Clinical Significance of Urinary Neutrophil Gelatinase-associated Lipocalin Levels in Defining the Various Etiologies of Acute Kidney Injury in Liver Cirrhosis Patients.

BACKGROUND/AIMS: A diagnosis of hepatorenal syndrome (HRS) is based on a differential evaluation of acute kidney injury (AKI), which may aggravate the clinical course. This study assessed the clinical significance of the urinary neutrophil gelatinase- associated lipocalin (u-NGAL) levels in a differential diagnosis of AKI in patients with liver cirrhosis (LC). METHODS: Patients with LC who developed AKI were enrolled prospectively. Clinically, patients with AKI were classified into prerenal azotemia (PRA), HRS, and acute tubular necrosis (ATN) groups. RESULTS: Fifty-five patients (male, 74.5%) with LC who exhibited AKI upon admission were enrolled; 28, 9, and 18 patients were included in the PRA, HRS, and ATN groups, respectively. The baseline model for end-stage liver disease (MELD) scores was similar in the subgroups. The median event creatinine level, measured at the time of the AKI diagnosis, was similar in the HRS and ATN subgroups. On the other hand, the median event u-NGAL level differed significantly between the three subgroups (PRA, HRS, and ATN: 37 vs. 134 vs. 2,625 ng/mL, p=0.003). In particular, the median u-NGAL level of the HRS group was clearly different from those of the PRA (p<0.001) and ATN (p<0.001) groups. Multivariable analysis revealed the natural logarithm of the u-NGAL level (hazard ratio [HR] 1.77, p=0.031) and the MELD score (HR 1.17, p=0.027) to be independent prognostic factors for in-hospital mortality in patients with LC and AKI. CONCLUSIONS: The median u-NGAL level differentiated HRS from ATN and served as a clinical indicator of in-hospital mortality for patients with LC and AKI.

AIMS65 scoring system is comparable to Glasgow-Blatchford score or Rockall score for prediction of clinical outcomes for non-variceal upper gastrointestinal bleeding.

BACKGROUND: Risk stratification for patients with nonvariceal upper gastrointestinal (NVUGI) bleeding is crucial for successful prognosis and treatment. Recently, the AIMS65 score has been used to predict mortality risk and rebleeding. The purpose of this study was to compare the performance of the AIMS65 score with the Glasgow-Blatchford score (GBS), Rockall score, and pre-endoscopic Rockall score in Korea. METHODS: We retrospectively studied 512 patients with NVUGI bleeding who were treated at a university hospital between 2013 and 2016. The AIMS65, GBS, Rockall score, and pre-endoscopic Rockall score were used to stratify patients based on their bleeding risk. The primary outcome was in-hospital mortality. The secondary outcomes were composite clinical outcomes of mortality, rebleeding, and intensive care unit (ICU) admission. Each scoring system was compared using the receiver-operating curve (ROC). RESULTS: A total of 17 patients (3.3%) died and rebleeding developed in 65 patients (12.7%). Eighty-six patients (16.8%) required ICU admission. The AIMS65 (area under the curve (AUC) 0.84, 95% confidence interval, 0.81-0.88)) seemed to be superior to the GBS (AUC 0.72, 0.68-0.76), the Rockall score (AUC 0.75, 0.71-0.79), or the pre-endoscopic Rockall score (AUC 0.74, 0.70-0.78) in predicting in-hospital mortality, but there was not a statistically significant difference between the groups (P = 0.07). The AUC value of the AIMS65 was not significantly different from the other scoring systems in prediction of rebleeding, endoscopic intervention, or ICU admission. CONCLUSIONS: The AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting the mortality, rebleeding, or ICU admission. Because AIMS65 is a much easier, readily calculated scoring system compared to the others, we would recommend using the AIMS65 in daily practice.

Clinical Interpretation of Elevated CA 19-9 Levels in Obstructive Jaundice Following Benign and Malignant Pancreatobiliary Disease.

BACKGROUND/AIMS: Elevated carbohydrate antigen (CA) 19-9 level may be unable to differentiate between benign and malignant pancreatobiliary disease with obstructive jaundice. The study aims to determine the clinical interpretation and the diagnostic value of CA 19-9 level in pancreatobiliary diseases with coexistent obstructive jaundice. METHODS: We retrospectively reviewed the data of 981 patients who underwent biliary drainage due to obstructive jaundice following pancreatobiliary disease at Sanggye Paik Hospital for 5 years. 114 patients with serial follow-up data for CA 19-9 level were included in this study (80 patients with malignancy and 34 patients with benign diseases). We compared the levels of CA 19-9 levels and the biochemical value before and after biliary drainage. RESULTS: The rate of CA 19-9 elevation (>37 U/mL) was significantly different between the benign group and the malignant group (59% vs. 90%, p=0.001). Despite the decrease in serum bilirubin after biliary drainage, CA 19-9 levels remained elevated in 12% of patients in the benign group and in 63% of patients in the malignant group (p<0.001). Finally, 12% of patients in the benign group turned out to have malignant disease. A receiver operating characteristic analysis provided a cut-off value of 38 U/mL for differentiating benign disease from malignant disease after biliary drainage (area under curve, 0.787; 95% confidence interval, 0.703 to 0.871; sensitivity, 62%; specificity, 88%). CONCLUSIONS: This study suggested that we should consider the possibility of malignant causes if the CA 19-9 levels remain high or are more than 38 U/mL after resolution of biliary obstruction.

Non-umbilical Cutaneous Metastasis of Pancreatic Adenocarcinoma as the First Clinical Manifestation: A Case Report.

Non-umbilical cutaneous metastases from pancreatic adenocarcinomas are extremely rare. Only a few cases have been reported in the literature. An 83-year-old Korean woman, with no previous medical history, presented with a painful nodule on her scalp. Histologic examination of the nodule revealed a metastatic adenocarcinoma, and immunohistochemical staining was positive for cytokeratin (CK) 7 and CK 19. These findings were consistent with a metastatic carcinoma of pancreatic origin. An abdominal computed tomography scan identified a mass on the pancreatic head and multiple enlarged lymph nodes. Pathological examination of an endoscopic ultrasound-guided fine needle biopsy of the pancreatic mass determined that it was a poorly differentiated carcinoma. The patient refused any treatment owing to her old age and short life expectancy. Four months later, the disease progressed rapidly, and the patient died.

Evaluation of Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile Assays for Direct Detection of Toxigenic Clostridium difficile in Stool Specimens.

BACKGROUND: We evaluated the performance of four commercial nucleic acid amplification tests (NAATs: Xpert C. difficile, BD MAX Cdiff, IMDx C. difficile for Abbott m2000, and Illumigene C. difficile) for direct and rapid detection of Clostridium difficile toxin genes. METHODS: We compared four NAATs on the same set of 339 stool specimens (303 prospective and 36 retrospective specimens) with toxigenic culture (TC). RESULTS: Concordance rate among four NAATs was 90.3% (306/339). Based on TC results, the sensitivity and specificity were 90.0% and 92.9% for Xpert; 86.3% and 89.3% for Max; 84.3% and 94.4% for IMDx; and 82.4% and 93.7% for Illumigene, respectively. For 306 concordant cases, there were 11 TC-negative/NAATs co-positive cases and 6 TC-positive/NAATs co-negative cases. Among 33 discordant cases, 18 were only single positive in each NAAT (Xpert, 1; Max, 12; IMDx, 1; Illumigene, 4). Positivity rates of the four NAATs were associated with those of semi-quantitative cultures, which were maximized in grade 3 (>100 colony-forming unit [CFU]) compared with grade 1 (<10 CFU). CONCLUSIONS: Commercial NAATs may be rapid and reliable methods for direct detection of tcdA and/or tcdB in stool specimens compared with TC. Some differences in the sensitivity of the NAATs may partly depend on the number of toxigenic C. difficile in stool specimens.

Appropriate empirical antibiotic use and 30-d mortality in cirrhotic patients with bacteremia.

AIM: To analyze whether prompt and appropriate empirical antibiotic (AEA) use is associated with mortality in cirrhotic patients with bacteremia. METHODS: A total of 102 episodes of bacteremia in 72 patients with cirrhosis were analyzed. AEA was defined as a using or starting an antibiotic appropriate to the isolated pathogen at the time of bacteremia. The primary endpoint was 30-d mortality. RESULTS: The mortality rate at 30 d was 30.4% (31/102 episodes). Use of AEA was associated with better survival at 30 d (76.5% vs 46.9%, P = 0.05), and inappropriate empirical antibiotic (IEA) use was an independent factor associated with increased mortality (OR = 3.24; 95%CI: 1.50-7.00; P = 0.003, adjusted for age, sex, Child-Pugh Class, gastrointestinal bleeding, presence of septic shock). IEA use was more frequent when the isolated pathogen was a multiresistant pathogen, and when infection was healthcare-related or hospital-acquired. CONCLUSION: AEA use was associated with increased survival of cirrhotic patients who developed bacteremia. Strategies for AEA use, tailored according to the local epidemiological patterns, are needed to improve survival of cirrhotic patients with bacteremia.

Optimal timing of endoscopic clipping for determining the resection line for laparoscopy-assisted distal gastrectomy.

BACKGROUND/AIMS: Pre-operative endoscopic clipping for determining the resection line in patients with early gastric cancer has been used safely, and its efficacy has been demonstrated. However, the optimal timing of endoscopic clipping for determining the resection line in early gastric cancer patients undergoing laparoscopy-assisted distal gastrectomy has not been investigated. METHODS: A retrospective analysis of 92 patients with early gastric cancer who underwent gastric resection after endoscopic clipping at Inje University Sanggye Paik Hospital (Seoul, Korea) was performed. We analyzed the clinical and endoscopic features of patients, number of clips, time from clipping to surgery, and number of patients showing detachment of clips from the gastric wall before surgery. Patients were categorized according to the following two groups: group A included patients whose clips were applied within one day before surgery and group B included patients whose clips were applied more than one day before surgery. RESULTS: Of the 92 patients, 56 were included in group A and 36 were included in group B. In 11 patients (12.0%, five in group A and six in group B, p=0.329), the clips were detached from the gastric wall before surgery. The mean time from clipping to surgery did not differ significantly between the detached and non-detached groups (11 patients, mean 4.6±4.6 days vs. 81 patients, mean 3.0±4.0 days, p=0.227). CONCLUSIONS: The timing of endoscopic clipping for localization of tumors in early gastric cancer patients undergoing gastrectomy is not important for determining the resection line.

Pure red-cell aplasia and autoimmune hemolytic anemia in a patient with acute hepatitis A.

Pure red cell aplasia (PRCA) and autoimmune hemolytic anemia (AIHA) have rarely been reported as an extrahepatic manifestation of acute hepatitis A (AHA). We report herein a case of AHA complicated by both PRCA and AIHA. A 49-year-old female with a diagnosis of AHA presented with severe anemia (hemoglobin level, 6.9 g/dL) during her clinical course. A diagnostic workup revealed AIHA and PRCA as the cause of the anemia. The patient was treated with an initial transfusion and corticosteroid therapy. Her anemia and liver function test were completely recovered by 9 months after the initial presentation. We review the clinical features and therapeutic strategies for this rare case of extrahepatic manifestation of AHA.

Comparison between ulinastatin and nafamostat for prevention of post-endoscopic retrograde cholangiopancreatography complications: a prospective, randomized trial.

OBJECTIVES: Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this prospective trial was to compare the effect of ulinastatin and nafamostat on the prophylaxis of post-ERCP complications. METHODS: A total of 159 patients who underwent ERCP were divided into ulinastatin (n = 53), nafamostat (n = 53) and control (n = 53) groups. Each patient received ulinastatin (150,000 units), nafamostat (20 mg), or placebo from 2-4 h before ERCP to 6-8 h after ERCP. The primary endpoint was the incidence of PEP, and the secondary endpoints were the incidence of post-ERCP hyperamylasemia, hyperlipasemia and abdominal pain. RESULTS: The overall incidence of PEP was 6.3% (10/159) and no significant differences were observed between ulinastatin and nafamostat groups in terms of the incidences of PEP (1.9% and 3.8%, P = 0.560), hyperamylasemia, hyperlipasemia, and abdominal pain, although these were significantly lower than those of the control group (P < 0.001). CONCLUSIONS: There was no significant difference for preventing PEP between ulinastatin and nafamostat and both drugs were efficacious for preventing post-ERCP complications.

Urachal cancer with direct caecal invasion: differential diagnosis from primary colon cancer.

A 56-year-old man who had a history of repeated previous treatment for cystitis was admitted with abdominal distension, dysuria, pollakiuria, nocturia and sensation of urine retention after emptying the bladder. A CT scan showed a 10 cm irregularly shaped soft tissue mass abutting the anterosuperior aspect of the urinary bladder with wall thickening and a soft tissue component in the caecum. Colonoscopy revealed an encircling huge fungating mass on the caecum. The tumour was removed surgically. Histological examination showed moderately differentiated adenocarcinoma extending to the caecal wall and the bladder mucosa, the origin of the mass was consistent with that of a urachal cyst. The epicentre of the tumour was located in the bladder wall, with a distinct margin as a pathological feature. The patient was diagnosed with urachal cancer and concurrent direct caecal invasion.

Longitudinal change of liver stiffness by transient elestography in chronic hepatitis B patients treated with nucleos(t)ide analogue.

BACKGROUND: Liver stiffness measurement (LSM) by transient elastography is a non-invasive method to assess liver fibrosis. Decline in LSM value has been reported after antiviral treatment (AVT) using nucleos(t)ide analogues (NUCs) in chronic hepatitis B (CHB) patients, however, factors associated with changes in LSM during AVT remains unclear. METHODS: A total of 76 CHB patients who received AVT with NUCs and had serial LSM (median duration: 16 months, range: 12 to 35 months) during AVT were analyzed. Complete virological response (CVR) was defined when hepatitis B virus DNA level was undetectable by real-time PCR assay (< 50 copies/mL). RESULTS: LSM value had significantly decreased after AVT with NUCs [median (quartile): 6.5 (4.7-9.2) to 5.3 (3.9-6.7), P<0.001]. The median change of LSM value/year was -0.8 (range: -9.5∼4.9). The annual change of LSM value was associated with baseline total bilirubin levels, HBeAg status and achievement of CVR during follow-up in univariable analysis, and achievement of CVR during follow-up was an only independent factor associated with the annual change of LSM value [beta coefficients (95% confidence interval)=-0.29 (-2.81∼-0.26), P=0.02]. The annual LSM change was significantly different between those who achieved and did not achieve CVR (median change: -1.08/year vs. 0.26/year, P<0.01), and more patients with CVR had decrease in LSM value (89% (47/53) vs. 35% (8/23), P<0.01). CONCLUSIONS: A significant decrease in LSM value was observed in CHB patients after AVT with NUCs. Achievement of CVR was significant factor associated with change in LSM value. Achieving CVR might be a key to decrease LSM value during AVT with NUCs.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure.

BACKGROUND: The early identification of severe acute pancreatitis is important for the management and for improving outcomes. The bedside index for severity in acute pancreatitis (BISAP) has been considered as an accurate method for risk stratification in patients with acute pancreatitis. This study aimed to evaluate the comparative usefulness of the BISAP. METHODS: We retrospectively analyzed 303 patients with acute pancreatitis diagnosed at our hospital from March 2007 to December 2010. BISAP, APACHE-II, Ranson criteria, and CT severity index (CTSI) of all patients were calculated. We stratified the number of patiants with severe pancreatitis, pancreatic necrosis, and organ failure as well as the number of deaths by BISAP score. We used the area under the receiver-operating curve (AUC) to compare BISAP with other scoring systems, C-reactive protein (CRP), hematocrit, and body mass index (BMI) with regard to prediction of severe acute pancreatitis, necrosis, organ failure, and death. RESULTS: Of the 303 patiants, 31 (10.2%) were classified as having severe acute pancreatitis. Organ failure occurred in 23 (7.6%) patients, pancreatic necrosis in 40 (13.2%), and death in 6 (2.0%). A BISAP score of 2 was a statistically significant cutoff value for the diagnosis of severe acute pancreatitis, organ failure, and mortality. AUCs for BISAP predicting severe pancreatitis and death were 0.80 and 0.86, respectively, which were similar to those for APACHE-II (0.80, 0.87) and Ranson criteria (0.74, 0.74) and greater than AUCs for CTSI (0.67, 0.42). The AUC for organ failure predicted by BISAP, APACHE-II, Ranson criteria, and CTSI was 0.93, 0.95, 0.84 and 0.57, respectively. AUCs for BISAP predicting severity, organ failure, and death were greater than those for CRP (0.69, 0.80, 0.72), hematocrit (0.45, 0.35, 0.14), and BMI (0.41, 0.47, 0.17). CONCLUSION: The BISAP predicts severity, death, and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria, CTSI, CRP, hematocrit, and BMI.

[A case of hepatic peribiliary cysts in a patient with alcoholic liver cirrhosis].

Hepatic peribiliary cysts (HPCs) are characterized by cystic dilatations of the peribiliary glands located throughout the branches of the biliary systems. Specifically, they are mainly located along the hepatic hilum and major portal tracts. The natural history and prognosis of HPCs are uncertain. In fact, almost all HPCs have been discovered incidentally during radiological examination or autopsy, and they are considered to be clinically harmless. Recently, several cases of HPCs associated with obstructive jaundice or liver failure were reported in patients with pre-existing liver disease in several studies. However, until now there have been no reports of such a case in Korea. Herein, we report a case of HPCs that show a disease course with a poor prognosis. These HPCs developed in a 47-year-old man with progressive alcoholic liver cirrhosis.

The clinical factors for predicting severe diverticulitis in Korea: a comparison with Western countries.

BACKGROUND/AIMS: It is unclear whether the risk factors associated with complicated diverticulitis in Asian and Western countries are the same. We evaluated the risk factors associated with severe diverticulitis (SD) in Korea and compared the clinical characteristics of diverticulitis according to location. METHODS: A retrospective review of 190 patients hospitalized with acute diverticulitis from January 2005 to June 2010 was conducted. SD was defined as one of the following: perforation, abscess, obstruction, sepsis, or peritonitis that required an urgent operation. RESULTS: Twenty-four patients (12.6%) were diagnosed with SD. SD was significantly associated with older age, a fever over 38℃, changes in bowel habits and a high visceral adipose tissue (VAT)/total adipose tissue (TAT) ratio. Multivariate analysis showed that the risk factors for developing SD were an age of 40 years or more (odds ratio [OR], 3.2; p=0.032), male gender (OR, 4.0; p=0.021) and left-sided diverticulitis (OR, 6.2; p=0.017). Right-sided diverticulitis (n=175, 92.1%) was significantly associated with younger ages, fewer changes in bowel habits, fewer comorbidities and non-SD. CONCLUSIONS: This study suggests that the risk factors for developing SD in Korea, where right-sided diverticulitis is predominant, are the male gender, an age of more than 40 years old, and left-sided diverticulitis. Given that there are different risk factors for developing SD in Western countries, different strategies for the treatment of diverticulitis in the Korean population seem to be needed.

[Clinical factors predicting for neoplastic transformation of gastric hyperplastic polyps].

BACKGROUND/AIMS: Hyperplastic polyps (HPs) are the most common cause of all benign epithelial gastric polyps, constituting 30 to 93%. Although gastric HPs are usually considered as benign lesions compared with adenoma, neoplastic transformation has been known to occur rarely. We aimed to identify the clinical factors of gastric HPs predicting for neoplastic transformation. METHODS: Between January 2002 to August 2010, a total of 274 gastric HPs, which had been removed by endoscopic polypectomy or surgical resection from 210 patients, were analyzed retrospectively. RESULTS: Neoplastic transformation was found in 15 cases (5.5%) of 274 HPs including 10 cases of low grade dysplasia (3.7%), 2 cases of high grade dysplasia (0.7%) and 3 cases of adenocarcinoma (1.1%). Neoplastic transformations were significantly associated with >1 cm in size (n=10 [66.7%] vs. n=91 [35.1%], p=0.024), with pedunculated shape (n=9 [60.0%] vs. n=62 [23.9%], p=0.002), with previous history of gastrectomy (n=3 [20.0%] vs. n=3 [1.2%], p=0.002) and with synchronous neoplastic lesions occurring elsewhere in the gastric mucosa (n=5 [33.3%] vs. n=31 [12.0%], p=0.021). However, no significant difference was found between HPs with and without neoplastic transformation in terms of age, sex, number of polyps detected per patient, location, macroscopic appearance such as erosion, hyperemia. CONCLUSIONS: Neoplastic transformation of gastric HPs had significant relationships with ž1 cm in size, pedunculated shape, postgastectomy state, and synchronous neoplastic lesion. Therefore, endoscopic polypectomy should be considered in these HPs to avoid the risk of missing HPs with neoplastic potential.

A case of corrosive injury-induced pharyngeal stricture treated by endoscopic adhesiolysis using an electrosurgical knife.

Here, we report a case of corrosive injury-induced pharyngeal stricture in a 69-year-old female, which was successfully treated with endoscopic adhesiolysis using an electrosurgical knife. The patient had ingested sodium hydroxide in an attempted suicide, and immediate endoscopy revealed corrosive injuries of the pharynx, esophagus, and stomach. When a liquid diet was permitted, she complained of nasal regurgitation of food. Follow-up endoscopy revealed several adhesive bands and a web-like scar that did not allow passage of the endoscope into the hypopharyngeal area. For treatment of the hypopharyngeal stricture, the otolaryngologist attempted to perform an excision of the fibrous bands around the esophageal inlet using microscissors passed through an esophagoscope, but this procedure was not effective. We then dissected the mucosal adhesion and incised the adhesive bands using an electrosurgical knife. After this procedure, nasal regurgitation of food no longer occurred. To our knowledge, this case is the first report of endoscopic adhesiolysis with an electrosurgical knife in a patient with a corrosive injury-induced pharyngeal stricture.

[A case of Chlamydia trachomatis peritonitis mimicking tuberculous peritonitis].

Lymphocytic ascites with low serum-ascites albumin gradient (SAAG) are observed mainly in tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic disease. However, pelvic inflammatory disease (PID) induced generalized peritonitis causing diffuse ascites has been rarely described. We report a 26-year old female patient, who was diagnosed as generalized peritonitis with diffuse ascites due to Chlamydia trachomatis infection. Gynecologic examination did not show the clue of PID and in the analysis of ascites, low SAAG, predominant lymphocyte count and high level of adenosine deaminase were noted. Although the best impression was tuberculous peritonitis on the base of these findings, the laparoscopic finding was consistent with PID and the PCR for C. trachomatis infection in cervical swab was positive. This case suggests that C. trachomatis peritonitis should be considered as a rare cause of low SAAG and lymphocytic ascites in sexually active women and should be intensively evaluated including laparoscopic examination.

[A case of tuberculous peritonitis developed during chemotherapy for tuberculous pleurisy as paradoxical response].

After the start of anti-tuberculous treatment, paradoxical worsening of tuberculous lesions has been described. However, abdominal tuberculosis as paradoxical response is relatively rare. This report describes the 26-year-old female who suffered from peritoneal tuberculosis while treating tuberculous pleurisy with anti-tuberculous medications. It was considered as paradoxical response, rather than treatment failure or else. She was successfully managed with continuing initial anti-tuberculous medications. When a patient on anti-tuberculous medications is presented with abdominal symptoms, the possibility of paradoxical response should be considered to avoid unnecessary tests and treatments, which may result in more suffering of the patient. Herein, we report a case of peritoneal tuberculosis as paradoxical response while treating tuberculous pleurisy.

Characterization of cases of Clostridium difficile infection (CDI) presenting at an emergency room: molecular and clinical features differentiate community-onset hospital-associated and community-associated CDI in a tertiary care hospital.

Definition of community-onset, hospital-acquired Clostridium difficile infection (CO-HA-CDI) is difficult in patients presenting with diarrhea at hospitals or outpatient clinics, especially 4 to 12 weeks after the last discharge. We performed C. difficile stool culture for 272 diarrheic patients visiting the emergency room (ER) between January 2006 and June 2010. C. difficile was isolated from 36 cases (13.2%), and isolation rates increased year by year, from 10.1% in 2008 to 12.4% in 2009 and 16.7% in 2010. Among 32 toxin-positive isolates, 13 (40.6%) and 19 (59.4%) were associated with CO-HA-CDI and community-acquired CDI (CA-CDI), respectively, if cases with CDI diagnosed within 12 weeks after discharge were considered hospital associated. The majority (70%) of CO-HA-CDI cases occurred within 2 weeks after hospital discharge, although the interval from discharge to onset of symptoms was as long as 10 weeks. We found via tcdA and tcdB and repetitive sequence PCR analysis, that toxin A-positive/toxin B-positive isolates were the most prevalent in both CO-HA-CDI (53.8%) and CA-CDI (94.7%) cases. Toxin A-negative/toxin B-positive isolates were also still highly associated with HA-CDI cases but were also observed in CA-CDI cases. Younger age, fewer underlying diseases, lack of prior antibiotic use, and genetic diversity of isolates in repetitive sequence PCR were the main characteristics in CA-CDI cases visiting the ER.

[A case of hemophagocytic syndrome complicated by acute viral hepatitis A infection].

Hemophagocytic syndrome (HPS) is a rare but serious condition that is histopathologically characterized by activation of macrophage or histiocytes with hemophagocytosis in bone marrow and reticuloendothelial systems. Clinically it presents with high fever, hepatosplenomegaly, pancytopenia, liver dysfunction, and hyperferritinemia. Hepatitis A virus is a very rare cause of secondary HPS. We report a case of a 22-year-old woman infected by hepatitis A virus who was consequently complicated with HPS. She presented typical clinical features of acute hepatitis A, and showed clinical and biochemical improvements. However, HPS developed as a complication of acute hepatitis A and the patient died of intraperitoneal bleeding caused by hepatic decompensation and disseminated intravascular coagulation.