OUR MISSION

Protracted Bacterial Bronchitis(PBB) in Adult 12/05/24

It is now known that the bronchi and lungs are usually not completely sterile. It is thought that, like the gut where intestinal bacteria live, bacterial colonies (flora) in the bronchial lungs may form biofilms that are normally in balance with the ciliated cells of the bronchi and the immune cell population. However, if the immune system is weak from birth, if the cilia of the bronchial wall cells are poorly functioning, or if the recovery of the bronchial wall cells is delayed by a cold, the power relationship with the bacterial flora may deteriorate, leading to a chronic state of inflammation.

Adults PBB develop a persistent cough when affected by a preceding respiratory viral infection. The duration of cough illness ranged from 1.4 to 8.5 months (median 3 months), with many lasting more than 8 weeks. Characteristic symptoms are a very expectorant cough, yellow sputum (often despite no detectable pathogens in particular) (the result of neutrophilic airway inflammation and increased sputum lymphocytes) and a sensation of sputum stuck in the throat that is difficult to remove. These symptoms are considered useful for clinical diagnosis.
On the other hand, unlike asthma, wheezing is not present and is not seasonal. Radiological bronchiectasis is not present. It is defined by the absence of other causes of chronic cough such as asthma, COPD or smoking.

The majority of patients were female (as with bronchiectasis and chronic cough, which is associated with gender differences in cough reflex sensitivity) and predominantly middle-aged (late 40s to late 60s).
Some reports suggest that 28% of adult PBBs subsequently had radiological bronchiectasis, suggesting that PBB and bronchiectasis may represent different parts of the same underlying process of endobronchial infection and inflammation.

Persistent and Recurrent Bacterial Bronchitis—A Paradigm Shift in Our Understanding of Chronic Respiratory Disease

Clinical characteristics of protracted bacterial bronchitis in adults

Persistent bacterial bronchitis in adults – a precursor to bronchiectasis?

Upper Airway Cough Syndrome (UACS) 10/13/24

Upper Airway Cough Syndrome (UACS) is a group of chronic coughs with symptoms of the upper airway from the back of the nose to the throat, with abnormal sensations arising from the pharynx, most commonly the sensation of a posterior nasal discharge.
This condition is very common in adults with chronic cough lasting more than eight weeks.

A persistent dry (less expectorant) cough lasting at least eight weeks with a sensation of something stuck in the pharynx, especially the presence of mucus in the pharynx, is considered to be UACS.

UACS was previously known as posterior rhinorrhoea syndrome. However, it is unclear whether the mechanism of the cough is due to discharge of secretions from the nose or sinuses into the pharynx or to direct inflammation/stimulation of cough receptors in the upper respiratory tract. In addition, the sensation referred to as posterior rhinorrhoea may actually be a manifestation of a sensory neuropathic process and may not be related to the rate or volume of nasal discharge. Expert opinion is moving towards the view that many of the features of UACS are part of the general ‘cough hypersensitivity syndrome’, and furthermore, some researchers object to the existence of the disease category UACS itself as a single clinical entity. For these reasons, the post-rhinorrhoeic symptoms associated with chronic cough are now commonly viewed as a condition called UACS, and the fiction that a dripping nose causes a cough is a thing of the past.

While attempts at empiric treatment with antihistamines and hyperemia removers are not futile from a therapeutic point of view, treatment for cough from the lower respiratory tract alone can partly help to reduce upper respiratory tract symptoms.

BMJ Best Practice

Varicella and shingles outbreaks expected to continue. 07/15/24

Chickenpox is prevalent among children. In addition, there have been cases of secondary infection in the home that have spread to adults.

The chickenpox vaccine is essentially a vaccine whose effectiveness wears off over time. Breakthrough infection with chickenpox can occur even after the chickenpox vaccine is administered. It is known that 1.6 out of approximately 1,000 people will contract the real chickenpox virus 1 year after vaccination, 9.0 out of 1,000 people after 5 years, 20.4 out of 1,000 people after 8 years, and 58.2 out of 1,000 people after 9 years, even after two doses of the vaccine.

Human immunity is gradually suppressed as we age. It is well known that immunity to various infectious diseases, especially to the varicella virus, declines with age. Conversely, immunity to infectious diseases is thought to be stimulated by frequent exposure to many sources of infection.

Most people are extremely susceptible to chickenpox breakthrough infection and shingles as a result of losing contact with many viruses, including the varicella virus, for a period of four years or more. In particular, the rate of breakthrough infection among children and students is likely to be much higher than it was in 2007, when the above study was conducted.

(Currently, no additional Varicella vaccination is recommended for children or students; two doses of Singrix ®︎ are recommended for those over 50 years of age.)

Waning of varicella immuniry
Heterogeneity of memory T cells in aging

Rhinovirus/enterovirus, a common cold, seems to be the most common now.　06/22/24

A 2-year-old boy complained of severe abdominal pain. We learned that he had respiratory failure due to pneumonia and was going into shock. He was discharged from the hospital without incident, although he was placed on a ventilator in the intensive care unit. Genetic testing showed that the infection was caused by a single or simultaneous infection with either rhinovirus or enterovirus (both of which are the most common and common cold viruses).

Within the group of viruses called Enteroviruses, there are three well-known non-polio enteroviruses: enterovirus D68 (EV-D68), enterovirus A71 (EV-A71), and coxsackievirus A6 (CV- A6). These cause viremia, especially from gastrointestinal infections; EV-D68 causes additional respiratory illness; EV-A71 and CV-A6 cause hand-foot-and-mouth disease; rhinoviruses, with more than 160 different types, are also very similar to non-polio enteroviruses and are members of the same They are classified as members of the Enterovirus genus group. In particular, rhinoviruses classified as type C are very similar to enterovirus D68 and cause viremia. Rhinoviruses usually increase in the fall and spring, but are basically prevalent all year round.

Most cases of rhinovirus are only a nasal flu, but can cause worsening of wheezing and asthma, otitis media, sinusitis, bronchitis, bronchiolitis, and pneumonia.
This year, since spring, there has been an increase in asthma, otitis media, sinusitis, bronchitis, and pneumonia in both children and adults, which can be attributed to the rhinovirus outbreak. The virus usually invades the intestinal tract, causing gastroenteritis symptoms such as abdominal pain and vomiting, and can also be carried in the bloodstream to cause skin rashes (hand-foot-and-mouth disease, herpangina). Similarly, rhinovirus C, part of the rhinovirus family, not only causes pneumonia, but can also be spread throughout the body in the bloodstream, causing abdominal pain or gastroenteritis as a shock symptom.

US, Europe heighten dengue surveillance as cases surge in Central, South America; WHO launches global dashboard 06/07/24

According to WHO, the number of dengue cases worldwide has increased significantly over the past five years, with more than 7.6 million cases reported so far in 2024, of which 16,000 are severely ill and more than 3,000 have died. WHO warns that many dengue-endemic countries have inadequate surveillance and reporting systems.
To enhance global tracking, WHO has launched a new dashboard. Data are now available for 103 countries. This year, local cases have been reported in all regions except Europe.
In Southeast Asia, Indonesia reported a sharp increase in cases, while Bangladesh, Nepal, and Thailand reported more cases than at the same time in 2023. In the Western Pacific, Malaysia and Vietnam are the most affected. Thirteen countries in Africa continue to be affected, and outbreaks of dengue fever continue to be reported in fragile conflict zones in the Eastern Mediterranean region.
Several factors, including changes in circulating serotypes and climate change, have contributed to the surge in dengue fever, “at least five countries (Bangladesh, India, Myanmar, Nepal, and Thailand) are currently experiencing monsoon seasons, creating favorable conditions for the breeding and survival of the Aedes mosquito,” the WHO noted.

CIDRAP

Report of fatal human case of H5N6 avian influenza 　　　　　06/02/24

A 52-year-old woman from southeast China’s Fujian Province has died after contracting H5N6 avian influenza. This is the 90th case of H5N6 human infection in the past decade.
(The subtype currently infecting mammals in the Americas and spreading to humans in the United States, and the subtype detected in mammals in the country last year, is H5N1.)

According to the Hong Kong Health Protection Center, the woman’s symptoms began on April 13, she was hospitalized on April 20, and died on April 30. Investigation revealed that she had been in contact with poultry in her backyard before she became ill.

The woman was from Quanzhou, the largest city in Fujian Province, with a population of over 8 million.

Highly pathogenic H5N6 is known to circulate among poultry in China and other Asian countries, but so far only China and Laos have reported human cases. Human cases are rare, and most occur in people who come in contact with poultry or poultry rearing environments. Infections are often severe and can lead to death.

China has now reported 90 cases of H5N6 infection since the first human case was reported in 2014. The last case was reported in the country in mid-January.

CIDRAP

Measles is sweeping the globe, and will soon be pouring into Japan.　　02/26/24

The global outbreak of measles (measles) is increasing the risk of extremely serious complications and death.
In the United States, the United Kingdom, and European Union countries, the spread of the disease continues unabated. In the United States, measles cases have been reported in California, Georgia, Missouri, New Jersey, Pennsylvania, Washington, Ohio, Maryland, Minnesota, and Florida. It is believed to be an influx of cases from international travelers.

Measles is so contagious that even a single case is considered an outbreak. One measles patient can infect 12 to 18 people who are not immunized by vaccine or natural infection. In contrast, about 2 persons in the corona. Two doses of measles vaccine protect 97% of children, but because the virus spreads rapidly by airborne (aerosol) transmission, at least 95% of the population must have completed two doses of vaccine to stop the spread.

In the U.S., only 93% of children were vaccinated in 2022-23, and in Japan, only 93% were vaccinated in 2021 and 95% in 2022 for the first phase, and 93% in 2021 and 92% in 2022 for the second phase.

A person who has measles can spread the virus for 9 days, from 4 days before to 4 days after a skin rash develops. An infected person can be contagious up to 2 hours after leaving a room.

When 10,000 children are infected with measles, 2,000 (20%) will be hospitalized, 1,000 (10%) will develop ear infections with possible permanent hearing loss, 500 (5%) will develop pneumonia, and 10-30 (0.1~0.3%) will die. Measles patients are susceptible to secondary bacterial infections such as pneumonia, one of the most common causes of death in measles patients.

Subacute sclerosing panencephalitis, a devastating long-term complication of measles, causes memory loss, irritability, movement disorders, seizures, and blindness, which may occur 6 to 8 years after recovery from measles. Antiepileptic drugs may relieve symptoms but do not cure the disease. Recent studies indicate that this complication is more common than previously thought, occurring in about 1 in 600 (0.16%) young children exposed to measles.

It is predicted that the disease will soon begin to spread domestically in Japan, under the same conditions of declining vaccination coverage during a pandemic and increasing inbound numbers. Children who have not been vaccinated are urged to be vaccinated as soon as possible.

First human influenza A(H5N1) (bird flu) virus infection of the year in Cambodia 02/16/24

Four recent human infections with highly pathogenic avian influenza (H5N1) (bird flu) viruses have been reported in Cambodia. These are the first human infections with the H5N1 virus confirmed in Cambodia in 2024. The four infected patients, three children (one of whom died) and one adult, were all confirmed in late January or early February.

All patients had a recent history of exposure to sick poultry (birds raised as livestock) or dead poultry prior to illness onset.

At this time, there are no indications of human-to-human transmission associated with these four cases of H5N1 virus infection in Cambodia.

The first two patients were epidemiologically unrelated and were admitted to different Cambodian hospitals, but both recovered and were discharged home. Both patients had been exposed to sick birds prior to the onset of symptoms; a 3-year-old child patient’s backyard chickens were found dead around her home, and a 69-year-old patient raised poultry and fighting cocks, three of which tested positive for H5N1.

The third patient died shortly after being transported to a pediatric hospital in the capital; the fourth patient was admitted for observation and treatment; the third and fourth patients were siblings, but lived in different villages.
The fourth patient’s family brought dead poultry to the third patient’s family, and both siblings were exposed.

An investigation is underway to monitor these two close contacts and identify further transmission. The U.S. CDC is working with the Ministry of Health’s Cambodian Department of Communicable Disease Control (C-CDC), the National Institute of Public Health (NIPH) of Cambodia, the Ministry of Agriculture, Forestry and Fisheries, Institut Pasteur du Cambodge (IPC), the World Health Organization (WHO), the United States Agency for International Development (USAID), the Food and Agriculture Organization, and the Wildlife Conservation Society of Cambodia to address these sporadic human infections.

Genetic sequencing of specimens from the first and third patients identified both H5N1 viruses as H5 clade 2.3.2.1c, which has been circulating among birds and poultry in Cambodia for many years. This is different from the H5N1 virus that has circulated widely in poultry in several world regions.
Genetic sequencing of the specimen from the fourth patient is ongoing.

Four of the six human infections with H5N1 viruses in Cambodia during 2023 were fatal; since the first infection was reported in 2003, 64 cases have been reported in Cambodia, including 41 deaths.

Further sporadic human infections are not unexpected in persons with direct or close unprotected exposure to poultry infected with the H5N1 virus in areas where the H5N1 virus is endemic among poultry.

Human metapneumovirus infection 　　02/12/24

Human metapneumoviruses cause upper respiratory tract infections (rhinitis, pharyngitis, sinusitis) to lower respiratory tract infections (bronchitis, bronchiolitis, pneumonia) in all age groups. The majority of cases are presumed to be upper respiratory tract infections, but lower respiratory tract infections are more common in infants and the elderly.
The incubation period is 4 to 6 days, viral load is high 1 to 4 days after fever, and viral excretion continues for 1 to 2 weeks. However, since many patients have mild disease, it is difficult to control the spread of infection by testing, and antigen testing should not be performed blindly on children with mild disease in order to prevent epidemics.
Since there are no antiviral drugs available, treatment is symptomatic and depends on the severity of symptoms, and testing does not change the course of treatment.
In cases of secondary bacterial infections, antibiotics should be used, and in children with bronchial asthma, treatment of the asthma will be necessary.
Lower respiratory tract inflammatory symptoms, such as a fever that lasts about 5 days like the flu and respiratory symptoms like RS virus infection, may occur together.
First infection begins at 6 months of age, 50% at 2 years of age, 75% at 5 years of age, and once by 10 years of age at the latest, but a single infection does not confer lifelong immunity, and re-infection occurs over and over.
Severe cases are more common in infants over 1 year of age, although RS virus is more common in infants under 6 months of age.
Epidemics occur from February to June after the influenza pandemic, often peaking in March and April.

Pneumonia due to Rhinoviruses. 01/24/24

From 2023 to the present, pneumonia has been very common. More and more people with a prolonged cough, whether or not they have a fever, are being found to have pneumonia on x-ray.
The increase is not limited to infants and young children whose immune systems have not yet fully developed, people with weakened immune systems, and the elderly, but all generations. (It is believed that this is due to immune memory against infections that has been reduced because it was not activated during the pandemic period.)
It is estimated that viral and bacterial infections account for 36% and 64% of pneumonia cases, respectively, but often begin with a viral infection and are joined by bacterial infections, and often both viral and bacterial infections are detected.
When pneumonia is found, it is often bacterial in origin and requires treatment with appropriate antibiotics. (However, due to a severe shortage of antibiotics, appropriate treatment is not available at this time.)
The most common causative virus during the past year was actually the most common cold virus, rhinovirus. It is likely that rhinovirus is still the cause of many pneumonia cases. Exacerbations of bronchial asthma, sinusitis, and otitis media, which are assumed to be caused by this virus, continue to be extremely common.
Rhinovirus is a so-called “common cold” with no effective vaccine because of the large number of mutated strains, and it is a life-long recurring illness. Since no test kits exist, clinical diagnosis can only be inferred from clinical symptoms based on published epidemiological information.
For prevention, hand washing and masks are effective.

National Institute of Infectious Diseases Japan, lower respiratory tract infection-derived virus2023~2024
CDC Rhinoviruses

Reference Values for Hypertension in Children – Hypertension in children is clearly abnormal

Infant 120/70
Grade 1-3 130/80
Grade 4-6 135/80
Grade 7-9 (male) 140/85
Grade 7-9 (female) 135/80
Grade 10-12 140/85
If above, there is hypertension

If hematuria or proteinuria is indicated as (+) in your school urinalysis, blood pressure should be measured, and if hypertension is also found,further examination is needed immediately.

Alcohol disinfection alone is not sufficient for adenovirus

Adenovirus is a virus that mainly causes pharyngitis, pharyngoconjunctival fever (pool fever), and gastroenteritis. It is a viral infection that is originally found throughout the year. In the current epidemic, all of these patterns are seen. (Although very rare, it can also cause infectious symptoms in the urinary tract, liver, central nervous system, and heart.)　

There are more than 70 different types of the virus, and it can be contracted many times. The incubation period is 2-14 days when it comes to the throat and 3-10 days when it comes to the gastrointestinal tract.

It is transmitted through the eyes, nose, and mouth via the hands that touch them. Adenovirus is a double-stranded RNA virus without an envelope, so alcohol, synthetic detergents, and chlorhexidine cannot be used to remove it from hands or utensils. Careful hand washing is essential, but if every inch of the hand is not carefully washed, the virus can remain on the fingers even after 10 seconds of hand washing.

80% of urticaria in children is caused by common cold

Urticaria is an itchy, swollen rash that disappears within 24 hours but appears as if it has moved to another location.
　There is also “stimulus-induced urticaria” with a definite cause, but most cases in children are “idiopathic urticaria” with no identifiable cause.
　The cause of “acute idiopathic urticaria,” which resolves within one to four weeks, can be stress or fatigue, but most cases are caused by a cold virus that entered the body before or after the onset of urticaria. Therefore, once the cold is cured spontaneously, the urticaria will also heal on its own.

Timing of EpiPen use – there is no case where it would have been better not to shot

What happens if you accidentally shot someone with an EpiPen when they are not anaphylactic?
(Answer) If you inject a normal person, they will feel hot flashes and heart will pound, but it is only a temporary phenomenon and will return to normal in about 15 minutes. The adrenaline is a type of hormone originally produced in an organ in the human body called the adrenal medulla.

It is impossible to predict the course of anaphylaxis. Injecting adrenaline intramuscularly within 30 minutes reduces the risk of multiple doses of adrenaline, decreases the rate of hospitalization, and reduces biphasic reactions that occur over time. Conversely, delayed administration increases the risk of biphasic reactions. Adrenaline (EpiPen) is a drug that prevents severe reactions, and it is crucial that it be injected intramuscularly before anaphylaxis peaks.

Voice is hoarse, throat and chest tightness, dog-barking cough, persistent strong cough, wheezing cough, difficulty breathing
Repeated vomiting, unbearable abdominal pain
Swelling of the face, skin rash all over the body, unbearable itching, pale lips or fingernails, difficult to feel the pulse, tachycardia, drowsiness, fear, headache, limping, leaking urine or stool
If any one of these is present, EpiPen must be used.

There is no “don’t inject or shouldn’t have injected” situation for EpiPen prescribed.

(Obvious tachycardia per minute: 6 months of age 180, 1-2 years 170, 3-5 years 160, 7-9 years 155, 10-11 years 145, 12-14 years 140, 15-17 years 135, 18 years and older 130)

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