To clarify the characteristic features of nosocomial pneumonia in a community hospital, we performed a clinical analysis of 147 patients (155 episodes) with nosocomial pneumonia. The following results were obtained. 1, Regarding the risk factors for nosocomial pneumonia, factors such as the patient whose age was over 65 years, a duration of admission of over one month, performance status 4 and underlying respiratory diseases associated with the appearence of nosocomial pneumonia. 2, The causative microorganism isolated from the sputum of the patient with nosocomial pneumonia was frequently a multi-drug resistant microorganism such as Methicillin-resistant Staphylococcus aureus (MRSA). 3, regarding treatment, although several antibiotics were administered for a long time, mechanical ventilation was used on 31% of the patients, and steroid pulse therapy was carried out on 24%. The clinical efficacy was poor witha 50% mortality rate. The reason why treatment of nosocomial pneumonia was difficult is thought to be been related to the general condition of these inpatients and to the appearence of a multi-drug resistant, polymicrobial microorganisms.
We treated two cases of primary pulmonary cryptococcosis with fluconazole (FLCZ), the clinical usefulness of FLCZ was evaluated. FLCZ was administered orally in doses of 300mg daily for about six months. Concentrations of FLCZ were measured in the serum of the two cases and in the bronchoalveolar lavage (BAL) fluid in one case. The following results were obtained: 1. Clinical cures were obtained in the two cases. 2. The serum levels of FLCZ was 15.1μl/ml, 13.6μg/ml two hours after administration of 100 mg in case 1, that of levels were 11.1μg/ml, 8.9μg/ml one hour and 4.5 hours, respectively, after administration of 100mg in case 2. BAL was performed 4.5 hours after administration of 100mg in case 2, the BAL fluid level of FLCZ was 0.7μg/ml. 3. The minimal inhibitory concentration of FLCZ against one strain obtained from the cytology brush in case 1 was 4.0μg/ml. 4. The cryptococcal antigen titer decreased with the improvement of clinical signs and the resolution of chest X-ray abnormalities within about six months, and there was no relapse. From these results, we consider that FLCZ is a useful antifungal agent for primary pulmo-nary cryptococcosis, and we therefore recommend a six month treatment.
Immunoglobulin (Ig) production by human B cells in thymus-independent (TI) and-dependent (TD) immune response against Staphylococcus aureus was investigated in vitro. Highly purified human peripheral B cells were cultured either in the presence of formalinized Cowan I strainStaphylococcus aureus (SAC) or with anti-CD3 stimulated T cells, and Ig content in supernatants was analyzed after 10 days of culture by specific sandwitch ELISA. When activated with SAC in the absence of T cells, B cells produced minimal amounts of Ig. In the presence of interleukin-2 (IL-2) or supplemental recombinant CD40 ligand plus IL-2, Ig production by SAC-induced B cells was dramatically enhanced. When cultured with T cells stimulated with low concentrations of anti-CD3 or when cultured with smaller numbers of T cells, B cells produced large amounts of Ig, whereas T cells stimulated with higher concentrations of anti-CD3 or large numbers of T cells failed to induce effective Ig secretion by B cells. These findings suggest that TI immune response against Staphylococcus aureus is strongly enhanced in the presence of activated T cells in an antigen non-specific manner, indicating its critical role in the local humoral immune defense. Moreover, it is indicated that the secretion of Ig induced by TD antigens participates in the immune defense against Staphyloccocus aureus dependent on activated T cell/B cell ratio or an impact of CD3 stimulation on T cells.
A study of enteroaggregative Escherichia coli (EAggEC) which was recently reported as a causative agent of diarrhea was attemped, by isolating these organisms from the fecal samples collected from sporadic diarrhea patients in Miyazaki Prefecture during the period from January 1993 to April 1998, and by investigating several characteristics of the isolates. By using the PCR method targetting aggR gene which was a transcriptional activator of aggregative adherence fimbria I expression, thirty four strains of aggR (+)-Escherichia coli (E. coli) were detected from 2, 652 fecal samples. Twenty nine of these 34 isolates were confirmed as EAggEC by demonstration of aggregative adherence to HEp-2 cells, and the other 5 isolates were not EAggEC because they showed negative adherence to HEp-2 cells. The above mentioned, aggR-PCR method revealed that there were a few non-EAggEC strains with aggR gene. It has been reported that aggregative adherence fimbriae are encoded by the plasmid of about 60Md. All of the 29 EAggEC isolates possessed plasmids of about 50Md or more, and these plasmids were suggested to relate to aggregative adherence fimbriae. Sixteen (55%) of the 29 isolates were classified serologically into two serotypes, O111: H21 and 0126: H27, and the other 13 isolates were classified into ten groups or more which included a few strains in a group. EAggEC heat-stable enterotoxin 1 (EAST1) gene was demonstrated in nineteen of 29 isolates. In drug susceptibility test, 72%, 59% and 21% of the 29 isolates showed resistance to Ampicillin, Cefazolin, and Streptomycin, respectively.
We examined fecal specimens of Japanese residents in developing countries in order to know the prevalence of intestinal parasites in the group. One fecal specimen was collected from each 981 (in 1995) and 1275 (in 1996) Japanese living in Asia, the Middle East, Europe, Africa and Latin America. The specimens were fixed with 10% formalin in each area, and were examined in Japan by concentration method (formalin-ether sedimentation) to find protozoan cysts or helminth eggs The infection rate of intestinal parasites was 3.0% in 1995 and 2.4% in 1996. The rate was high in Africa (1995: 5.7%, 1996: 4.7%) and Asia (1995: 3.8%, 1996: 3.0%). Regarding to thespecies of the parasites, Giardia lamblia (17 cases), Trichuris trichiura (14) and Ascaris lurn bricoides (11) were detected frequently. Additionally, 7 cases of Heterophyes heterophyesinfection were found in Asia and the Middle East. The infection rate was higher in adults than that in children, and a positive relationship between the infection rate and duration of stay was observed. Among the Japanese infected with intestinal parasites, abdominal symptoms such as diarrhea or abdominal pain were common (36.8%). It is also noteworthy that 28.1% of the Japanese infected had a history of gastric diseases such as gastric ulcer.Although the infection rate of intestinal parasites among Japanse residents in developing countries was low, compared to that of the naives in the countries, the rate is still higher than that in Japanese living in the home country. It is necessary to continue preventive measures such as health education in order to eradicate intestinal parasitic infections from this group.
Two hundreds and twenty-six children under five years of age with pneumonia were recruited from an urban poor area in Nairobi, Kenya, and examined for pathogens for 1 year from February 1997. One hundred and twenty-eight of the 226 patients were pathogen-positive cases. The patients under 1-year-old were 61.8% of the pathogen-positive cases. A total 192 organisms were isolated from 128 pathogen-positive patients. Streptococcus pneumoniae had the highest prevalence rate of 31.3%, followed by respiratory syncytial virus with 10.4%, Candida albicans with 9.9%, Moraxella (B) catarrhalis with 7.8%. In S. pneumoniae, 66.7% of the orgamism was resistant to oxacillin. It was also shown that 51.1% and 65.1% of the S. pneumoniae strains were resistant to gentamicin and trimethoprim/sulfam, respectively. From these results, it is clear that a lot of multi-drug resistant S. pneumoniae strains including penicillin-resistant S. pneumoniae were frequently detected in an urban poor area.
We compared the urinary sediment method to counting chamber method in evaluating pyuria, in order to elucidate an issue of urinary sediment method. The KOVA system®was used for counting chamber method. Three hundred and ten urine specimens from the patients who visited Fuji City Central Hospital in March, 1995, were employed. The numbers of leukocytes of each specimen was counted by means of urinary sediment method and counting chamber method, and compared. The urinary leukocyte count evaluating by means of these two methods were correlated well. However, the discrepancy of urinary leukocyte counts by means of these two methods were recognized in two specimens. In these two specimens, the leukocyte count was 1 to 4/5HPF by means of urinary sediment method, but more than 50μl by means of counting chamber methods. Significant bacteria (104cfu/ml or more), positive esterse reaction, and high pH (8.5) were recognized in both spesiemens. In addition, one of two these specimens was hypotonic (specific gravity was 1.008). Therefore, it was suggested that leukocytes were sometimes disrupted with centrifugation. These results indicate that counting chamber method is more useful urinary sediment method to detect pyuria.
We examined the preventative effect against enterohemorrhagic Escherichia coli O157: H7 (EHEC) infection in rabbits on administration of probiotics contained in Streptococcus faecalis, Clostridium butyricum and Bacillus mesentericus. The probiotics were administered to 5 days old Japanese white rabbits throughout the experiment. Inoculation of 106 colony forming units (CFUs) of EHEC per rabbit was tried 8 days after birth. Three days after EHEC inoculation, in the control group (not administered probiotics), diarrhea was observed in approximately 80% of the rabbits, on the other hand, in the group administered probiotics, rabbits showed diarrhea in 15%. In necropsy, the number of EHEC in the contents of the cecum and the number of attaching and effacing (AE) lesions were fewer in the probiotics group than in the control group. These results suggest that infant rabbits are useful as a colitis model for EHEC, and the probiotics are effective for the prevention of the growth of EHEC in the intestine and for diarrhea.
A 44-year-old woman with a history of intermittent fever for several years was admitted because of burn on her leg. On admission, she had hepatosplenomegaly and fever. Antibiotic therapy was started for bacterial infection of the burn. She lost her appetite and IVH was started. During the treatment, high fever appeared and chest X-ray films showed multiple nodular infiltrates throughout both lung fields.Candida albicans was isolated from IVH catheter culture and pulmonary candidiasis was suspected. Her fever and lung involvements were successfully treated with fluconazole. During the course, serum anti-EB-VCA-IgG antibody persisted at a hight iter and anti-EBNA antibody remained negative. EB virus DNA was detected in the peripheral blood and bone marrow. Thus, she was diagnosed as chronic active EB virus infection.
A 40-year-old Japanese male stayed in Zimbabwe and developed a fever above 38°C during which he noted a typical eschar in the lumbar region and also regional inguinal lymphadenopathy. Although not conspicuous, erythematous eruptions accompanied by itching were observed on the face, trunk and lower extremities. After returning to Japan and visiting our hospital, he was suspected of rickettsiosis and put on minocycline which gradually led to the improvement of the symptoms. Immunofluorescence antibody determinations disclosed rising titers against Rickettsia conorii (R. conorii) for both IgM and IgG classes. The second patient, a 34-year-old Japanese male, developed fever, generalized erythema and a typical eschar while staying in South Africa. The first blood sample showed positive IgM and IgG antibodies against R. conorii, and the second sample a decline in IgM but not in IgG class antibodies. Both cases were diagnosed as spotted fever group rickettsiosis based on their clinical manifestations including typical eschar and also the results of antibody determinations. Most of the previous cases of spotted fever group rickettsiosis in Africa have been regarded as Mediterranean spotted fever which is caused by R. conorii and transmitted by Rhipicephalus sanguineus. However, recently, the presence of another type of spotted fever group rickettsiosis, African tick-bite fever, caused by Rickettsia africae and transmitted by Amblyomma hebraeum has been proposed. Although clinical features of the two rickettsiosis are reported to be separable, apparent cross reaction between the two organisms hampers the use of conventional antibody determinations for their differentiation. For the two cases presented here identificationof the causative rickettsia species was impossible, because they were not isolated. With ever increasing numbers of international travel, physicians should be alert to the possibility of spotted fever group rickettsiosis when encountering febrile patients returning from endemic countries. This is particularly important considering that beta-lactam antibiotics commonly used as an empiric therapy are not effective, and the disease has a potential to develop into severe forms.
We report a case of imported paratyphoid fever associated with Giardia lamblia and Isospora belli infection. The patient was a 23-year-old Japanese female with complaints of high grade fever and diarrea after 10 days traveling to Nepal. Salmonella Paratyphi A was isolated from the blood and fecal cultures on admision and Ciprofloxacin of 200 mg tid was administered for 14 days. Fecal examination revealed cysts of G.lamblia at the same time and metronidazole of 250 mg tid for 7 days was effective for their eradication. During the follow-up studies oocysts of I. belli were found and cotrimoxazole of 960mg bid for 10 days was effective for their eradication. Fecal examinations on parasites which is rare in Japan such as I. belli are recommended to the cases returning from tropical areas.
A 78-year-old female was admitted with complaints of malaise and fatigue in the legs. The patient was diagnosed as severe aplastic anemia and treatment was started with metenolone and steroid pulse therapy. Administration of antibiotics and granulocyte-colony stimulating factor which led to a resolution of the high fever. About four months after admission, the patient developed vomiting and abdominal pain with a spiking fever. The next day after suddenly losing consciousness, she died. B. cereus was isolated from blood cultures. Autopsy specimens of the liver, cardiac muscle and lung showed changes due to B. cereus. This pathogen is widely distributed in nature. We should not overlook B. cereus as a contamination, but rather should consider it a potential pathogen in immunocompromised hosts, when it is isolated from blood cultures.