Anti-phospholipid antibodies (aPLs) are a heterogeneous group of autoantibodies that are frequently found in the plasma of patients with systemic lupus erythematosus (SLE). Although the presence of aPLs is associated with arterial and/or venous thrombotic complications in SLE patients, the mechanisms leading to thrombus formation remain unclear. We previously showed that aPLs induced monocyte tissue factor (TF) expression and the production of inflammatory cytokines such as TNF-α from monocytes. These thrombus-forming effects are considered to be exerted by the binding of aPLs to the surface of peripheral blood cells such as monocytes; however, the receptors recognized by aPLs have not yet been clarified. We confirmed by flow cytometric analysis that the expression of monocyte surface CD14 decreased when monocytes were stimulated with aPLs. Therefore, assuming that CD14 is a receptor that recognizes aPLs, we stimulated healthy human peripheral blood mononuclear cells with IgG-aPLs and analyzed the expression level of CD14 on the monocyte surface. Results showed that the expression level of CD14 on the monocyte surface was significantly reduced in only one case. Furthermore, it was revealed that the expression of TF on the surface of monocytes was suppressed by the treatment of monocytes with a monoclonal anti-CD14 antibody before stimulation. These results suggest that a signal by aPLs was transmitted via CD14 and may induce various inflammatory reactions such as TF expression on monocytes.

Purpose: Carotid plaque ulceration is considered to be one of the risk factors for cerebral infarction. Carotid plaque ulcerations are detected in many asymptomatic patients in daily medical practice. The purpose of this study is to investigate the relationship between asymptomatic carotid plaque ulceration and the subsequent neurological outcome. Methods: The study population included 87 patients with carotid plaque ulceration at the initial carotid ultrasonography test. These patients were assigned to the ulceration group. This group was matched with 87 patients, drawn from 1,526 eligible patients without carotid plaque ulceration, by the propensity score method in terms of age, gender, mean intima-media thickness, max intima-media thickness, hypertension, diabetes, dyslipidemia, and administration of antiplatelet agents, eicosapentaenoic acid, and statins. These 87 patients were designated as the non-ulceration group. We retrospectively investigated the subsequent development of neurologic symptoms in the two groups. Results: During the follow-up period, only two patients in the ulceration group developed neurologic symptoms caused by transient ischemic attack. On the other hand, in the non-ulceration group, none developed neurologic symptoms. Moreover, no statistically significant differences were found between these groups. Conclusion: Carotid plaque ulceration in asymptomatic patients was not significantly associated with the subsequent development of neurologic symptoms.

Background: Transmembrane domain containing 3 gene (Tm2d3) has been implicated in Notch signaling and development of Alzheimer disease. To investigate the functions of Tm2d3, we analyzed a knockout mouse strain with an exon of Tm2d3 deleted using the Clustered Regulatory Interspaced Short Palindromic Repeats (CRISPR)-CRISPR-associated (Cas) 9 method. We analyzed the timeline in which the Tm2d3 knockout mice can be obtained. Methods and results: To obtain mice with knocked out Tm2d3, which is an autosomal gene, we crossed pairs of heterozygotes and analyzed the genotypes of the offspring mice by the PCR method. The genotypes of the obtained mice were only the wild type and heterozygotes, and there were no Tm2d3 knockout mice. Next, the pregnant mice obtained by the same mating method were cesarean sectioned over time to examine the fetal genotypes. Tm2d3 knockout mice were present at a rate of about 1/4 until embryonic days 9.5 to 16.5. Conclusion: Results suggest that the Tm2d3 knockout allele was a recessive lethal gene.

[Aims] There are many measurement conditions for muscle strength evaluation using surface electromyogram (EMG) and it is relatively difficult to measure muscle strength stably depending on the settings. We have reported that a specific assessment is possible using the discharge-load index (DLI) that we devised. In this study, we confirmed the characteristics and accuracy of DLI and verified whether it could be applied to the evaluation of individual muscle strength exertion ability. [Methods] The DLI of rectus femoris muscle (RF) was measured in 27 healthy volunteers. EMG was carried out in each subject with a load of 1–3 kg. The changes in the volume of muscle discharge were evaluated as the rate of increase in muscle discharge. Before the experiment, the circumferences of the thigh and RF were measured. In addition, the exercise history and exercise habits of the subjects were investigated. [Results] There were no significant differences in DLI between the right and left sides and genders. DLI was not significantly correlated with the circumference of the thigh, but was significantly negatively correlated with that of RF. When results were classified by exercise history and exercise habits, past exercise history did not affect DLI, but DLIs were significantly lower in the group with current exercise habits. All subjects showed no significant changes in DLI with age. However, in the group without exercise habits, DLI increased with aging. On the other hand, the group with exercise habits had a low DLI even in old age. [Conclusions] DLI may be used to assess the ability of each individual to exert strength.

Alcohol dependence is an addiction that causes psychological and physical dependence and makes it difficult for those affected to control their intake of alcohol. The μ (mu), δ (delta) and κ (kappa) opioid receptors are thought to be associated with the development of alcohol dependence. Research has shown that μ opioid receptor knockout mice exhibit reduced alcohol consumption and reduced preference for alcohol. In this study, we confirmed whether mu opioid receptor (OPRM1) polymorphisms (IVS2+691C/G, −172G/T and −1748G/A) indeed have an effect on alcohol dependence formation in 64 patients, with 73 healthy people used as a control group. We compared the genotype, allele, carrier (minor allele carriers versus major allele homozygous carriers) and haplotype frequencies between these groups. In addition, the 1510A allele of acetaldehyde dehydrogenase 2 (ALDH2) polymorphism (1510G/A) causes poor metabolism of acetaldehyde, a major metabolite of alcohol. We also focused on ALDH2 1510G/G (ALDH2 *1/*1) carriers in the subjects. Three OPRM1 and one ALDH2 genotypes were determined by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. No significant differences were found in the frequency of OPRM1 polymorphisms between those suffering from alcohol dependence and the control group. We concluded that the three OPRM1 polymorphisms (IVS2+691C/G, −172G/T and −1748G/A) were not likely to be risk factors for alcohol dependence in a Japanese population. This report is the first in a Japanese population. Nevertheless, further analysis of the opioid receptor gene in a large sample size is required.

Recently, it has been reported that the ratio of carbohydrate deficiency transferrin (%CDT) present in transferrin is useful as a marker of alcohol consumpstion. In general, Japanese people tend to drink less alcohol than Westerners. Therefore, it is necessary to examine the cutoff value, but there are few reports on this issue. We examined the Japanese cut-off value of %CDT in the detection of daily drinking habits in the medical examination business. The subjects were 234 patients who visited our medical examination center in February 2018. The questionnaire was used to classify 74 patients into the nondrinking group, 80 patients into the occasionally drinking group, and 80 patients into the daily drinking group. As a result of the examination, we found that the cut-off value for identifying a habitual drinker, that is, one who drinks daily, was 1.96%, the sensitivity was 18.8%, and the specificity was 95.0%.

There are two methods of urine qualitative analysis using urine test strips: visual judgement and instrumental judgement based on the results of an automatic urine analyzer. The analyzer has an additional function for judging abnormal coloration at the same time as judging concentration. In the measurement of urinary glucose concentration using the fully automated urine analyzer US-3500, we encountered multiple specimens in which flags indicating abnormal coloration were displayed but no abnormal coloration was observed by visual judgement. In this study, we investigated the cause of this discordance between visual and instrumental judgements. Because no abnormality was found in the comparison between the urinary glucose concentrations measured using the analyzer and urinary glucose quantitative values or in the measurements using multiple types of lot test strips, doubts were cast on the accuracy of the identification criteria for abnormal coloration of urinary glucose in the US-3500. We therefore asked the manufacturer to investigate it. In a plot created by applying the index calculated from the reflectance obtained from the measurement to the identification criteria for abnormal coloration, there were multiple specimens that were distributed near the identification line, indicating that the setting was such that flags for abnormal coloration were likely to be generated. This investigation led to the improvement of the US-3500’s instrumental parameters by the manufacturer. After changing the parameters, the number of specimens misjudged as abnormal coloration has been significantly reduced, and more accurate results of instrumental judgement are now available.

In recent years, medical staff members have worked on task shifting and task sharing at each facility to lighten the burden imposed on doctors and nurses. In our hospital, clinical laboratory technologists have conducted uniform management and primary readings of capsule endoscopy as one of the ways of task shifting and sharing since 2013. Now, we aim to cut back the burden of instructors of capsule endoscopy and to promptly provide reports and accurate examination. Capsule endoscopy is better than the old method because we can observe every part of the small intestines with patients experiencing minimum suffering. However, because of its characteristics, we cannot deny that sometimes we cannot observe all parts of the small intestines and that it takes more time to examine abnormal tissues than normal tissues. The latter is especially a heavy burden for doctors. We found the solution to these problems, and by trial and error, we were able to develop the method that we are currently using. We have encountered various cases after introducing the first interpretation. Among them, we will present symbolic cases that we could intervene in early treatment by immediate cooperation among doctors, clinical laboratory technologists, and instructors of capsule endoscopy. In addition, we will report on the clinical laboratory technologists’ efforts towards task shifting and task sharing on capsule endoscopy in our hospital.

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is an attractive alternative to the radioimmunoassay (RIA) method; however, discordance between non-RIA and RIA measurement results has been reported. Here, we aimed to evaluate the performance of the chemiluminescence enzyme immunoassay (CLEIA) for aldosterone (FUJIREBIO Inc.) detection. The correlation of the conventional method (x) and CLEIA (y) for aldosterone was y = 1.46x + 53.63, r = 0.976. No significant difference was observed between the CLEIA results and the LC-MS/MS results. However, when the RIA results were compared with the CLEIA and LC-MS/MS results, significantly larger differences were observed. Our results revealed that CLEIA showed a good correlation with LC-MS/MS and thus the basic performance of the “Lumipulse aldosterone” reagent was considered to be sufficient.

For the effective isolation of SARS-CoV-2 and early treatment of coronavirus disease 2019 (COVID-19), diagnostic methods with improved operating efficiency, flexibility, and the fastest time-to-results with the highest throughput are required. The HISCL^TM SARS-CoV-2 antigen test to screen for SARS-CoV-2-infected persons has been carried out in our hospital. However, the evaluation of data showed some discrepancies in results between the antigen test and the RT-qPCR test. In this study, we evaluated the results of the SARS-CoV-2 antigen test performed in Nagoya University Hospital and validated the cutoff index (C.O.I.) using the obtained measurement data. The optimal C.O.I. was determined using a receiver operating characteristic (ROC) curve. From April 6 to January 31, there were 6,646 routine antigen tests processed, with 71 positive results (1.0 to 47,318.6 C.O.I.). In these tests, 48 patients were diagnosed as having COVID-19, and the rate of positivity concordance between the antigen and RT-qPCR tests was 67.6%. The area under the curve (AUC) was 0.93 and the optimal C.O.I. was 3.95, where the corresponding sensitivity and specificity were 85.4% and 91.3%, respectively. These results suggest that SARS-CoV-2 screening with a positive C.O.I. of 4.0 makes it possible to provide the highest sensitivity while maintaining high specificity with high throughput.

We evaluated the clinical performance of an immunochromatographic antibody test (ICT), namely, a colloidal gold immunochromatography test “NOZOMI^®” for the IgG antibody against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) S protein. We examined 142 serum specimens collected from 92 patients with COVID-19 and also 50 serum specimens collected from febrile non-COVID-19 patients. Additionally, 50 medical staff members who had completed two doses of SARS-CoV-2 vaccines were also included in this study. The sensitivity, specificity, and accuracy for IgG for the S protein were 51.1% (47/92), 96.0% (48/50), and 80.8%, respectively. Among the 50 non-COVID-19 serum specimens, two generated a false-positive result in this ICT “NOZOMI^®”. However, IgG for the S protein was satisfactorily detected in 100.0% (17/17) of specimens collected > 22 days after symptom onset. In case of medical staff members, the IgG-S antibody was quantitatively evaluated using the Elecsys^® Anti-SARS-CoV-2 S RUO antibody test, and the serum specimens determined to have an antibody titer of 500 U/mL or higher also showed a positive result in the ICT test “NOZOMI^®”. Our preliminary data suggest that ICT has potential use in the implementation of the COVID-19 immunity passport.

Immunostaining aids in pathological diagnosis and selection of therapeutic agents. The Chubu Branch of Japanese Association of Medical Technologists conducts an annual immunostaining survey with the aim improving techniques of histopathological analysis. Unstained specimens labeled with cultured cell lines expressing the p53 protein were distributed to 71 participating institutions, and the specimens and process questionnaires were collected after immunostaining was performed. Members of a committee for evaluating Ishikawa cell immunostaining visually assessed the specimens: staining scores of 4.0–3.7 points were optimal, those of 3.6–3.4 points were good, those of 3.3–3.1 points were acceptable, and those of points below 3.0 indicated that more effort was required. Optimal or good scores were judged as not interfering with diagnosis. Of the 71 participating centers, 59 (83%) had optimal or good staining techniques and no diagnostic problems, whereas four centers required immediate improvement. Only 41 laboratories (62%) followed the recommended staining process, which suggests that the results may be affected by the combination of manufacturers of primary antibodies with various types of automated staining equipment and detection systems. Clones of primary antibodies, management methods, models of automated staining equipment, and differences in detection systems at each institution affect immunostaining results, and it is difficult to eliminate interinstitutional differences even if techniques and processes are standardized. However, we believe that quality assurance and standardization of immunostaining will be realized if these surveys are conducted regularly, the results of facilities are reviewed, the current situation is understood, and the results are examined and improved.

Although many hospitals in Japan outsource microbiological testing, there is a possibility that test results are not fully utilized in facilities without infectious disease specialists or microbiology technicians. We conducted a questionnaire survey on facilities outsourcing microbiological testing via e-mail in the Kyushu–Okinawa and Kinki regions from April to September 2021. We received responses from 77 facilities in eight prefectures in the Kyushu–Okinawa region and 51 facilities in six prefectures in the Kinki region. Eighty-three percent of the facilities had less than 200 beds, 16% had 200–499 beds, and 1% had more than 900 beds. The percentages of the facilities that obtained additional reimbursement for infection prevention 1 and 2 were 15% and 67%, respectively, and 18% did not obtain additional reimbursement. In about 60% of the facilities，there was no or almost no periodic review of the outsourcing contract, indicating that the contract was not reviewed once it was signed. Quality control of specimens was conducted in only 30% of hospitals and outsourcing companies. About 50% of the facilities did not mention quality control in their reports, and about 50% of the facilities made comprehensive comments or some comments on drug-resistant bacteria. About 30% of the facilities agreed not to perform susceptibility testing for normal bacterial flora, and many facilities left it to the outsourcing company. Through this questionnaire, we could see the problems and difficult issues encountered in both the outsourcing companies and requesting hospitals. In the future, it will be necessary to review and supervise outsourcing contracts by utilizing the regional collaboration system on infectious diseases.

The purpose of this study was to evaluate the effectiveness of the intrahospital referral collaboration system for hepatitis-virus-positive patients to hepatology specialists. The following intrahospital collaboration (laboratory department alert system) was conducted from November 2017 to June 2020. (1) Medical technologists: When a blood test reveals positivity for the HB antigen (HBsAg) or HCV antibodies (HCVAbs), medical technologists indicate an alert in the electronic medical record recommending intrahospital referral to the gastroenterology department. (2) Physicians: After confirming the alert, the physician in charge explains the result to the patient and refer the patient to gastroenterology. In July 2020, we conducted an automatic alert system that allows physicians to recognize a recommendation for referral to gastroenterology when the electronic medical record of an HBsAg- or HCVAb-positive patient is opened. The intrahospital referral rates before collaboration, after the implementation of the laboratory department alert system, and after that of the automatic alert system were 6.0%, 28.8%, and 39.5% for HBsAg-positive patients and 8.6%, 30.7%, and 28.6% for HCVAb-positive patients, respectively. The number of intrahospital referrals increased after collaboration compared with before collaboration. The intrahospital referral rates and the number of referrals increased through the intrahospital referral collaboration, and the hepatitis-virus-positive patients were efficiently referred to gastroenterology.

Medical devices can be commercialized only after being evaluated in clinical practice; therefore, there is a need for medical–industrial collaboration that involves medical professionals from the earliest stages of development. Products that have been commercialized through such collaboration include nursing supplies, diagnostic equipment, and treatment equipment, but the number of products that clinical laboratory technicians have helped to commercialize is small compared with other medical professions. Our hospital offers a human resources development course in medical device development and conducts support projects with the aim of developing products that meet medical needs. Recently, I have participated as a clinical laboratory technician in the Unsui Course, which teaches the medical device development process, from identifying medical needs to product planning and proposals, taking on the challenge of developing products in collaboration with members of various professions. Although this was a short-term course, participants carried out in many activities, including identifying issues and medical needs at a pathological examination site, considering those issues and needs, formulating solutions, and implementing those solutions. Product development was not easy, and it took time and effort for all team members to understand the testing work and medical needs. However, I discovered the joy of turning product ideas into reality. Participating in this course was a valuable experience that allowed me to reaffirm the importance of being involved in product development as a medical professional, understand the value of medical supplies and inspection equipment used in daily work, and appreciate the significance and issues of daily inspection work.

We conducted a questionnaire survey on the task shift/share from pathologists to medical technicians regarding the law that will come into effect in 2024. Pathological diagnosis is considered as the final basis for treatment, so careful measures are required. However, the task shift/share from pathologists to medical technicians makes much sense to solve the chronic shortage of Japanese pathologists. According to the responses to the questionnaire, in 54% of the facilities (575/1,058 pts), many medical technicians did not know about task shifting. In 67% (498/745 pts) of the facilities, medical technicians answered that they were ready to relocate their tissue slicing work or were in the process of relocating at the facility. It was found that the induction of the image analysis system and that of the whole slide image device did not spread in Japan. We found that making the draft of the pathological diagnosis report is impossible in 73% (635/869 pts) of the facilities. Autopsy is performed by a pathologist in 59% (599/1,018 pts) of the facilities, and in 73% (517/706 pts), it is not performed when a pathologist is absent. Prior to the enforcement of the law, I would like you to communicate with doctors and review the pathological examination work.

We examined the possible use of anti-SARS-CoV-2 antibody reagents for identifying previously infected persons. The reagents were Elecsys Anti-SARS-CoV-2 RUO (Roche Diagnostics K.K. (C)), ARCHITECT SARS-CoV-2 IgG (Abbott Japan LLC (A-G)), and SARS-CoV-2 IgM (Abbott Japan LLC (A-M)). Conservative samples from 16 SARS-CoV-2-positive patients and nine SARS-CoV-2-negative patients determined by the SARS-CoV-2PCR test conducted from February to October 2020 were used in the reagent examination. As a result, 13 of the 16 patients who were SARS-CoV-2-positive by the PCR test were confirmed to be positive (sensitivity 81.3%) using C, and 14 patients were confirmed to be SARS-CoV-2-positive (sensitivity 87.5%) using A-G and A-M. On the other hand, in the nine patients that were SARS-CoV-2-negative by the PCR test, all three reagents gave a negative result (specificity 100%). C/A-G is an antibody to the nucleocapsid protein and can detect IgG. A-M is an antibody to the spike protein and can detect IgM. Because the number of cases was limited, results showed no significant difference in the type of protein of interest and IgG/IgM, and the patients who were not found SARS-CoV-2-positive by the PCR test were confirmed to be so using all three reagents. Since C/A-G is detected even long after infection, it can possibly be used for the determination of past infection. A-M needs to be examined for the effect of the vaccine.

Molecular targeted therapy and cancer genomic medicine have been promoted in Japan, and the numbers of orders of genetic tests and companion diagnostics and completed tests have increased significantly. The sample requirements differ among these tests, and medical technologists’ workload has been increasing. Improved work efficiency and standardization are thus necessary. We report the current status of genetic tests and efforts to improve the related work efficiency at our hospital. We investigated the status of genetic tests at the hospital over the period from 2016 to 2020. As a result, we found that the number of orders increased by approximately 2.5-fold, and the number of genetic tests examined in one year increased by approximately twofold. To improve work efficiency and standardization, we created three types of check sheet (for companion diagnostics, genetic tests for lung cancer, and cancer multigene panel tests) and have been using them while revising them as the need arises. Their main features are descriptions of (1) sample information and confirmation contents, (2) the priority of multiple orders, (3) the application form required for ordering genetic tests and requirements for sample submission, and (4) sample suitability for pathologists and the number of unstained slides. The check sheets have helped staff share information, improve work efficiency, and standardize work. Medical technologists play an important role in genetic tests from the pre-analysis stage. The processes from receiving orders to submitting samples and information management are also important. Our analyses revealed that the use of check sheets has been very effective for improving our hospital’s genetic tests and companion-diagnostics-related work efficiency.

We encountered a case of bloodstream disease caused by Trueperella bernardiae, which is the second case in Japan. The patient was a woman in her 80s, with a medical history of dementia, disuse syndrome after cerebral infarction, and aspiration pneumonia. She was admitted to our hospital with fever, respiratory failure, and impaired consciousness, and she was diagnosed as having left obstructive pyelonephritis and associated septic shock. On the same day, a transurethral stent was placed, and a renal pelvis sample and two sets of blood culture samples were collected. Proteus mirabilis, methicillin-resistant Staphylococcus aureus, and coryneform gram-positive rods were detected in the renal pelvis sample. In the blood culture, coryneform gram-positive rods were detected in three of four cell cultures on the 5th day of culture, and the catalase test was negative for such coryneform gram-positive rods. Therefore, VITEK MS was performed and the blood culture was identified as T. bernardiae. Later, a detailed examination of the coryneform gram-positive bacillus derived from the renal pelvis sample revealed that it was catalase-negative and had biochemical properties consistent with those of the blood-derived strain, suggesting the bloodstream with the urinary tract as the invasion route of T. bernardiae. Whenever coryneform gram-positive bacillar cells are detected in a severe infectious disease or sterile material, it is important to perform a catalase test, keeping this bacterium in mind. The patient received tazobactam/piperacillin from the 1st day of illness and was discharged from the hospital on the 26th day of illness.

The standard therapy of autoimmune hemolytic anemia is by steroid administration, and blood transfusion is generally avoided but may be administered in cases of life-threatening anemia. We report here a case of severe autoimmune hemolytic anemia that was refractory to steroids and even blood transfusion but recovered by plasma exchange. In this case, we performed plasma exchange to eliminate autoimmune antibodies. After plasma exchange resulted in a rapid and good therapeutic response, we administered rituximab to suppress CD20-positive B cells and maintain the response. Although there is no established evidence yet for the effectiveness of plasma exchange, it seemed to be a good therapeutic option to obtain a rapid and successful effect against severe refractory hemolytic anemia as in our patient.

A 3-year-old male visited our hospital owing to fever and passing red urine in December 20XX. Initial blood tests showed a hemoglobin level of 9.0 g/dL, a reticulocyte count of 1.6%, a lactate dehydrogenase level of 850 U/L, and a haptoglobin level of less than 2 mg/dL. Direct Coombs and Donath-Landsteiner (D-L) tests yielded positive results. He was diagnosed as having paroxysmal cold hemoglobinuria (PCH). The patient recovered by avoiding cold stimulation, but the D-L test result remained positive and was only confirmed to be negative 10 months after the disease onset. The D-L test usually shows a negative result in most cases of PCH 7 months after the onset of the disease, but in this case, the test result was positive for more than 7 months, making this a rare case.

Moraxella nonliquefaciens is a commensal organism in the human upper respiratory tract. It is the causative organism of pediatric bronchitis and pediatric sinusitis, and it is rarely detected in corneal swabs. Here, we report a case of corneal ulcer caused by M. nonliquefaciens. A man in his seventies presented with left eye pain and was diagnosed as having an infectious corneal ulcer, anterior chamber abscess, and endophthalmitis with thinning of the left corneal ring. Gram staining of the corneal swab revealed large gram-negative bacilli arranged in pairs with square ends. Although small, smooth, white, nonhemolytic colonies developed on TSA II 5% sheep blood agar in 24 h, no growth was observed on BTB lactose-containing agar. The organism tested positive for catalase and oxidase. However, the organism was not correctly identified on the basis of a differential diagnosis of species by conventional biochemical analysis. The organism was subsequently identified to be M. nonliquefaciens using VITEK MS mass spectrometry (99%), and 16S rRNA gene analysis showed 99.71% compatibility with M. nonliquefaciens. Drug susceptibility test results of the organism revealed resistance to macrolide antimicrobials. The patient’s corneal ulcer improved with the administration of quinolone antimicrobials, cefcapene-pivoxil, and other antimicrobials. Although mass spectrometry is a useful method for identifying M. nonliquefaciens, it is important to speculate the possibility of M. nonliquefaciens on the basis of the results of conventional methods such as morphologic characteristics, results of culture tests and catalase and oxidase tests of laboratory materials, and reports of doctors-in-charge.

We present a case of infective endocarditis (IE) diagnosed through the detection of Granulicatella adiacens in a blood culture that turned positive at night. A man in his 50s had a fever of over 37°C, which did not surpass 39°C, and malaise for a few days. He was transferred to our hospital on experiencing impaired consciousness and dysarthria. Brain magnetic resonance imaging, performed on suspicion of a lesion, revealed an infarct centered in the left occipital lobe. After collecting various specimens, tazobactam/piperacillin was administered but changed to ampicillin because gram-positive streptococci were detected. Initially, a streptococcal infection was suggested. However, on subculturing, as no growth was observed on 5% sheep blood agar, nutritionally variant streptococci (NVS) were suspected, and chocolate agar and brucella HK agar were used. Anaerobic subculturing revealed colonies showing alpha-hemolysis. Owing to strong NVS suspicion, an additional gentamicin dose was administered. Transesophageal echocardiography was performed to detect the infarction source, which indicated IE; thus, the diagnosis cardiogenic cerebral embolism was made. The organism identified as G. adiacens was also detected in his warts. Thus, the patient’s condition was diagnosed as endocarditis caused by G. adiacens. Since IE treatment is of a long duration, identifying the causative agent is crucial, and selecting an appropriate isolation medium is important because NVS such as G. adiacens do not grow in a normal medium.

We encountered a rare case of liver echinococcosis in a Bolivian woman in her 20s living in the Chubu region of Japan. Because of fever and general fatigue, she visited a nearby hospital and was suspected of having a liver abscess following an abdominal CT scan. The patient was referred to our hospital for detailed examination and treatment. A 45-mm-size monocystic lesion with thick film formation was discovered at the S4/S8 boundary and was aspirated under ultrasonic guidance. Clinical microscopic and cytologic examinations were performed, and scolex and hooks were found. The patient was diagnosed as having liver echinococcosis. She came to Japan from Bolivia two years ago. In Bolivia, many wild cats and dogs live near residential areas, and it is a region where echinococcosis occurs frequently. The patient might be infected with liver echinococcosis while she was in Bolivia.

Smudge cells are fragile cells that ruptured through the physical process of smear preparation. Smudge cells have often been observed in smear specimens of lymphoid neoplasms, particularly in cases of chronic lymphocytic leukemia. The presence of many smudge cells in a smear preparation may indicate a neoplastic disease. In a patient, the finding of smudge cell aggregation in a bone marrow smear specimen led us to suspect hematological malignancies. The patient was a 50-year-old woman who complained of high-grade fever and was admitted to our hospital. Blood examination revealed anemia, thrombocytopenia, and elevations of serum lactate dehydrogenase, C-reactive protein, ferritin, and soluble IL-2 receptor levels. Although these findings suggest hematological disorders such as malignant lymphoma, whole-body computed tomography showed no swollen lymph nodes. Bone marrow examination showed many smudge cell aggregations and large lymphoma cells. These lymphoma cells were positive for CD20. On the basis of these bone marrow findings, random skin biopsy was performed. CD20-positive lymphoma cells were observed in blood vessels of cutaneous tissues. Therefore, this patient was diagnosed as having intravascular large B-cell lymphoma (IVLBCL). Generally, early diagnosis of IVLBCL is reported to be difficult because of the lack of overt lymphadenopathy and mass formation. Smudge cell aggregations in bone marrow smear specimens may be helpful in the diagnosis of hematologic malignancies. It is possible that smudge cells may be observed in not only chronic lymphocytic leukemia but also other hematologic malignancies.

Background: Urinary sediment analysis may reveal adenocarcinomas including primary tumor and metastatic tumor, as well as contaminations. Herein, we report a case in which a rare adenocarcinoma was detected in a patient who underwent bladder augmentation using the ileum 53 years ago. Case: The patient was a man in his 70s. Fifty-three years ago, he underwent left nephrectomy and bladder augmentation using the ileum for renal tuberculosis and bladder tuberculosis. Urinalysis revealed atypical cells, and histopathological analysis of a cystoscopic biopsy specimen performed afterwards confirmed adenocarcinoma derived from the ileum. Conclusion: We encountered a rare case of adenocarcinoma detected by urinary sediment examination. Currently, bladder augmentation using the ileum is rarely performed. However, as in this case, many patients develop adenocarcinoma after a long period of time, so we believe that we may still encounter such cases in today examinations. Therefore, after it is important to understand its clinical background and morphological features, performing microscopic examination.

Peritonitis is a frequent complication of peritoneal dialysis (PD). Common etiologic agents are staphylococcal species, whereas infections caused by rapidly growing mycobacteria (RGM) are considered rare. We report here a case of PD-associated peritonitis caused by RGM, specifically Mycobacterium mageritense. The patient, a woman in her 60s undergoing continuous ambulatory peritoneal dialysis (CAPD), was admitted to our hospital because of persistent diarrhea and general malaise, leading to the suspicion of PD-associated peritonitis. CAPD drainage fluid was collected and cultured in a blood culture bottle for 42 h. Ziehl–Neelsen staining showed the presence of acid-fast bacilli. The colonies formed were further analyzed and identified as M. mageritense by mass spectometry (MALDI Biotyper). The patient was treated with meropenem (temporarily changed to imipenem/cilastatin) and levofloxacin, and she was discharged after five weeks because her symptoms were better. This case demonstrates the importance of the accurate identification of mycobacterial species and drug susceptibility testing for the appropriate diagnosis and treatment of PD-associated peritonitis.

Here, we report a case of bacteremia caused by Streptobacillus moniliformis, in which information provided by the biomedical laboratory scientist led to the rapid identification and selection of appropriate antimicrobial agents. A 50-year-old man with diabetes was admitted to our hospital with the chief complaint of arthritis. Owing to the elevated levels of inflammatory markers, he was hospitalized and underwent a thorough examination. Culture of blood and articular fluid on admission revealed a filamentous gram-negative bacillus and small colonies measuring 1–2 mm on blood/chocolate agar. Gram staining of colonies showed pleomorphic gram-negative bacillus with chaining and clumping. The information provided by the biomedical laboratory scientist led to the finding that the patient had a history of contact with mice. This information also led to the early identification of the bacterium as S. moniliformis. Identification and susceptibility testing are important because incomplete treatment of infection with this organism has been reported to lead to relapse. However, mass spectrometry and genetic analysis are necessary to definitively identify the species. Although S. moniliformis is considered a causative agent of rat-bite fever, the entry route is unknown in many cases without a history of rat bites. This case highlighted the importance of the biomedical laboratory scientist and questioning patients about animal contact history in the treatment of infectious diseases.

The patient was a 67-year-old man who was on hemodialysis because of diabetic nephropathy and end-stage renal disease. There was a sign of infection in the subcutaneous arteriovenous fistula of the right forearm more than three weeks before he visited our hospital, and a culture test was performed three times in a nearby clinic, but all the tests showed negative results. He was urgently taken to our hospital because of neck pain during hemodialysis. After cervical computed tomography (CT) imaging in the emergency outpatient department, he suddenly experienced cardiopulmonary arrest and was resuscitated. It was determined that the epidural occupying the lesion found by cervical CT compressed the cervical spinal cord, leading to respiratory arrest. For this patient, surgery and antibiotic treatment were not possible owing to poor neurological prognosis. Blood cultures collected on the day of admission to determine the cause became positive for a bacterium on the 6th day of admission, which was identified as Mycobacteroides abscessus complex. Even rapidly growing mycobacteria require more time to grow than general bacteria, and it is difficult to detect them unless they are tested with the bacteria in mind and epidural abscesses may cause a rapid onset of irreversible symptoms. From these findings, it was considered that appropriate and prompt responses are important for such cases. If bacteria are not detected in cultures performed for the purpose of detecting general bacteria but the signs of infection persist, it is important to assume mycobacterium, perform appropriate tests, and provide information to the doctor in charge.