A 30-year-old man was admitted to hospital for the management of massive hemoptysis. He had a long history of childhood cutaneous infections and recurrent pneumonia complicated by empyema, and thoracic and pulmonary abscesses that required prolonged intravenous antibiotics and surgical decortications. His family history was unremarkable. A previous sweat test was negative. Further investigations revealed marked eosinophilia and grossly elevated serum immunoglobulin (Ig) E levels of 2510 IU/L (normal range 0 to 100 IU/L), but normal IgA, IgG and IgM levels, which led to the clinical diagnosis of Job's syndrome. Despite prophylactic oral antibiotics (predominantly ampicillin-based), he suffered from further bouts of severe pneumonia with massive hemoptysis and the subsequent development of a large right upper lobe cavitating abscess that required lobectomy. Interestingly, the abscess culture grew Stenotrophomonas maltophilia, which was successfully treated with sulperazone (cefoperazone and sodium sulbactam).During the current admission 10 years later, he again presented with dyspnea and life-threatening hemoptysis. Multiple scars were noted from previous skin abscesses of the face and limbs, as well as from bilateral thoracotomy incisions. Breath sounds were reduced bilaterally, especially over the right side. A complete blood panel revealed leukocytosis (white blood cell count 16.4×10 9 /L [normal range 4×10 9 /L to 11×10 9 /L]), predominantly neutrophils (85.1%) and eosinophils (9.5%). A chest radiograph showed consolidative changes and cavitations over the right lower zone. Computed tomography revealed multiple pneumatoceles (Figure 1), the largest being 5.5 cm in size, with fluid levels in the right lower lobe. Urgent angiography was performed and two culprit hypertrophic bronchial arteries supplying the right main and right lower lobe bronchi ( Figure 2A) were successfully occluded by microsphere embolization (500 µm to 700 µm) ( Figure 2B), with subsequent resolution of hemoptysis. In addition, percutaneous drainage of the dominant lung abscess was performed. Both sputum and abscess fluid cultures grew Penicillium marneffei, which produces a characteristic soluble red pigment at 30°C (Figure 3). The patient was treated with amphotericin B and the prophylactic antibiotic cefepime. Despite appropriate antifungal and antibiotic therapy, his contralateral lung also rapidly became infected and he finally succumbed to respiratory failure. DisCussionThe term Job's syndrome was coined in 1966 by Davis et al (1), who described a rare condition characterized by recurrent staphylococcal skin infections, sinusitis, otitis media and pulmonary infections. Other clinical manifestations described since then include candida endocarditis, keratitis and corneal perforation, craniofacial and dental abnormalities, and skeletal deformities (2). Pulmonary complications such as recurrent pneumonia, pneumatocele formation and lung abscesses caused by bacterial and fungal infections are also common (3-7) ( Table 1).The mode of inher...

A new interprofessional geriatric medicine curriculum was recently introduced at a large undergraduate Asian medical school. A longitudinal controlled interventional cohort study was conducted to evaluate the effect of the new curriculum on the knowledge and attitudes of medical students. The medical students under the new curriculum formed the intervention cohort, and those under the former curriculum formed the control cohort. To test knowledge, the University of California at Los Angeles (UCLA) geriatrics knowledge test (GKT) was used in Year 2 and the University of Michigan GKT in Year 5. Geriatrics attitudes were evaluated using the UCLA geriatrics attitudes test in Years 2 and 5. Not surprisingly, geriatrics knowledge at the end of Year 5 of medical school was enhanced to a greater degree in the intervention cohort than the control cohort, although improvements in geriatrics attitudes in each cohort were of similar magnitude by the end of Year 5, suggesting that factors other than a formal geriatrics curriculum influenced the improvements in geriatrics attitudes. This article is one of few published on the effectiveness of geriatrics curricular innovations using validated knowledge and attitude outcomes in a longitudinal controlled study design and will be useful to other medical institutions seeking to improve the geriatrics knowledge and attitudes of their students.

Heart failure and frailty are clinical syndromes that present with overlapping phenotypic characteristics. Importantly, their co-presence is associated with increased mortality and morbidity. While mechanical and electrical device therapies for heart failure are vital for select patients with advanced stage disease, the majority of patients and especially those with undiagnosed heart failure would benefit from early disease detection and prompt initiation of guideline-directed medical therapies. In this article, we review the problematic interactions between heart failure and frailty, introduce a focused cardiac screening program for community-living elderly initiated by a mobile communication device app leading to the Undiagnosed heart Failure in frail Older individuals (UFO) study, and discuss how the knowledge of pre-frailty and frailty status could be exploited for the detection of previously undiagnosed heart failure or advanced cardiac disease. The widespread use of mobile devices coupled with increasing availability of novel, effective medical and minimally invasive therapies have incentivized new approaches to heart failure case finding and disease management.