The spiral Gram-negative bacterium Helicobacter cinaedi (H. cinaedi) is usually isolated from immunocompromized patients, and the number of patients in whom H. cinaedi is isolated from their blood culture is increasing in Japan. To elucidate why the number of cases is increasing, we tried to analyze separate cases of H. cinaedi. H. cinaedi was isolated from the blood culture of 24 cases, and the isolate was from the pleural effusion of 1 cases between September 2009 and March 2010. In our cases, H. cinaedi was frequently isolated after anticancer chemotherapies (44 isolates) and steroid therapies (42 isolates). The patientsʼclinical symptoms were fever (43 isolates), gastrointestinal symptoms (4 isolates）and skin symptoms（8 isolates). In all cases, the H. cinaedi growth was found only in an aerobic bottle, and it needed a long time (2-7 days) to grow. In 14 cases out of 25 cases, H. cinaedi bacteremia was recurred. We analyzed recurrent cases statistically. The result showed there was a significant difference between the kinds of quinolones (p＝0.0018). H. cinaedi infections have a good prognosis, but the infection tends to recur after anticancer chemotherapies. A report has suggested that the minimal inhibitory concentrations of quinolones increased is case of recurrence, we should pay attention to the use of antibacterial agents. Furthermore, the effective method to eliminate or prevert infection [recurrence] remains unknown. Our results show that H. cinaedi infections may prolong the duration of hospitalization. If H. cinaedi is isolated in a patient, it is necessary to set the culture conditions for H. cinaedi. Furthermore, there is a need for appropiate antibiotic selection and medication for H. cinaedi.
The etiologic role of recently identified respiratory viruses for lower respiratory tract disease (LRTD) remains unclear in Japan. The purpose of this study was to investigate the prevalence of respiratory viruses in young children with LRTD. We prospectively examined 721 children who were under two years old and admitted to a single medical center in Japan with LRTD between April 2007 and March 2012. Viral nucleotic acids were taken from their nasal swabs. Each sample was examined with（RT―) PCR for respiratory syncytial virus (RSV), enterovirus (EV), human metapuemovirus (hMPV), human bocavirus (HBoV), parainfluenza virus (PIV), and adenovirus (AdV). We detected at least one virus agent in 466 (65％) ; 83 patients (12％) were co-infected with different viruses. No virus was detected in 255 patients (35％). RSV (27％) was most common, followed by EV (11％), hMPV (6.9％), HBoV (3.3％), PIV (2.9％), and AdV (2.2％). Seasonal distribution was seen in each virus. Infants under 6 months old were frequently positive for RSV or EV. In 20 patients (2.8％) who required mechanical ventilation because of respiratory failure, 18 patients were positive for RSV nospace between “and/or”EV.
A Shiga toxin 2 producing enterohemorrhagic Escherichia coli (EHEC) O121 : H19 was isolated from a 2- year-old child who attending a nursery. An EHEC O121 outbreak in two nurseries (A, B), involving a total of 17 infected persons including 12 children, was revealed through contact investigation. The symptoms of all infected persons were almost all mild, and no one developed the hemolytic uremic syndrome. The combination use of desoxycholate-hydrogen sulfide-lactose (DHL) and CHROMagar STEC as selective isolation media was employed for efficient fecal examination. Nursery A and nursery B were combined as one group after the outbreak in nursery A was confirmed. As a result, EHEC O121 infected persons were also detected in children from nursery B. The 17 strains of EHEC O121 obtained from the total population showed almost the same pulsed-gel electrophoresis (PFGE) pattern, suggesting that these strains were very closely related. However, 13 of these 17 strains obtained from nursery A were susceptible to cefotaxime, whereas the remaining 4 strains obtained from nursery B showed cefotaxime resistance. A cefotaxime resistant Escherichia coli（E. coli) O86 strain was isolated in the stool specimen from a child who had been infected with the cefotaxime resistant EHEC O121. Both the cefotaxime resistant EHEC O121 and E. coli O86 had the same drug resistant gene (blaCTX-M-1 group). The child was the index case of these 4 later cases and had received noantibiotics therapy prior to the laboratory examination. These findings suggested the possibility that an EHEC O121 strain had acquired a drug resistant gene from E. coli O86 in the digestive tract of the child.
Recurrent fever often occurs during the treatment of bacterial meningitis in children. Few studies have focused on the difference between the patients with and without recurrent fever. The pathogenesis and clinical significance of recurrent fever remain to be elucidated. The objectives of this study were to clarify the clinical features of the patients with recurrent fever, and to identify the predictive factors for recurrent fever in childhood bacterial meningitis. We conducted a hospital-based retrospective chart review and confirmed 52 cases of bacterial meningitis. Recurrent fever was observed in 27 of 52 (52％) patients overall, and 27 of 47 (57％) patients with dexamethasone（DEX）therapy. All patients with recurrent fever received DEX therapy. The mean date of recurrent fever occurrence was 6.2 ± 2.0 days after admission. The median duration of recurrent fever was 5 days (range 1-19 days). The proportion of patients ＜2 years of age was higher in patients with recurrent fever than those without recurrent fever (p＝0.041). Initial peripheral white blood cell count was lower in patients with recurrent fever (p＝0.008). Of the 52 children, 10 (19％) showed neurological sequelae. Neurological sequelae were more frequent in patients with recurrent fever than those without recurrent fever, although this was not statistically significant (p＝0.078). Univariate and multivariate logistic regression analysis showed that the most powerful predictive factor for recurrent fever in patients with DEX therapy was young age (＜2 years) (adjusted odds ratio, 5.1 ; 95％confidence interval,1.3-20.7). These results suggest that recurrent fever is related to the two known factors for sequelae, low peripheral white blood cell count and young age. Recurrent fever should be recognized as a possible risk factor for neurological sequelae.
From February to December 20XX, penicillin-resistant Streptococcus pneumoniae (PRSP) showing MICs of 16-32μg/mL to cefotaxime (CTX) and 4-8μg/mL to meropenem (MEPM) were isolated from 6 patients hospitalized at the general hospital S (2 cases) and hospital A (4 cases), close to the hospital S. Five elderly patients among these six cases came from nursing care facilities or nursing care-related medical facilities. All elderly persons (mean age : 81.7 years) were diagnosed as having pneumonia at the time of admission and the problematic PRSP was isolated from sputum samples collected on admission. Notably, all of these PRSP isolates simultaneously showed high resistance to macrolide agents mediated by an erm (B) gene and to fluoroquinolone agents via mutations in the gyrA and parC genes. Eventually, they were identified as multidrug-resistant S. pneumoniae (MDRSP) with high resistance to many agents. The capsule type of all strains was serotype 19F and multilocus sequence typing (MLST) revealed that they belonged to clonal complex (CC) 7993, which has not been reported before. It was thus concluded that the MDRSP that had spread within the nursing facilities was transmitted to the general hospitals via the elderly inpatients with pneumonia caused by these agents. Although one case finally had a poor outcome, the pneumococcal infection was not the direct trigger of the event. The current ratio of MDRSP is concluded to be very low. However, general hospitals that accept patients for therapeutic purposes from nursing-care facilities have to share epidemiological information in a timely manner with the nursing homes to prevent nosocomial infections.
[Background] For effective non-routine vaccination in women of childbearing age as a countermeasure against congenital rubella syndrome (CRS), it is important to know the specific age group in which fewer members have rubella immunity. [Methods] We analyzed rubella hemagglutination-inhibition (HI) antibody data (about 890,000) accumulated from 2008 through 2013 at a commercial diagnostic laboratory, which originated from the serum specimens sent mainly from obstetrics & gynecology clinics and hospital departments in Japan. Changes during the above period in the pattern of the annual curve for the prevalence of rubella antibodies (HI antibody titer ≧8) by age, were observed. [Results] The antibody prevalence among women in their twenties decreased gradually from 2008 to 2013. However, the prevalence at ≦22 years of age in the 2013 specimens was found to have risen, which we believe is the effect of the five-year interim vaccination program for high-school students that began in 2008. The lowest antibody prevalence at 23 years of age in 2013 corresponded to the highest numbers of female patients at the same age in the 2013 rubella epidemic among the adult population. [Conclusions] The analysis of extensive data accumulated for rubella anti bodies assayed at the commercial diagnostic laboratory was useful for monitoring the susceptibility of the women to rubella infection in Japan, and that the Oct. 1987 to Mar. 1990 birth cohort (age 23－25 in 2013) is a high-risk group for CRS.
A 48-year-old female with a past history of systemic lupus erythematosus had developed autoimmune hepatitis (AIH) at the age of 45 years, and administration of PSL 30mg/day was initiated. However, AIH exacerbation was suspected based on elevation of hepatic and biliary tract enzymes such as ALP (1207U/L) with a fever of 38ºC after tapering off the steroids to PSL 7.5mg daily, and she was thus hospitalized. A liver biopsy was recommended, but she refused. Thus, we suspected concomitant AIH and autoimmune cholangitis (AIC). Although high-dose steroid treatment including steroid pulse therapy was administered, there was no improvement. We performed a liver biopsy on the 66th hospital day, after obtaining the patientʼs consent. Epithelioid granuloma was detected in the liver leaflet as the background of the AIH and AIC findings. In addition, acid fast bacteria were detected with auramine and Ziehl-Neelsen staining, raising the possibility of tuberculosis. Additionally, granuloma was also seen in her bone marrow, and miliary tuberculosis was suspected. Anti-tuberculous therapy with isoniazid, rifampicin, ethambutol and pyrazinamide was initially administered, but the regimen was changed to levofloxacin, ethambutol, and streptomycin due to the side effects of the earlier medications. Liver functions improved and the inflammatory reaction became negative. The patient was discharged on the 138th hospital day. Ultimately, no acid fast bacteria were detected with culture, PCR of her bone marrow, or liver biopsy. However, miliary tuberculosis was definitively diagnosed from the pathological findings and her clinical course. AIH was an underlying disease, and the discrimination from AIH exacerbation was difficult. Consequently, the diagnosis was miliary tuberculosis without the lung involvement and the main lesion was in the liver. It is important to take account of miliary tuberculosis in the differential diagnosis of fevers of unknown origin with elevation of hepatic and biliary tract enzymes, and to make a definitive diagnosis with a liver biopsy.
A 63-year-old previously healthy man was admitted to our hospital with diarrhea that had lasted for about 4 weeks, high fever and dyspnea. Chest computed tomography showed consolidation with a low density area in the right middle lobe and small nodules with feeding vessels in the right upper lobe. On Day 8, a cavity was observed in the consolidation, and the lymph nodes in the mediastinum became necrotic. Yersinia pseudotuberculosis (serotype 4b) was cultured from blood, bronchial washing fluid, and lung tissue specimens. We diagnosed the lung lesions as septic pulmonary embolism caused by enterocolitis. We started treatment with tazobactam/piperacillin. It has been reported that high-dose ceftriaxone (CTRX) is effective,but CTRX at normal doses and other β-lactams are less effective or even ineffective. Therefore, we changed to CTRX (4g/day) on Day 5, CTRX (2g/day) on Day 8, and oral cefditoren pivoxil (600mg/day ; a thirdgeneration cephalosporin) on Day 18. Antibiotic therapy resulted in a favorable response. The patient was discharged from our hospital on day 25 in good health. To the best of our knowledge, this is the first case of a lung abscess caused by Y. pseudotuberculosis reported in Japan.
We experienced two cases of pulmonary aspergillosis, which deteriorated during treatment with generic itraconazole (ITCZ) because of low plasma concentration. One case was chronic pulmonary aspergillosis and the other was allergic bronchopulmonary aspergillosis (ABPA). Treatment of both cases was started with a brand-name-ITCZ, and changed to a generic ITCZ. Deterioration of pulmonary aspergillosis occurred after 8 months and 9 months from change to generic ITCZ respectively. In the first case, the ITCZ-plasma concentration was 46.9ng/mL and of OH-ITCZ 96.5ng/mL with generic ITCZ at the dose of 300mg/day, but increased to 1,559.7ng/mL and to 2,485.0ng/mL with the brand-name-ITCZ 300mg/day, respectively. In the second case, the ITCZ-plasma concentration was 27.2ng/mL and of OH-ITCZ 20.1ng/mL with 150mg/day for generic ITCZ, but reached 857.3ng/mL and to 1,144.2ng/ml with the brand-name-ITCZ 300mg/day, respectively. After treatment failure, the first case was changed to voriconazole, then brand-name-ITCZ 300 mg/day, and the second case to the brand-name-ITCZ 300mg/day, with successful clinical course. Plasma concentrations of ITCZ can differ significantly depending on the patient or type of ITCZ. The ITCZ-plasma concentration should be controlled after changing from a brand-name-ITCZ to a generic ITCZ.
An 80-year-old Japanese man had a fall presented with a 3-week history of right lumbago exacerbated by body movement as well as a 1-week history of anomalous behavior and appetite loss. He visited our hospital complaining of difficulty in standing up. He had a history of mitral prolapse due to an unknown rupture of the chordae tendineae 3 years earlier, which resulted in moderate mitral valve regurgitation and atrial fibrillation. Upon visiting the hospital, he had petechial hemorrhage and jaundice of the conjunctiva, a systolic murmur (Levine II/VI) at the apex and 4th interspace of the left sternal border, and a positive right straight leg raising test result. Moderate bilirubinemia and disseminated intravascular coagulation which were considered to have been produced secondarily were observed. Infective endocarditis was suspected, and 3 sets of blood culture were extracted. The patient was admitted on the same day. Blood cultures were positive for Streptococcus gallolyticus subsp. gallolyticus (6/6) on the following day. Transesophagela echocardiography was carried out on the same day, and vegetation with a diameter of 4mm was observed in the anterior mitral leaflet ; the patient was subsequently diagnosed as having infective endocarditis. Colonic endoscopy was performed after hospitalization. Twelve colonic adenomata were found, and endoscopic mucosal resection was performed on one polyp. The bacterium found in the culture was classified as Streptococcus bovis type I, which causes infective endocarditis and bacteremia. Furthermore, this bacteria is a relatively rare causative organism of infective endocarditis. Tolerance to macrolide and tetracycline are reported in the literature. Moreover, the cell wall of this bacterium may have low pathogenicity as well as cause chronic inflammation in the large intestine mucous membrane, colonic polyps, and colorectal cancer. Several colonic adenomata and a partial shift to a malignant pathology were observed in this case. When this bacterium is detected, searching for a pathological change in the large intestine is believed to be indispensable.