Radiographic manifestations of pulmonary tuberculosis (TB) in patients with diabetes mellitus (DM) have previously been reported, with inconsistent results. We conducted a study to investigate whether glycemic control has an impact on radiographic manifestations of pulmonary TB. Consecutive patients with culture-positive pulmonary TB who had DM in three tertiary care hospitals from 2005–2010 were selected for review and compared with a similar number without DM. Glycemic control was assessed by glycated haemoglobin A1C (HbA1C). A pre-treatment chest radiograph was read independently by two qualified pulmonologists blinded to patients’ diabetic status. Films with any discordant reading were read by a third reader. 1209 culture positive pulmonary TB patients (581 with DM and 628 without DM) were enrolled. Compared with those without DM, TB patients with DM were significantly more likely to have opacity over lower lung fields, extensive parenchymal lesions, any cavity, multiple cavities and large cavities (>3 cm). The relative risk of lower lung field opacities was 0.80 (95% CI 0.46–1.42) for those with DM with A1C9%; and that of any cavity over no cavity was 0.87 (95% CI 0.46–1.62) for patients with DM with A1C9%, relative to patients without DM. Glycemic control significantly influenced radiographic manifestations of pulmonary TB in patients with DM.

Background: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < –4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. Results: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO₂, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Coronavirus disease-2019 (COVID-19) causes severe pneumonia and acute respiratory distress syndrome. According to the current consensus, immunosuppressants, such as dexamethasone and anti-interleukin-6 receptor monoclonal antibodies, are therapeutic medications in the early stages of infection. However, in critically ill patients, viral, fungal, and bacterial coinfection results in higher mortality. We conducted a single-center, retrospective analysis of 29 mechanically ventilated patients with artificial airways. Patients were adults with confirmed COVID-19 infection and severe pneumonia. Acute respiratory distress syndrome was diagnosed according to the Kigali modification of the Berlin definition. Six patients had invasive pulmonary aspergillosis coinfection based on elevated serum galactomannan levels and/or bronchoalveolar lavage fluid. We present two cases with brief histories and available clinical data. We also conducted a literature review to determine whether immunosuppressants, such as tocilizumab, increase infection risk or invasive aspergillosis in patients with COVID-19. There is no conclusive evidence to suggest that tocilizumab increases coinfection risk. However, further studies are needed to determine the optimal dose, between-dose interval, and timing of tocilizumab administration in patients with COVID-19.

Rationale: Postoperative acute respiratory distress syndrome (ARDS) often results in severe morbidity and mortality in surgical patients. The etiology of this condition is complex, especially in cancer patients. Patient concerns: We encountered a 53-year-old woman with left breast cancer, cT1cN2M0, stage IIIA with left axillary lymph node metastasis. She had received chemotherapy with 4 cycles of doxorubicin plus cyclophosphamide, and 4 cycles of trastuzumab plus docetaxel within a span of 6 months. Subsequently, she underwent left simple mastectomy and axillary lymph node dissection, shortly after which she developed respiratory distress with progressive desaturation and hemoptysis. Diagnosis: ARDS was diagnosed using the Berlin criteria. Her arterial blood gas analysis revealed profound hypoxemia and her chest imaging was suggestive of pulmonary edema. She developed diffuse alveolar hemorrhage (DAH) that was confirmed with bronchoscopy and hemorrhagic samples on bronchoalveolar lavage. Interventions: She was mechanically ventilated with lung protective measures for management of ARDS. In addition to antibiotic cover with amoxicillin sodium-potassium clavulanate for occult infections during her stay in the intensive care unit, we administered epinephrine inhalations, intravenous treatment with tranexamic acid, and methylprednisolone for DAH. Outcomes: Her clinical course improved; she was extubated successfully on day 7 and discharged home on day 11. Lessons subsections: Chemotherapeutic agents may cause pulmonary toxicity through a direct cytotoxic effect or immune-mediated reactions and result in an increased risk of development of ARDS. Furthermore, surgery may trigger a systemic inflammatory response syndrome that can also induce ARDS. In our patient, the development of ARDS was attributed to the combined effects of surgery and chemotherapeutic agents (trastuzumab or docetaxel). When patients undergo major surgery after receiving chemotherapeutic agents, careful consideration is necessary to prevent the development of ARDS.

Background: Serum lactate is a key biomarker of tissue hypoperfusion and metabolic stress in sepsis. Although lactate clearance is widely recognized, many intensive care units record only a peak lactate within 24 h (pLac-24h). The prognostic value of pLac-24h among patients receiving blood purification therapy remains unclear in Asian intensive care settings. Methods: We retrospectively analyzed the 2018–2020 ICU dataset from MacKay Memorial Hospital, Taiwan. Among 16,693 adult ICU admissions, 2506 patients received continuous renal replacement therapy (CRRT) as blood purification for severe sepsis or septic shock. Of these, 1264 (50.4%) had available pLac-24h data, and 27 (1.1%) also required extracorporeal membrane oxygenation (ECMO). The primary outcome was 28-day all-cause mortality. Multivariate logistic regression adjusted for age, sex, APACHE II score, infection source, and CRRT/ECMO use. Discrimination was evaluated by receiver operating characteristic (ROC) curves and decision-curve analysis. This analysis was conducted as a predefined sub-analysis of an institutional ICU database. Results: The mean age of the cohort was 65.7 ± 13.4 years, and 64.8% were male. Median pLac-24h was 5.1 mmol/L (IQR 3.2–8.6). The overall 28-day mortality among CRRT patients was 47.3%. Mortality rose progressively across pLac-24h quartiles (Q1–Q4: 28.9%, 39.4%, 54.7%, and 68.1%; p < 0.001). Each 1 mmol/L increase in pLac-24h independently predicted higher mortality (adjusted OR 1.18, 95% CI 1.10–1.26, p < 0.001). The area under the ROC curve for pLac-24h predicting 28-day mortality was 0.78 (95% CI 0.74–0.82), outperforming the APACHE II score (AUC 0.69, p = 0.02). Conclusions: In critically ill patients with septic shock undergoing CRRT, peak lactate within 24 h was a strong, independent predictor of 28-day mortality. pLac-24h offers a pragmatic, readily available prognostic indicator when serial lactate measurements are unavailable, supporting its integration into bedside risk assessment in real-world Asian ICU practice.