Acute myocarditis secondary to Campylobacter jejuni enteritis: A case report.

Acute myocarditis is a rare complication of Campylobacter jejuni enteritis. Herein, we report the case of a 20-year-old man who presented with chest pain that developed three days after the onset of enteritis. Electrocardiogram, echocardiogram, and cardiac enzyme levels suggested myocarditis. Cardiac magnetic resonance imaging revealed a late gadolinium enhancement in the inferior wall. Degeneration and necrosis of myocardial cells and lymphocyte-dominant inflammatory cell infiltration were found in the tissue obtained by endomyocardial biopsy. Acute myocarditis associated with C. jejuni enteritis was confirmed by these findings and C. jejuni detected in the stool culture. The symptoms of enteritis and myocarditis remitted 10 days after the onset. The left ventricular ejection fraction was improved from 40 % to 57 %.In previous cases, endomyocardial biopsy has not been performed because of mild myocarditis. The lack of pathological reports makes the mechanism of myocarditis associated with C. jejuni enteritis unknown. We report a case of myocarditis associated with C. jejuni enteritis, which was diagnosed using cardiac magnetic resonance imaging and endomyocardial biopsy. Learning objective: Acute myocarditis is a rare but important complication of Campylobacter jejuni enteritis. Cardiac magnetic resonance imaging is useful for diagnosis. Most cases of myocarditis associated with C. jejuni enteritis were mild and remitted without specific treatment. In the present case, endomyocardial biopsy was performed and CD4-positive lymphocytes were predominantly detected in the myocardial tissue.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature.

BACKGROUND: Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates. CASE PRESENTATION: A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death. CONCLUSIONS: In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

Circulating intermediate CD14++CD16+monocytes are increased in patients with atrial fibrillation and reflect the functional remodelling of the left atrium.

AIMS: A recent large clinical study demonstrated the association between intermediate CD14++CD16+monocytes and cardiovascular events. However, whether that monocyte subset contributes to the pathogenesis of atrial fibrillation (AF) has not been clarified. We compared the circulating monocyte subsets in AF patients and healthy people, and investigated the possible role of intermediate CD14++CD16+monocytes in the pathophysiology of AF. METHODS AND RESULTS: This case-control study included 44 consecutive AF patients without systemic diseases referred for catheter ablation at our hospital, and 40 healthy controls. Patients with systemic diseases, including structural heart disease, hepatic or renal dysfunction, collagen disease, malignancy, and inflammation were excluded. Monocyte subset analyses were performed (three distinct human monocyte subsets: classical CD14++CD16-, intermediate CD14++CD16+, and non-classical CD14+CD16++monocytes). We compared the monocyte subsets and evaluated the correlation with other clinical findings. A total of 60 participants (30 AF patients and 30 controls as an age-matched group) were included after excluding 14 AF patients due to inflammation. Atrial fibrillation patients had a higher proportion of circulating intermediate CD14++CD16+monocytes than the controls (17.0 ± 9.6 vs. 7.5 ± 4.1%, P < 0.001). A multivariable logistic regression analysis demonstrated that only the proportion of intermediate CD14++CD16+monocytes (odds ratio: 1.316; 95% confidence interval: 1.095-1.582, P = 0.003) was independently associated with the presence of AF. Intermediate CD14++CD16+monocytes were negatively correlated with the left atrial appendage flow during sinus rhythm (r= -0.679, P = 0.003) and positively with the brain natriuretic peptide (r = 0.439, P = 0.015). CONCLUSION: Intermediate CD14++CD16+monocytes might be closely related to the pathogenesis of AF and reflect functional remodelling of the left atrium.

Reduction in coronary microvascular resistance through cardiac resynchronization and its impact on chronic reverse remodelling of left ventricle in patients with non-ischaemic cardiomyopathy.

AIMS: Left bundle branch block (LBBB) induces mechanical dyssynchrony, thereby compromising the coronary circulation in non-ischaemic cardiomyopathy. We sought to examine the effects of cardiac resynchronization therapy (CRT) on coronary flow dynamics and left ventricular (LV) function. METHODS AND RESULTS: Twenty-two patients with non-ischaemic cardiomyopathy (New York Heart Association class, III or IV; LV ejection fraction, ≤35%; QRS duration, ≥130 ms) were enrolled. One week after implantation of the CRT device, coronary flow velocity and pressure in the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCx) were measured invasively, before and after inducing hyperemia by adenosine triphosphate administration, with two programming modes: sequential atrial and biventricular pacing (BiV) and atrial pacing in patients with LBBB or sequential atrial and right ventricular pacing in patients with complete atrioventricular block (Control). We assessed hyperemic microvascular resistance (HMR, mean distal pressure divided by hyperemic average peak velocity) and the relationship between the change in HMR and mid-term LV reverse remodelling. Hyperemic microvascular resistance was lower during BiV than during Control (LAD: 1.76 ± 0.47 vs. 1.54 ± 0.45, P < 0.001; LCx: 1.92 ± 0.42 vs. 1.73 ± 0.31, P = 0.003). The CRT-induced change in HMR of the LCx correlated with the percentage change in LV ejection fraction (R = -0.598, P = 0.011) and LV end-systolic volume (R = 0.609, P = 0.010) before and 6 months after CRT. CONCLUSION: Cardiac resynchronization therapy improves coronary flow circulation by reducing microvascular resistance, which might be associated with LV reverse remodelling.

Anaerobiospirillum succiniciproducens-induced bacteremia in a healthy man.

Anaerobiospirillum succiniciproducens is rarely associated with bacteremia but results in significant mortality. Almost all reported bacteremia cases have occurred in immunocompromised hosts, such as those with alcoholic liver disease, atherosclerosis, recent surgery, malignancies, or acquired immunodeficiency syndrome. We describe here, to our knowledge, the first clinical evidence for A succiniciproducens bacteremia in a healthy man. A 61-year-old man had fallen from a roof and was admitted to our emergency department with severe left flank pain without an external wound. He was given transcatheter arterial embolization for the left kidney injury on the same day, and his condition stabilized. Four days after admission, he had fever without gastrointestinal signs and symptoms. Spiral-shaped, gram-negative anaerobic bacteria were isolated from 2 sets of blood cultures, and the oxidase and catalase test results were negative. The isolated bacteria were different from the Campylobacter spp. On the next day, the bacteria were confirmed as A succiniciproducens by 16S rRNA sequencing. The patient responded to sulbactam/ampicillin. On day 13, the patient was discharged with a 7-day prescription for oral amoxicillin/clavulanate. Six months after admission, the patient was free of recurrent infection. A succiniciproducens bacteremia can occur in healthy adults. When large gram-negative spiral-shaped bacteria are detected, this bacterial species should be considered and differentiated from the Campylobacter spp because A succiniciproducens is often resistant to macrolide antibiotics.

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

PURPOSE: Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time. RESULTS: ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01). CONCLUSIONS: Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.

Chromobacterium haemolyticum-induced bacteremia in a healthy young man.

BACKGROUND: The genus Chromobacterium consists of 7 recognized species. Among those, only C. violaceum, commonly found in the soil and water of tropical and subtropical regions, has been shown to cause human infection. Although human infection is rare, C. violaceum can cause life-threatening sepsis, with metastatic abscesses, most frequently infecting those who are young and healthy. CASE PRESENTATION: We recently identified a case of severe bacteremia caused by Chromobacterium haemolyticum infection in a healthy young patient following trauma and exposure to river water, in Japan. The patient developed necrotizing fasciitis that was successfully treated with a fasciotomy and intravenous ciprofloxacin and gentamicin. CONCLUSIONS: C. haemolyticum should be considered in the differential diagnosis of skin lesions that progressively worsen after trauma involving exposure to river or lake water, even in temperate regions. Second, early blood cultures for the isolation and identification of the causative organism were important for initiating proper antimicrobial therapy.

Surgical airways for trauma patients in an emergency surgical setting: 11 years' experience at a teaching hospital in Japan.

PURPOSE: Airway management of trauma patients during emergency surgeries can be very difficult and presents a challenge for anesthesiologists. Difficult airways are associated with emergency surgical airways (ESA), but little is known about ESA in the operating room. We conducted this study to clarify the present use of ESA for trauma patients in emergency surgery settings. METHODS: We performed a retrospective review of all trauma patients requiring emergency surgery under general anesthesia at our hospital from January 2002 to December 2012, focusing on ESA. RESULTS: During the study period, 15,654 trauma patients were treated at our hospital, of whom 554 (3.5 %) required emergency surgery. Four of these patients (0.72 %) received ESA as definitive airway management. Two patients with severe facial injury and distorted upper airways and 1 patient with penetrating neck trauma received open standard tracheostomy (OST). These three patients received OST as the initial approach to intubation. A fourth OST was performed after several unsuccessful attempts at endotracheal intubation. No cases were classified as "cannot ventilate, cannot intubate" (CVCI), and there were no complications associated with ESA. All cases had good outcomes. Statistical analysis revealed that patients with severe facial trauma (Abbreviated Injury Scale ≥3) received ESA at a significantly higher rate than others (p = 0.015, odds ratio 14.1). CONCLUSION: One of the most important functions of anesthesiologists is risk management. We should recognize risks that can cause CVCI situations, and make proper clinical decisions, including providing ESA, to assure patient safety.

Development of a robust LC-MS/MS method for determination of desmosine and isodesmosine in human urine.

Desmosine (DES) and isodesmosine (IDES) are both pyridinium amino acid isomers that serve as cross-linking molecules binding the polymeric chains of amino acids into elastin. Found in urine, they are markers for the degradation of elastin which occurs in chronic obstructive pulmonary disease (COPD). In this study, a robust method using ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS) with selected reaction monitoring (SRM) mode was developed for the analysis of DES and IDES in human urine. Pyridylethyl-cysteine (PE-Cys) as internal standard (I.S.) was employed for the quantification of DES and IDES. The analytes and I.S. were extracted by solid-phase extraction with Oasis MCX cartridges and separated on an AccQ-Tag Ultra column. The assay was accurate (-6.8% to 14.5%) and precise (2.8% to 13.8%) within the concentration range of 1 to 250 pmol/mL. Moreover, the recovery and stability (working/ I.S. solution, urine samples with added elastin, and pretreated sample) was investigated, and these parameters were found acceptable. The UPLC-MS/MS method was validated and had good reproducibility and stability for the quantification of DES and IDES, which requires only 100 mL of human urine. This assay will be a useful means for measuring DES and IDES levels in urine with robustness and characterizing patients with COPD.

[Primary diaphragmatic schwannoma which needed to be distinguished from a liver tumor].

A 55-year-old woman was admitted because of a tumor located in the ventral region of S4 of the liver, just beneath the diaphragm. A CT scan revealed the round tumor to be delineated as a 33 mm in size, with an outer capsule. The tumor was visualized as concentric circles which presented high-, low-, and high- signal patterns on T2-weighted MRI. It also presented a triphasic pattern in which the border and the central part were not contrasted as a low signal pattern, while the middle part was contrasted as a high signal pattern by T1-weighted enhanced imaging with Gd-DTPA. Angiography revealed that the tumor did not originate from the liver but from the diaphragm, so it was surgically resected as a primary diaphragmatic tumor. We report a schwannoma which originated from the diaphragm, that showed characteristic imaging findings and required to be distinguished from a liver tumor.

[Synchronous double invasive ductal carcinomas of the pancreas with multifocal branch duct intraductal papillary mucinous neoplasms of the pancreas].

A 52-year-old man with a history of distal gastrectomy for gastric cancer was admitted to our hospital because of jaundice. CT scan revealed double tumors in the pancreatic head and body concomitant with multicystic lesions of the pancreas. Total pancreatectomy with splenectomy and remnant gastrectomy was performed. Final histological diagnosis was double invasive ductal carcinomas of the pancreas head and tail with multifocal branch duct intraductal papillary mucinous adenomas of the pancreas. The present case suggests that entire pancreas might have malignant potential in patients with intraductal papillary mucinous neoplasms.