[Two cases of pulmonary aspergilosis, which deteriorated with generic itraconazole].

We experienced two cases of pulmonary aspergillosis, which deteriorated during treatment with generic itraconazole (ITCZ) because of low plasma concentration. One case was chronic pulmonary aspergillosis and the other was allergic bronchopulmonary aspergillosis (ABPA). Treatment of both cases was started with a brand-name-ITCZ, and changed to a generic ITCZ. Deterioration of pulmonary aspergillosis occurred after 8 months and 9 months from change to generic ITCZ respectively. In the first case, the ITCZ-plasma concentration was 46.9 ng/mL and of OH-ITCZ 96.5 ng/mL with generic ITCZ at the dose of 300 mg/day, but increased to 1,559.7 ng/mL and to 2,485.0 ng/mL with the brand-name-ITCZ 300 mg/day, respectively. In the second case, the ITCZ-plasma concentration was 27.2 ng/mL and of OH-ITCZ 20.1 ng/mL with 150 mg/day for generic ITCZ, but reached 857.3 ng/mL and to 1,144.2 ng/ml with the brand-name-ITCZ 300 mg/day, respectively. After treatment failure, the first case was changed to voriconazole, then brand-name-ITCZ 300 mg/day, and the second case to the brand-name-ITCZ 300 mg/day, with successful clinical course. Plasma concentrations of ITCZ can differ significantly depending on the patient or type of ITCZ. The ITCZ-plasma concentration should be controlled after changing from a brand-name-ITCZ to a generic ITCZ.

Emergence of fluoroquinolone-resistant Streptococcus pyogenes in Japan by a point mutation leading to a new amino acid substitution.

OBJECTIVES: Streptococcus pyogenes causes various diseases in humans. While the prevalence of fluoroquinolone-resistant S. pyogenes isolates has been increasing since 2000 in the USA and Europe, it has remained very low in Japan. We isolated a fluoroquinolone-resistant S. pyogenes strain and analysed its genetics. METHODS: TU-296, a strain of S. pyogenes resistant to levofloxacin (MIC 16 mg/L), was isolated from the throat of a patient in their thirties with pharyngitis in autumn 2007. We carried out susceptibility tests for various antimicrobial agents and PCR analysis of the genes gyrA, gyrB, parC and parE in the quinolone resistance-determining region, followed by sequencing of the PCR products to find mutation(s) and the resulting amino acid substitution(s). We then sequenced the PCR product of the emm gene and determined the emm genotype. RESULTS: S. pyogenes TU-296 was found to have the following mutations and amino acid substitutions: adenine 476 to cytosine in gyrA and cytosine 367 to thymine in parC, resulting in Glu-85→Ala in GyrA and Ser-79→Phe in ParC. The genotype of the isolate was emm11. CONCLUSIONS: Amino acid substitutions in fluoroquinolone-resistant S. pyogenes have already been reported from Europe and the USA, including Ser-81→Phe or Tyr and Met-99→Leu in GyrA, as well as Ser-79→Phe, Tyr or Ala and others in ParC. Numerous point mutations were found in parC and parE of S. pyogenes TU-296. In addition, a new amino acid substitution was detected (Glu-85→Ala in GyrA). To our knowledge, there have been no previous reports of this substitution in a clinical isolate of S. pyogenes.

High prevalence of extended-spectrum ß-lactamases and qnr determinants in Citrobacter species from Japan: dissemination of CTX-M-2.

OBJECTIVES: Extended-spectrum ß-lactamases (ESBLs) have become a problem among AmpC-producing Enterobacteriaceae and the emergence of concomitant quinolone resistance in ß-lactamase-producing isolates poses a global threat. In this study we investigated the prevalence and regional variation of ESBLs in Japanese clinical isolates of Citrobacter spp. and analysed plasmid-mediated quinolone resistance (PMQR) determinants in ESBL-producing Citrobacter spp. METHODS: A total of 348 clinical isolates of Citrobacter spp. collected throughout Japan were studied. Screening and the boronic acid disc test were performed to detect ESBLs in Citrobacter spp. with chromosomal AmpC ß-lactamases. PCR and sequencing were done to identify ESBL and PMQR genes. For ESBL-producing Citrobacter spp., PFGE was performed using the SfiI restriction enzyme. RESULTS: The number of ESBL-producing isolates confirmed phenotypically was 67 (19.3%). The prevalence of ESBL-producing Citrobacter koseri was significantly higher (32.1%) than that of ESBL-producing Citrobacter freundii (4.6%) (P < 0.01). Moreover, the prevalence of ESBLs was notably higher among C. koseri from southern Japan (60.0%). CTX-M-2 was predominant in C. koseri. Of the ESBL-producing C. koseri analysed, 23.2% possessed PMQR determinants, and there was a significant association between qnrB4 and bla(SHV-12). The 57 ESBL-producing Citrobacter spp. possessing bla(CTX-M), bla(SHV) or bla(TEM) were divided into 18 unique PFGE types. CONCLUSIONS: This is the first report about the prevalence of PMQR determinants among ESBL-producing Citrobacter spp. from Japan. Our data suggest that ESBLs and PMQR determinants are spreading among C. koseri in Japan.

Trends in antimicrobial susceptibility of Streptococcus pneumoniae in the Tohoku district of Japan: a longitudinal analysis from 1998 to 2007.

Streptococcus pneumoniae is a common cause of respiratory tract infections (RTIs). The prevalence of Streptococcus pneumoniae strains with reduced susceptibility to antimicrobial agents has dramatically increased worldwide. Susceptibility to nine antimicrobial agents and serotypes were determined among 1,644 Streptococcus pneumoniae strains isolated from patients with RTIs in the Tohoku district of Japan from October to December every year from 1998 to 2007. The prevalence of penicillin G-nonsusceptible Streptococcus pneumoniae (PNSP) strains increased gradually from 48.5% in 1998, reached a statistical peak in 2004 (65.1%) and then decreased to 51.5% in 2007. Streptococcus pneumoniae strains with each serotype 3, 6, 19 and 23 were constantly detected, and the distribution of these serotypes in PNSP strains did not significantly change during the study period. A trend of Streptococcus pneumoniae strains nonsusceptible to other beta-lactams tested was similar to that of PNSP strains, except for cefditoren, to which the resistance rate was < 20% throughout the analysis period. The prevalence of strains nonsusceptible to erythromycin and minocycline were consistently > 60%. Almost all penicillin G-resistant Streptococcus pneumoniae (PRSP) strains were resistant to both erythromycin and minocycline throughout the analysis period. The prevalence of strains resistant to fluoroquinolones tested were < 3% over the study period. Our longitudinal surveillance demonstrated for the first time that decreased prevalence of both beta-lactam- and multidrug-resistant strains has been occurring since 2004 in a region of Japan. Careful monitoring of antimicrobial susceptibility of Streptococcus pneumoniae should be continued.

[Successful reintroduction of mesylate imatinib after pneumonitis in two patients with gastrointestinal stromal tumor (GIST)].

We report 2 cases of successful reintroduction of mesylate imatinib for gastrointestinal stromal tumor (GIST) after drug-induced pneumonitis. Both of them were women in the fifth decade who had been medicated by mesylate imatinib about for 5 months previously, and had been given a diagnosis of imatinib mesylate-induced pneumonitis. After only cessation of that drug, symptoms and shadows on chest X-ray film improved. However, we had to reintroduce the drug because of the growth of primary tumor, so we gave half the previous dose of imatinib mesylate, with low dose prednisone. There has been no recurrence of drug related pneumonitis and effective control of the primary tumor was obtained. The evidence acquired from our cases suggests that it may be possible to reintroduce imatinib mesylate carefully by adjusting the dose with low dose prednisone in a GIST patient, without causing recurrence of drug-induced pneumonitis.

[Results of a survey of community-acquired-pneumonia and evaluation of old and new Japanese Respiratory Society guidelines].

We evaluated the usefulness of domestic and foreign guidelines for the diagnosis and treatment of patients with community-acquired-pneumonia at 23 institutions in 6 prefectures of the Tohoku Area, from December 2003 to November 2004. Based on the old and new Japanese Respiratory Society (JRS) guidelines, we evaluated severity, clinical efficacy and detection of atypical pneumonia. As for severity, the old guidelines led to the diagnosis of an excessive number of 'severe' cases. On the other hand, patients were appropriately diagnosed as having mild, moderate, severe, or very severe disease based on the new JRS guidelines (2005). The severity classification often correlated with the Pneumonia Severity Index (PSI) of the IDSA guidelines. The efficacy rate for patients who were prescribed the recommended drug according to the old JRS guidelines was 85.7% and for those who did not use the recommended drug it was 68.7% (p < 0.001).

Neutrophil survival-enhancing activity in sputum from patients with diffuse panbronchiolitis.

Diffuse panbronchiolitis (DPB) is a life-threatening airway disease in which neutrophils persistently and massively emigrating to the airways cause progressive and irreversible tissue damage. However, the pathogenesis of the airway inflammation remains unclear. The failure of non-inflammatory removal of emigrating neutrophils due to delayed apoptosis has been proposed as a mechanism by which the neutrophilic inflammation persists. Therefore, we aimed to investigate whether an activity that delays neutrophil apoptosis is present at the inflamed sites in DPB. Neutrophils isolated from normal volunteers were cultured with sputum extracts of patients with DPB, and viability and apoptosis of neutrophil was evaluated for the culture period. Neutrophils cultured with sputum extracts for 2 and 3 days showed significantly enhanced survival compared to those with medium alone. The neutrophil survival-enhancing activity in sputum extracts was heat-labile and partially, but significantly, neutralized with anti-human GM-CSF, but not with anti-human G-CSF antibody. The enhancement of neutrophil survival was associated with an inhibition of apoptosis demonstrated by cytology, TUNEL assay and DNA fragmentation analysis. These results suggest that neutrophil apoptosis is prevented by survival-enhancing factors including GM-CSF in the airways of DPB, leading to neutrophil death by necrosis that causes further recruitment and activation of neutrophils.

The increase in surface CXCR4 expression on lung extravascular neutrophils and its effects on neutrophils during endotoxin-induced lung injury.

Inflammatory stimuli, such as a microbes or lipopolysaccharides, induce a rapid release of neutrophils from the bone marrow and promote neutrophil migration into inflamed sites to promote host defense. However, an excess accumulation and retention of neutrophils in inflamed tissue can cause severe tissue injuries in the later stages of inflammation. Recent studies have reported that both CXCL12 levels in injured lungs and its receptor, CXCR4, on accumulated neutrophils in injured lungs, increased; furthermore, these studies showed that the CXCL12/CXCR4 signaling pathway participated in neutrophil accumulation in the later stages of lipopolysaccharide (LPS)-induced lung injury. However, the mechanisms underlying this increase in surface CXCR4 expression in neutrophils remain unclear. In this study, we found that surface CXCR4 expression increased in extravascular, but not intravascular, neutrophils in the lungs of LPS-induced lung injury model mice. Furthermore, ex vivo studies revealed that CXCL12 acted not only as a chemoattractant, but also as a suppressor of cell death for the lung neutrophils expressing CXCR4. Sulfatide, one of the native ligands for L-selectin, induced the increase of surface CXCR4 expression on isolated circulating neutrophils, suggesting that the activation of L-selectin may be involved in the increase in surface CXCR4. Our findings show that surface CXCR4 levels on neutrophils increase after extravasation into injured lungs, possibly through the activation of L-selectin. The CXCL12/CXCR4 signaling pathway plays an important role in the modulation of neutrophil activity during acute lung injury, not only by promoting chemotaxis but also by suppressing cell death.

Prolongation of neutrophil survival by the culture supernatant of Pseudomonas aeruginosa.

BACKGROUND AND OBJECTIVES: The pathogenesis of airway inflammation in diffuse panbronchiolitis (DPB) is unknown. Neutrophil survival-enhancing activity, partially mediated by granulocyte-macrophage colony-stimulating factor (GM-CSF), has been shown in the sputum from DPB patients. This study investigated the mechanisms of GM-CSF expression in the airways of DPB patients. This involved examining the effects of mucoid Pseudomonas aeruginosa strains derived from chronically colonized patients with DPB on neutrophil survival and GM-CSF expression. METHODS: Neutrophils from healthy subjects were cultured with the culture supernatants of P. aeruginosa isolated from sputum of DPB patients in the presence or absence of anti-GM-CSF and anti-GM-CSF receptor (alpha chain) antibodies, and viable neutrophils were counted daily. GM-CSF gene expression in neutrophils was evaluated by RT-PCR. RESULTS: Neutrophils cultured with the culture supernatants showed significantly prolonged survival, compared with neutrophils cultured with the control broth. The neutrophil survival-enhancing activity in the culture supernatants was lost by heating. The enhanced survival of neutrophils was abolished in the presence of anti-GM-CSF and anti-GM-CSF receptor (alpha chain) antibodies. GM-CSF mRNA was detected in neutrophils cultured with the bacterial supernatants, but not in those with the control broth. CONCLUSION: P. aeruginosa-derived factors (rich in proteins) stimulated neutrophils to synthesize GM-CSF, which enhanced neutrophil survival in an autocrine/paracrine fashion.