Rapid Progression of Aortitis Caused by Methicillin-Sensitive Staphylococcus Aureus in a Patient With Pneumonia: A Case Report.

Infected aortic aneurysm is a rare but fatal disease that occurs through various mechanisms. In this report, we describe the case of a patient who was hospitalized for acute pneumonia and developed an infected aortic aneurysm in the descending aorta during the hospitalization. A 73-year-old Japanese man presented to the emergency department with a chief complaint of fever. He had a history of chronic renal failure due to nephrosclerosis and was on regular hemodialysis three times a week. The patient presented with an elevated inflammatory response, anemia, and low platelet counts after various tests. Computed tomography (CT) showed ground-glass opacity in the left lung with a small amount of pleural effusion, leading to a diagnosis of pneumonia. The patient was admitted to the hospital on the same day, and a course of antibiotics (ceftriaxone [CTRX]) was started. On the fourth day of hospitalization, methicillin-susceptible Staphylococcus aureus (MSSA) was detected in the blood sample, which was collected from the patient on the day of admission. The patient was treated for MSSA pneumonia and bacteremia, and the antibiotics were changed to cefazolin (CEZ). Treatment with antimicrobials resulted in a negative blood culture retest on day 5 and improvement of the inflammatory response. On the 12th day, improvements in pneumonia and pleurisy were observed on the CT scan; however, an abnormal bulge was seen on the dorsal side of the descending thoracic aorta with suspected partial vessel wall disruption, suggesting a ruptured infected aortic aneurysm. Despite treatment with antibiotics, the thoracic descending aortic aneurysm continued to dilate with progressing rupture, and the patient died on the 25th day of hospitalization. This is the first report of an infected aneurysm caused by Staphylococcus aureus, despite a negative blood culture. Patients at high risk might develop infected aneurysms, and the possibility of rapid dilation should always be considered.

Massive Gastric Dilatation and Multi-Organ Ischemia Due to Superior Mesenteric Artery Syndrome: A Rare Case Report.

BACKGROUND Superior mesenteric artery (SMA) syndrome, a rare condition in which the SMA and aorta occlude the third duodenal portion, can cause serious complications. We present the case of an 83-year-old Japanese man who presented with shock because of massive gastric dilatation due to SMA syndrome and developed multi-organ ischemia. CASE REPORT The day before admission, the patient had visited the emergency department with abdominal pain and was sent home following spontaneous symptom resolution, but experienced abdominal pain flare-up. His history included diabetes mellitus, hypertension, gastric ulcer, prostatic hypertrophy, esophageal hiatal hernia, and esophageal cancer. Plain computed tomography showed gastric dilatation and obstruction of the duodenal third portion by the SMA, leading to SMA syndrome diagnosis. Since a nasogastric tube could not be manually inserted into the stomach and the gastric dilatation could not be decompressed, the tube was inserted endoscopically. Endoscopy revealed mechanical obstruction of the gastric cardia and gastric mucosal ischemia. He was admitted to intensive care, and blood pressure was maintained with vasopressors and blood transfusion. The next day, contrast-enhanced computed tomography performed for persistently elevated lactate levels revealed extensive ischemia affecting multiple gastrointestinal organs. Surgery and other treatments were considered too risky due to the patient's advanced age and condition. Best supportive care was administered after discussion with the family, and he died on the second day of hospitalization. CONCLUSIONS SMA syndrome with extensive ischemia and infarction is rare. Given this, clinicians should remain vigilant for its potential complications.

Overwhelming Post-splenectomy Infection Caused by Escherichia coli 20 Years After Splenectomy: A Case Report.

Post-splenectomy patients are at increased risk of infection. This complication is called overwhelming post-splenectomy infection (OPSI), which is uncommon but has high mortality. We describe a case of a man in his 80s who presented with septic shock with purpura fulminans caused by pyelonephritis. He had undergone a splenectomy in his 50s and had been taking prednisolone for the past six months for suspected immunoglobulin G4 (IgG4)-related disease. He was admitted to the intensive care unit but died the day after admission. OPSI is generally caused by encapsulated bacteria. However, in the present case, the causative agent was Escherichia coli, a bacterium that typically causes urinary tract infections. Post-splenectomy patients are known to have compromised bacterial clearance, and accumulation of bacteria such as E. coli can induce acute sepsis after splenectomy. Thus, physicians must have a high index of suspicion when treating splenectomy patients for the possibility that they may rapidly deteriorate to severe conditions such as OPSI, and the patients must be informed about the risk of severe infections, which can be fatal.

Spinal cord infarction after withdrawal of veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: A case report.

BACKGROUND: Spinal cord infarction is a rare central nervous system angiopathy that impairs motor, sensory, and autonomic nerves and occurs due to various reasons. This study reports a case of spinal cord infarction in a patient following myocardial infarction that was managed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CASE SUMMARY: A 78-year-old Japanese man visited the emergency department with a complaint of chest tightness. He had a history of hypertension, dyslipidemia, diabetes, chronic renal failure, and postoperative bladder cancer. Myocardial infarction was diagnosed after ST elevation in lead aVR was identified by electrocardiogram during the visit, and cardiopulmonary arrest occurred twice during our examination and treatment. After percutaneous coronary intervention with an intra-aortic balloon pump and VA-ECMO, the patient was admitted to the intensive care unit. His circulation stabilized, and he was withdrawn from the intra-aortic balloon pump on day 3 of illness and from VA-ECMO on day 4. However, his consciousness remained impaired. When the patient's consciousness improved on day 14, lower limb weakness was identified. Magnetic resonance imaging conducted on the following day revealed spinal cord infarction in the 5th to 12th thoracic vertebrae. CONCLUSION: Spinal cord infarction due to VA-ECMO is extremely rare but has a poor neurological prognosis upon onset. Necessary countermeasures include conducting regular neurological examinations and high blood pressure maintenance, which is very difficult in VA-ECMO patients. Therefore, patient care will benefit from the experiences reported in such cases.

ARDS Clinical Practice Guideline 2021.

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html ). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

ARDS clinical practice guideline 2021.

BACKGROUND: The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. METHODS: The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. RESULTS: Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4-8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D); we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D); we suggest against routinely implementing NO inhalation therapy (GRADE 2C); and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). CONCLUSIONS: This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jrs.or.jp/publication/jrs_guidelines/). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Recurrent Takotsubo Syndrome Due to Hypoglycemic Attacks.

Takotsubo syndrome (TTS) is a disorder with transient cardiac dysfunction triggered by stress. Rarely, hypoglycemia can also trigger TTS, but there are no case reports of repeated TTS due to hypoglycemia. We report the case of a 51-year-old Japanese woman who was brought to the emergency department with impaired consciousness and shock vitals. Blood tests revealed severe hypoglycemia. She also had an abnormal electrocardiogram with a QS pattern in the anterior thoracic guidance, which led to the diagnosis of TTS after repeated echocardiographic evaluation by a cardiologist. The diagnosis of hypoglycemic coma was made, and the patient was admitted to the intensive care unit (ICU). The patient had anorexia nervosa and had been suffering from a hypoglycemic coma due to anorexia for some time. The patient had a history of hypoglycemic coma about one year before and had been hospitalized in the ICU with TTS at that time. We report the world's first case of repeated TTS due to hypoglycemia. Since hypoglycemia is hemodynamically associated with increased heart rate and systolic blood pressure, TTS should be included in the differential diagnosis when shock vitals are repeated in patients with frequent hypoglycemia.

Analysis of Clinical Isolates of Extended-Spectrum ß-Lactamase-Producing Bacteria with Primer and Probe Sets Developed to Detect blaCTX-M, blaTEM, and blaSHV Using a Fully Automated Gene Detection System.

In this study, we evaluated extended-spectrum ß-lactamase (ESBL)-producing bacteria with the newly developed primer and probe sets to detect blaCTX-M, blaTEM, and blaSHV using BD MAXTM, a fully automated multiplex polymerase chain reaction assay system. In 36 isolates confirmed by whole-genome sequencing to have blaCTX-M, blaTEM, or blaSHV, the developed primer and probe sets accurately detected each gene without being influenced by the presence of other ß-lactamase genes. In nine control strains that do not harbor either blaCTX-M, blaTEM, or blaSHV no cross-reaction was observed. In 191 strains phenotypically determined to be ESBL-producers by conventional antimicrobial susceptibility tests, 189 strains were blaCTX-M-, blaTEM-, or blaSHV-positive as assessed by BD MAXTM using the developed primer and probe sets, and two strains were negative for these genes. Whole-genome sequencing revealed that these two strains were phenotypically false-positive ESBL-producers. The accuracy of the primer and probe sets seems to be satisfactory, and they may be applicable to detect CTX-M-type ESBL-producing bacteria.

The Effectiveness of Japan's Community Centers in Facilitating Social Participation and Maintaining the Functional Capacity of Older People.

This study examines the effectiveness of a community center in Japan at promoting social participation and sustaining its regular users' functional capacity. The surveys were distributed to 108 physically and cognitively independent local older people; 72 responses were received. There were 16 regular users and 56 nonregular users. An inverse probability of treatment-weighted Poisson regression analysis was performed, and prevalence rate ratios were computed for social participation and functional capacity according to respondents' use of the center. Results showed that using the center regularly facilitated social participation, contributing to the maintenance of living functions. Regular users' social participation was promoted through opportunities in sports and volunteer organizations. Their living functions were maintained through instrumental self-maintenance and intellectual activity. Community centers evidently enable beneficial gatherings of older people, encourage social participation, and help to maintain higher level activities of daily living. Thus, they might offer effective preventative care for older people.

IL-13 attenuates early local CXCL2-dependent neutrophil recruitment for Candida albicans clearance during a severe murine systemic infection.

To investigate the role of IL-13 during a severe systemic Candida albicans infection, BALB/c control and IL-13-/- mice were examined for colony forming units (CFU) in the kidneys and survival days after intravenous infection. Proinflammatory mediators and cell recruitment into the tissue were measured by quantitative real-time PCR, a multiple ELISA system, and morphological cell differentiation. The IL-13-/- group exhibited a lower CFU number in the kidneys at 4 days and survived longer than the control mice, which was accompanied by significantly higher expression of C-X-C motif ligand 2 (CXCL2), IFN-γ, and polymorphonuclear neutrophils (PMNs) in the infected kidneys. By contrast, the expression of transforming growth factor ß (TGF-ß) and IL-17 A on day 10 were significantly higher in the control mice than in the IL-13-/- group. When using an intratracheal infection model, the IL-13-/- group recruited a greater number of PMNs in 6 h, with rapidly increased CXCL2 in the alveolar space. In vitro testing with cultured bone-marrow-derived cells demonstrated rapid CXCL2 mRNA upregulation at 3 h after contact with C. albicans, which decreased with recombinant IL-13 pretreatment, whereas rIL-13 retained TGF-ß upregulation. In a murine model of Candida systemic infection, preexistent IL-13 limits both the rapid CXCL2 elevation and PMN aggregation in the target organ to suppress inflammatory mediators, which also attenuates local pathogen clearance within four days.

Severe epidemic myalgia with an elevated level of serum interleukin-6 caused by human parechovirus type 3: a case report and brief review of the literature.

BACKGROUND: Human parechovirus type 3 (HPeV-3) is known to cause cold-like symptoms, diarrhea, or severe infections such as sepsis in infants and children. In adults, HPeV-3 infection is rarely diagnosed because the symptoms are generally mild and self-limiting; however, this infection has been linked to epidemic myalgia, regardless of the presence of underlying diseases, immunosuppression, or sex. CASE PRESENTATION: We describe an adult case of severe systemic myalgia and orchiodynia after infection with HPeV-3, which was transmitted from the child of the patient. Interleukin-6 (IL-6) level was found to be elevated in the patient's serum. CONCLUSION: Severe myalgia associated with HPeV-3 infection is potentially caused by an elevated serum level of IL-6.

Efficacy of 1.0% chlorhexidine-gluconate ethanol compared with 10% povidone-iodine for long-term central venous catheter care in hematology departments: a prospective study.

The efficacy of 1% chlorhexidine-gluconate ethanol and 10% povidone-iodine for skin antisepsis of central venous catheter (CVC) sites were compared among hematology patients. The CVC site colonization rates of those groups were 11.9% and 29.2%, respectively, and the catheter-associated blood stream infections were 0.75 and 3.62 per 1,000 catheter-days, respectively. One percent chlorhexidine-gluconate ethanol was superior to povidone-iodine to reduce skin colonizers at CVC sites even when catheters were used for long duration.

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section.

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.

Repeated embolization of intercostal arteries after blunt chest injury.

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.

[Case of iodism complicated with severe airway stenosis due to pharyngolaryngeal edema].

A 22-year-old man was admitted to our hospital with dilute iodine tincture poisoning. He had ingested 150 mL in a suicide attempt. On arrival, he was in need of urgent airway management as he was repeatedly vomiting. Although we had difficulty with endotracheal intubation because of remarkable pharyngolaryngeal mucosal edema induced by dilute iodine tincture, we managed to secure the airway. On the 2nd day, laryngoscope showed severe mucosal erosion from the upper to middle pharynx and epiglottis. On the 4th day, we performed a tracheoctomy in anticipation of prolonged airway management. On the 16th day, laryngoscopy showed improvement in each of the 2nd day findings. On the 30th day, the patient was transferred to a psychiatric hospital. Generally, iodine poisoning induces multiple organ disorders and there have been several reports describing iatrogenic iodine poisoning. However, cases of severe airway stenosis due to ingestion of iodine are very rare. Presently, members of the public can easily purchase dilute iodine tincture in Japan, therefore emergency medical personnel should be aware of iodine poisoning as a method of suicide attempt.

[The effect of working memory on learning from texts].

This study examined the effect of working memory on learning from texts. In Experiment 1, participants preformed a word clustering task involving key words from an explanatory text (pretest), and then read the text, which was presented sentence-by-sentence. Next, they performed a second clustering task (post-test), a problem solving task, and a reading span test (RST). The results suggested that the individual differences of the RST scores correlated with the scores for problem solving. In Experiment 2, the results suggested that the individual differences of the RST scores influenced the clustering performance at the level of the situation model when the text was presented all together. Moreover, the result of multiple dimension scaling suggested that the situation models of high-span readers reflected the structure of the text more than those of low-span readers. These results indicate that readers with high reading span scores construct coherent situation models of texts and make use of them for learning from texts.

Dengue fever as an acute febrile disease after overseas travel: a report of two cases.

Dengue fever (DF) is a relatively common infection in travelers, with about 100 cases being reported annually in Japan, and this number is increasing. We herein describe two patients who developed a fever after returning to Japan from Southeast Asia and who were serologically diagnosed with DF. Patient 1 was a 19-year-old man who spent 6 days in Thailand and developed diarrhea and a fever after returning to Japan. Virological studies showed dengue virus (DV) serotype 3 by reverse transcriptase PCR (RT-PCR), and anti-DV IgM and IgG antibodies were both positive by enzyme-linked immunosorbent assay (ELISA). Patient 2 was a 43-year-old man who spent time in various Asian countries and developed a fever and arthralgia after returning to Japan. Virological studies showed DV serotype 2 by RT-PCR, and anti-DV IgM and IgG antibodies were both positive by ELISA. DF and other febrile diseases, including Chikungunya fever, should be strongly suspected in patients who develop fever after returning to Japan from other Asian countries, irrespective of whether patients remember being bitten by mosquitoes.

Two cases of acute atraumatic compartment syndrome complicated with severe heat stroke.

Acute compartment syndrome is a life-threatening complication in trauma patients. Not only regional neuromuscular disability, but also systemic organ disorders can result from prolonged tissue ischemia. In this report, we describe 2 cases of acute atraumatic compartment syndrome complicated with severe heat stroke. In both cases, emergency fasciotomy was rapidly performed after recognition of the syndrome, but serious regional neuromuscular disabilities remained. Microvascular endothelial injury is an important mechanism of acute atraumatic compartment syndrome. Thrombi diffusely formed in the compartmental space hinder establishment of reperfusion even after fasciotomy. Furthermore, disruption of fibrinolysis due to heat stroke could enhance this damage.