Background：Acute infectious purpura fulminans (AIPF), a rare syndrome of infection-induced ischemic necrosis of the extremities (symmetric peripheral gangrene), is due most often to Neisseria meningitidis in the US and the UK, but is not endemic to Japan. Purpose：We reviewed clinical AIPF manifestations in Japan. Methods：(A) We retrospectively analyzed six cases of AIPF in the last seven years. (B) We reviewed the medical literature up to 2008 using PubMed search and Japana Centra Revuo Medicina (Igakuchuozasshi) findings. Results：(A) None of the 6 subjects-5 men and 1 woman aged 44 to 69 old- had a history of splenectomy. Except for one case, their disease was community-acquired and immunocompetent. Causative organisms were Streptococcus pneuomoniae (66.7％), Gram negative rods, and Legionella pneumophilla. No localized infectious focus was apparent except for one of Legionella pneumonia. Systemic purpura progressed rapidly within 12 to 96 hours of initial fever or influenza-like symptoms. Main AIPF manifestations are shock and disseminated intervascular coagulation, but not all subjects had both. Six-month mortality was 33.3％, with death within two days of admission. Survivors all required at least two limbs to be amputated. (B) The Japanese literature reported AIPF occurring in 64 cases- 11 neonatal due to congenital protein C deficiency,seven pediatric, and 46 adults. Organisms most commonly involved were S. pneumoniae at 41.3％, and Neisseria meningitidis at 15.2％. The most common pathogen reported in a PubMed search was Neisseria meningitidis. Conclusions：In Japan, S. pneumoniae is the most frequent isolate associated with AIPF, and progression to AIPF occurs mainly in adults, who commonly suffer frequent amputations andhighmortality.Rapidprogressing systemic purpura following common-cold-like symptoms is the key to early diagnosis, even if the patient is immunocompetent, not splenectomized, or has no apparent infectious foci.
Recurrent Group A Streptococcus (GAS) infection was defined as a case in which GAS infection was suspected during June 2006～December 2008 and GAS was detected more than 2 times by throat culture. T serotype and emn genotype were investigated for GAS bacteria isolated from children with recurrent GAS infection. Bacteria gene homology was studied using pulsed-field gel electrophoresis (PFGE). Of the 43 cases of GAS infection in 21 children used as subjects, 20 had GAS infection 2 times and one 3 times. A comparison of the first and second infection in subjects (and the second and third for the child with 3), bacteria isolated from 11 cases had coincident properties and those from the remaining 11 not-coincident. The mean period of first and second infections (second and third for the child with 3) was 29.1±17.1 days for the coincident group and 215.2±187.8 days for the not-coincident group. A significant group difference in period was seen (p＝0.0013). Ten of 12 children with recurrent GAS infection within 8 weeks of the first infection and one of 10 who had it more than 8 weeks after that were included in the coincident group, indicating a significant difference (p＝0.0028).
Iliopsoas abscess, a rare disease, has shown a recent alarming increase in the number of patients, especially among older people. This clinical study of iliopsoas abscess in 11 cases seen from 2005 to 2008, showed the average age of patients to be 76 years-higher than the average. Causes were often orthopedic diseases such as pyogenic spondylitis. The four most commonly recognized underlying diseases were spinal, including lumbar spinal canal stenosis and lumbar disc herniation. Antibiotic induced a cure in only 6 of 11 cases. In this conservatively treated group, average abscess diameter was significantly smaller than in the non conservatively treated group. Conservative treatment thus requires that such abscess be detected as early as possible.
We report a rare case of Reyeʼs-like syndrome associated with suspected pertussis infection. A 26-year-old woman admitted comatose and found in laboratory studies to have acute liver dysfunction, severe hypoglycemia and prolonged prothrombin time, was diagnosed with clinical Reyeʼs-like syndrome due to aspirin use. Her child was probably infected with pertussis, which she contracted and which,in turn, triggered Reyeʼs-like syndrome.
Capnocytophaga canimorsus, a commensal bacterium from the carine mouth, causes septicemia in human beings through bites or scratches. We report a case of a 60-year-old man contracting septicemia due to C. canimorsus infection after a dog bite who died less than 12 hours after admission. We observed neutrophils with intracytoplasmic bacilli in the peripheral blood smear. We discuss clinical presentation and autopsy findings.
A 6-year-old boy admitted for empyema was found to have Streptococcus pneumoniae serotype 1 isolated from both blood and drainage fluid. The organism had no mutated genes encoding penicillin-binding proteins and was susceptible to all antibiotics. Empyema caused by S. pneumoniae serotype 1 in childhood has not, to our knowledge, been reported in Japan. In many countries where nanovalent pneumococcal conjugate vaccine (PCV7) has been introduced, serotype 1 frequency is especially high and empyema prevalence has increased. Monitoring of this S. pneumoniae serotype may be more important in invasive pneumococcal disease (IPD) than previously thought, especially in empyema, even after PCV7 is introduced in Japan.
A 67-year-old woman with acute Philadelphia-chromosome-positive mixed phenotype leukemia developed bilateral periorbital ecthyma gangrenousum (EG) subsequent to periorbital edema while undergoing combined imatinib mesylate (imatinib) chemotherapy. Although initial periorbital edema was considered an imatinib side effect, the lesion deteriorated rapidly with high fever in the neutropenic phase, and the woman died of septic shock. Cultures from blood and exudative fluid grew Pseudomonas aeruginosa,afterwhichEG was diagnosed. EG is a well-recognized emergent cutaneous infection most commonly associated with Pseudomonas aeruginosa bactremia. Because some patients present with EG a few days prior to developing lifethreatening septicemia, it is important that EG be diagnosed correctly. Imatinib side effects such as edema are usually tolerable, and imatinib is widely used to treat Philadelphia-chromosome-positive leukemia, particularly in those with acute lymphoblastic leukemia, and neutropenic patients undergoing imatinib therapy are expected to increase in number. Delay in initiating appropriate therapy is correlated with poor outcome,so drug side effects and EG must be carefully differentiated when skin edema with surrounding erythema is noted in neutropenic patients undergoing imatinib therapy.
We report a case of rapidly progressive necrotizing soft tissue infection and sepsis followed by a patientʼs death. We suspected Vibrio vulnificus infection because the patientʼs underlying disease was cirrhosis and the course extremely rapid. No microbe had been detected at death. We extracted DNA from a blood culture bottle. SYBR green I real-time PCR was conducted but could not detect V. vulnificus vvh in the DNA sample. Aeromonas hydrophila was cultured and identified in blood and necrotized tissue samples. Real-time PCR was conducted to detect A. hydrophila ahh1, AHCYTOEN and aerA in the DNA sample extracted from the blood culture bottle and an isolated necrotized tissue strain, but only ahh1 was positive. High-mortality in necrotizing soft tissue infections makes it is crucial to quickly detect V. vulnificus and A. hydrophila.We found real-time PCR for vvh, ahh1, AHCYTOEN,andaerA useful in detecting V. vulnificus and A. hydrophila in necrotizing soft tissue infections.
We report two cases of severe tetanus infection. Case 1 : A 73-year-old non-vaccinated man who fell in a local park developed a wound on the left little finger. The wound was debrided and a tetanus toxin shot given on day 4 following the injury. He developed trismus on day 6 requiring deep sedation and mechanical ventilation in the intensive care unit (ICU), with human anti-tetanus immune globulin (TIG) and antibiotics administered. Despite a very severe autonomic dysfunction, he recovered and was discharged mobile after 2 months of rehabilitation. Case 2 : A 37-year-old woman fully vaccinated against tetanus in her childhood had apparently had booster vaccine for at least 20 years and was being treated for hyperthyroidism with thiamazole. She sustained two lacerations on the fingers of her right hand in her backyard. She noticed difficulty in opening her mouth on day 3 follwing the injury and was seen on day 7, for high fever and difficulty in speaking. She was diagnosed clinically as having tetanus and underwent wound debridement, and a shot of tetanus toxin, TIG,and antibiotics. On hospital admission day 2, she developed spasms and her blood pressure dropped drastically. She died the next day due to endotoxin shock caused by other bacteria. C.tetani is widely distributed in Japan, and these cases underscore the importance of maintaining adequate tetanus antibody levels through booster administration every 10 years in immune adults and appropriate post-exposure treatment with tetanus toxin and/or prophylactic TIG administration.