Resolution Of Pulmonary Infiltrates Research Articles

Whipple’s disease presenting as weight gain and constipation in a Chinese woman

BackgroundWhipple’s disease is a chronic infection due to Tropheryma whipplei, commonly reported in the Caucasian but not in the Chinese population.Case presentationA 52-year-old female with good past health, was diagnosed with Whipple’s disease, presenting with constipation, unintentional weight gain, and fleeting polyarthralgia. Investigations prior to admission showed raised CA125 and computed tomography of the abdomen showed multiple retroperitoneal mesenteric lymphadenopathies. Extensive investigations performed on secondary causes of weight gain were unrevealing. Subsequent PET-CT scan revealed generalized lymphadenopathy involving the left deep cervical, supraclavicular, and retroperitoneal mesenteric area. Excisional biopsy of the left supraclavicular lymph node was performed, with histology showing infiltrations of Periodic acid-Schiff positive foamy macrophages. T. whipplei DNA was detected in her serum, saliva, stool, and lymph node by PCR targeting the 16S ribosomal RNA gene. She was started on intravenous ceftriaxone, and then stepped down to oral antibiotics for a total of 44 months. The recurrence of fever after 12 days of ceftriaxone raised the suspicion of Immune Reconstitution Inflammatory Syndrome (IRIS). Serial imaging showed a gradual reduction in the size of retroperitoneal lymphadenopathies. Literature review on Whipple’s disease in the Chinese population identified 13 reports of detectable T. whipplei DNA in clinical specimens. The majority of the cases were pneumonia, followed by culture-negative endocarditis, encephalitis, and skin and soft tissue infection. However, most patients with pneumonia were diagnosed based on next generation sequencing alone, with the resolution of pulmonary infiltrates without adequate duration of antibiotics, suggesting the possibility of colonization instead of infection. The recommendation of long-term doxycycline suppression after treatment may be supported by the slow response of retroperitoneal lymphadenopathies to antibiotics in our patient.ConclusionsUnintentional weight gain and constipation could be atypical presentations of Whipple’s disease. It is a rare disease in the Chinese population despite the advancement of molecular techniques in the diagnosis of infections. A prolonged course of antibiotics may be required due to slow clinical response as documented by serial imaging in our case. The possibility of IRIS should be considered in patients with breakthrough fever during treatment of Whipple’s disease.

Resolution of Chest X-Ray Opacities in Patients with Ventilator-associated Pneumonia.

Chest Radiograph accompanied by clinical and laboratory findings are required for diagnosis and follow-up of patients with suspected ventilatorassociated pneumonia (VAP). However, there are no reliable data whether follow-up chest-X-ray (CXR) is needed or not, moreover, when the physicians request CXR and how many times CXR is required. We aimed to determine association of the clinical improvement with resolution of pulmonary infiltrates as well as time of resolution. The patients with a diagnosis of VAP based on Clinical Pulmonary Infection Score (CPIS) were enrolled in this study. Clinical evaluation and follow-up were continued and CXR was performed sequentially in two-day intervals until clinical improvement or occurrence of other events including death. Fischer test was used to analyze the association of clinical improvement with radiographic resolution. Out of the seventy -five patients, pneumonia was clinically improved in 48 cases. Mean duration of the clinical improvement was 5.3±4.5 days. Among these patients, pulmonary infiltrations in 44 patients were resolved completely (13.8±5.8 days). Twentyseven patients had no clinical improvement and all of them revealed no infiltration resolution according to the sequential imaging studies. Resolution of radiographic involvement significantly was associated with clinical improvement (p=0.000). Radiographic resolution occurs in most of patients who survived VAP and there is strong relationship between radiographic resolution and clinical improvement. Moreover, our data revealed that CXR clearance occurred earlier than anticipated previously. Thus, sequential follow-up CXR in VAP had no further clinical value.

Influence of common antibiotics (amoxicillin / clavulanate, clarithromycin, imipenem / cilastatin), on the clinical course of pulmonary TB and community-acquired pneumonia

Summary. This was the first retrospective clinical study of efficacy of common antibiotics (amoxicillin / clavulanate, clarithromycin, imipenem / cilastatin) administered ex juvantibus to differentiate pulmonary tuberculosis and community-acquired pneumonia (CAP). Administration of these antibiotics in 162 patients with confirmed pulmonary TB led to significant activation of pulmonary inflammation, extended infiltration of the lung tissue, cavitation and bronchogenic dissemination, culturing of M. tuberculosis from sputum and clinical worsening of the disease. On contrary, in 108 patients with CAP, the same antibiotics resulted in resolution of pulmonary infiltrates and relief of signs of the disease. Amoxicillin / clavulanate, clarithromycin and imipenem / cilastatin were proven not to have any effect on M. tuberculosis including those with MDR; they do not pertain to antiTB chemotherapeutic drugs.

Late-onset differentiation syndrome in a child with acute promyelocytic leukemia

All-trans retinoic acid (ATRA) improves the outcome of patients with acute promyelocytic leukemia (APL) [1, 2]. ATRA administration leads to complete remission in APL patients by inducing growth arrest and differentiation of the leukemic clone. Caution is needed during ATRA treatment because of the potential development of differentiation syndrome (DS), formerly known as retinoic acid syndrome. It is a cardiorespiratory syndrome characterized by unexplained fever, weight gain, respiratory distress, interstitial pulmonary infiltrates, pleural and pericardial effusions, acute renal failure, cardiac failure, and hypotension [3, 4]. Although this syndrome commonly develops during the first week after starting ATRA treatment [3, 4], late-onset DS has been observed in a substantial number of patients [4]. We report a child with APL who developed DS after 21 days on ATRA treatment. A 9-year-old boy was diagnosed as having APL with t(15;17)(q22;q11.12) and PML/RARa transcript. He was registered on the JPLSG (Japan Pediatric Leukemia/Lymphoma Study Group) AML-P05 protocol and ATRA was administered at 45 mg/m/day, PO. When his WBC count was over 5,000/lL, he received dexamethasone (DEX: 0.4 mg/kg/day, IV) for DS prevention (Fig. 1). Promyelocytes disappeared in his peripheral blood after starting daunorubicin and cytosine arabinoside. He became febrile on the 16th day and antibiotics were given with successful resolution of fever. On the 17th day, serum C-reactive protein (CRP) level increased to 1.6 mg/dL and he complained of chest pain. Chest X-ray, electrocardiogram, and echocardiography showed normal findings. On the 20th day, he again became febrile at 39 C and antibiotics were changed. On the 21st day, his urine output decreased from 549 to 248 mL in 8 h and he produced foamy sputum with fresh blood. He subsequently became dyspneic. Pulse oxymetry showed oxygen saturation at 85% and BP rapidly fell from 92/56 to 80/50 mmHg. Weight gain or peripheral edema was not observed, but serum creatinine level transiently increased from 0.26 to 0.32 mg/dL. Chest X-ray revealed bilateral patchy confluent opacities. Although echocardiography demonstrated no pericardial fluid, left ventricular ejection fraction (LVEF) decreased to 26%. At this point, serum CRP level was 5.6 mg/dL and brain natriuretic peptide was 757.4 pg/mL. Cultures of blood, urine, and sputum were negative. A probable diagnosis of DS was made. ATRA was discontinued and DEX (0.4 mg/kg/day, IV) was started. He was also treated with dobutamine and milrinone, leading to an increase of LVEF to 55% several hours later. His respiratory status promptly improved with resolution of pulmonary infiltrates. Myelocyte and metamyelocyte counts increased up to 200/lL from the 21st day through to the 24th day (Fig. 1). The pathogenesis of DS is not completely understood, although several mechanisms have been proposed. First, adhesion and aggregation of APL cells may be promoted by increased expression of CD11b, CD11c and CD54 (ICAM-1) during ATRA treatment [5]. Second, differentiated APL cells secrete serine proteases [6] and matrix metalloproteases [7], which can promote coagulopathy and cellular invasion, respectively. Third, ATRA-treated APL cells secrete inflammatory cytokines such as IL-8, IL-1b, G-CSF, and TNF-a [8] as well as CC chemokines such as monocyte chemoattractant protein-1, macrophage inflammatory protein (MIP)-1a, and MIP-1b [9]. H. Yoshida R. Matsumura E. Sato Y. Hashii H. Ohta (&) K. Ozono Department of Pediatrics, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita 565-0871, Japan e-mail: ohta@ped.med.osaka-u.ac.jp

Adult Respiratory Distress Syndrome with Increased Serum and Bronchoalveolar Lavage Fluid Levels of Squamous Cell Carcinoma-Related Antigen.

We report a case with adult respiratory distress syndrome (ARDS) associated with increased levels of squamous cell carcinoma-related antigen (SCC) in the serum and bronchoalveolar lavage fluid (BALF). ARDS was likely induced by ibuprofen, based on the presence of pancytopenia and a weakly positive drug lymphocyte stimulating test (DLST). High serum and BALF levels of interleukin (IL)-8, neutrophil elastase as well as SCC were detected. Corticosteroid therapy resulted in clinical improvement, resolution of pulmonary infiltrates on chest roentgenogram and normalization of serum and BALF levels of IL-8, neutrophil elastase and SCC.