There are lots of infectious diseases accompanied with exanthema. When the physicians see the patients with exanthema, they should carefully examine the form of exanthema and accessory symptoms. The physicians also should inquire of the patients about past history, history of vaccination and situation of current infectious disease epidemic in surrounding area. These clinical approaches lead to specific diagnosis. On this manuscript, I show the photos of several major infectious exanthema caused by viral, bacterial, bacterial toxin and so on.

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We compared reactivity between Chlamydia serovar antigens and sera from 18 patients using immunoblotting (IB) and enzyme-linked immunosorbent assay (ELISA). The antigens used were Chlamydia trachomatis serovar L2, D, E, and C organisms for IB and synthetic peptides derived from C, E, G, and L2-VDIV genes for ELISA.
Eleven of 12 sera collected from Chlamydia antigen-positive women with cervicitis strongly reacted with C. trachomatis serovar E, as did one serum with serovar C in immunoblotting profiles. ELISA coated individually with peptides E and C strongly reacted with the sera of 6 different natients. The IB result between serovar L2, D, E, and C and sera from the 60ther women patients showed reactivity at E≥D≥L2≥C. ELISA using a synthetic peptide mixture including C, E, G and L2 peptides gave positive results for all 18 sera. These results indicate that IB sensitivity differes with the C. trachomatis serovar antigen used and that certain cases may produce inconsistent results between IB and ELISA. Results of ELISA and IB are thus not always consistent, indicating that different synthetic peptides should be used in ELISA for detecting of low-level C. trachomatis antibodies.

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We studied distribution of thermostable direct hemolysin (TDH)-and TDH-related hemolysin (TRH)-producing Vibrio parahaemolyticus in coastal sea water, sediment, and shellfish and related retail shellfish contamination in Shimane Prefecture, Japan, between 2002 and 2004. V. parahaemolyticus was isolated from>80% of sea water, sediment, and shellfish. The detection of TDH gene (tdh) and TRH gene (trh)-positive V parahaemolyticus in sea water was 11%, in sediment 16%, and in shellfish 26%. The number of genes and gene-related in seawater was 23 MPN/L, in sediment 29 MPN/100g, and in shellfish 460 MPN/10g. TDHand TRH-producing V. parahaemolyticus detected in seawater was 5%, in sediment 11% and in shellfish 14%. The continuous distribution of TDH-producing O2: K28, O4: K88, O4: K37, and O4: KUT organisms on the western coast and TRH2-producing O5: k30, O5: K43, O10: K19, O10: KUT, O11: K40, O11: KUT, and OUT: KUT organisms on the Oki Island coast suggested the settlement of these organisms in these coastal environments. From 7 (12%) of 59 retail short-necked clam samples, we isolated TDH-producing O1: KUT, O3: K6 (2 strains from 2 samples imported from Korea), O4: K12, OUT: K8, and TRH2-producing OUT: K40 and OUT: K51 organisms. These findings suggested that TDH-and TRH-producing V. parahaemolyticus are widely distributed along the coast of this prefecture and are transported by contaminated retail shellfish from other areas

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I evaluated performance of the Mycoplasma pneumoniae-specific IgM antibody rapid detection test (ImmunoCard Mycoplasma, IC, Meridian, USA) and compared it to the particle agglutination (PA) test and ELISA tests (Mycoplasma pneumoniae IgG, IgA, IgM ELISA medac, Medac Diagnostika, Germany). Serum samples numbering 112 were obtained from 70 pediatric patients (<16 years old) with M.pneumoniae infection diagnosed by a PA test (four-fold or greater rise by paired serum samples or >/=1:640 by a single serum sample). Of these, 82 samples (73.2%) were positive in IC and 91 (81.3%) positive in ELISA IgM tests. Specifically, for samples obtained within 7 days following the onset of fever, 6 of the 14 positive in the ELISA IgM test were negative in IC and 4 of the 18 samples negative in the ELISA IgM test were positive in IC. I ascribed this difference to the difference in antigens used in each test. In the analysis of sequential serum samples from 2 patients with M.pneumoniae pneumonia, IC was still positive in 248-and 527-day samples for which a PA test and the ELISA IgM and IgG tests indicated no acute infection. Nine (36.0%) of 25 serum samples obtained from apparently healthy adult volunteers were positive in IC. Of the 9 IC-positive cases, ELISA tests suggested possible recent infection at most in 3 cases, while the remaining 6 cases had no evidence of acute infection. In conclusion, although IC is sufficiently sensitive as a rapid screening test for detecting M.pneumoniae-specific IgM antibody, a positive result in the test does not always indicate acute infection by this organism. To ensure accurate diagnosis of M. pneumoniae infection, paired serum samples are thus required for conventional methodologies.

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For infection control in pediatric hospitals, we investigated the risk of pertussis and diphtheria infections among pediatric healthcare workers. Forty-nine Japanese pediatric healthcare workers in 12 general hospitals were screened for antibodies of pertussis toxin (PT), filamentous hemagglutinin (FHA), and diphtheria toxin (DT). The seropositive rates of anti-PT IgG (protective level, >10U/mL), anti-FHA IgG (>10U/mL), and anti-DT (>0.1IU/mL) were 50, 82, and 59%, respectively. During this survey period (Oct. 2003-Feb. 2004), 16 (33%) of the healthcare workers were in contact with pertussis-infant (s). However, all culture and PCR tests for Bordetella pertussis were negative. One of the 16 exposed healthcare workers, a male pediatrician, had serological evidence of a pertussis infection, but no disease symptomatic of pertussis. Our observations indicate that i) 50 and 41% of Japanese pediatric healthcare workers were seronegative for pertussis (anti-PT IgG) and diphtheria antibodies, respectively, and ii) although the healthcare workers had a high rate of contact with pertussis-infant (s), the infection rate was low. For pertussis and diphtheria infection control in pediatric hospitals, it is important for healthcare workers to be aware of their own protection levels against these diseases.

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Objective: To detect nosocomial outbreaks early we construct syndromic surveillance for inpatients with fever, respiratory symptoms, diarrhea, vomiting, or rash and evaluate it statistically.
Methods and Materials: In hospital using electronic medical records since August 1999, we studied the number of inpatients with a certain symptoms from 1999 to 2005. To prospectively detect outbreaks after January 1, 2005, we first estimated the baseline using data from August 1, 1999 to the day before any given day. We then predicted the number of patients on the day and judge whether an outbreak has occurred, evaluating this by checking it sensitivity and specificity to detect outbreaks other than those with previous patterns.
Results: From August 1999 to December 2005, 115, 532 patients had fever, 126, 443 respiratory symptoms, 87, 923 diarrhea, 32, 858 vomiting, and 11, 212 In 2005, in prospective detection, 23, 617 had fever, 23, 698 respiratory symptoms, 14, 671 diarrhea, 5, 893 vomiting, and 2, 486 rash.
Discussion: This hospital had a nosocomial Noro virus outbreak on January 27, 2005. Syndromic surveillance identified an outbreak of vomiting at a 0.1% criterion. Our system thus detects nosocomial outbreaks and is of practical use. The next step will be ward-by-ward examination, after which we will experiment with rapid information collection, analysis, reports of results, and investigation by infection control teams.

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In July 2002, a large outbreak of legionellosis occurred in a bathhouse with spa facilities in Miyazaki Prefecture. Among the visitors, 295, including suspected cases had pneumonia and/or symptoms of fever, coughing, etc. Of these, 37% were hospitalized and 7 died. Clinical samples from 95 mainly inpatients were collected and microbiologically tested at our laboratory. Legionella pneumophila serogroup (SG) 1 was isolated from 3 of 24 in sputum culture, and none of the 3 had been treated effectively with antibiotics at sputa collection. L. pneumophila antigen in urine was detected by using enzyme immunoassay and/or immunochromatographic kits in 23 of 75 patients. Serum antibodies to L. pneumophila SG1 and Legionella dumoffii were detected in 5 each of 66 patients-9 cases including a case at mixed infection-by microplate agglutination test and/or indirect immunofluorescence assay. At our laboratory, 32 were diagnosed with legionellosis. In this outbreak, 14 were diagnosed at other laboratories, resulting in 46 confirmed cases.
Urine antigen was detected more frequently by Binax NOW immunochromatographic assay than by Biotest EIA-31% versus 16% of cases tested. Both assays detected urine antigen only in samples collected within 4 weeks after onset. Antigen concentration in urine enhanced sensitivity-58% and 51%-and extended the period of antigen detection beyond 5 weeks.
Both antibody titers to L. pneumophila SG1 and L. dumoffii in more than 90% of sera collected within 3 weeks after onset were<1:16. The rate of serum antibody titer to≥1:128 within 3 weeks was 1.6%, during 4 to 6 weeks less than 10%, and after 7 weeks or more 8 to 25%.
After an administrative report was published, L. pneumophila DNA in sputa was detected in 5 of 17 patients by nested PCR, resulting in extra 3 cases. Altogether, urinary antigen detection and PCR were more effective in laboratory diagnostic tests than culture and serology. Culture combined with molecular epidemiology is critical, however, for confirming the source of infection.

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Nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA) occurred at a major in Yamagata prefecture hospital between May 2004 and June 2005. We studied pulsed-field gel electrophoresis patterns, antimicrobial susceptibility patterns, and bacteriological features, such as coaglase type for eight isolates, including two of methicillin-resistant Staphylococcus epidermidis (MRSE). Our results suggest that this case was caused by a single strain of multidrug-resistant S. aureus. These 8 clinical isolates indicated reduced susceptibility to vancomycin and teicoplanin. PCR assay results for detection of the staphylococcal vanA, vanB, and vanC gene were all negative as all isolates. In transmission electron microscopy, cell walls appeared thicker than those of a susceptible strain from food poisoning. MRSA with reduced susceptibility to glycopeptide antibiotics may not be treated successfully with vancomycin or teicoplanin, making it important to closely observe MRSA with reduced susceptibility to glycopeptide antibiotics.

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A 29-year-old woman chiropractor with repeated episodes of bacteremia and positive for cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and antiproteinase-3 (PR3) antibody had an 11-year history of asthma and repeated hospitalization. While hospitalized she developed a spiking nocturnal fever with chills and erythema of the lower leg. Her fever resolved spontaneously, but corticosteroid therapy and antibiotics did not effectively reduce her symptoms. Plain X-ray film and CT showed pulmonary changes, and lung biopsy granulomas without vasculitis. Immunological studies showed a positive PR3-ANCA (c-ANCA) test, and skin biopsy of the crural erythema showed foreign body granuloma. Multiple blood cultures were positive for several strains of bacteria, including Fusobacterium necrophurum, Mycobacterium fortuitum, and Clostridium species. When placed in a single room and monitored, she did not develop new fever or erythema. Because self-injury was assumed, she was diagnosed as having Münchausen syndrome. This is, to our knowledge, the first report of Milnchausen syndrome with PR3-ANCA positivity. In patients with repeated infections, the possibility of self-injury, the development of PR3-ANCA positivity, and pulmonary granuloma with a disease profile similar to vasculitis syndrome should be considered in the definitive diagnosis.

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We report a case of infectious purpura fulminans due to pneumococcal pneumonia in a 61-year-old man presenting multiple organ failure and pneumococcal bacteremia secondary to pneumonia on admission. His lower limbs showed rapidly progressive purpura and symmetrical dry gangrene. He had no history of or apparent immunodeficiency, including asplenia, in abdominal ultrasonography. Despite of therapy, he died on day 15 after admission.
Infectious purpura fulminans involves skin lesions with severe infection often accompanied by disseminated intravascular coagulation and septic shock.
Although it occurs mainly in childhood, especially as a complication of Neisseria meningitis or Varicella virus infection, it has also been reported in adult, as a rare complication of invasive pneumococcal infection. Most had immunodeficiency such as asplenia or postsplenectomy. Purpura fulminans in a previously healthy adult is very rare and this is insofar as we know, the first report in Japan detailing the development from pneumococcal pneumonia.

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A 45-year-old homosexual man with pneumocystis pneumonia and esophageal candidiasis tested positive in ELISA and Western blot analysis for HIV-1. His CD4⁺ T cell count was 43/μL and his HIV-RNA load was 250, 000copies/ml He was treated with Trimetoprim-Sulfamethoxazole, Prednisolone and Fluconazole. Valganciclovir was added to treat CMV retinitis. During the clinical course, 21 days after admission, the patient presented with a temperature of 39°C and blood analysis showed neutropenia. Cefepime and G-CSF were initiated, but new consolidation was observed in the upper left lobe in chest radiography. He underwent bronchoscopy and lavage culture was positive for Aspergillus fumigatus. Serum testing of galactomannan was also positive and pulmonary aspergillosis was diagnosed. The patient was initially treated with Micafungin but switched to Voriconazole when clinical symptoms worsened. An eventual clinical response was observed and pulmonary aspergillosis was controlled. Unfortunately, he died of sepsis due to MRSA 2 months later.
Pulmonary aspergillosis is a devastating complication with poor prognosis in patients with HIV infection. Amphotericin-B has been the mainstay of pulmonary aspergillosis treatment, but reports indicate mortality exceeding 80%. Use of Voriconazole, a relatively new antifungal agent, may lower mortality with fewer adverse effects than conventional antifungal therapy.

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Cat scratch disease is associated with a variety of systemic manifestations. We report a pediatric case associated with pneumonia, pleural effusion, and pericarditis. A 3-year-old boy developed prolonged fever unresponsive to antibiotic treatment, including azithromycin and minocycline. Although the fever resolved with corticosteroid treatment, Bartonella henselae IgG titer was positive in indirect fluorescence antibodies, as was Rickettsia japonica IgG titer. Both titers were significantly reduced by serum absorption with B. henselae antigens, and we observed a serological cross-reaction between B. henselae and R. japonica.

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