Remimazolam anaphylaxis in a patient not allergic to brotizolam: a case report and literature review.

BACKGROUND: Remimazolam is a recently developed, ultrashort-acting benzodiazepine that is used as a general anesthetic. Some cases of remimazolam anaphylaxis have been reported, but its characteristics are not fully understood. We present an interesting case report and review of the literature to better understand remimazolam anaphylaxis. CASE PRESENTATION: A 75-year-old man scheduled for robot-assisted gastrectomy was administered remimazolam for the induction of general anesthesia. After intubation, low end-expiratory CO2, high airway pressure and concurrent circulatory collapse were observed. Bronchoscopy revealed marked tracheal and bronchial edema, which we diagnosed as anaphylaxis. The patient suffered cardiac arrest after bronchoscopy but recovered immediately with intravenous adrenaline administration and chest compressions. We performed skin prick tests for the drugs used during induction except for remimazolam, considering the high risk of systemic adverse reactions to remimazolam. We diagnosed remimazolam anaphylaxis because the skin prick test results for the other drugs used during anesthesia were negative, and these drugs could have been used without allergic reactions during the subsequent surgery. Furthermore, this patient had experienced severe anaphylactic-like reactions when he underwent cardiac surgery a year earlier, in which midazolam had been used, but it was not thought to be the allergen at that time. Based on these findings, cross-reactivity to remimazolam and midazolam was suspected. However, the patient had previously received another benzodiazepine, brotizolam, to which he was not allergic, suggesting that cross-reactivity of remimazolam may vary among benzodiazepines. In this article, we reviewed the 11 cases of remimazolam anaphylaxis that have been described in the literature. CONCLUSIONS: Remimazolam is an ultrashort-acting sedative; however, it can cause life-threatening anaphylaxis. In addition, its cross-reactivity with other benzodiazepines is not fully understood. To increase the safety of this drug, further research and more experience in its use are needed.

Zooplankton act as cruise ships promoting the survival and pathogenicity of pathogenic bacteria.

Bacteria in general interact with zooplankton in aquatic ecosystems. These zooplankton-bacterial interactions help to shape the bacterial community by regulating bacterial abundances. Such interactions are even more significant and crucially in need of investigation in the case of pathogenic bacteria, which cause severe diseases in humans and animals. Among the many associations between a host metazoan and pathogenic bacteria, zooplankton provide nutrition and protection from stressful conditions, promote the horizontal transfer of virulence genes, and act as a mode of pathogen transport. These interactions allow the pathogen to survive and proliferate in aquatic environments and to endure water treatment processes, thereby creating a potential risk to human health. This review highlights current knowledge on the contributions of zooplankton to the survival and pathogenicity of pathogenic bacteria. We also discuss the need to consider these interactions as a risk factor in water treatment processes.

Preyssler-type phosphotungstate is a new family of negative-staining reagents for the TEM observation of viruses.

Transmission electron microscopy (TEM) is an essential method in virology because it allows for direct visualization of virus morphology at a nanometer scale. Negative staining to coat virions with heavy metal ions must be performed before TEM observations to achieve sufficient contrast. Herein, we report that potassium salts of Preyssler-type phosphotungstates (K(15-n)[P5W30O110Mn+], M = Na+, Ca2+, Ce3+, Eu3+, Bi3+, or Y3+) are high-performance negative staining reagents. Additionally, we compare the staining abilities of these salts to those of uranyl acetate and Keggin-type phosphotungstate. The potassium salt of Preyssler-type phosphotungstates has the advantage of not requiring prior neutralization because it is a neutral compound. Moreover, the potassium counter-cation can be protonated by a reaction with H+-resin, allowing easy exchange of protons with other cations by acid-base reaction. Therefore, the counter-cations can be changed. Encapsulated cations can also be exchanged, and clear TEM images were obtained using Preyssler-type compounds with different encapsulated cations. Preyssler-type phosphotungstates may be superior negative staining reagents for observing virus. Polyoxotungstates (tungsten-oxide molecules with diverse molecular structures and properties) are thus promising tools to develop negative staining reagents for TEM observations.

Environmental factors affecting Edwardsiella ictaluri-induced mortality of riverine ayu, Plecoglossus altivelis (Temminck & Schlegel).

We analysed the predisposing factors for Edwardsiella ictaluri infection in the riverine ayu Plecoglossus altivelis on the basis of environmental and epidemiological data obtained in a tributary to and the lower reaches of the Tama River, Japan, in July and August 2011-2015. Mortality of ayu due to E. ictaluri infection was observed only in the tributary in August 2012 and 2013; both periods were unusually hot. During these mortality events, daily average water temperatures rose approximately 3-4°C over 4-8 days, reaching the optimum temperature for E. ictaluri infection (>25°C) and approaching the upper tolerable limit for ayu (30°C). Diurnal water temperature ranges (DWTRs) in the tributary during the mortality events exceeded 6°C, which was 1-2°C greater than in the lower reaches. Experimental infection of ayu with E. ictaluri resulted in higher mortality when exposed to 6°C DWTR than to 4°C DWTR. Furthermore, water levels in the tributary were generally low in August 2012 and 2013 because of low rainfall. From these results, we conclude that unusually high-water temperatures combined with high DWTRs and low water levels drove riverine ayu mortality from E. ictaluri infection.

Pathological and immunohistochemical studies following the experimental infection of ayu (Plecoglossus altivelis) by Edwardsiella ictaluri.

In recent decades, several mass mortalities were recorded in riverine ayu (Plecoglossus altivelis) in Tokyo Metropolis, Hiroshima Prefecture, and Yamaguchi Prefecture, Japan; in these outbreaks, microbiological and pathological examinations revealed Edwardsiella ictaluri as the causative agent. In this study, histopathological findings and immunohistochemical localization of the bacteria following experimental infection of ayu were discussed. Infection experiments were performed using 44 healthy cultured ayu fingerlings using E. ictaluri isolate (H90). The fish were injected with the isolate intraperitoneally with a dose of 5.1 × 105 cfu/fish, while the control fish were injected with sterile phosphate buffered saline. The fish were observed for clinical signs, with daily collection of dead fish, and isolation of bacteria from the posterior kidney was performed and confirmed to be E. ictaluri by slide agglutination using anti-PH0744 serum. Daily collection of five moribund fish for necropsy and tissue specimens collection from hepatopancreas, spleen, posterior kidney, gills, brain, heart, and intestine for histopathological and immunohistochemical examination. Post-mortem lesions were recorded as exophthalmia, bloody ascitis, hemorrhagic kidney and distended gallbladder, meningio-encephalitis, hemorrhagic vent, and petechial hemorrhages on viscera. Histopathological examination revealed diffuse severe congestion in blood vessels and several degenerative and necrotic changes inconcurrent with positive antigenic staining by immunohistochemistry.

Comparative immunohistological study on using capsaicin, piperine, and okadaic acid for the transepithelial passage of the inactivated viral and bacterial vaccines in fish.

The practical difficulty of parenteral application of fish vaccines against devastating fish diseases diverted the interest toward oral vaccination. Search for effective methods to enhance the oral uptake of viral and bacterial vaccines is continuing. The current research focus on a new role of mucosal fish vaccine adjuvants inducing the antigen uptake by enhancing vascularity or increasing intestinal permeability. Some inflammatory substances cause reversible pathology to the intestinal epithelium, which could be employed for the transepithelial passage of vaccine particles. The natural inflammatory substances used were capsaicin, piperine, and okadaic acid as 1 mg, 2 mg, and 1 µg/fish, respectively. Two inactivated vaccines were used as antigens to test the effect of these inflammatory substances in two different fish hosts. Tested vaccines were inactivated redspotted grouper nervous necrosis virus vaccine in sevenband grouper (Epinephelus septemfasciatus) and inactivated Edwardsiella tarda vaccine in red sea bream (Pagrus major) fish models. The inflammatory substances and each vaccine were anally intubated to fish. Capsaicin proved to be effectively aiding the transepithelial passage of vaccine particles more than piperine, while okadaic acid had no detectable effect.

Continuation and replacement of Vibrio cholerae non-O1 clonal genomic groups isolated from Plecoglossus altivelis fish in freshwaters.

The dissemination and abundances of Vibrio species in aquatic environments are of interest, as some species cause emerging diseases in humans and in aquatic organisms like fish. It is suggested that Vibrio cholerae non-O1 infections of Plecoglossus altivelis ('ayu') were spread to various parts of Japan through the annual transplantation of juvenile fish. To investigate this, we used genome-aided tracing of 17 V. cholerae strains isolated from ayu between the 1970s and 1990s in different Japanese freshwater systems. The strains formed a genomic clade distinct from all known clades, which we designate as the Ayu clade. Two clonal genomic groups identified within the clade, Ayu-1 and Ayu-2, persisted for a few years (between 1977 to 1979 and 1987 to 1990, respectively), and clonal replacement of Ayu-1 by Ayu-2 took place over an 8-year period. Despite the high similarity between Ayu-1 and Ayu-2 (> 99.9% identity and > 97% fraction of genomes shared), differences in their gene repertoires were found, raising the possibility that they are phenotypically distinct. These results highlight the importance of genome-based studies for understanding the long-term dynamics of populations over the timescale of years.

A novel jumbo Tenacibaculum maritimum lytic phage with head-fiber-like appendages.

A novel jumbo bacteriophage (myovirus) is described. The lytic phage of Tenacibaculum maritimum, which is the etiological agent of tenacibaculosis in a variety of farmed marine fish worldwide, was plaque-isolated from seawater around a fish aquaculture field in Japan. The phage had an isometric head 110-120 nm in diameter, from which several 50- to 100-nm-long flexible fiber-like appendages emanate, and a 150-nm-long rigid contractile tail. The full genomes of the two representative phages (PTm1 and PTm5) were 224,680 and 226,876 bp long, respectively, both with 29.7% GC content, and the number of predicted open reading frames (ORFs) was 308 and 306, respectively. The average nucleotide sequence identity between PTm1 and PTm5 was 99.95%, indicating they are quite similar to each other. A genetic relationship was found in 15.0-16.6% of the predicted ORFs among the T. maritimum phages PTm1 and PTm5, the Tenacibaculum spp. phage pT24, and the Sphingomonas paucimobilis phage PAU. Phylogenetic analysis based on the terminase large subunit genes revealed that these four phages (PTm1, PTm5, pT24 and PAU) are more closely related than the other 10 jumbo myoviruses that have similar genome sizes. Transmission electron microscopy observations suggest that the head fibers of the T. maritimum phage function as tentacles to search and recognize the host cell surface to facilitate infection.

Comparative genomic analysis of three lytic Lactococcus garvieae phages, novel phages with genome architecture linking the 936 phage species of Lactococcus lactis.

To date, a number of bacteriophages that infect Lactococcus garvieae isolated from marine fish have been identified. However, the evolutionary insight between L. garvieae phages and other viral community have not yet been immersedly investigated. In this study, completed genomic sequence of phage PLgY-30 was obtained, a comparative analysis of three lytic phages, which have been using for phage typing and treatment of L. garvieae infecting marine fish, is conducted. The results revealed that the genomes of lytic phages specific for L. garvieae isolated from diseased marine fish share a high level of homology and almost all proteins are conserved. At genome level, no similarity was detected for either PLgY-30 or PLgY-16, while PLgW-1 shares only very limited homology (1%) with other sequences in Genbank database. In addition, the function of only 35% of ORFs in the PLgY-30 phage genomes could be predicted, demonstrating that it is novel phage. At protein level, lytic phage proteins shared a significant similarity to various proteins of global phage species isolated from dairy fermentation facilities that utilize L. lactis as a primary starter culture, called the 936 phage group. Genome organization and architecture of three lytic phages are also similar to that of the 936 phage group. To our knowledge, this is the first time lytic bacteriophages infecting L. garvieae from marine fish were characterized to genome level.

Host range and influence of a cell capsule on the phage efficacy of three Lactococcus garvieae lytic phages.

Three lytic phages (PLgW-1, PLgY-16, and PLgY-30) were previously used for phage-typing Lactococcus garvieae, a bacterial pathogen of various marine fish species, and were demonstrated to be potential therapeutants for infections caused by L. garvieae. The morphology, host range, and efficacy of these phages have not been investigated in detail, however. The current study examined the lysis spectrum of these 3 phages against 16 different genotypes of L. garvieae and the influence of a bacterial capsule on phage efficacy, to aid in developing an effective treatment for lactococcosis in fish. Morphological analysis by transmission electron microscopy revealed that all 3 phages belonged to the family Siphoviridae and had a minor difference in morphology. These phages lysed a high proportion of their bacterial host (93.7% of the different L. garvieae genotypes). In addition, the efficacy of the plating assays was affected by both the phages and their bacterial host, in which phage efficacy was clearly affected by a bacterial capsule. The results of this study may be useful for developing appropriate strategies to use these phages to control various genotypes of L. garvieae causing disease in marine fish.

Complete Genome Sequence of the Lytic Giant Bacteriophage pT24 Infecting Tenacibaculum spp., Isolated from a Shrimp Culture Pond.

The lytic bacteriophage pT24, which infects Tenacibaculum spp., was isolated from the water of a whiteleg shrimp (Litopenaeus vannamei) culture pond in Thailand. This giant bacteriophage with myovirus morphology comprised 234,670 bp with 296 predicted genes.

ORF13 in the Type III secretion system gene cluster of Edwardsiella tarda binds to the mammalian factor Cugbp2.

The Type III secretion system (TTSS) is essential for the intracellular replication of Edwardsiella tarda in phagocytes of fish and mammals, and a hypothetical gene (orf13) located in the TTSS gene cluster is required for intracellular replication and virulence of E. tarda. Here, we show that under TTSS-inducing conditions, the protein ORF13 was secreted into culture supernatant. Then, using a yeast 2-hybrid screen, we show that the mammalian factor Cugbp2, which regulates apoptosis in breast cancer cells, directly interacts with ORF13. A pull-down assay revealed that ORF13 binds to the C-terminal region of Cugbp2. Our results suggest that ORF13 may facilitate E. tarda replication in phagocytes by binding to Cugbp2.

Identification of genes associated with the penetration activity of the human type of Edwardsiella tarda EdwGII through human colon epithelial cell monolayers.

Edwardsiella tarda is a Gram-negative pathogen with a broad host range including fish and humans. E. tarda causes gastrointestinal and extraintestinal infections in humans. In present study, the penetration activities of 22 strains of E. tarda, including 10 human isolates and 12 diseased fish isolates, through Caco-2 cell monolayers were evaluated. All the human isolates exhibited penetration activity in contrast to the fish isolates, which did not. In order to identify genes responsible for penetration activity, we screened transposon (Tn) insertion mutants for reduced penetration activity. Two Tn insertion mutants showed markedly reduced penetration activity, and we identified the wecC and fliF genes as Tn insertion sites. The wecC and fliF genes encode UDP-N-acetyl-d-mannosamine dehydrogenase, which is involved in synthesis of enterobacterial common antigen and flagellar basal body M-ring protein, respectively. Motility activity, including swarming and swimming, by the wecC mutant was weaker than that by the wild-type strain, while the fliF mutant was immotile. These results indicated that the swarming and swimming abilities mediated by the wecC and fliF genes appeared to be essential for penetration activity of E. tarda through Caco-2 cell monolayers. We also demonstrated that it was possible to group E. tarda strains into two types of human isolates and diseased fish isolates based on distribution of the wecC gene, type III and type VI secretion system genes. PCR detection of the wecC gene may represent a useful method for detecting the human type of E. tarda, which may have the ability to cause human infection.

Cell Culture Isolation of Piscine Nodavirus (Betanodavirus) in Fish-Rearing Seawater.

Piscine nodavirus (betanodavirus) is the causative agent of viral nervous necrosis (VNN) in a variety of cultured fish species, particularly marine fish. In the present study, we developed a sensitive method for cell culture isolation of the virus from seawater and applied the method to a spontaneous fish-rearing environment. The virus in seawater was concentrated by an iron-based flocculation method and subjected to isolation with E-11 cells. A real-time reverse transcriptase PCR (RT-PCR) assay was used to quantify the virus in water. After spiking into seawater was performed, a betanodavirus strain (red spotted grouper nervous necrosis virus [RGNNV] genotype) was effectively recovered in the E-11 cells at a detection limit of approximately 10(5)copies (equivalent to 10(2)50% tissue culture infective doses [TCID50])/liter seawater. In an experimental infection of juvenile sevenband grouper (Epinephelus septemfasciatus) with the virus, the virus was isolated from the drainage of a fish-rearing tank when the virus level in water was at least approximately 10(5)copies/liter. The application of this method to seven band grouper-rearing floating net pens, where VNN prevailed, resulted in the successful isolation of the virus from seawater. No differences were found in the partial sequences of the coat protein gene (RNA2) between the clinical virus isolates of dead fish and the cell-cultured virus isolates from seawater, and the viruses were identified as RGNNV. The infection experiment showed that the virus isolates from seawater were virulent to seven band grouper. These results showed direct evidence of the horizontal transmission of betanodavirus via rearing water in marine aquaculture.

V-GAP: Viral genome assembly pipeline.

Next-generation sequencing technologies have allowed the rapid determination of the complete genomes of many organisms. Although shotgun sequences from large genome organisms are still difficult to reconstruct perfect contigs each of which represents a full chromosome, those from small genomes have been assembled successfully into a very small number of contigs. In this study, we show that shotgun reads from phage genomes can be reconstructed into a single contig by controlling the number of read sequences used in de novo assembly. We have developed a pipeline to assemble small viral genomes with good reliability using a resampling method from shotgun data. This pipeline, named V-GAP (Viral Genome Assembly Pipeline), will contribute to the rapid genome typing of viruses, which are highly divergent, and thus will meet the increasing need for viral genome comparisons in metagenomic studies.

Full-genome sequence of a novel myovirus, GF-2, infecting Edwardsiella tarda: comparison with other Edwardsiella myoviral genomes.

Edwardsiellosis, which is caused by Edwardsiella tarda, a Gram-negative bacterium, is one of the most serious infectious diseases in both marine and freshwater fish farms worldwide. Previously, we reported the complete genome sequences of three E. tarda-lytic bacteriophages (two podoviruses and a myovirus), which were isolated from fish tissues and fish-rearing seawater. Further genomic information regarding E. tarda phages is important for understanding phage-host interactions as well as for applications of the phages for the control of disease. Here, we report the complete genome sequence of a novel E. tarda phage (GF-2) of myovirus morphology (family Myoviridae), isolated from tissue homogenates of a cultured Japanese flounder (Paralichthys olivaceus) that succumbed to edwardsiellosis in Japan. The size of the entire genome was 43,129 bp, with a GC content of 51.3 % and containing 82 open reading frames (ORFs). The GF-2 genome possesses lysogeny-related genes that have not been found in the reported Edwardsiella phage genomes. Comparative genomics of Edwardsiella myophages suggest that the C-terminal domains of the tail fiber proteins have relevance to their host specificity. Thus, GF-2 genome information provides a novel resource for our understanding of the molecular mechanisms involved in their host specificity and for detection of E. tarda in aquaculture environments.

Complete genome sequence analysis of two Pseudomonas plecoglossicida phages, potential therapeutic agents.

Pseudomonas plecoglossicida is a lethal pathogen of ayu (Plecoglossus altivelis) in Japan and is responsible for substantial economic costs to ayu culture. Previously, we demonstrated the efficacy of phage therapy against P. plecoglossicida infection using two lytic phages (PPpW-3 and PPpW-4) (S. C. Park, I. Shimamura, M. Fukunaga, K. Mori, and T. Nakai, Appl Environ Microbiol 66:1416-1422, 2000, http://dx.doi.org/10.1128/AEM.66.4.1416-1422.2000; S. C. Park and T. Nakai, Dis Aquat Org 53:33-39, 2003, http://dx.doi.org/10.3354/dao053033). In the present study, the complete genome sequences of these therapeutic P. plecoglossicida phages were determined and analyzed for deleterious factors as therapeutic agents. The genome of PPpW-3 (myovirus) consisted of 43,564 bp with a GC content of 61.1% and 66 predicted open reading frames (ORFs). Approximately half of the genes were similar to the genes of the Escherichia coli phage vB_EcoM_ECO1230-10 (myovirus). The genome of PPpW-4 (podovirus) consisted of 41,386 bp with a GC content of 56.8% and 50 predicted ORFs. More than 70% of the genes were similar to the genes of Pseudomonas fluorescens phage ϕIBB-PF7A and Pseudomonas putida phage ϕ15 (podoviruses). The whole-genome analysis revealed that no known virulence genes were present in PPpW-3 and PPpW-4. An integrase gene was found in PPpW-3, but other factors used for lysogeny were not confirmed. The PCR detection of phage genes in phage-resistant variants provided no evidence of lysogenic activity in PPpW-3 and PPpW-4. We conclude that these two lytic phages qualify as therapeutic agents.

Type III secretion system genes of Edwardsiella tarda associated with intracellular replication and virulence in zebrafish.

The Type III secretion system (T3SS) is essential for intracellular replication of Edwardsiella tarda in phagocytes of fish and mammals. Two possible effector candidate genes (eseE and eseG) and 7 hypothetical genes (esaB, escC, orf13, orf19, orf26, orf29, and orf30) located in the T3SS gene cluster were inactivated by an allelic exchange method, and we found that E. tarda strains carrying insertion mutations in escC, orf13, orf19, orf29, and orf30 were unable to replicate within J774 macrophages and HEp-2 epithelial cells. Furthermore, the virulence of these mutants to zebrafish was severely attenuated as well. These data suggest that the escC, orf13, orf19, orf29, and orf30 genes are required for intracellular replication and virulence of E. tarda.

Complete Genome Sequence of the Edwardsiella ictaluri-Specific Bacteriophage PEi21, Isolated from River Water in Japan.

We present the complete genome sequence for a novel Edwardsiella ictaluri-specific bacteriophage, PEi21, isolated from river water in Japan. An initial comparative genome analysis revealed that the phage was closely related to the previously reported Edwardsiella tarda phage MSW-3 isolated from a red sea bream farm in Japan.

Complete Genome Sequence of a Novel Myovirus Which Infects Atypical Strains of Edwardsiella tarda.

We present the genome sequence of a novel Edwardsiella tarda-lytic bacteriophage, MSW-3, which specifically infects atypical E. tarda strains. The morphological and genomic features of MSW-3 suggest that this phage is a new member of the dwarf myoviruses, which have been much less studied than other groups of myoviruses.