Case of severe eosinophilic pneumonia, induced by several antibiotics, requiring mechanical ventilation]

We report a case of severe eosinophilic pneumonia induced by several antibiotics, requiring mechanical ventilation. A 44-year-old man had been admitted previously to a different hospital because of a high fever and dry cough continuing for a week. Although bacterial pneumonia was diagnosed and he had been treated with several antibiotics, his respiratory state worsened gradually and he was refered to our hospital with severe hypoxia. He needed mechanical ventilation on the fifth hospital day. TBLB identified eosinophilic pneumonia. Although we discontinued all antibiotics and started steroid therapy, he became feverish and his leukocyte count, which was neutrophil dominant, elevated again. We suspected bacterial pneumonia and administered antibiotics that he had never received before. However we had to discontinue these antibiotics soon because of a further inflammatory response. His condition then improved gradually and he was weaned from mechanical ventilation. It is rare for drug-induced eosinophilic pneumonia to become so severe that mechanical ventilation is necessary. We thought that an allergic reaction may have been induced by the series of several antibiotics, inducing severe pneumonia.     

COVID-19 Pneumonia Resembling an Acute Exacerbation of Interstitial Pneumonia

An 84-year-old man was admitted with hypoxemia and ground-glass opacities with traction bronchiectasis in both lungs and mild fibrosis on computed tomography. We first suspected that he had acute exacerbation of interstitial pneumonia and initiated methylprednisolone pulse therapy. On day 4, he was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia. Although the ground-glass opacities were improved with corticosteroid treatment alone, the hypoxemia persisted, and the plasma D-dimer level increased. Anticoagulant therapy was initiated, and the hypoxemia was improved. COVID-19 pneumonia may result in radiological findings similar to those of acute exacerbation of interstitial pneumonia, and corticosteroids and anticoagulant therapy may lead to favorable outcomes.     

Acute respiratory failure due to pneumocystis pneumonia successfully treated with combined use of sivelestat sodium hydrate

A 22-year-old man was admitted to our hospital with fever, cough and dyspnea. His chest radiograph showed diffuse ground-glass attenuation in both lung fields. Arterial blood gas analysis showed hypoxemia (PaO2 28.7 Torr breathing room air) and he required mechanical ventilation within 6 hours after admission. Gomori methenamine silver (GMS) stain of the bronchoalveolar lavage (BAL) fluid smear showed round and indented organisms, and polymerase chain reaction revealed pneumocystis jirovecii in the BAL fluid. The HIV antibody was positive and peripheral blood CD4-positive lymphocytes decreased to 4.0%. Pneumocystis pneumonia complicated with acquired immunodeficiency syndrome (AIDS) was diagnosed. There was no four-fold rise in screen viral titers. We treated him with antibiotics, trimethoprim-sulfamethoxazole, ganciclovir, fos-fluconazole, steroid pulse therapy and sivelestat sodium hydrate. Respiratory failure was relieved within 5 days following treatment. The percentage of neutrophils in the BAL fluid was elevated (44.6%). Neutrophil elastase on admission was increased and improved to the normal range after treatment. Sivelestat sodium hydrate is an anti-neutrophil elastase inhibitor and may be one of the treatment options for acute respiratory failure due to pneumocystis pneumonia in AIDS patients.     

A case of Legionella pneumonia with myelodysplastic syndrome]

A 40-year-old man was admitted with high fever and cough. Pneumonic shadows of the left middle and lower lung fields increased rapidly, and his blood gases worsened. Initial treatment with cefmenoxime, piperacillin, and minocycline was ineffective. Administration of rifampicin was started for suspected legionella pneumonia, but it did not control the spread of the pneumonia shadows. After addition of an antifungal agent and trimethoprim-sulfamethoxazole, his symptoms gradually improved. Isolation of Legionella pneumophila from sputum specimens collected on the 4th day of admission confirmed the diagnosis on day 10. The patient was then given oral rifampicin plus cefmenoxime to prevent mixed infection, and showed a satisfactory improvement. Legionella pneumonia developed secondary to compromise of the patient's immunity due to steroid therapy for MDS. After recovering from Legionella pneumonia, the patient subsequently developed tuberculous pleurisy and Pneumocystis carinii pneumonia, which were cured by antituberculous therapy and trimethoprim-sulfamethoxazole. However, acute hepatitis followed by hepatic failure developed, and he died on day 121 after admission.     

A case of severe Chlamydia pneumoniae pneumonia requiring mechanical ventilation and complicated with disseminated intravascular coagulation]

A previously healthy 48-year-old man presented to his primary care physician with high fever, dry cough and dyspnea. Pneumonia was diagnosed and intravenous administration of imipenem/cilastatin was begun, but his respiratory condition worsened and he was admitted to our hospital with severe hypoxia. A chest radiograph showed reticular opacity and consolidation in both lung fields. The case was complicated with disseminated intravascular coagulation. Analysis of the bronchoalveolar lavage fluid showed increases in the total cell counts and an elevated percentage of lymphocytes. Sputum, blood and bronchoalveolar lavage examinations failed to reveal etiology to explain his severe respiratory illness. Treatment consisted of mechanical ventilation and administration of steroid pulse-therapy and gabexate mesilate. On the basis of his clinical course, we suspected possible atypical pneumonia, and began therapy with intravenous minocyclin and oral erythromycin administration. On the third hospital day, the arterial blood gas data improved and the bilateral pulmonary infiltration on the chest radiographs disappeared. Using paired sera, we detected increases of 1.35 in ID for anti-Chlamydia pneumoniae IgG antibodies by ELISA, and arrived at a diagnosis of Chlamydia pneumoniae pneumonia.     

Pneumocystis carinii and cytomegalovirus pneumonia in a previously healthy adult

A case of Pneumocystis carinii pneumonia and cytomegalovirus infection occurring in a previously healthy adult male homosexual who was not receiving known immunosuppressive therapy is described. This 35-year-old man had been treated with metronidazole and tetracycline for an intermittent diarrheal illness of 5 months' duration. He was then admitted to the hospital where he was found to have a small infiltrate in the left lower lobe, and this process soon involved both lungs. Initially, Pneumocystis carinii infection and later cytomegalovirus infection were diagnosed by lung biopsy and culture. Peripheral blood lymphopenia was present and he had in vivo and in vitro abnormalities of his cellular immune responses. He was unresponsive to Bactrim as well as pentamidine and pyrimethamine therapy and died 7 wk after hospitalization.     

A case of Pneumocystis carinii pneumonia during treatment for miliary tuberculosis

A 30-year old man of Myanmar origin was admitted to our hospital because of productive cough, anorexia, weight loss and fever. Sputum smear was strongly positive for M. tuberculosis (Gaffky 6) and sputum culture proved M. tuberculosis. Caseous necrosis with Langhans giant cells was observed in the biopsied specimens of the liver and bone marrow. He was diagnosed as miliary tuberculosis. Treatment with combined use of isoniazid, rifampicin, ethambutol and streptomycin was started. After one month, his cough resolved, fever subsided and chest X-ray findings improved. Two months later, non-productive cough and fever recurred. Chest radiograph and computed tomographic scan of the chest revealed diffuse ground-glass opacity. Specimens taken by transbronchial biopsy showed pneumocystis carinii in alveoli. Pulsed use of methyprednisolone with Trimethoprim-sulfamethoxazole was started. The symptoms and chest X-ray findings disappeared and he recovered uneventfully. Tests for HIV infection were negative. Anti-HTLV antibody was negative. There were no other suggestive evidences of immune suppression. CD4+T cell count was low, when Pneumocystis carinii pneumonia occurred. The relation between miliary tuberculosis, Pneumocystis carinii pneumonia and CD4-T lymphocytopenia has remained unelucidated.     

A case in which progressive emphysematous changes were seen on chest computed tomography associated with Pneumocystis carinii pneumonia in a patient with AIDS]

A 60-year-old man was admitted to our hospital complaining of progressive dyspnea. On admission, he had marked hypoxemia, and his chest radiography and computed tomography (CT) showed ground glass opacities and multiple emphysematous changes in both lung fields. On examining the patient's bronchoalveolar lavage fluid (BALF). Pneumocystis carinii pneumonia (PCP) was diagnosed. A serological test for human immunodeficiency virus (HIV)-1, 2 was positive, and acquired immunodeficiency syndrome (AIDS) was diagnosed. Since the chest CT performed a month before the patient's admission to our hospital revealed ground glass opacities in both lung fields we thought that he had already developed PCP at that time. In comparison with his previous CT, the chest CT on admission showed progressive ground glass opacities and emphysematous changes. Although PCP is known to display various findings on chest radiography and CT, emphysematous changes are rarely reported in Japan. In this case we were able to confirm these changes and observe its progression using chest CT.     

A case of mumps pneumonia complicated with acute respiratory failure]

A 38-year-old male with swollen parotid glands was admitted to our hospital with dyspnea on effort. Positive serum IgM antibody for mumps supported a diagnosis of mumps. Computed tomography (CT) scan showed a ground-glass appearance in both lower lungs. On the third day of hospitalization, bronchoalveolar lavage demonstrated an elevation of both the total cell (2.0 x 10(6)/cc) and the lymphocyte count (83%), as well as a decrease of the CD 4+/CD 8+ ratio (0.4). Bronchial biopsy specimens revealed infiltration of lymphocytes in both the bronchiolar walls and the alveolar septa. These data were suggestive of mumps pneumonia. The patients suffered acute respiratory failure on the seventh day of hospitalization, which improved after 3 days of high-dose methyl prednisolone therapy. This is the first report of adult mumps pneumonia in Japan. As a result of the examination of the bronchoalveolar lavage and a bronchial biopsy of viral pneumonia which had been reported in the past, mumps pneumonia was a corresponding opinion to other viral pneumonia.     

Churg-Strauss syndrome with alveolar hemorrhage]

A 35 year-old man was admitted to our hospital because of cough, wheezing, and paresthesia of the right upper extremity. He demonstrated marked eosinophilia, bronchial asthma, and mononeuritis multiplex. We diagnosed Churg-Strauss syndrome. Serum MPO-ANCA was elevated to 189 U/ml. Chest high-resolution computed tomography showed panlobular ground-glass attenuation in both lungs. BALF showed bloody fluid, and TBLB revealed findings consistent with eosinophilic pneumonia. Lung biopsy by VATS revealed eosinophilic pneumonia, pulmonary vasculitis, capillaritis, and hemosiderosis. The patient recovered after treatment with prednisolone and cyclophosphamide. We concluded that alveolar hemorrhage due to pulmonary capillaritis could be a complication in cases of Churg-Strauss syndrome.     

A case of Pneumocystis jiroveci pneumonia that presented with cavity and cystic changes in a malignant thymoma patient]

A 53-year-old man had received various chemotherapy and steroid treatments for malignant thymoma. He had demonstrated persistent fever since the beginning of January 2006, and chest radiograph showed consolidation in the left middle lung fields. Bacterial pneumonia was suspected, but antibiotics were not effective. He was referred and admitted to our hospital on January 16. Chest radiograph and CT scan on admission showed diffuse ground-glass opacities, consolidation with cavity, and cystic changes. Pneumocystis jiroveci Pneumonia was diagnosed by examination of alveolar lavage. This patient was regarded as immunodeficient because of steroid treatment, low counts of CD4-positive lymphocytes, and the complication of hypogammagloblinemia. We reported this case of a non-HIV patient with atypical images demonstrating Pneumocystis jiroveci pneumonia.     

Case of acute interstitial pneumonia that responded to therapy but relapsed six months later]

A 66-year-old man was admitted because of general fatigue. A chest computed tomography showed bilateral alveolar consolidation and ground glass opacities. Although we treated him with broad-spectrum antibiotics, his symptoms and chest image findings did not improve. Thoracoscopic lung biopsy (rS2, S9) was performed. The specimens showed obstructive type intraluminar organization and interstitial inflammatory thickening. Membranous organization was seen in a limited area. The etiology of the illness could not be identified. We diagnosed acute interstitial pneumonia (AIP) because the specimens showed diffuse alveolar damage pattern (DAD/P) and because of unknown etiology. The symptoms and chest image findings were improved on treatment with corticosteroid and cyclophosphamide. However, he was readmitted because of dyspnea 6 months later after the thoracoscopic lung biopsy. Chest computed tomography showed bilateral diffuse ground glass opacities and reticular opacities in both lower lobes. We employed mechanical ventilation, antibiotics, sivelestat sodium hydrate and steroid pulse therapy, but he died without any response to treatment. The findings of autopsy revealed DAD/P accompanied by a new lesion mainly composed of membranous organization and hyaline membrane. We believe this case is valuable when considering the variety of responses to treatment of AIP and prognosis.     

Dramatic improvement of severe Pneumocystis carinii pneumonia by corticosteroids despite lack of antipneumocystis therapy in acquired immunodeficiency syndrome]

A 30-year-old Thai man was admitted to our hospital complaining of general fatigue, pyrexia, dyspnea, and a productive cough. He was in serious respiratory failure and had a PaO2 of 45.9 Torr in room air. Chest radiography showed marked infiltration of both lungs. Pneumocystis carinii pneumonia (PCP) associated with acquired immunodeficiency syndrome (AIDS) was ruled out by a negative test for HIV antibody. He was given corticosteroids including methylprednisolone mini-pulse therapy and antibiotics. This therapy improved his condition and his radiological picture dramatically without antipneumocystis therapy. Bronchoscopy was performed and the transbronchial lung biopsy revealed PCP. On re-examination for HIV-1 antibody, the result was positive. Western blot analysis yielded a definite diagnosis of HIV-1 infection. Our experience strongly supports previous reports that advocated corticosteroids as adjunctive therapy for moderate to severe PCP associated with AIDS and gives us the significance of corticosteroids.     

A case of systemic fat embolism in mixed connective tissue disease associated with interstitial pneumonia during steroid treatment]

A 67-year-old man with a four-year history of mixed connective tissue disease (MCTD) associated with interstitial pneumonia was admitted to our hospital with a complaint of dyspnea and moist cough. Because the interstitial pneumonia was exacerbated, he was given high-dose steroid treatment (pulse therapy and sequential oral treatment of PSL 50 mg/day). After treatment his general condition showed some improvement, but then he suddenly died of acute respiratory failure. Autopsy disclosed fat emboli in the lungs, kidneys, liver and myocardium. The fat embolism may have been a consequence of the steroid treatment. Fat embolism should be taken into account as one of the causes of the acute respiratory failure in collagen vascular disease patients receiving steroid treatment.     

Spontaneous resolution of Pneumocystis carinii pneumonia]

A 58-year-old woman was admitted to our hospital complaining of fever, dry cough, and exertional dyspnea. Chest radiographs showed diffuse interstitial infiltrates in both lungs, and blood gas analysis showed moderate hypoxemia. The levels of serum KL-6 and beta-D-glucan were markedly elevated. Bronchoscopy was performed and Pneumocystis carinii was found in the BALF and transbronchial lung biopsy specimens. A positive reaction for the HTLV-I antibody was obtained, and HTLV-I proviral DNA was demonstrated. A conclusive diagnosis of Pneumocystis carinii pneumonia in a smoldering ATL patient was made on these grounds. Without specific treatment for Pneumocystis carinii pneumonia, the symptoms and abnormal chest radiographic findings disappeared. This case suggests that the fluctuation in cell-mediated immunity associated with HTLV-I carriers may allow recovery from Pneumocystis carinii pneumonia even without antipneumocystis therapy.     

Severe chlamydia pneumoniae pneumonia requiring mechanical ventilation and steroid therapy in an elderly patient

A 75-year-old man first developed dyspnea and low-grade fever in late March. A chest X-ray film showed infiltration in the right lower lung field and blood gas analysis revealed severe hypoxemia. Accordingly, he was diagnosed as having pneumonia and was admitted to our hospital on March 11, 2003. Mechanical ventilation for progressive respiratory failure was started immediately after admission, and he was treated with antibiotics. Chlamydia pneumoniae pneumonia was diagnosed due to an increase of the Chlamydia pneumoniae antibody titer. He had prolonged respiratory failure despite antibiotic therapy. Therefore, steroid therapy was started on day 15 for respiratory failure. At 21 days after admission, the infiltration was found to be decreased on chest X-ray films and improvement of hypoxemia allowed extubation. In conclusion, when severe community-acquired pneumonia occurs in elderly patients, we should remember the possibility of atypical pneumonia such as that due to Chlamydia pneumoniae infection.     

Successful treatment with tacrolimus of progressive interstitial pneumonia associated with amyopathic dermatomyositis refractory to cyclosporine

A 58-year-old male was admitted to our hospital because of periungual nailfold an erythema and erythematous rash on the dorsal joints of his hands and feet, but no muscle weakness. He was thus diagnosed to have amyopathic dermatomyositis. He had moderate hypoxemia and his chest computed tomography scans demonstrated bilateral ground-glass opacities, implicating complication with interstitial pneumonia. Therapy was initiated with pulsed methylprednisolone followed by high-dose corticosteroids, pulsed cyclophosphamide, and cyclosporine. The skin manifestations improved; however, the pulmonary infiltrates and hypoxemia deteriorated during the 2-month period of the treatment. The treatment was switched from cyclosporine to tacrolimus because of an inadequate clinical response to the therapy, and this resulted in the resolution of interstitial pneumonia. This case indicates that tacrolimus administration should be considered for patients with this life-threatening disorder when it is judged to be refractory to cyclosporine.     

A case of AIDS-complicated lung infection mimicking acute eosinophilic pneumonia]

A 34-year-old man was admitted with dyspnea and low grade fever. Chest radiograph and computed tomography (CT) showed bilateral, ground glass opacities and perihilar consolidation. Bronchoalveolar lavage (BAL) was performed. The percentage of eosinophils in the BAL fluid (BALF) was elevated (20.5%). BALF smear and culture showed normal flora. Acute eosinophilic pneumonia was diagnosed and steroid therapy was performed. Afterwards he was transferred to our hospital. The HIV antibody was positive and peripheral blood CD-4 positive lymphocytes decreased to 10/microl, cytomegalovirus (CMV) antigenemia was positive and beta-D-glucan increased. CMV infection and pneumocystis pneumonia (PCP) complicated with AIDS was diagnosed. Trimethoprim/sulfamethoxazole, ganciclovir, and antifungal drugs were administered, but he suffered pneumothorax on the 18th day after admission and died. Histopathologic findings from an autopsy lung specimen revealed CMV infection and PCP. It is known that the percentage of eosinophils in the BALF increases in some cases of PCP complicated with AIDS. We emphasize that it is necessary to consider PCP when the percentage of eosinophils in the BALF increase.     

A case of Pneumocystis carinii pneumonia with pulmonary cysts and increased level of serum KL-6]

In August, 1999, a 46-year-old man with fever, cough, and dyspnea was admitted to a hospital. On the basis of the clinical and radiographic findings, bacterial pneumonia was suspected. Antibiotics were not effective, because of atypical lymphocytes in the peripheral blood and positive anti-human T-cell leukemia virus antibody, and he was transferred to our hospital. A chest radiograph and a CT scan revealed bilateral ground-glass opacities with huge multiple cysts. Intensive treatment of Pneumocystis carinii pneumonia associated with human T-cell leukemia was unsuccessful. Pneumocystis carinii was found in the bronchoalveolar lavage fluid. Human T-cell leukemia and Pneumocystis carinii pneumonia were diagnosed. In this case, numerous pulmonary cysts were progressing rapidly, the largest cyst being 8.7 cm in diameter, and the largest cyst in our experience either in clinical practice or in reading of the literature in Pneumocystis carinii pneumonia. The maximum serum KL-6 was markedly increased to 15,200 U/ml, which is the highest level reported for Pneumocystis carinii pneumonia.     

Fatal cytomegalovirus-associated adrenal insufficiency in an AIDS patient receiving corticosteroid therapy

A 35-year-old homosexual man, who had already received sulfamethoxazole/trimethoprim and steroid therapy because of human immunodeficiency virus (HIV)-related Pneumocystis jiroveci pneumonia, was referred to our hospital. He was also diagnosed as having cytomegalovirus (CMV) co-infection, and started receiving intravenous gancyclovir for CMV infection on the 2nd day of admission into our hospital. He had to continue the steroid therapy because his respiratory condition did not improve. On the 10th hospitalization day, when 40 mg of prednisolone was administered, cardiopulmonary arrest suddenly occurred, and his laboratory data showed hyponatremia and hyperpotassemia. In spite of resuscitation, he died two days later. The postmortem examination revealed that he died of adrenal failure due to CMV infection. In general, CMV is thought to cause adrenalitis, but rarely leads to manifestations of adrenal insufficiency during the clinical course. It is important to be aware that grave adrenal failure due to CMV infection can develop even under steroid therapy.