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The emergence of the Alpha variant of novel coronavirus 2019 (SARS-CoV-2) is a concerning issue but their clinical implications have not been investigated fully.We conducted a nested case-control study to compare severity and mortality caused by the Alpha variant (B.1.1.7) with the one caused by the wild type as a control from December 2020 to March 2021, using whole-genome sequencing. 28-day mortality and other clinically important outcomes were evaluated.Infections caused by the Alpha variant were associated with an increase in the use of oxygen (43.4% vs 26.3%. p = 0.017), high flow nasal cannula (21.2% vs 4.0%, p = 0.0007), mechanical ventilation (16.2% vs 6.1%, p = 0.049), ICU care (30.3% vs 14.1%, p = 0.01) and the length of hospital stay (17 vs 10 days, p = 0.031). More patients with the Alpha variant received medications such as dexamethasone. However, the duration of each modality did not differ between the 2 groups. Likewise, there was no difference in 28-day mortality between the 2 groups (12% vs 8%, p = 0.48), even after multiple sensitivity analyses, including propensity score analysis.The Alpha variant was associated with a severe form of COVID-19, compared with the non-Alpha wild type, but might not be associated with higher mortality.

Apart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.c METHODS: We conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors' outcomes with MV durations of14 days and ≤14 days.We included 85 patients with a median age of 69 years (interquartile range, 64-75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5-65] vs. 100 [85-100]), ICU mobility scale (8 [5-9] vs. 10 [10-10]), and functional oral intake scale (3 [1-7] vs. 7 [7-7]) (P 0.0001).Although four-fifths of the patients survived and50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.

Purpose Coronavirus disease 2019 (COVID-19) has placed a great burden on critical care services worldwide. Data regarding critically ill COVID-19 patients and their demand of critical care services outside of initial COVID-19 epicenters are lacking. This study described clinical characteristics and outcomes of critically ill COVID-19 patients and the capacity of a COVID-19-dedicated intensive care unit (ICU) in Kobe, Japan. Methods This retrospective observational study included critically ill COVID-19 patients admitted to a 14-bed COVID-19-dedicated ICU in Kobe between March 3, 2020 and June 21, 2020. Clinical and daily ICU occupancy data were obtained from electrical medical records. The last follow-up day was June 28, 2020. Results Of 32 patients included, the median hospital follow-up period was 27 (interquartile range 19–50) days. The median age was 68 (57–76) years; 23 (72%) were men and 25 (78%) had at least one comorbidity. Nineteen (59%) patients received invasive mechanical ventilation for a median duration of 14 (8–27) days. Until all patients were discharged from the ICU on June 5, 2020, the median daily ICU occupancy was 50% (36–71%). As of June 28, 2020, six (19%) died during hospitalization. Of 26 (81%) survivors, 23 (72%) were discharged from the hospital and three (9%) remained in the hospital. Conclusion During the first months of the outbreak in Kobe, most critically ill patients were men aged ≥ 60 years with at least one comorbidity and on mechanical ventilation; the ICU capacity was not strained, and the case-fatality rate was 19%. Supplementary Information The online version contains supplementary material available at 10.1007/s00540-021-02897-w.

Background Patients with coronavirus disease 2019 (COVID-19) and underlying cardiovascular comorbidities have poor prognoses. Our aim was to identify the impact of serum lactate dehydrogenase (LDH), which is associated with mortality in acute respiratory distress syndrome, on the prognoses of patients with COVID-19 and underlying cardiovascular comorbidities. Methods Among 1518 patients hospitalized with COVID-19 enrolled in the CLAVIS-COVID (Clinical Outcomes of COVID-19 Infection in Hospitalized Patients with Cardiovascular Diseases and/or Risk Factors study), 515 patients with cardiovascular comorbidities were analyzed. Patients were divided into tertiles based on LDH levels at admission [tertile 1 (T1), Graphical abstract Image, graphical abstract

The discussion of neurocritical care management in post-cardiac arrest syndrome (PCAS) has generally focused on target values used for targeted temperature management (TTM). There has been less attention paid to target values for systemic and cerebral parameters to minimize secondary brain damage in PCAS. And the neurologic indications for TTM to produce a favorable neurologic outcome remain to be determined. Critical care management of PCAS patients is fundamental and essential for both cardiologists and general intensivists to improve neurologic outcome, because definitive therapy of PCAS includes both special management of the cause of cardiac arrest, such as coronary intervention to ischemic heart disease, and intensive management of the results of cardiac arrest, such as ventilation strategies to avoid brain ischemia. We reviewed the literature and the latest research about the following issues and propose practical care recommendations. Issues are (1) prediction of TTM candidate on admission, (2) cerebral blood flow and metabolism and target value of them, (3) seizure management using continuous electroencephalography, (4) target value of hemodynamic stabilization and its method, (5) management and analysis of respiration, (6) sedation and its monitoring, (7) shivering control and its monitoring, and (8) glucose management. We hope to establish standards of neurocritical care to optimize brain function and produce a favorable neurologic outcome.

Density stratification is formed in the natural environment such as the lake water system due to the temperature difference of surface water and deep water, leading the damage of lake ecosystem. To dispel the density stratification, several researches in using liquid and gas phase jet to destruct and mix the density stratification was conducted. However, the effect in using gas-liquid two-phase jet to mix the density stratification has not been clarified. In this study, we performed the mixing experiments of density stratification with stained water and salt water. Based on the visualization method and the image processing, the density changing during the experiment was obtained in quantitatively and the dimensionless density distribution was built. Furthermore, the influence of air lift pipe in mixing was investigated. From the density distribution, we classified the result into three kinds of mixed behavior by analyzing the temporal transition of density stratification. Additionally, the mixing pattern with air lift pipe connected with the distance between the nozzle and the entrance of pipe.

Purpose We evaluated whether longer term hemodialysis (HD) is associated with a higher incidence of vasoplegic syndrome (VS) after cardiac surgery. Methods This retrospective, single-center cohort study included 562 consecutive patients who underwent cardiac surgery in a tertiary hospital from January 2015 to December 2016. We assessed VS occurrence and its relationship with HD duration and other risk factors. To assess the effect of the HD duration on VS occurrence, we constructed ordinal variables: HD = 0 (non-HD), 0 180 min were significantly more common in the VS group (P 180 min) were subjected to multivariate regression analysis. Long-term HD was identified as an independent predictor of VS (odds ratio, 2.29, 95% confidence interval, 1.66–3.18). Conclusions Longer term HD may be associated with a higher VS incidence after cardiac surgery. VS should be given attention after cardiac surgery in chronic HD-dependent patients.

Background: The optimal rate of feeding advancement after initiation of early enteral nutrition (EEN) for underweight, critically ill patients is unknown. Methods: We conducted a retrospective chart review in intensive care unit (ICU) patients with a body mass index (BMI) < 20.0 kg/m2. Patients were categorized into Group R, which reached the energy target within 3 days of EEN initiation, and Group S, which reached the energy target 4 or more days after EEN initiation. Results: A total of 65 patients with a median age of 73 years were included in the study. No significant differences were observed between the two groups for all-cause mortality, ICU-free days, or length of hospital stay. Ventilator-free days (VFDs) were significantly fewer in Group R than in Group S (18.0 [0.0 - 22.0] vs. 21.0 [16.3 - 24.8] days; P = 0.046). A significantly higher number of patients requiring mechanical ventilation (MV) at hospital discharge were observed in Group R than in Group S (29% vs. 8%; P = 0.030). Multivariable analyses with adjustment for confounders found that days required to reach target energy intake after EEN initiation were significantly and independently associated with the requirement for MV at hospital discharge, but not with VFDs. Conclusion: A slow rate of feeding advancement after initiation of EEN in critically ill patients having a BMI of

The present study aimed to investigate the relationship between the occurrence of ventilator-associated events (VAE) in the intensive care unit and the timing of rehabilitation intervention. We included subjects who underwent emergency tracheal intubation and received rehabilitation. We performed rehabilitation according to our hospital&rsquo, s protocol. We assessed the mechanical ventilation parameters of inspired oxygen fraction and positive-end expiratory pressure, and a VAE was identified if these parameters stabilized or decreased for &ge, 2 days and then had to be increased for &ge, 2 days. We defined time in hours from tracheal intubation to the first rehabilitation intervention as Timing 1 and that to first sitting on the edge of the bed as Timing 2. Data were analyzed by the t-test and &chi, 2 tests. We finally analyzed 294 subjects. VAE occurred in 9.9% and high mortality at 48.3%. Median values of Timing 1 and Timing 2 in the non-VAE and VAE groups were 30.3 &plusmn, 24.0 and 30.0 &plusmn, 20.7 h, and 125.7 &plusmn, 136.6 and 127.9 &plusmn, 111.4 h, respectively, and the differences were not significant (p = 0.95 and p = 0.93, respectively). We found no significant relationship between the occurrence of VAE leading to high mortality and timing of rehabilitation intervention.

The American Society for Parenteral and Enteral Nutrition recommends hypocaloric feeding for critically ill patients with a BMI of=30.0 kg/m2. However, the cut-off value of obesity in Japan is BMI25.0 kg/m2, due to the higher prevalence of type 2 diabetes mellitus, and cardiovascular risk factors, even at a lower BMI than in Western populations. Thus, the optimal energy intake for critically ill, overweight Asian patients is unknown.A retrospective chart review was conducted in patients with BMI of=25.0 kg/m2 in an emergency intensive care unit (EICU). Patients were categorized into two groups by average daily energy intake during the first week in the EICU, with Group A at50% of requirement and Group B at=50%.A total of 72 patients with a median BMI of 27.5 kg/m2 were included in the study. No significant differences between the groups were observed for all-cause mortality, ICU-free days, or length of hospital stay. The number of ventilator-free days (VFDs) was significantly higher in Group A than Group B (20.0 [15.5-24.5] vs 17.0 [2.0-21.0] days; p=0.042). On multiple adjusted analysis, however, we found that %energy intake/requirement was not independently associated with VFDs (regression coefficient=0.019; 95% confidence interval, -0.115-0.076).Energy intake in the first week in the EICU did not influence clinical outcomes in critically ill, overweight Japanese patients. Confirmation of these results in larger, randomized trials is required.

This meta-analysis compared the effects of non-invasive ventilation (NIV) with invasive mechanical ventilation (InMV) and standard oxygen (O2) therapy on mortality and rate of tracheal intubation in patients presenting acute respiratory failure (ARF). We searched the MEDLINE, EMBASE and Cochrane Central Register of clinical trials databases between 1949 and May 2015 to identify randomized trials of NIV for ARF. We excluded the ARF caused by extubation, cardiogenic pulmonary edema, and COPD. The meta-analysis included 21 studies and 1691 patients, of whom 846 were assigned to NIV and 845 to control (InMV or standard O2 therapy). One hundred ninety-one patients (22.6%) in the NIV group and 261 patients (30.9%) in the control group died before discharge from hospital. The pooled odds ratio (OR) for short-term mortality (in-hospital mortality) was 0.56 (95% CI 0.40–0.78). When comparing NIV with standard O2 therapy, the short-term mortality was 155 (27.4%) versus 204 (36.0%), respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.36–0.85). When comparing NIV with InMV, the short-term mortality was 36 (12.9%) versus 57 (20.5%) patients, respectively. For this comparison, the pooled OR of short-term mortality was 0.56 (95% CI 0.34–0.90). Tracheal intubation was performed in 106 patients (22.7%) in the NIV and in 183 patients (39.4%) in the standard O2 group, representing a pooled OR of 0.37 (95% CI 0.25–0.55). There were publication biases and the quality of the evidence was graded as low. Compared with standard O2 therapy or InMV, NIV lowered both the short-term mortality and the rate of tracheal intubation in patients presenting with ARF.

Summary Background Trial of noninvasive ventilation (NIV) in the emergency department (ED) for heterogeneous acute respiratory failure (ARF) has been optional and its clinical benefit unclear. Methods We conducted a retrospective cohort study comparing between two periods, October 2001–September 2003 and October 2004–September 2006, i.e., before and after adopting an NIV-trial strategy in which NIV was applied in the ED to any noncontraindicated ARF patients needing ventilatory support and was then continued in the intermediate-care-unit. During these two periods, we retrieved cases of ARF treated either invasively or with NIV, and compared the patients' in-hospital mortalities and the length of ICU and intermediate-care-unit stay. Results Compared were 73 (invasive 56, NIV 17) and 125 cases (invasive 31, NIV 94) retrieved from 271 and 415 emergent admissions with proper pulmonary etiologies for mechanical ventilation, respectively. Of their respiratory failures, type (hypercapnic/non-hypercapnic, 0.97 vs. 0.98) and severity (pH 7.23 vs. 7.21 for hypercapnic; PaO 2 /FiO 2 133 vs. 137 for non-hypercapnic) were similar, and the rate of predisposing etiologies was not significantly different. However, excluding those with recurrent aspiration pneumonia for whom NIV was mostly used as "ceiling" treatment, significant reductions in both overall in-hospital mortality (38%–19%, risk ratio 0.51, 95% CI 0.31–0.84), and median length of ICU and intermediate-care-unit stay (12 vs. 5 days, P Conclusions NIV-trial in the ED for all possible patients with ARF of pulmonary etiologies, excluding those with recurrent aspiration pneumonia, may reduce overall in-hospital mortality and ICU stays.

BACKGROUND: We evaluated the efficacy of high-flow nasal cannula (HFNC) therapy, a promising respiratory support method for acute hypoxemic respiratory failure (AHRF). METHODS: We conducted a retrospective single-center cohort study comparing the periods before (June 2010 to May 2012) and after (June 2012 to May 2014) HFNC introduction (pre- and post-HFNC periods). During these periods, we retrieved cases of AHRF treated with any respiratory support (invasive ventilation, noninvasive ventilation [NIV], and HFNC) and compared in-hospital mortality, ICU/intermediate care unit/hospital stay, and need for mechanical ventilation. RESULTS: Eighty-three subjects (65 treated with NIV, and 18 treated with invasive ventilation) and 89 subjects (33 treated with HFNC, 43 treated with NIV, and 13 treated with invasive ventilation) identified from 782 pre-HFNC and 930 post-HFNC records of acute respiratory failure who required emergent admissions to the respiratory care department were analyzed. Overall, the in-hospital mortality rate was similar, although there was a non-significant and slight decrease from 35 to 27% ( P = .26). There was no significant difference among ICU, intermediate care unit ( P = .80), and hospital ( P = .33) stay. In the post-HFNC period, significantly fewer subjects required mechanical ventilation (NIV or invasive ventilation) (100% vs 63%, P < .01). Additionally, there were significantly fewer ventilator days (median [interquartile range] of 5 [2–11] vs 2 [1–5] d, P < .05) and more ventilator-free days (median [interquartile range] of 18 [0–25] vs 26 [20–27] d, P < .01). CONCLUSIONS: HFNC might be an alternative for AHRF subjects with NIV intolerance.

Background The implementation of a protocol has been associated with improvements in the processes of care in clinical settings. Although stress ulcer prophylaxis is recommended for critically ill patients at high risk, there is currently no consensus on its use. Therefore, we herein developed a protocol for stress ulcer prophylaxis, and evaluated therapeutic outcomes in a before-after study. Methods The protocol was developed by considering the effectiveness, disadvantages (including adverse events) and cost of each agent based on previous findings. Patients who were admitted to the 8-bed emergency intensive care unit (ICU) of our hospital for more than 24 h during the year before and after implementation of the study were eligible. Each investigation item was evaluated retrospectively. Results There were 211 and 238 study patients before and after implementation of the protocol, respectively. The baseline characteristics of patients on/during ICU admission were similar in the two groups. The proportion of medicated patients was 79.6 % before and 84.5 % after protocol implementation. Before implementation of the protocol, 4.3 % of patients developed clinically important gastrointestinal bleeding, and this incidence decreased significantly to 0.8 % after its implementation (P = 0.019). The frequency at which medication was discontinued due to adverse events was slightly lower after implementation of the protocol. No significant differences were observed in the costs of stress ulcer prophylactic agents or mortality in the ICU. Conclusions The results of the present study indicated that the development and implementation of a protocol for stress ulcer prophylaxis, for which there are currently no criteria, improved a main outcome, clinically important gastrointestinal bleeding.

We herein report a case of fatal fulminant hepatitis secondary to crizotinib administration. The patient was 54-year-old female with a history of Hepatitis C infection (not current), dermatomyositis and steroid-induced diabetes mellitus. She was diagnosed with advanced lung adenocarcinoma with anaplastic lymphoma kinase rearrangement. We began 400 mg of crizotinib as first-line therapy. No adverse effects were seen until Day 16. On Day 29, she was admitted to hospital with elevated liver enzymes (aspartate aminotransferase 3236 IU/l, alanine aminotransferase 5201 IU/l) and coagulopathy (prothrombin time

A case of a 61-year-old man who developed ipsilateral re-expansion pulmonary edema after pleural drainage for a right pneumothorax is described. The patient’s chest x-ray revealed a totally collapsed right lung. After insertion of a chest drainage tube, he began to produce a moderate amount of serous, yellowish sputum. Despite continuous positive airway pressure support, his dyspnea gradually worsened and his oxygenation could not be maintained; therefore, to improve his hypoxemic state, intubation was necessary. His chest x-ray following chest tube insertion showed ipsilateral diffuse infiltrates. These radiographic and physical findings were consistent with re-expansion pulmonary edema. The present case was complicated by extreme hypotension and tachycardia due to massive fluid loss. His condition gradually improved with invasive mechanical ventilation. Re-expansion pulmonary edema is an uncommon complication of pleural drainage for pneumothorax, and therapy is supportive. In the present case, the exceptional severity of the pulmonary edema, as well as its general concept, is reviewed in accordance with other relevant literature.

Background: Human herpes viruses (HHVs) are important pathogens in acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Rapid and efficient diagnostic tools are needed to detect HHVs in the lung in ALI/ARDS patients. Objectives: This study aimed to evaluate the usefulness of multiplex and real-time polymerase chain reaction (PCR) analysis of bronchoalveolar lavage fluid (BALF) for detecting HHV reactivation in ALI/ARDS patients. Methods: Between August 2008 and July 2012, eighty-seven BALF samples were obtained from ALI/ARDS patients with unknown etiology and analyzed for HHVs. The types of HHVs in the BALF samples were determined using qualitative multiplex PCR followed by quantitative real-time PCR. Results: Multiplex PCR identified herpes simplex virus type 1 (HSV-1) (n = 11), Epstein-Barr virus (EBV) (n = 16), cytomegalovirus (CMV) (n = 21), HHV type 6 (HHV-6) (n = 2), and HHV-7 (n = 1) genomic DNA in 35 (40%) of the BALF samples, including 14 (16%) samples containing 2 or 3 HHV types. CMV and EBV reactivation was rare in immunocompetent patients, whereas reactivation of HSV-1 was predominantly observed in intubated patients regardless of their immune status. Overall, HHVs were almost exclusively found in patients with immunosuppression or endotracheal intubation. Real-time PCR detected 0.95-1.59 × 106 copies of viral DNA/μg human genome DNA, and HSV-1 (n = 4), CMV (n = 9), and HHV-6 (n = 1) were identified as potentially pathogenic agents. Conclusions: The implementation of multiplex and real-time PCR of BALF was feasible in ALI/ARDS patients, which allowed efficient detection and quantification of HHV DNA.

Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications.We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively.Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography.When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB).We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups.There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups.Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

A 34-year-old pregnant woman was diagnosed with pneumonia at another hospital in her 26th week of pregnancy. Antibiotics were administered, but they were not effective. She was then introduced and admitted to our hospital. Lung cancer was suspected from her chest-CT scan on admission. Caesarian section was performed on the day after admission at 33 weeks of gestation. Adenocarcinoma of the lung was diagnosed based on the results of a right-axillary lymph node biopsy performed simultaneously with the caesarian section. On the 8th day after admission, we began to administer gefitinib. We expected positive results from gefitinib, because the patient fitted the optimal profile: female, never smoker, adenocarcinoma histology. Her respiratory condition had worsened dramatically after her caesarian section, so she was given noninvasive positive pressure ventilation from the 13th day after admission. Disseminated intravascular coagulation progressed, and her chest X-ray showed bilateral extensive infiltration. Moreover, tests showed that her tumor was negative for epidermal growth factor recepter mutation, so we judged that gefitinib was not effective for her. Although her performance status was very poor, she and her family strongly desired further chemotherapy. We thus began to administer gemcitabine, but her respiratory condition deteriorated further, and she died on the 17th day after admission. Lung cancer combined with pregnancy is a very rare situation, so we report this case with some references.

We report an autopsied 33 year old pregnant woman with racemose hemangioma of the bronchial arteries. She was first given a diagnosis of racemose hemangioma of the bronchial arteries at age 19 and underwent surgical ligation. Nevertheless, she had to be admitted to the hospital for bronchial artery embolizations every time hemoptysis recurred. In her 21st gestational week, she was admitted to our hospital because of her 9th recurrent massive hemoptysis and dyspnea. Bronchial artery embolizations were repeatedly performed under intubation to ventilate the healthy left lung separately. We succeeded in temporarily stopping the hemoptysis, but her case was complicated by bacterial pneumonia and septic shock. Her baby was born dead on day 11 and she died on day 12. The autopsy revealed abnormal convoluted and dilated arteries branching from the right intercostal and subclavian arteries and intruding into the lung parenchyma through adhesion caused by her previous thoracostomy. The connections of these abnormal arteries with pulmonary arteries and veins, which had been shown by angiography, were confirmed by autopsy. The autopsy findings suggest that temporal surgical procedures with thoracostomy in this condition can induce abnormal neovascularization via pleural adhesion.

A 58-year-old female with systemic lupus erythematosus (SLE) and anti-phospholipid syndrome (APS) was referred and admitted to our hospital because of fever and pancytopenia. She had been taking small dose of prednisolone and azathiprine since 2003 with stable SLE and APS. Two weeks before the admission, she developed fever and common cold-like symptoms and was admitted to a hospital. Antibiotics were ineffective and thrombocytopenia manifested. Under a diagnosis of progressive SLE, bolus methylprednisolone was administrated. However, she became pancytopenic and was transferred to our hospital. A bone marrow aspirate showed the hemophagocytosis and chest CT scanning revealed interstitial pneumonia. Cytomegalovirus (CMV) antigenemia test gave a positive result. A diagnosis of CMV-induced hemophagocytic syndrome (HPS) and CMV pneumonia was made. Gancyclovir resolved the pancytopenia, pneumonia, and fever. There have been only 3 reported cases of CMV-related HPS in collagen disease.

A 72-year-old critically ill and intubated man was transferred to our hospital, because of worsening pneumonia unresponsive to Cefazolin and Meropenem, from the hospital where he had been admitted 8 days before to start maintenance hemodialysis for chronic renal failure but had fever from admission. In a few days his critical condition rapidly subsided with the initiation of Ciprofloxacin and his sputum culture on GVPC medium indicated Legionellosis, which was afterwards identified as L. longbeachae by PCR and DNA-DNA hybridization. After recovery he said that he had been fond of gardening and had been gardening immediately before the initial admission. Moreover, several reports from Australia suggested inhalation of aerosolized potting soil as the route of L. longbeacachae infection; therefore, we examined the soil of his home garden and identified it. Thus, we present this case as the first of L. longbeachae pneumonia in Japan, proved to be infected via inhalation of aerosolized home garden soil.

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.