Severe sepsis and septic shock are major healthcare problems with high mortality, ranging from 20% to 60%, affecting millions of individuals around the world each year. The speed and appropriateness of therapy administered in the initial hours after severe sepsis develops have an important impact on the outcome. In 2004, an international guideline that the bedside clinician could use to improve the outcomes in severe cases of sepsis and septic shock was published. Several landmark studies recently demonstrated that therapeutic strategies may reduce mortality substantially. The “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock: 2008”, using a new evidence-based methodology system for assessing the quality of evidence and the strength of the recommendations, was updated. The revised version is based on an updated search into 2007. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improving the outcomes of critically ill patients. We review the treatment guidelines of sepsis and septic shock.
Background: Mycobacterial Interspersed Repetitive Units (MIRUs) that are located mainly in intergenic regions dispersed throughout the Mycobacterium tuberculosis genome. The selected MIRU loci, which were composed of a 12-locus set, demonstrated a high power for discrimination of Mycobacterium tuberculosis isolates collected from Kangwon province of Korea. To evaluate its ability to discriminate the M. tuberculosis strains, 45 clinical isolates were genotyped using the methods IS6110 RFLP and MIRU. Methods: All the samples were collected during the period from January 2007 to December 2007 from TB patients, who were residents and registered to a public health center of Kangwon Province in Korea. A total of 45 DNAs were extracted from clinical isolated mycobacterial strains and genotyped using IS6110 RFLP, the MIRU method. Results: We compared the 12-MIRU with IS6110 RFLP in the 45 samples, the 12-locus version offered less discriminatory power (Hunter-Gaston discriminatory index [HGDI]: 0.959 vs 0.998; 57.78% of clustered cases vs 8.89%). Conclusion: This 12-locus MIRU can be useful when additional combinations of other loci for genotyping M. tuberculosis in Korea where the Beijing family strains are dominant.
Background: The smoking prevalence in asthma patients are similar to those in the general population. Asthma and active cigarette smoking can interact to create more severe symptoms, an accelerated decline in lung functionand impaired therapeutic responses. Accordingly, asthmatics with a history of smoking were examined to define the clinical characteristics and lung function of smoking asthmatics. Methods: The medical records of 142 asthmatics with a known smoking history were reviewed. The patients were divided into three groups according to their smoking history - current smokers, former smokers and non-smokers. The clinical characteristics, lung function, and annual declines of the forced expiratory volume in one second (FEV1) were compared. Results: Fifty-three of the 142 patients (37%) were current smokers, 24 were former smokers (17%) and 65 were non-smokers (45%). The patients with a hospital admission history during the previous year included 16 currentsmokers (30%), 4 former smokers (17%) and 7 non-smokers (11%) (p=0.02). The mean FEV1 (% predicted) was 76.8±19.8%, 71.6±21.1% and 87.9±18.7% for current smokers, former smokers and non-smokers, respectively (p＜0.001). The FEV1/forced vital capacity (FVC) (ratio, %) values were 63.6±12.6%, 59.3±14.9% and 72.1±11.8% in current smokers, former smokers and non-smokers, respectively (p＜0.001). The corresponding mean values forthe individual FEV1 slopes were not significant (p=0.33). Conclusion: Asthmatic smokers demonstrated higher hospital admission rates and lower lung function. These findings suggest that the smoking history is an important predictor of a poor clinical outcome in asthma patients.
Background: Pulmonary paragonimiasis is a subacute to chronic inflammatory disease of the lung caused by lung flukes that result in prolonged inflammation and mechanical injury to the bronchi. However, there are few reports on the bronchoscopic findings of pulmonary paragonimiasis. This report describes the bronchoscopic findings of pulmonary paragonimiasis. Methods: The bronchosocpic findings of 30 patients (20 males, median age 50 years) with pulmonary paragonimiasis between May 1995 and December 2007 were reviewed retrospectively. Results: The diagnoses were based on a positive serologic test results for Paragonimus-specific antibodies in 13 patients (43%), or the detection of Paragonimus eggs in the sputum, bronchial washing fluid, or lung biopsy specimens in 17 patients (57%). The bronchoscopic examinations revealed endobronchial lesions in 17 patients (57%), which were located within the segmental bronchi in 10 patients (59%), lobar bronchi in 6 patients (35%) andmain bronchi in 1 patient (6%). The bronchoscopic characteristics of endobronchial lesions were edematous swelling of the mucosa (16/17, 94%) and mucosal nodularity (4/17, 24%), accompanied by bronchial stenosis in16 patients (94%). Paragonimus eggs were detected in the bronchial washing fluid of 9 out of the 17 patients with endobronchial lesions. The bronchial mucosal biopsy specimens showed evidence of chronic inflammationwith eosinophilic infiltration in 6 out of 11 patients (55%). However, no adult fluke or ova were found in the bronchial tissue. Conclusion: Bronchial stenosis with mucosal changes including edematous swelling and mucosal nodularity is the most common bronchoscopic finding of pulmonary paragonimiasis.
Background: Bronchiectasis (BE) remains a rare respiratory disease in Korea. This retrospective study was done to investigate the potential pathogenic microorganisms (PPMs) that cause in patients with BE, through the use of sputum specimens. Methods: One hundred eleven adult patients, who had undergone chest computed tomography (CT), sputum gram stain/culture, and BE detected by chest CT, were included in this study. Sputum adequacy was determined by using Murray-Washington classification. Results: The mean (±SD) age of patients was 60.9 (±14.0). The number of PPMs was 167 (67%) in the total 248 isolated organisms. The most frequent PPMs were P. aeruginosa (23.4%), K. pneumoniae (10.5%), and S. aureus (8.4%). The proportion of adequate sputum (AS) was 25.8% in the total sputum specimens. The patients with AS were 41 (37%) and the patients with inadequate sputum (IS) were 70 (63%). The proportion of P. aeruginosa was higher in AS compared to that of IS (44% vs. 19%, p=0.004). The BE score was also higher in P. aeruginosa (＋) patients compared to that of P. aeruginosa (−) patients (10.8 vs. 7.6, p=0.001). Conclusion: Although the proportion of AS in the total sputum was low, PPMs were isolated in most patients with BE. It is likely that P. aeruginosa was isolated in AS and AS patients had higher BE scores.
Background: Dust clouds blown by the wind from the arid deserts of Mongolia and Northeast China are known as Asian dust storms. Ambient particulate matter with a diameter ＜10 μm (PM10) is associated with the exacerbation of respiratory diseases and increased mortality of heart and lung disease patients. The fibrotic effects of PM10 of Asian dust to pulmonary fibroblast cells are unknown. This study examined the production of reactive oxygen species (ROS), TGF-β, NF-κB, PDGF-α and Fibronectin in fibroblasts exposed to Asian dust particles. Methods: Air samples were collected using a high volume air sampler (Sibata model HV500F) with an air flow of 500 L/min for at least 6 hours. The MRC-5 cells were exposed to 0, 50 and 100 μg/mL of PM10 for 24 hours. ROS was detected by measuring the level of oxidized DCF using FACS. TGF-β, NF-κB, PDGF-α and fibronectin were detected by western blotting. Results: There was no increase in the ROS, TGF-ß and PDGF-α levels in the MRC-5 cells exposed to PM10. The NF-κB level was higher in the MRC-5 cells exposed to 50 and 100 μg/mL of PM10 for 24 hours. The fibronectin level in the MRC-5 cells after 24 hours incubation with 50 μg/mL PM10 was significantly higher than the control group (PM10 50 μg/mL 113.27±8.65 of control, p=0.005). Conclusion: PM10 from Asian dust increases the activation of NF-κB and fibronectin expression in MRC-5 fibroblast cells.
Background: A combination of salmeterol and fluticasone propionate (SFC) and tiotropium bromide (TIO) is commonly prescribed for COPD patients but there is little data on their effectiveness, particularly in COPD patients with bronchial hyperresponsiveness. This study compared the spirometric improvement based on the change in FEV1, FEV1/FVC, and IC as well as the clinical outcomes of the therapeutic strategies with SFC and TIO versus the individual components in patients with severe COPD and bronchial hyperresponsiveness. Methods: This study examined the spirometric data and clinical outcomes of 214 patients with COPD and hyperresponsiveness, who were divided into three groups according to the therapeutic regimen (TIO only, SFC only, and a triple therapy regimen). Results: All regimen groups showed early improvement in the FEV1 and IC (at 3- and 6 months after treatment). However, long-term beneficial effects were observed only in the SFC group (at 24 months after treatment). However, these beneficial effects decreased after a 36-month follow up. In all spirometric results, the 12-, 24-, and 36-months data showed a similar degree of improvement in the three groups. The triple therapy group showed higher St. George’s Respiratory Questionnaire scores and lower acute exacerbations and hospitalization. Conclusion: SFC can be a more important component in the pharmacological treatment of severe COPD patients with hyperresponsiveness than TIO, particularly in the spirometric and clinical outcomes.
Background: Endobronchial ultrasonogram (EBUS) has increased the diagnostic yield of a bronchoscopic biopsy of peripheral pulmonary lesions (PPL). This study evaluated the diagnostic yield of EBUS-guided transbronchial biopsy (TBB) and the visibility of EBUS PPL. Methods: Between August 2007 and November 2008, 50 patients (32 men and 18 women, median age, 61.1±10 yrs; range, 16 to 80 yrs) whose PPL lesions could not be detected with flexible bronchoscopy were enrolled in this study. Among the 50 patients, 40 cases were malignant lesions (adenocarcinoma 25, squamous cell carcinoma 10, small cell carcinoma 5) and 10 cases were benign lesions (tuberculoma 7, fungal ball 1, other inflammation 2). Results: The mean diameter of the target lesion was 35.4±4.3 mm. Of the 50 patients examined, the overall diagnostic yield by EBUS-TBLB was 46.0% (23/50). The visualization yield of EBUS was 66.0% (33/50). A definitive diagnosis of PPL localized by EBUS was established using EBUS-TBLB in 69.6% (23/33) of cases. The diagnostic yields from washing cytology and brushing cytology from a bronchus identified by EBUS were 27.0% and 45.4% respectively. The diagnostic yields reached 78.7% when the three tests (washing cytology, brushing cytology and EBUS-TBLB) were combined. The visualization yield of EBUS in lesions ＜20 mm was significantly lower than that in lesions ≥20 mm (p=0.04). The presence of a bronchus leading to a lesion (open bronchus sign) on the chest CT scan was associated with a high visualization yield on EBUS (p=0.001). There were no significant complications associated with EBUS-TBLB. Conclusion: EBUS-TBLB is a safe and effective method for diagnosing PPL. The lesion size and open bronchus signs are significant factors for predicting the visualization of EBUS.
A benign pulmonary metastasizing leiomyoma is a recognized clinical entity that has been infrequently reported in the medical literature. We report two cases of a benign pulmonary metastasizing leiomyoma. A 35-year-oldwoman who underwent myomectomy and a cesarean section approximately 6 years earlier visited our hospital for further evaluation of incidentally revealed multiple lung nodules. A diagnostic percutaneuous biopsy wasperformed. Finally she was diagnosed with a benign metastasizing leiomyoma. The patient then received LH-RH and has been followed up since. The other 44-year-old woman presented after an initial radiology evaluationrevealed the presence of multiple, small-sized lung nodules. She underwent a right middle lung wedge resection to confirm the diagnosis. Finally she diagnosed with a benign metastasizing leiomyoma. The multiple lung noduleshave been followed up closely.
Acute eosinophilic pneumonia (AEP) is characterized by idiopathic acute febrile illness, diffuse pulmonary infiltration, severe hypoxemia, and pulmonary eosinophilia. We report a case of AEP associated with intramuscular administration of progesterone as luteal phase support after in vitro fertilization. A 33-year-old woman presented to our emergency room with tachypnea and hypoxemia, complaining of fever and cough for 4 days, and dyspnea for 2 days. The symptoms began 9 days after the first injection of progesterone. Chest radiograph showed bilateral infiltrates, located predominantly in the periphery of the lungs, with blunting of the costophrenic angle. Symptoms and chest radiograph dramatically improved after corticosteroid therapy and shifting the progesterone from an intramuscular form of administration to a vaginal form of administration.
Sarcoidosis is a granulomatous disease that can involve any organ, although it primarily involves the lungs, intrathoracic lymph nodes, skin, and eyes. We present a case of sarcoidosis with pancytopenia, resulting from bone marrow involvement. A 35-year-old man was admitted to hospital for chronic cough and blurred vision. On chest computed tomography, there were multiple pulmonary nodules and mediastinal lymph nodes enlargement. As the patient also showed pancytopenia, we performed a bone marrow biopsy, as well as a transbronchial lung biopsy. Both biopsies showed non-caseating granulomas. We diagnosed the patient with sarcoidosis with pulmonary, bone marrow, uvea, liver and spleen involvement. After oral steroid therapy, the patient’s symptoms as well as his pancytopenia improved. We present this case to demonstrate the significance of bone marrow biopsy in cases of sarcoidosis with pancytopenia, as well the possibility of clinical improvement with steroid treatment.
Yellow nail syndrome is a rare cause of pleural effusions. This syndrome is characterized by yellow discoloration of nails, lymphedema, and respiratory disorders, including pleural effusion, chronic bronchitis, bronchiectasis, and chronic sinusitis. The etiology of this syndrome is obscure, but the pathogenesis seems to be related with impaired lymphatic drainage. We report a case of yellow nail syndrome in a 70-year-old female with the typical clinical findings (yellow discoloration of nails, lymphedema, and chronic pleural effusion) of this disorder and with proven lymphatic obstruction on lymphoscintigraphy.
Idiopathic pulmonary alveolar proteinosis (PAP) is a rare disorder characterized by surfactant component accumulation in the alveolar space. Idiopathic PAP has recently been recognized as a autoimmune disease of impaired alveolar macrophage function caused by autoantibodies against granulocyte-macrophage colony-stimulating factor(GM-CSF). While whole lung lavage has been the standard treatment, not every patient shows a complete response. Subcutaneous injection or inhalation of GM-CSF is another promising treatment option for PAP. A 45-year-old patient visited our hospital for dyspnea, he was diagnosed as PAP and underwent whole lung lavage. Eighteen months later, the patient had not achieved complete remission in despite of initial response. After then he was administered with GM-CSF (5 μg/kg/day, subcutaneous injection) for fivetimes a week during 2 months. Nine months later, the abnormal shadows in high-resolution computed tomography (HRCT) decreased and the patient fully recovered in forced vital capacity. After 60 months, the HRCT scan showed complete remission of PAP.
An intramedullary spinal cord metastasis (ISCM) rarely develops in systemic cancer but is indicative of a poor prognosis. A 56-year-old man was admitted due to weakness of the lower extremities. He had received radiotherapy 3 months prior for a brain metastasis that had developed 1 year after achieving a complete response from chemotherapy for extended stage small cell lung cancer. Although the brain lesion had improved partially, ISCM from the cervical to lumbar-sacral spinal cords, which was accompanied by a leptomeningeal dissemination, was diagnosed based on magnetic resonance imaging of the spine and cerebrospinal fluid cytology. Finally, he died of sudden cardiac arrest during treatment. This is the first case of ISCM involving the whole spinal segments. Physicians should be aware of the subsequent development of ISCM in lung cancer patients with a previously known brain metastasis who present with new neurological symptoms.