A retrospective study of the epidemiology of Clostridium difficile infection at a University Hospital in Japan: genotypic features of the isolates and clinical characteristics of the patients.

Clostridium difficile is a major cause of antibiotic-associated diarrhea and frequently results in healthcare-associated infections. The epidemiology of C. difficile infection (CDI), including the prevalent polymerase chain reaction (PCR) ribotypes and the clinical characteristics of the patients, is not well known in Japan, compared to the situation in the United States and Europe. We performed PCR ribotyping of C. difficile isolates from 71 consecutive patients with CDI at a University Hospital over a 3-year period and investigated the clinical features of those patients. CDI was diagnosed when a patient with diarrhea or colitis was found to have toxin B-positive C. difficile with no other enteropathogenic microorganisms. Toxin A-positive, toxin B-positive, binary toxin-positive (A(+)B(+)CDT(+)) strains; toxin A-positive, toxin B-positive, binary toxin-negative (A(+)B(+)CDT(-)) strains; and toxin A-negative, toxin B-positive, binary toxin-negative (A(-)B(+)CDT(-)) strains were isolated from 4, 58, and 9 patients, respectively, indicating that infections with binary toxin-positive strains were uncommon (5.6%). PCR ribotyping of the isolates demonstrated that among the 71 strains, 20 different PCR ribotypes were identified and that types smz, yok, and hr were predominant (19, 14, and 13 isolates, respectively), all of which were A(+)B(+)CDT(-). No specific time periods or wards were found to be associated with the three types; PCR ribotyping analysis clearly showed that the three types spread almost evenly in all wards for the 3 years studied. Comparative analysis of the clinical characteristics of patients harboring the three C. difficile types indicated that the duration of CDI was longer in the yok group than in the hr group. PCR ribotyping, which is easy to perform, appears to give us useful information to trace CDI cases in clinical settings. Further, the analysis of a large number of CDI cases may allow evaluation of the possible relationship between specific C. difficile types and the clinical features of patients.

[Case of chronic necrotizing pulmonary aspergillosis complicated by elevated eosinophils and serum IgE].

A 76-year-old man who was being treated for bronchial asthma and pulmonary emphysema by his family physician experienced dyspnea and was referred to our department with suspected pneumonia. The patient responded poorly to sulbactam/cefoperazone and clarithromycin. A cavity lesion appeared in the left upper lobe, Aspergillus was detected from his purulent sputum, and an Aspergillus fumigatus-precipitating antibody was seen. Therefore, chronic necrotizing pulmonary aspergillosis was diagnosed. Blood tests showed elevated levels of eosinophils and serum IgE, and Aspergillus-specific IgE was detected. Following the administration of micafungin and itraconazole, the cavity lesion diminished in size, and his eosinophil and serum IgE levels decreased. The patient was believed to have had chronic necrotizing pulmonary aspergillosis accompanied by allergic reactions to Aspergillus.

[Two cases of recurrent non-small cell lung cancer successfully treated with S-1 as fifth-line chemotherapy].

There is at present no defined role for S-1 chemotherapy in patients with advanced non-small cell lung cancer (NSCLC) who previously failed chemotherapy. Two cases of multidrug-resistant, NSCLC that were successfully treated with S-1 as fifth-line chemotherapy are reported. A 75-year-old man was diagnosed as having pulmonary adenocarcinoma, cT1N3M0, stage III B. He was treated with S-1 as fifth-line chemotherapy after treatment with cisplatin(CDDP)and vinorelbine(VNR), docetaxel (DOC), gemcitabine (GEM) and VNR, and amrubicin (AMR). After completing two courses, chest computed tomography(CT)showed a partial response( PR)of the recurrent tumors, and the serum carcinoembryonic antigen level decreased. Currently, seven courses have been completed, and this treatment will be continued due to the tumor response of stable disease. A 65-year-old woman was referred for treatment of recurrent pulmonary adenocarcinoma after right upper lobe resection. She was treated with S-1 as fifth-line chemotherapy after treatment with GEM and VNR, carboplatin(CBDCA) and paclitaxel ( PTX), DOC, and gefitinib. After completing five courses, chest CT showed PR of the intrapulmonary metastases. Though grade 3 toxicity-anemia in the first case and an elevated serum amylase level in the second case were observed in both cases, the patients' quality of life was preserved. S-1 could therefore be a treatment option for patients with advanced NSCLC who previously underwent chemotherapy unsuccessfully.

Small-cell lung cancer arising after chemotherapy for a patient with lymphoma of pulmonary mucosa-associated lymphoid tissue-a case report.

A 76-year-old woman was admitted to our hospital with infiltrations evident in the right lower lobe on chest computed tomography. Bronchoscopic biopsy showed lymphoma of mucosa-associated lymphoid tissue (MALT). Lymphoma of the pulmonary MALT became enlarged at 8 months after diagnosis and dyspnea developed. Four courses of chemotherapy(rituximab+ cladribine)resulted in a partial response. However, 14 months after the chemotherapy, she developed multiple lung and liver tumors accompanied by disseminated intravascular coagulation syndrome. A histological examination of bone marrow aspiration showed small cell carcinoma. We administered one course of carboplatin and etoposide, but bone marrow suppression was so severe that further chemotherapy was precluded. To our knowledge, this is a rare case of small cell lung cancer arising from the treatment of lymphoma of pulmonary MALT.

Tonsillar tuberculosis associated with pulmonary and laryngeal foci.

Tonsillar tuberculosis is one of the uncommon forms of extrapulmonary tuberculosis. We report a case of tonsillar tuberculosis associated with pulmonary and laryngeal foci. A 23-year-old female was admitted for evaluation of hoarseness and difficulty in swallowing. Bilateral palatine tonsils were enlarged, and a tonsillectomy was performed. Since a histological study revealed tonsillar tuberculosis, antituberculous agents were administered. After the treatment the pulmonary lesions detected with chest computed tomography were improved, and her symptoms were relieved. The possibility of tonsillar tuberculosis should be considered when unexplained enlarged tonsil is observed in patients with pulmonary tuberculosis.

Amrubicin monotherapy for elderly patients with previously treated lung cancer.

OBJECTIVE: The novel anthracycline agent amrubicin, has been approved in Japan to treat small and non-small cell lung cancers (SCLC and NSCLC). The present study evaluates the toxicity and effect of amrubicin especially in elderly patients with previously treated lung cancer. PATIENTS AND METHODS: This retrospective study analyzed data from 51 patients (<70 years of age, n=29; > oor =70 years of age, n=22) with lung cancer (NSCLC, n=21; SCLC, n=30) who were treated with amrubicin at our hospital, between July 2003 and October 2009. All patients had recurrent or refractory lung cancer after one or more chemotherapy regimens. We compared the outcomes of patients younger and older than 70 years of age. Amrubicin (30-40 mg/m(2)/day) was infused depending on patient performance status and laboratory data over a period of 5 minutes on days 1-3, with courses repeated at intervals of at least 3 weeks. The dose was modified according to myelosuppression. RESULTS: The mean number of treatment cycles, mean dose and mean interval of amrubicin administration did not significantly differ between patients aged <70 and > or =70 years. The rate of hematological toxicities (> or = Grade 3) also did not significantly differ between the two age groups (leukopenia, 48.3% and 59.1% for age <70 and > or =70 years, p=0.573; neutropenia, 65.5% vs. 77.3%, p=0.536; anemia, 20.7% vs. 22.7%, p=1.000; thrombocytopenia, 13.8% vs. 31.8%, p=0.173). The incidence of grade 2-4 non-hematological toxicities also did not significantly differ between the groups. The response rate of SCLC and disease control rate of NSCLC were similar in the younger and older groups. CONCLUSION: Amrubicin monotherapy might be equally tolerated by elderly and younger patients. Further studies are needed to investigate the benefit of amrubicin monotherapy among elderly patients with previously treated lung cancer.

Efficacy of S-1 monotherapy for non-small cell lung cancer after the failure of two or more prior chemotherapy regimens.

The efficacy and safety of S-1 monotherapy for patients with advanced or recurrent non-small cell lung cancer (NSCLC) after the failure of two or more prior chemotherapy regimens were investigated. Records of 36 patients with advanced or recurrent NSCLC who received S-1 monotherapy between January 2005 and December 2008, following the failure of previous chemotherapy, were reviewed retrospectively at two institutions. S-1 was given orally twice daily on days 1-28 every six weeks; the dose was based on body surface area. The median number of prior chemotherapy regimens was three (range 2-5), and that of courses given per patient was two (range 1-10). No patient achieved complete response, 4 patients (11.1%) achieved partial response, 10 patients (27%) had stable disease and 18 patients (50%) had progressive disease. The median progression-free survival was 3 months and the median overall survival was 15.2 months. No grade 4 hematological toxicity was noted. Grade ≥3 non-hematological toxicities were observed in 5 patients (13.9%). No deaths related to S-1 monotherapy occurred. S-1 monotherapy exhibits activity with acceptable toxicity as third-line or subsequent chemotherapy for advanced NSCLC.

Rapid analysis of Clostridium difficile strains recovered from hospitalized patients by using the slpA sequence typing system.

Clostridium difficile is a nosocomial pathogen that is transmissible between patients via hospital staff and via contaminated environmental surfaces. Recently, a typing system based on the slpA sequence for C. difficile was developed. To elucidate the validity and efficacy of the system in the setting of a local hospital, we carried out typing of C. difficile from patients in our hospital using the system. Twenty-eight stool samples obtained from 17 patients with C. difficile-associated diarrhea were investigated. Twenty-two of the 28 samples were positive for C. difficile by stool culture, and they were able to be classified by slpA sequence typing. The smz-1 and smz-2 strains were revealed to be the predominant types in our hospital, accounting for 73% of all strains. The yok-1, yok-2, t25-1, hr-1, and hj2-2 strains were identified in 1 patient each. The smz-1 strain was identified in all wards except for ward D, while smz-2 was identified in 3 of 4 patients in ward D and was restricted to this ward. Nosocomial infection of smz-1 and smz-2 in our hospital was demonstrated. Distinguishing smz-1 from smz-2 by slpA sequence typing clarified the transmission of C. difficile among patients. In conclusion, slpA sequence typing was useful in the setting of a local hospital and may be a powerful tool for the epidemiological study of C. difficile infection.

Endobronchial metastasis from primary papillary serous carcinoma of the peritoneum.

A 59-year-old woman was admitted to our hospital with a left lower lobe opacity and mediastinal shift on the chest X-ray. She had been complaining of intermittent nonproductive cough and exertional dyspnea. Chest computed tomography (CT) showed an endobronchial tumor of the left main to the lower bronchus, atelectasis of the left lower lobe, and mediastinal shift. Bronchoscopy revealed a polypoid tumor at the distal portion of the left main bronchus that occluded the bronchus. Biopsy specimens from the endobronchial tumor were shown to be serous papillary adenocarcinoma. Since the patient had been treated surgically for primary papillary serous carcinoma of the peritoneum (PSCP) 10 years earlier, immunohistochemical examinations were performed. The diagnosis of endobronchial metastasis of PSCP was confirmed by immunohistochemical staining with cancer antigen 125 (CA125), vimentin, and Wilms tumor-1 (WT-1). This is a rare case of endobronchial metastasis from PSCP.