A national survey on esophageal perforation: study of cases at accredited institutions by the Japanese Esophagus Society.

OBJECTIVE: To get a clear view of the current state of treatment for esophageal perforation in Japan. Esophagus perforations are the most serious gastrointestinal tract perforations and are associated with high morbidity and mortality. The optimal treatment choice remains unknown. METHODS: We conducted a retrospective clinical review of 182 esophageal perforation cases at 108 hospitals accredited by the Japanese Esophageal Society between January 2010 and December 2015. RESULTS: We found that 20.9% of patients were incorrectly diagnosed initially. We observed mediastinum emphysema in 83.5% of patients, and serious abscess formations of the mediastinum and intrathoracic cavity in 38.6% and 29.6%, respectively. The lower esophagus was the most commonly perforated site (77.7%). Management of esophageal perforations included nonoperative treatment in 20 patients (11%) and operative treatment in 162 patients (89%). The overall mortality rate was 6.9%. The survivors had significantly shorter times from symptom appearance to visit (p = 0.0016), and from time to visit to diagnosis confirmation (p = 0.0011). Moreover, patients older than 65 years, white blood cells less than 3000/mm3, C-reactive protein > 10 mg/L, or abscesses in the thoracic cavity showed significantly higher mortality than others. CONCLUSION: Shortening the time from onset to the start of treatment contributes to reduce mortality in patients with esophageal perforation. Moreover, strict medical treatment is necessary to lower the mortality rate of elderly patients with strong inflammation and abscesses in the thoracic cavity.

Empyema thoracis secondary to community-acquired Panton-Valentine leukocidin (PVL) methicillin-resistant Staphylococcus aureus (MRSA) infection.

We report a case of a previously fit middle-aged man presenting to the outpatient setting with unilateral pleural effusion, with minimal symptoms. On subsequent investigations, he was diagnosed with empyema thoracis secondary to Panton-Valentine leukocidin (PVL)-toxin positive community-acquired methicillin-resistant Staphylococcus aureus (MRSA). The patient was treated with prolonged antibiotics and pleural drainage, and he remained haemodynamically stable throughout hospital admission. PVL is a cytolytic exotoxin produced by some strains of S. aureus Such strains often cause recurrent skin and soft tissue infections, usually in previously fit and healthy individuals. Less commonly, invasive infections occur; these carry a high mortality rate if associated with necrotising pneumonia or septic shock. PVL genes are present in approximately 2% of clinical isolates of S. aureus in the UK. PVL-producing MRSA infections are on the rise and present significant clinical and public health challenges.

Microbiological analysis of fluids in postsurgical gastroesophageal intrathoracic leaks obtained by endoscopy: a new way to optimize antibiotic therapy.

BACKGROUND/AIMS: Postsurgical gastroesophageal intrathoracic leakage is a potentially life-threatening condition that is frequently accompanied by mediastinitis and subsequent sepsis. Aspiration of fluids from intrathoracic leaks during endoscopy for microbiological analysis is rarely performed in clinical routine. The aim was to evaluate the role of routine microbiological analysis of intrathoracic leaks via endoscopy and its impact on antibiotic therapy. METHODS: This is a prospective, observational single-center study. Seventeen consecutive patients who presented for endoscopic treatment of intrathoracic leaks were included. Concomitantly, fluids from intrathoracic leaks during endoscopic intervention and blood cultures were obtained and a microbiological analysis was performed. RESULTS: Bacteria and/or fungi were detected by culture of fluid aspirated from intrathoracic leaks in 88% cases, but in none of the blood cultures. In 15 patients, microbial colonization of the leakage was detected despite previous empiric antibiotic therapy; treatment had to be adjusted in all patients according to the observed antibiotic susceptibility profile. CONCLUSIONS: The microbiological colonization of postsurgical gastroesophageal intrathoracic leaks in patients is frequent. Only the direct microbiological analysis of fluids from intrathoracic leaks, but not of blood cultures, is effective for optimizing an antibiotic therapy in such patients.

Fluid rim sign: a new ultrasonographic sign of soft tissue aspergillosis.

The air crescent sign is a well-known important diagnostic finding in invasive pulmonary aspergillosis. Herein we report a distinctive but rare ultrasonographic appearance in a patient with myositis secondary to Aspergillus flavus infection, which can be considered as the soft tissue counterpart of the air crescent sign.

Fatal case of community-acquired empyema thoracis and candidemia caused by Candida albicans.

We report a fatal case of community-acquired empyema thoracis and candidemia caused by Candida albicans. The patient responded poorly to human recombinant activated protein C and intravenous fluconazole treatment and died of profound shock with multiple organ failure 8 days after admission.

Cavitary pulmonary zygomycosis caused by Rhizopus homothallicus.

We report the first two proven cases of cavitary pulmonary zygomycosis caused by Rhizopus homothallicus. The diagnosis in each case was based on histology, culture of the causal agent, and the nucleotide sequence of the D1/D2 region of the 28S ribosomal DNA.

Attempts to revive Mycobacterium tuberculosis from 300-year-old human mummies.

Environmental persistence of Mycobacterium tuberculosis is subject to speculation. However, the reality that infected postmortem tissues can be a danger to pathologists and embalmers has worrisome implications. A few experimental studies have demonstrated the organism's ability to withstand exposure to embalming fluid and formalin. Recently, a failure was reported in an attempt to resuscitate an original isolate of Robert Koch to determine the lifetime of the tubercle bacillus. The present study also considers a historical approach to determine persistence under favorable environmental conditions. It asks whether acid-fast forms observed in tissues of 300-year-old Hungarian mummies can be resuscitated. Finding organisms before the advent of antibiotics and pasteurization may yield valuable genetic information. Using various media modifications, as well as guinea pig inoculation, an attempt was made to culture these tissues for M. tuberculosis. In addition, a resuscitation-promoting factor, known to increase colony counts in high G+C bacteria, was applied to the cultures. Although an occasional PCR-positive sample was detected, no colonies of M. tuberculosis were obtained. Our results may indicate that the life span of the tubercle bacillus is less than a few hundred years, even though in the short run it can survive harsh chemical treatment.

Absceso supraesternal y de base cervical tardío. Presentación de un caso y revisión de la literatura / Late suprasternal and neck base access. Report of a case and literature review

Las infecciones profundas supraesternales tras cirugía cardíaca son infrecuentes pero pueden comprometer la vida del paciente. Tras una esternotomía es posible encontrarnos con abscesos cérvico-torácicos tardíos especialmente en presencia de factores de riesgo. Presentamos el caso de una mujer diabética de 67 años intervenida de bypass aortocoronario que fue diagnosticada de absceso supraesternal y de la base cervical en relación a su intervención 11 años después de la misma. Fue necesario practicar drenaje de la colección e instaurar antibioticoterapia de amplio espectro con buena evolución posterior. 4 meses después fue ingresada de nuevo por presentar un absceso torácico y requirió tratamiento por Cirugía Cardíaca. El seguimiento clínico fue de 3 años y no se han detectado nuevas recurrencias

Deep suprasternal infections secondary to cardiac surgery are uncommon but can compromise the life of the patient. After a sternotomy it is possible to find late cervico-thoracic abscesses specially in the presence of risk factors. We are reporting the case of a diabetic female of 67 years old with aortocoronary bypass who was diagnosed of suprasternal and neck base abscess in relation to her intervention 11 years later. It was necessary to practice drainage of the collection and wide spectrum antibioticotherapy with good evolution. 4 months after the surgery she was admitted again suffering a thoracic abscess that required treatment by Cardiac Surgery. The clinical follow-up was 3 years and no new recurrences have been detected

Prevalence of and carcass condemnation from maedi-visna, paratuberculosis and caseous lymphadenitis in culled sheep from Quebec, Canada.

We determined the prevalence of lung and mammary gland lesions associated with maedi-visna (MV) infection, the prevalence of paratuberculosis (PTB), and the prevalence and lesions distribution of caseous lymphadenitis (CL) in culled sheep. Total of 451 ewes and 34 rams were selected randomly from two slaughterhouses in Quebec, Canada. MV serostatus was determined by recombinant ELISA test. PTB diagnosis was based on characteristic histological lesions in the terminal ileum, ileocecal lymph node and/or ileocecal valve and CL by gross detection of abscesses and isolation of Corynebacterium pseudotuberculosis. Seroprevalence of MV was 44% (95% CI: 40, 48). Seropositivity increased with age and was higher in ewes than in rams. The percentages of lung and mammary gland lesions in seropositive sheep were 14 and 40%, respectively, but mammary gland lesions lack specificity. The prevalence of PTB was 3% (95% CI: 2, 5). PTB increased with age and was lower among sheep with abscesses. The prevalence of CL was >/=21% (95% CI: 17, 24). The most-prevalent site of caseous lymphadenitis lesions was the thoracic cavity. The risk of carcass condemnation was significantly associated with region, body score and abscesses. Only the presence of abscesses was associated with an increase in trimming of carcasses.

Transposon mutagenesis of Mycoplasma gallisepticum.

There are few systems available for studying the genetics of the important avian respiratory pathogen, Mycoplasma gallisepticum. These techniques are needed to develop a mechanism to study the molecular pathogenesis of M. gallisepticum. Tn916 has the ability to transpose into the M. gallisepticum genome by both transformation and conjugation. In this study, PEG-mediated transformation was employed for the transfer of Tn916 into M. gallisepticum and create a transposon mutant library. Transformants were obtained at a frequency of approximately 5 x 10(-8) per recipient CFU. A total of 424 MG/Tn916 mutants were constructed and sequence data from the transposon junctions of 71 mutants was obtained and used to identify transposon insertion sites. Insertions were found throughout the genome in nearly all of the major gene categories, making this the first extensive characterization of a transposon mutant library of M. gallisepticum. Transposon stability was also examined, and it was determined that for two mutants the element was stably maintained in vivo in the absence of selective pressure.