Clinical features, management, and outcome of iliopsoas abscess associated with cardiovascular disorders: a hospital-based observational case series study.

BACKGROUND: Iliopsoas abscess (IPA) is a rare clinical entity and is difficult to diagnose due to its insidious onset and nonspecific symptoms. The association between IPA and cardiovascular disorders (CVD) has been rarely reported. Computed tomographic (CT) scan can provide a definitive diagnosis of IPA and associated foci of adjacent structures. IPA is a life-threatening condition, especially when associated with CVD. MATERIALS AND METHODS: We conducted a hospital-based observational study of IPA associated with CVD. Data were collected from the electronic clinical database of Taichung Veterans General Hospital (1520-bed tertiary referral hospital in central Taiwan) between July 2007 and December 2017. The diagnosis of IPA associated with CVD was confirmed by classical findings on CT and transesophageal echocardiography with compatible clinical presentation and cultures from pus/tissue and blood. RESULTS: Fifteen patients of IPA associated with CVD were studied. They included 12 males (80%) and 3 females (20%), with a mean age 63.2 ± 16.9 years (31-85 years). CVD included stent-graft/endograft infection of abdominal aortic aneurysm (AAA) (40%), primary mycotic AAA (33.3%), and infective endocarditis (26.7%). Staphylococcus aureus is the most common microorganism in pus/tissue cultures (n = 3, 37.5%) and in blood cultures (n = 6, 40%). The average length of hospital stay was 33.1 ± 20.5 days (range, 3-81 days; median, 33 days). Hospital stay lasted 42.6 ± 19.2 days in the survival group and 19.0 ± 14.1 days (P = 0.018) in the non-survival group. Incidence of patients staying in the intensive care unit (ICU) with intubation > 3 days was 33% in the survival group and 100% (P = 0.028) in the non-survival group. Intra-hospital mortality rate was 40%. Poor prognostic factors in the non-survival group were hypoalbuminemia, hyponatremia, involved disc/vertebral body and/or epidural abscess, and ICU stay with intubation > 3 days. Cumulative survival rate was 25% under conservative treatments and 66.3% under aggressive treatments (P = 0.038). CONCLUSION: Due to high mortality rates, clinicians should keep a high suspicion index for IPA associated with CVD through clinical presentation, physical examination, and imaging study. Timely empiric antibiotics for common bacteria, drainage for IPA, endovascular repair, or vascular reconstruction by graft replacement or bypass with intensive care should be mandatory to shorten the hospital stay, reduce medical costs, and lower mortality rate.

Risk Factors and Scoring Systems to Predict the Mortality Risk of Afebrile Adult Patients with Monomicrobial Gram-Negative Bacteremia: A 10-Year Observational Study in the Emergency Department.

BACKGROUND: The mortality rate of afebrile bacteremia has been reported to be as high as 45%. This investigation focused on the risk factors and predictive performance of scoring systems for the clinical outcomes of afebrile patients with monomicrobial gram-negative bacteria (GNB) in the emergency department (ED). METHODS: We conducted a retrospective analysis of afebrile adult ED patients with monomicrobial GNB bacteremia from January 2012 to December 2021. We dissected the demographics, clinical pictures, and laboratory investigations. We applied five scoring systems and three revised systems to predict the clinical outcomes. RESULTS: There were 600 patients included (358 males and 242 females), with a mean age of 69.6 ± 15.4 years. The overall mortality rate was 50.17%, reaching 68.52% (74/108) in cirrhotic patients. Escherichia coli was the leading pathogen (42.83%). The non-survivors had higher scores of the original MEDS (p < 0.001), NEWS (p < 0.001), MEWS (p < 0.001), qSOFA (p < 0.001), and REMS (p = 0.030). In univariate logistic regression analyses, several risk factors had a higher odds ratio (OR) for mortality, including liver cirrhosis (OR 2.541, p < 0.001), malignancy (OR 2.259, p < 0.001), septic shock (OR 2.077, p = 0.002), and male gender (OR 0.535, p < 0.001). The MEDS demonstrated that the best predictive power with the maximum area under the curve (AUC) was measured at 0.773 at the cut-off point of 11. The AUCs of the original NEWS, MEWS, qSOFA, and REMS were 0.663, 0.584, 0.572, and 0.553, respectively. We revised the original MEDS, NEWS, and qSOFA by adding red cell distribution width, albumin, and lactate scores and found a better predictive power of the AUC of 0.797, 0.719, and 0.694 on the revised MEDS ≥11, revised qSOFA ≥ 3, and revised NEWS ≥ 6, respectively. CONCLUSIONS: The original MEDS, revised MEDS, revised qSOFA, and revised NEWS were valuable tools for predicting the mortality risk in afebrile patients with monomicrobial GNB bacteremia. We suggested that clinicians should explore patients with the risk factors mentioned above for possible severe infection, even in the absence of fever and initiate hemodynamic support and early adequate antibiotic therapy in patients with higher scores of the original MEDS (≥11), revised MEDS (≥11), revised NEWS (≥6), and revised qSOFA (≥3).

Features and treatment modality of iliopsoas abscess and its outcome: a 6-year hospital-based study.

BACKGROUND: Percutaneous drainage (PCD) and surgical intervention are two primary treatment options for iliopsoas abscess (IPA). However, there is currently no consensus on when to use PCD or surgical intervention, especially in patients with gas-forming IPA. This study compared the characteristics of patients with gas-forming and non-gas forming IPA and their mortality rates under different treatment modalities. An algorithm for selecting appropriate treatment for IPA patients is proposed based on our findings. METHODS: Eighty-eight IPA patients between July 2007 and February 2013 were enrolled in this retrospective study. Patients < 18 years of age or with an incomplete course of treatment were excluded. Demographic information, clinical characteristics, and outcomes of different treatment approaches were compared between gas-forming IPA and non-gas forming IPA patients. RESULTS: Among the 88 enrolled patients, 27 (31%) had gas-forming IPA and 61 (69%) had non-gas forming IPA. The overall intra-hospital mortality rate was 25%. The gas-forming IPA group had a higher intra-hospital mortality rate (12/27, 44.0%) than the non-gas forming IPA group (10/61, 16.4%) (P < 0.001). Only 2 of the 13 patients in the gas-forming IPA group initially accepting PCD had a good outcome (success rate = 15.4%). Three of the 11 IPA patients with failed initial PCD expired, and 8 of the 11 patients with failed initial PCD accepted salvage operation, of whom 5 survived. Seven of the 8 gas-forming IPA patients accepting primary surgical intervention survived (success rate = 87.5%). Only 1 of the 6 gas-forming IPA patients who accepted antibiotics alone, without PCD or surgical intervention, survived (success rate = 16.7%). In the non-gas forming IPA group, 23 of 61 patients initially accepted PCD, which was successful in 17 patients (73.9%). The success rate of PCD was much higher in the non-gas forming group than in the gas-forming group (P <0.01). CONCLUSIONS: Based on the high failure rate of PCD and the high success rate of surgical intervention in our samples, we recommend early surgical intervention with appropriate antibiotic treatment for the patients with gas-forming IPA. Either PCD or primary surgical intervention is a suitable treatment for patients with non-gas forming IPA.

Predictive Performance of Scoring Systems for Mortality Risk in Patients with Cryptococcemia: An Observational Study.

Cryptococcal infection is usually diagnosed in immunocompromised individuals and those with meningeal involvement, accounting for most cryptococcosis. Cryptococcemia indicates a poor prognosis and prolongs the course of treatment. We use the scoring systems to predict the mortality risk of cryptococcal fungemia. This was a single hospital-based retrospective study on patients diagnosed with cryptococcal fungemia confirmed by at least one blood culture collected from the emergency department covering January 2012 and December 2020 from electronic medical records in the Taichung Veterans General Hospital. We enrolled 42 patients, including 28 (66.7%) males and 14 (33.3%) females with a mean age of 63.0 ± 19.7 years. The hospital stay ranged from 1 to 170 days (a mean stay of 44.4 days), and the overall mortality rate was 64.3% (27/42). In univariate analysis, the AUC of ROC for MEWS, RAPS, qSOFA, MEWS plus GCS, REMS, NEWS, and MEDS showed 0.833, 0.842, 0.848, 0.846, 0.846, 0.878, and 0.905. In the multivariate Cox regression analysis, all scoring systems, older age, lactate, MAP, and DBP, indicated significant differences between survivor and non-survivor groups. Our results show that all scoring systems could apply in predicting the outcome of patients with cryptococcal fungemia, and the MEDS displays the best performance. We recommend a further large-scale prospective study for patients with cryptococcal fungemia.

Scoring Systems to Evaluate the Mortality Risk of Patients with Emphysematous Cystitis: A Retrospective Observational Study.

BACKGROUND: Emphysematous cystitis (EC) is a complicated urinary tract infection (UTI) characterized by gas formation within the bladder wall and lumen. Immunocompetent people are less likely to suffer from complicated UTIs, but EC usually occurs in women with poorly controlled diabetes mellitus (DM). Other risk factors of EC include recurrent UTI, neurogenic bladder disorder, blood supply disorders, and prolonged catheterization, but DM is still the most important of all aspects. Our study investigated clinical scores in predicting clinical outcomes of patients with EC. Our analysis is unique in predicting EC clinical outcomes by using scoring system performance. MATERIALS AND METHODS: We retrospectively collected EC patient data from the electronic clinical database of Taichung Veterans General Hospital between January 2007 and December 2020. Urinary cultures and computerized tomography confirmed EC. In addition, we investigated the demographics, clinical characteristics, and laboratory data for analysis. Finally, we used a variety of clinical scoring systems as a predictor of clinical outcomes. RESULTS: A total of 35 patients had confirmed EC, including 11 males (31.4%) and 24 females (68.6%), with a mean age of 69.1 ± 11.4 years. Their hospital stay averaged 19.9 ± 15.5 days. The in-hospital mortality rate was 22.9%. The Mortality in Emergency Department Sepsis (MEDS) score was 5.4 ± 4.7 for survivors and 11.8 ± 5.3 for non-survivors (p = 0.005). For mortality risk prediction, the AUC of ROC was 0.819 for MEDS and 0.685 for Rapid Emergency Medicine Score (REMS). The hazard ratio of univariate and multivariate logistic regression analyses of REMS for EC patients was1.457 (p = 0.011) and 1.374 (p = 0.025), respectively. CONCLUSION: Physicians must pay attention to high-risk patients according to clinical clues and arrange imaging studies as soon as possible to confirm the diagnosis of EC. MEDS and REMS are helpful for clinical staff in predicting the clinical outcome of EC patients. If EC patients feature higher scores of MEDS (≥12) and REMS (≥10), they will have higher mortality.

Case report of acute encephalitis following the AstraZeneca COVID-19 vaccine.

Coronavirus disease 2019 (COVID-19) vaccines have proven to be safe, effective and life-saving. However, little information is available on the neurological complications of COVID-19 vaccine. Here, we report a case who developed acute encephalomyelitis 1 week after being vaccinated with AstraZeneca COVID-19 vaccine (AZ vaccine). Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) was also suspected. After intravenous dexamethasone and subcutaneous fondaparinux therapy, he returned to normal life without neurological sequelae. Four months later, he received Moderna COVID-19 vaccine without any sequelae.

Performance of Scoring Systems in Predicting Clinical Outcomes of Patients with Emphysematous Pyelonephritis: A 14-Year Hospital-Based Study.

Background: Emphysematous pyelonephritis (EPN) is a rare but severe necrotizing infection causing there to be gas in the pelvicalyceal system, renal parenchyma, and perirenal or pararenal space. Physicians should attend to EPN because of its life-threatening septic complications. The overall mortality rate has been reported to be as high as 20−40%. In addition, most patients had diabetes mellitus (DM) and obstructive uropathy. The most common isolated microorganism is Escherichia coli. This study aims to analyze the risk factors and performance of scoring systems in predicting the clinical outcomes of patients with EPN. Materials and Methods: We collected the data of patients with EPN in this single hospital-based retrospective study from the electronic medical records of Taichung Veterans General Hospital between January 2007 and December 2020. Radiological investigations of abdominal computed tomography (CT) confirmed the diagnosis of EPN. In addition, we analyzed demographics, clinical characteristics, and laboratory data. Finally, we used various scoring systems to predict clinical outcomes. Results: A total of fifty patients with EPN, whose diagnoses were confirmed through CT, were enrolled in the study. There were 18 males (36%) and 32 females (64%), with a mean age of 64.3 ± 11.3 years. The in-hospital mortality rate was 16%. A DM of 34 (68%) patients was the most common comorbidity. Fever was the most common symptom, found in 25 (50%) patients. The Mortality in Emergency Department Sepsis (MEDS) score was 4.64 ± 3.67 for survivors and 14.25 ± 5.34 for non-survivors (p < 0.001). The National Early Warning Score (NEWS) was 3.64 ± 2.33 for survivors and 7.13 ± 4.85 for non-survivors (p = 0.046). The Rapid Emergency Medicine Score (REMS) was 5.81 ± 1.97 for survivors and 9.13 ± 3.87 for non-survivors (p = 0.024). Regarding performance of mortality risk prediction, the AUC of ROC was 0.932 for MEDS, 0.747 for REMS, and 0.72 for NEWS. Conclusions: MEDS, REMS, and NEWS could be prognostic tools for the prediction of the clinical outcomes of patients with EPN. MEDS showed the best sound performance. In those with higher scores in MEDS (≥12), REMS (≥10), and NEWS (≥8), we recommended aggressive management and appropriate antimicrobial therapy as soon as possible to reduce mortality. Further large-scale studies are required to gain a deep understanding of this disease and to ensure patient safety.

Evolution of trimethoprim/sulfamethoxazole resistance in Shewanella algae from the perspective of comparative genomics and global phylogenic analysis.

OBJECTIVE: Shewanella algae is a zoonotic marine bacterium that causes a variety of infections in immunocompromised patients or those who have been exposed to seawater. The development of trimethoprim/sulfamethoxazole (TMP/SMX) resistance in S. algae are found in human and environment isolates during the past ten years, and thus the treatment options are decreasing. METHODOLOGY: In the study, we conduct a comparative genomic study to identify the resistant mechanism of TMP/SMX-resistance in S. algae. RESULTS: We found the resistance of TMP/SMX in S. algae is associated with the existence of sul1 and dfrA12 within the class 1 integron. The gene cassette dfra12-aadA2-qacEΔ1/sul1 within the class 1 integron is highly conserved. In addition, the class 1 integron and encapsulated sul1 are significantly enriched in Enterobacteriaceae in NCBI and UniProt databases. CONCLUSION: Our study suggests that the horizontal transfer of TMP/SMX resistance via class 1 integron is most frequently occurred within Enterobacteriaceae and has spread to a wide range of sources including soil, poultry, and marine water.

Performance of Scoring Systems in Predicting Clinical Outcomes in Patients with Bacteremia of Listeria monocytogenes: A 9-Year Hospital-Based Study.

BACKGROUND: Listeria monocytogenes (LM) is a facultative anaerobe, Gram-positive bacillus which is widely distributed in nature, and can be separated from soil, water, and rotten vegetables. Immunocompetent people are less likely to suffer from LM infection or may only show gastrointestinal symptoms. However, immunocompromised elderly people, pregnant women, and newborns may develop life-threatening invasive infections. The mortality rate of LM infection is as high as 25-30%. The aim of this study is to investigate clinical scores of patients with bacteremia of LM confirmed by one or more blood cultures. We analyzed their demographics and laboratory findings in relation to their clinical outcomes. MATERIALS AND METHODS: This was a hospital-based retrospective study on patients with bacteremia of LM. Data were collected from the electronic clinical database of Taichung Veterans General Hospital between January 2012 and December 2020. Bacteremia of LM was confirmed by at least one blood culture. Demographics, clinical characteristics, and laboratory data were collected for analysis. A variety of clinical scoring systems were used to predict the clinical outcome. RESULTS: A total of 39 patients had confirmed bacteremia of LM. Among them, 1 neonatal patient was excluded. The remaining 38 patients were studied. They included 16 males (42.1%) and 22 females (57.9%), with a mean age of 59.9 ± 19.6 years. Their hospital stay averaged 23.3 ± 20.9 days. The in-hospital mortality rate was 36.8%. Mortality in Emergency Department Sepsis (MEDS) Score was 6.6 ± 4.0 for survivors and 12.4 ± 4.4 for non-survivors (P < 0.001). The National Early Warning Score (NEWS) was 3.9 ± 2.8 for survivors and 7.8 ± 3.1 for non-survivors (P = 0.001). Regarding the prediction of mortality risk, the AUC of ROC was 0.829 for MEDS and 0.815 for NEWS. CONCLUSIONS: MEDS and NEWS were both good predictors of the clinical outcome in LM bacteremic patients. In those with higher scores of MEDS (≥10) and NEWS (≥8), we recommended an early goal-directed therapy and appropriate antibiotic treatment as early as possible to reduce mortality. Further large-scale studies are required to gain a deeper understanding of this disease and to ensure patient safety.

Detection of S83V GyrA mutation in quinolone-resistant Shewanella algae using comparative genomics.

BACKGROUND: Shewanella algae is a zoonotic pathogen that poses a serious health threat to immunocompromised hosts. Treatment of S. algae infections is challenging due to the pathogen's intrinsic resistance to a variety of ß-lactam antibiotics. Therapeutic options have become further limited by the emergence of quinolone-resistant strains. Currently, there are few studies concerning the genetic and molecular mechanisms underlying acquired quinolones resistance in S. algae. qnrA was once proposed as the candidate gene related to quinolones resistance in S. algae. However, recent studies demonstrated qnrA are highly conservative and does not confer resistance to quinolones in S. algae. METHODS: A total of 27 non-duplicated isolates of S. algae strains were examined. MICs of ciprofloxacin were determined using Vitek 2. Whole genome sequencing was performed using MiSeq platform. Comprehensive Antibiotic Resistance Database and ResFinder were used for annotation of quinolones resistance genes. Multiple sequence alignment by EMBOSS Clustal Omega were used to identified mutation in quinolone resistance-determining regions. To investigation of the alteration of protein structure induced by mutation, in silico molecular docking studies was conducted using Accryl Discovery studio visualizer. RESULTS: All S. algae harbored the quinolone-resistance associated genes (qnrA, gyrA, gyrB, parC, and parE) regardless its resistance to ciprofloxacin. Comparison of these genomes identified a nonsynonymous mutation (S83V) in chromosome-encoded gyrase subunits (GyrA) in quinolone-resistant strain. We found this mutation disrupts the water-metal ion bridge, reduces the affinity of the quinolone-enzyme complex for the metal ions and therefore decrease the capability of quinolones to stabilize cleavage complexes. CONCLUSIONS: The study provides insight into the quinolone resistance mechanisms in S. algae, which would be helpful for the evolution of antibiotic resistance in this bacterium.

Psoas abscess associated with aortic endograft infection caused by bacteremia of Listeria monocytogenes: A case report and literature review (CARE Complaint).

RATIONALE: Endograft infection following endovascular stent for aortic aneurysm is rare (0.6%-3%), but it results in high mortality rate of 25% to 88%. PATIENT CONCERNS: A 66-year-old hypertensive man underwent an endovascular stent graft for abdominal aortic aneurysm 18 months ago. Recurrent episodes of fever, chills, and abdominal fullness occurred 6 months ago before this admission. Laboratory data showed 20 mg/dL of C-reactive protein and abdominal computed tomography (CT) revealed an aortic endoleak at an urban hospital, so 4-day course of intravenous (IV) amoxicillin/clavulanic acid was given and he was discharged after fever subsided. He was admitted to our hospital due to fever, chills, and watery diarrhea for 1 day. Abdominal CT showed left psoas abscess associated with endograft infection. Blood culture grew Listeria monocytogenes. DIAGNOSIS: Left psoas abscess associated with endograft infection caused by bacteremia of Listeria monocytogenes. INTERVENTIONS: IV ampicillin with 8 days of synergistic gentamicin was prescribed and it created satisfactory response. Ampicillin was continued for 30 days and then shifted to IV co-trimoxazole for 12 days. OUTCOMES: He remained asymptomatic with a decline of CRP to 0.36 mg/dL and ESR to 39 mm/h. He was discharged on the 44th hospital day. Orally SMX/TMP was prescribed for 13.5 months. LESSONS: Only few cases of aortic endograft infection caused by Listeria monocytogenes had been reported. In selected cases, particularly with smoldering presentations and high operative risk, endograft retention with a prolonged antimicrobial therapy seem plausible as an initial therapeutic option, complemented with percutaneous drainage or surgical debridement if necessary.

Renal actinomycosis with retroperitoneal abscess in a cirrhotic patient: A case report (CARE-complaint).

RATIONALE: Renal actinomycosis is a rare clinical infection, subacute to chronic presentation caused by the Actinomyces bacteria. Actinomyces israelii is diagnosed in the overpowering majority of reported cases. Abdominopelvic manifestation forms 10% to 20% of all actinomycosis, and may be misdiagnosed as either a malignancy or chronic inflammation due to the lower correct preoperative diagnostic rate (<10%). PATIENT CONCERNS: A 38-year-old man with alcoholic liver cirrhosis experienced right flank pain, abdominal pain, and fever for 3 days. Leukocytosis, acute kidney injury, and impaired liver function were found. A computed tomographic scan demonstrated multiple renal cystic lesions, along with fluid accumulation at the right subphrenic and retroperitoneal spaces. DIAGNOSES: Renal actinomycosis was confirmed via cultures of both the abscess and nephrectomy specimen which grew A israelii and the pathological findings of multiple renal abscesses of actinomycosis with the characteristics of sulfur granules. INTERVENTIONS: A nephrectomy was performed for an inadequate percutaneous drainage of renal abscess. OUTCOMES: A full course of antibiotics with intravenous penicillin G (3 million units every 4 hours) was prescribed for 2 weeks, followed by oral penicillin V given at a dose of 2 grams per day for 6 months at our out-patient facility. LESSONS: A precise diagnosis of primary renal actinomycosis depends on any histopathological findings and/or cultures of specimens. A high dose of intravenous penicillin G is the first choice, followed by oral penicillin V, with the duration of each being dependent upon the individual condition.

Incidence of and risk factors for cryptococcosis in kidney transplant recipients in Taiwan-A nationwide population-based study.

OBJECTIVES: The aim of this study was to determine the long-term incidence of cryptococcosis in kidney transplant recipients (KTRs) and to analyze its risk factors. METHODS: This retrospective population-based cohort study analyzed data obtained from Taiwan's National Health Insurance Research Database for KTRs during 2000-2012 and matched cohorts. Both populations were followed until death, development of cryptococcosis, or December 2013. RESULTS: A total of 4,933 KTRs and 49,930 matched patients were included. The cryptococcosis incidence rates for the KTR cohort and matched cohort were 10.59 and 0.4 per 10,000 person-years, respectively. The hazard ratio for cryptococcosis among KTRs was 26.65 (p<0.001); and 43.77 (p<0.001) for cryptococcosis affecting the central nervous system (CNS). The Kaplan-Meier method confirmed an elevated cumulative incidence of cryptococcosis among KTRs (1.00% vs. 0.04%). Predictors for cryptococcosis were advanced age (OR 1.39, 95% CI 1.02-1.89, P=0.038) and cancer (OR 2.63, 95% CI 1.22-5.67, P=0.013), but not the use of any particular class of immunosuppressants. CONCLUSIONS: KTRs are at dramatically higher risk of developing cryptococcosis, especially with CNS involvement, relative to a non-KTR matched cohort. Older KTRs and those with cancer are at even higher risk of developing cryptococcosis.

Chryseobacterium meningosepticum sepsis complicated with retroperitoneal hematoma and pleural effusion in a diabetic patient.

Intra-abdominal infection due to Chryseobacterium meningosepticum is rare, and bacteremia complicated with pleural effusion and retroperitoneal hematoma caused by C. meningosepticum has not been reported previously. A 57-year-old diabetic man presented with bacteremia with retroperitoneal abscess and pleural effusion caused by C. meningosepticum on the 12th day of hospitalization. His clinical condition improved after antimicrobial therapy with levofloxacin and rifampin, debridement of the retroperitoneal hematoma and left-side chest tube insertion. Antibiotics were administered for 1 month, and he was later transferred to a local respiratory care ward under afebrile condition. C. meningosepticum should be included in the list of suspected nosocomial infections, especially in patients with immunocompromised status. Administration of appropriate antibiotics, such as quinolone, minocycline, trimethoprim-sulfamethoxazole or rifampin, and treatment of local infection improve the clinical outcome of patients with C. meningosepticum infection.

Primary splenic lymphoma associated with hemophagocytic lymphohistiocytosis complicated with splenic rupture.

Primary splenic lymphoma (PSL) is a rare disease with ambiguous definition, comprising less than 1% of non-Hodgkin's lymphoma. Even rarer is PSL combined with hemophagocytic lymphohistiocytosis (HLH), which has presentations of fever, cytopenia, hepatosplenomegaly, hyperferritinemia, and phagocytosis of hematopoietic cells in the reticuloendothelial system. We report the case of a 77-year-old man who presented with HLH initially. Refusing diagnostic splenectomy, he received chemotherapy. Spontaneous splenic rupture occurred after chemotherapy. In the following emergency operation, PSL was diagnosed. He received another 5 courses of chemotherapy with the R-CNOP regimen (rituximab, cyclophosphamide, mitoxantrone, vincristine, prednisolone). Now he has no residual or relapsed disease. Diagnostic splenectomy for adult HLH patients without definite etiologies may play an important role.

Clinical characteristics of non-O1/non-O139 Vibrio cholerae isolates and polymerase chain reaction analysis of their virulence factors.

BACKGROUND AND PURPOSE: Non-O1/non-O139 Vibrio cholerae can cause invasive extraintestinal disease as well as enteritis. The pathogenesis of invasive non-O1/non-O139 V. cholerae infections remains to be determined. This study compared the clinical manifestations and predisposing factors between bacteremic and non-bacteremic non-O1/non-O139 V. cholerae infections and examined virulence-associated genes in the pathogenic strains causing invasive disease. METHODS: We retrospectively investigated clinical characteristics of 18 bacteremic patients and 18 non-bacteremic patients, including demographic, laboratory and clinical data. Fourteen clinical isolates (ten isolated from blood and four from stool specimens) were obtained for polymerase chain reaction tests of the presence of virulence-associated genes ctxA, ctxB and tcpA. RESULTS: There was no difference in age, gender and gastrointestinal symptoms including abdominal pain and diarrhea, laboratory findings including leukocytosis and anemia, or underlying immunocompromised condition, except cirrhosis, between the bacteremic and non-bacteremic groups. Compared to patients with non-bacteremic infections, patients with non-O1/non-O139 V. cholerae bacteremia were significantly more likely to have cirrhosis and thrombocytopenia (0.0% vs 77.8% and 5.9% vs 72.2%, respectively; p<0.001). The cholera toxin genes (ctxA and ctxB) were found in only one strain (isolated from the stool specimen of a patient with enteritis) among fourteen clinical strains (7%). The tcpA gene, encoding the toxin-coregulated pilus, was present in thirteen of fourteen isolates (93%) [including ten isolates from blood, and three isolates from stool specimens]. CONCLUSIONS: Cirrhotic patients with thrombocytopenia were vulnerable to non-O1/non-O139 V. cholerae bloodstream invasion. The low prevalence of ctxA and ctxB genes in stool specimens indicates other toxins could have contributed to diarrhea. The fact that the tcpA gene was highly prevalent in clinical isolates in this study could imply an important role of tcpA in the pathogenesis of invasive disease caused by non-O1/non-O139 V. cholerae.

Prostatic abscess of Klebsiella pneumonia complicating septic pulmonary emboli and meningitis: A case report and brief review.

Prostatic abscess is a rare entity with an incidence of 0.5%-2.5% in all prostate diseases and usually occurs in the 5th and 6th decades of life with immunocompromised status. Prostatic abscess might be a process of evolution from acute prostatitis. Klebsiella pneumoniae is the leading microorganism in the diabetic patients of prostatic abscess in Taiwan. A 60-year-old diabetic man, with a one-week history of acute bacterial prostatitis was reported in this study, presenting to the emergency department with sudden altered mental status. The abdominal computed tomographic scan demonstrated lobulated prostatic abscess and multiple septic pulmonary emboli with lung abscesses. Analysis of cerebrospinal fluid showed white blood cells of 10771 counts/mm3 with segmented neutrophils of 99%. Cultures of blood, cerebrospinal fluid and sputum yielded Klebsiella pneumoniae. We concluded that computed tomographic scan can make a definite diagnosis of prostatic abscess associated with complications and management with empiric antibiotics and adequate drainage is suggested.

High-Mobility InSe Transistors: The Role of Surface Oxides.

In search of high-performance field-effect transistors (FETs) made of atomic thin semiconductors, indium selenide (InSe) has held great promise because of its high intrinsic mobility and moderate electronic band gap (1.26 eV). Yet the performance of InSe FETs is decisively determined by the surface oxidation of InSe taking place spontaneously in ambient conditions, setting up a mobility ceiling and causing an uncontrollable current hysteresis. Encapsulation by hexagonal boron nitride (h-BN) has been currently used to cope with this deterioration. Here, we provide insights into the role of surface oxides played in device performance and introduce a dry-oxidation process that forms a dense capping layer on top, where InSe FETs exhibit a record-high two-probe mobility of 423 cm2/V·s at room temperature and 1006 cm2/V·s at liquid nitrogen temperature without the use of h-BN encapsulation or high-κ dielectric screening. Ultrahigh on/off current ratio of >108 and current density of 365 µA/µm can be readily achieved without elaborate engineering of drain/source contacts or gating technique. Thickness-dependent device properties are also studied, with optimized performance shown in FETs comprising of 13 nm thick InSe. The high performance of InSe FETs with ultrathin dry oxide is attributed to the effective unpinning of the Fermi level at the metal contacts, resulting in a low Schottky barrier height of 40 meV in an optimized channel thickness.

Diagnostic value of the Binax NOW assay for identifying a pneumococcal etiology in patients with respiratory tract infection.

BACKGROUND AND PURPOSE: Streptococcus pneumoniae is a common pathogen in respiratory tract infections which is usually underestimated with conventional tests, largely due to the fragility of the bacteria. This study assessed the diagnostic value of a rapid test (Binax NOW) for the detection of the pneumococcal antigen in urine. METHODS: Unconcentrated urine samples from 1243 adults and 91 children hospitalized with respiratory tract infections were tested. RESULTS: In all adults with respiratory tract infections, the diagnostic results were as follows: sensitivity, 29 (60%) of 48; specificity, 748 (92.2%) of 811; negative predictive value, 748 (97.5%) of 767; false-positive rate, 63 (68%) of 92. The diagnostic results were similar in adults with lower respiratory tract infections: sensitivity, 21 (64%) of 33; specificity, 658 (92.2%) of 714; negative predictive value, 658 (98.2%) of 670; false-positive rate, 56 (73%) of 77. In children with respiratory tract infections, the diagnostic results were: sensitivity, 4 of 4; specificity 18 (64%) of 28; negative predictive value, 18 of 18; false-positive rate, 10 of 14. The low specificity of the test in children may be due to frequent pneumococcal nasopharyngeal colonization. CONCLUSIONS: High negative predictive values and high false-positive rates were found in both adults and children, indicating that a negative result may be more useful than a positive one in clinical practice. The high specificity of this test in adults indicates its potential value in the choice of initial antibiotic treatment by eliminating pneumococcal infection as a likely cause of respiratory tract infection in a proportion of patients.

Clinical significance of Candida species isolated from cerebrospinal fluid.

Candida species have only rarely been isolated from the cerebrospinal fluid. Some of these isolates are true pathogens with a high morbidity and mortality, while others are only colonizers or contaminants. Spontaneous recovery from Candida meningitis has also been reported. The purpose of this study was to identify factors indicative of patients positive for Candida from cerebrospinal fluid who should receive antifungal therapy. A total of 36 patients with a positive cerebrospinal fluid culture for Candida were included in this retrospective analysis. Seventeen of these patients had received antifungal therapy under the impression of Candida meningitis. The differences in the case fatality rate and the duration of hospitalization between the antifungal treatment and untreated groups were statistically significant (p<0.04 and p<0.005, respectively). Statistical analysis showed a significant difference in the percentage of patients with previous ventricular shunt (14/17 vs 8/19, p<0.05), central venous line in situ (9/17 vs 1/19, p<0.005), multiple positive cerebrospinal fluid culture (11/17 vs 1/19, p<0.0005), isolation of Candida at least 20 days after hospitalization in adults (6/7 vs 1/13, p<0.005), and cerebrospinal fluid white blood cell count (median 77 vs 2 /mm3, p<0.005). These results suggest that antifungal agent should be initiated promptly in patients whose cerebrospinal fluid is positive for Candida and who have one or more of the identified risk factors.