FUJI DRI-CHEM is a highly sensitive immunochromatographic detection system using silver amplification for ｔhe influenza virus (silver amplification method). We compared the results between clearline as a conventional immunochromatographic method (conventional method) and the silver amplification method using 203 specimens obtained between December 2014 and January 2015 in Nagasaki University Hospital. The concordance rate between the two methods was 94.1% (191/203). The positive rate was higher in the silver amplification method (15.8%, 32/203) than in the conventional method (10.8%, 22/203). In this study, physicians decided treatment option based on the result of the conventional method, because we did not report the result of the silver amplification method. Among 32 positive cases in the silver amplification method which were considered to be true positive, a neuraminidase inhibitor was administered to 9.1% (1/11) of the negative cases and 90.5% (19/21) of the positive cases in the conventional method. Conversely, an antibacterial drug was administered to 45.5% (5/11) of the negative cases and 19.0% (4/21) of the positive cases in the conventional method. Furthermore, 6 cases, which were negative in the conventional method and positive in the silver amplification method, were hospitalized without diagnosis of influenza and appropriate administration of neuraminidase inhibitors. These results suggested that the silver amplification method with high sensitivity can contribute to the appropriate use of neuraminidase inhibitors, reduction of unnecessary use of antibacterial drugs, and appropriate infection control.

Bacterial sepsis is a leading cause of death worldwide. Rapid identification of causative pathogens is particularly important for treatment success, but conventional methods such as blood culture are time consuming. In this study, we developed and evaluated a combined cell-direct PCR/nucleic acid lateral flow (cdPCR/NALF) assay for rapid detection of bacterial DNA from Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter cloacae which are often isolated from blood culture. We focused on the process that neutrophils ingest bacteria during the early stage of infection. First of all, we prepared leukocyte samples which ingested one of the seven target bacterial strains in vitro and applied them to the cdPCR/NALF assay. By using the cdPCR assay, the bacterial DNA was directly amplified from monolayers of leukocytes coated on PCR tube. The species of bacteria were exactly identified by the NALF assay in a species-specific manner. Next, we compared the detection limit of a culture method and the cdPCR/NALF assay using blood incubated with E. coli or S. aureus in vitro. With the cdPCR/NALF assay, bacterial DNA in neutrophils was directly detected from whole blood within 4.5 h. Positive result with the cdPCR/NALF assay was also obtained from some culture-negative samples (＜10 colony forming unit/mL). Finally, the number of bacteria in the neutrophils was estimated with a realtime PCR assay. Positive result from the cdPCR/NALF assay was obtained when approximately 10¹ cells of bacteria were present in 200,000 leukocytes. These results indicated that the cdPCR/NALF assay was able to detect bacterial DNA in neutrophils with high sensitivity and specificity. The proposed assay is expected to have broad applicability in many clinical laboratories for identifying causative pathogens in sepsis.

We report herein on a Japanese patient with Ancylostoma ceylanicum infection on returning from Papua New Guinea who was diagnosed by molecular identification of the parasite eggs. The patient was a 26-yearold male who stayed at Lorengau city, Manus Province, Papua New Guinea for 2 years. He was providing guidance about agricultural technology and doing his work barefoot with local residents. After returning from Papua New Guinea, hookworm eggs were detected during a feacal examination as part of a health checkup and he was referred to our hospital for further examination and treatment. He had not had any health problem such as dermatitis, fever or respiratory or abdominal symptoms during his stay in Papua New Guinea. On admission to our hospital, the laboratory data revealed a normal WBC count with hypereosinophilia (20.9%). Feacal examination with the Kato cellophane thick smear technique showed 220 eggs/g feces of hookworm eggs. For species identification, DNA extracted from eggs obtained by the floatation method with saturated sodium chloride solution were subjected to a PCR assay specific for the mitochondrial cytochrome c oxidase subunit 1 (Cox1), ribosomal internal transcribed spacers (ITS) -1 and ITS-2 genes. The cox1 region was very close to, and ITS-1/ITS-2 region were shown to have a 100% sequence identity with the A. ceylanicum sequence. The patient was treated with a single dose of pyrantel pamoate (10 mg/kg). No eggs were found in further feacal examinations and the eosinophilia improved to a normal level at 4 weeks after the treatment. Eosinophilia in returning travelers is one of the clues for suspicious helminth infections even though the patients are asymptomatic. Physicians should recognize the possibilities of helminth infection including hookworm and proceed to appropriate parasitological examinations considering the countries the travelersʼ have visited, their living environment, their activities while there, and the endemic parasite species.

A 59-year-old man was referred to our hospital with acute respiratory failure. He had returned from Hong Kong one week before the symptoms appeared. Although avian influenza has been reported in China since 2013, a pharyngeal swab revealed influenza A (H1N1) pdm09 instead of influenza A (H7N9). The patient required intensive care including extracorporeal membrane oxygenation and continuous hemodiafiltration. Emerging and re-emerging infectious diseases are globally endemic. However, intensive care systems in Japan might not be sufficient to care for patients presenting with acute respiratory failure after returning from abroad. An optimal system for the acceptance and intensive care of such patients should be considered.

A 70-year-old man, with abnormalities on his chest X-ray, was admitted to our hospital. He had a history of hypersensitivity pneumonitis and tuberculosis, but he was not being treated with any medication, including steroids, at the time of admission. On admission, chest computed tomography (CT) revealed a cavity with consolidation in the left upper lobe and ground glass opacity in the right upper and lower lobes of the lungs. Cunninghamella bertholletiaewere isolated from the CT-guided aspiration specimen. After three weeks of treatment with liposomal amphotericin B and itraconazole, the chest CT showed minor improvement in the cavity. After bronchial arterial embolization, a left upper lobectomy was performed. Histopathological examination of the resected left upper lobe revealed fungal hyphae in the cavity, which was surrounded with fibrosis, and small, necrotizing granulomas. Thus, the patient was diagnosed as having pulmonary C. bertholletiae infection, arising in a residual tuberculous cavity. Twelve days after surgery, respiratory failure developed, and progressed rapidly, despite administration of steroid pulse therapy and mechanical ventilation. The patient died one month after the surgery.

A previously healthy 47-year-old male car driver visited our hospital because of 4-day history of high fever and multiple arthralgia of the major joints. Laboratory data showed a high level of CRP (25.1mg/dL), severe thrombocytopenia (18,000/μL), and liver dysfunction (AST 320U/L, ALT 772U/L).
Physical examination revealed polyarthritis of the shoulders, elbows, knee joints, ankles, and hip joints. A pinkish macro rash was visible on the lower abdomen, lower extremities, and foot arches. Small black crusts on his right index finger with little discharge were incidentally found, and the patient reported that he had been bitten by his dachshund one day before the onset of the fever. Soon after admission, he was given platelet transfusion, low-molecular-weight heparin and Imipenem/Cilastatin (IPM/CS) under the tentative diagnosis of sepsis. Gram-negative thin rod-shaped bacteria were observed in the initial blood cultures after 48 hours, which was identified as Capnocytophaga canimorsus by mass spectrometry, PCR and sequence analysis of 16S rRNA gene and gyrB gene. IPM/CS was continued for 14 days. Physical symptoms such as fever, rash and multiple arthritis improved within 10 days. The platelets, CRP, and AST/ALT returned to near normal levels after 12 days. CT, MRI and ultrasound examinations of the painful joints revealed a small amount of fluid in the knee joints, but were otherwise non-specific. We report herein on a case of C. canimorsus sepsis which presented with polyarthritis of the major joints and a multiple pinkish macro-rash, treated adequately with IPM/CS. Early diagnosis and immediate broad-spectrum antibiotics could be the keys to the treatment of severe C. canimorsus infection.

We present 2 cases of disseminated Streptococcus agalactiae bacteremia. The first case was a 62-year-old man who suffered from S. agalactiae bacteremia with vertebral osteomyelitis and discitis with paravertebral infection, multiple arthritis, meningitis and a brain abscess. He was treated with long-term antimicrobial therapy. The second case was a 69-year-old man who suffered from S. agalactiae bacteremia with vertebral osteomyelitis and discitis with paravertebral infection, endophthalmitis and a psoas abscess. He was treated with drainage and long-term antimicrobial therapy. Although neither case was diagnosed as having definite infective endocarditis, they were complicated with multiple metastatic abscesses. S. agalactiae is not a typical causative organism of infective endocarditis. However it can complicate disseminated infection in a similar manner as infective endocarditis.

A 56-year-old woman with a history of bronchiectasis presented with fever and a wet cough in August 2015. Chest radiography and CT scans carried out by her local doctor showed bronchiectasis and bronchial wall thickening with an infiltration shadow in the lingular lobe and left S⁶. No pathogenic bacteria were detected from a sputum culture, a bronchoscopy was performed and Exophiala dermatitidis was cultured from the bronchoalveolar lavage fluid.
She was diagnosed as having pulmonary phaeohyphomycosis caused by E. dermatitidis. Itoraconazole 150mg/day in capsule form was started in December 2015. Before confirming any amelioration, she was referred to our hospital in April 2016. We switched the treatment to itraconazole oral solution 200mg/day and it improved her symptoms and laboratory findings. We reported herein on this rare case of pulmonary phaeohyphomycosis caused by E. dermatitidis and effectively treated with itraconazole oral solution.

During our medical rescue operation following the Kumamoto Earthquake which struck in April 2016, a number of victims exhibiting digestive symptom visited our first-aid clinic beside the Large-Scale Evacuation Shelter which was opened at a middle school in the northwest of Kumamoto prefecture. As some of the patients were diagnosed as having noroviral infection, we report herein on the time course and our intervention to prevent the infection spreading.
Notably, the number of patients with gastroenteritis increased rapidly（12 patients in one day）, especially after heavy rainfall persisiting for a whole day, and at least one patient was confirmed as having noroviral infection. Therefore, we decided to conduct the interventions to prevent spread of infection, including : i）cleanup of the evacueesʼ dwelling space associated with regulations concerning outdoor shoes ; ii）sterilizing all restrooms with sodium hypochlorite ; iii）encouraging hand hygiene ; and iv）isolating patients with diarrhea. Consequently, the number of patients gradually decreased.
According to the summarized data from April 16th to May 15th, 64 patients with diarrhea visited our aid station. Among them, more than 11 patients were tested with a rapid noroviral infection diagnosis kit,and two were positive. The mean incidence of infectious gastroenteritis per 1,000 evacuees was 5.8 persondays. We were able to control of infection in this shelter in a relatively short period. In conclusion, we should consider the early intervention to prevent the spread of infection, and furthermore, preparation beforehand of infection control manuals and medical supplies are extremely important.