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Background Non‐small cell lung cancer (NSCLC) patients with pre‐existing respiratory diseases have been excluded in clinical trials of immune checkpoint inhibitor (ICI) therapy, and it is unknown whether the same degree of response can be expected as that in patients without pre‐existing respiratory diseases and if they are associated with increased risk for various immune‐related adverse events (irAEs) and ICI pneumonitis. This study aimed to evaluate predictive factors of clinical response, prognostic factors, risk factors of irAEs, and ICI pneumonitis in NSCLC patients with or without pre‐existing respiratory diseases. Methods We conducted a retrospective study of 180 NSCLC patients who received ICI monotherapy of nivolumab, pembrolizumab, or atezolizumab from 1 January 2016 to 31 March 2019. Results A total of 119 patients had pre‐existing respiratory diseases, including 20 with pre‐existing idiopathic interstitial pneumonias (IIPs). A total of 85 patients experienced irAEs, of which ICI pneumonitis was the most frequent adverse event, occurring in 27 patients. Of the three patients who died from irAEs, all from ICI pneumonitis, two had pulmonary emphysema and one had pre‐existing IIP. In multivariate analyses, irAEs were associated with objective response rate (ORR) and favorable OS, and IIPs were associated with increased risk for ICI pneumonitis. However, IIPs were not associated with low ORR or poor OS. Conclusions Pre‐existing IIPs were a risk factor for ICI pneumonitis. However, this study showed that ICI therapy can be offered to patients with pre‐existing respiratory diseases with the expectation of the same degree of response as that in patients without pre‐existing respiratory diseases. Key points Significant findings of the study: Pre‐existing IIPs were a risk factor for ICI pneumonitis, but objective response rate and prognosis of patients with IIPs were similar to those of other patients. What this study adds: In patients with pre‐existing IIPs, ICI pneumonitis should be noted. However, ICI therapy can be offered to patients with pre‐existing respiratory diseases with the expectation of the same degree of response as that in patients without pre‐existing respiratory diseases, Pre‐existing IIPs were a risk factor for ICI pneumonitis. Objective response rate and prognosis of patients with IIPs were similar to those of other patients.

We retrospectively analyzed the severity, the mortality and the initial antimicrobial therapy in 195 patients with Streptococcus pneumoniae pneumonia (SPP). Of these, 59 (30.3%) patients had mixed pneumonia. In patients with mixed SPP, the three most frequent pathogens were influenza virus (27 patients), Haemophilus infuluenzae (14 patients), and Mycoplasma pneumoniae (8 patients). Of these, 21 (35.5%) patients were classified as severe or very severe according to the Japanese Respiratory Society diagnostic criteria among 59 patients of mixed SPP. Severe and very severe pneumonia was significantly associated with mixed infections (P = 0.018). The initial antimicrobial therapy was classified as beta-Lactam alone (113 patients), combination therapy including a beta-Lactam (72 patients), and a fluoroquinolone alone (10 patients). If we limit out study to mild-moderate pneumonia, initial combination therapy was significantly effective in patients with mixed SPP. Even in pneumonia caused by Streptococcus pneumoniae, further efforts to identify etiology are necessary.

A 62-year-old woman with rheumatoid arthritis was given 4 mg/body methotrexate (MTX) every week and 5 mg prednisolone every day. She developed a severe cough starting in the evening after starting taking MTX and after a fever of 38 degrees and dyspnea appeared the patient was hospitalized. On admission, chest CT findings showed diffuse ground glass attenuation. Pathological findings of specimens obtained by transbronchial lung biopsy showed alveolitis with epithelioid cell granuloma. As a section of the specimen did not show cyst staining by Grocott stain, MTX-induced pneumonitis was diagnosed. The same day, methylprednisolone pulse therapy was started and trimethoprim-sulfamethoxazole (TMP-SMX) was given simultaneously, while MTX was discontinued. On hospital day 3, subsequent data showed a high serum level of beta-D glucan and a positive PCR result for Pneumocystis jiroveci in bronchoalveolar lavage fluid (BALF). Additional section of the specimen showed eosinophilic foamy areas on HE staining and cysts measuring 8 microm, consistent with the Pneumocystis jiroveci lesions by Grocott stain. We present a case of rheumatoid arthritis complicated by methotrexate-induced pneumonitis in which pneumocystis pneumonia was demonstrated by clinical and pathological findings.

The aim of this study was to determine the etiology and outcome of community-acquired pneumonia (CAP) in relation to age and severity in hospitalized patients. Overall, 652 consecutive patients with CAP were studied retrospectively during a 4-year period from 2002. Severity of pneumonia was classified according to the guidelines of the Japanese Respiratory Society (JRS 2005) and American Thoracic Society (ATS 2001). The etiology was identified in 401 of 652 (61.5%) cases. The four most frequent pathogens were Streptococcus pneumoniae (26.2%), influenza virus (12.4%), Mycoplasma pneumoniae (10.9%), and Haemophilus influenzae (5.9%). The most common pathogen in the younger (15-44 years) group and very severe patients (JRS) was Mycoplasma pneumoniae (38.4%) and influenza virus (28.6%), respectively. The three most frequent pathogens in severe CAP patients (ATS) were Streptococcus pneumoniae (29.0%), influenza virus (17.4%), and Legionella species (13.0%). The overall mortality was 6.4%. The mortality of CAP patients among aged 1544, 45-64, 65-74, and 75 years or older was 1.4%, 3.3%, 6.9% and 9.3%, respectively. The mortality of mild, moderate, severe, and very severe patients (RS) was 0%, 4.1%, 15.5%, and 53.6%, respectively. The mortality of non-severe and severe patients (ATS) was 1.8% and 23.9%, respectively. Age and severity had influence on the prevalence of the main microbial pathogens. Streptococcus pneumoniae remained the most important pathogen that needs consideration in initial antibiotic therapy in patients with CAP of all ages and severities. Pathogens identified in patients with severe CAP in Japan were similar to those of Western countries, except for the high incidence of the influenza virus.