Eighteen patients with miliary tuberculosis (MTB) were admitted to our hospital from 1994 to 2003. The mean age of the patients was 63.9 years (range 19-92). Past history of tuberculosis was recognized in one case. Six cases suffered from another underlying diseases, and 3 of them had been treated with corticosteroids. Smear, PCR and culture of sputum were positive for mycobacterium tuberculosis in 61%, 79% and 94% of cases, respectively. Chest computed tomography revealed diffuse micronodular shadow and diffuse infiltration in 100% and 22% of cases, respectively. The laboratory findings of 18 patients with MTB were compared with 240 patients with non-MTB who were admitted to our hospital from 1999 to 2001. Body mass index, serum total protein, albumin and peripheral blood lymphocyte count were significantly lower in MTB patients than in non-MTB patients. Five patients died during admission, 3 of them died of MTB and 2 of them died of cardiac disease. In the 3 died patients due to MTB, 2 of them had been treated with corticosteroids for fever, 2 of them had acute respiratory distress syndrome and 3 of them had disseminated intravascular coagulation. Serum total protein, albumin and platelet count were lower in the died patients due to MTB than in the living patients.

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In 2004, 3 new rapid influenza diagnostic kits using immunochromatography that allow type differentiation became commercially available. They are the ESPLINE Influenza A & B-N (Fujirebio Corp., Japan: ESPLINE-N hereafter), Quick Vue Rapid SP influ (Quidel Corp., USA: Quick Vue), and POCTEM INFLUENZA A/B (INTERNATIONAL REAGENTS Corp., Japan: POCTEM).
The authors performed a prospective study that compared the usefulness among the 3 kits in 151 children with suspected influenza, who were examined within 3 days after onset, between January and March, 2004.
Nasopharyngeal aspirates were collected, and viruses were isolated. The residual samples were diluted and centrifuged, and the supernatant was used for the rapid diagnosis tests. Influenza virus AH3 was isolated in 95 children and influenza B virus in 3.
In the 95 children with influenza virus AH3, the sensitivity and specificity of ESPLINE-N were 100% and 100%, respectively, those of Quick Vue were 99% and 91%, and those of POCTEM were 91% and 100%. The sensitivity of POCTEM was significantly lower than that of the other 2 kits (p<0.01), and the specificity of Quick Vue was significantly lower than that of the other 2 kits (p<0.05).
Examination was performed within 1 day after onset in 55 of the 95 children, including 30 who underwent examination within 6 hours after the development of fever. The body temperature was less than 38.0°C in 14 of the 95 children. In all children including these children, virus detection was possible by ESPLINE-N.
ESPLINE-N allowed very accurate diagnosis of influenza A using samples prepared by diluting and centrifuging nasopharyngeal aspirates.

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We examined the antimicrobial susceptibility testing of 1, 024 Haemophilus influenzae isolates recovered from Japanese children. Percent distribution of β-lactamase-negative ampicillin (ABPC)-resistant strain (BLNAR; ABPC-MIC≥4μg/ml) was 15.0%. Prevalence of BLNAR increased remarkably from 12.7 to 22.1% in recent 4 years. Furthermore, the frequency of highly resistant strains (ABPC-MIC≥8μg/ml) increased from 28.6 to 56.9% among BLNAR. Decreased susceptibility for cephems was observed in non-BLNAR strains including serotype b strain isolated from the cerebrospinal fluid

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We evaluated the transferability of vanA gene from vancomycin-resistant Enterococcus faecalis (VREF) to vancomycin-sensitive E. faecalis (VSEF) in vitro and in vivo. In vitro conjugal transfer experiment by filter mating, the vanA gene of VREF was transferable at the high frequency to VSEF and a mutant strain which cured vanA gene of VREF. In vivo studies in the digestive tract of specific pathogen-free mice pretreated with oral antibiotics, transconjugants were also detected from the feces of a mouse at the lower frequency. However, the colonization of transconjugants was transient. The vanA gene in the donor and the transconjugant strain was confirmed by using a polymerase chain reaction method.
These results suggest that VSEF colonizing in the human digestive tract might be developed to VREF by transferring of the vanA gene.

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The effect of entry delayed blood culture bottles until the start of incubation for mechanical detection of organism were compared using 2 major blood culture systems; BACTEC 9240 system and BacT/ALERT 3D system.
Total of 13 bacterial strains; 5 gram-positive cocci, 7 gram-negative bacilli and Candida parapsilosis which were isolated mainly from blood cultures were used as the test strains. BACTEC 92F, 93F and BacT/ALERT FA, FN bottles were used as the blood culture bottles. All the bottles inoculated with the test strains were incubated and evaluated immediately after standing at room temperature for 24, 42, 48, 54 or 72 hours, using the respective automated blood culture systems. All the bottles were subcultured.
The effect of entry delay the blood culture bottles for the mechanical detection was observed in many gram-negative organisms in BACTEC 9240 system. The blood cultures were evaluated not to be positive in 4 of the 10 samples on delaying for 24 hours or in any of the samples on delaying for 42 hours in the BACTEC 92F bottles inoculated with Escherichia coli. In Serratia marcescens, the blood cultures were evaluated not to be positive in 5 of the 10 samples on delaying for 24 hours or in any of the samples on delaying for 42 hours in the BACTEC 92F bottles. In Klebsiella pneumoniae, the blood cultures were evaluated not to be positive in 9 of the 10 samples on delaying for 42 hours. In Enterococcus faecalis, Pseudomonas aeruginosa and Proteus mirabilis, the blood cultures were evaluated not to be positive in 5-6 of the 10 samples on delaying for 42 hours. On the other hand, the blood cultures were evaluated to be positive in most of the samples of Acinetobacter calcoaceticus (except 3 of the 10 samples which were evaluated not to be positive) on delaying for 42 hours in BacT/ALERT 3 D system. The samples except part of Streptococcus spp. were detected by subculture in both the bottles.
These results indicate that the delayed time of blood culture bottles before inoculation with the test bacterial samples affects the positive detection of blood cultures markedly in the blood culture system. Therefore, the immediate incubation was considered to be necessary.

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There is no nationwide outbreak of rubella after 1992 in Japan, but a local outbreak remains. Recently, some cases of congenital rubella syndrome (CRS) were reported after a local outbreak. An outbreak of rubella among hospital personnel occurred in our hospital located on Tanegashima Island on March and April 2003 after a visit of one rubella patient. Fifteen employees, including 7 clerks, 6 nurses, one doctor, and one radiologist, experienced rubella. A total of 259 employees in our hospital employees were examined for anti rubella hemagglutination inhibition (HI) tests with informed consent and recommended to take rubella vaccines. Sixty-seven employees (26%) among 257 examined for tests were found susceptible to rubella, and 53 employees were vaccinated. After vaccination, the outbreak was stamped out immediately. There was no rubella patient infected from employee. Nine among the 15 infected employees had declared to have a history of rubella or rubella vaccines before onsets, suggesting interviews are not reliable. There were many susceptible persons and rubella patients among elderly women and male personnel; therefore, measures are needed for elderly personnel as well as younger employees. In addition, adequate measures should be taken to prevent CRS, because many female personnel capable of pregnancy work in hospitals. The cost of the rubella HI tests and vaccination was approximately \200, 000 (about 1, 600). The absence due to illness per one person was 6 days, and the wage per one day was about \12, 000 (about 100) on the average. The overall cost required in the outbreak was estimated to be approximate \1, 400, 000 (about $12, 000). Considering that an outbreak of rubella causes not only a large amount of expenditure but also loss of hospital income, the investment to prevent a rubella outbreak is quite valuable in the management of a hospital.

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We examined enterohemolysin (Ehly) production, and detected the hlyA gene and the eaeA gene for the intestinal mucosal adherence factor intimin in 131 strains of human-derived verotoxinproducing Escherichia coli (VTEC) and 140 strains of livestock (cattle and swine)-derived VTEC to evaluate their hazards to humans.
The hlyA gene was confirmed in 98.5% of human-derived, in 50.5% of cattle-derived, and in 10.3% of swine-derived VTEC strains. Ehly-positive rates were 96.2-97.7%, 45.9-55.0%, and 10.3-20.7% in human-, cattle-, and swine-derived VTEC strains, respectively. Thus, the positive rates differed among strains of different species origins. However, all 12 cattle-derived O157VTEC strains had hlyA, and were Ehly-positive. Although 97.7% of human-derived strains and all cattle-derived O157VTEC strains had eaeA, only 8.1% of cattle derived strains of serotypes other than O157 and 3.4% of swine-derived strains had eaeA.
In human-and cattle-derived strains, the presence of eaeA was associated with Ehly: all eaeAcarryingstrains had hlyA, and almost all of them were Ehly-positive. Cattle-derived eaeA-carrying strains accounted for 29.5-35.3% of Ehly-positive strains, compared to 100% in human-derived strains. Only 3-4% of Ehly-negative strains had eaeA, and none of the non-hlyA-carrying strains had eaeA.
These findings suggest that 2 factors, eaeA and Ehly, serve as useful indicators for the evaluation of hazard to humans, and that Ehly is a useful indicator because cattle-derived Ehly-positive strains may have eaeA.

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We report a rare case of life-threatning pneumothorax induced by multiple intrapulmonary cavitary lesion due to Absidia corymbifera and methicillin-resistant Staphylococcus aureus (MRSA). The patient was a 58-year-old man who had undergone kidney transplantation three year ago due to diabetes renal failure. He had been treated with immunosuppressive drugs and prednisolone, but he had neutropenia and an abnormal shadow on the chest X-ray. His chest X-ray findings became worse inspite of broadspecrtum antibiotis, vancomycin, antivirus drug, γ-globulin and antifungal drug therapy. He came to our emergency center because of dyspnea due to right massive pleural effusion and peumothorax about two months after onset of neutropenia. His arterial blood gas showed severe hypoxia and the chest CT scan showed birateral pleural effusion and multiple intrapulmonary cavities. He was treated with chest tube drainage and intubated, but he died of progressive respiratory failure on admission day 3. Macroscopic and microbiologic findings of necroptic lung revealed the cavity with fistula in the middle lobe, which included debris with mucor and MRSA. The species of mucor identified as Absidia corymbifera as a result of analysis of BLAST with nested-PCR using the palafinblock.

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