Diagnosis Of Severe Community-acquired Pneumonia Research Articles

The Role of Ultrasound in Diagnosing Community-Acquired Pneumonia

BACKGROUND The literature review is devoted to an urgent problem of the diagnosis of pneumonia in the practice of an anesthesiologist-resuscitator using ultrasound. The literature review describes the methodological foundations of this method, its advantages and disadvantages, sensitivity and specificity for the diagnosis of severe community-acquired pneumonia in the practice of an anesthesiologist-resuscitator.AIM OF STUDY The analysis of the most modern domestic and foreign evidence base based on the information content of lung ultrasound in CAP in the practice of an anesthesiologist-resuscitator.MATERIAL AND METHODS Russian publications were searched in the elibrary.ru database, foreign publications were searched in the PubMed database. Publications (literature reviews, observational studies, double-blind randomized trials) were searched for the period 2010–2020. A total of 1379 publications were initially selected, identified through database searches. After removing duplicates, the number of publications was reduced to 695. Of this number, 503 publications were excluded. The remaining 192 full-text articles were evaluated for text acceptability. Due to inconsistency with the main sections of the review, 77 articles were deleted from them. The remaining 115 ones were included in the qualitative synthesis and 67 ones were selected in the quantitative synthesis.RESULTS The ultrasound is a promising and worthy alternative to other imaging modalities. According to the results chest X-ray was inferior to lung ultrasound in diagnosing the presence of fluid in the pleural cavities. The sensitivity of ultrasound in assessing pleural effusion reaches 100%, the specificity is 99.7%. Pulmonary ultrasonography plays an important role in the diagnosis of pneumonia and is a promising alternative to chest X-ray and chest CT.DISCUSSION Since POCUS is performed at the patient’s bedside, the results are available to the doctor in real time, which helps in diagnosis and treatment. Sequential examinations can be performed to monitor disease progression and response to treatment. However, many facilities do not have the ability to store ultrasound images, so other healthcare professionals cannot see them.FINDINGS The ultrasound examination of the lungs is unlikely to replace computed tomography of the chest, as it does not have 100% specificity, however, it is indispensable in bedside examination and is the doctor’s sonographic “stethoscope”, which significantly expands diagnostic capabilities.

Predictive factors and outcomes of severe community acquired pneumonia in patients with respiratory failure

Objectives:To explore the risk factors, pathogens and outcomes of severe community-acquired pneumonia (SCAP) in patients with respiratory failure.Methods:A prospective observational study was conducted at Northwest General Hospital & Research Centre, Peshawar, Pakistan from February 2016 to October 2018. All patients with Community-acquired pneumonia (CAP) who fulfilled the inclusion criteria were recorded consecutively. Diagnosis of SCAP was made following the criteria established by the IDSA/ATS in the consensus guidelines on the management of CAP in adults published in 2007. In-hospital mortality was the main outcome.Results:The final analysis comprised a total of 100 patients with SCAP. The mean age was 60.0±18.01 years, and 54.0% were female patients. Afghani patients represented 22.0% of the total patients. The most common comorbidity associated with SCAP was hypertension (42.0%). The most commonly isolated etiological agents were Acinetobacter baumannii, followed by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli. In-hospital mortality was 45%. On multivariate analysis, factors associated with in-hospital mortality were age (OR 1.054; 95%Cl 1.01-1.10; p=0.021), presence of two or more complications (OR 4.51; 95%Cl 1.18-17.28; p=0.028), septic shock (OR 6.44; 95%Cl 1.55-26.803; p=0.010), length of mechanical ventilation (OR 1.17; 95%Cl 1.01-1.40; p=0.043), and paO2 (OR 4.51; 95%Cl 1.18-17.28; p=0.004).Conclusion:A high mortality rate was observed in our study. Age, presence of two or more complications, septic shock, length of mechanical ventilation, and low paO2 were identified to be independent predictors of mortality for patients with SCAP.

Клинико-лабораторные маркеры тяжести течения новой коронавирусной инфекции (COVID–19)

The aim of the research. To study clinical and laboratory features of the new coronavirus infection (COVID-19) in order to develop a model that would allow, taking the publicly available research methods into account, to carry out early diagnosis of severe community-acquired pneumonia against the background of the new coronavirus infection. Material and methods. A total of 82 COVID-19 patients who complied with inclusion and exclusion criteria were enrolled. Depending on the clinical severity, three study groups were formed: group 1 included 13 patients with uncomplicated COVID-19, group 2 consisted of 39 patients with non-severe forms of pneumonia that developed against COVID-19 and group 3 was comprised of 30 patients with COVID-19 complicated by severe pneumonia. The groups were comparable in age and gender. All patients underwent general clinical examination, laboratory tests, including general and biochemical blood analysis, as well as chest computed tomography. Results. The clinical picture in COVID-19 patients differed depending on the disease severity. Coughing and shortness of breath were more often observed in patients with severe pneumonia; sore throat, on the contrary, was more often noted in patients with uncomplicated COVID-19. On admission to the inpatient facility, patients with severe pneumonia had higher body temperature and respiratory rate, with simultaneous decrease in blood oxygen saturation. One half of the patients with severe pneumonia had hypertensive disease in medical history, and one third had ischaemic heart disease. As a rule, uncomplicated COVID-19 patients did not have ischaemic heart disease. It was found through laboratory analysis of blood that groups of patients significantly differed in the levels of neutrophils, lymphocytes, monocytes, basophils and eosinophils. Conclusion. The use of such clinical and laboratory data as acute respiratory failure, fever, the levels of neutrophils, monocytes, lymphocytes, eosinophils and basophils makes it possible to identify patients with more severe pneumonia against the background of COVID-19 even before chest computed tomography.

Adherence to Guidelines for Assessment and Empiric Antibiotics Recommendations for Community-Acquired Pneumonia at Ambo University Referral Hospital: Prospective Observational Study.

ObjectiveThe high incidence and substantial morbidity and mortality associated with community-acquired pneumonia necessitate an accurate assessment and appropriate management of patients. This observational prospective study aimed to evaluate the physicians’ adherence to the Ethiopian Standard Treatment Guideline for assessment and an empiric antibiotic selection for Community-acquired pneumonia.ResultsThe study indicated that the pneumonia severity assessment tool, CURB-65 score, was never used. Of 141 patients referred to an admitting diagnosis of severe community-acquired pneumonia, only 50 were subsequently found to satisfy the guideline criteria, over-diagnosis of 41.9%. Large proportions of the participants (130, 60%) were prescribed antibiotics in the last three months. The most commonly prescribed single antibiotic was Ceftriaxone (47, 21.7%), while ceftriaxone plus azithromycin was the most common combination, 110 (50.7%). In general, the extent of non-adherence to the national guideline for the use of antibiotics was 36.4%. In conclusion, the use of CRB65 scores was uncommon in the study setting. Poor adherence to Ethiopian Standard Treatment Guideline regarding the decision of hospital admission (41.9%) and the antimicrobial selection (36.4%) was determined.

Blind Spots of Traditional Microbiological Tests for Severe Community-Acquired Pneumonia in Adults and Availability of Nonculture Techniques: A Nationwide Survey of Physicians in China

In China, no national survey has been conducted to evaluate physicians' attitudes and compliance with guidelines in the management of adult patients with community-acquired pneumonia (CAP). Therefore, this study aimed to evaluate physicians' awareness of the use of microbiological tests in the management of severe CAP (SCAP) and to investigate the availability of nonculture tests in China. A nationwide electronic questionnaire survey was conducted among Chinese physicians between March and July 2018, which assessed their viewpoints concerning the issues in the management of SCAP. A total of 6333 physicians completed this survey, evenly covering all career stages. Among these, 3208 (50.6%) and 1936 (30.6%) had blind spots in the application of blood and sputum cultures in the management of SCAP, respectively. Nonteaching hospital, nonrespirologists, and junior career stage were independently associated with misunderstandings. Regarding nonculture methods, 52.7% of the facilities had no access to polymerase chain reaction-based pathogen detection tests. The accessibility of urinary antigen tests for Streptococcus pneumoniae (42.5%) and Legionella pneumophila (38.5%) was also low. The main barriers were inland and remote region, lower hospital level, and nonteaching hospital. Insufficient use of sputum and blood cultures, together with low accessibility of major nonculture techniques, were noticeable barriers to achieving microbiological diagnosis of SCAP in China. To help curb the overuse of broad-spectrum antibiotics, further measures should be taken to raise awareness among nonspecialists and promote rapid nonculture tests, especially in nonteaching hospitals and developing regions.

Ceftaroline for severe community-acquired pneumonia: A real-world two-centre experience in Italy and Spain

BackgroundCeftaroline is one of latest additions to the armamentarium for treating community-acquired pneumonia (CAP). This study aimed to describe the outcome of severe CAP (SCAP) in a cohort of hospitalised patients treated with ceftaroline. MethodsA retrospective, observational study of patients with SCAP treated with ceftaroline in two hospitals in Spain and Italy. The primary objective was to explore 30-day mortality after diagnosis of SCAP. ResultsDuring the study period the following were observed: there were 89 cases of SCAP treated with ceftaroline and 53 cases used in combination with other antibiotics (60%). Overall, 30-day mortality and clinical failure were 20% (18 of 89) and 36% (32 of 89), respectively. Independent predictors of 30-day mortality were: increasing age (OR for 1 year increase 1.0, 95% CI 1.0–1.1, P 0.043), presence of solid neoplasm (OR 4.0, 95% CI 1.0–15.1, P 0.044) and concomitant therapy with oseltamivir (OR 8.5, 95% CI 1.2°57.3, P 0.029). The only independent predictor of clinical failure was the time elapsing from SCAP diagnosis to ceftaroline therapy (OR for each passing day 1.5, 95% CI 1.1–1.9, P 0.003). The clinical success rate was 64% (57 of 89). In the subgroups of patients with proven Streptococcus pneumoniae, methicillin-susceptible Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) infection, clinical success was 83% (10 of 12), 75% (three of four) and 56% (five of nine), respectively. ConclusionsConsidering its spectrum of activity, ceftaroline could represent an important therapeutic option for SCAP. Further studies are needed to identify the precise clinical success rate against MRSA in a larger cohort of patients with SCAP.

Diagnosis of severe community-acquired pneumonia caused by Acinetobacter baumannii through next-generation sequencing: a case report

BackgroundAcinetobacter baumannii is a gram-negative aerobic bacillus that is commonly causes of hospital-acquired infections. Community-acquired pneumonia caused by Acinetobacter baumannii (CAP-Ab) is rare but fatal if diagnosis and treatment are delayed. Conventional culture of clinical specimens is the main method for clinical diagnosis of A. baumannii infections which may suffer from limited positive rate and is time consuming. Timely and precise diagnosis of CAP-Ab remains challenging.Case presentationA 66-year-old man with 24 h history of acute fever and dyspnea was admitted to our hospital. He was diagnosed as severe community acquired pneumonia (CAP), septic shock, respiratory failure and acute kidney injury. Next-generation sequencing (NGS) was performed on the patient’s sputum and blood, which identified numerous A. baumannii nucleotide sequences in the sample of sputum and led to the rapid diagnosis and treatment of community acquired pneumonia caused by A. baumannii. This result was confirmed by subsequent sputum culture.ConclusionsThis case described that the successful application of the next generation sequencing assisting the speedy diagnosis of A. baumannii infection provides a new idea for the timely diagnosis of CAP-Ab and highlights that NGS is a promising tool in rapid etiological diagnosis of acute and severe infectious diseases.

Abstract P-175: RISK FACTORS FOR MORTALITY IN CHILDREN WITH SEVERE COMMUNITY-ACQUIRED PNEUMONIA ADMITTED TO AN PEDIATRIC INTENSIVE CARE UNIT

Aims & Objectives: To determine the clinical characteristics and outcome of severe community-acquired pneumonia (S-CAP) in children admitted to PICU of one referral center and to identify risk factors for poor outcomes. Methods Retrospective study that included children admitted to PICU of the Institute of Tropical Medicine of Asuncion, from 2004 to 2016 with a diagnosis of S-CAP. Clinical, microbiological and outcome were obtained from patient records, with emphasis in the analysis of duration of mechanical ventilation (MV), duration of stay in the PICU, and survival or death. Associations of variables with mortality were tested using standard statistical tools. Results During the study period, 222 children with S-CAP was admited to PICU, with a mean age of 38,1 + 47,8 months, and a male/female ratio of 1.7:1. Eighty-nine patients (40%) required VM. Bacteremia was observed in 42 patiens (19%). Staphyloccus aureus (27 patients, 12%) and Streptococcus pneumoniae (12 patients, 5%) were the most frequent organims isolated. The mean duration of stay in the PICU was 12,7 ± 11,6 days and the mortality was 18.9% (42 patients). Risk factors associated with mortality were leukopenia (WBC< 4500/mm3) [p<0,0009 RR 2.34 (1.3-4,2)], presence of bacteremia [p<0,00001 RR 2,88 (1,7-4,8)], staphyloccocal etiology [p=0.01 RR2,23 (1,2-4)], and mechanical ventilation requirement [p <0,000001 RR 60,35 (8,5 - 430.8)] Conclusions Severe pediatric pneumonia accounts for a significant number of PICU admissions in our country and is associated with significant mortality (18,9%),. The presence of leukopenia, bacteremia and mechanical ventilatory requirement were identified as early prognostic variables independently associated with poor clinical outcome.

Analysis on risk factors for severe community acquired pneumonia in the elderly

Objective To evaluate the risk clinic factors of severe community-acquired pneumonia in older adults, and to provide examples for its clinic application. Methods Sixty-four case patients who were admitted for a diagnosis of severe community-acquired pneumonia in older adults in Beijing Haidian Hospital from January 2013 to July 2015 were selected as observation group.One hundred cases patients also admitted for a diagnosis of community-acquired pneumonia were selected as control group.Within 24 h of admission, the clinical data were collected, medical history were collected, and the serum biochemistry, coagulation index fibrin degradation product, D-dimer and inflammatory factor procalcitonin were detected.The data were analyzed by univariate analysis, and logistic regression analysis was used to analyze the variables with significant difference in single factor analysis. Results Single factor analysis showed that the percentage of severe pneumonia with central nervous system disorders, severe pneumonia with aspiration, severe pneumonia with two or more comorbidities, aspiration and severe pneumonia with bedridden patient in observation group were obviously higher than the control group, the difference between two groups have remarkable statistical significance((82.21%(53/64) vs.32%(32/100), 60.93%(39/64) vs.1%(1/100), (84.37%, 54/64) vs.54%(54/100), 90.62%(58/64) vs.28%(28/100), 59.37%(38/64) vs.11%(11/100); P<0.01 or P<0.05). The mortality of observation group was higher than the control group, the difference between two groups have remarkable statistical significance(56.62%(36/64)] vs.3%(3/100), P=0.001). Albumin of severe pneumonia was obviously lower than the control group, the difference between two groups have remarkable statistical significance((27.79±8.53) g/L vs.(33.66±9.63) g/L, P=0.011). Fibrin degradation product of severe pneumonia was obviously lower than the control group, the difference between two groups have remarkable statistical significance((10.98±1.32) ng/L vs.(3.61±0.98) ng/L, P=0.002). D- dimer of severe pneumonia was obviously higher than the control group, the difference between two groups have remarkable statistical significance((2.68±0.56) mg/L vs.(0.42±0.12) mg/L, P=0.001). Procalcitonin of severe pneumonia was obviously higher than the control group, the difference between two groups have remarkable statistical significance ((1.63±0.32) ng/L vs.(0.13±0.21) ng/L, P=0.015). The result of multiple factors logistic regression analysis showed the aspiration, hypoproteinemia, D-dimer were severe community-acquired pneumonia in older adults's independent risks(OR=1.782, 1.208, 1.356, P<0.05). Conclusion Aspiration, hypoproteinemia, D-dimer are the factors of risking suffering severe community-acquired pneumonia in older adults.D-dimer could be the detection index of severe community-acquired pneumonia in older adults. Key words: Community-acquired pneumonia; Older; D-dimer; Aspiration

Mortality predictors in patients with severe community-acquired pneumonia requiring ICU admission

Community-acquired pneumonia (CAP) is a major cause of mortality. This prospective study was conducted to describe patient’s characteristics, mortality rate, and etiological pathogens in patients with severe CAP who required ICU admission and to determine the predictors of mortality. This was a multicenter prospective observational study of 57 consecutive patients who were admitted to the ICU with diagnosis of severe CAP from October 2012 to August 2015. Overall 57 patients were included in the study and the overall ICU mortality rate was 49.1%. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities associated with severe CAP. Comparison between survivors and nonsurvivors revealed that mortality was associated with old age (P=0.01), low diastolic blood pressure (P=0.04), low PaO2/FiO2 (P=0.04), high acute physiology and chronic health evaluation II (APACHE II) score (P=0.001), (CURB-65) score (P=0.005), low hemoglobin (P=0.008), and high urea (P=0.04). The univariate analysis demonstrated that the following were the predictors of mortality: age older than 65 years (P=0.03); APACHE II score greater than 20 (P=0.007); CURB-65 of 3 or greater (0.03); total leukocyte count less than 4 or greater than 11×109/(P=0.04); PaO2/FiO2 less than 250 (P=0.03); serum urea greater than 30 mg/dl (P=0.04); presence of septic shock (P=0.003); mechanical ventilation requirement (P=0.02); and bilateral or multilobar infiltrate on chest radiograph (P=0.03). Multiple regression analysis identified high APACHE II score (>20) and septic shock as significant independent predictors of mortality in severe CAP. Microbiological identification was obtained in 52.6% of cases, with positive blood culture in 17.5%. The most frequently isolated pathogens were Streptococcus pneumonia (S. pneumonia) (19.3%) and Staphylococcus aureus (S. aureus) (15.8%). Mortality rate in patients with severe CAP was high as reported by most of the other studies. The presence of septic shock and high APACHE II were independent predictors of mortality. Heart disease and chronic obstructive pulmonary disease were the most common comorbidities. Microbiological identification was obtained in 52.6% of cases, and S. pneumonia and S. aureus were the most frequently isolated pathogens.

Bodybuilders pneumonia.

Bodybuilders pneumonia.

Community-acquired necrotizing pneumonia caused by methicillin-resistant Staphylococcus aureus producing Panton–Valentine leukocidin in a Chinese teenager: case report and literature review

Methicillin-resistant Staphylococcus aureus (MRSA) has now been established as an important community-acquired pathogen. Although necrotizing pneumonia caused by community-acquired MRSA (CA-MRSA) strains producing Panton-Valentine leukocidin (PVL) has been reported with increasing frequency in many countries, it has been reported in only a few children younger than 1 year of age in Mainland China. We describe a case of life-threatening necrotizing pneumonia due to PVL-positive CA-MRSA in a 15-year-old previously healthy female who presented with high fever, shivering, a dry cough, and dyspnea. Details of the clinical outcomes, microbiological data, and therapies for this patient were collected and compared with those of cases reported in the literature on CA-MRSA. Computed tomography (CT) findings showed cavitary consolidations in both lungs and bilateral pleural effusion. MRSA strains isolated from the patient's sputum and pleural fluid were susceptible to most non-β-lactam antimicrobial agents except for clindamycin and erythromycin. Both of these isolates tested positive for the mecA gene as well as PVL genes, and were identified as ST59-MRSA-SCCmec type IV-spa type t437. The patient was treated successfully with linezolid, fosfomycin, and teicoplanin. To our knowledge, this is the first report from Mainland China of necrotizing pneumonia due to PVL-positive CA-MRSA among those aged older than 1 year. CA-MRSA necrotizing pneumonia should be considered in the differential diagnosis of severe community-acquired pneumonia, particularly in previously healthy individuals.

Etiology and outcome of severe community acquired pneumonia in immunocompetent adults

BackgroundCommunity Acquired Pneumonia (CAP) is a commonly encountered disease, one third of which is Severe Community Acquired Pneumonia (SCAP) that can be potentially fatal. There is a paucity of data on etiology and outcome of patients with SCAP in South Asian Population.MethodsA retrospective cross-sectional study was conducted from March 2002 till December 2008 on patients of 16 years and above who were admitted with the diagnosis of SCAP in accordance to the criteria of American Thoracic Society Guidelines (2001). The patients underwent clinical and diagnostic evaluations to detect the severity of illness as well as the etiology and other risk factors influencing the eventual outcome of SCAP.ResultsA total of 189 patients were included in the study. The mean age was 60 ± 18.0 years and 110 (58%) patients were males. The most common isolated pathogens were Staphylococcus aureus (15 patients), Streptococcus pneumoniae (14 patients) and Pseudomonas aeruginosa (9 patients). The highest mortality was seen in patients with Pseudomonas aeruginosa (89%) and Staphylococcus aureus (53%). Overall mortality rate was 51%. On univariate analysis, septic shock (p <0.001), prior antibiotic use (p = 0.04), blood urea nitrogen > 30 mg/dl (p = 0.03), hematocrit < 30% (p = 0.03) and Acute Physiology and Chronic Health Evaluation (APACHE) II score > 20 (p < 0.001) were significantly different between the patients who survived as compared to those who did not. On multivariate analysis, septic shock (p <0.001, OR: 4.70; 95% CI= 2.49-8.87) was found to be independently associated with mortality.ConclusionThe microbes causing SCAP in our study are different from the usual spectrum. Staphylococcus aureus and Pseudomonas aeruginosa were the common causative pathogens and associated with high mortality. It is important to establish clinical guidelines for managing SCAP according to the etiologic organisms in our setting.

A 17‐year‐old girl with severe respiratory failure and circulatory shock

A 17-year-old girl presented to her general practitioner with a 1-week history of fever, arthralgia, general malaise and dry cough. She had a history of systemic onset juvenile idiopathic arthritis (SOJIA), diagnosed at age 2 years and treated with aspirin, and had been in remission for 13 years. She was initially treated by her GP with oral roxithromycin, and admitted to hospital 3 days later with worsening of her symptoms. Her admission chest x-ray (Box 1) revealed bilateral perihilar infiltrates. A diagnosis of severe community-acquired pneumonia was made and broad spectrum antibiotics were commenced, including vancomycin, moxifloxacin, and oseltamivir. Despite this treatment, her condition deteriorated. On Day 3 of admission she required endotracheal intubation and circulatory support with noradrenaline 18n50 mg/kg/min, and was admitted to the intensive care unit (ICU). She remained hypotensive, with a mean arterial pressure of 50mmHg, and with sinus tachycardia of 132 beats/min, and subsequently required renal replacement therapy. She remained febrile for the first 3 days after admission (temperature range 37.5dCn39dC), and her temperature settled to normal after appropriate therapy was initiated. Investigations included a computed tomography scan of her abdomen, which showed hepatosplenomegaly, and liver function tests, which showed elevated conjugated bilirubin (36 mmol/L; reference range [RR], l 4mmol/L), g -glutamyl transferase (84U/L; RR,l 24 U/L), lactate dehydrogenase (3540U/L; RR, 150n280U/L), alanine aminotransferase (108U/L; RR, 10n30U/L) and aspartate transaminase (388U/L; RR, l 30U/L). Other abnormal parameters were her haemoglobin level (93g/L; RR, 120n160 g/L), platelet count (65 x 109/L; RR, 150n400 109/L), white cell count (2.9 x 109/L; RR, 4.5n13 x 109/L), international normalised ratio (2.1; RR, 0.9n1.2) and fibrinogen level (0.9 g/L; RR, g 2.5 g/L). Elevated inflammatory markers included C-reactive protein (301mg/L; RR, l 5mg/L) and serum ferritin (50 500mg/L; RR, 7n140 mg/L). A transthoracic echocardiogram showed a left ventricular ejection fraction of 60%, a mild reduction in right ventricular contractility, and a right ventricular systolic pressure of 48mmHg. A full screen for sepsis was performed, including a nasopharyngeal aspirate, bronchoalveolar lavage, blood cultures and serological testing; all were unremarkable. Other immunological tests performed were for Mycoplasma pneumoniae antibodies, Streptococcus pneumoniae urinary antigen, Legionella pneumophila urinary antigen, herpes simplex virus, cytomegalovirus, EpsteinnBarr virus (EBV) IgM and IgG, influenza A and B, H1N1 influenza RNA, respiratory syncytial virus, parainfluenza and adenovirus DNA, Q fever (Coxiella burnetti) IgM and IgG, and serological tests for hepatitis, dengue fever IgM and Leptospira IgM, all of which were non-reactive. Urinalysis revealed a white blood cell count of 140 x 106/L (RR,l 10x 106) and an erythrocyte count of g 500x 106/L (RR,l 10x 106/L) with no microbial growth on culture. A bone marrow aspirate with trephine was performed on Day 4 (Day 2 in the ICU), and EBV DNA was detected in the resulting sample using a qualitative DNA test. The patientrs failure to improve, in combination with her past history of SOJIA, hepatosplenomegaly and a very high ferritin level led to a preliminary diagnosis of macrophage activation syndrome (MAS). Immunosuppressive treatment in the form of high-dose methylprednisolone (10mg/kg daily) and intravenous immunoglobulin (1 g/kg daily) were commenced. Inotrope and ventilatory requirements improved within 24 hours of this treatment. On Day 9 of admission she was extubated, and was discharged home on high-dose steroids 8 days later with no complications. Her bone marrow aspirate histological examination showed haemophagocytosis which confirmed the diagnosis of MAS (Box 2).

Severe adenovirus community-acquired pneumonia mimicking Legionella

Dear Editor, I read with interest the report of Drs. Hakim and Tleyjah on severe adenovirus pneumonia in your journal [1]. Their literature review reminds us of the reemergence of adenoviral community-acquired pneumonia (CAP) and that it may mimic other causes of CAP, particularly the atypical pneumonias, e.g., Legionnaire’s disease [2, 3]. As the authors correctly state, adenovirus is the only viral cause of CAP that may resemble bacterial pneumonia with focal/ lobar infiltrates or consolidation. However, as with other viral causes of pneumonia, early the chest X-ray in adenoviral CAP may be normal, even when the patient is short of breath and hypoxemic. The two most likely radiologic presentations of adenovirus is a completely normal chest X-ray with hypoxemia and symptoms of pneumonia or with lobar infiltrate/consolidation. Unlike influenza, routinely associated with leukopenia, adenoviral CAP is associated with a normal or elevated white blood cell (WBC) count, excluding viral influenza. An important clue noted by the authors, which has been our experience as well is the presence of conjunctival suffusion when present. Another important point is that viral pneumonias are ordinarily not accompanied by loose stools/diarrhea [4]. Adenovirus is most likely to be confused in this respect with Mycoplasma pneumoniae or Legionnaire’s disease, which is a common feature of both. Adenoviral CAP in patients with lobar infiltrates mimic Legionnaire’s disease, which may be differentiated from Legionella by the absence of hyponatremia, hypophosphatemia, and highly elevated serum levels [5]. As with conjunctival suffusion, an important clue to adenoviral pneumonia is wheezing, more common in children that, if present, should suggest adenovirus [1]. Recently, we have had a case of adenoviral CAP in a normal host different to that reported by the authors. The patient was a 36-year-old immunocompetent male who presented with severe CAP with a prominent dry cough and headache. On physical examination, he had a questionable faint truncal rash and conjunctival suffusion. Auscultation of the chest revealed no rales. His WBC count was 7.3 K/ mm with monocytosis. Relative lymphopenia was not present. His platelet count was 280,000 K/mm. Because of his headache and possible rash, the question of aseptic meningitis was raised and a lumbar puncture was performed. His cerebrospinal fluid (CSF) showed 8 WBCs/hpf with a normal glucose, protein, and lactic acid level. Head magnetic resonance imaging (MRI) was negative. He was hypoxemic on room air. Both his erythrocyte sedimentation rate (ESR) and liver function tests (LFTs) were unelevated and cold agglutinin titers were negative. His creatine phosphokinase (CPK) was unelevated. Titers for Legionella, M. pneumoniae, and Chlamydia pneumoniae were negative. His Legionella urinary antigen test was negative. His adenovirus titer was elevated 1:128 (normal<1:8). As the authors suggest, adenoviral CAP is probably more common than recognized. It is an easily missed diagnosis and should be included in the differential diagnosis of severe CAP in patients. Early on, in immunocompetent CAP patients without pulmonary infiltrates, the differential diagnosis should include influenza and cytoEur J Clin Microbiol Infect Dis (2009) 28:313–315 DOI 10.1007/s10096-008-0611-6

Severe community acquired pneumonia update: mortality, mechanisms and medical intervention

Severe community-acquired pneumonia (CAP) in the intensive care unit (ICU) is associated with a high mortality rate of about 30% [1], and this rate has remained largely unaltered since the discovery of antibiotics in the 1950s [2]. Until now, no therapies have been designed specifically as adjunct agents for the treatment of severe CAP. In the majority of cases, broad-spectrum antibiotics or pathogen-directed therapies are effective in eradicating the causative organism(s), but they do not address causative effects from pathways of inflammation and coagulation, which are characteristic of the host response to infection. Initially activated as a protective host response, these inflammatory and coagulation pathways may become unregulated and paradoxically may cause tissue damage in the setting of severe CAP. A major component of both of these pathways is tissue factor (TF), a microvascular endothelial glycoprotein that becomes exposed to the systemic circulation after tissue damage. TF is an attractive therapeutic target for adjunctive treatment in severe CAP because it is the initiating factor in the TF coagulation pathway (which ultimately results in thrombin generation and fibrin deposition) [3] and has been shown to stimulate directly the production and release of proinflammatory cytokines (through the protease-activated receptor system) [4]. The largest phase III randomized, placebo-controlled study ever undertaken in patients with severe CAP is currently underway to investigate whether targeting the TF pathway with a specific TF pathway inhibitor can significantly reduce 28-day all-cause mortality in the primary target population. The objective of this symposium is to review the epidemiology of severe CAP, examine current clinical practice and treatment guidelines, and investigate the evidence supporting the potentially central role of TF in the pathophysiology of severe CAP. Jordi Rello MD, PhD is Chief of the Critical Care Department at the Joan XXIII University Hospital in Tarragona, Spain. Professor Rello has been actively involved in clinical research for the past 20 years, focusing on the prevention and control of hospital-acquired infections, severe CAP and treatment of infections in critically ill patients. His presentation focused on the epidemiology, diagnosis and severity scoring of severe CAP, and the impact that treatment guidelines have had [5]. Tom van der Poll MD, PhD is Head of the Centre for Experimental and Molecular Medicine in the Academic Medical Centre in Amsterdam. His research is based in the Centre for Infection and Immunity Amsterdam (CINIMA) and focuses on innate immune responses to bacterial and myco-bacterial infection. He also serves on the Steering Committee of the International Sepsis Forum. His presentation focused on the pathogenesis of severe CAP, in particular covering the roles played by TF as a critical component of the infectious, inflammatory and coagulation pathways [6]. Pierre-Francois Laterre MD is Head of the Intensive Care Unit at St. Luc University Hospital, Universite Catholique de Louvain in Brussels, Belgium. Professor Laterre's professional and scientific activities have focused on the diagnosis, investigation and treatment of sepsis, particularly its interaction with the coagulation cascade. As Co-Chair for the symposium, his presentation focused on the rationale for TF as a therapeutic target in severe CAP and reviewed the design of the ongoing phase III CAPTIVATE study of tifacogin [7]. Jean-Paul Mira MD is Professor of Critical Care Medicine and Chair of the Medical Intensive Care Unit at the Cochin University Hospital; he is also Head of the Variability of Innate Immunity Research Laboratory at the Cochin Institute, both in Paris, France. His research interests are cellular responses to micro-organisms, Toll-like receptor signalling, functional genomics, genetic predisposition to sepsis and sepsis-induced immunosuppression. His presentation focused on the potential for biomarkers to assist physicians in the diagnosis of severe CAP and their possible future role in directing appropriate treatment [8]. The second Co-Chair, Steve Opal MD, who is Professor of Medicine from the Brown Medical School, Pawtucket, Rhode Island, USA, hosted the questions from the audience and directed responses from faculty.