Yuarn-Jang Lee’s research while affiliated with Taipei Medical University and other places

Patient: Male, 68-year-old Final Diagnosis: Acute respiratory distress syndrome (ARDS) • Klebsiella pneumoniae infection • metapneumovirus infection • myocarditis Symptoms: Fever • shortness of breath Clinical Procedure: — Specialty: Infectious Diseases Objective Rare coexistence of disease or pathology Background Human metapneumovirus (hMPV), classified in the Pneumoviridae family, is primarily known for causing lower respiratory tract infections in children, the elderly, and immunocompromised individuals. However, rare instances have shown that hMPV can also affect other systems, such as the cardiovascular system, leading to conditions like myocarditis. Case Report We describe a 68-year-old man with a medical history of diabetes, hypertension, and liver cirrhosis who presented to the Emergency Department (ED) exhibiting symptoms of fever, cough, and dyspnea. His condition deteriorated rapidly, progressing to septic shock and requiring increased oxygen support, which led to his transfer to the medical intensive care unit (MICU). Diagnostic evaluations, including cardiac echocardiography and coronary angiography (CAG), confirmed the presence of myocarditis while excluding acute myocardial infarction. Despite aggressive interventions, including extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) therapy, the patient’s condition worsened, and he died 3 days after admission. Polymerase chain reaction (PCR) testing of a throat swab confirmed hMPV infection, with Klebsiella pneumoniae simultaneously identified via sputum culture. The bacterial susceptibility report indicated that the bacteria were sensitive to piperacillin/tazobactam, which had been administered since the patient arrived at our ED, which suggests that the bacterial infection alone cannot fully explain the patient’s condition. Conclusions Compared to previously reported cases of hMPV-related myocarditis, this case is the first to demonstrate notably adverse outcomes associated with the concurrent presence of bacterial infection. The rapid progression and poor outcome despite aggressive treatment emphasize the need for early diagnosis and management of such co-infections.

Background Human metapneumovirus (hMPV), classified in the Pneumoviridae family, primarily causes lower respiratory tract infections in children and immunocompromised individuals. However, rare cases have highlighted hMPV infections manifesting beyond the respiratory system, including cardiac impairment. Case presentation We report the case of a 68-year-old man who presented at the emergency room with dyspnea and fever and who rapidly progressed to septic shock with increasing oxygen requirements, necessitating transfer to the medical intensive care unit (MICU). Diagnostic evaluations comprising cardiac echocardiography and coronary angiography were utilized to confirmmyocarditis while ruling out acute myocardial infarction. Despite the implementation of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP)therapy, the patient succumbed to the illness three days after admission to the MICU. Polymerase chain reaction (PCR) of a throat swab confirmed the diagnosis of Metapneumovirus infection, and Klebsiella pneumoniae was concurrently detected through sputum culture. Conclusions Compared to previously reported cases of metapneumovirus-related myocarditis, this case is the first to demonstrate a notably adverse outcome associated with the concurrent presence of bacterial infection.

Background Nontuberculous mycobacteria (NTM), an extremely rare pathogen causing cervicofacial infections, may result in permanent hearing impairment or intracranial complications. Due to the lack of specific manifestations during the initial onset of NTM otomastoiditis, physicians may misdiagnose it as cholesteatoma or other common bacterial infections. Patient concerns A 44-year-old male who complained of left-sided aural fullness, otalgia, and dizziness for 2 months. Diagnosis The initial diagnosis was hypothesized to be cholesteatoma based on a whitish mass with mucoid discharge filling the entire outer ear canal on otoscopy and left-sided mixed hearing loss. However, NTM was identified by microbial culture at the 2-month follow-up after surgery. Interventions The patient underwent a left-sided exploratory tympanotomy. Because NTM otomastoiditis was diagnosed, 3 weeks of starting therapies were administered with azithromycin (500 mg/day, oral administration), cefoxitin (3 g/day, intravenous drip), and amikacin (750 mg/day, intravenous drip). The maintenance therapies were azithromycin (500 mg/day, oral administration) and doxycycline (200 mg/day, oral administration) for 7 months. Outcomes The patient’s clinical condition improved initially after surgery, but the otomastoiditis gradually worsened, combined with subtle meningitis, 2 months after surgery. The external auditory canal became swollen and obstructed, making it difficult to monitor the treatment efficacy through otoscopy. Thus, we used regular vestibular function tests, including static posturography, cervical vestibular evoked myogenic potentials, and video Head Impulse Test, to assess recovery outcomes. After antibiotic treatment, the infectious symptoms subsided significantly, and there was no evidence of infection recurrence 7 months after treatment. Improvements in static posturography and cervical vestibular evoked myogenic potentials were compatible with the clinical manifestations, but video Head Impulse Test showed an unremarkable correlation. Lessons The clinical condition of NTM otomastoiditis may be evaluated using vestibular tests if patients have symptoms of dizziness.

Background: Cavernous sinus thrombosis is a rare and potentially life-threatening condition that can have various causes. Symptoms of this disorder include headache, reduced visual acuity, focal neurological symptoms, seizures, and cranial nerve deficits, depending on the structures involved. Although rare, sensory and motor trigeminal neuropathy can be an initial presentation of cavernous sinus thrombosis. Case presentation: A 67-year-old female presented with trigeminal neuralgia, followed by tinnitus, vertigo, and trismus. Upon arrival at the emergency department, she also exhibited fever, dizziness, and neck stiffness. The patient had received a tooth implant months before experiencing these symptoms. Initial magnetic resonance imaging revealed homogeneously increased T2 signal and contrast enhancement of bilateral temporalis and masseter muscles, indicating denervation changes of the bilateral trigeminal nerves. Imaging features of basal meningitis and cavernous sinus thrombosis were also noted. Lumbar puncture and laboratory tests were performed, and blood culture revealed Streptococcus intermedius. The patient was diagnosed with meningitis and cavernous sinus thrombosis, complicated by trigeminal neuropathy. She was treated with vancomycin and amoxicillin, and her clinical symptoms greatly improved. Follow-up magnetic resonance imaging studies showed regression of the trigeminal denervation signals. Conclusion: This case report highlights a rare presentation of cavernous sinus thrombosis and basal meningitis, where the initial symptom was trigeminal neuropathy. Denervation changes of the bilateral trigeminal nerves were detected in the MRI study. Therefore, clinicians should be aware that trigeminal neuropathy may be the earliest manifestation of cavernous sinus thrombosis. It is crucial to consider secondary causes of this life-threatening disease to ensure prompt diagnosis and management.