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.     

Remission of rheumatoid arthritis after acute disseminated varicella-zoster infection

A 65-year-old immunocompetent male presented with symmetric polyarthritis of 12 weeks and paresthesias in the distribution of the left median nerve distribution of 4 weeks duration. He had tender joint count of 20 and swollen joint count of 12. He was positive for rheumatoid factor and his erythrocyte sedimentation rate was 52 mm. Nerve conduction study demonstrated polyneuropathy. Radiographs showed severe juxta articular osteopenia at the wrist and the metacarpophalangeal joints. He received methotrexate of 10 mg/week and prednisolone of 0.15 mg/kg/day along with nonsteroidal antiinflammatory drugs (NSAIDs) with a diagnosis of seropositive rheumatoid arthritis (RA). Thirteen weeks after therapy, he presented to the outpatient clinic with disseminated vesicular eruptions all over his body with erythematous base and pneumonia involving the left upper lobe. Tzanck smear from the lesions and serology (IgG) for varicella-virus infection were positive. A diagnosis of acute disseminated varicella zoster with pneumonia was made. The patient improved on parenteral acyclovir and broad-spectrum antibiotics. With the improvement in rash and pneumonia after 2 weeks, the patient noticed a marked improvement in the joint symptoms. Arthritis remained in remission without the need for any disease-modifying drug or NSAID for next the 24 months and continued to be so until the last follow-up. Our case presents a unique phenomenon of RA remission after disseminated varicella-zoster infection in an immunocompetent individual.     

A case of dermatomyositis complicated with pneumomediastinum that was successfully treated with cyclosporin A]

We reported the case of a 39-year-old man with dermatomyositis (DM) complicated with subcutaneous emphysema and pneumomediastinum during steroid therapy. The patient had complained of muscle weakness, dyspnea and skin eruption on his anterior chest wall 6 months prior to admission. He was diagnosed as having DM on the basis of an elevation in myogenic enzymes, myogenic changes in electromyography, a skin biopsy and a muscle biopsy. Chest roentgenogram revealed interstitial pneumonia (IP) in the lower lobes of the lungs. The administration of prednisolone (60 mg/day) was initiated, which resulted in improvement of DM. Fifteen days after the initiation of the steroid therapy, the patient developed subcutaneous emphysema and pneumomediastinum. Additional administration of cyclosporin A (CsA) enabled us to rapidly taper the dose of prednisolone without aggravating the diseases. Several reports have shown that vasculitis might be involved in the pathogenesis of pneumomediastinum in DM patients. Infection and tissue fragility due to steroid therapy worsen the outcome of those patients. CsA therapy may improve the outcome through the anti-vasculitic- and steroid sparing-effects.     

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.     

Factor V inhibitor with double cancer

A 84-year-old man was admitted with palpitation, edema of legs and anemia during a long course of diabetes mellitus, prostatic hypertrophy and prostatic cancer. He revealed purpura on the hands and massive microhematuria. He had received antibiotic therapy for a urinary tract infection for a period of time, but he had no history of hemorrhagic tendency or blood transfusion. Coagulation studies showed the prolongation of whole blood clotting time and PT (prothrombin time). Activity of factor V was 14% of that normal control plasma. The titer of factor V inhibitor was 4.9 Bethesda units/ml. The inhibitor of the patient was supposed to belong to IgA and IgG judging from inhibitor neutralization test. PT was improved after discontinuance of administration of antibiotics and administration of azathioprine. Moreover, even after administration of prednisolone with antibiotics, PT and activity of factor V recovered to normal range. He died from respiratory failure. Autopsy revealed double cancer of prostate and descending colon. The appearance of factor V inhibitor was likely caused by antibiotics, double cancer, and age-related immune disorders.     

A case of acute exacerbation of desquamative interstitial pneumonia after video-assisted thoracoscopic surgery (VATS)]

A 70-year-old man in whom nodular and reticular shadows had been noted on chest radiography since 1992 was admitted to our hospital with complaints of persistent cough and dyspnea on exertion in August, 2000. The definitive diagnosis of lung abnormalities was not confirmed by TBLB. He was re-admitted to our hospital to undergo a lung biopsy by video-assisted thoracoscopic surgery. Although desquamative interstitial pneumonia was diagnosed, respiratory failure developed rapidly after surgery. He responded well to high-dose steroid administration followed by maintenance therapy with a moderate dose of steroid, resulting in a considerable importance of the clinical condition associated with a significant decrease in the ground-glass opacities and infiltrative shadows. Although we could find no literature reporting acute exacerbation of DIP, our case demonstrates that DIP may also be acutely exacerbated when a severe insult is superimposed.     

A case of Legionnaires' disease cured with a combination of erythromycin and steroid therapy]

A 53-year-old male was admitted to Keio University Hospital with a pneumonia shadow in the left lung field and respiratory failure. Because there was progression of respiratory failure, mechanical ventilation was required to maintain appropriate oxygenation. Although erythromycin administration was started at the time of admission, a steroid (prednisolone 60 mg/day) was added a few days later to temporarily inhibit the acute inflammatory response in the lung parenchyma. This intensive therapy resulted in resolution of the patient's pneumonia and improvement of his respiratory failure. No pathogens were detected in the clinical specimens. Indirect immunofluorescence examination demonstrated a marked increase in titers against Legionella pneumophila serogroup 1, which was sufficient to confirm a diagnosis of Legionnaires' disease. The causative organism of this disease, a gram-negative short rod, is rarely cultured on conventional culture media. Two clinical subtypes are known based on clinical manifestations: 1) the Pontiac fever-type in which the predominant symptom is fever alone; and 2) the pneumonia-type which was observed in the epidemic in Philadelphia when the disease was first reported in 1976. The present case of Legionnaires' disease was the severe pneumonia-type which was successfully treated with a combination of erythromycin and a steroid.     

Sorafenib-induced acute interstitial pneumonia in patients with advanced hepatocellular carcinoma: report of three cases

Little is known about acute interstitial pneumonia (AIP) induced by sorafenib therapy in patients with advanced hepatocellular carcinoma (HCC). Here, we present three patients with advanced HCC who developed AIP during sorafenib therapy, with fatal complications in two cases. Case 1 was a 76-year-old man who developed dyspnea. Chest CT showed interstitial pneumonia. Sorafenib was discontinued immediately, and prednisolone was started. His pneumonia resolved. A drug-induced lymphocyte stimulation test for sorafenib was positive. Case 2 was a 75-year-old man and case 3 was a 77-year-old man, both of whom developed high-grade fever and hypoxemia during sorafenib therapy, and were diagnosed with AIP. In spite of high-dose steroid therapy, their respiratory failure worsened and both patients died. In all three cases, serum KL-6 or surfactant protein D concentrations were elevated, and blood and sputum cultures did not grow pathogens. All three patients were smokers with restrictive lung disease on preoperative respiratory function testing, but did not have respiratory symptoms before sorafenib therapy. The clinical features of these three cases suggest that male gender, older age, smoking history, and lung disease are associated with acute sorafenib-induced AIP in patients with advanced HCC.     

Sustained coronavirus disease 2019-related organizing pneumonia successfully treated with corticosteroid

A 70-year-old Japanese man contracted severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and required oxygen to maintain oxygen saturation (>90%), 5 weeks after onset of coronavirus disease 2019 (COVID-19) symptoms. Transbronchial lung cryobiopsy revealed pathological features of organizing pneumonia with alveolar epithelial injury, and prednisolone administration led to alleviation of respiratory symptoms and recovery of respiratory function. This case report is the first to demonstrate the use of corticosteroids to successfully treat post-COVID-19 respiratory failure in a patient with biopsy-proven organizing pneumonia. We propose that steroid treatment be considered for patients with persistent respiratory dysfunction as COVID-19 pneumonia sequelae.     

Relapsing polychondritis in a patient with myelodysplastic syndrome]

Relapsing polychondritis is a rare disorder of uncertain origin characterized by recurrent inflammation of cartilage. A case of myelodysplastic syndrome (MDS) associated with relapsing polychondritis is reported. A 60-year-old man who had been diagnosed as MDS was admitted because of pain and swelling in the bilateral preauricular regions and cheek. A diagnosis of relapsing polychondritis was made by coexistence of auricular chondritis, arthropathy, ocular inflammation and audio-vestibular disturbance. He also developed ocular palsies and optic neuritis. He was treated with prednisolone, azathioprine, dapsone, and then with steroid pulse therapy. Moreover, plasmapheresis and high dose gamma-globulin therapy were undertaken. However, all these treatments were unsuccessful and he died of respiratory failure.     

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.     

Rheumatoid arthritis complicated with acute interstitial pneumonia induced by leflunomide as an adverse reaction

A 49-year-old Japanese man with rheumatoid arthritis acutely developed a skin eruption and severe non-productive cough seventeen days after the administration of leflunomide. Because all bacteriology findings were negative, steroid pulse-therapy was initiated promptly due to the rapidity of chest X-ray progression and the deterioration of arterial blood oxygen pressure. Although cough was induced by methotrexate, interstitial pneumonia was not detected clinically before leflunomide administration. He finally died of respiratory failure 128 days after the onset of acute interstitial pneumonia. According to the post-market surveillance, as high as approximately 1.1% of the patients on,leflunomide have developed interstitial pneumonia in Japan. It is important to emphasize that acute interstitial pneumonia due to leflunomide is a very severe and potentially fatal side effect.     

A case of legionella pneumonia associated with acute respiratory distress syndrome (ARDS) and acute renal failure treated with methylprednisolone and sivelestat]

A 48-year-old man with diabetes mellitus and alcholic chronic pancreatitis was admitted to our hospital with fever and dyspnea. Chest x-ray film showed infiltration of the right upper lung field and blood exam demonstrated marked increase in CPK and renal dysfunction. Intravenous ceftriaxone sodium was started, but the next day, we started intravenous ciprofloxacin because the urine sample was positive for the Legionella antigen. Hemodialysis was started for acute renal failure due to rhabdomyolysis, and mechanical ventilation was introduced due to worsening of acute respiratory failure. Despite these treatments, bilateral infiltration on chest x-ray worsened, resulting in acute respiratory distress syndrome (ARDS). After administration of intravenous pulse methylpredonisolone and sivelestat (neutrophil elastase inhibitor), the patient was successfully weaned from mechanical ventilation. He was also removed from hemodialysis, and discharged from hospital with a good performance status 28 days later. The outcome in this case suggested that treatment with pulse steroid and sivelestat sodium in addition to antibiotics may be effective for Legionella pneumonia complicated by ARDS and acute renal failure.     

Successful use of immunosuppressive agents for the treatment of progressive rheumatoid interstitial lung disease: a case report]

Interstitial pneumonia (IP) is sometimes a fatal complication of rheumatoid arthritis (RA). We describe a patient with progressive rheumatoid interstitial pneumonia, who responded to intravenous intermittent cyclophosphamide (IV-CY) and cyclosporine (CsA). A 62-year-old man with rheumatoid arthritis was admitted to this hospital because of dyspnea. Examinations on admission revealed that he had active RA with vasculitis and IP Initially, he responded to high-dose corticosteroid therapy. A lung biopsy performed after initial corticosteroid therapy revealed diffuse interstitial pneumonia with marked infiltrations of macrophages into the air spaces. On corticosteroid therapy with prednisolone 30 mg/day, the IP became exacerbated and was refractory to the current high-dose steroid treatment. He responded to intravenous cyclophosphamide, but his IP remained unstable. After CsA treatment was started, a clinical remission was obtained. In this case, CsA was the most effective agent tried. Clinical and pathological considerations led us to speculate that activated alveolar macrophages played a crucial role in the pathogenesis of steroid-resistant IP in this patient, and that the clinical remission induced by CsA may have been due to its inhibitory effect on alveolar macrophages.     

Successful treatment of steroid-resistant methotrexate-induced interstitial pneumonia with peripherally administered ulinastatin

A 76-year-old woman with rheumatoid arthritis who had been taking methotrexate (MTX) for 9 months was admitted because of acute respiratory failure. A chest radiograph revealed diffuse ground-glass attenuation. MTX-induced interstitial pneumonia (IP) was strongly suspected. Her respiratory failure worsened in spite of steroid pulse therapy. Intravenous administration of ulinastatin, however, dramatically improved her clinical condition. The second ulinastatin treatment was also effective. This case suggests that peripherally administered ulinastatin may be effective for steroid-resistant MTX-induced IP.     

A case of receipieut of kidney transplantation presenting life-threatning preumothorax due to the rupture of intrapulmonary multiple infections cavities caused by Absidia corymbifera and methicillin-resistant Staphylococcus aureus

We report a rare case of life-threatning pneumothorax induced by multiple intrapulmonary cavitary lesion due to Absidia corymbifera and methicillin-resistant Staphylococcus aureus (MRSA). The patient was a 58-year-old man who had undergone kidney transplantation three year ago due to diabetes renal failure. He had been treated with immunosuppressive drugs and prednisolone, but he had neutropenia and an abnormal shadow on the chest X-ray. His chest X-ray findings became worse inspite of broad-spectrum antibiotis, vancomycin, antivirus drug, gamma-globulin and antifungal drug therapy. He came to our emergency center because of dyspnea due to right massive pleural effusion and peumothorax about two months after onset of neutropenia. His arterial blood gas showed severe hypoxia and the chest CT scan showed birateral pleural effusion and multiple intrapulmonary cavities. He was treated with chest tube drainage and intubated, but he died of progressive respiratory failure on admission day 3. Macroscopic and microbiologic findings of necroptic lung revealed the cavity with fistula in the middle lobe, which included debris with mucor and MRSA. The species of mucor identified as Absidia corymbifera as a result of analysis of BLAST with nested-PCR using the palafin-block.     

Role of prednisolone treatment in severe Mycoplasma pneumoniae pneumonia in children

Mycoplasma pneumoniae pneumonia (MP) is responsible for 10-40% of cases of pediatric community-acquired pneumonia. Occasionally, progression to severe pneumonia occurs despite appropriate antibiotic therapy. We retrospectively evaluated the effect of prednisolone in 15 children with MP whose clinical and radiographic course worsened despite broad-spectrum antibiotics, including appropriate macrolides. The mean ( +/- SD) age was 6.1 +/- 1.9 years, and 10 were boys. All children had received macrolides at presentation, but they had persistent fever and progressively worsening radiographic findings. In addition to broad-spectrum antimicrobial therapy, we added prednisolone (1 mg/kg for 3-7 days, then tapered over 7 days) on day 6 (+/-1.5 days) of admission. Fourteen children became afebrile within 24 hr, and their clinical status and radiographic findings improved over several days. The white blood cell count at presentation was 7,500 +/- 2,000/mm3, with a proportion demonstrating lymphopenia (lymphocyte differential, 19.7 +/- 5.7%). In conclusion, corticosteroid treatment appeared to be temporally associated with clinical and radiographic improvement, and may be helpful for reducing morbidity in children with macrolide-nonresponsive severe MP. Further studies may be warranted.     

Leflunomide induced acute interstitial pneumonia

We describe a 54-year-old woman with rheumatoid arthritis (RA), who developed acute respiratory failure 2 weeks after cessation of 6-week treatment with leflunomide. We diagnosed interstitial pneumonia, probably induced by leflunomide because acute respiratory failure was preceded by elevated serum liver enzyme concentration and hypertension. She showed dramatic improvement with prednisolone and cholestyramine. Prompt treatment may improve the prognosis. In Japan, leflunomide has been implicated as a possible cause to initiate or exacerbate interstitial pneumonia in patients with RA according to postmarketing surveillance. Clinicians should exclude pulmonary disease prior to initiating leflunomide treatment in patients with RA on the basis of a thorough history and physical examination, and chest radiograph.     

Disseminated histoplasmosis associated with the acquired immune deficiency syndrome

Disseminated histoplasmosis developed in a previously healthy man as the initial manifestation of the acquired immune deficiency syndrome. Following apparently successful therapy with intravenous amphotericin B, he presented two months later with a subacute pneumonitis syndrome diagnosed by bronchoscopy as Pneumocystis carinii pneumonia. He showed response to intravenous trimethoprim/sulfamethoxazole with resolution of his symptoms and clearing of chest radiographic findings. While he was receiving antibiotics, oral candidiasis developed and has persisted for more than two months despite topical therapy and discontinuation of all antibiotics.     

A case of Legionnaires' disease with acute renal failure improved by continuous hemodiafiltration

A 52-year-old man was admitted to our hospital because of fever and dyspnea. Chest X-ray film showed infiltrative shadows in the right lower lung fields and serum creatinine was 6.7 mg/dl. The patient was diagnosed as pneumonia complicated with acute renal failure. He was treated with antimicrobial therapy. However he developed respiratory failure and exhibited mental confusion. Legionnaires' disease was suspected, because pneumonia was found to be associated with multiple organ dysfunction. We started treatment with intravenous administration of minocycline and continuous hemodiafiltration and his condition had been rapidly improved. We diagnosed this case as legionnaires' disease due to the positive of urinary Legionella pneumophila serogroup 1 antigen. Since the cases of legionnaires' disease with acute renal failure are serious, prompt diagnosis and adequate treatment are essential.