (n = 29) adjunctive corticosteroid use. Outcomes of PcP were assessed by respiratory failure and 30-day and 90-day all-cause mortality. Survival curves were analyzed by the Kaplan-Meier method and estimated by the log rank test. All-cause mortality of moderate-to-severe PcP at 90 days was lower in the solid-organ transplant recipients than in all other patients (6/26 [23%] versus 34/62 [55%], respectively; P = 0.006), and mortality at 30 days was lower in patients with hematologic malignancies than in all other patients (4/26 [15%] versus 24/62 [39%], respectively; P = 0.03). The outcomes of PcP were not significantly different in moderate-to-severe PcP patients with and without adjunctive corticosteroid use, regardless of recent corticosteroid use. Survival analysis of PcP patients with and without corticosteroid use by the Kaplan-Meier method also did not reveal any difference (log rank test; P = 0.81). There again was no difference within the subgroup of PcP patients with solid-organ transplants. Adjunctive corticosteroid use may not improve the outcome of moderate-to-severe PcP in non-HIV-infected patients.

Increased incidence of herpes zoster in the setting of cytomegalovirus preemptive therapy after kidney transplantation.

Herpes zoster (HZ) is a common infectious disease after kidney transplantation (KT). The incidence of HZ may increase during cytomegalovirus (CMV) preemptive therapy. We therefore evaluated the incidence, risk factors, and clinical outcomes of HZ after KT, according to the type of CMV prophylaxis used.

Is caspofungin really an effective treatment for Pneumocystis jirovecii pneumonia in immunocompromised patients without human immunodeficiency virus infection? Experiences at a single center and a literature review

Abstract Caspofungin, an antifungal agent that acts on the cell wall by inhibiting β-1,3-glucan synthesis, is likely to be effective for treating Pneumocystis pneumonia, because one of the identifying characteristics of Pneumocystis jirovecii is the presence of β-1,3-glucan in its cell wall. Previous case reports in which the efficacy of caspofungin was found to be favourable have supported this hypothesis. However, of 4 HIV-negative patients who received caspofungin as a salvage regimen at Asan Medical Center, none showed a response. Our negative experience opposes the optimistic view of caspofungin use for Pneumocystis pneumonia expressed in previous reports.

Outcomes of non-HIV-infected patients with Pneumocystis pneumonia and concomitant pulmonary cytomegalovirus infection.

Abstract Background: The pathogenic effect of concomitant pulmonary cytomegalovirus (CMV) infection on morbidity and mortality of Pneumocystis jirovecii pneumonia (PCP) has been questioned in the case of non-HIV-infected patients. Methods: We conducted a retrospective cross-sectional study of patients who were diagnosed with PCP by bronchoalveolar lavage. We compared demographics, clinical characteristics, morbidity, and mortality in non-HIV-infected PCP patients with (n = 31) and without (n = 75) pulmonary CMV infection. Morbidity was assessed by length of hospital stay, admission to the intensive care unit, and use of mechanical ventilation. Mortality was defined as 30-day and 90-day all-cause mortality. Results: Morbidity and mortality did not differ between PCP patients with and without pulmonary CMV infection. In multivariate analysis using the Cox proportional hazard model, haematological malignancy (relative risk (RR) 0.20, 95% confidence interval (95% CI) 0.06–0.71), PCP treatment duration (RR 0.81, 95% CI 0.75–0.88), changing to a second-line regimen due to treatment failure (RR 4.51, 95% CI 1.61–12.64), and mechanical ventilation (RR 17.99, 95% CI 4.83–67.04) were independently associated with 30-day all-cause mortality. Being a solid organ transplant recipient (RR 0.17, 95% CI 0.05–0.56) and the use of mechanical ventilation (RR 6.49, 95% CI 2.84–14.83) were independently associated with 90-day all-cause mortality. However, concomitant pulmonary CMV infection was not associated with either 30-day or 90-day mortality. Conclusions: Our results suggest that concomitant pulmonary CMV infection does not significantly affect the prognosis of PCP, as indicated by morbidity and mortality in non-HIV-infected patients with PCP. Based on this result, we propose that it is not essential to administer an anti-CMV regimen when CMV is co-isolated from the bronchoalveolar lavage in patients with PCP.

Clinical and molecular characterization of rhinoviruses A, B, and C in adult patients with pneumonia

BACKGROUND Human rhinoviruses (HRVs) have increasingly been reported to be associated with lower respiratory tract infections. HRV-C has been associated with more severe respiratory illnesses in children. OBJECTIVES We investigated the clinical and molecular characteristics of HRV-A, HRV-B, and HRV-C in adults with pneumonia. STUDY DESIGN HRV genotyping and quantitative real-time reverse-transcriptase polymerase chain reaction were performed on 392 adult respiratory specimens consecutively collected from June 2012 to May 2013. Pneumonia was identified by review of medical records and chest radiographs. RESULTS Adult patients with pneumonia and identified HRV genotypes (n=165) were included. HRV-A, HRV-B, and HRV-C were identified in 97, 28, and 40 patients, respectively. No differences in underlying diseases, APACHE II score, or frequency of co-infection were observed between the HRV species. Compared with HRV-A, HRV-B was more often associated with neutropenia (21.4% vs. 7.2%, p=0.07), hospital acquisition (32.1% vs. 7.2%, p=0.048), and fever (78.6% vs. 49.3%, p=0.003). Mean viral load (copies/ml) was lower for HRV-B (10(2.6) vs. 10(4.1) in HRV-A and 10(4.3) in HRV-C), and high viral loads (≥10(4)) occurred most frequently with HRV-C (70.0% vs. 57.7% for HRV-A and 21.4% for HRV-B). The incidence of severe pneumonia was similar for HRV-A (18.6%), HRV-B (21.4%), and HRV-C (20.0%), and in-hospital mortality rates did not differ significantly (15.5%, 10.7%, and 12.5%, respectively). CONCLUSIONS In contrast to previous pediatric studies, no differences were observed in clinical severity or outcomes between the different HRV species in adult patients with pneumonia.

Risk factors for hospital-acquired pneumonia caused by carbapenem-resistant Gram-negative bacteria in critically ill patients: a multicenter study in Korea

We performed a case-control study to identify risk factors of carbapenem-resistant Gram-negative bacteria (CRGNB) as an increasing cause of hospital-acquired pneumonia (HAP). The study included critically ill adult patients with HAP whose microbial etiology was identified at eight tertiary centers in Korea between June 2008 and December 2009. Eighty two patients with 86 isolates of CRGNB (62 Acinetobacter baumannii, 14 Pseudomonas aeruginosa, and 10 Stenotrophomonas maltophilia) were included in the case group, and 122 patients with carbapenem-susceptible Gram-negative bacteria were included in the control group. Diabetes mellitus (adjusted odds ratio [aOR] 2.82, 95% confidence interval [95% CI] 1.25-6.38), radiologic score ≥5 (aOR 4.56, 95% CI 2.36-8.81), prior fluoroquinolone (aOR 2.39. 95% CI = 1.07-5.35), or carbapenem usage (aOR 2.82, 95% CI 1.75-17.83) were found to be independent risk factors. Fluoroquinolone and carbapenem should be cautiously used to avoid HAP caused by CRGNB.

Risk factors for mortality in patients with invasive mucormycosis.

Background Mucormycosis is an uncommon and life-threatening fungal infection. The clinical predictors of outcome were evaluated in patients with invasive mucormycosis. Materials and Methods We retrospectively reviewed histologically proven cases of invasive mucormycosis in our institution from 1996 to 2012. Results A total of 64 patients were analyzed. The median age was 59 years (interquartile range [IQR], 50-67), and 32 patients (50%) were male. The most common underlying diseases were diabetes mellitus (67%), hematologic malignancy (22%), and solid cancer (19%). The most common infection sites were the rhino-orbito-cerebral area (56%) and the lungs (31%). The 180-day all-cause mortality was 33%. Disseminated infection was associated with increased mortality (hazard ratio [HR]: 169.74, 95% confidence interval [CI]: 6.41 to 4492.64; P = 0.002). Pulmonary infection (HR: 0.08, 95% CI: 0.01 to 0.66; P = 0.02) and complete surgical removal of infected tissue (HR: 0.12, 95% CI: 0.02 to 0.64; P = 0.01) were associated with decreased mortality. Conclusions These results suggest that patients with mucormycosis had a lower risk of mortality if they developed a pulmonary infection, rather than a disseminated infection and with complete debridement of infected tissue.

Clindamycin-primaquine versus pentamidine for the second-line treatment of pneumocystis pneumonia

There are limited data on the efficacy of alternative regimens for treating patients with pneumocystis pneumonia (PCP). We compared the efficacy of clindamycin-primaquine (C-P) with that of pentamidine as a secondline treatment for PCP. Among 91 patients receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a first-line treatment for PCP, 31 (34%) did not respond and 7 (8%) had adverse reactions. Fourteen patients received C-P and 9 received pentamidine as a second-line regimen because of treatment failure or an adverse reaction to TMP-SMX. The response rate of patients to C-P was higher than the response rate to pentamidine (9/14; 64% vs 1/9; 11%; P = 0.03).

Comparison of clinical manifestations, outcomes and cerebrospinal fluid findings between herpes simplex type 1 and type 2 central nervous system infections in adults.

In previous reports on the viral causes of central nervous system (CNS) infections, it has been generally recognized that HSV‐1 is a major cause of encephalitis, while HSV‐2 is the predominant cause of aseptic meningitis in adults. To examine this matter, the clinical characteristics in the two types of HSV CNS infections were investigated. In a retrospective cohort study which included all adult patients (≥16 years) between January 1999 and December 2013 in a 2,700‐bed tertiary care hospital, all the patients in whom PCR of the CSF for HSV was positive were identified. Ninety‐five patients with positive CSF PCR results for HSV were included, 21 with HSV‐1 and 74 with HSV‐2. Many patients with HSV‐1 had encephalitis (13/21, 61.9%), whereas most patients with HSV‐2 had meningitis (62/74, 83.8%). However, HSV‐1 and HSV‐2 accounted for similar proportion of patients with HSV encephalitis (13/25, 52.0% vs. 12/25, 48.0%). Neurological sequelae were more frequent among patients with HSV‐1 (9/21, 42.9% vs. 6/74, 8.1%; P = 0.001). The present study suggests that HSV‐2 is not only a major cause of aseptic meningitis, but also it may cause serious manifestation as HSV‐1 encephalitis in adults. J. Med. Virol. 86: 1766–1771, 2014.