Background：Liver fibrosis progresses earlier and the prevalence of hepato cellular carcinoma (HCC) is higher in HIV/HCV-coinfected patients compared with HCV-monoinfected patients. More careful observation is necessary for patients with advanced liver fibrosis and elderly patients after achieving a sustained virologic response (SVR) with interferon (IFN)-based therapy owing to the high prevalence of HCC. Though an increase of fatalities becomes the problem in HIV/HCV-coinfected patients, mostly through hemophilia,transmitted from non-heated plasma-derived products more than 30 years ago, there are few reports which have investigated the long-term prognosis in Japan.
Materials and Methods：The subjects were 15 HIV/HCV-coinfected patients (5%) among 313 HIV infected patients at Hiroshima University Hospital from April 2005 to October 2016, and we collected data retrospectively from the clinical records regarding the treatment history and outcome of HCV and the longterm prognosis.
Results：From 12 patients among the subjects who were treated with IFN-based regimen, 10 patients (83%) had achieved an SVR. The median age was 50 years and the median observation period was 118 months in 7 patients out of 10 (long-term observation group) who were observed for more than 24 months,and there has been no case of recurrence case in this group. From 4 patients among 5 with a detectable HCV viral load (the detectable viral load group) including 2 previously untreated patients who were treated with Direct Acting Antivirals (DAAs), 3 patients achieved a viral response. One patient developed HCC in both the long-term observation group and detectable viral load group. Both of them were HCV genotype 3a,and had a risk factor for HCC such as diabetes mellitus and drinking alcohol. The results of the liver biopsies were A3, F4 grade (new Inuyama classification) at the point of the operation for HCC.
Conclusions：The treatment outcome for HIV/HCV-coinfected patients was mostly good in our hospital. However, there were cases of onset of HCC in HIV/HCV-coinfected patients similar to that seen in HCV-monoinfected patients regardless of achieving SVR with IFN-based therapy. Clinicians should perform a screening examination for HCC more carefully in patients with advanced liver fibrosis and risk factors for HCC development.
Background：In 2014, an outbreak of autochthonous Dengue Fever (DF) occurred in Japan. However,there are insufficient data on the diagnostic approach when we suspect infection with DF.<BR> Methods：We defined autochthonous DF suspected cases as；I) Patients without any foreign travel history in the previous three months, and II) Patients who were referred from another hospital for the purpose of further examination for DF, or patients who visited our hospital expecting an examination for DF. Clinical and laboratory data were collected from the medical records of the “autochthonous DF suspected cases”who visited the travel clinic of the National Center for Global Health and Medicine, Tokyo, Japan, from 25th August to 26th September, 2014. <BR> Results：Forty-seven patients were included for this study. Nine cases were diagnosed as having DF. Mosquito bite history, history of travel to endemic areas, decreased white blood cell count, and decreased platelet count were statically significant risk factors for DF. Among non-DF cases, nine cases with bacterial infections and six hospitalized cases were included.<BR> Conclusion：The majority of the final diagnoses of autochthonous DF suspected cases were common febrile illnesses, however, there were some bacterial infections and severe cases. Mosquito bite history, history of travel to endemic areas, decreased white blood cell count, and decreased platelet count will be useful for differentiation among DF cases and non-DF cases.
Antimicrobial resistance (AMR) is an increasingly serious global concern for medicine, public health, and the economy. In 2016, the Japanese government announced a national AMR action plan targeting the reduction of antimicrobial consumption and the AMR rate in pathogenic bacteria. Tokyo Metropolitan Childrenʼs Medical Center implemented a coordinated antimicrobial stewardship program (ASP) from 2011 including preauthorization of restricted antimicrobial agents, restrictive reporting on susceptibility to broad spectrum antimicrobials, standardization of infection treatment and prophylaxis, real-time therapeutic drug monitoring, and education on infectious diseases. The study aimed to assess the hospitalʼs current ASP according to the outcome indicators of the National AMR Action Plan. Changes in the antimicrobial consumption rate were measured by days of therapy per 1,000 patient-days and the number of prescriptions per 1,000 visits in fiscal years 2010 and 2015. AMR rates excluding duplicate data were extracted from isolates in fiscal year 2015. The changes in the inpatient and outpatient antimicrobial consumption rate were -8.0% and -27.6%,respectively (goal：-33.3%). The changes in the consumption rate for all intravenous and restricted intravenous agents were＋5.0% and -23.0%, respectively (goal：-20.0%). The changes in the inpatient and outpatient consumption rate of restricted oral agents were -73.9% and -91.2%, respectively (goal：-33.3%). The changes in oral cephalosporins, macrolides, and fluoroquinolones consumption were -49.6%, -54.9% and -85.7%, respectively (goal：-50%). The non-susceptibility rate of Streptococcus pneumoniae to penicillin was 47.8% (goal：≦15%). The methicillin resistance rate of Staphylococcus aureus was 39.4% (goal：≦20%). The non-susceptibility rate of Escherichia coli to levofloxacin was 29.1% (goal：≦25%). The non-susceptibility rates of Pseudomonas aeruginosa, E. coli,and Klebsiella pneumoniae to imipenem were 9.2% (goal：≦10%), 0.8% (goal：0.1-0.2%), and 0% (goal：0.1-0.2%), respectively. Oral cephalosporins, macrolides, and fluoroquinolones consumption rates closely approached the AMR action plan goals due to the restriction of oral 3rd cephalosporins and fluoroquinolones. Although oral macrolides use was unrestricted, improper prescription for viral infections was reduced through education. Consumption of restricted intravenous agents was successfully decreased. However, consumption of the intravenous agents did not decrease due to an increase in the use of nonrestricted intravenous agents. Further assessment of the unrestricted use of intravenous agents is needed. The AMR rate of S pneumoniae, S. aureus, and enterobacteriaceae were also influenced by the transmissions and antimicrobial pressures on both the other hospitals and clinics or at the level of the community. An ASP conducted by a single childrenʼs hospital had a limited impact on reducing the AMR rate of these pathogens, as AMR could emerge elsewhere. The AMR rate of P. aeruginosa to imipenem can be reduced or sustained by establishing an ASP at medical facilities. Judicious use of antimicrobials in all medical facilities including primary care and community hospitals is critical for preventing the emergence of AMR.
Conflicting results have been reported regarding pneumonia as diagnosed using chest X-rays or the clinical severity of RSV and hMPV infection. In this study, we investigated whether chest X-ray-diagnosed pneumonia may be associated with the clinical severity of RSV and hMPV infection. The participants were retrospectively selected from patients hospitalized in Hiroshima City Funairi Citizens Hospital between April 2014 and March 2015 who tested positive with RSV or hMPV rapid tests. Based on chest X-rays,pneumonia was confirmed in 24.6% (31/126 patients) of the RSV-positive and 42.5% (31/73 patients) of the hMPV-positive patients. We found that the percentage of individuals with pneumonia was significantly higher in hMPV-positive than in RSV-positive patients (p＜0.01). We observed no significant difference in clinical severity between patients with RSV-related pneunmonia and those with hMPV-related pneumonia,as assessed using labored breathing, SpO2 on admission, serum CRP level, and duration of hospitalization. We next compared the clinical severity of RSV-positive patients and hMPV-positive patients with or without pneumonia. The patients with pneumonia showed a slightly decreased SpO2 on admission and increased serum CRP level, but these changes were not significantly different from a clinical perspective. There was no significant difference in labored breathing and duration of hospitalization. Thus, our study revealed that the percentage of patients with pneumonia was higher in hMPV-positive than RSV-positive patients；however,this difference cannot serve as a predictive factor of clinical severity. In addition, clinical severity was similar for patients with RSV- and hMPV-related pneumonia.
Viral respiratory tract infection is sometimes complicated by wheezing in infants and small children. In particular for respiratory syncytial virus (RSV), the number of patients with which has increased increases in recent years, surveillance is particularly important. This study was designed to investigate the prevalence of respiratory viruses in children with acute respiratory tract infection. We prospectively examined 301 children with acute lower respiratory infection who were admitted to a single clinic in Matsumoto, Nagano Prefecture (as a model area) from October 2013 to February 2016. Using PCR, we attempted to detect RSV and human rhinovirus (HRV) and investigated the clinical information of these patients. Viruses were detected from 269 (89.4%) patients. RSV was detected in 138 (45.8%) patients, through the epidemic season from late fall to early spring. Patients in whom RSV was detected often had wheezing and the proportion gradually increased in the investigation period. On the other hand, HRV was detected in 112 (37.2%), from which 61.9% of patients demonstrated HRV with wheezing. Our results suggested that HRV infection is involved in the severity of symptoms in the same manner as RSV.
A 34-year-old man with no significant medical history was seen at our outpatient department with a three-month history of weight loss, diarrhea and fatigue. Colonoscopy was performed, showing red and edematous mucosa in the ileocecal valve. A biopsy specimen with hematoxylin and eosin staining revealed basophilic and flocculent colonies that adhered to the surface epithelium. The organisms were dyed black by Warthin-Starry staining. These findings were compatible with intestinal spirochaetosis. We ruled out any other disease through biochemical examination of blood, esophagogastroduodenoscopy, capsule endoscopy,computed tomography and stool culture and diagnosed intestinal spirochaetosis. The patient improved after treatment with 1500mg/day of Metronidazole for 7 days. Colonoscopy was performed again after 8 months. The mucosa in the ileocecal valve was normal, and a biopsy specimen showed the spirochaetal infection had disappeared. Case reports of intestinal spirochaetosis are rare due to the low level of awareness of the disease. The present case suggests that we have to rule out intestinal spirochaetosis as a cause of chronic diarrhea.
Carbapenem-resistant Enterobacteriaceae (CRE) are resistant to almost all β-lactam antibiotics. Colistin,the production of which had been halted in Japan because of its serious side effects and the availability of safer alternatives, was re-evaluated as an antibiotic against CRE and re-approved in March 2015. However,the pediatric use of colistin has been reported in only few studies. A 4-year-old girl with juvenile myelomonocytic leukemia underwent stem cell transplantation (SCT) from her mother after the rejection of umbilical cord blood transplantation. Two months after engraftment, her neutrophil count gradually decreased. She developed sepsis caused by carbapenem-resistant Escherichia coli with severe neutropenia. Although multidrug therapy was initiated, E. coli continued to be detected in her blood cultures. We initiated colistin as an emergency measure and infused it into the patient at a dose of 5mg/kg/day. Despite clinical and microbiological responses and an immediate negativity of blood cultures, she redeveloped a high fever, and E. coli was again detected in her blood cultures. The colistin dose was increased to 7mg/kg/day. Neutrophils from her father were transfused after the patient had the central venous catheter was removed. Eventually,her temperature normalized, and her blood cultures became negative again. Colistin was administered for 14 days. No side effects related to colistin were detected. It is suggested that colistin in multidrug therapy can be safely and effectively used for children with severe CRE infections.
We report herein on what is, to our knowledge, the first case of leptospirosis infection acquired in Guam and imported into Japan. The patient was a 31-year-old Japanese man who stayed in Guam for 4 days in early January 2017. He initially experienced headache and high fever 10 days after returning to Japan, and was admitted our hospital 15 days after returning. On admission, he also had conjunctivitis, renal dysfunction, liver dysfunction, and proteinuria. He reportedly had gone mountain climbing in Guam and on the way getting off the mountain, he had lost his way and walked in the river. We suspected leptospirosis and began administering intravenous ceftoriaxione. However, Leptospira DNA was not detected in the blood collected at admission. His fever and other symptoms subsided within 3 days. A microscopic agglutination test was performed using serum collected on days 3 and 10. This revealed a greater-than-four-fold increase in antibody titers against several strains in serum collected on day 10 and the leptospirosis diagnosis was confirmed. Diverse activities can be undertaken when traveling abroad, and this case showed that not only waterborne activities but also climbing, which is seemingly unrelated to fresh water, also presents opportunities for infection. Accurate diagnosis depends on having as much information as possible concerning the worldwide infectious disease climate.