Does This Adult Patient With Jolt Accentuation of Headache Have Acute Meningitis?

OBJECTIVE: In order to identify appropriate candidates with suspected meningitis for lumbar puncture (LP), study designs and diagnostic values of jolt accentuation of headache (JA) were reviewed. BACKGROUND: Acute meningitis is a life-threatening disease that requires LP for accurate diagnosis. JA was reported the most sensitive indicator of cerebrospinal fluid pleocytosis; however, subsequent studies have failed to confirm this claim. METHODS: We reviewed articles concerning JA, published prior to December 2017, using MEDLINE and Japanese medical databases. Seven original articles based on independent cohorts were eligible for inclusion and articles citing these 7 were thoroughly searched (11 in total). Additionally, all medical records of our previously reported cohort were reviewed again to explore how the patients' background influenced diagnostic values of JA. RESULTS: We hypothesized that an oversimplified dichotomy of JA findings, pleocytosis, and meningitis created a misconception that JA is a universal indicator of meningitis. We clarify the difference between them and present altered mental status (AMS) as a key to decrease the sensitivity of JA. Notably, the sensitivity and specificity of JA were relatively low in unselected groups, while they tended to be high in the selected sub-groups with acute onset of headache and fever, without AMS or neurological deficits. Unselected populations included etiologies of pleocytosis other than acute meningitis, which might weaken the association between JA and pleocytosis. CONCLUSION: JA is not a universal, stand-alone, indicator of meningitis in febrile patients with headache. Therefore, we propose a stepwise approach for patients with suspected acute meningitis. AMS or neurological deficits suggest an intracranial pathology, which may necessitate a lumbar puncture. JA seems a useful tool for distinguishing acute aseptic meningitis from upper respiratory infection when used in the selected cohort of febrile patients (≥37°C) with recent-onset headache (within 2 weeks before presentation) and normal mental status. This approach and diagnostic values of JA should be further investigated by prospective studies using operationally sorted candidates.

[A case of severe Legionella pneumonia in which survival was achieved without sequelae with the use of extracorporeal membrane oxygenation (ECMO)].

A 54-year-old man presented with fever and dyspnea about a week before his admission. We diagnosed Legionella pneumonia from his chest X-ray imaging which showed bilateral lobe consolidation excluding the left upper lobe, and his sputum culture yielded Legionella pneumophilla serogroup 1. Combination therapy with levofloxacin and rifampin was started on admission. However, the patient developed severe acute respiratory distress syndrome (ARDS) and then extracorporeal membrane oxygenation (ECMO) was initiated on the 2nd day. His respiratory status gradually improved after that and he was weaned from ECMO on the 7th day. He was discharged without sequelae on the 36th day. The outcome suggests that use of ECMO should be considered for patients with severe Legionella pneumonia.

C-reactive protein and the neutrophil-to-lymphocyte ratio on admission predicting bacteraemia with COVID-19.

BACKGROUND: Bacteraemia can co-occur with COVID-19. The present study aimed to determine the cut-off value for C-reactive protein (CRP) and the neutrophil-to-lymphocyte ratio (NLR) for predicting bacteraemia in patients with COVID-19. METHODS: Patients admitted to Tokyo Metropolitan Tama Medical Centre for COVID-19 treatment between 1 April 2020 and 30 October 2022 were included. Patients transferred from other hospitals and those whose CRP and/or neutrophil count was not measured at admission were excluded. Community-acquired bacteraemia was diagnosed if true bacteraemia was diagnosed in patients via a blood culture performed within 72 h of admission. The cut-off value for CRP and the NLR for community-acquired bacteraemia were determined using receiver operating characteristic analysis. RESULTS: Among 2989 patients hospitalized for COVID-19 treatment, 19 received the diagnosis of community-acquired bacteraemia, for which CRP ≥ 6.3 was determined to be the cut-off value. The sensitivity and specificity of the cut-off was 89.5% and 73.3%, respectively. The NLR cut-off value was ≥ 7.7, which had a sensitivity and specificity of 84.2% and 84.0%, respectively. CONCLUSIONS: Considering the possibility of the co-occurrence of bacteraemia with COVID-19, a blood culture should be performed when CRP is ≥ 6.3 or the NLR is ≥ 7.7.

[First aid of heat-related illness].

The first step in treating heat-related illness is recognizing it. The prognosis of heat stroke, the most critical type of the heat-related illnesses, is directly related to the time that hyperthermia lasted. The most important sign to be aware of heat stroke is altered mental status, because the brain is extremely sensitive organ to high temperature. Once a patient is identified as potentially suffering from heat stroke, immediate cooling and transportation to the appropriate hospital should be started. On the other hand, mild illness may be treated by on-site management including rest and oral hydration. The major point of the first aid of heat-related illness is taught as "FIRE". The abbreviation of Fluid, Ice(cooling), Rest and recognition of the Emergency. Here, I want to make some comments in reverse order of "FIRE", emphasizing that the most important first step is recognition of the emergency.

Development of a risk stratification scoring system for deep vein thrombosis upon psychiatric admission.

AIM: Psychiatric patients have increased risk of deep vein thrombosis (DVT). However, there is no systematic data on risk assessment of DVT among psychiatric inpatients. The aim of this study was to develop a risk stratification scoring system for DVT among psychiatic patients on admission. METHODS: A systematic review of psychiatric patient's charts, who were admitted to the Tokyo Metropolitan Matsuzawa Hospital from June 2012 to February 2016 and underwent screening for DVT, was conducted. Patients were randomly divided into development (n = 2634) and validation (n = 2634) groups. Estimated risk values in the multiple logistic regression model for the development sample were rounded to the nearest integer, and used as points of associated factors in the risk stratification scoring system; the total scores were tested in the validation sample. The score's discriminatory ability was assessed with the area under the receiver operating characteristic curve (AUC). RESULTS: Among the 5268 patients, 258 (4.9%) had DVT. Advancing age, female sex, active cancer, previous venous thromboembolism, transfer from a general hospital, catatonia, and major depressive episode were all significantly associated with the presence of DVT in the development sample. The total score showed good discriminatory ability in the validation sample (AUC: 0.816, 95% confidence interval: 0.781-0.851); scores of 0-1, 2-3, 4-5, and ≥ 6 were associated with very low risk (0.7%), low risk (4.6%), moderate risk (14.9%), and high risk (35%) for DVT, respectively. CONCLUSION: Our risk stratification scoring system showed good performance for detection of DVT among psychiatric patients on admission.

Ultrasensitive enzyme-linked immunosorbent assay for the detection of MPT64 secretory antigen to evaluate Mycobacterium tuberculosis viability in sputum.

OBJECTIVES: This study examined Mycobacterium tuberculosis (MTB)-secreted MPT64 as a surrogate of bacterial viability for the diagnosis of active pulmonary TB (PTB) and for follow-up treatment. METHODS: In this proof-of-concept prospective study, 50 PTB patients in the Tokyo metropolitan region, between 2017 and 2018, were consecutively included and 30 healthy individuals were also included. Each PTB patient submitted sputum on days 0, 14 and 28 for diagnosis and follow-up, and each healthy individual submitted one sputum sample. The following were performed: smear microscopy, Xpert MTB/RIF, MGIT and solid culture, and MPT64 detection on the sputum samples. Ultrasensitive ELISA (usELISA) was used to detect MPT64. The receiver operating characteristic analyses for diagnosis and follow-up revealed the optimal cut-off value of MPT64 absorbance for detecting culture positivity at multiple intervals. RESULTS: The sensitivity of MPT64 for diagnosing PTB was 88.0% (95% CI 75.7-95.5) and the specificity was 96.7% (95% CI 82.8-99.9). The specificity of MPT64 for predicting negative culture results on day 14 was 89.5% (95% CI 66.9-98.7). The sensitivity of MPT64 for predicting positive culture results on day 28 was 81.0% (95% CI 58.1-94.6). CONCLUSIONS: This study revealed that MPT64 is useful for diagnosing active PTB in patients and predicting treatment efficacy at follow-up.

[A cluster of paragonimiasis westermani infections in Thai immigrants].

We report a cluster of infections in four female Thai immigrants aged between 35 and 49 years who developed paragonimiasis westermani within 16 months of ingesting freshwater crabs purchased from a market in Japan. Their symptoms included cough, bloody sputum, chest pain, and dyspnea. Radiographic and CT findings comprised pleural effusion, pneumothorax, air-space consolidation, and nodular opacities. Paragonimus eggs were identified in the feces of one patient, and in the pleural effusion and the bronchoalveolar lavage fluid (BALF) of another. All diagnoses of paragonimiasis westermani were established by enzyme-linked immunosorbent assay (ELISA) of their serum. Paragonimiasis is a re-emerging disease in Japan. Moreover, since the number of immigrant patients is increasing, it is necessary to pay attention to infectious diseases resulting from their eating habits as well as imported diseases.

A rare case of full neurological recovery from severe nonexertional heatstroke during a bedrock bath.

We report a rare case of full neurological recovery in a 77-year-old woman with an initial Glasgow Coma Scale of 3 while taking a bedrock bath. Severe heatstroke was quickly diagnosed, and intensive treatment was immediately provided. Laboratory data showed multi-organ failure, and her electroencephalogram showed very low amplitude, indicating a poor prognosis; however, she gradually recovered consciousness, and her electroencephalogram normalized, showing a Glasgow Coma Scale of 15 at discharge. This case demonstrated that physicians should pay careful attention when withholding treatment from a patient with severe heatstroke accompanied by a poor initial electroencephalogram result and laboratory data.

Investigation and treatment of pulmonary embolism as a potential etiology may be important to improve post-resuscitation prognosis in non-shockable out-of-hospital cardiopulmonary arrest: report on an analysis of the SOS-KANTO 2012 study.

Background: The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital. Methods and Results: All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P < 0.0001 and P < 0.0001, respectively; 3 months, P = 0.0018 and P < 0.0001, respectively). In multiple logistic regression analysis, pulmonary embolism and incidental hypothermia were found to be significant independent prognostic factors for 1- and 3-month survival and the favorable brain function rate. Conclusions: In patients who suffer non-shockable out-of-hospital cardiac arrest, but who experience the return of spontaneous circulation after arriving at hospital, the investigation and treatment of pulmonary embolism as a potential etiology may be important for improving post-resuscitation prognosis.

A cluster of central line-associated bloodstream infections due to rapidly growing nontuberculous mycobacteria in patients with hematologic disorders at a Japanese tertiary care center: an outbreak investigation and review of the literature.

BACKGROUND Rapidly growing nontuberculous mycobacteria (RGM) are considered rare pathogens, causing central line-associated bloodstream infection. We identified an outbreak of central line-associated bloodstream infection due to RGM at a hematology-oncology ward during a 5-month period. DESIGN Outbreak investigation and literature review. SETTING A Japanese tertiary care center. PATIENTS Adults who were hospitalized at the hematology-oncology ward from October 15, 2011, through February 17, 2012. RESULTS A total of 5 patients with a bloodstream infection due to RGM (4 cases of Mycobacterium mucogenicum and 1 case of Mycobacterium canariasense infection) were identified; of these, 3 patients had acute myeloid leukemia, 1 had acute lymphocytic leukemia, and 1 had aplastic anemia. Four of the 5 patients received cord blood transplantation prior to developing the bloodstream infection. All central venous catheters in patients with a bloodstream infection were removed. These patients promptly defervesced after catheter removal and their care was successfully managed without antimicrobial therapy. Surveillance cultures from the environment and water detected M. mucogenicum and M. canariasense in the water supply of the hematology-oncology ward. The isolates from the bloodstream infection and water sources were identical on the basis of 16S-rRNA gene sequencing. CONCLUSIONS The source of RGM in the outbreak of bloodstream infections likely was the ward tap water supply. Awareness of catheter-related bloodstream infections due to nontuberculous mycobacteria should be emphasized, especially where immunocompromised patients are at risk. Also, using antimicrobials after catheter removal to treat central line-associated bloodstream infection due to RGM may not be necessary. Infect Control Hosp Epidemiol 2015;36(1): 76-80.

[Evaluation of Streptococcus pneumoniae-urinary antigen detection kit in patients with community acquired pneumonia].

We evaluated a new rapid urinary antigen detection kit. NOW Streptococcus pneumoniae (Binax Inc., USA) that detected S. pneumoniae antigen by immunochromatographic membrane assay, with 66 Japanese adult patients of community acquired pneumonia. Twenty-two (33.3%) patients were found to be positive with the kit and S. pneumoniae was isolated from six patients (27.3%) of these 22 patients. S. pneumoniae was not isolated from eight of the 22 patients by blood or sputum culture. Analysis of clinical laboratory data showed that the levels of C-reactive protein (CRP) in the serum were significantly higher in the urine-antigen positive group than those in the urine-antigen negative group. There were no significant difference between the two groups including renal function, urinalysis, clinical symptom, and severity of pneumonia. Our study suggests that more cases of community acquired pneumonia are caused by S. pneumoniae than conventional tests can currently confirm. Since it is not technically complex, does not require equipment, and detects within as quickly as in 15 minutes, the S. pneumoniae urinary antigen kit is useful for rapid diagnosis of community acquired pneumonia in adults.

Increased synthesis of anti-tuberculous glycolipid immunoglobulin G (IgG) and IgA with cavity formation in patients with pulmonary tuberculosis.

Tuberculous glycolipid (TBGL) antigen is a cell wall component of Mycobacterium tuberculosis and has been used for the serodiagnosis of tuberculosis. We investigated correlations between the levels of anti-TBGL antibodies and a variety of laboratory markers that are potentially influenced by tuberculous infection. Comparisons between patients with cavitary lesions and those without cavitary lesions were also made in order to determine the mechanism underlying the immune response to TBGL. Blood samples were obtained from 91 patients with both clinically and microbiologically confirmed active pulmonary tuberculosis (60 male and 31 female; mean age, 59 +/- 22 years old). Fifty-nine patients had cavitary lesions on chest X-rays. Positive correlations were found between anti-TBGL immunoglobulin G (IgG) and C-reactive protein (CRP) (r = 0.361; P < 0.001), between anti-TBGL IgA and soluble CD40 ligand (sCD40L) (r = 0.404; P < 0.005), between anti-TBGL IgG and anti-TBGL IgA (r = 0.551; P < 0.0000005), and between anti-TBGL IgM and serum IgM (r = 0.603; P < 0.00000005). The patients with cavitary lesions showed significantly higher levels of anti-TBGL IgG (P < 0.005), anti-TBGL IgA (P < 0.05), white blood cells (P < 0.01), neutrophils (P < 0.005), basophils (P < 0.0005), natural killer cells (P < 0.05), CRP (P < 0.0005), KL-6 (sialylated carbohydrate antigen KL-6) (P < 0.0005), IgA (P < 0.05), and sCD40L (P < 0.01). The observed positive correlations between the anti-TBGL antibody levels and inflammatory markers indicate the involvement of inflammatory cytokines and NKT cells in the immunopathogenesis of pulmonary tuberculosis.

Endobronchial cryptococcosis in AIDS.

Although cryptococcosis is a common thoracic complication among patients with AIDS, endobronchial abnormalities have rarely been reported. A 45-year-old man presented with a productive cough, fever, and headache. His CD4+ cell count was 7/mm3 and testing for antibodies to HIV-1 was positive. Radiological examination revealed consolidation in the left lung, including cavitation. Bronchoscopic examination demonstrated white, slightly raised, plaque-like lesions in the trachea and left bronchi. Histopathological examination of endobronchial biopsy specimens revealed granulation tissue with abundant encapsulated yeast in the tissue. Cryptococcus neoformans was cultured from the bronchial lavage specimen. Cryptococcal infection should be included in the differential diagnosis of endobronchial abnormalities in patients with AIDS.