Pulmonary sequestration infected with nontuberculous mycobacteria:a report of two cases and literature review

We report two cases of pulmonary sequestration infected with nontuberculous mycobacteria(NTM): Mycobacterium avium and Mycobacterium abscessus.Chest computed tomography showed pneumonic consolidation in the right lower lobe,which received a systemic blood supply from the descending aorta in both patients.Video-assisted thoracoscopic surgeries were successfully performed and pathologica]examinations revealed multiple caseating granulomas.A review of the literature revealed only seven previous case reports of pulmonary sequestration infected with NTM,and no case with Mycobacterium abscessus has been reported.

Hepatitis B in healthcare workers: Transmission events and guidance for management

Hepatitis B virus(HBV) is the most efficiently transmissible of the bloodborne viruses that are important in healthcare settings. Healthcare workers(HCWs)are at risk for exposure to HBV from infected patients and, if infected, are similarly at risk of transmitting HBV to patients. Published cases of HBV transmission from HCW to patient are relatively rare, having decreased in frequency following the introduction of standard(universal) precautions, adoption of enhanced percutaneous injury precautions such as double-gloving in surgery, and routine HBV vaccination of HCWs. Here we review published cases of HCW-to-patient transmission of HBV, details of which have helped to guide the creation of formal guidelines for the management of HBV-infected HCWs. We also compare the published guidelines for the management of HBV-infected HCWs from various governing bodies, focusing on their differences with regard to vaccination requirements, viral load limits, frequency of monitoring, and restrictions on practice. Importantly, while there are differences among the recommendations from governing bodies, no guidelines uniformly restrict HBV-infected HCWs from performing invasive or exposure-prone procedures.

Individualized anti-thrombotic therapy for acute myocardial infarction complicated with left ventricular thrombus: A case report

BACKGROUND Presently,there is no established standard anti-blood clot therapy for patients facing acute myocardial infarction(AMI)complicated by left ventricular thrombus(LVT).While vitamin K antagonists are the preferred choice for oral blood thinning,determining the best course of blood-thinning medication remains challenging.It is unclear if non-vitamin K antagonist oral blood thinners have different effectiveness in treating LVT.This study significantly contributes to the medical community.CASE SUMMARY The blood-thinning treatment of a patient with AMI and LVT was analyzed.Triple blood-thinning therapy included daily enteric-coated aspirin tablets at 0.1 g,daily clopidogrel hydrogen sulfate at 75 mg,and dabigatran etexilate at 110 mg twice daily.After 15 d,the patient’s LVT did not decrease but instead increased.Clinical pharmacists comprehensively analyzed the cases from the perspective of the patient’s disease status and drug interaction.The drug regimen was reformulated for the patient,replacing dabigatran etexilate with warfarin,and was administered for six months.The clinical pharmacist provided the patient with professional and standardized pharmaceutical services.The patient’s condition was discharged after meeting the international normalized ratio value(2-3)criteria.The patient fully complied with the follow-up,and the time in the therapeutic range was 78.57%,with no serious adverse effects during pharmaceutical monitoring.CONCLUSION Warfarin proves to be an effective drug for patients with AMI complicated by LVT,and its blood-thinning course lasts for six months.

Alzheimer’s disease and type 2 diabetes mellitus:Pathophysiologic and pharmacotherapeutics links

At present,Alzheimer’s disease(AD)and type 2 diabetes mellitus(T2DM)are two highly prevalent disorders worldwide,especially among elderly individuals.T2DM appears to be associated with cognitive dysfunction,with a higher risk of developing neurocognitive disorders,including AD.These diseases have been observed to share various pathophysiological mechanisms,including alterations in insulin signaling,defects in glucose transporters(GLUTs),and mitochondrial dysfunctions in the brain.Therefore,the aim of this review is to summarize the current knowledge regarding the molecular mechanisms implicated in the association of these pathologies as well as recent therapeutic alternatives.In this context,the hyperphosphorylation of tau and the formation of neurofibrillary tangles have been associated with the dysfunction of the phosphatidylinositol 3-kinase and mitogen-activated protein kinase pathways in the nervous tissues as well as the decrease in the expression of GLUT-1 and GLUT-3 in the different areas of the brain,increase in reactive oxygen species,and production of mitochondrial alterations that occur in T2DM.These findings have contributed to the implementation of overlapping pharmacological interventions based on the use of insulin and antidiabetic drugs,or,more recently,azeliragon,amylin,among others,which have shown possible beneficial effects in diabetic patients diagnosed with AD.

Combined silicosis and mixed dust pneumoconiosis with rapid progression: A case report and literature review

BACKGROUND Rapidly progressive pneumoconiosis(RPP) occasionally occurs in coal workers, particularly those with high exposure to silica. Here, we report the case of a 64-year-old male miller with RPP. CASE SUMMARY The patient had a persistent cough for one month and had been clinically diagnosed with pulmonary tuberculosis in 2011. He worked in a stone processing factory from the ages of 20 through 37 and has owned his own mill for the past 25 years. His chest radiograph showed significant increases in the size and number of lung nodules since his last follow-up in 2013. By percutaneous needle lung biopsy, the nodular lesions showed diffuse infiltration of phagocytic macrophages and birefringent crystals by polarizing microscopy. He was finally diagnosed with RPP of mixed dust pneumoconiosis combined with silicosis. CONCLUSION In this case, mixed dust pneumoconiosis with silicosis might be accelerated by persistent exposure to graindust from working in a mill environment.

Characteristics of fever and response to antipyretic therapy in military personnel with adenovirus-positive community acquired pneumonia

Background:In 2014,an outbreak of adenoviral pneumonia occurred in the Korean military training center.However,there are limited data on the characteristics of the fever and its response to antipyretic therapy in immunocompetent adults with adenovirus-positive community-acquired pneumonia(CAP).Methods:The medical records of the patients who were admitted to the Armed Forces Chuncheon Hospital for the treatment of CAP between January 2014 and December 2016 were retrospectively analyzed.The patients were divided into three groups,namely,the adenovirus-positive(Adv)group,the adenovirus-negative(Non-Adv)group and the unknown pathogen group,according to the results of a polymerase chain reaction(PCR)test and sputum culture used to measure adenovirus and other bacteria or viruses in respiratory specimens.We evaluated and compared the demographics,clinicolaboratory findings and radiological findings upon admission between the two groups.Results:Out of the 251 military personnel with CAP during the study periods,67 were classified into the Adv group,while 134 were classified into the Non-Adv group and 50 were classified into the unknown pathogen group.The patients in the Adv group had a longer duration of fever after admission((3.2±1.6)d vs.(1.9±1.2)d vs.(2.2±1.5)d,P=0.018)and symptom onset((5.8±2.2)d vs.(3.9±2.5)d vs.(3.7±2.0)d,P=0.006)than patients in the Non-Adv and unknown pathogen groups,respectively.The patients in the Adv group had a higher mean temperature at admission(37.8±0.3 vs.37.3±0.3 vs.37.3±0.3,P=0.005),and more patients were observed over 40 and 39 to 40(14.9%vs.2.2%vs.4.0%,35.8%vs.3.7%vs.6.0%,P<0.001)than those in the Non-Adv and unknown pathogen groups,respectively.The Adv group more commonly had no response or exhibited adverse events after antipyretic treatment compared to the Non-Adv group(17.9%vs.1.5%,35.0%vs.4.3%,P<0.001,P=0.05,respectively).In addition,the time from admission to overall clinical stabilization was significantly longer in the patients in the Adv group than in those in the Non-Adv group((4.3±2.8)d vs.(2.9±1.8)d,P=0.034,respectively).Furthermore,no significant difference in the length of hospital stay was observed between the two groups,and no patient died in either group.Conclusions:In this study,Adv-positive CAP in immunocompetent military personnel patients had distinct fever characteristics and responses to antipyretic treatment.

Boarding issue in a commercial flight for patients with cavitary pulmonary tuberculosis: A case report

BACKGROUND Several studies have demonstrated that airborne transmission of Mycobacterium tuberculosis bacteria from patients with active pulmonary tuberculosis(TB) to other passengers or crew members can occur during long flights. As such, non-infectious TB patients are usually allowed to undertake air travel after taking the appropriate anti-TB drugs. However, the global guidelines for air travel for patients with TB are inconsistent and insufficiently detailed with respect to cavitary pulmonary TB(CPTB).CASE SUMMARY Here, we report a case in which a patient with multiple CPTB was permitted air travel, following negative sputum acid-fast bacilli smear tests after administration of proper anti-TB medication. The patient’s culture results were pending.CONCLUSION This case revealed that more specific guidelines regulating air travel for patients with CPTB are necessary.

AML presenting as a mediastinal mass and right ventricular failure

Extrinsic compression of the pulmonary arteries by mediastinal masses, while rare, is the most common cause of non-congenital peripheral pulmonary artery stenosis. Granulocytic myeloid sarcomas are an extramedullary manifestation of acute myeloid leukemia, with a wide variability in their presentation. They can present either de novo as soft tissue masses or in conjunction with acute myeloid leukemia. Myeloid sarcomas are uncommon and their prognosis is generally considered poor when present in patients with acute myeloid leukemia (AML). We present a case of a granulocytic myeloid sarcoma causing pulmonary artery stenosis and right ventricular failure. This case represents a unique cause of pulmonary arterial stenosis.

Clinical application of combined detection of SARS-CoV-2-specific antibody and nucleic acid

BACKGROUND The global outbreak of human severe acute respiratory syndrome coronavirus(SARS-CoV)-2 infection represents an urgent need for readily available,accurate and rapid diagnostic tests.Nucleic acid testing of respiratory tract specimens for SARS-CoV-2 is the current gold standard for diagnosis of coronavirus disease 2019(COVID-19).However,the diagnostic accuracy of reverse transcription polymerase chain reaction(RT-PCR)tests for detecting SARS-CoV-2 nucleic acid may be lower than optimal.The detection of SARS-CoV-2-specific antibodies should be used as a serological non-invasive tool for the diagnosis and management of SARS-CoV-2 infection.AIM To investigate the diagnostic value of SARS-CoV-2 IgM/IgG and nucleic acid detection in COVID-19.METHODS We retrospectively analyzed 652 suspected COVID-19 patients,and 206 non-COVID-19 patients in Wuhan Integrated TCM and Western Medicine Hospital.Data on SARS-CoV-2 nucleic acid tests and serum antibody tests were collected to investigate the diagnostic value of nucleic acid RT-PCR test kits and immunoglobulin(Ig)M/IgG antibody test kits.The j2 test was used to compare differences between categorical variables.A 95%confidence interval(CI)was provided by the Wilson score method.All analyses were performed with IBM SPSS Statistics version 22.0(IBM Corp.,Armonk,NY,United States).RESULTS Of the 652 suspected COVID-19 patients,237(36.3%)had positive nucleic acid tests,311(47.7%)were positive for IgM,and 592(90.8%)were positive for IgG.There was a significant difference in the positive detection rate between the IgM and IgG test groups(P<0.001).Using the RT-PCR results as a reference,the specificity,sensitivity,and accuracy of IgM/IgG combined tests for SARS-CoV-2 infection were 98.5%,95.8%,and 97.1%,respectively.Of the 415 suspected COVID-19 patients with negative nucleic acid test results,366 had positive IgM/IgG tests with a positive detection rate of 88.2%.CONCLUSION Our data indicate that serological IgM/IgG antibody combined test had high sensitivity and specificity for the diagnosis of SARS-CoV-2 infection,and can be used in combination with RT-PCR for the diagnosis of SARS-CoV-2 infection.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND The coronavirus disease 2019(COVID-19)course may be affected by environmental factors.Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates.However,individual-level impact of these factors has not been thoroughly evaluated yet.AIM To study the association of climatological factors related to patient location with unfavorable outcomes in patients.METHODS In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study:COVID-19 Registry cohort,the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay.Adjusting for baseline parameters and admission date,multivariable regression modeling was utilized.Generalized estimating equations were used to fit the models.RESULTS Twenty-two thousand one hundred eight patients from over 20 countries were evaluated.The median age was 62(interquartile range:49-74)years,and 54%of the included patients were males.The median age increased with increasing latitude as well as the frequency of comorbidities.Contrarily,the percentage of comorbidities was lower in elevated altitudes.Mortality within 28 d of hospital admission was found to be 25%.The median hospital-free days among all included patients was 20 d.Despite the significant linear relationship between mortality and hospital-free days(adjusted odds ratio(aOR)=1.39(1.04,1.86),P=0.025 for mortality within 28 d of admission;aOR=-1.47(-2.60,-0.33),P=0.011 for hospital-free days),suggesting that adverse patient outcomes were more common in locations further away from the Equator;the results were no longer significant when adjusted for baseline differences(aOR=1.32(1.00,1.74),P=0.051 for 28-day mortality;aOR=-1.07(-2.13,-0.01),P=0.050 for hospital-free days).When we looked at the altitude’s effect,we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission(aOR=0.96(0.62,1.47),1.04(0.92,1.19),0.49(0.22,0.90),and 0.51(0.27,0.98),for the altitude points of 75 MASL,125 MASL,400 MASL,and 600 MASL,in comparison to the reference altitude of 148 m.a.s.l,respectively.P=0.001).We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study.When the baseline features were taken into account,however,this did not stay significant.CONCLUSION Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.

Outcomes of combined mitochondria and mesenchymal stem cellsderived exosome therapy in rat acute respiratory distress syndrome and sepsis

BACKGROUND The treatment of acute respiratory distress syndrome(ARDS)complicated by sepsis syndrome(SS)remains challenging.AIM To investigate whether combined adipose-derived mesenchymal-stem-cells(ADMSCs)-derived exosome(EXAD)and exogenous mitochondria(mitoEx)protect the lung from ARDS complicated by SS.METHODS In vitro study,including L2 cells treated with lipopolysaccharide(LPS)and in vivo study including male-adult-SD rats categorized into groups 1(sham-operated-control),2(ARDS-SS),3(ARDS-SS+EXAD),4(ARDS-SS+mitoEx),and 5(ARDS-SS+EXAD+mitoEx),were included in the present study.RESULTS In vitro study showed an abundance of mitoEx found in recipient-L2 cells,resulting in significantly higher mitochondrial-cytochrome-C,adenosine triphosphate and relative mitochondrial DNA levels(P<0.001).The protein levels of inflammation[interleukin(IL)-1β/tumor necrosis factor(TNF)-α/nuclear factor-κB/toll-like receptor(TLR)-4/matrix-metalloproteinase(MMP)-9/oxidative-stress(NOX-1/NOX-2)/apoptosis(cleaved-caspase3/cleaved-poly(ADP-ribose)polymerase)]were significantly attenuated in lipopolysaccharide(LPS)-treated L2 cells with EXAD treatment than without EXAD treatment,whereas the protein expressions of cellular junctions[occluding/β-catenin/zonula occludens(ZO)-1/E-cadherin]exhibited an opposite pattern of inflam-mation(all P<0.001).Animals were euthanized by 72 h post-48 h-ARDS induction,and lung tissues were harvested.By 72 h,flow cytometric analysis of bronchoalveolar lavage fluid demonstrated that the levels of inflam-matory cells(Ly6G+/CD14+/CD68+/CD11b/c+/myeloperoxidase+)and albumin were lowest in group 1,highest in group 2,and significantly higher in groups 3 and 4 than in group 5(all P<0.0001),whereas arterial oxygen-saturation(SaO2%)displayed an opposite pattern of albumin among the groups.Histopathological findings of lung injury/fibrosis area and inflammatory/DNA-damaged markers(CD68+/γ-H2AX)displayed an identical pattern of SaO2%among the groups(all P<0.0001).The protein expressions of inflammatory(TLR-4/MMP-9/IL-1β/TNF-α)/oxidative stress(NOX-1/NOX-2/p22phox/oxidized protein)/mitochondrial-damaged(cytosolic-cytochrome-C/dynamin-related protein 1)/autophagic(beclin-1/Atg-5/ratio of LC3B-II/LC3B-I)biomarkers exhibited a similar manner,whereas antioxidants[nuclear respiratory factor(Nrf)-1/Nrf-2]/cellular junctions(ZO-1/E-cadherin)/mitochondrial electron transport chain(complex I-V)exhibited an opposite manner of albumin among the groups(all P<0.0001).CONCLUSION Combined EXAD-mitoEx therapy was better than merely one for protecting the lung against ARDS-SS induced injury.

肺癌分期分类相关的解剖学、生物学及理念

尽管用于此修订本的大样本量患者数据库已极大地拓宽了我们的知识面,但最新提出的肺癌分期系统仍以解剖学特征为基础。可以预见,由于所鉴定出的患者亚群数目不断增加,肺癌分期系统变得愈加复杂。表述这些亚组的临床特征有可能为我们提供肿瘤亚组特殊的生物学行为特性的线索。本文探索了可用于以解剖学为基础的新分期系统的肿瘤生物学相关观念。

Propofol pump controls nonconvulsive status epilepticus in a hepatic encephalopathy patient: A case report

BACKGROUND Status epilepticus is an emergent and critical condition which needs management without hesitation. Nonconvulsive status epilepticus (NCSE) tends to be less recognized, and its diagnosis is delayed in comparison with overt status epilepticus because of the absence of specific clinical signs. It is often difficult to make a diagnosis, particularly in patients with hepatic encephalopathy. CASE SUMMARY A 38-year-old man with a history of alcoholic liver cirrhosis presented with altered mental status;the initial diagnosis was hepatic encephalopathy. Although optimal treatment for hepatic encephalopathy was administered, the patient's mental status did not improve. A final diagnosis of NCSE was made by continuous electroencephalogram (EEG) monitoring. Treatment with levetiracetam and propofol pump was immediately started. The patient’s consciousness gradually improved after discontinuation of propofol therapy, and no further epileptic discharge was observed by EEG monitoring. After 1 wk, the patient returned to full consciousness, and he was able to walk in the hospital ward without assistance. He was discharged with minimal sequela of bilateral conjunctivitis. CONCLUSION In cases of persistent altered mental status without reasonable diagnosis, NCSE should be considered in hepatic encephalopathy patients with persistently altered levels of consciousness, and EEG monitoring is very important. We also recommend propofol as a safe and efficient therapy for NCSE in liver cirrhosis patients.

Clinical outcomes in patients with ICU-related pancreatitis

AIM:To identify risk factors predictive of intensive care unit(ICU) mortality in patients with ventilator-related pancreatitis.The clinical outcomes of patients with ventilator-related pancreatitis were compared with those of patients with pancreatitis-related respiratory failure as well as controls.METHODS:One hundred and forty-eight patients with respiratory failure requiring mechanical ventilation and concomitant acute pancreatitis were identified from a prospectively collected dataset of 9108 consecutive patients admitted with respiratory failure over a period of five years.Sixty patients met the criteria for ventilator-related pancreatitis,and 88(control patients),for pancreatitis-related respiratory failure.RESULTS:Mortality rate in ventilator-related pancreatitis was comparable to that in ICU patients without pancreatitis by case-control methodology(P=0.544).Multivariate logistic regression analysis identified low PaO2/FiO2(OR:1.032,95% CI:1.006-1.059,P=0.016) as an independent risk factor for mortality in patients with ventilator-related pancreatitis.The mortality rate in patients with ventilator-related pancreatitis was lower than that in patients with acute pancreatitis-related respiratory failure(P<0.001).CONCLUSION:We found that low PaO2/FiO2 was an independent clinical parameter predictive of ICU mortality in patients with ventilator-related pancreatitis.

Increased survivin expression contributes to apoptosis-resistance in IPF fibroblasts

Fibroblasts perform critical functions during the normal host response to tissue injury, but the inappropriate accumulation and persistent activation of these cells results in the development of tissue fibrosis. The mechanisms accounting for the aberrant accumulation of fibroblasts during fibrotic repair are poorly understood, although evidence supports a role for fibroblast resistance to apoptosis as a contributing factor. We have shown that TGF-β1 and endothelin-1 (ET-1), soluble mediators implicated in fibrogenesis, promote fibroblast resistance to apoptosis. Moreover, we recently found that ET-1 induced apoptosis resistance in normal lung fibroblasts through the upregulation of survivin, a member of the Inhibitor of Apoptosis (IAP) protein family. In the current study, we sought to determine the role of survivin in the apoptosis resistance of primary fibroblasts isolated from the lungs of patients with Idiopathic Pulmonary Fibrosis (IPF), a fibrotic lung disease of unclear etiology for which there is no definitive therapy. First, we examined survivin expression in lung tissue from patients with IPF and found that there is robust expression in the fibroblasts residing within fibroblastic foci (the “active” lesions in IPF which correlate with mortality). Next, we show that survivin expression is increased in fibroblasts isolated from IPF lung tissue compared to cells from normal lung tissue. Consistent with a role in fibrogenesis, we demonstrate that TGF-β1 increases survivin expression in normal lung fibroblasts. Finally, we show that inhibition of survivin enhances susceptibility of a subset of IPF fibroblasts to apoptosis. Collectively, these findings suggest that increased survivin expression represents one mechanism contributing an apoptosis-resistant phenotype in IPF fibroblasts.

Angiotensin converting enzymes inhibitors or angiotensin receptor blockers should be continued in COVID-19 patients with hypertension

BACKGROUND Recent studies have revealed that sustained ingestion of angiotensin converting enzymes inhibitors or angiotensin receptor blockers(ACEIs/ARBs)had no harmful effects on coronavirus disease 2019(COVID-19)patients complicated with hypertension.AIM To investigate the impact on COVID-19 patients complicated with hypertension who discontinued using ACEIs/ARBs.METHODS All COVID-19 patients complicated with hypertension admitted to our isolated unit were consecutively recruited in this study.Some patients switched from ACEIs/ARBs to calcium channel blocker(CCBs)after admission,while others continued using non-ACEIs/ARBs.We compared characteristics and clinical outcomes between these two groups of patients.RESULTS A total of 53 patients were enrolled,27 patients switched from ACEIs/ARBs to CCBs while 26 patients continued with non-ACEIs/ARBs.After controlling potential confounding factors using the Cox proportional hazards model,hospital stay was longer in patients who discontinued ACEIs/ARBs,with a hazard ratio of 0.424(95%confidence interval:0.187-0.962;P=0.040),upon discharge than patients using other anti-hypertensive drugs.A sub-group analysis showed that the effect of discontinuing use of ACEIs/ARBs was stronger in moderate cases[hazard ratio=0.224(95%confidence interval:0.005-0.998;P=0.0497)].CONCLUSION Patients in the discontinued ACEIs/ARBs group had longer hospital stays.Our findings suggest that COVID-19 patients complicated with hypertension should continue to use ACEIs/ARBs.

旧金山不含IS6110结核分支杆菌菌株的流行病学

IS6110通常作为结核分支杆菌的分子流行病学和诊断研究的基础,然而,不含IS6110的菌株已有报道。如果这种菌株常见,将使结核分支杆菌的分子研究受到限制。对来自旧金山的一个人群样本的1569份标本进行指纹分析显示:不含IS6110的菌株的比例低于1％,由于这种比例低,在旧金山可以进行IS6110指纹分析,而在其它地方可能存在问题。

老年重症肺炎严重性评分系统的比较

材料和方法 对象病例来自1996年6月～1999年9月在Buffalo纽约州立大学的两个三级医疗中心.分别为Erie Country医学中心和Buffalo General医院ICU病房需机械通气且≥75岁的重症肺炎患者.本项研究得到了Buffalo大学Institutional Review Board的确认.在告知研究对象研究目的研究和计划后,患者本人及家属同意参加. 入选对象标准:①较轻的呼吸道感染症状,伴有潜在病原体;②X线发现有新的肺炎浸润;③存在以下任两种临床表现:体温高于38℃,白细胞增多(＞11.0×109/l)或嗜中性粒细胞减少(＜3.5×109/l),脓痰或呼吸道分泌物的性质改变,肺泡-动脉氧分压差增加;④院外获得性感染.

A 60-Year-Male Post Corneal Transplantation with Acute Pneumonia

Pneumonia is a common complication in organ transplantation patients. Multiple respiratory pathogens such as bacteria, viruses and fungi are potentially coexisted. A 60-year-old male with left eye post corneal transplantation developed acute severe pneumonia caused by Pneumocystis jiroveci (PJP) coinfection with Nocardia spp. and Cytomegalovirus (CMV). He was hospitalized due to acute respiratory failure. Chest radiographs and chest Computed Tomography (CT) revealed extensive ground-glass opacities. PJP was diagnosed from Bronchoalveolar Lavage Fluid (BALF). The pneumonia was persistent despite of receiving intravenous cotrimoxazole. Tracheal aspirate showed faint gram-positive filamentous beaded branching organisms. Consequently Nocardia spp. was proven. Intravenous cotrimoxazole was continued and intravenous imipenem was added. After a course of dual antibiotics, pneumonia was gradually improved. A week after, he developed the worsened acute respiratory failure. The bronchoscopy was performed. The new pathogens were not detected from BALF microbiology. The BALF cytology was unremarkable. PJP was detected by Polymerase Chain Reaction (PCR) from BALF. CMV antigenemia was detected from BALF and blood. Intravenous ganciclovir was given. This report describes PJP coinfected with Nocardia spp. and CMV in post corneal transplantation patient suffering from severe pneumonia. Multiple respiratory pathogens are common among transplantation patients representing host immunosuppression and inadequate antimicorbial prophylaxis.

Association of blood transfusion with acute kidney injury after transcatheter aortic valve replacement: A metaanalysis

AIM To assess red blood cell(RBC) transfusion effects on acute kidney injury(AKI) after transcatheter aortic valve replacement(TAVR). METHODS A literature search was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and clinicaltrials.gov from the inception of the databases through December 2015. Studies that reported relative risk, odds ratio or hazard ratio comparing the risks of AKI following TAVR in patients who received periprocedural RBC transfusion were included. Pooled risk ratio(RR) and 95%CI were calculated using a random-effect, generic inverse variance method. RESULTS Sixteen cohort studies with 4690 patients were included in the analyses to assess the risk of AKI after TAVR in patients who received a periprocedural RBC transfusion. The pooled RR of AKI after TAVR in patients who received a periprocedural RBC transfusion was 1.95(95%CI: 1.56-2.43) when compared with the patients who did not receive a RBC transfusion. The meta-analysis wasthen limited to only studies with adjusted analysis for confounders assessing the risk of AKI after TAVR; the pooled RR of AKI in patients who received periprocedural RBC transfusion was 1.85(95%CI: 1.29-2.67). CONCLUSION Our meta-analysis demonstrates an association between periprocedural RBC transfusion and a higher risk of AKI after TAVR. Future studies are required to assess the risks of severe AKI after TAVR requiring renal replacement therapy and mortality in the patients who received periprocedural RBC transfusion.