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Streptococcus suis (S. suis) is an emerging zoonotic pathogen that causes bacterial meningitis in humans. S. suis is an encapsulated gram-positive facultative anaerobic bacterium and is an important pathogen in pigs. This infectious disease usually manifests in humans as meningitis, endocarditis, septicemia, and arthritis. Most cases originate in Southeast Asia, and human S. suis infections are often reported in countries with a high density of pigs. Meningitis is a common clinical manifestation of S. suis infection. Moreover, hearing loss is a common complication that can be bilateral, profound, and/or permanent. This report presents two cases of bacterial meningitis and hearing loss caused by S. suis in patients without a history of direct exposure to pigs in an intensive pork industry region.

Background We aimed to investigate the prevalence of low back pain (LBP) and its associated agricultural work-related, biomechanical factors among this population. Methods We analyzed initial survey data from the Safety for Agricultural Injury of Farmers cohort study involving adult farmers in Jeju Island. The prevalence of LBP was calculated with associated factors. Results In total, 1,209 participants were included in the analysis. The overall prevalence of LBP was 23.7%. Significant associations for LBP were the type of farming activity, length of farming career, prior agricultural injury within 1 year, and stress levels. Multivariate logistic regression analysis revealed three biomechanical factors significantly related to LBP: repetitive use of particular body parts; the inappropriate posture of the lower back and neck. Conclusions Some occupational, and biomechanical risk factors contribute to LBP. Therefore, postural education, injury prevention education, and psychological support will be needed to prevent LBP.

Background/Aims: Secondary infection with influenza virus occurs in critically ill patients and is associated with substantial morbidity and mortality; however, there is limited information about it in patients with severe coronavirus disease 2019 (COVID-19). Thus, we investigated the clinical outcomes of and risk factors for secondary infections in patients with severe COVID-19.Methods: This study included patients with severe COVID-19 who were admitted to seven hospitals in South Korea between February 2020 to February 2021. Multivariate logistic regression analyses were performed to assess factors associated with the risk of secondary infections.Results: Of the 348 included patients, 104 (29.9%) had at least one infection. There was no statistically significant difference in the 28-day mortality (17.3% vs. 12.3%, p = 0.214), but in-hospital mortality was higher (29.8% vs. 15.2%, p = 0.002) in the infected group than in the non-infected group. The risk factors for secondary infection were a high frailty scale (odds ratio [OR], 1.314; 95% confidence interval [CI], 1.123 to 1.538; p = 0.001), steroid use (OR, 3.110; 95% CI, 1.164 to 8.309; p = 0.024), and the application of mechanical ventilation (OR, 4.653; 95% CI, 2.533 to 8.547; p < 0.001).Conclusions: In-hospital mortality was more than doubled in patients with severe COVID-19 and secondary infections. A high frailty scale, the use of steroids and application of mechanical ventilation were risk factors for secondary infection.

OBJECTIVES To investigate the impact of normothermia on compliance with sepsis bundles and in-hospital mortality in patients with sepsis who present to emergency departments. DESIGN Retrospective multicenter observational study. PATIENTS Nineteen university-affiliated hospitals of the Korean Sepsis Alliance participated in this study. Data were collected regarding patients who visited emergency departments for sepsis during the 1-month period. The patients were divided into three groups based on their body temperature at the time of triage in the emergency department (i.e., hypothermia [ 38°C]). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 64,021 patients who visited emergency departments, 689 with community-acquired sepsis were analyzed (182 hyperthermic, 420 normothermic, and 87 hypothermic patients). The rate of compliance with the total hour-1 bundle was lowest in the normothermia group (6.0% vs 9.3% in hyperthermia vs 13.8% in hypothermia group; p = 0.032), the rate for lactate measurement was lowest in the normothermia group (62.1% vs 73.1% vs 75.9%; p = 0.005), and the blood culture rate was significantly lower in the normothermia than in the hyperthermia group (p < 0.001). The in-hospital mortality rates in the hyperthermia, normothermia, and hypothermia groups were 8.5%, 20.6%, and 30.8%, respectively (p < 0.001), but there was no significant association between compliance with sepsis bundles and in-hospital mortality. However, in a multivariate analysis, compared with hyperthermia, normothermia was significantly associated with an increased in-hospital mortality (odds ratio, 2.472; 95% CI, 1.005-6.080). This association remained significant even after stratifying patients by median lactate level. CONCLUSIONS Normothermia at emergency department triage was significantly associated with an increased risk of in-hospital mortality and a lower rate of compliance with the sepsis bundle. Despite several limitations, our findings suggest a need for new strategies to improve sepsis outcomes in this group of patients.

Severe fever with thrombocytopenia syndrome (SFTS) caused by the SFTS virus (SFTSV), a novel Phlebovirus, is endemic to South Korea, central and northeastern China, and western Japan. SFTS poses a threat to public health because of its high mortality and secondary transmission. Ticks and domestic animals are hosts for SFTSV in endemic areas. There is no specific treatment for SFTS, and avoiding tick bites is the best way to prevent infection. Early therapeutic plasma exchange (TPE) is a rescue therapy in patients with rapidly progressive SFTS. Here, we present a patient with SFTS who was improving on TPE but died suddenly due to acute lung injury after TPE.

BACKGROUND: The impact of mechanical ventilation parameters and management on outcomes of patients with coronavirus disease 2019 (COVID-19) ARDS is unclear. METHODS: This multi-center observational study enrolled consecutive mechanically ventilated patients with COVID-19 ARDS admitted to one of 7 Korean ICUs between February 1, 2020–February 28, 2021. Patients who were age < 17 y or had missing ventilation parameters for the first 4 d of mechanical ventilation were excluded. Multivariate logistic regression was used to identify which strategies or ventilation parameters that were independently associated with ICU mortality. RESULTS: Overall, 129 subjects (males, 60%) with a median (interquartile range) age of 69 (62–78) y were included. Neuromuscular blocker (NMB) use and prone positioning were applied to 76% and 16% of subjects, respectively. The ICU mortality rate was 37%. In the multivariate analysis, higher dynamic driving pressure (ΔP) values during the first 4 d of mechanical ventilation were associated with increased mortality (adjusted odds ratio 1.16 [95% CI 1.00–1.33], P = .046). NMB use was associated with decreased mortality (adjusted odds ratio 0.27 [95% CI 0.09–0.81], P = .02). The median tidal volume values during the first 4 d of mechanical ventilation and the ICU mortality rate were significantly lower in the NMB group than in the no NMB group. However, subjects who received NMB for ≥ 6 d (vs < 6 d) had higher ICU mortality rate. CONCLUSIONS: In subjects with COVID-19 ARDS receiving mechanical ventilation, ΔP during the first 4 d of mechanical ventilation was independently associated with mortality. The short-term use of NMB facilitated lung-protective ventilation and was independently associated with decreased mortality.

Old age is associated with disease severity and poor prognosis among coronavirus disease 2019 (COVID-19) cases; however, characteristics of elderly patients with severe COVID-19 are limited. We aimed to assess the clinical characteristics and outcomes of patients hospitalized with severe COVID-19 at tertiary care centers in South Korea. This retrospective multicenter study included patients with severe COVID-19 who were admitted at seven hospitals in South Korea from 2 February 2020 to 28 February 2021. The Cox regression analyses were performed to assess factors associated with the in-hospital mortality. Of 488 patients with severe COVID-19, 318 (65.2%) were elderly (≥65 years). The older patient group had more underlying diseases and a higher severity score than the younger patient group. The older patient group had a higher in-hospital mortality rate than the younger patient group (25.5% versus 4.7%, p-value < 0.001). The in-hospital mortality risk factors among patients with severe COVID-19 included age, acute physiology and chronic health evaluation II score, presence of diabetes and chronic obstructive lung disease, high white blood cell count, low neutrophil-lymphocyte ratio and platelet count, do-not-resuscitate order, and treatment with invasive mechanical ventilation. In addition to old age, disease severity and examination results must be considered in treatment decision-making.

Background The ratio of oxygen saturation (ROX) index, defined as the ratio of oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) to respiratory rate, can help identify patients with hypoxemic respiratory failure at high risk for intubation following high-flow nasal cannula (HFNC) initiation; however, whether it is effective for predicting intubation in coronavirus disease 2019 (COVID-19) patients receiving HFNC remains unknown. Moreover, the SpO2/FiO2 ratio has been assessed as a prognostic marker for acute hypoxemic respiratory failure. This study aimed to determine the utility of the ROX index and the SpO2/FiO2 ratio as predictors of failure in COVID-19 patients who received HFNC. Methods This multicenter study was conducted in seven university-affiliated hospitals in Korea. Data of consecutive hospitalized patients diagnosed with COVID-19 between February 10, 2020 and February 28, 2021 were retrospectively reviewed. We calculated the ROX index and the SpO2/FiO2 ratio at 1 h, 4 h, and 12 h after HFNC initiation. The primary outcome was HFNC failure defined as the need for subsequent intubation despite HFNC application. The receiver operating characteristic curve analysis was used to evaluate discrimination of prediction models for HFNC failure. Results Of 1,565 hospitalized COVID-19 patients, 133 who received HFNC were analyzed. Among them, 63 patients (47.4%) were successfully weaned from HFNC, and 70 (52.6%) were intubated. Among patients with HFNC failure, 32 (45.7%) died. The SpO2/FiO2 ratio at 1 h after HFNC initiation was an important predictor of HFNC failure (AUC 0.762 [0.679–0.846]). The AUCs of SpO2/FiO2 ratio at 4 h and ROX indices at 1 h and 4 h were 0.733 (0.640–0.826), 0.697 (0.597–0.798), and 0.682 (0.583–0.781), respectively. Multivariable analysis showed that the patients aged ≥70 years are 3.4 times more likely to experience HFNC failure than those aged p = 0.009). The SpO2/FiO2 ratio (HR 0.983 [0.972–0.994], p = 0.003) at 1 h was significantly associated with HFNC failure. Conclusions The SpO2/FiO2 ratio following HFNC initiation was an acceptable predictor of HFNC failure. The SpO2/FiO2 ratio may be a good prognostic marker for predicting intubation in COVID-9 patients receiving HFNC.

The aim of this study was to determine whether the late failure of high-flow nasal cannula (HFNC) is associated with mortality in patients with coronavirus disease 2019 (COVID-19). This multicenter study included seven university-affiliated hospitals in the Republic of Korea. We collected the data of patients hospitalized with COVID-19 between 10 February 2020 and 28 February 2021. Failure of HFNC was defined as the need for mechanical ventilation despite HFNC application. According to the time of intubation, HFNC failure was divided into early failure (within 48 h) and late failure (after 48 h). During the study period, 157 patients received HFNC and 133 were eligible. Among them, 70 received mechanical ventilation. The median time from HFNC initiation to intubation of the early failure group was 4.1 h (interquartile range [IQR]: 1.1–13.5 h), and that of the late failure group was 70.9 h (IQR: 54.4–145.4 h). Although the ratio of pulse oximetry/fraction of inspired oxygen (ROX index) within 24 h of HFNC initiation tended to be lower in the early failure group than in the late failure group, the ROX index before two hours of intubation was significantly lower in the late failure group (odds ratio [OR], 5.74 [IQR: 4.58–6.98] vs. 4.80 [IQR: 3.67–5.97], p = 0.040). The late failure of HFNC may be associated with high mortality in COVID-19 patients with acute respiratory failure.

Background Mortality rates associated with sepsis have increased progressively in Korea, but domestic epidemiologic data remain limited. The objective of this study was to investigate the characteristics, management and clinical outcomes of sepsis patients in Korea. Methods This study is a multicenter retrospective cohort study. A total of 64,021 adult patients who visited an emergency department (ED) within one of the 19 participating hospitals during a 1-month period were screened for eligibility. Among these, patients diagnosed with sepsis based on the third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) were included in the study. Results Using the Sepsis-3 criteria, 977 sepsis patients were identified, among which 36.5% presented with septic shock. The respiratory system (61.8%) was the most common site of infection. The pathogen involved was identified in 444 patients (45.5%) and multi-drug resistance (MDR) pathogens were isolated in 171 patients. Empiric antibiotic therapy was appropriate in 68.6% of patients, but the appropriateness was significantly reduced in infections associated with MDR pathogens as compared with non-MDR pathogens (58.8% vs. 76.0%, P

Chronic thromboembolic pulmonary hypertension is potentially curable with a pulmonary endarterectomy. However, approximately 20% of patients have persistent pulmonary hypertension after pulmonary endarterectomy, which is a major risk factor for postoperative death. Here, we report a 34-year-old woman who suffered persistent severe pulmonary hypertension following a successful pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) and atrial septostomy were successfully performed as rescue treatments, and active rehabilitation during ECMO was prescribed to facilitate recovery.

Aims: Although the cases of macrolide-resistant Mycoplasma pneumoniae (MRMP) have been increasing substantially among children, there are very few studies that have focused on MRMP in adults. This ...

Due to rapid advances in our understanding of the molecular pathogenesis of non‐small cell lung cancer (NSCLC), the 2015 World Health Organization (WHO) classification has defined large cell carcinoma (LCC) as a subtype that is lacking glandular or squamous cells, and any neuroendocrine differentiation. Accordingly, LCC is one of the rarest subtypes of NSCLC. LCC usually presents as a large peripheral tumour with prominent necrosis and its specific characteristics are not well known. Here, we report a case of LCC identified during differential diagnosis of diffuse alveolar haemorrhage in a patient with haemoptysis.

Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are a major cause of drug-induced hypersensitivity, called "NSAID hypersensitivity". A confirmative diagnosis is necessary for ensuring drug safety and finding alternative drugs. No reliable test other than direct challenge is diagnostic. An intravenous (IV) aspirin challenge has rarely been tried. Objective To assess the safety and efficacy of the aspirin IV provocation test. Methods A retrospective and descriptive study in a hospital. Clinical data were reviewed in patients who had aspirin IV provocation test with lysine aspirin. Results In 71 patients suspected of having NSAID hypersensitivity, aspirin IV provocation test was performed. Most provocations were performed on the same day. Forty-three (60.6%) showed a positive response to the challenge. The positive reactions were rescued mostly by antihistamines or glucocorticoids and rarely with bronchodilators and epinephrine. Three patients who showed a negative response to the aspirin challenge were shown to have single-NSAID hypersensitivity. For confirmation of NSAID hypersensitivity in these patients, the sensitivity of the IV aspirin provocation test was 93.5%. Conclusions Aspirin IV provocation test with lysine aspirin on the same day is safe and efficacious for diagnosing NSAID hypersensitivity.

Nonsecretory multiple myeloma is a rare variant of multiple myeloma characterized by the proliferation of clonal plasma cells in the bone marrow. It is difficult to establish an early and accurate diagnosis of nonsecretory multiple myeloma because in nonsecretory myeloma cases, monoclonal immunoglobulin cannot be detected in the serum or urine via electrophoresis. In this report, we describe a case of nonsecretory multiple myeloma presenting as recurrent vertebral compression fractures in a 70-year-old male patient and suggest that nonsecretory multiple myeloma can be included in the differential diagnosis of multiple and recurrent vertebral compression fractures, despite the lack of detectable monoclonal immunoglobulin in the serum or urine by electrophoresis.

Coxiella burnetii infects humans and wild and domesticated animals. Although reported cases on Jeju Island, off the coast of South Korea, are rare, the region is considered to have a high potential for Q fever. We investigated the seroprevalence of antibodies to C. burnetii in 230 farmers living in ten rural areas on Jeju Island between January 2015 and December 2019. Blood samples were collected and examined for C. burnetii Phase I/II IgM and IgG antibodies. Trained researchers collected ticks from rural areas. Clone XCP-1 16S ribosomal RNA gene sequencing was performed to identify Coxiella species from the collected ticks. The overall seroprevalence of antibodies to C. burnetii in farmers was 35.7%. The seroprevalence was significantly higher in fruit farmers. Of the collected ticks, 5.4% (19/351) of the Haemaphysalis longicornis ticks harbored C. burnetti. A high seroprevalence of antibodies to C. burnetii was observed in this region of Jeju Island, confirming that C. burnetti is endemic. Physicians should thus consider Q fever in the differential diagnosis of patients that present with acute fever after participating in outdoor activities.

Severe fever with thrombocytopenia syndrome (SFTS) is associated with a high mortality caused by rapidly progressive multiple organ failure. SFTS virus induces immunosuppression, mediated by interleukin-10 production, reduction of CD3+ and CD4+ T cells, and cytokine storms, and this may lead to various complications in critical SFTS patients. Recently, there have been reports of cases of invasive pulmonary Aspergillosis (IPA) in patients with SFTS in the absence of predisposing factors of IPA. However, there is no known relationship between SFTS and mycosis. Here, we report a SFTS patient with a low CD4+ T-cell count and a high viral load, who developed possible IPA in the absence of common risk factors for mycosis. This case adds to the evidence that IPA may occur as a complication of SFTS.

Amniotic fluid embolism (AFE) is a rare but fatal obstetric emergency, which is characterized by a sudden cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation (DIC). We report a case of sudden cardiac arrest due to an amniotic-fluid embolism which was successfully treated with veno-arterial extracorporeal membrane oxygenation (ECMO). A 32-year-old female at 39.1 weeks of gestation was scheduled for induction labor. During labor, a sudden generalized tonic-clonic seizure was developed followed by dyspnea and hypotension. An immediate vaginal delivery was performed, and the baby was healthy. Despite the appropriate cardiopulmonary resuscitation, she became hypoxemic and experienced recurrent cardiovascular collapse. ECMO was applied promptly, and the patient became stable rapidly and was discharged without any complications. ECMO seems to be a proper treatment option for catastrophic amniotic-fluid embolism.

Introduction: The intensive care unit (ICU) admission of patients with hematologic malignancies is gradually increasing. Life-threatening events are common, and acute respiratory distress syndrome (ARDS) is one of the most critical conditions. The aim of this study was to investigate the clinical characteristics and outcomes of ARDS in patients with hematological malignancies admitted to the ICU. Methods: A retrospective study was performed on all patients with ARDS with hematological malignancies in a single tertiary teaching hospital between 2008 and 2015. Data on the treatment of and the outcomes of ARDS were collected to determine the clinical characteristics associated with ICU mortality. Results: During the 8-year study period, among a total of 821 patients with ARDS admitted to the ICU, all 185 patients with hematological malignancies were included in the analysis. Most of the patients (88.1%) had moderate-to-severe ARDS, and the median PaO2/FiO2 ratio was 122 (interquartile range: 88-157). The overall ICU mortality rate was 57.3% (50.0% for mild, 52.0% for moderate, and 67.7% for severe ARDS). After the univariate and the multivariate logistic regressions, the factors independently associated with a higher ICU mortality were severe ARDS (odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.17-5.25), identification of carbapenem-resistant gram-negative bacteria (OR: 6.61; 95% CI: 1.31-33.41), the amount of blood product transfusion (OR: 1.25; 95% CI: 1.13-1.38), and the progressive or refractory disease (OR: 3.01; 95% CI: 1.31-6.91). Mortality was independently lower in patients who received the initial low tidal volume ventilation (OR: 0.37, 95% CI: 0.14-0.96). Conclusion: The outcome of ARDS in patients with hematological malignancies is associated with the severity of the underlying diseases, the presence of multidrug-resistance pathogens, and the amount of transfusion; however, strict application of low tidal volume ventilation may improve the outcome of these patients at the time of diagnosis.

Exogenous lipoid pneumonia is an uncommon medical condition resulting from aspiration or inhalation of oily material. Generally, lipoid pneumonia has nonspecific clinical and radiological presentations, and may be misdiagnosed as bacterial pneumonia or lung cancer. We describe an unusual case of exogenous lipoid pneumonia accompanied by peripheral blood and pulmonary eosino philia. A 63-year-old man was admitted with progressively worsening exertional dyspnea and productive cough for 5 days. A chest radiograph showed abnormalities in the lower lobe of the right lung, and a diagnosis of community-acquired pneumonia was made; intravenous antibiotics were administered. However, dyspnea and hypoxia gradually worsened and peripheral blood eosino philia developed. A bronchoscopy was performed and bronchoalveolar lavage fluid analysis showed markedly increased numbers of eosinophils (40%). Subsequently, a comprehensive review of history revealed that he fell asleep with camellia oil in his mouth for 2 weeks to relieve foreign body sensation of the throat. Sputum and bronchoalveolar lavage fluid cytology showed the presence of lipid-laden macrophages. He was diagnosed with lipoid pneumonia and acute eosinophilic pneumonia. Chest radiograph and symptom were rapidly improved after treatment with intravenous methylprednisolone. (Allergy Asthma Respir Dis 2019;7:57-60)

Propionibacterium acnes is one of the commensals living on the human skin and glands, implicated mainly in acnes, but seldom in deep infection. Pleural empyema is rarely complicated with closed thoracostomy. We experienced 1 case of empyema caused by P. acnes after pleural biopsy and closed thoracostomy through a percutaneous pigtail catheter. A 79-year-old man was admitted for cough, purulent sputum and shortness of breath. Three weeks ago, closed thoracostomy and pleural biopsy were performed to confirm a diagnosis for his recurrent pleural effusion. He had increased amount of right pleural effusion. Through the pigtail cathe ter, pleural effusion was removed. Gram-positive rods were observed in Gram stain, but not cultured. By 16S rRNA analysis, P. acnes was confirmed as the pathogen. His empyema was repeatedly treated with antibiotics, fibrolysis and irrigation. Pleural decortication was recommended. We report the first case of empyema with P. acnes in Korea, possibly complicated with closed thoracostomy pro cedures. (Allergy Asthma Respir Dis 2019;7:61-64)