Acute Interstitial Pneumonia Research Articles

Pathology, isolation and characterisation of virulent and diverse Mannheimia haemolytica and Pasteurella multocida associated with fatal pneumonia in sheep, Rajasthan, India

Pneumonia, a major sheep disease, causes high mortality among affected animals predominantly the lambs. It is caused by a number of microbes including Mannheimia haemolytica/Pasteurella multocida. It was aimed to explore the pathology in the lungs due to pneumonia, and to isolate and characterise the virulent M. haemolytica/P. multocida strains. The lung tissues and heart blood specimens were collected by necropsy of sheep (n = 96). These samples were used for isolation and characterisation of M. haemolytica/P. multocida. Moreover, the fresh and square-shaped lung pieces were also taken to perform the histopathological analysis. Grossly, the petechial and ecchymotic haemorrhages, congestion and consolidation in lung lobes were observed at necropsy. Pneumonia was diagnosed as acute fibrinous-bronchopneumonia (36), suppurative chronic bronchopneumonia (10), acute interstitial pneumonia (32) and acute pulmonary congestion (18) based on histological lesions. Bacterial isolation recovered M. haemolytica alone or along with P. multocida and/or Bibersteinia trehalosi identified by phenotypic characters and sequencing of 16S rRNA. Haemolytic colonies were documented to carry the PHSSA, plpE and Rpt2 genes. P. multocida identification at species level was carried out by KMT1 gene detection. These isolates were noted to carry the capsule types A (hyaD-hyaC gene) and D (dcbF gene) and outer membrane protein genes ompH and omp87. Sequencing revealed nucleotide variability in Rpt2, ompH and omp87 genes.We highlighted the occurrence of fatal ovine pneumonic pasteurellosis/mannheimiosis caused and/or complicated by virulent M. haemolytica/P. multocida strains.

Staphylococcus pseudintermedius septicemia in puppies after elective cesarean section: confirmed transmission via dam\u2019s milk

BackgroundIn humans, transmission of bacteria causing fatal sepsis in the neonates through mother’s milk has been reported. In dogs, it is believed that bacteria from canine milk are not the primary cause of neonatal infections. Staphylococcus pseudintermedius is colonizing the skin and mucocutaneous junctions in adult dogs and can act as an opportunistic pathogen. This bacterium was previously isolated from the canine milk and, although, its transmission from the dam’s milk to the newborn puppies causing a neonatal sepsis was suggested, this hypothesis has not been confirmed.Case presentationA 4.5-year-old healthy Boston terrier dam had an elective cesarean section, delivering five normal puppies and one dead runt. Next day, two puppies developed pustules on their legs and around the muzzle. After two more days, strings of blood were noticed in the stool of the biggest puppy that suddenly died later that night. The same day, blood became visible in the feces of all other puppies. Necropsy of the dead puppy revealed a distended abdomen, catarrhal gastroenteritis with lymphadenopathy, dark red and slightly firm lung, mild dilatation of the right heart chamber and congestion of the liver, spleen, pancreas and meninges. The thoracic cavity contained white-yellow slightly opaque exudate, and there was transudate in the abdominal cavity. Histopathology revealed an acute interstitial pneumonia and multifocal myocardial necrosis with mineralization. Bacteriology of the internal organs, body cavity effusions of the dead puppy and dam’s milk revealed a diffuse growth of S. pseudintermedius in pure culture. Whole genome sequencing (WGS) revealed that all isolates belonged to the sequence type 241 and differed in 2–5 single nucleotide polymorphisms; thus, the epidemiological link between the outbreak-associated isolates was confirmed.ConclusionsThis is the first report of a confirmed transmission of S. pseudintermedius through dam’s milk causing a neonatal sepsis in a puppy after an elective cesarean section. The epidemiological link between S. pseudintermedius isolates obtained from dam’s milk and internal organs of the affected puppy was confirmed by WGS. Our findings indicate that milk of healthy dams can serve as a reservoir of bacteria that can cause fatal sepsis in the newborn puppies.

Korean Guidelines for Diagnosis and Management of Interstitial Lung Diseases: Part 1. Introduction.

Idiopathic interstitial pneumonia (IIP) is a histologically identifiable pulmonary disease without a known cause that usually infiltrates the lung interstitium. IIP is largely classified into idiopathic pulmonary fibrosis, idiopathic non-specific interstitial pneumonia, respiratory bronchiolitis-interstitial lung disease (ILD), cryptogenic organizing pneumonia, desquamative interstitial pneumonia, and acute interstitial pneumonia. Each of these diseases has a different prognosis and requires specific treatment, and a multidisciplinary approach that combines chest high-resolution computed tomography (HRCT), histological findings, and clinical findings is necessary for their diagnosis. Diagnosis of IIP is made based on clinical presentation, chest HRCT findings, results of pulmonary function tests, and histological findings. For histological diagnosis, video-assisted thoracoscopic biopsy and transbronchial lung biopsy are used. In order to identify ILD associated with connective tissue disease, autoimmune antibody tests may also be necessary. Many biomarkers associated with disease prognosis have been recently discovered, and future research on their clinical significance is necessary. The diagnosis of ILD is difficult because patterns of ILD are both complicated and variable. Therefore, as with other diseases, accurate history taking and meticulous physical examination are crucial.

Safety-Related Regulatory Actions and Risk Factors for Anticancer Drugs in Japan.

The approval of anticancer drugs in Japan has increased to meet high medical demand. To maximize the benefits of anticancer drugs, adverse drug reactions (ADRs) must be properly managed. However, in some cases, clinically significant safety issues are detected after launch, and safety-related regulatory actions (SRRAs) are implemented. We aimed to determine the characteristics of SRRAs for anticancer drugs approved in Japan and to identify factors related to the drug development and regulatory approval process associated with the occurrence of an SRRA. We defined an SRRA as the issuance of a 'Yellow Letter', 'Blue Letter', or an official notification by the Ministry of Health, Labor and Welfare. Anticancer drugs approved in Japan as new active ingredients from April 2004 to July 2016 were analyzed using publicly available information. The Kaplan-Meier survival curve was plotted to estimate the probability of the occurrence of an SRRA, and the Cox proportional hazards model was used to identify risk factors associated with the occurrence of an SRRA. Independent variables were selected using backward/forward stepwise selection according to Akaike's Information Criterion. An SRRA was implemented for 38 of 63 anticancer drugs. Approximately 70% of SRRAs occurred within 2years after approval, and the median time between approval and the occurrence of an SRRA was 1.6years (interquartile range 0.94-2.4). No Yellow Letter was issued during the follow-up period; however, one Blue Letter was issued for 'acute lung injury and interstitial pneumonia' for sorafenib. According to official notifications, 'clinically significant adverse reactions' was the most revised section of package inserts (62%). The probability of an SRRA at the 1-, 2- and 3-year follow-up was 15.9% (95% confidence interval [CI] 6.4-24.4%), 41.3% (95% CI 27.8-52.3%), and 56.8% (95% CI 41.8-68.0%), respectively. Monoclonal antibodies were associated with a low risk of occurrence of an SRRA (hazard ratio [HR] 0.29, p = 0.019), while the large number of patients in pivotal studies (per 100 patients) was associated with a high risk of occurrence (HR 1.07, p = 0.012). The high-risk period for the occurrence of an SRRA for anticancer drugs in Japan was within 2years after approval. Among the factors related to the drug development and regulatory approval process, anticancer drugs in the form of non-monoclonal antibodies, and whose pivotal studies included a large number of patients, were more likely to be associated with an SRRA. Postmarketing follow-up should therefore be carefully performed, especially in the first 2years after approval and for non-monoclonal antibody anticancer drugs. Moreover, postmarketing follow-up is crucial, even if large-scale pivotal studies for regulatory approval have already been performed.

Neumonías intersticiales idiopáticas

Idiopathic interstitial pneumonias (IIPs) are a group of parenchymal lung diseases of unknown aetiology and with similar clinical, radiological and functional features. They are classified as chronic (idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia), smoking-related (respiratory bronchiolitis-associated interstitial lung disease and desquamative interstitial pneumonia), acute/subacute (cryptogenic organizing pneumonia and acute interstitial pneumonia), and rare (lymphoid interstitial pneumonia and pleuroparenchymal fibroelastosis).

Preliminary evidence that hydrostatic edema may contribute to the formation of diffuse alveolar damage in a Holstein calf model

Background: Two notable findings of clinically healthy feedlot cattle suggest they may have pulmonary hydrostatic edema during the finishing phase of production: increased pulmonary arterial wedge pressures and pulmonary venous hypertrophy. The goal of this study was to determine if increased pulmonary arterial wedge pressure (PAWP) in a Holstein calf could lead to diffuse alveolar damage consistent with the early, exudative phase of acute interstitial pneumonia of feedlot cattle. Methods: Six male Holstein dairy calves were given daily subcutaneous injections of the nonspecific ß-adrenergic agonist isoprenaline (10 mg/kg/d), to induce left ventricular diastolic dysfunction, or sterile water for 14 days. On Day 14, pulmonary arterial pressures and wedge pressures were measured, echocardiography performed, and the ratio of mitral valve flow velocity (E) to septal lengthening velocity (e’) calculated. Calves were euthanized on Day 15 and lung lesions semi-quantitatively scored. Results: Mean PAWP was 12 ± 1 mm Hg in calves that received isoprenaline and 7 ± 1 mm Hg in controls ( P = 0.01). Calves that received isoprenaline tended to have greater relative wall thickness than control calves ( P = 0.15) and greater E/e’ ratios ( P = 0.16), suggestive of concentric hypertrophy and diastolic dysfunction, respectively. Calves that received isoprenaline also tended to have a left ventricle and interventricular septum that was 29 ± 10 g heavier than control calves ( P = 0.10) when controlling for body mass. Hyaline membranes, the hallmark feature of diffuse alveolar damage, were evident in lung sections from all calves that received isoprenaline but none of the controls. Conclusions: Consistent with prior pathological and physiological studies of feedlot cattle, this study provides preliminary evidence that cattle presenting with clinical signs and pathology consistent with early stage acute interstitial pneumonia could be attributable to hydrostatic edema associated with left ventricular failure.

HIGH DOSE CORTICOSTEROIDS IN ACUTE MANAGEMENT OF ACUTE INTERSTITIAL PNEUMONIA

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Little advancements have been made in the management of acute interstitial pneumonia (AIP) since its discovery. This case report describes the use of high dose corticosteroids in the resolution of presumed AIP. CASE PRESENTATION: The patient is a middle aged, African American, nonsmoking female with a past medical history of morbid obesity and obstructive sleep apnea complicated by noncompliance with nightly CPAP who presented with a combination of fevers, chills and emesis. She was initially treated with vancomycin and pipercillin-tazobactam. Her hospital course was rapidly complicated by fluid refractory hypotension, which required ICU transfer for vasopressor therapy. At the time of transfer, the patient was found to be profoundly hypoxemic requiring the initiation of high flow nasal cannula at a rate of 55 liters per minute and 100% FiO2. Plain chest film at that time was notable for hypoinflation without other abnormalities. Chest CT completed shortly thereafter revealed a few small ground glass opacities in the bilateral apices, small pleural effusions and dependent compressive atelectasis of the lower lobes. Within 24 hours, the patient developed diffuse airspace disease on plain film chest imaging. When she failed to respond to aggressive diuresis, concern for a potential noninfectious, inflammatory process was considered. This diagnosis was furthered when repeat chest CT imaging demonstrated multilobar, diffuse ground glass opacities with septal thickening and consolidations in the setting of a sedimentation rate greater than 100. She was then started on high dose steroids (methylprednisolone 500mg IV every 6 hours) for presumed acute interstitial pneumonia. Repeat CT chest completed four days into the course of corticosteroid therapy revealed near complete resolution of the radiographic abnormalities. The patient was also weaned off supplemental oxygen over the same time period and was ultimately discharged on a prolonged prednisone taper. DISCUSSION: AIP is often defined as a rapidly progressive respiratory failure in the setting of bilateral radiographic infiltrates and an absence of a known, underlying inciting cause. While the diagnosis of AIP requires a surgical lung biopsy demonstrating organizing diffuse alveolar damage, it too often is a diagnosis of exclusion given the severity of most patients' illness. Corticosteroids have been shown to inhibit proinflammatory mediators and limit the fibrotic response seen in the pathogenesis of AIP. Patients are believed to require deliberate steroid tapers to prevent reoccurrence. CONCLUSIONS: This case report reaffirms the notion that high dose corticosteroid therapy can be useful in the acute management of AIP. There are currently limited treatment options for AIP, and given the high mortality associated with AIP more advanced therapies need to be investigated. Reference #1: Avnon LS, Pikovsky O, Sion-vardy N, Almog Y. Acute interstitial pneumonia-Hamman-Rich syndrome: clinical characteristics and diagnostic and therapeutic considerations. Anesth Analg. 2009;108(1):232-7. Reference #2: Suh GY, Kang EH, Chung MP, et al. Early intervention can improve clinical outcome of acute interstitial pneumonia. Chest. 2006;129(3):753-61. Reference #3: Vourlekis JS. Acute interstitial pneumonia. Clin Chest Med. 2004;25(4):739-47, vii. DISCLOSURES: No relevant relationships by Seth Brant, source=Web Response No relevant relationships by Jared Dyer, source=Web Response

A CASE OF ACUTE INTERSTITIAL PNEUMONIA

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Acute interstitial pneumonia (AIP) is a rare and life-threatening condition resulting in acute respiratory failure. Early recognition is paramount as patients often deteriorate rapidly. The pathogenesis is not well understood. Computed tomography (CT) imaging may show a pattern similar to that observed in acute respiratory distress syndrome (ARDS) (1) and the histopathologic pattern is characterized by diffuse alveolar damage (DAD). CASE PRESENTATION: We present a 56 year-old male with a history of tobacco use and type-2 diabetes mellitus who presented with new symptomatic anemia (hemoglobin 7.3 mg/dL), fever (39.4 degrees Celsius), tachycardia, and a non-productive cough. Physical examination was unremarkable except for skin and conjunctival pallor. Laboratory values revealed neutropenia (absolute neutrophil count of 0.33 K/uL) and 33 percent blast cells on the differential. CT chest demonstrated bilateral ground glass opacities and small bilateral pleural effusions. A bone marrow biopsy and peripheral flow cytometry findings were consistent with acute myeloid leukemia (AML). Broad-spectrum antibiotics were initiated for neutropenic fever. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial biopsies to evaluate for infection prior to initiation of chemotherapy. Infectious work up and cytology findings were negative. Pathology from the biopsy demonstrated a mild inflammatory infiltrate with fibrin exudate and hyaline membranes consistent with DAD, a non-specific finding consistent with acute lung injury. The patient proceeded to develop acute hypoxic respiratory failure with rapidly rising oxygen requirements. Following a negative rheumatologic work up, a diagnosis of AIP was made. Pulse-dose steroids were initiated and over the next several days his respiratory status significantly improved. Steroids were tapered over the course of several months and he was able to tolerate initiation of chemotherapy. A follow up CT chest after one month showed improvement of the ground glass opacities noted on the initial scan. DISCUSSION: DAD in a non-specific histological finding that may result from various types of lung injury. When there is no known trigger, it is called AIP or Hamman-Rich Syndrome. The exact mechanism of AIP is not well understood. Treatment consists primarily of supportive measures, which may include mechanical ventilation and extracorporeal membrane oxygenation (ECMO) (2). Management of early stages of AIP has had some success with high dose steroids (3). Evidence for the role of non-steroid immunosuppressive agents is limited. CONCLUSIONS: Prompt recognition of AIP is critical. Despite treatment, it carries a poor prognosis. The mainstay of therapy consists of supportive measures and the use of steroids. AIP is a diagnosis of exclusion and one must consider other known causes of DAD, including infection, medications, and autoimmune processes. Reference #1: Avnon LS, Pikovsky O, Sion-Vardy N, Almog Y. Acute Interstitial Pneumonia–Hamman-Rich Syndrome: Clinical Characteristics and Diagnostic and Therapeutic Considerations. Anesthesia & Analgesia. 2009 Jan 1;108(1):232-7. Reference #2: Newmarch W, Puopolo A, Weiler M, Casserly B. Hamman-Rich syndrome: a forgotten entity. Monaldi Archives for Chest Disease. 2017 May 18;87(1). Reference #3: Suh GY, Kang EH, Chung MP, Lee KS, Han J, Kitaichi M, Kwon OJ. Early intervention can improve clinical outcome of acute interstitial pneumonia. CHEST Journal. 2006 Mar 1;129(3):753-61. DISCLOSURES: No relevant relationships by Michael Esposito, source=Web Response No relevant relationships by Craig Fryman, source=Web Response No relevant relationships by Becky Lou, source=Web Response No relevant relationships by Gulrukh Zaidi, source=Web Response

SAVED BY SILVER STAIN: A CASE OF DISSEMINATED HISTOPLASMOSIS

SESSION TITLE: Chest Infections 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Disseminated histoplasmosis is a rare, life-threatening manifestation of Histoplasma capsulatum infection that typically occurs in the immunocompromised or elderly. The time course and clinical manifestations are variable, making it an often-challenging diagnosis. CASE PRESENTATION: A 51-year-old female with rheumatoid arthritis on methotrexate and golimumab presented with a 6-week-history of progressive cough, dyspnea, and fever. She was a non-smoker, had no pets, and lived in North Carolina but had traveled to Ohio and Indiana in the last 3 months. Before presentation, she was treated for community acquired pneumonia but returned with mild respiratory distress, hypoxemia (SpO2 78% on room air), and leukocytosis. She was admitted to a local hospital where a chest CT scan revealed bilateral diffuse ground-glass and reticular opacities. Workup, including bronchoalveolar lavage, was negative for influenza, TB, legionella antigen, PCP, and HIV. Despite two weeks of treatment with antibiotics and high dose steroids, she developed worsening hypoxemia and pancytopenia, leading a to surgical lung biopsy which revealed acute interstitial pneumonia vs connective tissue disease-associated ILD. The patient was then transferred to our hospital on high-flow nasal cannula. Given her history of immunosuppression, special stains of her lung biopsy were performed, with silver stain showing yeast consistent with H. capsulatum. Serum antibody and urine antigen were both positive. Given her pancytopenia and respiratory failure, she was diagnosed with disseminated Histoplasmosis and started on amphotericin and steroids were weaned. Pancytopenia resolved after days; hypoxemia improved more slowly. After an 8 week hospitalization, she was discharged on supplemental O2 with a plan for 12 months of itraconazole. DISCUSSION: Disseminated histoplasmosis in the setting of anti-TNF-alpha therapy has been described in the literature. However, its incidence remains low in non-endemic areas and diagnosis requires a high index of suspicion. Atypical radiographic and pathologic findings in this case made the diagnosis more challenging. Pulmonary histoplasmosis typically manifests with patchy or nodular infiltrates on imaging and granuloma formation on histopathology. Inhibition of TNF-alpha impedes granuloma formation, which is the primary host mechanism for sequestering and controlling infection by mycobacterial and fungal pathogens such as H. capsulatum. Our patient's TNF-alpha inhibitor elevated her risk for severe disease and obscured potential landmarks in a complicated diagnostic picture. CONCLUSIONS: Histoplasmosis is an important diagnostic consideration in patients with a potential exposure who present with acute pulmonary disease. Immunosuppression, particularly with TNF-alpha inhibitors, significantly increases the risk for disseminated disease and masks classic clinical and pathologic features. Reference #1: Vergidis, P., Avery, R. K., Wheat, L. J., Dotson, J. L., Assi, M. A., Antoun, S. A., … Hage, C. A. (2015). Histoplasmosis Complicating Tumor Necrosis Factor-α Blocker Therapy: A Retrospective Analysis of 98 Cases. Clinical Infectious Diseases, 61(3), 409-417 DISCLOSURES: research funding relationship with United Therapeutics / Boehringer Ingelheim Please note: $20001 - $100000 Added 03/02/2018 by Christina Barkauskas, source=Web Response, value=Grant/Research Support Removed 03/02/2018 by Christina Barkauskas, source=Web Response research support relationship with Boehringer Ingelheim Please note: >$100000 Added 03/02/2018 by Christina Barkauskas, source=Web Response, value=Grant/Research Support research support relationship with United Therapeutics Please note: $20001 - $100000 Added 03/02/2018 by Christina Barkauskas, source=Web Response, value=Grant/Research Support No relevant relationships by Chris Mosher, source=Web Response No relevant relationships by Sweta Patel, source=Web Response No relevant relationships by Christopher Pumill, source=Web Response No relevant relationships by Daniel Turner, source=Web Response

AN EVANESCENT RIGHT ATRIAL MASS FROM CATHETER-RELATED THROMBOSIS

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: A diagnosis of catheter-related upper extremity deep vein thrombosis (CRUE-DVT) should be considered in the differential for right atrial mass in a patient with history of malignancy and presence of peripherally inserted central catheter (PICC) because the pulmonary embolism (PE) can be fatal even with anticoagulation.[1] CASE PRESENTATION: A 34 year old male with a history of diabetes mellitus, chronic kidney disease, testicular cancer status post orchiectomy with mediastinal metastatic seminoma resection, and intravenous drug use, presented with acute encephalopathy. He was admitted for diabetic ketoacidosis secondary to sepsis from osteomyelitis of his right foot and found to have MRSA bacteremia and candida glabrata fungemia. The patient continued to improve clinically until he developed acute hypoxic respiratory failure requiring ventilator support several days after admission. Physical exam was notable for tense right upper extremity at site of PICC without erythema or tenderness. Laboratory studies were notable for WBC of 21.5 with neutrophilia, and MRSA from right foot abscess culture and blood cultures. CT of thorax revealed extensive diffuse bilateral groundglass opacities with intralobular thickening and areas of consolidation, concerning for aggressive acute interstitial pneumonia. Bronchoalveolar lavage showed mildly elevated eosinophilia suggestive of eosinophilic pneumonia, for which the patient was treated with corticosteroids. A critical care transesophageal echocardiogram (TEE) was performed to evaluate for endocarditis and revealed a small gelatinous appearing mass contiguous with right atrial wall at the entrance of superior vena cava and interatrial shunt with suspected patent foramen ovale (Figure 1-3). Right upper extremity venous duplex ultrasonography showed completely thrombosed right basilic, brachial, axillary, and subclavian veins likely catheter-related with thrombus extension to right atrium.PICC was removed for concern of right atrial thrombus infection and anticoagulation was started. The repeat TEE performed 10 days later did not reveal a right atrial mass. The patient left the hospital against medical advice, with a therapeutic international normalized ratio but returned within 24 hours following a cardiac arrest. CT thorax angiography revealed PE with right ventricular strain, and the patient expired 48 hours later, with anoxic brain injury noted following resuscitation. DISCUSSION: CRUE-DVT should be considered with an evanescent right atrial mass, and a duplex ultrasonography should be considered because incidence of PE can be as high as 36 percent in patients with malignancy.[2,3] Optimal therapy is unknown although anticoagulation and infection-driven catheter removal appear to be the first line therapy. CONCLUSIONS: CRUE-DVT patients with ASD can develop PE and paradoxical arterial embolism, which can prove fatal, even with anticoagulation. Reference #1: Monreal M et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study. Thromb Haemost. 1994;72(4):548. Reference #2: Muñoz FJ et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest. 2008;133(1):143. Reference #3: Prandoni P et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med. 1997;157(1):57. DISCLOSURES: No relevant relationships by Michel Boivin, source=Web Response No relevant relationships by Chih-Wei Chang, source=Web Response No relevant relationships by Nicholas Villalobos, source=Web Response

MS19.01 Drug-Induced Pneumonitis with IO: How worried should we be for our Lung Cancer Patients

MS19.01 Drug-Induced Pneumonitis with IO: How worried should we be for our Lung Cancer Patients

Pneumocystis jirovecii infection in patients with acute interstitial pneumonia

ObjectiveAcute interstitial pneumonia (AIP) is a severe disease of unknown etiology. Pneumocystis jirovecii is an atypical opportunistic fungus able to colonize patients with chronic pulmonary disease and inducing alveolar macrophage activation. The aim of this study was to evaluate the possible association between Pneumocystis jirovecii and AIP. Subjects and methodsThe presence of P. jirovecii in bronchoalveolar lavage fluid in the four confirmed cases of AIP identified in a tertiary-care hospital over a period of 9 years was studied using a 2-step nested-PCR protocol assay. ResultsP. jirovecii was identified in the four cases. None of them had HIV infection. Two of the patients were treated empirically with trimethoprim-sulfamethoxazole, the only survivor was being one of them. ConclusionsOur data suggest that Pneumocystis could trigger or favor the development of AIP. Further studies are needed to evaluate the role of the pathogen in the physiopathology of this disease.

Comparison of three vaccine programs on the health, growth performance, and carcass characteristics of high-risk feedlot heifers procured from auction-markets

A total of 2,575 beef heifers (BW = 568 ± 28.1 lb; 258 ± 12.7 kg) at high-risk of developing bovine respiratory disease (BRD) were enrolled in a randomized complete-block design study at a commercial feedlot to evaluate the effect of 3 vaccine programs on health, growth performance, and carcass characteristics. Dates of arrival to the feedyard served as the blocking factor and 10, 3-pen blocks were enrolled in the study (n = 10 replications per vaccine program). Chute- order randomization was used during arrival processing to assign heifers to 1 of 3 vaccine programs that differed by vaccine products or timing of the pentavalent modified-live viral vaccination: 1) Pyramid® 5 and Presponse® SQ during arrival processing (PRE), 2) Titanium® 5 and Nuplura® PH during arrival processing (TNA), and 3) Nuplura® PH during arrival processing with Titanium® 5 delayed until 28 days- on-feed (TND). No booster vaccinations were administered. Overall mortality, BRD morbidity, and BRD treatment success risks did not differ among the vaccine programs (P>0.13). There were numerically fewer mortalities attributable to acute interstitial pneumonia in TNA heifers than the TND and PRE heifers (probability of difference = 0.99 and 1.00, respectively). Mortality attributable to BRD did not differ between vaccine programs (probability of difference < 0.48). Endotoxin concentrations were measured in the Mannheimia haemolytica vaccines, and were lower in Nuplura® PH than Presponse® SQ. An arrival vaccine program implementing Titanium® 5 and Nuplura® PH had similar efficacy on BRD- related health outcomes as vaccinating with Pyramid® 5 and Presponse® SQ. Delaying a pentavalent viral vaccine until 28 days-on-feed did not affect health or growth-performance outcomes in this study.

Isolated Acute Appendicitis Caused by Aspergillus in a Patient Who Underwent Lung Transplantation: A Case Report

Invasive aspergillosis is an important cause of morbidity and mortality in patients who have undergone lung transplantation. Aspergillus infections usually involve the respiratory tract, with vascular invasion and subsequent dissemination. However, acute appendicitis associated with localized aspergillosis is rare, especially among patients who have undergone prophylaxis with voriconazole. We present a case of primary Aspergillus appendicitis diagnosed by histologic examination in a patient who underwent lung transplantation. A 51-year-old woman with dermatomyositis underwent lung transplantation for acute interstitial pneumonitis. According to our institution's protocol, the patient was treated with immunosuppressive therapy and prophylaxis with voriconazole, ganciclovir, and trimethoprim sulfamethoxazole during the post-transplantation period. Twenty-eight days after transplantation, the patient developed mild abdominal pain and paralytic ileus. There was no apparent infection sign. Abdominal computerized tomography indicated a wall defect of the appendix with multifocal fluid collection, mesenteric leave thickening, and pneumoperitoneum. These findings were consistent with perforated appendicitis, and the patient underwent an appendectomy. The histopathology examination of the resected appendix showed inflammation and abscess. Periodic acid–Schiff–positive and Grocott-Gomori methenamine silver–positive fungal hyphae with acute-angle branching were observed, demonstrating muscular invasion. A galactomannan antigen test obtained on the same day had negative results. The trough level of voriconazole was well maintained and was subsequently adjusted through monitoring of circulating drug concentration. Simultaneously, other potential sites of disseminated Aspergillus were considered and examined, but no other site of systemic Aspergillus infection was detected. Voriconazole treatment was maintained for 3 months, and no aspergillosis relapse or other invasive fungal infections were observed.

Combined pharmacotherapy for osteonecrosis of the femoral head after severe acute respiratory syndrome and interstitial pneumonia: two and a half to fourteen year follow-up

The purpose of this study was to retrospectively analyze the clinical, functional, and radiological outcomes of combined pharmacotherapy to ONFH after high-dose corticosteroid therapy. From August 2003 to June 2015, five patients (ten hips) of ONFH in ARCO stage I, after SARS and Interstitial pneumonia, were treated by combined pharmacotherapy. Lipo-prostaglandin E1 10μg iv Bid × 28days, enoxaparin 6000iu H QD × 12weeks, alendronate sodium tablet 10mg QD × 1year. The patients were fully weight-bearing following completion of the follow-up. For these five patients (ten hips), Harris score was 100 from the diagnosis to final follow-up time. Radiologic findings show no signs of collapse, necrotic focus was repaired, and ARCO stages were changed from IC into IIB. This combined pharmacotherapy has promising treatment results for delaying or preventing collapse of ONFH in ARCO stage I.

Preliminary evidence that hydrostatic edema may contribute to the formation of diffuse alveolar damage in a Holstein calf model.

Background: Two notable findings of clinically healthy feedlot cattle suggest they may have pulmonary hydrostatic edema during the finishing phase of production: increased pulmonary arterial wedge pressures and pulmonary venous hypertrophy. The goal of this study was to determine if increased pulmonary arterial wedge pressure (PAWP) in a Holstein calf could lead to diffuse alveolar damage consistent with the early, exudative phase of acute interstitial pneumonia of feedlot cattle. Methods: Six male Holstein dairy calves were given daily subcutaneous injections of the nonspecific ß-adrenergic agonist isoprenaline (10 mg/kg/d), to induce left ventricular diastolic dysfunction, or sterile water for 14 days. On Day 14, pulmonary arterial pressures and wedge pressures were measured, echocardiography performed, and the ratio of mitral valve flow velocity (E) to septal lengthening velocity (e') calculated. Calves were euthanized on Day 15 and lung lesions semi-quantitatively scored. Results: Mean PAWP was 12 ± 1 mm Hg in calves that received isoprenaline and 7 ± 1 mm Hg in controls ( P = 0.01). Calves that received isoprenaline tended to have greater relative wall thickness than control calves ( P = 0.15) and greater E/e' ratios ( P = 0.16), suggestive of concentric hypertrophy and diastolic dysfunction, respectively. Calves that received isoprenaline also tended to have a left ventricle and interventricular septum that was 29 ± 10 g heavier than control calves ( P = 0.10) when controlling for body mass. Hyaline membranes, the hallmark feature of diffuse alveolar damage, were evident in lung sections from all calves that received isoprenaline but none of the controls. Conclusions: Consistent with prior pathological and physiological studies of feedlot cattle, this study provides preliminary evidence that cattle presenting with clinical signs and pathology consistent with early stage acute interstitial pneumonia could be attributable to hydrostatic edema associated with left ventricular failure.

Time course of polyhexamethyleneguanidine phosphate-induced lung inflammation and fibrosis in mice

Pulmonary fibrosis is a chronic progressive disease with unknown etiology and has poor prognosis. Polyhexamethyleneguanidine phosphate (PHMG-P) causes acute interstitial pneumonia and pulmonary fibrosis in humans when it exposed to the lung. In a previous study, when rats were exposed to PHMG-P through inhalation for 3 weeks, lung inflammation and fibrosis was observed even after 3 weeks of recovery. In this study, we aimed to determine the time course of PHMG-P-induced lung inflammation and fibrosis. We compared pathological action of PHMG-P with that of bleomycin (BLM) and investigated the mechanism underlying PHMG-P-induced lung inflammation and fibrosis. PHMG-P (0.9 mg/kg) or BLM (1.5 mg/kg) was intratracheally administered to mice. At weeks 1, 2, 4 and 10 after instillation, the levels of inflammatory and fibrotic markers and the expression of inflammasome proteins were measured. The inflammatory and fibrotic responses were upregulated until 10 and 4 weeks in the PHMG-P and BLM groups, respectively. Immune cell infiltration and considerable collagen deposition in the peribronchiolar and interstitial areas of the lungs, fibroblast proliferation, and hyperplasia of type II epithelial cells were observed. NALP3 inflammasome activation was detected in the PHMG-P group until 4 weeks, which is suspected to be the main reason for the persistent inflammatory response and exacerbation of fibrotic changes. Most importantly, the pathological changes in the PHMG-P group were similar to those observed in humidifier disinfectant-associated patients. A single exposure of PHMG-P led to persistent pulmonary inflammation and fibrosis for at least 10 weeks.

Respiratory Mites ( Orthohalarachne diminuata) and β-hemolytic Streptococci-Associated Bronchopneumonia Outbreak in South American Fur Seal Pups ( Arctocephalus australis).

Although mites of the Orthohalarachne genus are common parasites of otariids, their role as agents of disease and in causing population-level mortality is unknown. In the austral summer of 2016, there was an increase in mortality among South American fur seal ( Arctocephalus australis) pups at Guafo Island, Northern Chilean Patagonia. Pups found dead or terminally ill had moderate to marked, multifocal, mucopurulent bronchopneumonia associated with large numbers of respiratory mites ( Orthohalarachne diminuata) and rare Gram-positive cocci. In lung areas less affected by bronchopneumonia, acute interstitial pneumonia with marked congestion and scant hemorrhage was evident. Bacteria from pups dying of bronchopneumonia were isolated and identified as Streptococcus marimammalium and Streptococcus canis. Respiratory mites obstructed airflow, disrupted airway epithelial lining, and likely facilitated the proliferation of pathogenic β-hemolytic streptococci, leading to severe bronchopneumonia and death of fur seal pups. An abrupt increase in sea surface temperature in Guafo Island corresponded to the timing of the bronchopneumonia outbreak. The potential role of environmental factors in the fur seal pup mortality warrants further study.

Acute interstitial pneumonia (hamman-rich syndrome) - a life threatening respiratory disease

Acute interstitial pneumonia (AIP) is an idiopathic lung disease characterized by rapidly progressive dyspnoea, respiratory failure developing over days to weeks in patients without pre-existing lung disease. AIP show a very poor prognosis, with high mortality and remains unfamiliar to physicians. In this report, we present a case of a mid-age male with AIP who, was treated with intensive medical facilities, still showed a rapid progressive clinical deterioration, and eventually died of respiratory failure.Bangladesh J Medicine Jul 2017; 28(2) : 91-94

Acute Interstitial Pneumonia after Lung Resection in a Patient with Leucocytoclastic Vasculitis but No History of Interstitial Lung Disease. The Importance of Anaesthetic Technique and Early Use of Steroids

Acute Interstitial Pneumonia after Lung Resection in a Patient with Leucocytoclastic Vasculitis but No History of Interstitial Lung Disease. The Importance of Anaesthetic Technique and Early Use of Steroids