Cytokine Profiles Before and After Exchange Transfusions in Severe Late-Onset Neonatal Group B Streptococcus Meningitis: A Case Report.

Streptococcus agalactiae or group B streptococcus (GBS) is a pathogen that causes severe neonatal infections, resulting in sepsis, pneumonia, and meningitis. Neonatal GBS meningitis has a poor neurological prognosis and a high mortality rate. GBS disease is classified as early- and late-onset if the onset age is 0-6 and 7-89 days after birth, respectively. There is currently no effective preventive strategy against late-onset GBS (LOGBS) disease. Here, we report a case of female infant with LOGBS meningitis who recovered from the septic shock by two exchange transfusions (ExTs) but still experienced severe neurological sequela. She was born at a gestational age of 39 weeks via caesarian section due to oligohydramnios and had fever 11 days after birth. GBS was detected in her cerebrospinal fluid (CSF) and blood but not in the vaginal or breast-milk cultures of the mother. The patient was treated with intravenous antibiotic administration; however, she suddenly developed pulseless ventricular tachycardia and asystole the next day. Her heart rate was normalized via cardiopulmonary resuscitation. We also performed two ExTs, and she recovered from the septic shock. Cytokine-profile analysis revealed that the serum and CSF levels of various pro-inflammatory and anti-inflammatory cytokines were elevated before the ExTs, after which the serum levels of several of these cytokines decreased. Two ExTs were effective in saving the life of the patient but did not improve the neurological prognosis. Given that neonatal GBS meningitis has high fatality and sequela rates; thus, it is necessary to establish a preventive strategy.

Critically Severe Case of Neonatal Herpes with High Viral Load and Hemophagocytic Syndrome.

Neonatal disseminated herpes simplex virus (HSV) infection is a severe disease with high mortality and morbidity; yet, the pathophysiology remains unclear. Here, we report a male infant with disseminated HSV type 1 (HSV-1) infection, complicated by hemophagocytic lymphohistiocytosis (HLH) and multiple organ failure. The infant, born at 39 weeks of gestation by normal delivery, developed fever (38.5˚C) with the high serum C-reactive protein levels on the 1st day of life, and exhibited tachypnea on the 3rd day. On the 5th day of life, the patient received mechanical ventilation and was transferred to our neonatal ICU. Real-time PCR for HSV-1 DNA revealed an extremely high serum concentration (1.0 × 109 copies/µL), and he was diagnosed with HSV-1 infection. Acyclovir (ACV) and corticosteroid pulse therapies with methylprednisolone were started. Continuous hemodiafiltration (CHDF) using cytokine-absorbing hemofilters was also initiated because of renal failure. These therapies, however, failed to control the disease, and the patient died on the 41st day of life. The dose of ACV on CHDF might not be adequate, although we could not measure the serum ACV concentrations. After the patient's death, we measured his serum cytokine concentrations taken four times during the clinical course. Serum concentrations of interleukin (IL)-6, IL-10, IL-1ß, and interferon (IFN)-γ were elevated at the time of admission and were remarkably decreased by 10 days after treatment. In particular, the concentrations of IL-1ß and IFN-γ were lower than the measurable ranges. It is therefore important to measure serum cytokine concentrations in real time to prevent excessive immune suppression.

Neonatal meningitis and recurrent bacteremia with group B Streptococcus transmitted by own mother's milk: A case report and review of previous cases.

This article reports a case of neonatal meningitis and recurrent bacteremia caused by group B Streptococcus (GBS) transmitted via the mother's milk. A 3-day-old neonate suffered early-onset meningitis due to GBS, from which he recovered after antibiotic treatment for 4 weeks. GBS was not detected in the vaginal or stool cultures of the neonate's mother before delivery. However, 4days after treatment of GBS meningitis, the neonate developed GBS bacteremia. As the mother repeatedly showed signs of mastitis after the delivery, bacterial culture tests were performed on her breast milk, in addition to vaginal and stool culture tests. GBS was exclusively detected in the mother's breast milk. The GBS strains detected in the cerebrospinal fluid of the neonate and the mother's breast milk were both serotype III, and were confirmed to be identical through pulsed-field gel electrophoresis analysis. As horizontal GBS transmission between the mother and neonate was indicated, breastfeeding was ceased and replaced with formula milk. No recurrence of bacterial meningitis or bacteremia due to GBS was observed thereafter. Physicians need to consider culturing breast milk in cases of recurrent neonatal GBS infections, even in mothers without prior detection of GBS in conventional vaginal or stool cultures before delivery.

Laparoscopic extra-abdominal suturing technique for the repair of Larrey's diaphragmatic hernia using the port closure needle (Endo Close®): A case report.

INTRODUCTION: Morgagni's or Larrey's diaphragmatic hernias are relatively uncommon. If the defect is too large for primary closure, the use of a mesh is inevitable. Although primary closure is adaptable for relatively small defects, it is difficult to suture the hernial orifice in which the anterior rim is absent. Herein, we present the case of a patient with Larrey's diaphragmatic hernia that was easily and securely repaired using the recently developed laparoscopic extra-abdominal suturing technique via the port closure needle (Endo Close®; Medtronic, Minneapolis, USA). PRESENTATION OF CASE: An 89-year-old woman complaining of vomiting was transferred to our hospital. Computed tomography scan showed Larrey's diaphragmatic hernia. Laparoscopic repair was performed after gastric decompression. We diagnosed Larrey's hernia on the left side of the falciform ligament. The transverse colon was herniated through the defect. Since the hernial defect was located below the substernal space, there was no tissue to stitch at the anterior rim of the hernial orifice. We performed the extra-abdominal suturing technique, suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall using the port closure needle (Endo Close®) without the need for a mesh. The patient was discharged on the 8th postoperative day. There was no evidence of recurrence at 8 months postoperatively. DISCUSSION: The recently developed extra-abdominal suturing technique using Endo Close® to suture the full thickness of the anterior abdominal wall achieved secure mattress suture and easy extra-abdominal tying. CONCLUSION: This method may be useful in terms of easiness and security of suture.

[A case of postpancreaticoduodenectomy local recurrence successfully treated with extended resection].

A 68 -year-old man underwent a pancreaticoduodenectomy after being diagnosed with primary duodenal cancer. The postoperative pathological diagnosis was tub2, SE, ly1, v1, panc3, pn+, N0. Although adjuvant chemotherapy was administered, local recurrence in the portal region was detected 18 months later. The recurrent tumor pressed against the region of the bile duct anastomosis, which caused obstructive jaundice. After serum bilirubin levels were reduced, resection of the recurrent tumors was performed. This required resection of the transverse colon, parts of the portal vein, and the inferior vena cava. The bile duct anastomotic region, which had been infiltrated by the tumor, was excised and rebuilt. The postoperative pathological diagnosis was tub2. The patient continued to receive adjuvant chemotherapy and showed no signs of recurrence 9 months after surgery. Extended resection for local recurrences of primary duodenal cancer may be an effective means of disease control.

A case of gastric cancer following living donor liver transplantation.

Only a few cases of de novo malignancy, especially gastric cancer after living donor liver transplantation (LDLT), have been reported. We report a case of gastric cancer following LDLT, after which immunosuppressants were minimized in accordance with the results of the mixed lymphocyte reaction (MLR) assay. A 65-year-old woman had previously undergone LDLT for hepatocellular carcinoma associated with hepatitis B virus infection. The liver graft had been donated by her son. During the course of postoperative surveillance with the MLR assay in order to minimize immunosuppressants, she was incidentally found to have gastric cancer during an endoscopic examination, 8 years after the liver transplantation. She underwent total gastrectomy with lymph node dissection. In this case, gastric cancer was detected 8 years after LDLT, which is longer than previously reported intervals between LDLT and malignancy detection. The number of patients undergoing LDLT is increasing, and the prognosis after liver transplantation has improved. Therefore, endoscopic surveillance programs are important for detecting malignancies in the early stages in liver transplant recipients.