Pannus-related left main trunk ostial stenosis after aortic valve replacement.

A 34-year-old woman was hospitalized with shortness of breath and chest tightness and pain. She had undergone aortic valve replacement for aortic stenosis at the age of 18 years. Transthoracic echocardiography showed left ventricular asynergy and a high aortic valve pressure gradient. Thus, structural valve deterioration was diagnosed. Coronary computed tomography and coronary angiography revealed left main trunk ostial stenosis that had caused acute anteroseptal myocardial infarction. Urgent surgery revealed pannus formation around the prosthetic valve and covering the ostium of the left main trunk. A Bentall procedure and coronary artery bypass grafting were performed. The postoperative course was uneventful.

Checklist for infection control in the emergency department.

The risk of encountering human-to-human infections, including emerging infectious diseases, should be adequately and appropriately addressed in the emergency department. However, guidelines based on sufficient evidence on infection control in the emergency department have not been developed anywhere in the world. Each facility examines and implements its own countermeasures. The Japanese Association for Acute Medicine has established the "Committee for Infection Control in the Emergency Department" in cooperation with the Japanese Association for Infectious Diseases, Japanese Society for Infection Prevention and Control, Japanese Society for Emergency Medicine, and Japanese Society for Clinical Microbiology. A joint working group has been established to consider appropriate measures. This group undertook a comprehensive and multifaceted review of infection control measures for emergency outpatients and related matters, and released a checklist for infection control in emergency departments. This checklist has been prepared such that even small emergency departments with few or no emergency physicians can control infection by following the checklist, without committing any major errors. The checklist includes a control system for infection control, education, screening, and vaccination, prompt response to suspected infections, and management of the risk of infection in facilities. In addition, the timing of the check and interval at which the check is carried out are specified as categories. We hope that this checklist will contribute to improving infection control in the emergency department.

Toxoplasmic Encephalitis Followed by Primary EBV-Associated Post-Transplant Lymphoproliferative Disorder of the Central Nervous System in a Patient Undergoing Allogeneic Hematopoietic Stem Cell Transplant: A Case Report.

Toxoplasmic encephalitis (TE) and post-transplant lymphoproliferative disorder of the central nervous system (CNS-PTLD) are major complications after allogeneic hematopoietic stem cell transplant (allo-SCT); both are fatal without timely diagnosis and disease-specific treatment. Differential diagnosis of TE and CNS-PTLD can be challenging because brain biopsy, a gold standard for diagnosis, is sometimes not possible, owing to poor patient condition after allo-SCT. Here, we describe a case of isolated CNS-PTLD arising during the therapeutic course of TE. A 51-year-old man was admitted with mental abnormalities and fever on Day 106 after allo-SCT to treat myelodysplastic syndrome. Magnetic resonance imaging (MRI) revealed multiple nodular and ring-enhanced lesions in the brain, and the result of polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid was positive; therefore, he was diagnosed with TE. Anti-Toxoplasma therapy led to clinical improvement, and the result of subsequent PCR was negative. However, he developed left-sided hemiplegia on Day 306. Head MRI revealed a new lesion and a growing lesion, presenting as ring-enhanced nodules. Brain biopsy was performed, and a pathologic diagnosis of Epstein-Barr virus-associated CNS-PTLD was made. There was no evidence of TE. He was treated successfully by reducing immunosuppressants, followed by rituximab administration and a donor lymphocyte infusion, resulting in complete remission. While T.gondii-specific PCR has great value for diagnosis of TE, CNS-PTLD can be diagnosed only by brain biopsy; hence, brain biopsy may be warranted in cases of suspected PTLD.

A Prospective, Randomized, Open-Label Trial of Early versus Late Favipiravir Therapy in Hospitalized Patients with COVID-19.

Favipiravir is an oral broad-spectrum inhibitor of viral RNA-dependent RNA polymerase that is approved for treatment of influenza in Japan. We conducted a prospective, randomized, open-label, multicenter trial of favipiravir for the treatment of COVID-19 at 25 hospitals across Japan. Eligible patients were adolescents and adults admitted with COVID-19 who were asymptomatic or mildly ill and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomly assigned at a 1:1 ratio to early or late favipiravir therapy (in the latter case, the same regimen starting on day 6 instead of day 1). The primary endpoint was viral clearance by day 6. The secondary endpoint was change in viral load by day 6. Exploratory endpoints included time to defervescence and resolution of symptoms. Eighty-nine patients were enrolled, of whom 69 were virologically evaluable. Viral clearance occurred within 6 days in 66.7% and 56.1% of the early and late treatment groups (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [95% CI], 0.76 to 2.62). Of 30 patients who had a fever (≥37.5°C) on day 1, times to defervescence were 2.1 days and 3.2 days in the early and late treatment groups (aHR, 1.88; 95% CI, 0.81 to 4.35). During therapy, 84.1% developed transient hyperuricemia. Favipiravir did not significantly improve viral clearance as measured by reverse transcription-PCR (RT-PCR) by day 6 but was associated with numerical reduction in time to defervescence. Neither disease progression nor death occurred in any of the patients in either treatment group during the 28-day participation. (This study has been registered with the Japan Registry of Clinical Trials under number jRCTs041190120.).

Multiple Pulmonary Nodules in Leptospirosis.

A 21-year-old man presented with the chief complaints of fever and sore throat after visiting Cambodia and Thailand. Computed tomography revealed multiple pulmonary nodules. After performing antibiotic therapy, the pulmonary nodules without bacteremia disappeared completely. Paired microscopic agglutination tests revealed seroconversion against Leptospira serogroup Autumnalis. Thus, he was diagnosed with multiple pulmonary nodules caused by leptospirosis. Leptospirosis is a common zoonosis that occurs in tropical and subtropical areas. Its various clinical features include unspecified fever and Weil's disease. Although diffuse alveolar hemorrhaging is known to occur in severe leptospirosis, multiple pulmonary nodules resembling septic emboli or vasculitis are a rare complication.

Aortic root remodelling with external ring annuloplasty in acute type A aortic dissection.

OBJECTIVES: To investigate the early and mid-term results of aortic root remodelling with external ring annuloplasty in acute type A aortic dissection. METHODS: From January 2015 to April 2019, a total of 194 patients underwent emergency or urgent operation for acute type A aortic dissection in our hospital. Of these, outcomes in 18 patients who underwent valve-sparing aortic root remodelling with external ring annuloplasty were retrospectively evaluated. RESULTS: The mean age of the 18 patients was 49 ± 14 years. Fourteen patients (78%) were men. Five patients had Marfan syndrome and 2 patients had bicuspid aortic valve. Two patients had coronary malperfusion and 1 patient had cerebral malperfusion. All 18 patients underwent aortic root remodelling with external ring annuloplasty. Cusp repair using central cusp plication was required in 9 patients. Concomitant procedures were hemiarch replacement in 8 patients, total arch replacement in 7 patients, partial arch replacement in 1 patient and coronary artery bypass grafting to the right coronary artery in 3 patients. Thirty-day mortality rate was 5.6% (1 of 18). Postoperative echocardiography showed aortic regurgitation of <1+ in all patients. During follow-up (mean 56 ± 41 months), 1 case of recurrent aortic regurgitation required aortic valve replacement. CONCLUSIONS: Aortic root remodelling with external ring annuloplasty may be an appropriate treatment in middle-aged or younger patients presenting with acute type A aortic dissection.

A survey on infection control in emergency departments in Japan.

AIM: Infection control in the emergency department is important for hospital risk management; however, few clinical guidelines have been established. This study aimed to determine whether hospitals in Japan have infection control manuals, and investigate the contents of manuals, consulting systems, and isolation facilities for emergency departments. METHODS: A total of 517 hospitals certified as educational institutions for board-certified acute care physicians in Japan were requested between March and May 2015 to provide a written evaluation of the infection control in the emergency department. RESULTS: A total of 51 of 303 (16.8%) hospitals had no manuals regarding infection control in the emergency department. Among 250 hospitals having emergency department manuals, 115 (46.0%) did not include contents regarding disinfection and sterilization for imaging examination rooms, and only 44 (17.6%) had criteria for contacting the emergency medical service when patients are suspected of, or diagnosed with, communicable diseases. Of the 303 hospitals, 277 (91.4%) prepared specific manuals for the 2009 pandemic influenza. Of the 303 hospitals, 80 (26.4%) did not prepare manuals for the Ebola virus disease outbreak in West Africa in 2014. Furthermore, 92 (30.4%) of the 303 hospitals did not have any negative-pressure isolation rooms. CONCLUSIONS: Practices and guidelines necessary for infection control in the emergency department were not sufficiently covered in the hospitals studied. Education, information sharing, and a checklist for preparing manuals are needed to establish better infection control systems in emergency departments.

Wohlfahrtiimonas chitiniclastica Bacteremia Hospitalized Homeless Man with Squamous Cell Carcinoma.

We report a case of Wohlfahrtiimonas chitiniclastica bacteremia in an elderly man in Japan who had squamous cell carcinoma. Blood cultures were initially negative for W. chitiniclastica but were positive on day 20. Careful attention needs to be paid to this organism in patients who have chronic wounds with maggots.

Clinical characteristics and epidemiology of intestinal tapeworm infections over the last decade in Tokyo, Japan: A retrospective review.

BACKGROUND: Tapeworm (cestode) infections occur worldwide even in developed countries and globalization has further complicated the epidemiology of such infections. Nonetheless, recent epidemiological data on cestode infections are limited. Our objectives were to elucidate the clinical characteristics and epidemiology of diphyllobothriosis and taeniosis in Tokyo, Japan. METHODOLOGY/PRINCIPAL FINDINGS: We retrospectively reviewed 24 cases of human intestinal cestode infection from January 2006 to December 2015 at a tertiary referral hospital in Tokyo, Japan. The patients included were diagnosed with cestode infection based on morphological and/or molecular identification of expelled proglottids and/or eggs and treated in our hospital. Fifteen and 9 patients were diagnosed with diphyllobothriosis and taeniosis, respectively. The median patient age was 31 years (interquartile range [IQR]: 26-42 years), and 13 (54%) were male. Most of the patients (91.7%) were Japanese. All patients were successfully treated with praziquantel without recurrence. Diphyllobothriosis was caused by Diphyllobothrium nihonkaiense in all patients. Taeniosis was due to infection of Taenia saginata in 8 [88.9%] patients and T. asiatica in 1 [11.1%] patient. All patients with taeniosis were infected outside Japan, as opposed to those with diphyllobothriosis, which were domestic. The source locations of taeniosis were mostly in developing regions. The median duration of the stay of the patients with taeniosis at the respective source location was 1 month (IQR: 1-8). CONCLUSIONS/SIGNIFICANCE: The cestode infection, especially with D. nihonkaiense, has frequently occurred, even in Japanese cities, thereby implicating the probable increase in the prevalence of diphyllobothriosis among travelers, as the number of travelers is expected to increase owing to the Tokyo Olympics/Paralympics in 2020. In addition, medical practitioners should be aware of the importance of providing advice to travelers to endemic countries of taeniosis, including the potential risks of infection and preventive methods for these infections.

Cryptococcus gattii genotype VGIIa infection imported from Vancouver Island to Japan.

A 71-year-old Japanese man with travel history to the Vancouver Island, Canada was diagnosed the pulmonary and central nervous system infections caused by Cryptococcus gattii genotype VGIIa. This is the first imported case of Cryptococcus gattii genotype VGIIa infection from endemic area of North America to Japan. He was recovery with no residual neurological dysfunction by early resection of brain mass and antifungal therapy. Early surgical resection of cerebellar cryptococcoma may shorten the length of induction therapy with antifungal drugs.

Aortic root remodeling in a patient with Turner syndrome using the reference curves of aortic diameters in children.

We report the successful surgical treatment of aortic regurgitation in a 27-year-old woman with Turner syndrome (TS) who was admitted with exacerbation of dyspnea on exertion. Echocardiography showed a bicuspid aortic valve with severe aortic regurgitation and computed tomography showed dilatation of the ascending aorta and aortic root. Due to the patient's low body surface area (due to TS), standard determination of aortic size was not possible; therefore, we used the reference curves of aortic diameters in children. Because of the possibility of fatal ascending aortic dissection and rupture, we performed concomitant aortic root remodeling and aortic valve repair.

A Case of Dengue Fever Imported from Burkina Faso to Japan in October 2016.

Dengue fever remains underreported in Africa due to a lack of awareness among healthcare providers, the presence of other febrile illnesses, and insufficient laboratory testing. We present a case of dengue fever imported from Burkina Faso to Japan, where an outbreak of dengue was reported on October 18, 2016. Phylogenetic analysis revealed that the isolate from our patient belonged to a distinct cluster of sylvatic dengue viruses, suggesting that dengue viruses have been maintained in mosquitoes and human cycles in Burkina Faso for more than 30 years.

Chikungunya Fever in Traveler from Angola to Japan, 2016.

Simultaneous circulation of multiple arboviruses presents diagnostic challenges. In May 2016, chikungunya fever was diagnosed in a traveler from Angola to Japan. Travel history, incubation period, and phylogenetic analysis indicated probable infection acquisition in Angola, where a yellow fever outbreak is ongoing. Thus, local transmission of chikungunya virus probably also occurs in Angola.

A Cranial-Sided Approach for Repeated Mitral Periprosthetic Leak After Right Pneumonectomy.

A 72-year-old man presented with worsening dyspnea on effort. He underwent right pneumonectomy 40 years ago, then mitral valve replacement through a right thoracotomy 8 years ago with repeat surgery to repair a periprosthetic valve leak; the mediastinum was displaced to the right, and the heart was rotated counterclockwise. Transthoracic echocardiography showed periprosthetic valve leak recurrence near the left atrial appendage. We repaired the periprosthetic valve leak through a median sternotomy. Transecting the main pulmonary artery allowed us to widely open the cranial-sided left atrium. We obtained good exposure of the mitral valve, and repaired the periprosthetic valve leak using pledgeted sutures and a pericardial patch.

Successful surgical treatment for total circumferential aortic and mitral annulus calcification: application of half-and-half technique.

Patients with total circumferential mitral annular calcification (MAC) extending into the intervalvular fibrous body and aortic annulus have a high risk of cardiac surgery, which remains a technical challenge for surgeons. Our technique for MAC is characterized as simple supra-mitral annular prosthesis insertion after minimum debridement of calcification ("half-and-half technique"). To date, our technique has been applied in only simple MAC cases and has good results. Herein, we report successful two cases of total circumferential MAC, extending into the intervalvular fibrous body and aortic annulus that were treated by a simple double valve replacement with application of our "half-and-half technique".

Delayed Intestinal Ischemia after Surgery for Type A Acute Aortic Dissection.

We report a rare case of delayed intestinal ischemia after total arch replacement for type A acute aortic dissection. At the onset of acute aortic dissection, computed tomography (CT) angiography revealed celiac trunk occlusion and progressive dissection into the superior mesenteric artery without stenosis. However, following total arch replacement, visceral malperfusion was not detected by exploratory laparotomy. On postoperative day 12, the patient developed paralytic ileus without an elevated lactate level. CT angiography revealed new superior mesenteric artery stenosis by a thrombosed false lumen with persistent celiac trunk occlusion. Endovascular treatment including stent implantation resolved intestinal ischemia.

Less-Invasive Endovascular Treatment of Arch Aneurysm With Aberrant Right Subclavian Artery.

We report a patient with an arch aneurysm with an aberrant right subclavian artery who underwent successful endovascular treatment with the chimney technique and bilateral carotid artery-to-subclavian artery bypasses. We used a chimney graft in the left carotid artery to preserve its flow. The bilateral carotid-to-subclavian artery bypasses preserved perfusion of the bilateral vertebral arteries. A thoracic stent graft was subsequently deployed in the aortic arch over the chimney graft of the left carotid artery. There have been few reports about less-invasive treatment for arch aneurysm with aberrant right subclavian artery. This technique was an effective strategy to avoid a high-risk open operation.

Two Cases of Granulomatous Mastitis Caused by Corynebacterium kroppenstedtii Infection in Nulliparous Young Women with Hyperprolactinemia.

Recently, an association between granulomatous mastitis and local infection with Corynebacterium (C.) kroppenstedtii has been suggested. We herein report two cases of granulomatous mastitis resulting from C. kroppenstedtii infection in nulliparous young women with hyperprolactinemia. Both cases involved nulliparous patients with drug-induced hyperprolactinemia, and both individuals received incision and drainage, after which the pus was sent to our laboratory. Corynebacterium spp. grew on blood agar, and 16S rRNA gene sequencing identified the pathogen as C. kroppenstedtii. In conclusion, lactational changes caused by drug-induced hyperprolactinemia may increase the risk of granulomatous mastitis after C. kroppenstedtii infection.

Persistent seropositivity for yellow fever in a previously vaccinated autologous hematopoietic stem cell transplantation recipient.

The duration of a protective level of yellow fever antibodies after autologous hematopoietic stem cell transplantation in a previously vaccinated person is unclear. The case of a patient who had previously been vaccinated for yellow fever and who remained seropositive for 22 months after autologous peripheral blood stem cell transplantation for malignant lymphoma is described herein.