Clinico-bacterial and prognostic factors in patients with suspected blood stream infection and elevated serum procalcitonin levels.

This study determined prognostic factors by comparing clinico-bacterial factors based on significant elevated serum procalcitonin levels in patients with suspected bloodstream infection (BSI). We retrospectively analyzed the medical records of 1,052 patients (age ≥16 years) with fever (temperature ≥38°C) and serum procalcitonin levels of ≥2.0 ng/mL, and blood culture results. The optimal cutoff value of the significant elevation of procalcitonin was determined using the minimum P-value approach. Clinico-bacterial factors were analyzed per the procalcitonin levels, and significant independent factors for short-term survival were investigated in 445 patients with BSI. Patients with suspected BSI were aged, on average, 72.3 ± 15.1 years, and the incidence of positive blood culture was 42.3%; and the 14-day survival was 83.4%. Procalcitonin ≥100 ng/mL was the most significant predictor for survival. Multivariate analysis in patients with suspected BSI showed that estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 and procalcitonin ≥100 ng/mL were significant independent unfavorable prognostic factors. Microorganisms were similar between patients with procalcitonin level 2-99 ng/mL (n=359) and those with ≥100 ng/mL (n=86). Multivariate analysis in patients with BSI showed that eGFR <30 mL/min/1.73 m2, procalcitonin ≥100 ng/mL, and primary infectious foci were significant independent prognostic factors. Patients with foci in the gastrointestinal tract and respiratory system had unfavorable 14-day survival. In conclusions, eGFR <30 mL/min/1.73 m2 and procalcitonin ≥100 ng/mL were significant independent unfavorable prognostic factors for suspected BSI. Primary infectious foci (gastrointestinal tract and respiratory system) were associated with unfavorable short-term survival in patients with positive blood culture.

Clinical evaluation of FAPlus/FNPlus bottles compared with the combination of SA/SN and FA/FN bottles in the BacT/Alert blood culture system.

Background : The comparison of the performance of FAPlus/FNPlus bottles and combination of SA/SN and FA/FN bottles is not yet reported. Methods : We used human blood samples to investigate microorganism detection rates and the time to positivity (TTP) in a before-vs.-after study (a combination of SA/SN and FA/FN bottles from September 2012 to August 2013 vs. FAPlus/FNPlus bottles from September 2013 to August 2014). Results : The microorganism detection rate was significantly higher in the later period than in the earlier period (11.2% vs. 9.6%, P < 0.001), particularly for Enterococcus and Streptococcus species, nonfermentative Gram-negative bacilli, and Helicobacter cinaedi. TTP for pathogens was longer when FAPlus/FNPlus bottles were used than when a combination of SA/SN and FA/FN bottles was used (14.9 vs. 13.3 h, P = 0.014), particularly, in the case of Gram-negative bacilli including Escherichia coli. Conclusion : The microorganism detection rate was improved with the use of FAPlus/FNPlus bottles compared with the combination of SA/SN and FA/FN bottles ; however, FAPlus/FNPlus bottles seemed to be inferior to SA/SN and FA/FN bottles in terms of TTP. J. Med. Invest. 67 : 90-94, February, 2020.

Culture-based bacterial evaluation of the appendix lumen in patients with and without acute appendicitis.

PURPOSE: Controversy exists over whether bacterial flora within the appendix differs between patients with and without appendicitis. To examine these potential differences, we cultured the appendiceal luminal microbiota of patients with and without acute appendicitis, and identified the bacterial species therein. METHODS: Fifty-seven patients with acute appendicitis and 37 patients without acute appendicitis who underwent curative resection of colorectal cancer and prophylactic appendectomies (control group) were included. Appendicitis patients were classified into the phlegmonous group or the gangrenous appendicitis group histopathologically. There was no patient with perforated appendicitis. Aerobic isolates were identified using standard identification schemata, and anaerobic isolates were identified according to the Japanese guidelines. RESULTS: There were no significant differences among the three groups in the median number aerobe species present per patient. However, the median number anaerobe species in the gangrenous appendicitis group was significantly higher than that of the control group and the phlegmonous appendicitis group. In addition, the incidence of patients with Bacillus species, Fusobacterium nucleatum, and Bilophila wadsworthia increased as the disease progressed from phlegmonous to gangrenous appendicitis. CONCLUSION: The present results suggest that increased diversity of anaerobes and the translocation of Bacillus species, F. nucleatum, and B. wadsworthia are associated with the progression of acute appendicitis.

MEG Frequency Analysis Depicts the Impaired Neurophysiological Condition of Ischemic Brain.

PURPOSE: Quantitative imaging of neuromagnetic fields based on automated region of interest (ROI) setting was analyzed to determine the characteristics of cerebral neural activity in ischemic areas. METHODS: Magnetoencephalography (MEG) was used to evaluate spontaneous neuromagnetic fields in the ischemic areas of 37 patients with unilateral internal carotid artery (ICA) occlusive disease. Voxel-based time-averaged intensity of slow waves was obtained in two frequency bands (0.3-4 Hz and 4-8 Hz) using standardized low-resolution brain electromagnetic tomography (sLORETA) modified for a quantifiable method (sLORETA-qm). ROIs were automatically applied to the anterior cerebral artery (ACA), anterior middle cerebral artery (MCAa), posterior middle cerebral artery (MCAp), and posterior cerebral artery (PCA) using statistical parametric mapping (SPM). Positron emission tomography with 15O-gas inhalation (15O-PET) was also performed to evaluate cerebral blood flow (CBF) and oxygen extraction fraction (OEF). Statistical analyses were performed using laterality index of MEG and 15O-PET in each ROI with respect to distribution and intensity. RESULTS: MEG revealed statistically significant laterality in affected MCA regions, including 4-8 Hz waves in MCAa, and 0.3-4 Hz and 4-8 Hz waves in MCAp (95% confidence interval: 0.020-0.190, 0.030-0.207, and 0.034-0.213), respectively. We found that 0.3-4 Hz waves in MCAp were highly correlated with CBF in MCAa and MCAp (r = 0.74, r = 0.68, respectively), whereas 4-8 Hz waves were moderately correlated with CBF in both the MCAa and MCAp (r = 0.60, r = 0.63, respectively). We also found that 4-8 Hz waves in MCAp were statistically significant for misery perfusion identified on 15O-PET (p<0.05). CONCLUSIONS: Quantitatively imaged spontaneous neuromagnetic fields using the automated ROI setting enabled clear depiction of cerebral ischemic areas. Frequency analysis may reveal unique neural activity that is distributed in the impaired vascular metabolic territory, in which the cerebral infarction has not yet been completed.

Recurrent bacteremia with different strains of Streptococcus pyogenes in an immunocompromised child.

We report an immunocompromised child who experienced two episodes of bacteremia due to Streptococcus pyogenes. Random amplification of polymorphic DNA profiles, emm genotypes, superantigen profiles, antimicrobial susceptibility, and resistance-related genes were investigated, and the results showed different profiles between the two isolates. This is the first report describing recurrent bacteremia caused by different strains of S. pyogenes.

Clinical value of procalcitonin for patients with suspected bloodstream infection.

OBJECTIVES: Procalcitonin (PCT) might be a useful marker to exclude bacteremia or to predict the severity of bacteremia and its outcome. However, most previous studies of PCT were limited to particular patient populations. In addition, reports about PCT levels in patients with renal dysfunction have been conflicting. We investigated the predictive value of PCT in an unselected population with suspected bloodstream infections and also assessed the relationship between PCT and renal function. METHODS: We retrospectively analyzed medical records of 1,331 patients (age ≥1 8 years) with suspected bloodstream infections who had concurrent biochemical data and blood culture results. RESULTS: The PCT level was significantly elevated in patients with positive blood cultures, and it showed a significant relation with survival in patients with bacteremia. The optimal cutoff value of PCT for predicting a positive blood culture showed an increase as the estimated glomerular filtration rate declined. CONCLUSION: PCT can be a useful marker to exclude bacteremia and also to predict severe bacteremia, but renal function should be taken into account.

[Cervical lymphadenitis caused by Mycobacterium avium in an immunocompetent adult].

Cervical lymphadenitis due to Mycobacterium avium complex is relatively common in children but is extremely rare in adults, except in immunocompromised patients. In this report, we describe a case of isolated cervical lymphadenitis in an immunocompetent adult woman. Histological examination of the excised lymph node showed multiple epithelioid cell granulomata with necrosis. Further, from the biopsy specimen cultures, we identified the causative organism as Mycobacterium avium. The patient was not administered any antimycobacterial agents because the affected lymph node was removed completely and because of uncertainty regarding the benefits of such treatment. No recurrence was observed in the patient's neck region during postoperative follow-up at 8 months.

Existence of a neuropathic pain component in patients with osteoarthritis of the knee.

PURPOSE: Pain from osteoarthritis (OA) is generally classified as nociceptive (inflammatory). Animal models of knee OA have shown that sensory nerve fibers innervating the knee are significantly damaged with destruction of subchondral bone junction, and induce neuropathic pain (NP). Our objective was to examine NP in the knees of OA patients using painDETECT (an NP questionnaire) and to evaluate the relationship between NP, pain intensity, and stage of OA. MATERIALS AND METHODS: Ninety-two knee OA patients were evaluated in this study. Pain scores using Visual Analogue Scales (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), painDETECT, duration of symptoms, severity of OA using the Kellgren-Lawrence (KL) system, and amount of joint fluid were evaluated and compared using a Spearman's correlation coefficient by rank test. RESULTS: Our study identified at least 5.4% of our knee OA patients as likely to have NP and 15.2% as possibly having NP. The painDETECT score was significantly correlated with the VAS and WOMAC pain severity. Compared with the painDETECT score, there was a tendency for positive correlation with the KL grade, and tendency for negative correlation with the existence and amount of joint fluid, but these correlations were not significant. CONCLUSION: PainDETECT scores classified 5.4% of pain from knee OA as NP. NP tended to be seen in patients with less joint fluid and increased KL grade, both of which corresponded to late stages of OA. It is important to consider the existence of NP in the treatment of knee OA pain.

A permission system for carbapenem use reduced incidence of drug-resistant bacteria and cost of antimicrobials at a general hospital in Japan.

Some drug management systems have been established in Japanese hospitals to reduce medical costs and regulate drug usage. Among the many available prescription drugs, antimicrobials should be given special attention because their inappropriate use often leads to sudden outbreaks of resistant bacteria. As drug specialists, pharmacists should monitor the use of all drugs, particularly antimicrobials. Carbapenems are a class of broad-spectrum antimicrobials that are widely used to treat infections worldwide. However, their inappropriate use has led to an increase in the incidence of drug-resistant bacteria and consequently, medical costs, at hospitals. To reduce inappropriate use and drug resistance, we have established a permission system to control the use of carbapenems at the Japanese Red Cross Nagoya Daiichi Hospital. In this study, we retrospectively evaluated the applicability of the new permission system compared to that of the notification system and the non control system for 14 months each. The two management systems were able to maintain total antibiotic use density and control the outbreak of drug-resistant bacteria (P. aeruginosa, E. coli, and K. pneumoniae). The number of carbapenem prescriptions was decreased dramatically when this permission system was enforced. Compared to the non control system, the cost of antimicrobials was reduced by $757,470 for the 14-month study period using the permission system. These results suggest that our system to control the use of antimicrobials can efficiently suppress the incidence of drug-resistant bacteria and medical costs at hospitals.

Risk factors for extended-spectrum beta-lactamase-producing Escherichia coli infection in hospitalized patients.

The incidence of nosocomial infection caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria is increasing worldwide. Infections caused by ESBL producers have been associated with severe adverse clinical outcomes that have led to increased mortality, prolonged hospitalization, and rising medical costs. To avoid such adverse events and ineffective treatment, an appropriate use of drugs for infectious diseases is needed. To suppress the emergence and spread of drug-resistant bacteria in hospitals, it is important to be vigilant about ESBL-producing Escherichia coli (E. coli). In this study, we examined and compared seven items in a blood test between patients with ESBL-producing E. coli and non-ESBL-producing E. coli among febrile patients. We examined the levels of serum albumin, hemoglobin, and C-reactive protein (CRP), and the numbers of leucocytes, neutrophils, lymphocytes, and platelets in blood on the day of admission, the screening day during hospitalization, and the day immediately before discharge from the hospital. There were no significant differences in clinical background characteristics between the two groups of patients. In patients with invasive infections caused by ESBL-producing E. coli, serum albumin levels and the number of lymphocytes were significantly lower than those in patients not infected with ESBL producers. These values recovered to their baseline levels on the day of hospital discharge. This retrospective study suggests that serum albumin levels and the number of lymphocytes may serve as risk factors for infection by ESBL-producing E. coli, thereby supporting the appropriate use of antimicrobials in hospitals.

[A case of eosinophilic pneumonia which occurred after bone marrow transplantation for acute myeloid leukemia].

A 37-year-old woman with acute myeloid leukemia received allogeneic bone marrow transplantation (BMT) after systemic chemotherapy and total body irradiation. Soon after BMT both cutaneous and gastrointestinal graft-versus-host disease (GVHD) developed, but she was successfully treated with corticosteroids and tacrolimus. Thereafter, about 6 months after BMT a dry cough developed, and chest computed tomography (CT) showed a consolidated shadow in the right lower lobe which was resistant to antibiotics, and we finally diagnosed eosinophilic pneumonia based on a bronchoalveolar lavage analysis of the eosinophilia. The eosinophilic pneumonia in this case might have been associated with GVHD, because cutaneous GVHD simultaneously recurred. We report the details of this case because only a few such reports of eosinophilic pneumonia associated with GVHD have been previously described, and such cases may increase with the growing use of transplantations.

[Development of cervical tuberculous lymphadenitis in a patient with Crohn's disease receiving infliximab despite of chemoprophylaxis with isoniazid].

We herein report a case of a 41-year-old female with a 14-year history of Crohn's disease who had been treated with diet and mesalazine. Because of inadequate control, therapy with infliximab was planned. She had a positive result on the interferon-gamma release assay (QuantiFERON TB). After active tuberculosis was ruled out by chest x-ray and computed tomography, she was started on a six-month course of isoniazid 7 weeks prior to starting infliximab. After 10 doses of infliximab (15 months of therapy), she presented with pain of cervical lymphadenopathy. A biopsy of the lymph nodes revealed Langhans giant cells from granulomas and a positive result of polylmerase chain reaction for Mycobacterium tuberculosis. The treatment with infliximab was discontinued and anti-tuberculosis therapy was started. Although treatment for latent tuberculosis infection lowers the risk of reactivation of tuberculosis due to tumor necrosis factor alpha-blockers, it cannot completely inactivate tuberculosis. Despite the completion of chemoprophylaxis, patients receiving such agents should be instructed to watch out for any symptoms associated with pulmonary and extrapulmonary tuberculosis such as fever, cough, malaise, body weight loss, night sweating and lymphadenopathy, and they should also be closely followed up.

[A case of lymphomatoid granulomatosis which initially demonstrated a diffuse ground glass appearance].

Lymphomatoid granulomatosis is defined as an Epstein-Barr virus-associated B-cell lymphoma which possibly progresses to malignant lymphoma. The pulmonary lesions associated with this disease typically reveal multiple poorly defined nodules. A 71-year-old man with acute respiratory failure consulted a local doctor. A chest CT scan demonstrated a bilateral lower ground glass appearance. The shadow improved after pulse steroid therapy but it showed multiple nodules after the corticosteroid treatment was tapered. We finally diagnosed lymphomatoid granulomatosis (grade 2) based on the findings of a thoracoscopic lung biopsy. Pathologically, an angiocentric proliferation of large atypical lymphoid cells were observed which were positive for EBER (EBV-encoded small RNA). We herein report the details of this case because of its rare radiographic findings.

[The prevalence of cigarette smoking among asthmatic adults and association of smoking with emergency department visits].

UNLABELLED: We examined the prevalence of cigarette smoking among adults with acute asthma and the relationship between smoking status and visits to the emergency department of a hospital. SETTING AND PATIENTS: 198 subjects (79 men), in whom acute asthma had been newly diagnosed by physicians in a municipal hospital in 2005, were included in this study. RESULTS: Thirty-five percent of the enrolled asthmatic patients were current smokers with a mean of 21 pack-years, while 18% were former smokers, and 47% were never-smokers. The current smokers comprised 41% of all male patients and 31% of all female patients in this study. In the asthmatic patients aged 50 or older, 27% of men and 13% of women were current smokers, while in those younger than 50, the same percentages were 59% and 50%, respectively. Since July 31, 2007, 6 current smokers (8.7%) had visited the emergency department due to asthmatic attacks, while 3 (8.3%) were ex-smokers and 1 (1.1%) was a never-smokers (p < 0.011). CONCLUSION: Cigarette smoking was common among patients with acute asthma, especially younger women. A current-smoker status is therefore considered to be associated with emergency visits to hospitals due to asthmatic attacks.

[A case of cryptococcal pneumonia accompanying meningitis].

UNLABELLED: Cryptococcosis is a fungal infection caused by cryptococcus neoformans. Cryptococcal pneumonia occurs due to inhalation of the organism into the respiratory tract, sometimes accompanied by meningitis in immunocompromised patients, and can be life-threatening. We report a case of cryptococcal meningitis occurring during corticosteroid therapy for rheumatoid arthritis. CASE: A 82-year-old woman with rheumatoid arthritis was given a diagnosis of cryptococcal meningitis, and improved after administeration of amphotericin B in combination with flucytosine. However 3 weeks later, side effects occurred, she was given fluconazole alone, but her condition worsened and she died. In severe cases of cryptococcal meningitis, we should take into account drug susceptibility tests and drug concentrations at the site of infection.

[Two cases of herpes simplex esophagitis during treatment for lung cancer].

Herpes simplex virus (HSV) is one of the three major causes of infectious esophagitis, along with Candida albicans and Cytomegalo virus (CMV). Most cases occur in immunocompromised hosts, in whom this can be life threatening. We report two cases of herpes simplex esophagitis occurring during treatment for lung cancer. Case 1: An 80-year-old man with radiation pneumonia caused by radiotherapy for lung cancer was admitted for treatment with antibiotics and corticosteroids. Shortly after initiation of treatment, he complained of dysphasia. Endoscopic examination revealed herpes simplex esophagitis. Case 2: A 71-year-old man was given corticosteroids for cryptogenic organizing pneumonia following chemotherapy for lung cancer. During treatment, the patient complained of odynophagia. Endoscopic examination revealed herpes simplex esophagitis. Both cases died due to progression of lung cancer and acute respiratory distress syndrome, despite administration of acyclovir. When immunocompromised patients complain of prolonged dysphagia and odynophagia, the presence of herpes simplex esophagitis should be clarified by endoscopic examination. It is occasionally difficult to distinguish between HSV and Candida esophagitis by endoscopic observation alone. Esophageal mucosal endoscopic cytology can help differentiate between these three infectious agents.

[A case of severe adult-onset Still' s disease presenting with pleuropericarditis].

Adult-onset Still' s disease (AOSD) is an uncommon rheumatic disease characterized by high spiking fever, arthritis, an evanescent skin rash and variety of systemic symptoms, though initial onset of pleuropulmonary manifestation is relatively rare and could be responsible for a delay in diagnosis. We report a case of AOSD presenting with pleuritis with concomitant pericardial effusion. A 42-year-old Japanese man was admitted with a spiking fever of 40 degrees C, hyperleucocytosis (21.6 x 10(9)/l), and a high titer of C-reactive protein (16.84mg/dl). Chest X-ray film and computed tomography showed bilateral pleural effusion and massive pericardial effusion which both required tube drainage. Analyses of fluids revealed that both were exudative and sterile, and pleural biopsy showed nonspecific inflammation with mild fibrosis. Neither antibiotics nor antituberculosis drugs were effective. Rash, hepatosplenomegaly, polyarthritis, pharyngitis and right hypochondralgia were accompanied by serum hyperferritinemia. After exclusion of the possibility of infection, other connective tissue disease and malignancy, a diagnosis of AOSD was made. Improvement was not observed with nonsteroidal anti-inflammatory drug and corticosteroid therapy. Double filtration plasmapheresis (DFPP) following steroid pulse therapy alleviated the symptoms and the laboratory data immediately and corticosteroids could be tapered. DFPP is a safe therapeutic procedure and can be an alternative for refractory AOSD.

Prognosis of cough variant asthma: a retrospective analysis.

Patients with cough variant asthma, a common cause of chronic cough, may develop wheezing. We examined the determinants of this phenomenon and achievement of remission in 42 patients. During 4 years after diagnosis, wheezing developed in 13 of the patients. Early inhaled corticosteroid treatment was inhibitory against the development of wheezing by univariate analysis and by multivariate analysis with an odds ratio of 0.12 (95% confidence interval, 0.02 to 0.87, p = 0.037). Remission was achieved in 7 patients, who were younger than those without remission by univariate analysis (p = 0.048). Early treatment with inhaled corticosteroid may prevent the progression of cough variant asthma to classic asthma.

[Pulmonary infection caused by Mycobacterium szulgai: a case report].

We reported a case of pulmonary infection caused by Mycobacterium szulgai (M. szulgai) in an immunocompetent, asymptomatic 55-year-old man without underlying disease. A chest radiograph of an annual health examination revealed a right upper lobe infiltrate with thin-walled cavities, which was not present in the previous year. An acid-fast stain of bronchial washing fluid was positive, and antimycobacterial chemotherapy with isoniazid (400 mg/day), rifampin (450 mg/day), and ethambutol (750 mg/day) was initiated on presumptive diagnosis of the case as tuberculosis. DNA-DNA hybridization of sputum and bronchial washing samples identified M. szulgai as the causative organism. Antimicrobial susceptibility testing indicated that the isolate was sensitive to most common antimycobacterial drugs except capreomycin (CPM) and p-aminosalicylic acid (PAS), and was also sensitive to clarithromycin and fluoroquinolones including ofloxacin, levofloxacin, sparfloxacin, and ciprofloxacin. After 12 months of therapy, a repeat chest radiograph demonstrated improvement of the right upper lobe infiltrate. When M. szulgai is isolated, it almost always represents a true pathogen. Therefore, the detection of even a small number of M. szulgai warrants treatment based on susceptibility testing.