Survey of antibiotic resistance in Pseudomonas aeruginosa by The Tokyo Johoku Association of Pseudomonas Studies.

Pseudomonas aeruginosa resistance (minimum inhibitory concentration [MIC], > or =16 microg/ml defined as resistant) to meropenem, imipenem, panipenem, piperacillin, ceftazidime, cefozopran, cefoperazone, sulbactam/cefoperazone, amikacin, and tobramycin, as well as cross-resistance profiles, were investigated in P. aeruginosa strains isolated at eight hospitals in the Johoku area, Tokyo, during November 1998. Overall, 8.3% of isolates were imipenem-resistant and 4.6% were ceftazidime-resistant. However, the incidence of antibiotic-resistant P. aeruginosa was distinctly different at each hospital. P. aeruginosa resistance to imipenem ranged from (MIC) 1 to 64 microg/ml (MIC90 32 microg/ml), and its resistance to ceftazidime ranged from 2 to more than 128 microg/ml (MIC90, 64 microg/ml). Meropenem (MIC range, < or =0.25 to 16 microg/ml) was more active than panipenem (MIC range, 2 to 64 microg/ml). Cefozopran was more active than piperacillin, cefoperazone, or sulbactam/cefoperazone, but many strains were resistant to cefoperazone (17/57). Our analysis found cross-resistance to many beta-lactams, but the degree of cross-resistance was very variable.

Bacteremic Moraxella catarrhalis pneumonia in a patient with immunoglobulin deficiency.

A-75-year old woman with agammaglobulinemia developed Moraxella catarrhalis bacteremic pneumonia. M. catarrhalis pneumonia is rarely associated with bacteremia, and neutrophils have been reported as a significant factor in the host defense system against this bacteria. This case suggests that immunoglobulin also plays a key role in the host defense system against M. catarrhalis.

Acidic glycosaminoglycans of abdominal mucin in a case of pseudomyxoma peritonei caused by appendiceal cancer.

Although the use of intraperitoneal mucolytic agents is useful in the management of pseudomyxoma peritonei, effective removal of mucin is difficult even by repeated mucolysis in cases with massive ascites. To establish mucolytic therapy as a further effective procedure, biochemical analysis of mucin is required in greater detail. We reported here a case of pseudomyxoma peritonei caused by primary appendiceal cancer with biochemical analysis of mucin. The abdominal cavity in this case was filled with massive mucinous ascites. Although the mucolytic therapy was performed repeatedly, it was not effective in preventing mechanical ileus which was followed by surgical exclusion. Biochemical study of mucin showed that the mucin contained a small amount of hyaluronic acid, as characterized by electrophoretic study. These data led us to the hypothesis that the hyaluronic acid component plays a role in the pathogenesis of the replacement of mucin in the abdominal cavity.

[Immunoglobulin production by human peripheral B cells against Staphylococcus aureus].

Immunoglobulin (Ig) production by human B cells in thymus-independent (TI) and -dependent (TD) immune response against Staphylococcus aureus was investigated in vitro. Highly purified human peripheral B cells were cultured either in the presence of formalinized Cowan I strain Staphylococcus aureus (SAC) or with anti-CD3 stimulated T cells, and Ig content in supernatants was analyzed after 10 days of culture by specific sandwich ELISA. When activated with SAC in the absence of T cells, B cells produced minimal amounts of Ig. In the presence of interleukin-2 (IL-2) or supplemental recombinant CD40 ligand plus IL-2, Ig production by SAC-induced B cells was dramatically enhanced. When cultured with T cells stimulated with low concentrations of anti-CD3 or when cultured with smaller numbers of T cells, B cells produced large amounts of Ig, whereas T cells stimulated with higher concentrations of anti-CD3 or large numbers of T cells failed to induce effective Ig secretion by B cells. These findings suggest that TI immune response against Staphylococcus aureus is strongly enhanced in the presence of activated T cells in an antigen non-specific manner, indicating its critical role in the local humoral immune defense. Moreover, it is indicated that the secretion of Ig induced by TD antigens participates in the immune defense against Staphyloccocus aureus dependent on activated T cell/B cell ratio or an impact of CD3 stimulation on T cells.

[A case of primary HIV-1 infection].

A previously healthy 28 year old Japanese man came to us with a genital ulcer which appeared 13 days before admission to our hospital. He had subsequently fever (40 degrees C), arthralgia, a sore throat and oral aphtha 6 days before admission. He had a history of sexual contact with a female commercial sex worker one week before his illness. On the day of admission, he had shallow ulcers on the lip, tongue and penis. Initial laboratory test included leukopenia and thrombocytopenia. His fever abated 3 days after admission. His condition and bicytopenia recovered completely after 12 days of admission. Although, his serum HIV-1 antibody was negative when he was admitted, 3 months later the antibody was seroconverted. And p24 antigen and HIV-1 RNA of stocked serum were positive. Diagnosis of primary HIV-1 infection was made. Recently, HIV-1 infection has been increasing in Japan. Consideration of this disease in differential diagnosis of acute febrile illness is necessary.

Yolk sac tumor of the liver combined with hepatocellular carcinoma.

Hepatic yolk sac tumor is extremely rare, and only nine cases have been reported previously to our knowledge. We report the occurrence of a tumor combining hepatocellular carcinoma and yolk sac tumor. The clinical, pathologic, and immunohistochemical findings are presented. The patient was a 62-year-old Japanese man who died of hepatic failure and uncontrolled ascites. On autopsy, a large hepatic tumor was observed, which microscopically was composed of hepatocellular carcinoma and yolk sac tumor. The two components were intermingled, and transition zones were evident. Immunohistochemically, both components were positive for alpha-fetoprotein, but only the yolk sac tumor component was positive for carcinoembryonic antigen, epithelial membrane antigen, stage specific embryonic antigen-1, placental alkaline phosphatase, and keratin. To our knowledge, this is the first reported case of hepatic yolk sac tumor associated with hepatocellular carcinoma. The present tumor is best considered a variant of hepatocellular carcinoma showing yolk sac differentiation, and it provides another explanation for the histogenesis of extragonadal yolk sac tumor.

[A case of schistosomiasis suspected by circumoval precipitin test and diagnosed by rectal biopsy].

A forty-year-old female from Brazil was admitted to Teikyo Hospital because of easy fatigability, fullness of the abdomen and left hyochondralgia. She was anxious about Schistosoma mansoni infection, because three of her relatives died of the infection. Physical examinations revealed a tenderness at the left hypochondrium. Laboratory data showed no abnormal finding. No egg of S. mansoni was found in the stool. A circumoval precipitin test (COPT) with the serum showed a deposite around the egg. Enzyme-linked immunosorbent assay (ELISA) revealed the presence of antibody against S. mansoni in the serum. A colonoscopy showed no abnormal finding macroscopically. The rectal biopsy showed the existence of mild procitis. The diagnosis was made by finding the characteristic lateral-spined eggs in the biopsy specimens from the rectum. Treatment of 3 g of prazicantel per day for three days was started. She complained of mild nausea at the first dosing. A month later, another three-day-treatment was given. In the case where there are no eggs found in the stool, COPT and ELISA are usefull in detecting the disease, and colonoscopy is recommended in diagnosing the disease.

[Sarcoidosis representing multiple splenic nodules in a patient with IgA nephropathy].

We have encountered a 49-year-old female with persistent proteinuria and hematuria. Blood pressure, renal function, physical findings and chest X-p showed no abnormality, but blood tests disclosed mild thrombocytopenia, elevated serum ACE activity, serum lysozyme activity and serum IgA concentration. Abdominal echography and CT revealed multiple nodules in her spleen. In order to make a definite diagnosis and exclude the possibilities of malignant lymphoma or metastatic malignant tumor, splenectomy, and open renal biopsy were performed at the same time. On histological examinations, light microscopic appearance of the spleen was characterized by non-caseating granulomas compatible with sarcoidosis. Renal biopsy specimen showed diffuse proliferative glomerulonephritis with positive staining of IgA predominantly located in the mesangial area, compatible with IgA nephropathy. The present case may provide suggestive evidence for a link between sarcoidosis and IgA nephropathy in the pathogenesis. IgA nephropathy complicated by sarcoidosis is rare, and thus is of particular interest because common immunological abnormalities might be considered in the disease process of both diseases. We feel that despite a low index of suspicion, physicians must be alert to the possibility of IgA nephritis associated with sarcoidosis. The literature is reviewed regarding the relationship between IgA nephropathy and sarcoidosis.

[A case report of toxic shock-like syndrome due to group A streptococcal infection in an alcoholic].

A 47-year-old male with a history of alcohol abuse had a sore throat on June 8, 1994. On June 13, he had swelling and pain on his right fore-arm. He had tense swelling, redness and pain on the right lower abdomen, left upper arm and left lower leg with high fever and noticed erythema and blisters on his back of the right hand on June 18, which gradually expanding to the entire fore-arm. He was admitted to the local hospital on July 2, where he was operated with excision of the skin and drainage for an abdominal subcutaneous abscess and was given three antibiotics and an intravenous immunoglobulin preparation. Although he showed transient hypotension and moderate liver dysfunction, his condition improved day by day under such treatment. He was transferred to our hospital on July 7 because of the unknown etiology. Aspirate from the abscess contained gram-positive cocci in chains, and group A streptococci were isolated. Panipenem/betamipron was used for an antibiotic during roughly two weeks and excision of the skin and drainage for abscess was performed twice. His skin lesions were continued to improve, normalizing peripheral white blood cell counts, serum levels of CRP and the liver function. On July 24, the antibiotic was changed to intravenous ampicillin and administered for 16 days and amoxicillin was given orally after that, and he was discharged on August 16. An isolate of the infecting Streptococcus pyogenes produced pyrogenic exotoxin A, B and the serotype was T-3 type.

[An autopsy case of fungal (Mucor) cerebral aneurysm].

An autopsy of rupture of Mucor cerebral aneurysm, not diagnosed during the patient's life, was experienced. A 63-year-old female was admitted to our hospital with the chief complaint of disturbance of consciousness and high fever. Her past histories were diabetes mellitus, liver cirrhosis and nasal sinusitis. The remarkable findings on admission were moderate inflammatory data, high blood sugar level in serum and ascites. Brain CT film revealed a non-enhanced low-density area in the frontal region. The cerebrospinal fluid showed bloody color and white blood cell counts were 3300/microliter (mostly neutrophils). Under our suspected of bacterial encephalomeningitis, intravenous cefotaxime and ampicillin therapy was started immediately. Cultures of cerebrospinal fluid for bacteria were negative. The disturbance of her consciousness gradually improved under general treatment. However, her conscious level suddenly became a coma on the 6th hospital day and she died on the 9th hospital day. An autopsy revealed Mucor at the site of the rupture of the cerebral aneurysm.

Glutathione S-transferases as a cefpiramide binding protein in rat liver.

To clarify the intrahepatical transport mechanism of cefpiramide, we investigated effects of various agents mainly excreted into the bile by several different mechanisms on the biliary excretion of cefpiramide in rats. Sulfobromophthalein, indocyanine green, bilirubin and probenecid, known to be bound to glutathione S-transferases (GST) (EC 2.5.1.18) in liver cytosol, reduced the biliary excretion of cefpiramide, while neither secretory IgA, which is transported via vesicles in the liver, nor colchicine, which inhibits movements of vesicles, had any effect on the excretion of cefpiramide. Propranolol and metoprolol, metabolized by mixed function oxidases, had no effect on the biliary excretion of cefpiramide. In the chromatography of liver cytosol, the amount of sulfobromophthalein or benzylpenicillin bound to the GST fraction decreased in the presence of cefpiramide or probenecid. The study showed that cefpiramide was transported in the liver without relation to mixed function oxidases or vesichle-mediated transporting system, but in relation to GST which binds cefpiramide, sulfobromophthalein, benzylpenicillin and probenecid, indicating an important role of GST in the cefpiramide excretion into the bile.

[Useful abdominal ultrasonography for diagnosis of Fitz-Hugh-Curtis syndrome: two case reports].

Recently, Chlamydia trachomatis infection in sexually active women has increased. C. trachomatis cause pelvic inflammation. A few of these patients develop Fitz-Hugh-Curtis syndrome (FHCS). Clinical symptoms of FHCS include pain of sudden onset in the right upper quadrant mimicking acute biliary disease. Diagnosis of FHCS has been weighed upon laparoscopic findings. Since FHCS is a benign disorder which responds to appropriate antibiotics, non-invasive diagnostic method would be expected. We report here two cases of FHCS, diagnosed by a high serum antibody titer against C. trachomatis and clinical manifestations. Both cases showed small effusion in the pelvic cavity detected by ultrasonography, one of them was associated with small effusion in the right perirenal space suggesting perinephritis. Detection of small effusion intra abdominal cavity or pelvic space could be useful for non-invasive diagnosis of FHCS.

Effect of particle size on alumina-induced production of reactive oxygen metabolites by human leukocytes.

To assess the role of crystal size in the biologic response, we quantitated the generation of reactive oxygen metabolites in human polymorphonuclear leukocytes (PMNs) or mononuclear leukocytes (MNs) with a chemiluminescence assay using 6 alpha-alumina preparations with average diameters of 0.6, 0.8, 3.2, 7.5, 28 and 68 microns on the basis of equal weights (1 mg/ml), and also on the basis of surface areas (100 cm2/ml). On an equal weight alumina particles induced PMN chemiluminescence in the following order of magnitude: 3.2 microns > 7.5 microns, 0.8 micron > 0.6 micron > 28 microns, 68 microns. The particulates induced MN chemiluminescence: 3.2 microns > 0.8 micron > 0.6 micron > 7.5 microns > 28 microns, 68 microns. On the basis of identical surface areas, alumina elicited PMN chemiluminescence: 3.2 microns > 7.5 microns, 0.8 micron > 0.6 micron, 28 microns, 68 microns. The particulates induced MN chemiluminescence: 3.2 microns > 0.8 micron > 0.6 micron, 7.5 microns > 28 microns, 68 microns. The maximal effect of particle size on the alumina-induced production of reactive oxygen metabolites by human leukocytes was seen at around 3 microns.

Priming effect of hydroxyapatite on the chemiluminescence response in human polymorphonuclear leukocytes.

In order to determine whether hydroxyapatite modulates the response of polymorphonuclear leukocyte (PMN) to oxidative stimuli, human PMNs were incubated with a non-activating concentration (1 or 10 micrograms/ml) of hydroxyapatite prior to stimulation with N-formyl-methionyl-leucyl-phenylalanine (FMLP; 0.1 or 1 microM), phorbol 12-myristate 13-acetate (PMA; 100 pg/ml), sodium fluoride (50 microM), zymosan (1 microgram/ml), or the calcium ionophore A23187 (0.1 microM). Chemiluminescence was measured with an automatic microcomputer-controlled luminescence analyzer at 37 degrees C. Hydroxyapatite alone did not stimulate chemiluminescence at concentrations below 10 micrograms/ml. Levels 300-400% higher than 'stimulus only' controls without preincubation with hydroxyapatite have been recorded. This synergism between hydroxyapatite and subsequent stimuli reveals a new activity of hydroxyapatite and suggests that particulate material may prepare PMNs for an exaggerated inflammatory response to other phlogistic mediators. This is the first report demonstrating PMNs primed with particulate material.

[Two cases of Campylobacter fetus subsp. fetus sepsis].

We encountered two relatively rare cases of sepsis due to Campylobacter fetus subsp. fetus (C. fetus). Case 1. A 54-year-old female with abdominal polysurgery developed a slight fever and vomiting in August 1984. Despite the administration of some digestive drugs by her family doctor, these symptoms continued. In mid-October, she was hospitalized with high fever with chill and rigor on the skin. On the third hospital day, C. fetus was detected in the blood culture. After combination chemotherapy of intravenous drip infusion of latamoxef (LMOX) (2 g/day) and oral administration of erythromycin (EM) (800 mg/day), her symptoms improved. Case 2. A 57-year-old male with diabetic retinopathy and nephropathy was hospitalized because of slight fever, general edema and pleural effusion. On the 6th hospital day, C. fetus was detected in the blood culture and he was diagnosed with sepsis. Under treatment with the intravenous drip of LMOX (2 g/day) and oral administration of EM (1200 mg/day), his condition improved. Both cases had common underlying diseases such as hypoproteinemia with edema and problems in the lower intestinal tract; the former had polysurgery and malabsorption syndrome, the latter had diffuse ulceration of the colon. Such underlying conditions may have permitted the invasion of C. fetus into the blood.

Comparative study of the effects of cefodizime and HBW 538 in potentiating the production of reactive oxygen species by human polymorphonuclear leukocytes.

The immunomodulatory activity of cefodizime (CDZM), an aminothiazolylcephalosporin, was compared to that of HBW 538, a derivative of the CDZM side chain at position 3 (the mercaptothiazolyl group) in respect to the production of reactive oxygen species (ROS) by human whole blood and polymorphonuclear leukocytes (PMN) in vitro. Ten-fold diluted whole blood and PMN from healthy individuals were incubated with CDZM or HBW 538 alone at the concentrations of 1, 10, or 100 micrograms/ml, or CDZM or HBW 538 at 100 micrograms/ml in combination with tumor necrosis factor-alpha (TNF-alpha) at 100 U/ml or lipopolysaccharide (LPS) at 1 microgram/ml. The production of ROS was measured by a chemiluminescence (CL) assay in which luminol was added to a mixture and after which the PMN or whole blood were stimulated with nonopsonized zymosan or phorbol myristate acetate. The following results were obtained: (1) The CL responses of whole blood and PMN were slightly but not significantly enhanced by CDZM at 100 micrograms/ml, whereas both CL responses were significantly enhanced by exposure to HBW 538 at 10 and 100 micrograms/ml. (2) The enhanced PMN CL response which followed priming with TNF-alpha or LPS was not augmented by CDZM but was significantly augmented by HBW 538. These results indicate that the ability of the HBW 538 molecule to enhance the production of ROS by stimulated PMN and to act agonistically with TNF-alpha or LPS is abrogated when HBW 538 is part of the CDZM molecule.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of mefloquine-resistant Plasmodium falciparum malaria with convulsion after antimalarial treatment].

We report a case of 40-year-old with chloroquine- and mefloquine-resistant Plasmodium falciparum. He had a single grand mal seizure 37 days following retreatment with quinine intravenously, which resulted in rapid clearance of fever and parasitemia, in addition to mefloquine. He had a long history of seizures, which were well controlled by phenytoin. Because he has never had such a seizure before and computerized tomographic scanning of the brain after admission showed no abnormal findings which caused convulsions, it seemed to be an adverse reaction caused by antimalarial drugs. It is possible that a double or triple combination treatment for the emergence of multiresistant falciparum malaria might more frequently produce severe side effects, such as psychiatric reactions and convulsions. This case suggests that physicians must have a long follow-up period for chronic toxicity of antimalarial drugs, especially after using drug combinations for falciparum malaria.

The effect of crystallinity on hydroxyapatite-induced production of reactive oxygen metabolites by polymorphonuclear leukocytes.

To assess the role of crystallinity in biological response, we quantitated the generation of reactive oxygen metabolites in human polymorphonuclear leukocytes (PMN) with a chemiluminescence assay using three hydroxyapatite preparations with sintering temperatures of 1,200 degrees C and 900 degrees C and a drying temperature of 110 degrees C on the basis of equal weights (1 mg/ml). These crystals have almost the same average diameters and similar average zeta potentials. The crystals prepared at higher temperatures have higher crystallinity, or larger domain sizes, which were calculated by X-ray diffraction line broadening. The production of reactive oxygen metabolites by PMN in hydroxyapatite of 1,200 degrees C was 10-times that by PMN in hydroxyapatite of 900 degrees C and more than 50-times greater than that in hydroxyapatite of 110 degrees C. A single linear correlation was observed for a plot of log (peak chemiluminescence levels) vs. a plot of log (domain sizes). These results clearly show that the maximal effect of crystallinity on hydroxyapatite-induced production of reactive oxygen metabolites by human PMN was seen at higher crystallinity.

[A case of spontaneous bacterial peritonitis with ascites caused by hypoproteinemia after a massive bleeding from a gastric ulcer].

A case of spontaneous bacterial peritonitis (SBP) developed in an old man whose ascitic fluid was related neither to portal hypertension nor nephrotic syndrome, but with severe hypoalbuminemia emerged after a massive bleeding from a gastric ulcer in a malnutrition state. Ascitic fluid, increasing day by day, yielded Enterobacter cloacae and Bacteroides fragilis. Though autopsy was not carried out because of refusal of his family, neither liver necropsy, nor abdominal CT scan nor repeated abdominal ultrasonography showed findings suggesting existence of liver cirrhosis. In the presence of his ascites, the extent of a chemiluminescence (CL) response of polymorphonuclear cells from volunteers was significantly lower than that of his serum. This report shows that SBP can develop in a patient with ascites unrelated to portal hypertension when ascitic fluid induces little CL response.

Priming effect of pseudomonal leukocidin on chemiluminescence response of rabbit polymorphonuclear leukocytes.

To clarify effects of pseudomonal leukocidin (42.5 kd) on chemiluminescence (CL) production of polymorphonuclear leukocytes (PMNs), rabbit PMNs were stimulated by zymosan or phorbol myristate acetate (PMA) after pretreatment with the leukocidin, which by itself stimulated little chemiluminescence response. The extent of CL responses stimulated by zymosan or PMA was respectively 5.3- or 3.5-fold greater in leukocidin (1.5 micrograms/ml)-pretreated PMNs than in non-pretreated ones. The priming effect of the leukocidin was greater than that of G-CSF and related to some steps before NADPH oxidase activation. The increased CL productions might be related to tissue damages caused by pseudomonal infections in vivo.