A Case of Topical Ofloxacin-Induced Otomycosis and Literature Review.

The prevalence of fungal otitis externa, or otomycosis, has been increasing in recent decades. Fungi may act as primary pathogens in this condition, or they may occur as secondary infections after prolonged ototopical treatment with antibiotics, which alters the flora of the external auditory canal (EAC) and enables overgrowth of its fungal inhabitants. We report here a case of otomycosis by Candida parapsilosis, Malassezia obtusa, and Malassezia furfur as a secondary infection following prolonged otic ofloxacin treatment. To the best of our knowledge, although isolation of C. parapsilosis and M. furfur from the EAC is not uncommon, the recovery of M. obtusa has not yet been reported. We also conducted a literature review of the searchable data on PubMed concerning the isolation of Malassezia species from the human EAC.

Epidural abscess caused by Schizophyllum commune: A rare case of rhinogenic cranial complication by a filamentous basidiomycete.

Central nervous system (CNS) infections due to filamentous basidiomycetes are extremely rare. We encountered a case of epidural abscess due to Schizophyllum commune that extended from sinusitis. A 53-year-old Japanese man presented at our hospital with a headache. Computed tomography (CT) of the cranium and sinuses showed ethmoid and sphenoid sinusitis with no intracranial abnormalities. The patient was diagnosed with acute sinusitis and underwent antibiotic treatment. However, the symptoms deteriorated, and the patient came to our hospital again with consciousness disturbance. CT scan of the cranium and sinuses showed no improvement of sinusitis after antibiotic therapy and an epidural abscess emerged in the middle cranial fossa. Therefore, emergency craniotomy and endoscopic sinus fenestration were performed. Filamentous fungal elements were observed in both rhinorrhoea and epidural abscess. The symptoms improved after the operation and administration of liposomal amphotericin B. The clinical isolate was identified as S. commune by a molecular-based method. To our knowledge, this is the first report of epidural abscess due to this fungus. Although rare, clinicians should be aware that S. commune could be a causative agent of CNS infections.

Genotyping of Acinetobacter baumannii strains isolated at a Japanese hospital over five years using targeted next-generation sequencing.

Acinetobacter baumannii is a Gram-negative bacterial agent involved in nosocomial infections. In this five-year retrospective study, phylogenetic relationships among carbapenem-resistant A. baumannii strains that were isolated at Teikyo University Hospital in Tokyo metropolis, Japan, were explored. A panel of 72 carbapenem-resistant A. baumannii strains that isolated from January 2006 until August 2010 was studied. Next-Generation sequencing (NGS) was employed to perform large-scale genotyping of these isolates. They were separated, according to the time of isolation, into two genetically distinct groups, one correspondent to strains of the outbreak reported to local public health department in 2010 and the other contained strains from earlier isolations, suggesting different origins of the isolates. Moreover, taxa in each group showed two main clustering patterns. Multilocus sequence typing (MLST) study on 8 isolates from the last outbreak showed that they were from one sequence type, 92, displaying less discriminatory power comparing to large-sequence typing. The clonal lineage profiles produced in this retrospective study will be used as a reference database to compare future isolations of A. baumannii. This study demonstrates the power of NGS in conducting epidemiological researches, allowing a high resolution genotyping.

Complete genome sequences of 11 Streptococcus pneumoniae strains isolated from acute infectious purpura fulminans, sepsis, and pneumonia.

The complete genome sequences of 11 Japanese Streptococcus pneumoniae isolates were determined by hybrid assembly of long and short reads, including two strains isolated from patients with acute infectious purpura fulminans, six strains from patients with sepsis, and three strains from patients with pneumonia.

Usefulness of gram-stained sputum obtained just after administration of antimicrobial agents as the earliest therapeutic indicator for evaluating the effectiveness of empiric therapy in community-acquired pneumonia caused by pneumococcus or Moraxella catarrhalis.

We present here three cases in which morphological changes and/or a decreased number of Streptococcus pneumoniae or Moraxella catarrhalis could be observed in gram-stained sputum obtained just after the first administration of an antimicrobial agent. Case 1 was a 53-year-old man with pneumonia caused by gram-positive diplococcus, identified as S. pneumoniae, who was administered 2 g of ampicillin over a period of 1 h. Gram-stained sputum showed smaller or gram-negative pneumococci at the completion of administration of the agent, a decreased number of cocci at 1 h after administration, and almost no cocci at 12 h after the completion of administration. Case 2 was a 72-year-old woman with pneumonia caused by diplococcus, identified as S. pneumoniae, who was administered 2 g of ampicillin over a period of 1 h. Gram-stained sputum showed weakly stained, small cocci at the completion of administration of the agent and few cocci at 1 h after the completion of administration. Case 3 was a 58-year-old woman with pneumonia caused by a gram-negative diplococcus, identified as Moraxella catarrhalis, who was administered 1 g of cefotaxime over a period of 30 min. Gram-stained sputum showed few extracellular cocci and some intracellular cocci inside neutrophils 1 h after administration and no cocci 2 h after the completion of administration. These three cases showed that gram-stained sputum obtained just after and/or 1 h after administration of the first antimicrobial agent were suitable as the quickest therapeutic indicator of the effectiveness of empiric therapy, with the effectiveness of the agent being shown much earlier than with markers such as the white blood cell count and C-reactive protein level.

A case study of measles vaccination for university students during the measles outbreak in Tokyo, Japan, 2007.

In April 2007, seven students belonging to the same class at Teikyo University developed measles. To prevent the spread of infection, 27 of 106 students in the same class who had low anti-measles antibody titers as measured by hemagglutination inhibition (HI) assay were vaccinated. After the outbreak had subsided, the HI values were investigated in 103 students, and they answered questionnaires about their health condition during the period of the outbreak and their previous clinical histories of measles, including vaccination records. There was no new case of measles after introduction of the vaccination program. However, the HI titers of 42% of the students who were not vaccinated in this program were significantly elevated. Fever and catarrhal signs occurred in 7 of these students with pre-exposure titers of 8 or less. The post-exposure HI titers of 71% of students who were unaffected by measles and had high HI titers (>8) before the epidemic did not increase. These results suggested that people with low HI titers may become potential carriers of measles and that measurement of pre-exposure HI anti-measles antibody titer is a useful method for selection of candidates to undergo vaccination.

Case of Mycobacterium tuberculosis meningitis: Gram staining as a useful initial diagnostic clue for tuberculous meningitis.

A 32-year-old man was admitted to our hospital because of fever, headache, and loss of consciousness. Four days before admission, he had had difficulty speaking. On the day of admission, his colleague had found him to be unconscious and lying on his back. He was admitted to our hospital. The temperature at the eardrum was 35.2°C. Neurologic evaluation was negative. Computed tomography (CT) scan of the brain showed slight ventricular enlargement bilaterally. An X-ray film of the chest showed no abnormality. On the second hospital day, neck stiffness was noted. The cerebrospinal fluid (CSF) contained 870 white cells/µl, most of which were neutrophils; the glucose level in the CSF was 10 mg/dl, and the protein level was 140 mg/dl. Stained smears of the CSF, including Gram staining and India-ink preparations, disclosed no microorganisms. Capsular antigen tests for several bacteria were negative. Antimicrobial agents were started. However, by changing the microscope focus slightly while viewing Gram stains of the CSF, we could see brightened and Gram-positive bacilli that had been phagocytosed by neutrophils. This finding suggested the presence of Mycobacterium tuberculosis. Ziehl-Neelsen staining of the CSF and gastric juice revealed anti-acid bacilli. Polymerase chain reaction for M. tuberculosis in the gastric juice was positive. This case showed that Gram staining could be useful as an initial adjunct for the diagnosis of tuberculous meningitis, particularly when the CSF shows predominantly neutrocytic pleocytosis, but no other evidence of bacterial meningitis.

In vitro and in vivo anti-plasmodial activity of essential oils, including hinokitiol.

Abstract. The anti-plasmodial activity of 47 essential oils and 10 of their constituents were screened for in vitro activity against Plasmodium falciparum. Five of these essential oils (sandalwood, caraway, monarda, nutmeg, and Thujopsis dolabrata var. hondai) and 2 constituents (thymoquinone and hinokitiol) were found to be active against P. falciparum in vitro, with 50% inhibitory concentration (IC50) values equal to or less than 1.0 microg/ml. Furthermore, in vivo analysis using a rodent model confirmed the anti-plasmodial potential of subcutaneously administered sandalwood oil, and percutaneously administered hinokitiol and caraway oil against rodent P. berghei. Notably, these oils showed no efficacy when administered orally, intraperitoneally or intravenously. Caraway oil and hinokitiol dissolved in carrier oil, applied to the skin of hairless mice caused high levels in the blood, with concentrations exceeding their IC50 values.

The usefulness of changing focus during examination using Gram staining as initial diagnostic clue for infective tuberculosis.

Gram staining is a useful technique for detecting bacteria but is highly questionable in detecting Mycobacterium tuberculosis. Its detection generally requires special staining, such as Ziehl-Neelsen staining. We experienced three cases in which tuberculosis was first suggested by Gram staining of sputum or pus, confirmed by Ziehl-Neelsen staining, and diagnosed by polymerase chain reaction or culture. To find colorless tubercle bacilli in clinical samples with various organisms, varying the focus to slightly longer and shorter during study of the slides is indispensable. We present criteria for detecting infective pulmonary tuberculosis in Gram staining. First, in the ordinary focus, weakly stained, thin, gram-positive bacilli are found; second, with a slightly longer focus distance, the thin, cord-like, conspicuous gram-positive bacilli can be observed; and third, with a shorter focus distance, the gram-positive bacilli have changed into the brightened, colorless, or ghost ones. Four laboratory technologists each evaluated 20 Gram-stained samples after being lectured on the criteria, with no prior information about the sample. They accurately evaluated the presence of the bacilli in Gram-stained preparations in more than 90% of samples containing 3+ bacilli on Ziehl-Neelsen staining. Gram staining is available as an easy and rapid initial clue to recognize highly infective tuberculosis.

Exotic myiasis caused by 19 larvae of Cordylobia anthropophaga in Namibia and identified using molecular methods in Japan.

A case of exotic myiasis caused by tumbu fly (Cordylobia anthropophaga) parasitism acquired while travelling in the Republic of Namibia is reported. This is the fifth case reported in Japan, and is very unusual in that the patient was infected with 19 larvae. This is also the first case diagnosed using molecular methods in Japan. We cultured the extracted larvae in vitro and successfully obtained pupae.

Enhancing melting curve analysis for the discrimination of loop-mediated isothermal amplification products from four pathogenic molds: Use of inorganic pyrophosphatase and its effect in reducing the variance in melting temperature values.

Loop-mediated isothermal amplification (LAMP) is widely used for differentiating causative agents in infectious diseases. Melting curve analysis (MCA) in conjunction with the LAMP method reduces both the labor required to conduct an assay and contamination of the products. However, two factors influence the melting temperature (Tm) of LAMP products: an inconsistent concentration of Mg2+ ion due to the precipitation of Mg2P2O7, and the guanine-cytosine (GC) content of the starting dumbbell-like structure. In this study, we investigated the influence of inorganic pyrophosphatase (PPase), an enzyme that inhibits the production of Mg2P2O7, on the Tm of LAMP products, and examined the correlation between the above factors and the Tm value using MCA. A set of LAMP primers that amplify the ribosomal DNA of the large subunit of Aspergillus fumigatus, Penicillium expansum, Penicillium marneffei, and Histoplasma capsulatum was designed, and the LAMP reaction was performed using serial concentrations of these fungal genomic DNAs as templates in the presence and absence of PPase. We compared the Tm values obtained from the PPase-free group and the PPase-containing group, and the relationship between the GC content of the theoretical starting dumbbell-like structure and the Tm values of the LAMP product from each fungus was analyzed. The range of Tm values obtained for several fungi overlapped in the PPase-free group. In contrast, in the PPase-containing group, the variance in Tm values was smaller and there was no overlap in the Tm values obtained for all fungi tested: the LAMP product of each fungus had a specific Tm value, and the average Tm value increased as the GC% of the starting dumbbell-like structure increased. The use of PPase therefore reduced the variance in the Tm value and allowed the differentiation of these pathogenic fungi using the MCA method.

Detection of Fungi from an Indoor Environment using Loop-mediated Isothermal Amplification (LAMP) Method.

　Loop-mediated isothermal amplification (LAMP) is a useful DNA detection method with high specificity and sensitivity. The LAMP reaction is carried out within a short time at a constant temperature without the need for thermal cycling. We developed a LAMP primer set for detecting a wide range of fungi by aligning the sequences of the large subunit ribosomal RNA gene of Candida albicans (Ascomycota), Cryptococcus neoformans (Basidiomycota), and Mucor racemosus (Mucorales). The threshold of C. albicans rDNA as template with our LAMP primer set was in the range of 10-100 copies per a reaction. In this study, we evaluated the correlation between colony forming units (CFU) and LAMP detection rate using the LAMP method for environmental fungi. The LAMP method should be a useful means of detecting fungi in indoor environments, disaster areas, or even in confined manned spacecraft to prevent allergies or infections caused by fungi.

[Prophylactic efficacy of a basidiomycetes preparation AHCC against lethal Candida albicans infection in experimental granulocytopenic mice].

The prophylactic effects of a Basidiomycetes preparation, AHCC, against lethal Candida albicans infection were investigated in non treated or immunosuppressed mice. In the cyclophosphamide-or 5-fluorouracil (5-FU)-treated leukopenic mice and nontreated mice, the intraperitoneal administration of AHCC prior to C. albicans infection clearly prolonged the survival periods of the infected mice. In doxorubicin-treated mice, AHCC was less but significantly effective. On the other hand, in prednisolone-treated mice, AHCC was not effective. Oral administration of AHCC also protected the 5-FU-treated mice from lethal Candida infection, as indicated by prolongation of the survival periods and inhibition of Candida growth in the kidneys of these mice and by the increase in a number of neutrophils in their peripheral blood. These results suggested that AHCC may display a protective role against opportunistic fungal infection in leukopenic hosts.

Relationship between blood pressure and persistent epistaxis at the emergency department: a retrospective study.

BACKGROUND: Persistent nosebleed episodes have occurred in patients with idiopathic epistaxis from Kiesselbach's area despite confirmed location of the bleeding site, but the cause remains unclear. We tried to determine whether persistent epistaxis was associated with blood pressure. METHODS AND RESULTS: Between May 2009 and May 2010, the records for 133 adult patients with idiopathic epistaxis from Kiesselbach's area were obtained from the emergency department of our hospital. The bleeding site was pressed with a cotton strip for about 30 minutes, followed by checking for nosebleed. Comparison of background factors by the presence or absence of persistent epistaxis revealed a significantly higher systolic blood pressure in patients with persistent nosebleed than in those without (181.3 ± 26.9 vs. 156.6 ± 26.1 mm Hg; P < .0001). Persistent epistaxis was significantly more frequent in patients with hypertension than in those without (26% vs. 8%; P = .002). Multivariate logistic analysis revealed systolic blood pressure to be an independent factor associated with epistaxis persistence (odds ratio, 1.03; 95% confidence interval, 1.01-1.06; P = .002). CONCLUSION: Proper blood pressure management is necessary for the prevention of persistent epistaxis from Kiesselbach's area in the clinical setting of emergency care practice.

Polymerase chain reaction assay for specific identification of Candida guilliermondii (Pichia guilliermondii).

The incidence rates of fungemia caused by Candida guilliermondii have been increasing over the past several years. Although still relatively rare (1.3% of all cases of fungemia in Japan), most cases of C. guilliermondii fungemia occur in patients with cancer or hematological malignancy and their mortality rate is high. As C. guilliermondii tends to be resistant to various antifungal agents, early identification of this pathogen and treatment with an appropriate antifungal agent are required to improve survival rates in these patients. However, it is extremely difficult to differentiate C. guilliermondii (Pichia guilliermondii) from members of the C. famata complex. To date, identification based on DNA sequencing has been the only reliable method for the identification of fungal groups. Here, we used a polymerase chain reaction (PCR)-based method that we developed for the simple and reliable identification of C. guilliermondii (P. guilliermondii). A pair of specific primers was designed corresponding to the 18S rDNA sequence. The PCR system was applied to isolates from fungemia patients. These yeasts could not be identified with CHROMagar Candida, but were successfully identified using this PCR-based system.

Comparative study of direct polymerase chain reaction, microscopic examination and culture-based morphological methods for detection and identification of dermatophytes in nail and skin samples.

The positive rates of dermatophytes isolated and identified by conventional methods are rather low. Moreover, clinical isolates sometimes show atypical morphology, and in such cases microscopic methods are not applicable for identification. The present study was performed to assess the utility of specific polymerase chain reaction (PCR)-based methods for Trichophyton rubrum and Trichophyton mentagrophytes as diagnostic tools for dermatophytoses. Both conventional morphological identification and specific PCR methods based on the nuclear ribosomal internal transcribed spacer (ITS)1 DNA sequence were performed to identify dermatophyte species from clinical specimens of patients who visited Kawasaki Social Insurance Hospital between 16 May and 17 August 2005. Specific PCR methods were also directly applied to clinical specimens, and the results of the two methods were compared. The clinical samples examined consisted of 126 skin scale specimens and 80 nail specimens. The positive rates of culture isolation from clinical specimens were 67% and 33% for skin scale and nail specimens, respectively. In contrast, PCR analysis yielded a positive rate of 100% for clinical isolates from both skin scales and nails, and rates of 95% and 99% were obtained by direct application to clinical specimens. The results of the present study indicated that specific PCR is highly advantageous as a diagnostic tool for detection and identification of dermatophytes on direct application to skin scale or nail specimens.