Background: Recently, in addition to multi-drug resistant tuberculosis (MDR-TB), extensively drug-resistant tuberculosis (XDR-TB) has become rapidly growing public health threat. This study examined the clinical differences between pulmonary TB patients with extensively drug resistance (XDR) and multi-drug resistance (MDR) at the National Medical Center in Korea in order to determine the clinical characteristics associated more with XDR-TB than MDR-TB. Methods: Patients who received a diagnosis of culture-confirmed pulmonary TB and a drug sensitivity test (DST) for anti-TB drugs at the National Medical Center between January 2000 and August 2007 were enrolled in this study. The patients were identified into the XDR-TB or MDR-TB group according to the DST results. The clinical characteristics were reviewed retrospectively from the medical records. Statistical analysis for the comparisons was performed using a χ2-test, independent samples t-test or binary logistic regression where appropriate. Results: A total 314 patients with culture-confirmed pulmonary TB were included. Among them, 18 patients (5.7%) had XDR-TB and 69 patients (22%) had MDR-TB excluding XDR-TB. A comparison of the clinical characteristics, revealed the XDR-TB group to have a higher frequency of a prior pulmonary resection for the treatment of TB(odds ratio [OR], 3.974; 95% confidence interval [CI], 1.052∼15.011; P value 0.032) and longer average previous treatment duration with anti-TB drugs, including a treatment interruption period prior to the diagnosis of XDR, than the MDR-TB group (XDR-TB group, 72.67 months; MDR-TB group, 13.09 months; average treatment duration difference between two groups, 59.582 months; 95% CI, 31.743∼87.420; P value, 0.000). In addition, a longer previous treatment duration with anti-TB drugs was significantly associated with XDR-TB (OR, 1.076; 95% CI, 1.038∼1.117; P value, 0.000). A comparison of the other clinical characteristics revealed the XDR-TB group to have a higher frequency of male gender, diabetes mellitus (DM), age under 45, treatment interruption history, cavitations on simple chest radiograph and positive result of sputum AFB staining at the time of diagnosis of XDR. However, the association was not statistically significant. Conclusion: Pulmonary TB patients with XDR have a higher frequency of a prior pulmonary resection and longer previous treatment duration with anti-TB drugs than those with MDR. In addition, a longer previous treatment duration with anti-TB drugs is significantly associated with XDR-TB.
Background: Mycobacterium abscessus is the most pathogenic and drug-resistant rapid-growing mycobacterium.Clarithromycin or azithromycin are the only regular oral antimycobacterial agents that have an effect on M.abscessus. We tried to detect the clarithromycin-resistant strains from the clinical isolates of M. abscessus. Methods: We tried to isolate the clarithromycin-resistant strains from 220 clinical isolates of M. abscessus by performing using reverse hybridization assay (RHA) and the broth microdilution test (BMT). Results: Seven resistant strains (3.2%) from all the tested clinical isolates were detected by BMT. Three of these resistant strains were also detected by RHA and it was confirmed that they had point mutants. Conclusion: These results showed that clarithromycin resistance in M. abscessus clinical isolates is related to a point mutation and other unknown mechanisms.
Background: A paradoxical response is defined as the radiological and clinical worsening of a previous lesion or the development of new lesion after initial improvement during theprocess of antituberculous treatment. The related factors for the development of a paradoxical response in patients with tuberculous pleurisy are not certain. Methods: We selected patients with tuberculous pleurisy who had been treated for more than 4 months. The changes onthe serial chest X-ray findings before and after treatment were reviewed. Paradoxical responses were regarded as any worsening or development of new lesion at least 2 weeks after the initiation of treatment. The baseline clinical characteristics and laboratory findings of the peripheral blood and pleural fluid were compared between the patients with a paradoxical response and the patients without a paradoxical response. Results: Paradoxical responses appeared in sixteen patients (21%) among the 77 patients.It took a mean of 38.6 days after the treatment and the time to resolve the paradoxical response was a mean of 32.1 days. For the patients with a paradoxical response, the median age was younger (30.5 years vs 39.0 years, respectively) and the lymphocytic percentage of white blood cells in the pleural fluid was higher (82.1% vs 69.6%, respectively) than for the patients without a paradoxical response. Conclusion: The development of a paradoxical response during the treatment of patients with tuberculous pleurisy was not rare and this was related with the age of the patients and the percentage of lymphocytic white blood cells in the pleural fluid.
Background: A patient with a pleural effusion that is difficult to safely drain by a "blind" thoracentesis procedure is generally referred to a radiologist for ultrasound-guided thoracentesis. But such a referral increases the cost and the patient's inconvenience, and it causes delay in the diagnostic procedures. If ultrasound-guided thoracentesis is performed as a bedside procedure by a medical resident, then this will reduce the previously mentioned problems. So these patients with pleural effusions were treated by medical residents at our medical center, and the procedures included bedside ultrasound-guided thoracenteses.Methods: We studied 89 cases of pleural effusions from March 2003 to June 2005. A "blind" thoracentesis was performed if the amount of pleural effusion was moderate or large. Bedside ultrasound-guided thoracentesis was performed for small or loculated effusions or for the cases that failed with performing a "blind" thoracentesis. Results: "Blind" thoracenteses were performed in 79 cases that had a moderate or large amount of uncomplicated pleural effusions and the success rate was 93.7% (74/79 cases). Ultrasound-guided thoracentesis by the medical residents was performed in 15 cases and the success rate was 66.7% (10/15 cases). The 5 failedcases included all 3 cases with loculated effusions and 2 cases with a small amount of pleural effusion. All the failed cases were referred to one radiologist and they were then successfully treated. If we exclude the 3 cases with loculated pleural effusions, the success rate of ultrasound-guided thoracentesis by the medical residents increased up to 83% (10/12cases). Two cases of complications (1 pneumothorax, 1 hydrohemothorax) occurred during ultrasound-guided thoracentesis. Conclusion: Ultrasound-guided thoracentesis performed as a bedside procedure by a medical resident may be relatively effective and safe. If a patient has a loculated effusion, then it would be better to first refer the patient to a radiologist.
Background: As the number of older-aged people increases, the number of elderly patients who receive critical care services is expected to increase substantially. The objective of this study was to examine the clinical characteristics and outcomes of elderly patients who receive mechanical ventilation for more than 30 days in the medical intensive care unit (MICU) at a university hospital.Methods: We retrospectively examined forty-one elderly patients (≥65 years old) who were receiving mechanical ventilation, from April 2004 to March 2007, for periods exceeding 30 days at the MICU at Eulji University Hospital. Results: The MICU and hospitalmortality rate were 60.9% and 65.9%, respectively. The mean length of the ICU stay was 57.5 days and the mean duration of mechanical ventilation was 49.3 days. The most common reason for MICU admission was acute respiratory failure (73.2%), followed by sepsis (12.2%), neurological problems (9.8%),and gastrointestinal bleeding (4.9%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher for the nonsurvivors than for the survivors (28.0 vs. 25.0, respectively, p=0.03). The nonsurvivors received more red blood cell (RBC) transfusions during their ICU stay than did the survivors (84.0% vs. 43.8%, respectively p=0.007). The factors associated with hospital death were the APACHE II score and if the patient had received a RBC transfusion. Conclusion: The APACHE II score and a RBC transfusion were predictors of increased hospital mortality for the elderly patients who were on prolonged mechanical ventilation. These predictors may assist physicians to make clinical decisions for this patient population.
Pulmonary mucormycosis is an uncommon, serious opportunistic infection caused by fungi belonging to the order Mucorales and it occurs exclusively in debilitated or immuno compromised hosts. It is known that the fungi can invade the blood vessels and cause serious ischemic necrosis and bleeding5. We experienced a fatal case of pulmonary mucormycosis in a diabetic 75-year-old man who developed a progressive necrotizing lesion despite administering proper and prompt medical and surgical treatment. We report here on this case along with a review of the relevant medical literature.
This case demonstrates the rare occurrence of a radiolucent temporary resin bridge aspiration in adults while they are in a conscious and awaken state and the resultant formation of inflammatory polyps. Although no unique findings were noted in a chest x-ray, careful history taking accompanied by physical examinations can lead to clinical suspicion of foreign body aspiration in an earlier stage. Moreover, flexible bronchoscopy is a tool useful not only for the evaluation process but also for managing the aspirated foreign material.
Incidences of pulmonary thromboembolism markedly increase with age. Risk factors of pulmonary thromboembolism are surgery, trauma, acute medical illness, immobilization, pregnancy, usage of hormone, and advanced age. In the cases of thrombomembolism occurred in young age, the possibility of thrombophilc state is needed to be investigated. Among many diseases or state associated thrombophilic state, homocyteinemia should be considered a cause of thromboembolism before fifth decade. Homocyteinemia is caused by deficiency of N-5-methyltetrahydrofolate, cystathionie β-synthase and vitamin B12. The presence of the mutation of 5,10-methyleneterahydrofolate lead to homocyteinemia by deficiency of N-5-methyltetrahydrofolate. Homocysteine is acknowledged the risk factor of cardiovascular event, and storke. Homocysteinemia can be the cause of thromboemboism via damaging endotheial cell. We present two cases of pulmonary thromboembolism in young age which seem to be associated with homocysteinemia precipitated by mutation of 5,10 methyleneterahydrofolate.
A factor VII gene -401 G/A polymorphism was identified in a patient with a pulmonary embolism. The patient was a 71-year-old woman who presented with acute-onset dyspnea. A chest CT scan revealed a pulmonary embolism. Despite the administration of low-dose warfarin as anticoagulation therapy, there was an excessively prolonged prothrombin time (PT). The blood tests revealed lower factor VII activity than normal. Full factor VII gene sequencing revealed a G to A substitution at –401 in the promoter region. There were no other gene sequence anomalies. PCR-based analysis indicated lower factor VII gene expression in the patient than in a control subject. The data suggested the promoter polymorphism to be responsible for the lower transcription level. In conclusion, we encountered a case of Factor VII DNA polymorphism in a patient with a pulmonary embolism showing significantly reduced Factor VII activity.