深在性真菌感染症患者より分離される真菌の多くはCandida やCryptococcus などの酵母様真菌である．それらの抗真菌薬感受性は菌種により異なることから，迅速な菌種同定が治療において重要である．今回，新規自動同定装置（BD Phoenix ID yeast）による臨床で高頻度に分離される酵母様真菌同定および同定所要時間に関する検討を行い，BD Phoenix ID yeast により同定された酵母様真菌106株とAPI 20C AUXとの 一致数および不一致数は各々97株（91.5%），9 株（8.5%）であった．両者での不一致9例のうちBD Phoenix ID yeast 5 例，API 20C AUX 1 例は遺伝学的菌種同定結果と一致し，残り3 例は両同定法と遺伝学的同定法で異なる同定結果となった．同定所要時間はC. albicans，C. tropicalis，C. parapsilosis の約60% の株は4 時間で同定結果が得られ，約8 時間ではこれらの菌種に加えC. glabrata を含む主要な4 菌種の約90% 以上が同定された．BD Phoenix ID yeast はAPI 20C AUX との不一致株に対して遺伝学的同定結果とほぼ一致し，約80% の酵母様真菌を8 時間以内に同定可能であることから，臨床で有用な自動同定システムであることが示唆された．

2013年，さいたま市内で2つの腸管出血性大腸菌（enterohemorrhagic Escherichia coli；EHEC）O157感染事例が発生した．それぞれ異なる医療機関から腸管出血性大腸菌感染症発生届が提出され，ベロ毒素（Vero toxin；VT，または志賀毒素Shiga toxin；Stx）について，一方にはStx1産生，もう一方にはStx1およびStx2産生と記載されていた．通常別事例とされる内容であったが，保健所による聞き取り調査により，2事例に共通食があったことが判明した．最終的には，それぞれの事例の3名と1名からEHECが分離され，これら4株を当センターで解析した．その結果，全てO157：H-であり，Stx 遺伝子（stx）解析の結果，stx1 およびstx2 を保有していることが明らかになった．性状やPFGEの泳動パターンも一致したため，この4 株は同一クローン由来であると示唆された．一方，これらの菌株が保有していたStx2 遺伝子は，サブタイプのstx2c だった．Stx2のサブタイプの中には，Stx産生性を確認する検査法で検出感度が低いものがある． 一方の医療機関の発生届にStx2の記載がなかったのは，Stx産生性検査のこのような特性が影響した可能性が示唆された．聞き取り調査により発生届の内容が異なる2 事例の関連性が疑われ，菌株の検査によりそれが裏付けられた．本事例から，地方衛生研究所の検査体制の整備や精度の確保，さらに，疫学調査における各機関の相互の連携や迅速な情報のやり取りができる協力体制の確立が重要と考える．

序文：近年，HIV感染者の梅毒感染は世界的に問題になっている．梅毒は臨床症状からの診断はしばしば困難であり，HIV感染症に合併すると臨床症状や検査結果が非典型的になるため，診断や治療効果の判定には注意が必要である．また，梅毒は濃厚な性的接触がなくても感染し，再感染を繰り返す例も多い．米国のガイドラインでは，HIV感染者は症状の有無に関わらず最低年1回の定期的な検査が推奨されているが，本邦の臨床現場での検査と感染例の実態は明らかではない． 対象と方法：2011年6月から2012年6月までの期間に東京医科大学病院臨床検査医学科外来への受診歴があり継続的に経過観察を行っているHIV感染者を対象として，MSM症例で同期間中にtreponema palli dum latex agglutination（TPLA）法およびrapid plasma reagin（RPR）法検査を1回以上行った症例について解析した． 成績：対象者1,000症例のうちMSMは935例であった．そのうちTPLAおよびRPR法検査が1回以上行われたのは723症例であった．TPLA陽性は443例（61.3%），RPR陽性238例（32.9%）であった．RPR陽性例のうち93例95件が対象期間中の梅毒感染，19件は新規診断例と考えられた．93例の年齢中央値は37歳，CD4陽性細胞数中央値は465/μL であった．抗HIV療法施行例が76件，HIV-1 RNA量40copies/mL 未満は61件であった．顕性梅毒は44% で，最も多く認められた症状は2期症状の皮疹であった．約半数は定期スクリーニング検査を契機に梅毒が診断された．3分の2では梅毒の既往歴があった． 考察：HIV感染患者に梅毒感染者が多数認められた．本邦のHIV感染者には梅毒感染の注意喚起が必要であり症状の有無にかかわらず定期的な検査を行うことが早期の治療介入のために重要である．

感染管理上，手指衛生の遵守は重要であるが，医療現場における手指衛生は十分ではない．そのため，手指衛生の遵守率を評価し，その向上に向けた様々な取り組みが行われている．しかし手指衛生評価法のスタンダードである直接観察法は人的負担が大きく，ホーソン効果によるバイアス出現などの問題を有している．手指衛生自動モニタリングシステム（automated monitoring system，以下AMS）は，手指衛生機会と手指衛生実施の双方を認識することで，手指衛生遵守率（以下，遵守率）を自動でモニターし続けることが可能である．さらに個人ごとの遵守率が算出されるため，的確なフィードバックが可能となる．また，手指衛生を忘れたときに知らせてくれるリマインダー機能により，遵守率向上を促す．当院は国内で初めてAMS を導入し，その遵守率測定精度と導入がもたらす効果を検討した．【方法】①A 病棟において3 日間，AMS と直接観察法で遵守率を測定し，両者の遵守率を比較した．②B 病棟において13 週間，AMS を設置し，遵守率の変化を追跡した．最初の4 週間はリマインダー機能のみ使用し，次の4 週間はリマインダー機能に加え，個人ごとの遵守率のフィードバックを実施，最後の5 週間は再びリマインダー機能のみ使用した．【結果】①直接観察法による遵守率は75.0%，AMS による遵守率は78.3% であった．②リマインダー機能のみの最初の4 週間における各週の遵守率は順に48%，47%，47%，44% であったが，個人ごとの遵守率のフィードバックを追加した次の4 週間では55%，68%，71%，68% と遵守率の向上を認め，フィードバック実施前後における遵守率の改善は統計学的に有意であった（p＜0.01）．また，再びリマインダー機能のみとした5 週間後においても遵守率は68% と維持されていた．【結論】AMS は国内医療環境において，モニタリング機器としても，遵守率を改善させる機器としても十分な性能を持っている可能性がある．

We report a case of iatrogenic vesical tuberculosis diagnosed 4 years after intravesical immunotherapy using Bacillus Calmette- Guérin (BCG) for the treatment of bladder carcinoma. A 72-year-old man underwent a transurethral resection (TUR) of multiple noninvasive urothelial carcinomas and intravesical BCG infusion (40mg/week) for 7 weeks to prevent the recurrence of bladder carcinoma. BCG infusion therapy was terminated because of the appearance of Reiterʼs syndrome, including arthritis of the left toe joint, conjunctivitis and non-gonococcal urethritis as complications. The patient suffered from repeated cystitis, bladder atrophy and urethral stenosis. The cystitis improved with the administration of antibiotics (Levofloxacin) but persisted without a complete cure. Four years later, a cystoscopy revealed mucosal erosion and a white coating. An acid-fast bacteria examination of a urine sample using bacteria incubation and DNA PCR revealed the presence of Mycobacterium bovis. Finally, anti-tuberculosis therapy (INH＋REP＋EB) was initiated after the patient was diagnosed as having iatrogenic bladder tuberculosis resulting from BCG immunotherapy. The tuberculosis bacteria subsequently disappeared from the urine samples, and the gross appearance of the bladder mucosa improved. Bladder carcinoma has not recurred to date. Intravesical BCG infusion therapy has a good anti-tumor effect and can help prevent tumor recurrence after TUR therapy in case of noninvasive bladder carcinoma. However, there is a risk of severe complications arising from the BCG infusion. In the present case, an adequate bacteria examination was not performed, even though antibiotics were repeatedly administered for cystitis. In particular, the patient was not tested for the presence of acid-fast bacteria for 4 years after the intravesical BCG infusion therapy. Furthermore, among patients who received anti-bacteria therapy for repeated cystitis after BCG infusion, a bacteria examination including bacteria incubation, was not ordered in 19 out of 30 cases treated at our hospital over the past 5 years. In conclusion, bacteria examination, including tests for acid-fast bacteria, should be immediately performed when repeated and/or persistent cystitis occurs after BCG infusion therapy.

We report a 48-year-old healthy man who presented with a 1-week history of fever and epigastric pain. He had traveled to Indonesia and had been in sexual contact with a local woman 4 weeks prior to admission. His peripheral blood film showed atypical reactive lymphocytes. A serological test for cytomegalovirus IgM was positive and the quantitative cytomegalovirus DNA level was 1.1×10²copies/mL, whereas EpsteinBarr virus IgM, HIV antigen and antibody tests were negative. He was diagnosed as having an acute cytomegalovirus infection and was treated with acetaminophen. However, his clinical symptoms deteriorated on the 4th day after admission and a computed tomography examination showed splenomegaly with wedgeshaped splenic infarctions. Blood culture, antinuclear antibodies, antineutrophilic cytoplasmic antibodies, anticardiolipin antibodies, and lupus anticoagulant tests were negative. The protein C and protein S activities were normal. He was diagnosed as having a splenic infarction caused by an acute cytomegalovirus infection, and intravenous heparin administration was performed. On day 12, his symptoms had improved and he was discharged. Splenic infarctions caused by acute cytomegalovirus infection can develop in immunocompetent patients without any coagulation disorder. The possibility of splenic infarctions should be considered in patients with acute cytomegalovirus infection, especially those experiencing a worsening of abdominal pain.

In general, disseminated cryptococcosis usually occurs among immunocompromised patients, especially those with cell-mediated immunodeficiency, such as HIV-infected patients. We present herein a rare case of an apparently immunocompetent 33-year-old woman who developed disseminated cryptococcal diseases,which included meningitis and pneumonia with eosinophilia, and pulmonary tuberculosis during her disease course. Pneumonia with a diffuse micronodular pattern, immediately followed by meningitis, was diagnosed as disseminated cryptococcosis, because of the presence of yeast-like-fungi demonstrated by transbronchial lung biopsy and a positive cerebrospinal fluid (CSF) culture. In addition, the pneumonia exhibited eosinophilia in the peripheral blood and bronchoalveolar lavage fluid. Re-exacerbation of the pneumonia occurred approximately 3 weeks after onset, along with a sputum culture positive for Mycobacterium tuberculosis.Administration of anti-tuberculosis drugs resulted in recovery from the pulmonary tuberculosis. The treatment of cryptococcal meningitis was initiated using a standard induction regimen ; however, an unrecovered status, highlighted by elevated CSF pressure, persisted. Finally, full recovery was induced by the addition of flucytosine treatment (100mg/kg/day) and repeated daily via lumbar puncture. The allergic condition of this patient may have contributed to the onset of disseminated cryptococcosis.

Toxocariasis causes a variety of symptoms. We experienced a case of toxocariasis which was initially treated with steroids for Eosinophilic Granulomatosis with Polyangitis (EGPA). A 53-year-old woman with the past medical history of bronchial asthma presented at the outpatient department in the middle of August. She complained of chest discomfort lasting for one week. Ischemic heart disease was initially suspected due to ST depression on ECG and positive Troponin I. However coronary angiography did not reveal any abnormality. Her symptoms continued and after one month she presented at the hospital again with an elevated eosionophil count. Chest computed tomography showed ground glass opacities on both lungs. She was diagnosed as having EGPA based on her clinical symptoms and the results of the blood test which were consistent with the diagnostic criteria of EGPA. After prednisolone was prescribed, her symptoms and eosinophilia dramatically improved. However, we found that the histology of the lung and kidney was not compatible with EGPA and the result of serum parasite antibodies turned out to be strongly positive for toxocariasis after initiating predonisolone. Based on this result, we concluded that our patient had a case of toxocariasis and prescribed albendazole in addition to prednisolone. The patient completed a 3-week course of albendazole and a 3-month course of prednisolone without any problems. In general, steroids are not commonly used as a treatment of toxocariasis, however it seems to have been effective in this case. Toxocariasis shows a variety of symptoms and can be misdiagnosed as other diseases such as EGPA.

A 42-year-old woman was referred to our hospital with a diagnosis of influenza A and pneumonia out of the influenza season. Chest CT findings resembled interstitial pneumonia, but we initiated anti viral agents and antibiotics. Flexible fiberoptic bronchoscopy was performed on hospital day 3. Based on the results of an RT-PCR analysis of broncho-alveolar lavage, this patient was diagnosed as having influenza viral pneumonia. In the influenza season, we can easily suspect influenza as a differential diagnosis, even if the patientʼs chest CT findings resemble interstitial pneumonia. Out of the influenza season, clinicians should take into consideration influenza viral pneumonia as a differential diagnosis.