Sputum Gram Research Articles

GRANULOMATOUS LYMPHOCYTIC INTERSTITIAL LUNG DISEASE: MOST COMMON NONINFECTIOUS PULMONARY COMPLICATION OF COMMON VARIABLE IMMUNODEFICIENCY

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Common Variable Immunodeficiency (CVID) is the most common primary immunodeficiency. Patients with CVID suffer from recurrent sinopulmonary infections. Granulomatous lymphocytic interstitial lung disease (GLILD) is one of the dreaded noninfectious pulmonary complication of CVID. CASE PRESENTATION: A 28-year-old female was seen in Pulmonology clinic for evaluation of an abnormal CT scan of the chest, progressively worsening chest tightness, chronic productive cough and dyspnea on exertion for last 1 year. Patient had history of CVID, Chiari I malformation, and iron deficiency anemia. She worked with construction companies to monitor archeological changes. Vitals and physical exam on presentation were normal. Initial investigations showed thrombocytopenia; Sputum gram stain, fungal and acid-fast smear and aerobic and anaerobic cultures were unremarkable. CT scan of the chest, abdomen and pelvis with contrast showed diffuse reticulonodular pulmonary infiltrates predominantly in the basal lung fields, peri bronchial thickening in the lower lobes and mildly enlarged lymphadenopathy in the axilla, retroperitoneum and mesentery, and splenomegaly (13.5 cm). Differential diagnosis at the time were sarcoidosis, GLILD, fungal/atypical infections, vasculitis and malignancy. Bronchoscopy revealed acutely inflamed mucosa throughout the tracheobronchial tree, petechiae in right lower lobe. Bronchoalveolar lavage (BAL) in right medial segment and transbronchial biopsy (TBBx) in left lower lobe showed 54% lymphocytes, but no vasculitis, fungal/bacterial/viral infection, and malignancy. Working diagnosis was narrowed down to sarcoidosis and GLILD. Video assisted thoracoscopic surgery and open lung biopsy of right middle and lower lobes revealed nodular and diffuse mononuclear cell infiltrates and scattered non-necrotizing granulomas. 2nd opinion from a tertiary care center confirmed follicular bronchiolitis with associated non-necrotizing granulomatous inflammation and foci of fibrinous organizing pneumonia consistent with GLILD seen in CVID. DISCUSSION: GLLID is the most common cause of diffuse parenchymal lung disease in patients with CVID. It occurs in 8-22% of persons with CVID. The etiology of GLILD is unknown. It presents between the ages of 20 and 50. Presence of hypersplenism and polyarthritis increases the risk of GLILD in patients with CVID. Classic histopathologic pattern of GLILD is a cellular interstitial pneumonia with a combination of granulomatous and lymphoproliferative features. Optimal treatment is unknown. Glucocorticoids, IVIGs and immunosuppressive therapies have been tried. CONCLUSIONS: In patients with CVID development of respiratory signs or symptoms should be carefully evaluated for GLILD as presence of GLILD shortens the survival by approximately 50%. Reference #1: Fernández Perez ER. 2012 November. Granulomatous Lymphocytic Interstitial Lung Disease. Immunol Allergy Clin AM. 32(2012):621-32 Reference #2: Bates CA, Ellison MC, Lynch DA, et al. Granulomatous-lymphocytic lung disease shortens survival in common variable immunodeficiency. J Allergy Clin Immunol 2004;114(2):415–21. Reference #3: Tou w CM, van de Ven AA, de Jong PA, et al. Detection of pulmonary complications in common variable immunodeficiency. Pediatric Allergy Immunol 2010;21(5):793–805. DISCLOSURES: No relevant relationships by Shujaa Faryad, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response

Sputum Gram Stain for Bacterial Pathogen Diagnosis in Community-acquired Pneumonia: A Systematic Review and Bayesian Meta-analysis of Diagnostic Accuracy and Yield.

The clinical role of sputum Gram stain (SGS) in community-acquired pneumonia (CAP) diagnosis remains controversial. A 1996 meta-analysis of the diagnostic accuracy of SGS reported heterogeneous results. To update the available evidence, we performed a systematic review and a Bayesian standard and latent-class model meta-analysis. We searched Medline, Embase, and Cochrane Central by 23 August 2018 to identify studies reporting on the diagnostic accuracy, yield (percentage of patients with any pathogen[s] correctly identified by SGS), and clinical outcomes of SGS in adult patients with CAP. Two reviewers extracted the data. We quantitatively synthesized the diagnostic accuracy and yield, and descriptively analyzed other outcomes. Twenty-four studies with 4533 patients were included. The methodological and reporting quality of the included studies was limited. When good-quality sputum specimens were selected, SGS had a summary sensitivity of 0.69 (95% credible interval [CrI], .56-.80) and specificity of 0.91 (CrI, .83-.96) for detecting Streptococcus pneumoniae, and a sensitivity of 0.76 (CrI, .60-.87) and specificity of 0.97 (CrI, .91-.99) for Haemophilus influenzae. Adjusted analyses accounting for imperfect reference standards provided higher-specificity estimates than the unadjusted analyses. Bacterial pathogens were identified in 73% (CrI, 26%-96%) of good-quality specimens, and 36% (CrI, 22%-53%) of all specimens regardless of quality. Evidence on other bacteria was sparse. SGS was highly specific to diagnose S. pneumoniae and H. influenzae infections in patients with CAP. With good-quality specimens, SGS can provide clinically actionable information for pathogen-directed antibiotic therapies.

Usefulness of sputum gram stain for etiologic diagnosis in community-acquired pneumonia: a systematic review and meta-analysis

BackgroundImplementation of sputum Gram stain in the initial assessment of community-acquired pneumonia (CAP) patients is still controversial. We performed a systematic review and meta-analysis to investigate the usefulness of sputum Gram stain for defining the etiologic diagnosis of CAP in adult patients.MethodsWe systematically searched the Medline, Embase, Science Direct, Scopus and LILACS databases for full-text articles. Relevant studies were reviewed by at least three investigators who extracted the data, pooled them using a random effects model, and carried out quality assessment. For each bacterium (Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Gram-negative bacilli), pooled sensitivity, specificity, positive and negative likelihood ratios were reported.ResultsAfter a review of 3539 abstracts, 20 articles were included in the present meta-analysis. The studies included yielded 5619 patients with CAP. Pooled sensitivity and pooled specificity of sputum Gram stain were 0.59 (95% CI, 0.56–0.62) and 0.87 (95% CI, 0.86–0.89) respectively for S. pneumoniae, 0.78 (95% CI, 0.72–0.84) and 0.96 (95% CI, 0.94–0.97) for H. influenzae, 0.72 (95% CI, 0.53–0.87) and 0.97 (95% CI, 0.95–0.99) for S. aureus, and 0.64 (95% CI, 0.49–0.77) and 0.99 (95% CI, 0.97–0.99) for Gram-negative bacilli.ConclusionSputum Gram stain test is sensitive and highly specific for identifying the main causative pathogens in adult patients with CAP.Trial registrationThis study has been registered at PROSPERO International prospective register of systematic reviews under registration no. CRD42015015337.

Sputum Gram stain for diagnosing causative bacterial pathogens and guiding antimicrobial therapies in community-acquired pneumonia: a systematic review and meta-analysis protocol.

The clinical role of sputum Gram stain for rapid etiologic pathogen diagnosis in patients with community-acquired pneumonia (CAP) remains an unresolved controversy. Variability in protocols and reporting of diagnostic performance in different studies has hampered assessments of clinical utility and interpretation. Since the last meta-analysis published in 1996, several reports and resources to accurately evaluate the diagnostic accuracy of sputum Gram stain have become available. Therefore, we will conduct a systematic review and meta-analysis of the clinical validity and utility of sputum Gram stain. We will search PubMed, Ovid MEDLINE, Embase, and The Cochrane Controlled Register of Trials (CENTRAL) databases from inception through July 30, 2018, with no language restriction and perform a full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies that assess sputum Gram stain in adults (aged ≥18 years) with CAP. Two reviewers will independently extract data and rate each study's validity with standard quality assessment tools. We will subsequently perform standard and latent-class random-effects model meta-analyses to quantitatively synthesize the diagnostic accuracy and yield. Finally, we will assess the totality of evidence by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for diagnostic tests and strategies. Results of the analysis will be submitted for publication in a peer-reviewed journal. This systematic review and meta-analysis will provide a 30-year synopsis of clinical evidence on sputum Gram stain in patients with CAP.

Post renal transplant pulmonary nocardiosis - A case report

Nocardiosis is a rare opportunistic infection caused by an aerobic actinomycete, producing either local or disseminated disease. It is a systemic infection that usually begins in the lungs and has high predilection for brain, skin and subcutaneous tissues. It commonly affects solid organ transplant recipients on immunosuppressive drugs. The incidence of nocardiosis in solid organ transplant recipients is about 0.6%. In India, nocardiosis was reported in 1.4% of renal transplant recipients. We report a case of pulmonary nocardiosis in a postrenal transplant recipient. Patient presented with features suggestive of pneumonia not responding to antibiotics. Initial sputum gram stain and AFB was negative. Chest radiograph showed right parahilar non-homogenous opacity, and CT chest revealed right parahilar, and subcarinal adenopathy. Bronchoscopy was done which showed purulent secretion from right 6th bronchial segment and AFB stain of broncho alveolar lavage fluid, showed weak acid fast filamentous bacteria, suggestive of nocardiosis. Patient was treated with antibiotics imipenem and co-trimoxazole. Patient responded well to treatment and pneumonia was resolved.

Clinical, Radiological and Bacteriological Profile of Lung Abscess - An Observational Hospital Based Study.

BACKGROUND:The incidence of lung abscess acquired in the community is unknown, but this is a common clinical problem encountered in developing countries. The incidence of lung abscess was high in the pre-antibiotic era but the advent of susceptible antibiotics it has reduced with an equal fall in mortality to 8.7%. With the emerging antibiotic resistance and change in the trends of bacteriological profile causing lung abscess, it is the need of time to reevaluate lung abscess.AIM:The study aimed to determine the clinical, radiological and bacteriological profile of lung abscess.MATERIAL AND METHOD:The study was a non-randomized prospective observational study conducted in the department of pulmonary medicine for 18 months. In the study, patients > 15 years of age with clinical features of lung abscess were recruited and were subjected to chest X-ray, routine blood test. Sputum gram stain and culture, as well as antibiotic sensitivity according to the organism, were evaluated. Reports of all investigations along with patient characteristics and risk factors were analysed statistically using SPSS 20.0.RESULTS:Forty-six cases of lung abscess were included, and the majority of patients were found to be adults with a mean age of 42.9 years with a male to female ratio of 6.6:1. The most common predisposing factor was an unhygienic oral cavity in 28% of cases with alcohol ingestion being the most important risk factor in 22% of cases. The most common organism found in lung abscess cases was Klebsiella pneumoniae, and they were sensitive to ceftazidime.CONCLUSION:Our study shows that Klebsiella pneumoniae should be considered an important pathogen in community-acquired lung abscesses.

Bacteriological testing and recurrence prevention efforts in the diagnosis and treatment of nursing- and healthcare-associated pneumonia and aspiration pneumonia: A questionnaire survey of hospitals across Japan.

Clinical practice guidelines for nursing- and healthcare-associated pneumonia (NHCAP) were developed for pneumonia caused by drug-resistant bacteria and pneumonia in elderly patients, particularly aspiration pneumonia. The identification of pathogenic bacteria and implementation of efforts to prevent the recurrence of aspiration pneumonia are very important in clinical practice. This study examined the extent to which clinicians have established bacteriological testing and recurrence prevention efforts for NHCAP and aspiration pneumonia. Questionnaire surveys were mailed to the heads of internal medicine and respiratory medicine departments at 2490 Japanese hospitals. The questionnaire evaluated bacteriological testing for NHCAP or aspiration pneumonia and prevention of the recurrence of aspiration pneumonia. A total of 350 hospitals responded. These hospitals were grouped on the basis of whether a pulmonologist provided medical care for aspiration pneumonia and whether the hospital employed an infectious disease specialist. For hospitals in which pulmonologists treated aspiration pneumonia, the response rates for "is done in nearly all cases" were 70.0%, 84.7%, 31.6%, and 48.9% for sputum gram staining, sputum culture tests, blood culture tests, and pneumococcal vaccination, respectively. In hospitals that employed an infectious disease specialist, the response rates for "is done in nearly all cases" were 72.8% and 41.3% for sputum gram staining and blood culture tests, respectively. Recurrence prevention for aspiration pneumonia (other than pneumococcal vaccination) was not actively implemented. Sputum gram staining, sputum culture tests, and other bacteriological tests were implemented quite actively. However, physicians who treat aspiration pneumonia should implement efforts to prevent pneumonia recurrence more actively.

Systemic Immune Response Against Bacterial Infections in Pneumonia Patients at Babylon province

Pneumonia is a common disease that responsible for the mortality and morbidity rate among the world. In Babylon province there is a little study dealing with the association between bacterial pneumonia and immune state at systemic humoral and cellular levels. The present study aims to determine the bacterial causative agents of pneumonia in patients with measurement of some systemic humoral and cellular immune response aspect. This study involved 118 patients suffering from pneumonia. Sputum specimens were collected aseptically, then stained with acid fast stain and gram stain to detect the bacterial isolates. The specimens were cultured on specific culture media. Antibiotic susceptibility test was done for bacterial isolates according to CLSI and we measured the growth inhibition zones in millimeters. The patients were classified into nine groups according to the types of bacterial isolates, then blood samples were collected from them to measure the concentrations of IgG, IgA, IgM, C3 and C4 using single radial immunodiffusion assay with performed the Capillary Migration Inhibition test. In addition to assay the concentrations of IL-6 using ELISA kit. The results showed the sputum gram stain revealed the presence of neutrophils in 63 specimens from a total of 118 specimens (53.4%) while Ziehl-neelsen stain revealed Mycobacterium tuberculosis in 4 specimens with (3.4%). The common bacterial isolate were Streptococcus pneumoniae with rate (33.30 %), followed by Staphylococcus aureus with rate (14.30%), 8 cases (12.70%) for each one of Klebsiella pneumonia and Burkholderi acepacia, and 5 cases (7.90%) for each one of Escherichia coli and Streptococcus pyogenes, 3 cases (4.80%) for Acinetobacter spp. and 2 cases (3.20%) for each one of Pseudomonas aeruginosa and Haemophillus influenzae. The occurrence of pneumonia increased in patients aged between 47-62 years about 27 cases (42.9%), also it was increased in male rather than female 36 cases (57%). G+ and G- organisms showed susceptibility and resistant to different types of antibiotic that used in this study. The immunological parameters showed a significant increased (p≤0.05) in the concentrations of IgG, IgA, IgM, C3 and C4 with LIF and IL-6 at systemic humoral and cellular levels respectively compared with healthy control groups. We can conclude that Streptococcus pneumoniae was the most dominant bacterial isolates in causing pneumonia and the best antibiotic that used for treating the infections were Imipenem and Trimethoprim-Sulfamethoxazole with significant increased (p≤0.05) in all immunological parameters that used in this study.

Diagnostic value of sputum smear and simplified clinical pulmonary infection score of ventilator associated pneumonia in the early stage

Objective To explore the diagnostic value of sputum smear coupled with simplified clinical pulmonary infection score (CPIS) of ventilator associated pneumonia (VAP) in the early stage. Methods A cohort of 59 consecutive patients with VAP admitted in Intensive Care Unit from June, 2014 to June, 2016 were enrolled for a prospective and observational study. Concurrently, another 59 patients without pulmonary infection undergone mechanical ventilation over 48 hrs, were assigned into the control group. The criteria of exclusion were patients with pulmonary malignancies, autoimmune diseases and immunodeficiency. APACHEⅡscores of all patients were recorded. All patients’ inferior airway sputum which met the criteria was taken to make a validated sputum smear(i.e. polymorphonuclear leukocyte >25 and squamous epithelial cell <10 per low-power field) for Gram stain and culture on the admission day. Meanwhile, simplified CPIS were calculated. Data were statistically processed by SPSS 15.0, enumeration data were statistically analyzed by Chi-Square test, and measurement data were represented as Mean±SD. The significant differences in characteristics between two groups were analyzed by independent t test, and P<0.05 was considered statistically significant. As positive sputum smear and simplified CPIS≥5 were set respectively as a positive screening criterion, sensitivity, specificity, positive predictive value and negative predictive value of each marker and combined markers were calculated. Results There were no significant differences in demographics and clinical features (including age, sex, APACHEⅡscores) of patients in VAP and non-VAP patients (P>0.05). The rates of bacteria detected were Gram-negative [44.1% (26/59)], Gram-positive [40.6% (24/59)], none [10.2% (6/59)] and both [5.1% (3/59)] bacteria in VAP group, while [39.0% (23/59)], [30.5% (18/59)], [27.1% (16/59)] and [3.4% (2/59)] were found in non-VAP group correspondingly. There were no significant differences in the percentages of different bacteria in sputum smear between two groups(P>0.05). The values of diagnostic sensitivity of sputum smear and sputum smear coupled with simplified CPIS were 89.8% and 84.7%; the specificity were 27.1% and 79.7%; the positive predictive values were 55.2% and 80.6%; and the negative predictive values were 72.7% and 83.9%, respectively. Conclusions No matter the ventilated patients suffered VAP or not, bacteria might be detected from their lower respiratory tracts. Sputum smear could not be taken as an exclusively diagnostic evidence. While sputum smear coupled with simplified CPIS might improve the diagnostic efficacy of VAP, and provide the guildlines of appropriate choice of antibiotics employed in the early stage. Key words: Sputum smear and gram stain; Clinical pulmonary infection score; Ventilator associated pneumonia

Invasive Pulmonary Aspergillosis: An Emerging Association With Influenza B

SESSION TITLE: Bacterial Infections 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Invasive pulmonary aspergillosis (IPA) in critically ill patients is on the rise, but its exact incidence is unclear as the majority of the literature is focused on influenza A co-infection. CASE PRESENTATION: A previously healthy 70 year old male, a farmer by occupation, presented with a flu-like prodrome for 3 days prior to admission. Besides a 40-pack year smoking history, he had no known co-morbidities or risk factors and was found to have Influenza B (IB) and streptococcal pneumonia. His cardio-respiratory status rapidly deteriorated secondary to severe sepsis and ARDS requiring invasive mechanical ventilation. Radiographic imaging of the chest demonstrated multifocal heterogenous opacities of bilateral lung fields with ground glass opacification in the left lower lobe. Sputum gram stain and culture grew Aspergillus fumigatus and serum ß-D glucan assay levels were 193 pg/mL. Bronchoscopy showed mucosal hyperemia with raised pock-like lesions, clustered along the distal right mainstem and right upper lobe bronchi (Figure 1A). There was a non-sloughing, irregular, flat endobronchial lesion adherent to the right upper lobe secondary carina (Figure 1B). The bronchoalveolar lavage culture grew Aspergillus fumigatus and was positive for IB by polymerase chain reaction. The diagnosis of IPA was confirmed with an endobronchial forceps biopsy of the mucosal lesion. Combination therapy with voriconazole and oseltamivir was initiated, along with broad-spectrum antimicrobial coverage. Over twelve days, the clinical course improved with successful extubation and he was discharged home on voriconazole. DISCUSSION: IPA with influenza A has been associated with a rapidly progressive mortality, and recent literature has shown IB to cause equally serious infections.1,2 The earliest report of IPA with IB is from Japan in 2005.3 Disrupted ciliary clearance in the bronchial tree during IB infection predisposes the patient to an invasive fungal infection.3 Interestingly, our patient’s predilection to fungus can also be attributed to extensive smoking and a farming background. Treatment duration with voriconazole can range up to fifty weeks and should be closely monitored with imaging and microbiological evaluation. CONCLUSIONS: IPA with IB is a diagnosis with high morbidity and mortality,1,2 and further investigation is essential to determine its relationship with influenza outbreaks, clinical impact of rapid diagnosis and significance of combination therapy. Reference #1: Park, D.W., et al., Fatal clinical course of probable invasive pulmonary aspergillosis with influenza B infection in an immunocompetent patient. Tuberc Respir Dis (Seoul), 2014. 77(3): p. 141-4. Reference #2: Nulens, E.F., M.J. Bourgeois, and M.B. Reynders, Post-influenza aspergillosis, do not underestimate influenza B. Infect Drug Resist, 2017. 10: p. 61-67. Reference #3: Hasejima, N., et al., Invasive pulmonary aspergillosis associated with influenza B. Respirology, 2005. 10(1): p. 116-9. DISCLOSURE: The following authors have nothing to disclose: Nissy Ann Philip, Christopher Radchenko No Product/Research Disclosure Information

Fulminant Community-Acquired Hemorrhagic Pneumonia due to Pseudomonas aeruginosa in a Patient With Anorexia Nervosa

Community-acquired pneumonia (CAP) due to Pseudomonas aeruginosa is rare. We report a case of a 29-year-old female with anorexia nervosa admitted to our intensive care unit for CAP due to P. aeruginosa . Although she had no previously known pseudomonal risk factors, gram-negative rods found in the sputum Gram stain led to immediate administration of an antipseudomonal drug. Despite intensive care, she died on day 4 of hospitalization. Anorexia nervosa can be a risk factor for CAP due to P. aeruginosa . Gram-negative rods in the sputum of patients with severe CAP can be a key to choose antipseudomonal drugs. J Med Cases. 2017;8(6):183-186 doi: https://doi.org/10.14740/jmc2833w

Microscopic Analysis and Quality Assessment of Induced Sputum From Children With Pneumonia in the PERCH Study.

Background.It is standard practice for laboratories to assess the cellular quality of expectorated sputum specimens to check that they originated from the lower respiratory tract. The presence of low numbers of squamous epithelial cells (SECs) and high numbers of polymorphonuclear (PMN) cells are regarded as indicative of a lower respiratory tract specimen. However, these quality ratings have never been evaluated for induced sputum specimens from children with suspected pneumonia.Methods.We evaluated induced sputum Gram stain smears and cultures from hospitalized children aged 1–59 months enrolled in a large study of community-acquired pneumonia. We hypothesized that a specimen representative of the lower respiratory tract will contain smaller quantities of oropharyngeal flora and be more likely to have a predominance of potential pathogens compared to a specimen containing mainly saliva. The prevalence of potential pathogens cultured from induced sputum specimens and quantity of oropharyngeal flora were compared for different quantities of SECs and PMNs.Results.Of 3772 induced sputum specimens, 2608 (69%) had <10 SECs per low-power field (LPF) and 2350 (62%) had >25 PMNs per LPF, measures traditionally associated with specimens from the lower respiratory tract in adults. Using isolation of low quantities of oropharyngeal flora and higher prevalence of potential pathogens as markers of higher quality, <10 SECs per LPF (but not >25 PMNs per LPF) was the microscopic variable most associated with high quality of induced sputum.Conclusions.Quantity of SECs may be a useful quality measure of induced sputum from young children with pneumonia.

Prevalence of Tuberculosis among Community Acquired Pneumonia Diagnosed Patients

Aim: To evaluate the proportion of pulmonary TB among patients hospitalized with suspected communityacquired pneumonia (CAP). Methods: Consecutive patients diagnosed with community acquired pneumonia (CAP) admitted to a tertiary care centre over a 2 year period was studied prospectively. Systematic investigation of samples of sputum and blood cultures was performed. A subset of patients had urine antigen tests and serum serology. Results: We enrolled 104 CAP suspected patients in the study group according to the BTS guidelines for CAP. Among these patient’s sputum AFB smear positivity was observed in 21 cases (20.19%). 18 (17.30%) patients turned out to be sputum gram stain positive, but their respective cultures didn’t show any growth. 65 (62.50%) of them turned out to be gram stain and culture positive for bacteriological aetiology. The Commonest cause for CAP among sputum and blood culture positive cases was Streptococcus pneumoniae (19/65) followed by, Klebsiella pneumoniae (17/65), Staphylococcus aureus (13/65), Pseudomonas aeruginosa (8/65), Escherichia coli (4/65), Acinetobactor spp. (3/65). Conclusion: Tuberculosis is one of the leading causes of CAP in TB-prevalent areas. Our diagnostic index may help clinicians identify pulmonary TB cases immediately from CAP and initiate appropriate isolation and optimal treatment.

Productive Cough in Children and Adolescents - View from Primary Health Care System.

Cough is one of the most common symptoms that doctor faces in working with pediatric population, and according to some characteristics of cough, doctors can often conclude localization, and sometimes even the nature of the disease that causes it. Cough is not only the physiological defense reaction, but a symptom of a disease. According to duration it can be acute, chronic and recidivist, recurrent and persistent, strong or discreet, caused by changes in body position and changes in outside temperature. Pathoanatomically it is divided into lobar, lobular, alveolar and interstitial, pathogenetically to bronchogenic and hematogenous, as well as in immuno competent and immunocompromised, and clinically on the local and inpatient (72 hours after hospital admission). Considering the contents, cough can be productive–with secretion from the respiratory tract, and unproductive-dry, without secretion. By auscultation bronchial breathing, rattle and crepitus can be heard. The primary diagnostics is radiological, posterior to anterior (P-A) and lateral footage of the chest. Laboratory findings in typical pneumonia, are characterized by leukocytosis, neutrophilia and shift of blood image to the left. Sedimentation is accelerated and C-reactive protein is elevated. The basic bacteriological diagnosis is sputum Gram’s stain and culture of sputum. In atypical pneumonia, leukocytes are usually in the normal range, and it is necessary to do serological tests (IgM and IgG antibodies). The role of doctors in primary health care is auscultation differentiation of murmurs with confirmation of doubt if there is pathological findings by laboratory tests and treatment, depending on the type of cough. Treatment is essentially pharmacological, with irrefutable importance of non-pharmacological measures.

Fulminant Community-Acquired Hemorrhagic Pneumonia due to Pseudomonas aeruginosa in a Patient With Anorexia Nervosa

Community-acquired pneumonia (CAP) due to Pseudomonas aeruginosa is rare. We report a case of a 29-year-old female with anorexia nervosa admitted to our intensive care unit for CAP due to P. aeruginosa . Although she had no previously known pseudomonal risk factors, gram-negative rods found in the sputum Gram stain led to immediate administration of an antipseudomonal drug. Despite intensive care, she died on day 4 of hospitalization. Anorexia nervosa can be a risk factor for CAP due to P. aeruginosa . Gram-negative rods in the sputum of patients with severe CAP can be a key to choose antipseudomonal drugs. J Med Cases. 2017;8(6):183-186 doi: https://doi.org/10.14740/jmc2833w

Detailed analysis of sputum and systemic inflammation in asthma phenotypes: are paucigranulocytic asthmatics really non-inflammatory?

BackgroundThe technique of induced sputum has allowed to subdivide asthma patients into inflammatory phenotypes according to their level of granulocyte airway infiltration. There are very few studies which looked at detailed sputum and blood cell counts in a large cohort of asthmatics divided into inflammatory phenotypes. The purpose of this study was to analyze sputum cell counts, blood leukocytes and systemic inflammatory markers in these phenotypes, and investigate how those groups compared with healthy subjects.MethodsWe conducted a retrospective cross-sectional study on 833 asthmatics recruited from the University Asthma Clinic of Liege and compared them with 194 healthy subjects. Asthmatics were classified into inflammatory phenotypes.ResultsThe total non-squamous cell count per gram of sputum was greater in mixed granulocytic and neutrophilic phenotypes as compared to eosinophilic, paucigranulocytic asthma and healthy subjects (p < 0.005). Sputum eosinophils (in absolute values and percentages) were increased in all asthma phenotypes including paucigranulocytic asthma, compared to healthy subjects (p < 0.005). Eosinophilic asthma showed higher absolute sputum neutrophil and lymphocyte counts than healthy subjects (p < 0.005), while neutrophilic asthmatics had a particularly low number of sputum macrophages and epithelial cells. All asthma phenotypes showed an increased blood leukocyte count compared to healthy subjects (p < 0.005), with paucigranulocytic asthmatics having also increased absolute blood eosinophils compared to healthy subjects (p < 0.005). Neutrophilic asthma had raised CRP and fibrinogen while eosinophilic asthma only showed raised fibrinogen compared to healthy subjects (p < 0.005).ConclusionsThis study demonstrates that a significant eosinophilic inflammation is present across all categories of asthma, and that paucigranulocytic asthma may be seen as a low grade inflammatory disease.Electronic supplementary materialThe online version of this article (doi:10.1186/s12890-016-0208-2) contains supplementary material, which is available to authorized users.

A Study on Analysis of the Sputum Gram Staining and Culture in Patients with Lower Respiratory Tract Infections Attending a Tertiary Care Hospital

Background: Microscopical examination of expectorated sputum samples is the most commonly followed method in the Microbiological laboratory for diagnosis of lower respiratory tract infections (LRTIs). Sputum sample is usually contaminated with normal resident floral organisms of the oropharynx. For the diagnosis and management of LRTIs, collection of sputum sample, sputum microscopy and culture is very important. The present study was conducted to analyse the importance of the microscopical examination of Gram stained sputum smears and the sputum culture in patients with LRTIs. Materials & Methods: The place of the study was in the department of Microbiology in a tertiary care hospital. The study period was for one year from Jan 2015 to Dec 2015. Gram staining and culture were done for all the 130 sputum samples. Gram stained sputum smears were observed under microscope for presence of organisms, pus cells and epithelial cells. Quality of expectorated sputum samples were assessed by using Bartlett’s grading system. By using standard protocols bacterial isolates were identified. Kirby Bauer disc diffusion method on Mueller Hinton agar was performed for antibiotic susceptibility testing. Results and conclusion: Out of 130 sputum samples, 72 (55.4%) samples were acceptable based on Bartlett’s screening system and 58(44.6%) samples were in the not acceptable category. Among acceptable category, 64(78.05%) samples were showed culture positivity. Among non-acceptable category, 18(21.95%) samples were showed culture positivity. Klebsiella pnemoniae-31.71% was the commonest isolated organism followed by Pseudomonas aeruginosa-14.63% and Staphylococcus aureus -13.41%.In this study authors recommended to receive good quality of sputum and do initial sputum screening for diagnosing clinically relevant LRTIs. Keywords: Bartlett’s grading system, Gram stain, Non-acceptable category, Sputum acceptable category, Sputum culture

A Novel Board Review Conference Positively Impacting ID Fellow In-Service Scores

• Subsequently, the presenter has discussion slides which briefly discusses the topic that he/she has presented and the relevant information that is high yield for board exams. 52 year old male with DM, COPD, is seen a day after returning from New Zealand (NZ) and Australia. He did a lot of hiking in NZ and northern Australia where it was rainy. He started feeling unwell during the return trip. He complains of 3 days of fevers, chills, productive cough, and pleurisy. A bipolar gram negative rod is seen on sputum Gram Stain.

Outcome of community-acquired pneumonia with cardiac complications

BackgroundAlthough pneumonia is a leading cause of death, little consideration has been given to understanding the contributors to this mortality. Previous studies have suggested an increased mortality in pneumonia patients who develop cardiac complications. The aim of this study was to examine the risk factors and outcome of cardiac complications in admitted patients with community-acquired pneumonia. Patients and methodsThis study included 130 patients hospitalized with a primary diagnosis of community-acquired pneumonia. All patients were subjected to complete medical history, general and local chest examination, Laboratory investigations (complete blood count, renal and hepatic function tests, serum electrolytes, blood sugar, arterial blood gas analysis, CRP, procalcitonin, BNP, cardiac enzymes, blood and sputum Gram stain and culture, sputum PCR for Mycoplasma pneumoniae, Legionella pneumophila, Coxiella burnetii, and Chlamydophila species, urine antigen testing for S. pneumoniae and L. pneumophila, pharyngeal swabs for viral PCR.), radiological investigations, electrocardiographic studies (ECG) and echocardiography. ResultsAmong the studied 130 patients, 32 patients (24.6%) had cardiac complications [new or worsening heart failure in16 patients (12.3%), arrhythmias in 12 patients (9.2%), and acute myocardial infarction in 4 patients (3.1%)]. In comparing patients who developed cardiac complications with those who did not they had a significantly higher age (mean±SD 69±17.3 versus 49±19.1, p<0.05), included a significantly higher percentage of patients with preexisting cardiovascular diseases (40.6% versus 5.1%, p<0.05), had a significantly higher pneumonia severity index (PSI) (mean±SD 130±27 versus 73±29, p<0.05), a significantly longer hospital stay (mean±SD 22±7.1 versus 9±4.3, P<0.05) and a significantly higher mortality (21.8% versus 6.1%, P<0.05). ConclusionsCardiac complications are common in the admitted patients with pneumonia and they are associated with increased pneumonia severity and increased cardiovascular risk, these complications adds to the risk of mortality, so optimal management of these events may reduce the burden of death associated with this infection.

Current clinical and microbiological peculiarities of cystic fibrosis in children and adolescents

Aim. Statistical dataabout the prevalence of cystic fibrosis in children and adolescents in Dnipropetrovskfor last 5 years were analyzed to determine the clinical and microbiological peculiarities of cystic fibrosis.Methods and results.Analysis of the clinical and microbiological data of 35 patients using clinical and medical history, an assessment of physical development, radiological, sonographic, spirometric, microbiological examinationswas studied. The structure of the disease according to the clinical forms and respiratory tract microbiotawas specified. Factors reducing the quality of life of patients and causing unfavorable prognosis of the disease, including violations of nutritional status and the presence of sputum gram negative pathogens with high resistance to antibacterial agentswere studied.Conclusion.This demonstrates the necessity of more careful selection of therapy because children with identified resistant respiratory tract microbiota are at increased risk of severe and complicated course of CF.