A STUDY OF ATYPICAL TYPE II PNEUMOCOCCI

1. At least twelve subgroups of atypical Type II pneumococcus may be recognized by specific agglutination reactions. They have been designated Subgroups IIa, IIb, IIc, IId, IIe, IIf, IIg, IIh, IIj, IIk, IIl, and IIm. 2. These subgroups have an incidence of 11 per cent in lobar pneumonia, and of 18 per cent in normal mouths. 3. Certain groups, IIb, IIc, IIf, and IIm, occur in normal mouths. 4. Subgroups IIa and IIh are met with largely in connection with disease. 5. The mortality of acute lobar pneumonia due to these atypical Type II pneumococci is fairly high—32 per cent.     

STUDIES ON THE ETIOLOGY OF PRIMARY ATYPICAL PNEUMONIA : III. SPECIFIC NEUTRALIZATION OF THE VIRUS BY HUMAN SERUM

Significant increases in neutralizing antibodies were demonstrated in 42 of a total of 69 persons with a clinical diagnosis of primary atypical pneumonia. Detailed titrations of virus-neutralizing antibodies in a representative group of 28 patients are presented. Increases of four- to 64-fold were demonstrated. Acute-phase titers were 4 or less in 83 per cent and convalescent titers were 16 or over in 86 per cent of these cases. Only about half of the number of patients having increases in neutralizing antibodies also developed cold agglutinins and agglutinins for the indifferent streptococcus No. 344. Patients from the Eastern United States as well as those from the Pacific Coast were shown to develop virus-neutralizing antibodies. Patients with pneumococcal pneumonia and pneumonias caused by influenza virus type A or viruses of the psittacosis group did not have significant increases in neutralizing antibodies for the virus of atypical pneumonia. Cold agglutinins appeared in 3 cases of type A influenzal pneumonia. Sera from persons with atypical pneumonia, when tested against the 3 most prevalent respiratory viruses isolated from cotton rats and hamsters, failed to neutralize these agents or showed no significant change in neutralization titer.     

STUDIES ON PRIMARY ATYPICAL PNEUMONIA : III. A FACTOR IN NORMAL SERUM WHICH ENHANCES THE REACTION BETWEEN PAP VIRUS AND CONVALESCENT SERUM

A factor present in fresh normal human or guinea pig serum enhances the primary atypical pneumonia (PAP) antibody titers in serological reaction with its homologous virus as tested by indirect fluorescent antibody staining. This factor is not properdin. It has many properties similar to complement but may not be identical with complement. The addition of this enhancement factor to human sera convalescent from primary atypical pneumonia has made the serological test more sensitive without affecting its specificity.     

STUDIES ON THE ETIOLOGY OF PRIMARY ATYPICAL PNEUMONIA : A FILTERABLE AGENT TRANSMISSIBLE TO COTTON RATS,HAMSTERS, AND CHICK EMBRYOS

1. A filterable virus from certain cases of primary atypical pneumonia was transmitted to chick embryos by inoculation into the amnion of suspensions of bacteriologically sterile lung tissue or filtered sputum, and three strains were adapted by passage. 2. After intranasal inoculation into cotton rats or hamsters, suspensions of the infected chick embryo tissues produced pulmonary lesions which were similar to those seen after instillation of infective human material. 3. The agent propagated in chick embryos was specifically neutralizable by serum from patients recovered from primary atypical pneumonia and was not neutralized by the acute-phase specimens. 4. Passages of the virus in cotton rats and hamsters gave confusing results because of contamination with latent respiratory agents already present in the animals.     

Massive rhabdomyolysis and multiple organ dysfunction syndrome caused by leptospirosis

We report a case of leptospiral infection in a 63-year-old man who acquired the infection while swimming in canals and streams in Hawaii. The patient's course was atypical in that he was anicteric and had no evidence of meningitis when he presented with fever, rapidly progressive and severe rhabdomyolysis, thrombocytopenia, acute renal failure, and respiratory distress syndrome. Although he recovered after a protracted illness, he required major life support, including mechanical ventilation and hemodialysis. Initial antimicrobial therapy was designed to cover major bacterial and atypical pathogens, including leptospires. An in-depth work-up for causes of this catastrophic illness confirmed acute leptospirosis. Although rare, leptospirosis is a potentially lethal infection classically associated with hepatitis, azotemia, and meningitis. Most patients experience self-limited illness, with fever, myalgias, and malaise followed by an immune-mediated aseptic meningitis. A small proportion develop shock and multiple organ dysfunction. Whereas myalgias are ubiquitous in leptospiral infection, and most patients show mildly elevated muscle enzymes, life-threatening rhabdomyolysis is rare. This atypical case is reported to urge clinicians to consider leptospirosis in the evaluation of a patient with cryptogenic sepsis who develops multiple organ dysfunction associated with rhabdomyolysis. Appropriate antimicrobial therapy, with penicillin or doxycycline, can be life-saving. Received: 24 November 1999 Final revision received: 15 February 2000 Accepted: 7 March 2000     

血、尿胱抑素C检测对小儿肺炎肾功能监测的临床研究

目的探讨小儿肺炎不同时期血、尿胱抑素C(Cys C)变化及其临床价值。方法检测120例健康人员和214例小儿肺炎患者急性期、恢复期的血、尿胱抑素C、肌酐(Cr)、微量白蛋白(MA)、α1-微球蛋白(α1-MG)等指标,并对结果进行统计处理。结果重症肺炎急性期血、尿Cys C含量均显著高于对照组(均P<0.01);恢复期与对照组比较无显著性差异(均P>0.05);重症肺炎急性期与恢复期比较,二者有显著性差异(均P<0.05);轻症肺炎急性期、恢复期与对照组比较,均无显著性差异(均P>0.05)。结论重症肺炎对小儿肾功能有不同程度的损害,但肾功能损害是可逆性的;血、尿Cys C测定对小儿早期肾功能损害的诊断、治疗及疗效判断均具有十分重要的临床指导价值。     

Pulmonary forms of hemorrhagic fever with renal syndrome

Two cases of hemorrhagic fever with renal syndrome are reported. Pulmonary symptoms were manifest in the form of atypical and nasocomial (bacterial) pneumonia.     

小儿肺炎β2-微球蛋白与肾功能损害关系探讨

目的 :观察小儿肺炎血、尿 β2 微球蛋白 (β2 MG)的含量变化 ,探讨 β2 MG与肾功能损害关系以及肾功能损害早期诊断的敏感指标。方法 :采用放射免疫分析法测定 14 5例儿童肺炎急性期和恢复期血、尿β2 MG含量 ,同时检测血清肌酐 (Cr)及尿素氮 (BU N) ;与 82例健康儿童对照组进行比较。结果 :肺炎急性期血、尿 β2 MG含量均显著高于对照组 (P均 <0 .0 1) ;恢复期与对照组比较无显著性差异 (P均 >0 .0 5 ) ;急性期与恢复期比较 ,二者有显著性差异 (P均 <0 .0 5 ) ;肺炎轻型与重型比较 ,有显著性差异 (P均 <0 .0 5 )。肺炎患儿血β2 MG与血清 Cr、BU N相互关系间呈正相关 (r BUN=0 .6 35 ,r Cr=0 .6 2 1;P均 <0 .0 5 )。急性期血β2 MG增高异常率 (81% )明显高于血 Cr(13% )及 BU N(19% )异常率。结论 :肾功能损害可能是小儿肺炎时伴随的较普遍现象 ,以重型肺炎更明显 ,肾功能损害是可逆性的 ;血、尿β2 MG是监测小儿肺炎早期肾功能损害较敏感的指标。     

Infectious mononucleosis, diffuse pneumonia and acute respiratory failure in an elderly woman

Infectious mononucleosis (IM) is a benign disease and is frequently associated with mild respiratory symptoms. The pulmonary manifestations rarely dominate the clinical picture. We report a case of an older adult patient with IM who developed diffuse pneumonia and acute respiratory failure. The diagnosis of IM was confirmed serologically, whereas other possible causes of pneumonia were excluded in this study. Pulmonary manifestations of IM are discussed, and the atypical features that may be seen in older adults are simultaneously reviewed.     

Management of Pneumocystis pneumonia in patients with inflammatory disorders

Pneumocystis jirovecii is an atypical fungus that causes Pneumocystis pneumonia in immunocompromised patients. Underlying diseases associated with Pneumocystis pneumonia mainly consist of hematologic malignancies, solid tumors, organ transplant recipients and inflammatory disorders. Currently, inflammatory disorders represent 20% of underlying diseases. Corticosteroids are considered as a major risk factor. Recently introduced immunosuppressive drugs, such as antitumor necrosis factor monoclonal antibodies, could enhance the risk of Pneumocystis pneumonia. In patients with inflammatory disorders, lymphopenia is probably a determining factor but CD4+ T-cell count associated with the risk of Pneumocystis pneumonia remains unassessed. The diagnosis is based upon clinical, radiologic and biologic data. The identification of P. jirovecii usually requires a lower respiratory tract specimen, even if oral washes samples seem to be promising. According to recent data, immunofluorescent stains should be considered as the new gold standard, and specialized techniques such as PCR should be applied for sputum samples or oral washes. Recommendations on prophylaxis remains controversial except in patients with Wegener's granulomatosis and systemic lupus erythematosus. Cotrimoxazole is the preferred agent for prophylaxis as well as for treatment. An adjunctive corticosteroid therapy is usually prescribed despite the lack of evidence for utility in patients with inflammatory disorders. As person-to-person transmission is the most likely mode of acquiring P. jirovecii, isolation precautions should be advised.     

Management of Pneumocystis pneumonia in patients with inflammatory disorders

Pneumocystis jirovecii is an atypical fungus that causes Pneumocystis pneumonia in immunocompromised patients. Underlying diseases associated with Pneumocystis pneumonia mainly consist of hematologic malignancies, solid tumors, organ transplant recipients and inflammatory disorders. Currently, inflammatory disorders represent 20% of underlying diseases. Corticosteroids are considered as a major risk factor. Recently introduced immunosuppressive drugs, such as antitumor necrosis factor monoclonal antibodies, could enhance the risk of Pneumocystis pneumonia. In patients with inflammatory disorders, lymphopenia is probably a determining factor but CD4+ T-cell count associated with the risk of Pneumocystis pneumonia remains unassessed. The diagnosis is based upon clinical, radiologic and biologic data. The identification of P. jirovecii usually requires a lower respiratory tract specimen, even if oral washes samples seem to be promising. According to recent data, immunofluorescent stains should be considered as the new gold standard, and specialized techniques such as PCR should be applied for sputum samples or oral washes. Recommendations on prophylaxis remains controversial except in patients with Wegener's granulomatosis and systemic lupus erythematosus. Cotrimoxazole is the preferred agent for prophylaxis as well as for treatment. An adjunctive corticosteroid therapy is usually prescribed despite the lack of evidence for utility in patients with inflammatory disorders. As person-to-person transmission is the most likely mode of acquiring P. jirovecii, isolation precautions should be advised.     

Efficacy and safety of garenoxacin tablets on clinically diagnosed atypical pneumonia: Postmarketing surveillance in Japan

We performed a postmarketing surveillance study to determine the efficacy and safety of the oral quinolone antibacterial agent garenoxacin (Geninax^® Tablets 200 mg) against atypical pneumonia.Between October 2009 and July 2011, patients with community-acquired pneumonia visited 26 facilities in Japan; we collected survey forms from 105 of these patients who were suspected of having atypical pneumonia based on the Japanese Respiratory Society Guidelines for the Management of Community-Acquired Pneumonia in Adults. We examined the safety in 105 patients and the efficacy in 71 patients.1. The efficacy rates among patients suspected of having atypical pneumonia and those with a confirmed diagnosis of atypical pneumonia were 94.8% (55/58 patients) and 92.3% (12/13 patients), respectively. The efficacy rate was 4/4 for patients in whom Chlamydophila pneumoniae was detected (including 1 patient with a polymicrobial infection with another bacterial strain) and 90% (9/10 patients) for patients in whom Mycoplasma pneumoniae was detected (garenoxacin was ineffective in 1 of 2 patients with a polymicrobial infection with another bacterial strain).2. The incidence of adverse drug reactions (including abnormal laboratory tests) was 4.8% (5/105 patients). Among the adverse drug reactions, gastrointestinal disorders, infection and infestation, nervous system disorder, and skin and subcutaneous tissue disorder were observed in 2.9% of patients (3/105), 1.0% (1/105), 1.0% (1/105), and 1.0% (1/105), respectively.In conclusion, garenoxacin showed an efficacy rate of greater than 90% for suspected atypical pneumonia and confirmed atypical pneumonia. Garenoxacin is considered to be useful in daily practice.     

Gatifloxacin-induced hyperglycemia: a case report and summary of the current literature

BACKGROUND: Gatifloxacin is a fluoroquinolone antibiotic that has been associated with severe hypoglycemic and hyperglycemic events. OBJECTIVE: The purpose of this report was to describe a new case of gatifloxacin-associated hyperglycemia in an elderly patient and to provide a summary of case reports. CASE SUMMARY: A male patient, aged 86 years, was hospitalized with small bowel obstruction due to adhesions from a previous appendectomy. At the time of admission, the patient weighed 78.5 kg (ideal body weight, 73 kg), had a body mass index of 24.8 kg/m2, and had a calculated creatinine clearance of 45.6 mL/min. The patient's hospital medications were metoprolol, diltiazem, subcutaneous heparin, ranitidine, vancomycin, piperacillin/tazobactam, and aspirin. He also was treated with gatifloxacin 400 mg QD for suspected pneumonia during the hospital stay. After 4 days of the gatifloxacin regimen, the patient's mean blood glucose concentration increased from 133 mg/dL at the time of admission to 537 mg/dL. Although the patient exhibited signs of glycosuria (ie, urine glucose concentration >1000 mg/dL), he did not complain of symptoms of hyperglycemia, such as polyuria, polyphagia, or polydipsia. The hyperglycemia resolved after administration of gatifloxacin was discontinued and the patient had received regular insulin 15 U SC over 5 hours. DISCUSSION: The exact mechanism by which gatifloxacin induces hyperglycemia is unknown, but it may be related to vacuolation of pancreatic beta-cells, leading to a decrease in insulin secretion. This case, along with the 15 other summarized cases, adds to the evidence for an association between gatifloxacin and hyperglycemia. These patients had other risk factors that may have contributed to the development of hyperglycemia, including age >65 years and renal impairment. CONCLUSION: An elderly patient with no history of diabetes developed severe hyperglycemia after receiving doses of gatifloxacin 400 mg that had not been adjusted for age-related renal impairment. The hyperglycemia resolved after discontinuation of gatifloxacin.     

传染性非典型肺炎--附首例报告

目的：报道广州呼吸疾病研究所处理首例传染性非典型肺炎的临床诊断和治疗经验。方法：回顾性分析该例的临床资料及治疗经过。结果：该病人有2个多月呼吸道疾病失，病情突然加剧，表现为间质性肺炎及急性呼吸窘迫综合征，白细胞计数基本正常，但淋巴细胞比例偏低，经多种抗生素治疗无明显疗效。使用肾上腺皮质激素及机械通气等对症治疗78日痊愈出院。8位医护人员被感染。结论：该例为传染性非典型肺炎，起病突然及病情发展凶险，可能为一种新病原体感染，值得引起重视。     

STUDIES ON THE ETIOLOGY OF PRIMARY ATYPICAL PNEUMONIA : II. PROPERTIES OF THE VIRUS ISOLATED AND PROPAGATED IN CHICK EMBRYOS

Experiments to determine the optimum conditions for propagation of the virus of atypical pneumonia in chick embryos are described. Variations in the activity of infected chick embryo material were investigated. The highest dilution of chick embryo suspension producing pulmonary lesions in hamsters and cotton rats is not over 10^–3. Dilutions of 10^–4 infect chick embryos. The virus is unstable at room temperature and also loses activity when stored in a dry-ice refrigerator unless the suspensions are kept in sealed glass tubes. Filtration experiments indicate a maximum particle size of 180 to 250 mµ. The virus propagated in chick embryos produces pulmonary lesions in hamsters and cotton rats which have been immunized to their own non-bacterial agents inducing pulmonary lesions. Of these, the pneumonia virus of hamsters most frequently causes intercurrent respiratory infections, and methods of controlling epizootics due to this agent are described.     

The effectiveness of antibiotics in typical and atypical pneumonias depending on combination with glucocorticosteroids

Sixty-seven cases of prolonged pneumonia were analyzed. The study found that in cases with a typical onset the efficacy of antibiotics with predominantly bactericidal activity was much higher when they were administered in combination with glucocorticosteroids (GCS); bacteriostatic preparations were not used in such cases. In prolonged pneumonia with an atypical onset the efficacy of mainly bacteriostatic antibiotics was significantly higher than that of bactericidal ones, but the efficacy of both did not increase when they were combined with GCS. The use of GCS in addition to antibiotics shortens the time to pneumonia resolution in cases with both typical and atypical onset, regardless the character of antibacterial therapy.     

非典型肺炎的临床症状及其防护措施

目的 探讨非典型肺炎的临床症状及其防护措施.方法 统计分析国内首发省市(广东,广州)发病以来4个多月对个人、家庭、公共社区、医院、学校等所采取的综合预防干预.结果 4个多月后此病发病率及死亡率明显下降并且逐步得到控制.结论 要重视非典型肺炎的综合性防护,提高全民防护意识,切断病原体的传播途径,才能避免大面积疫情的恶性循环.     

非典型肺炎的临床症状及其防护措施

目的 探讨非典型肺炎的临床症状及其防护措施.方法 统计分析国内首发省市(广东,广州)发病以来4个多月对个人、家庭、公共社区、医院、学校等所采取的综合预防干预.结果 4个多月后此病发病率及死亡率明显下降并且逐步得到控制.结论 要重视非典型肺炎的综合性防护,提高全民防护意识,切断病原体的传播途径,才能避免大面积疫情的恶性循环.     

Health Economic Evaluation of Patients Treated for Nosocomial Pneumonia Caused by Methicillin-resistant Staphylococcus aureus: Secondary Analysis of a Multicenter Randomized Clinical Trial of Vancomycin and Linezolid

Purpose

Results from studies comparing health care resource use (HCRU), costs of treatment, and cost-effectiveness of linezolid compared with vancomycin therapy in the treatment of hospitalized patients with methicillin-resistant Staphylococcus aureus (MRSA) nosocomial pneumonia are limited in the published literature. We therefore conducted an analysis to compare the HCRU, costs of treatment, and cost-effectiveness of linezolid compared with vancomycin in the treatment of hospitalized patients with MRSA nosocomial pneumonia using data from a Phase IV clinical trial. The economic effect of moderate to severe adverse events (MSAEs) and the development of renal failure were also evaluated.

Methods

We performed a post hoc analysis of data from a Phase IV, double-blind, randomized, comparator-controlled, multicenter trial that compared linezolid and vancomycin treatment in patients with MRSA nosocomial pneumonia. HCRU and costs were compared based on treatment, development of MSAEs, and development of renal failure using data from the modified intent-to-treat population. Predictors of costs were evaluated using generalized linear models. A piggyback cost-effectiveness analysis was conducted to assess the incremental cost-effectiveness ratio of linezolid versus vancomycin, given the significantly higher clinical success of linezolid compared with vancomycin found in the trial.

Findings

Overall, HCRU and costs were similar between the linezolid and vancomycin treatment groups; drug costs were significantly higher and dialysis costs significantly lower for linezolid- compared with vancomycin-treated patients. Total treatment costs were approximately $8000 higher (P = .046) for patients who developed renal failure compared with those who did not. Renal failure occurred more commonly in patients randomized to receive vancomycin (15%) compared with linezolid (4%; P < .001). Region, ventilator-associated pneumonia, clinical failure, and development of renal failure were associated with significantly higher total costs. The point estimate incremental cost-effectiveness ratio for linezolid compared with vancomycin was $16,516 per treatment success, with linezolid dominant in 24% and dominated in <2% of bootstrapped samples.

Implications

This phase 4 clinical trial conducted in patients with MRSA-confirmed nosocomial pneumonia reveals that linezolid- compared with vancomycin-treated patients had similar HCRU and total overall costs. Fewer patients developed renal failure during the study while taking linezolid compared with vancomycin, and patients with a documented MSAE or renal failure had increased HCRU and costs. In summary, linezolid may be a cost-effective treatment strategy in MRSA-confirmed nosocomial pneumonia.     

老年吸入性肺炎临床特征荟萃分析

目的 分析老年吸入性肺炎的临床表现及病原学特点,为经验性治疗提供参考。方法 在中国期刊全文数据库检索2000~2014年有关老年吸入性肺炎的相关文章,从中筛选出资料完整,统计确切的文献36篇,进行分析总结。结果 2 851例老年吸入性肺炎患者的临床表现多不典型,均伴有慢性基础疾病,中枢神经系统疾病最多。主要病原菌是革兰阴性菌,且耐药率较高。结论 应当提高对老年吸入性肺炎临床表现的认识和早期诊断率,合理有效的经验性抗感染治疗,降低病死率。