Human enterovirus D68 (EV-D68) is a member of the Enterovirus genus (EVs) within the Picornaviridae family, and generally associated with respiratory tract infection. Meanwhile, previous reports suggest that EV-D68 was also associated with acute flaccid paralysis in the clinical cases in USA and Japan. Two conventional PCR assays have been commonly used for genetic analysis of EVs. One is the RTsemi-nested PCR assay (VP4-VP2-PCR) that amplifies the VP4-VP2 region for detection of EVs with high sensitivity and the other is the CODEHOP RT-semi-nested PCR assay (CODEHOP PCR) that amplifies the VP1 region for typing. These assays are useful for detection and identification of EVs in many clinical cases. However, we experienced some cases in which we could not identify EV-D68 with CODEHOP PCR from clinical specimens in spite of the results that EV-D68 sequences were detected by VP4-VP2-PCR. In addition, these assays would have trouble in detecting target sequences in those cases where the specimens under examination have been acquired from patients infected with multiple types of EVs. Therefore, we tried to develop a novel RT-semi-nested PCR assay that has high sensitivity and specificity for EV-D68. We designed original primers to be used for the amplification of the VP1 region of EV-D68 and optimized the RT-semi-nested PCR conditions. Sensitivity and specificity were examined with previously accumulated clinical specimens. As a result, we could confirm that our developed PCR assay had higher sensitivity than VP4-VP2-PCR and the assay had no cross reactivity with 23 kinds of enterovirus types, HRV-A, HRV-B, and HRV-C. We could identify EV-D68 with the assay in 2 specimens that were typed as another one by CODEHOP PCR. Furthermore, 1st-PCR of the assay had a higher detection capability from the clinical specimens, and we could obtain sequence data of the VP1 region sufficient to construct a phylogenetic tree. The results of the phylogenetic analysis revealed that lineage 1, 2 and 3 were detected in Saitama City. In conclusion, the PCR assay we developed in this study was useful in the diagnosis of EV-D68 from various kinds of clinical specimens.

Patients definitively diagnosed as having Capnocytophaga infection at our hospital between January 2004 and December 2015 were retrospectively investigated. Nine men and one woman (10 in total) were diagnosed as having Capnocytophaga infection. Their age ranged from 26 to 79 years (median：53.5 years). Patients were divided into three groups：(1) bacteremia in patients with hematological malignancies (Group A), (2) lung abscess in healthy persons (Group B), and (3) bacteremia as zoonoses (Group C). Eight strains of Capnocytophaga sputigena and 2 strains of Capnocytophaga canimorsus were isolated. All strains were susceptible to piperacillin, imipenem, meropenem, doxycycline, minocycline, and rifampicin, but resistant to gentamicin, polymyxin B, and sulfamethoxazole-trimethoprim. Susceptibility to other antibiotics varied. Some strains, especially those isolated from Group A patientsʼ were resistant to antibiotics such as penicillins, cephalisporons, and fluoroquinolones. Although Capnocytophaga infection is relatively rare, clinicians should be aware that prompt diagnostic procedure and appropriate treatment are required in the management of these infections.

It is important to understand the current results concerning isolated bacteria and their antimicrobial susceptibility through urine cultures to perform diagnosis and treatment of urinary tract infections among ill companion animals. However, there are very few investigations regarding the data of urine cultures based on nationwide-surveillance in Japan. The purpose of this study was to determine species identification of the bacteria and their antimicrobial susceptibility through urine cultures obtained from the animals with a nationwide approach. We analyzed the nationwide-surveillance data of bacterial identification and drug susceptibility by standard methods with urine specimens collected from approximate 1,000 animal clinics/hospitals from 1^st August 2014 to 31^st July 2016 (for two years). Of 6,179 urine samples collected, there were 5,246 bacterial strains isolated from the 3,941 specimens. The most prevalent species identified were Escherichia coli (34.4%)/Staphylococcus intermedius group (12.9%)/Enterococcus faecalis (10.2%)/Klebsiella pneumoniae (6.6%)/Proteus mirabilis (5.8%)/Pseudomonas aeruginosa (4.0%)/Enterococcus faecium (4.0%)/Group G Streptococci (3.2%)/Coagulase-negative Staphylococci (2.2%)/Enterobacter cloacae (1.7%), indicating that the total proportion was 85.0% of all isolated bacteria. We found that the rate of methicillin-resistant Staphylococci (MRS) was 57.6% among the isolates from the S. intermedius group. We also observed that the detection rates of extended-spectrum β-lactamase (ESBL) were E. coli 42.3%/K. pneumoniae 63.3%/P. mirabilis 20.3% among the Enterobacteriaceae isolates from 1^st August 2015 through 31^st July 2016. Carbapenem-resistant strains,multidrug-resistant P. aeruginosa, and vancomycin-resistant strains were not detected. Just as in human infections, the floral bacteria in the rectum were highly isolated from the animalsʼurine, and the proportions of MRS and ESBL-producing Enterobacteriaceae isolates were high-level. Our observations indicate the current characteristics of antimicrobial resistance among the urine-origin isolates from the animals, suggesting that we should promote antimicrobial stewardships in the animal clinical setting.

This study used a visual inspection to determine the dispersion of simulated vomitus and also used a coliphage as a surrogate for the norovirus. Gross visual observation revealed that dispersed droplets were noted 3.1m in a horizontal direction however the coliphage could be detected at a distance of 5m away. When recovering the airborne virus after the simulated vomitus was released, the coliphage could be detected in the air up to 89 min after release. The current findings indicate that simulated vomitus is dispersed at a greater distance than previously reported. Findings also indicate that droplets are airborne for a prolonged period after release. The fact that vomitus is widely dispersed must be taken into account, sufficient ventilation must be provided, and a 5m ring around the patient must be cleaned and disinfected.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) strains emerged in the 1990s. Initially, cases of CA-MRSA were differentiated from those of hospital-acquired MRSA (HA-MRSA) according to the clinical setting. However MRSA strains demonstrating the genetic characteristics of CA-MRSA,including strong susceptibility to several antibiotics, inclusion of staphylococcal cassette chromosome (SCC) mec type IV or V, and presence of the Panton-Valentine leukocidin (PVL) gene, are increasingly being isolated from hospitalized patients. Because the epidemiology and transmission of CA-MRSA in Japan remain unclear, we retrospectively evaluated the 51 MRSA strains isolated at our institution throughout 2014 ;these strains comprised 12 isolates from outpatients (outpatient group), 30 from admitted patients (inpatient group), and the remaining 9 cases from patients of the neonatal intensive care unit (NICU group). We analyzed the SCCmec type, PVL status, and drug susceptibilities of the isolated strains and used the PCR-based open reading frame typing (POT) assay to analyze genetic similarity among them. The prevalence of SCCmec type II (characteristic of a classic HA-MRSA) and SCCmec type IV was respectively 16.7 and 58.3% in the outpatient group, 50.0% and 46.7% in the inpatient group, and 0% and 66.7% for the NICU group. In addition, 4 PVL-positive strains were identified, all of which were outpatient group isolates that harbored SCCmec type IV. The MRSA strains of 3 patients whose NICU stays overlapped had the same POT index. Whereas 88.2% and 94.1% of SCCmec type II strains were resistant to clindamycin and levofloxacin, only 11.1% and 55.6% of type IV isolates were resistant to these agents. In conclusion, our results suggest that SCCmec type IV MRSA strains are expanding from their typical community context into in-hospital settings,where multidrug-resistant SCCmec type II MRSA isolates have traditionally been considered to predominate. In addition, SCCmec type IV MRSA strains isolated from 3 NICU patients showed evidence of horizontal transmission.

We herein report on the case of a 37-year-old HIV-infected Japanese man who was referred to our hospital with cervical lymphadenopathy. He was diagnosed as having extracavitary primary effusion lymphoma (PEL), and treatment with antiretroviral agents and CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) combination chemotherapy was initiated. Complete remission was achieved after 6 cycles of chemotherapy. The optimal treatment for extracavitary PEL is not clearly defined. Our case implies the benefit of using CHOP and concurrent antiretroviral therapy for this rare entity.

Helicobacter cinaedi, which is one of the enterohepatic Helicobacter. sp, causes bacteremia in immunocompromised and sometimes immunocompetent patients with skin lesion such as cellulitis. A 26-year-old woman under complete remission from acute lymphoblastic leukemia after chemotherapy (JALSG ALL202-U) was referred to our outpatient office with the complaint of about 2 months persistent erythema in the bilateral lower extremities. The chemotherapy had been completed 1 and a half years before, and since then trimethoprim-sulfamethoxazole and acyclovir for prophylaxis had been discontinued. The patient had a past medical history of bacteremia due to H. cinaedi treated with amoxicillin and doxycycline when she underwent maintenance therapy for leukemia. She visited the emergency room in our hospital with the complaint of skin lesions on her legs with high fever 2 months after her delivery. Her fever resolved immediately without antibiotic therapy. A total of 6 sets of aerobic and anaerobic blood culture were all negative. Because stool culture and nested PCR for H. cinaedi were both positive, we suspected H. cinaedi infection. We started 14 days of amoxicillin and consequently 28 days of kanamycin for therapeutic diagnosis. Her symptoms which had lasted for about 6 months improved 3 weeks after starting the antibiotics. Chronic skin lesions associated with H. cinaedi as in this case may be underdiagnosed due to the difficulty of diagnosis and its quite chronic clinical course which is unlike bacterial infection. It is difficult to decide whether H. cinaedi isolated from the stool samples was colonizing or was a sign of infection. However,this fact lead to the diagnosis of H. cinaedi infection. Further case reports will be necessary to confirm the association between H. cinaedi and chronic skin lesions.

A 78-year-old man presented with fatigue and muscle weakness. His serum creatine kinase level was elevated and an electromyogram showed myogenic conversion. He was diagnosed as having polymyositis. Whole-body computed tomography and an endoscopic study ruled out malignancy. He was prescribed 55mg of prednisolone (1mg/kg/day) and soon thereafter his muscle strength returned to normal. However, while on the steroid, he developed diarrhea. Fecal culture and a Clostridium difficile antigen test were negative. Nonetheless, he was prescribed metronidazole, 1,000mg, twice daily, as empirical therapy for C. difficile infection. His diarrhea progressively worsened, resulting in massive melena, shock, and a fever of 39℃. A subsequent blood culture was positive for Escherichia coli. He was started on 3g meropenem/day together with fluid and blood transfusions. An upper gastric endoscopy repeated during gastrointestinal bleeding showed diffuse hemorrhagic duodenitis and bleeding erosions. Duodenal biopsy showed strongyloidiasis. After treatment with 12mg ivermectin once every 2 weeks his fecal test remained positive；he was therefore started on a daily dose of ivermectin and albendazole. Despite treatment, he died from gastrointestinal bleeding. The autopsy revealed no evidence of active strongyloidiasis infection. This case demonstrates that, even with successful treatment, the complications of strongyloidiasis, especially gastrointestinal bleeding, can cause death. Thus, in Japan, based on epidemiologic trends, patients who have to undergo strong immunosuppressive therapy, including large doses of steroids for rheumatic disease, should be screened and prophylactically treated for Strongyloides stercoralis infection.

Toxoplasmosis is an infectious disease transmitted by ingestion of inadequately cooked meat, etc. If a woman is infected with Toxoplasma gondii for the first time during pregnancy, the fetus is at risk of congenital toxoplasmosis (via placental infection). We herein report on a patient who was born to a mother with a negative toxoplasma antibody test at an early stage of pregnancy, and was later diagnosed as having congenital toxoplasmosis based on decreased visual acuity at a medical check-up. A 3-year-old boy presented to our hospital with suspected low vision in the right eye. Fundus examination showed macular scarring in the right eye with accompanying reduced visual acuity. Both mother and child were positive for toxoplasma antibody IgG and negative for IgM, and the child was diagnosed as having congenital toxoplasmosis based on characteristic fundus findings. While being followed closely without treatment, retinochoroiditis of the left eye developed at the age of 4 years and 6 months, and treatment with pyrimethamine, sulfadiazine, leucovorin, and steroid was then started at another institution. This treatment improved visual acuity and fundus findings in the left eye. Congenital toxoplasmosis is an infectious disease in which early diagnosis and early treatment are beneficial. No therapy, however, has yet been established for children with non-apparent disease at birth and whose diagnosis was made after infancy, such as the child in our present report. Taking these factors into consideration, antibody tests during the prenatal check-up are important in order not to overlook potentially treatable pregnant women or infants, though the usefulness of antibody screening tests in all pregnant women has not been established in Japan. A thorough review of antibody screening tests in pregnant women, given circumstances such as the recent changes in food culture and internationalization,would appear to be warranted.