Chronic effects of an orally active selective endothelin-B-receptor antagonist in experimental congestive heart failure

Endothelin-B- (ETB) receptors located in vascular beds mainly mediate vasorelaxation, however, long-term treatment with a mixed ETA/ETB receptor antagonist has been shown to improve the survival rate of rats with heart failure in a similar way to ETA-receptor inhibitors. The inhibition of ETB-receptor-mediated action should therefore be beneficial in preventing the deterioration seen in heart failure, despite various adverse hemodynamic effects. We administered K-8794 (Kowa Co. Ltd, Japan, 2mg/kg/day, n = 6), an orally active selective ETB-receptor antagonist, to dogs with heart failure induced by rapid right ventricular pacing for 14 days, commencing 8 days after pacing. Control dogs were given a placebo (n = 6). Mean arterial pressure decreased and systemic vascular resistance increased in both groups at the end of the protocol. In the K-8794 group, however, those values were higher than in the control group. Cardiac output decreased in both groups, but there were no significant differences observed between the two groups. Plasma renin activity and aldosterone increased in both groups at the end of the protocol, however levels in the K-8794 group were significantly lower than those in the control group. In the K-8794 group, it was quite interesting to note that Na excretion and urine flow rate were higher than in the control group. Our findings thus suggest that, although ETB-receptor antagonism produces some hemodynamic disadvantages, it can successfully prevent body fluid retention through the suppression the activation the renin-angiotensin-aldosterone system in dogs with heart failure.

High levels of plasma brain natriuretic peptide and interleukin-6 after optimized treatment for heart failure are independent risk factors for morbidity and mortality in patients with congestive heart failure

OBJECTIVES

The aim of this study was to evaluate whether repetitive measurements of plasma levels of neurohumoral factors and cytokines before and after additional treatment are useful for predicting mortality in patients with congestive heart failure (CHF).

BACKGROUND

Neurohumoral and immune activation play an important role in the pathophysiology of CHF. However, the effects of serial changes in these factors on the prognostic value remain unknown.

METHODS

We measured plasma levels of neurohumoral factors and cytokines and left ventricular ejection fraction (LVEF) before and three months after optimized treatment for CHF in 102 consecutive patients with severe CHF (New York Heart Association class III to IV) on admission to our hospital. Physicians who were blind to the plasma neurohumoral factors until study completion treated patients using standard drugs. Patients were monitored for a mean follow-up period of 807 days.

RESULTS

Plasma levels of neurohumoral factors, cytokines and LVEF were significantly improved three months after optimized treatment. Cardiac death occurred in 26 patients. Among 19 variables including LVEF, only a high level of brain natriuretic peptide (BNP) and interleukin-6 (IL-6) at three months after optimized treatment showed significant independent relationships by Cox proportional hazard analysis with a high mortality for patients with CHF.

CONCLUSIONS

These findings indicate that high plasma BNP and IL-6 levels three months after optimized treatment are independent risk factors for mortality in patients with CHF, suggesting that sustained high plasma levels of BNP and IL-6 after additional standard treatment were independent risk factors for mortality in patients with CHF despite improvements in LVEF and symptoms.

Spironolactone inhibits the transcardiac extraction of aldosterone in patients with congestive heart failure

OBJECTIVES

The study evaluated the transcardiac extraction or spillover of aldosterone (ALDO) in normal subjects and in patients with congestive heart failure (CHF).

BACKGROUND

Aldosterone promotes collagen synthesis and structural remodeling of target organs such as the heart. Spironolactone, an ALDO receptor antagonist, has recently been reported to reduce the mortality of patients with CHF; however, the effects of spironolactone on the transcardiac gradient of ALDO have not been clarified.

METHODS

We measured plasma ALDO in the aortic root (AO) and coronary sinus (CS) in normal subjects and 113 consecutive CHF patients and also measured plasma procollagen type III aminoterminal peptide (PIIINP) in CS, a biochemical marker of myocardial fibrosis.

RESULTS

Plasma ALDO was significantly lower in the CS than in the AO in normal subjects (n = 15; 61.2 +/- 9.3 vs. 83.1 +/- 11.8 pg/ml, p < 0.0001). In 96 CHF patients who did not receive spironolactone, plasma ALDO was significantly lower in the CS than in the AO (59.3 +/- 3.9 vs. 73.8 +/- 4.9 pg/ml, p < 0.0001). In contrast to the difference in these 96 patients, there was no significant difference in ALDO between the AO and CS in 17 patients who received spironolactone (127.4 +/- 20 vs. 124.0 +/- 19 pg/ml, p = 0.50). Stepwise multivariate analyses showed that spironolactone therapy had an independent and significant negative relationship with the transcardiac gradient of plasma ALDO in patients with CHF. In addition, significant positive correlations were seen between the transcardiac gradient of plasma ALDO and PIIINP (r = 0.565, p < 0.0001) and the left ventricular end-diastolic volume index (r = 0.484, p < 0.0001).

CONCLUSIONS

These results indicate that plasma ALDO is extracted through the heart in normal subjects and in CHF patients who do not receive spironolactone and that spironolactone inhibits the transcardiac extraction of ALDO in CHF patients, suggesting that spironolactone blocks the effects of ALDO on the failing heart in patients with CHF.

[A case with esophageal carcinoma associated with metastatic pulmonary tumor in lung cancer at seven years after the resection of lung cancer]

A 69-year-old woman was admitted to our hospital because of dysphasia. The upper G-I examination showed a stenosis at the middle thoracic esophagus and poorly differentiated adenocarcinoma was revealed histologically. Chest CT scan showed a mass shadow in the right upper lobe of the lung. She had undergone a partial resection of right upper lobe because of lung cancer seven years before. She was diagnosed as metachrous double carcinoma of the lung and the esophagus. The method of surgery included right upper lobectomy of the lung, esophagectomy and intrathoracic esophageal reconstruction using the gastric tube. The patient manifested pneumonia due to the failure of the sutures after the surgery and died on the twentieth postoperative day. When conducting simultaneous resection of both cancer and esophageal reconstruction for the double cancer of the lung and the esophagus, it was considered necessary to conduct the anastomosis outside the thoracic cavity for the purpose of preventing the pulmonary complication due to the failure of the sutures.

Transcardiac extraction of circulating endothelin-1 across the failing heart

To determine the transcardiac gradient of plasma endothelin-1 (ET-1) in patients with congestive heart failure (CHF), we measured plasma levels of ET-1 in both the aortic root and the coronary sinus in 14 normal subjects and 79 consecutive patients with CHF. In normal subjects, plasma ET-1 was significantly higher in the coronary sinus than in the aortic root; these findings were also shown in patients with mild CHF, suggesting that there was ET-1 spillover across the heart. In contrast, plasma ET-1 was significantly lower in the coronary sinus than in the aortic root in patients with severe CHF, suggesting there was ET-1 extraction across the heart in patients with severe CHF. The transcardiac gradient of plasma ET-1 was correlated with the left ventricular end-diastolic volume index (r = 0.501, p <0.0001) and plasma level of procollagen type III amino terminal peptide in the coronary sinus (r = 0.54, p = 0.0008), a marker of myocardial fibrosis. Stepwise multivariate analysis showed that the transcardiac gradient of plasma ET-1 was an independent and significant relation with the left ventricular end-diastolic volume index in patients with CHF (r = 0.665, p <0.0001). These findings suggest that elevated circulating ET-1 is extracted across the failing heart with a significant correlation between the transcardiac gradient of plasma ET-1 and the left ventricular end-diastolic volume index, suggesting that ET receptors are upregulated in the failing ventricle and that the elevated circulating ET-1 might stimulate the process of left ventricular remodeling in patients with severe CHF.

Angiotensin II type 1 receptor antagonist decreases plasma levels of tumor necrosis factor alpha, interleukin-6 and soluble adhesion molecules in patients with chronic heart failure

OBJECTIVES

To evaluate the effects of an angiotensin (Ang II) type 1 receptor antagonist on immune markers in patients with congestive heart failure (CHF).

BACKGROUND

Ang II stimulates production of immune factors via the Ang II type 1 receptor in vitro, and the long-term effects of Ang II type 1 receptor antagonists on plasma markers of immune activation are unknown in patients with CHF.

METHODS

Twenty-three patients with mild to moderate CHF with left ventricular dysfunction were randomly divided into two groups: treatment with Ang II type 1 receptor (candesartan cilexetil) (n = 14) or placebo (n = 9). We measured plasma levels of immune factors such as tumor necrosis factor alpha (TNFalpha), interleukin-6 (IL-6), soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1). We also measured plasma levels of the neurohumoral factors such as atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) and cyclic guanosine monophosphate (cGMP), a biological marker of ANP and BNP.

RESULTS

Plasma levels of TNFalpha, IL-6, sICAM-1 and sVCAM-1 were increased in the 23 CHF patients compared with normal subjects and significantly decreased after 14 weeks of candesartan cilexetil treatment, but did not change in the placebo group. Plasma levels of BNP, which is a marker of ventricular injury, significantly decreased, and the molar ratio of plasma cGMP to cardiac natriuretic peptides (ANP + BNP) was significantly increased after candesartan cilexetil treatment, but did not change in the placebo group.

CONCLUSIONS

These findings suggest that 14 weeks of treatment with an Ang II type 1 receptor antagonist (candesartan cilexetil) decreased plasma levels of the immune markers such as TNFalpha, IL-6, sICAM-1 and sVCAM-1 and that it improved the biological compensatory action of endogenous cardiac natriuretic peptides in patients with mild to moderate CHF.

Plasma brain natriuretic peptide level as a biochemical marker of morbidity and mortality in patients with asymptomatic or minimally symptomatic left ventricular dysfunction. Comparison with plasma angiotensin II and endothelin-1

AIMS

To evaluate the level of plasma brain natriuretic peptide as a predictor of morbidity and mortality in patients with asymptomatic or minimally symptomatic left ventricular dysfunction.

METHODS

We measured plasma levels of atrial natriuretic peptide, brain natriuretic peptide, norepinephrine, angiotensin II, and endothelin-1 and monitored haemodynamic parameters in 290 consecutive patients with asymptomatic or minimally and newly symptomatic left ventricular dysfunction (functional classes I-II, mean left ventricular ejection fraction=37%). All patients were followed up for a median period of 812 days. The Cox proportional hazards model was used to assess the association of variables with mortality and morbidity.

RESULTS

At the end of the follow-up, 24 patients had suffered cardiac death and 25 had been hospitalized for worsening heart failure during the follow-up period. Among 21 variables such as clinical characteristics, treatment, haemodynamics, and neurohumoral factors, high levels of plasma brain natriuretic peptide (P<0.0001), norepinephrine (P=0.042), left ventricular end-diastolic volume index (P=0.0035), and left ventricular end-diastolic pressure (P=0.033) were shown to be independent predictors of mortality and morbidity by stepwise multivariate analysis. Moreover, only a high level of plasma brain natriuretic peptide (P<0.0001) was shown to be an independent predictor of mortality in these patients.

CONCLUSIONS

These results indicate that a high plasma brain natriuretic peptide level provides information about mortality and morbidity in patients with asymptomatic or minimally symptomatic left ventricular dysfunction.

Adrenocortical insufficiency associated with long-term high-dose fosfestrol therapy for prostatic carcinoma

A 59-year-old man was admitted to our hospital because of muscular pain, weakness, and anorexia. He had been treated with 600 mg/day of fosfestrol, a synthetic estrogen, for 10 years for prostatic carcinoma. Endocrinological studies demonstrated adrenocortical insufficiency due to inadequate ACTH secretion. After initiation of glucocorticoid replacement therapy, his symptoms subsided rapidly. To our knowledge, an association between estrogenic agents, including fosfestrol, and secondary adrenocortical insufficiency has not been previously reported. Physicians who treat patients with long-term and high-dose strong estrogenic agents should be cautious about the possible emergence of secondary adrenocortical insufficiency.

Elevation of metallothionein level in preneoplastic lesions during chemical hepatocarcinogenesis of the Fischer 344 rat

Metallothionein (MT) is inducible by various stimuli such as metals and physiological stress. Although elevated MT expression in certain type of tumors has been reported, there are few data available on the roles of MT in tumor formation. In this study, we immunohistochemically examined MT expression in gluthathione S-transferase placental type p (GST-P)-positive preneoplastic liver lesions induced by a chemical carcinogen and further examined the relationship between MT expression and the proliferative activity of the preneoplastic cells, using bromodeoxyuridine (BrdU) labeling indices. Eleven male Fischer rats (F344/DuCrj, 9 weeks old) were subjected to the Solt-Farber protocol. Thereafter, the livers were removed, frozen and sectioned serially for immunohistochemical staining of MT and GST-P. Eight rats were given six injections of BrdU before sacrifice. In 92.8% of GST-P positive lesions, high MT staining intensity was demonstrated. On the other hand, there was no correlation between the intensity of MT staining and the BrdU labeling indices of the preneoplastic lesions. Our results indicate that MT is a useful positive marker for preneoplastic liver lesions, though the reason why MT is expressed in the preneoplastic and neoplastic lesions remains to be elucidated.

Effects of a specific endothelin-converting enzyme inhibitor on cardiac, renal, and neurohumoral functions in congestive heart failure: comparison of effects with those of endothelin A receptor antagonism

BACKGROUND--Endothelin (ET)-1 is generated from big ET-1 by endothelin-converting enzyme (ECE). Plasma big ET-1 and ET-1 levels are strongly related to survival in patents with congestive heart failure (CHF). Because selective enzymatic processing of ET-1 formation appears to be an important therapeutic target for CHF, we investigated the acute effects of a specific ECE inhibitor on cardiorenal and endocrine functions in CHF compared with those of a selective ETA receptor antagonist. METHODS AND RESULTS--CHF was induced in beagle dogs by rapid right ventricular pacing (270 bpm, 14 days). Two incremental doses of a specific ECE inhibitor, FR901533, or a selective ETA receptor antagonist, FR139317 (1 and 3 mg/kg, n=8, respectively), were injected into dogs with CHF. FR901533 and FR139317 decreased mean arterial pressure and pulmonary capillary wedge pressure associated with reduction in systemic and pulmonary vascular resistance. These agents increased cardiac output but did not affect left ventricular fractional shortening. FR139317 exerted a greater depressor effect on mean arterial pressure than FR901533 (P<0.05). These agents decreased plasma atrial natriuretic peptide levels, but only FR901533 decreased plasma renin activity, angiotensin II, and aldosterone levels. Neither agent changed the plasma norepinephrine level despite the fall in blood pressure. These drugs increased the urinary water and sodium excretion rate associated with increases in the glomerular filtration rate and renal plasma flow, and the incremental magnitude induced by FR139317 was larger than that by FR901533 (P<0.05). CONCLUSIONS--An ETA receptor antagonist appeared to induce greater vasodilative effects on systemic and renal vasculature in CHF than an ECE inhibitor. However, the ECE inhibitor reduced the secretion of neurohumoral factors that are activated in proportion to the severity of CHF. Our acute complementary data may support the importance of the role of ECE in CHF and provide a rationale foundation for investigating the usefulness of long-term treatment with ECE inhibitors in CHF.

Relationship between endothelin-1 extraction in the peripheral circulation and systemic vascular resistance in patients with severe congestive heart failure

OBJECTIVES

This study was done to determine the spillover and extraction of endothelin-1 (ET-1) in the peripheral circulation, and to evaluate the factors that regulate local ET-1 extraction in the peripheral circulation in patients with congestive heart failure (CHF).

BACKGROUND

The relationship between the spillover and extraction of the ET-1 in the peripheral circulation and systemic vascular resistance (SVR) has not been fully clarified.

METHODS

We measured plasma levels of ET-1 both in femoral artery (FA) and femoral vein (FV) in 93 patients with CHF.

RESULTS

Plasma ET-1 was significantly higher in FV than in FA in New York Heart Association (NYHA) functional class II patients, but there was no difference of ET-1 between FA and FV in functional class III patients. In patients with functional class IV, plasma ET-1 was significantly lower in FV than in FA, and SVR was significantly higher than in patients with NYHA class II or class III. Moreover, a significant positive correlation existed between plasma ET-1 extraction across the lower leg and SVR in these patients. Among the various neurohumoral factors and hemodynamics, plasma levels of ET-1, angiotensin II in the FA showed an independent and significant relationship with the plasma arteriovenous difference of ET-1 in the lower limb.

CONCLUSIONS

Circulating ET-1 is extracted in peripheral circulation in patients with severe CHF, suggesting the possibility of upregulation of ET receptors of vascular beds in the lower limb in these patients. The peripheral extraction of ET-1 correlates with SVR in severe CHF patients and is mainly regulated by the local ET-1 and renin angiotensin systems.

[Effect of clarithromycin treatment of natural killer cell activity in patients with advanced non-small cell lung cancer]

The treatment of a 14-membered ring macrolide, clarithromycin (CAM), prolongs the survival time of patients with unresectable nonsmall cell lung cancer, and improves the host factor. As we previously reported, one of the underlying mechanisms is that the treatment of CAM increases the bioactivity of interleukin-12 (IL-12). In the present study, we administered CAM to murine lung cancer treatment models with Lewis lung carcinoma and to 18 patients with unresectable non-small lung cancer whose anticancer treatment had been terminated. The timing of CAM administration was examined and the time course of NK activity was measured. In the murine lung cancer treatment models, administration of CAM 7 days after anticancer chemotherapy more strongly inhibited the tumor growth and more rapidly and significantly increased NK activity, compared to the concomitant use of CAM with an anticancer chemotherapy. In humans, the NK activity which had decreased after anticancer treatment, tended to be increased after one month of treatment with CAM (p = 0.06). One month of treatment with CAM significantly increased the NK activity (p < 0.05) of the following subjects: patients with stage III in the clinical stages, patients with squamous cell carcinoma, patients who had received radiotherapy alone as pretreatment therapy, and patients whose pretreatment therapy effect was partial response (PR). We conjectured that increasing NK activity was one of the underlying mechanisms of the macrobiotic effect of CAM. CAM was especially effective for patients in the early clinical stages and patients who responded well to pretreatment therapy. Murine lung cancer models showed that non-concomitant use of CAM with anticancer chemotherapy was more effective.

[Clinical evaluation of lung abscess diagnosed by transtracheal aspiration]

We have diagnosed lung abscess according to findings of infiltration with cavity formation on chest X-ray and/or CT-scan and pathogens isolated from transtracheal aspirates. We evaluated the clinical features of 20 patients with lung abscess (18 males and 2 females, mean age; 54.3 years). Diabetus mellitus and periodontal diseases were prominent underlying diseases in patients with lung abscess. Cough was complained in 13 patients, chest or back pain in 9, purulent sputum in 8 and hemosputum in 5 when the patients admitted to our hospital. A temperature higher than 38 degrees C was present in 12 patients but temperature les than 37 degrees C in 2. Multiple microorganisms were cultured from TTA in 15 patients. A mean of 2.7 bacterial species per patient was isolated, aerobes alone being isolated in 2 patients, anaerobes alone in 3, and mixed aerobic and anaerobic isolates in 10. Seventeen strains of aerobes and 35 of anaerobes were isolated. Major pathogens were Streptococcus pneumoniae, Streptococcus intermedius and other in aerobes, and Peptostreptococcus micros, Fusobacterium necrophorum, Prevotella melaninogenica and others in anaerobes. Abnormality of chest X-ray was located on the right upper lobe in 6 patients, the right lower lobe in 6, the left upper lobe in 6, the left lower lobe in 4 and the right middle lobe in 1. All patients were cured only by treatment of antimicrobial agents, but cavity formation on chest X-ray remained in 4 patients after the treatment.

[A clinical study of respiratory infection isolating non-pathogenic Neisseria by transtracheal aspiration]

Neisseria species other than N. meningitidis and N. gonorrhoeae are generally regarded as commensal bacterial flora of the oropharynx, and little is known regarding cases of these non-pathogenic Neisseria species in the lower respiratory tract. We clinically examined respiratory tract infections from which non-pathogenic Neisseria species were isolated by transtracheal aspiration (TTA). The incidence of non-pathogenic Neisseria isolated was 54 (15.7%) out of 344 episodes of respiratory tract infections with isolated microorganisms from TTA, and was 17.6%, 15.8%, 14.3% for pneumonia, acute bronchitis, and chronic lower respiratory tract infection, respectively. All 54 episodes were isolated with other microorganisms such as alpha-Streptococcus spp. (75.9%), Haemophilus influenzae (25.9%) and anaerobics (22.2%). The isolation ratio according to the age group increased at 45 years of age or more, but did not increase with the advance of age. Predisposing factors were identified such as overt aspiration, iatrogenic procedure and heavy smoking. Cases without overt aspiration that had fevers of 38 degrees C or more or hypoxemia of less than PaO2 70 torr when detecting non-pathogenic Neisseria were observed more frequently in the aged than the non-aged. The findings suggest the detection of non-pathogenic Neisseria by TTA is influenced by the host state that the fall of microorganisms from the upper to lower respiratory tract cannot be defended or excluded by mucociliary transportation disorder due to underlying disease and smoking, or deterioration of physical status other than overt or silent aspiration.

Apoptosis in the lens anlage of the heritable lens aplastic mouse (lap mouse)

Adult homozygous lap mice show various eye abnormalities, such as aphakia, retinal disorganization, and dysplasia of the cornea and anterior chamber. In the fetal eye of a homozygous lap mouse, the lens placode seems to develop normally. However, the lens vesicle progresses abnormally to form a mass of cells without a cavity, and the mass vanishes soon afterward. We examined cell death in the lens anlage of this mutant. The lens anlagen of homozygous lap and normal mice from days 10 to 12 of gestation were observed by light microscopy after DNA end-labeling by immunohistochemistry and by transmission electron microscopy. By light microscopy, a slight frequency of cell death was detected in the lens anlage encircling the surface ectoderm and in the anlage or in the anlage of both homozygous lap mice and normal mice at day 10 of gestation. Cell death was seen in the lens anlage encircling the surface ectoderm in the normal mouse and sporadically in the anlage of the homozygous lap mouse at day 10.5 of gestation. Cell death was visible at the area of the lens vesicle attached to the surface ectoderm and encircling the surrounding surface ectoderm in the normal mouse, and in the lens anlage encircling the surface ectoderm and the apex areas of the lens anlage in the homozygous lap mouse at day 11 of gestation. At day 12 of gestation, almost no cell death was observed in the lens anlage of the normal mouse. However, extensive areas of cell death were still seen in the lens anlage at its apex, at the inner region, and encircling the surface ectoderm in the homozygous lap mouse. Electron microscopic observation showed that the dead cells observed in the lens anlagen by light microscopy in normal and lap mice are the result of apoptosis. In lap mice, cells with cytoplasmic condensation were observed mainly at days 10 and 10.5 of gestation. Many apoptotic bodies which had been phagocytosed by adjacent cells were seen predominantly at day 11 of gestation. At day 12 of gestation, apoptotic bodies phagocytosed by adjacent cells, which were seen at day 11, were still predominant, but there were more apoptotic bodies per cell and more digested apoptotic bodies than at day 11. These results indicate that cell death, resulting from apoptosis is involved in the disappearance of the lens anlage of lap mice.

[An epidemiological investigation for MRSA and PRSP in Kinki area. Kinki Infection Working Group]

Recent trends in the development of resistance of the Staphylococcus aureus and Streptococcus pneumoniae to antibiotics were investigated, using a questionnaire delivered to participants at a meeting of the Kinki District Society of Infections. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 55.4% of all isolated S. aureus, and more than 80% of MRSA was detected within hospitals. In outpatients, MRSA was often detected in pus, while in hospitalized patients, MRSA was often detected in sputum. Further, MRSA was accompanied by some other organisms (most frequently Pseudomonas aeruginosa) in 64.7% of MRSA positive patients. The sensitivity of MRSA to vancomycin (VCM) was 100%, to sulfamethoxazole-trimethoprim (ST) 99.2%, and to arbekacin, 98.6%. In contrast, Penicillin-resistant Streptococcus pneumoniae (PRSP) accounted for 42.4% of all isolates of Streptococcus pneumoniae. About 50% of PRSP was detected in out-patients. For both hospitalized patients and outpatients, PRSP was most frequently detected in sputum. PRSP was accompanied by some other organisms (most frequently Haemophilus influenzae) in 49.3% of PRSP positive patients, PRSP had high sensitivity to cephems, carbapenems and VCM.

[Clinical analysis of patients with sepsis--comparison between underlying diseases]

We evaluated the clinical data in 83 patients with sepsis, which was diagnosed by both Bone's definition of sepsis and positive isolates from blood culture, according to their underlying diseases. This study enrolled a total of 117 septic episodes in 83 patients (57 males and 26 females, mean age: 52.0 years). We classified 3 groups, including hematological malignancies (46 patients, 72 episodes), solid malignant tumors (23 patients, 25 episodes) and non-malignancies (14 patients, 20 episodes), by the underlying diseases. Of the total number of isolates from blood culture, 53.0% were single gram-positive bacteria, 33.3% were single gram-negative bacteria, 7.7% were single fungus and 6.0% were polymicrobial organisms. In addition, coagulase negative staphylococci was isolated most often in patients with hematological malignancies. Sepsis was often caused by infectious focuses of hemorrhoid, stomatitis or intravenous catheter in patients with hematological malignancies, by pneumonia in patients with solid malignant tumors and by urinary tract infection in patients with non-malignancies. Mortality of sepsis in patients with solid malignant tumors (48%) was highest in 3 groups. Septic patients, who were complicated with shock and/or DIC, has poor prognosis in all groups. Serum albumin level was significantly lower in dead patients than patients who survived. These results suggest that clinical features may be different according to the underlying diseases of patients with sepsis.

Chronic effects of a novel, orally active endothelin receptor antagonist, T-0201, in dogs with congestive heart failure

Endothelin (ET)-1 increases in plasma during congestive heart failure (CHF). Some ET antagonists improve hemodynamics, suggesting its potential benefits in the treatment of CHF. We examined the acute and chronic effects of a new ET receptor antagonist, T-0201 (Tanabe Seiyaku Co. Ltd., Japan), in CHF. To confirm the in vivo effects of T-0201, we observed the inhibitory effects of T-0201 (1-100 micrograms/kg) on the response of blood pressure to exogenously administered ET-1 (0.75 nmol/kg) in conscious normal dogs. Pretreatment with T-0201 significantly inhibited the ET-1-induced initial hypotension that is mediated by ETB receptors, and attenuated the subsequent hypertension, which is primarily mediated by ETA receptors. Thus, T-0201 at a dose of 100 micrograms/kg not only works as a potent ETA antagonist but also shows antagonist activity for ETB receptors in dogs. To evaluate the chronic therapeutic effects of T-0201, we administered T-0201 (0.3 mg/kg/day; n = 5) orally to dogs with CHF induced by rapid right ventricular pacing (22 days, 270 beats/min) for 15 days, beginning 8 days after pacing. T-0201 significantly prevented the deterioration of cardiorenal function during the development of CHF, expressed as a decrease in cardiac pressure and an increase in cardiac and urine output. These results suggest that chronic antagonism of both ET receptors prevents the progressive exacerbation of CHF.

Chronic liver injury promotes hepatocarcinogenesis of the LEC rat

The Long-Evans rat with a cinnamon-like color (LEC) is a mutant rat that spontaneously suffers from chronic liver injury and subsequent hepatocellular carcinoma (HCC) caused by abnormal copper accumulation in the liver. We attempted to elucidate the role of prolonged liver cell injury on LEC rat hepatocarcinogenesis using a copper-deficient diet (CuDD) to inhibit the occurrence of consequent liver injury. The animals were fed the CuDD from the age of 4 weeks until being killed at the age of 10 months. Diethylnitrosamine (DEN) was administered at the age of 8 weeks. Groups fed a basal diet (BD) with or without the administration of DEN were also assigned as control groups. The animals fed the BD manifested liver injury, while those fed the CuDD did not show liver dysfunction until death. The number and volume of glutathione S-transferase placental form (GST-P)-positive preneoplastic lesions in the liver, which were calculated from the data on two-dimensional planes, were examined to clarify the promotive effect of chronic liver injury on the development of HCC. Regarding the size of the lesions, which indicated the intensity of the promotive effect, the lesions in the livers of rats fed the BD with DEN were much larger than those of rats fed the CuDD with DEN. Feeding the LEC rats with CuDD completely suppressed the manifestation of liver injury, and it was clearly shown that prolonged liver injury had a promotive effect on the LEC rat hepatocarcinogenic process.

Interleukin-6 spillover in the peripheral circulation increases with the severity of heart failure, and the high plasma level of interleukin-6 is an important prognostic predictor in patients with congestive heart failure

OBJECTIVES

We 1) evaluated whether interleukin-6 (IL-6) is produced in the peripheral circulation in patients with congestive heart failure (CHF), 2) estimated the factors for increased IL-6, and 3) clarified the prognostic role of high plasma levels of IL-6 in patients with CHF.

BACKGROUND

Although plasma levels of IL-6 have been reported to increase in patients with CHF, and production of IL-6 in endothelial cells and vascular smooth muscle cells has been postulated from in vitro studies, the origin of the increase of IL-6 in CHF remains unknown. Moreover, the prognostic value of a high plasma level of IL-6, independent of classic neurohumoral factors, remains to be elucidated.

METHODS

A comparison was made of the plasma levels of IL-6 between the femoral artery and the femoral vein in 13 normal subjects and in 80 patients with CHF. In another study, we measured plasma IL-6 in 100 patients with CHF and follow-up data.

RESULTS

Plasma IL-6 levels increased significantly from the femoral artery to the femoral vein in normal subjects and in patients with CHF. Arteriovenous IL-6 spillover in the leg increased with the severity of CHF. Among the hemodynamic variables and the various neurohumoral factors, the plasma norepinephrine (NE) level showed an independent and significant positive relation with the plasma IL-6 level in patients with CHF. Moreover, treatment with beta-adrenergic blocking agents showed an independent and significant negative relation with plasma IL-6 levels. In 100 patients, plasma IL-6 (p < 0.0001), NE (p = 0.0004) and left ventricular ejection fraction (0.015) were significant independent prognostic predictors by Cox proportional hazards analysis.

CONCLUSIONS

Our findings indicate that the IL-6 spillover in the peripheral circulation increases with the severity of CHF and that the increase in plasma IL-6 is mainly associated with the activation of the sympathetic nervous system. High plasma levels of IL-6 can provide prognostic information in patients with CHF, independent of left ventricular ejection fraction and plasma NE, suggesting an important role for IL-6 in the pathophysiology of CHF.

[Campylobacter jejuni enteritis in three patients with HIV infection]

Gatrointestinal symptoms, which include diarrhea, are as common as respiratory symptoms in patients with HIV infection. Gastrointestinal symptoms may result from infections, neoplasma, HIV enteropathy or drug toxicity. Three HIV-infected patients admitted to our hospital complaining of diarrhea and fever. We confirmed their diagnosis as Campylobacter jejuni enteritis by bacteriological examination of their feces. All of them had eaten inadequately cooked meat in restaurants before the onset of their enteritis. Their symptoms immediately improved after the administration of antimicrobial agents. One strain of C. jejuni isolated in our cases, however, was resistant to ofloxacin. This case report suggests that we must counsel HIV-infected patients to avoid inadequately cooked food and observe resistant patterns of C. jejuni to antimicrobial agents in Japan in the future.

[Effect of cessation of erythromycin therapy on diffuse panbronchiolitis]

The effect of cessation of erythromycin (EM) therapy against diffuse panbronchiolitis was studied. Nine cases were examined. After cessation of EM therapy, the manifestations of disease were stable in five cases, but worsened in the other four. In the former five, the period from the onset of disease until EM therapy began was relatively short; when EM therapy was stopped the manifestations of disease had almost completely disappeared and chest roentgenography revealed resolution of diffuse, small, nodular opacities without remarkable bronchiectasis. In contrast, in the latter four cases, the clinical manifestations of disease did not disappear, and chest-roentgenographic evidence of bronchiectasis was common before the cessation of EM therapy. In conclusion, EM therapy for diffuse panbronchiolitis may be stopped if the clinical manifestations of disease (especially purulent sputum) disappear, if diffuse, nodular opacities resolve almost completely and if there is no evidence of bronchiectasis.

[A case of multiple muscular abscesses of the lower limbs by Staphylococcus aureus after chemotherapy for lung cancer]

A 67-year-old male was admitted to our hospital because of lung cancer and interstitial pneumonia. Cisplatin, vindesie and mitomycin C were administered for treatment of lung cancer. The leucocyte-counts declined to 1700/microliter on the eighth day after the chemotherapy. Though granulocyte colony-stimulating factor was administered, pain in the right thigh and high grade fever developed. Because Staphylococcus aureus was isolated from the blood specimen, piperacillin was administered. But the high grade fever continued and the pain was expanded to the right hip, left hip, thigh and leg. Because a computed tomograph of the lower limbs showed low density areas in bilateral gluteus maximus muscle right adductor magnus muscle, left biceps femoris muscle and left soleus muscle and the culture of an aspirate from abscess of right leg detected S. aureus, multiple muscular abscesses of the lower limbs was confirmed. We changed the antibiotics from PIPC to imipenem/cilastatin and minocycline on nineteenth day after the chemotherapy. His symptoms improved after the change of antibacterial agents. But he died of acute exacerbation of interstitial pneumonia, after about two months of the chemotherapy. Muscular abscesses of the limbs are very rare in Japan. Only four cases with muscular abscess of the limbs were reported in Japan, since 1988. This case suggests that a muscular abscess must be considered in the differential diagnosis of fever in patients with neutropenia.

Significant survival benefit to patients with advanced non-small-cell lung cancer from treatment with clarithromycin

We carried out a randomized study of 49 consecutive patients with unresectable primary lung cancer to determine whether clarithromycin (CAM), a 14-membered ring macrolide, can improve outcome. A total of 49 patients (42 patients with non-small-cell lung cancer and 7 patients with small-cell lung cancer) had received prior chemotherapy, radiotherapy or both during their hospital stay. They were randomly allocated into two study groups on the first visit after discharge: 25 patients (22 patients with non-small-cell lung cancer, 3 patients with small-cell lung cancer) were assigned to receive CAM (400 mg/day, orally), and 24 patients (20 patients with non-small-cell lung cancer, 4 patients with small-cell lung cancer) did not receive CAM. CAM treatment after randomization was open and the treatment was to be continued as long as the patients could tolerate CAM. There was no significant difference in the median survival time for small-cell lung cancer between the CAM group and the non-CAM group. However, CAM treatment significantly increased the median survival time for non-small-cell lung cancer patients, the median survival for the CAM group was 535 days and that for the non-CAM group was 277 days. Analyses of prognostic factors showed that only treatment with CAM was predictive of longer survival for non-small-cell lung cancer, and other tested covariates had no effects on the prognosis. There were no remarkable side effects observed in the CAM group throughout treatment. We conclude that long-term treatment using CAM is beneficial for unresectable non-small-cell lung cancer patients and that it can increase the median survival of patients with advanced disease.

[Prognostic analysis of sepsis in patients with lung cancer]

Sepsis is one of the most serious infections occurring in patients with lung cancer. Thus, we determined what is most predisposing factor in prognosis of sepsis in lung cancer patients; the type of causative bacteria, neutropenia or host nutritional status. A total of 27 lung cancer patients with sepsis, which consisted of 23 males and 4 females (mean age 70.7 +/- 6.6), were included in this study. The study was conducted from 1991 to 1995. All subjects were classified into the survival group and the dead group. Staphylococcus aureus or Esherichia coli most frequently isolated from the blood of the patients in the survival group, while either E. coli alone or multiple organisms were predominant in the dead group. Neutropenia did not affect the outcome of sepsis in lung cancer patients. In contrast nutritional status, as determined by serum albumin levels, was closely related to the mortality in septic lung cancer patients. These results predict that the prognosis of sepsis is dependent on nutritional status of lung cancer patients.

[The evaluation of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) level in peripheral blood of patients with chronic lower respiratory tract infection]

In the present study, we assessed the serum level of IL-6 and TNF-alpha by ELISA in patients with chronic lower respiratory tract infection. The serum levels of IL-6 and TNF-alpha of patients in acute exacerbation phase are higher than that of in stable phase. We also classified patients in acute exacerbation phase into two groups according to the microorganism of persistent infection. The serum level of IL-6 and TNF-alpha in the patients with persistent infection with Pseudomonas aeruginosa were higher than that with Haemophilus influenzae. Moreover, the serum level of IL-6 and TNF-alpha were found to be related with malnutrition which assessed by clinical indices such as the serum level of albumin and cholinesterase. The present result suggests that IL-6 and TNF-alpha may have relationship with not only inflammation in airway but also indices of nutrition in patients with chronic lower respiratory tract infection.

[Analysis of prognosis of bronchopulmonary infectious disease with lung cancer]

Bronchopulmonary infection affects the prognosis of lung cancer patients. Thus, we investigated the relationship between the prognosis of bronchopulmonary infectious diseases and their causative bacteria isolated by transtracheal aspiration (TTA) in lung cancer patients. In the present study, we determined which factor is more predisposing for the outcome of bronchopulmonary infections, the type of causative bacteria or the host nutritional status. A total of 107 lung cancer patients, which consisted of 105 males and 5 females (mean age 67.3 +/- 8.0), were included in this study. The study was conducted from 1981 to 1994. They were classified into the survival group and the deceased group. Causative agents of infection were compared between these 2 groups. S. pneumoniae, alpha-Streptococcus sp., M. catarrhalis, and Neisseria sp. were predominant in organisms isolated from TTA-specimens of lung cancer patients with bronchopulmonary infections, regardless of prognosis. Nutritional status, as determined by serum levels of cholinesterase, albumin, and cholesterol, was poor in the deceased group than in the survival group. These results indicate that the outcome of bronchopulmonary infections in lung cancer patients are affected mainly by the nutritional status of the host.

Expression of p21(waf-1/cip-1) is significantly induced in the livers of LEC rats with chronic liver injury

It is reported that hepatocytes isolated from LEC rats with chronic liver injury show reduced growth activity in primary culture. To elucidate the molecular basis of this phenomenon, we examined expression of p21(waf-1/ciP-1) and p27, cyclin-dependent kinase inhibitors, by northern blot analysis. The expression of p21(waf-1/cip-1 ) in the LEC rat liver was 3-fold higher than that of age-matched SD rat liver, while there was no significant difference in p27 expression level. Western blot analysis also revealed a significant increase in p21(waf-1/cip-1) in the nuclear matrix fraction of the LEC rat liver. Immunohistochemically, p21(waf-1/cip-1) was detected in the nuclei of normal LEC rat hepatocytes, but not in those of hepatocellular carcinoma cells, suggesting selective growth of neoplastic hepatocytes.

[A clinical study of chronic lower respiratory infection with Haemophilus influenza by transtracheal aspiration]

We have performed a clinical study on chronic lower respiratory tract infection (CLRTI) with Haemophilus influenzae (H. influenzae) by transtracheal aspiration (TTA) and analyzed clinical factors of the acute exacerbation. In 40 episodes (38 cases) of H. influenzae isolated from CLRTI, monobacterial infection with H. influenzae were 21 episodes and polymicrobial infection were 19 episodes. We classified the disease into acute exacerbated (27 episodes) and stable (13 episodes) phase and the former episodes were divided into bronchitis type (7 episodes) and pneumonia type (20 episodes). Polymicrobial infections were seen more in the pneumonia type (13 episodes) than in the bronchitis type (2 episodes). The principal organism detected with H. influenzae were alpha-Streptococcus and Neisseria sp. in the bronchitis type and S. pneumoniae in the pneumonia type. The acute exacerbated cases were divided into the following 4 patterns; 1. polymicrobial infection with continuous infection of P. aeruginosa, 2. monomicrobial infection after acute upper respiratory tract infection, 3. polymicrobial infection with S. pneumoniae after continuous infection of H. influenzae, 4. bacterial replacement by P. aeruginosa after acute exacerbation. The results of the study suggests that polymicrobial infection is an important chronic lower respiratory tract infection when caused H. influenzae.

[A clinical features of acute respiratory infection with Haemophilus influenzae by transtracheal aspiration]

We performed a clinical study of 26 cases (27 episodes) of acute respiratory infection with H. influenzae by trans tracheal aspiration (TTA) from May 1987 to April 1995. 15 episodes (14 cases) were bronchitis and 12 episodes (12 cases) were pneumonia. 8 episodes were monomicrobial infection and 19 episodes were polymicrobial infection. Compared to the group of patients of monomicrobial infection, the number of elderly patients and the levels of WBC and CRP were higher in the group of patients of monomicroibal infection. In bronchitis cases, monomicrobial infections of H. influenzae were 7 episodes and polymicrobial infection containing H. influenzae were 8 episodes. In the latter group, PaO2 level was lower and CRP was higher on average. All patients recovered, but the period for treatment was longer in the latter group. In the pneumonia group, only one episode was monomicrobal infection and 11 episodes were polymicrobial infection. Inspite of treatment, one patient died. It was considered that polymicrobial infection was an important factor of acute respiratory infection with H. influenzae.

[A case of AIDS with intractable cryptococcal meningitis]

A 38-year-old hemophiliac, who had been infected with HIV by the administration of blood products and had been diagnosed as AIDS by the onset of Pneumocystis carinii pneumonia, was admitted to our hospital with the complaints of headache and vomiting. After he was diagnosed as cryptococcal meningitis using the microscopy, cryptococcal antigen detection and culture of cerebrospinal fluid, treatment with amphotericin-B and fluconazole was started. As there was no clinical improvement, spinal drainage was performed and acetazolamide administered in order to reduce the intracranial pressure. Treatment was changed from AMPH-B and FLCZ to a combined therapy of AMPH-B and itraconazole. As his clinical features showed improvement, he was discharged home on a maintenance dose of ITCZ and acetazolamide after having been hospitalized for three months. This case-report may be of use in the management of cryptococcal meningitis in patients with AIDS.

[Effect of prolonged administration of erythromycin on the drug sensitivity and the biological properties of Streptococcus pneumoniae]

From April 1990 to February 1992 two hundred and ten strains of Streptococcus pneumoniae were isolated in the laboratory of Nara Medical University Hospital. Frequency of erythromycin resistant Streptococcus pneumoniae, prescription mode of macrolide antibiotics and biological properties were investigated. 1. Erythromycin resistant Streptococcus pneumoniae was predominantly isolated from the wards of the respiratory unit of Inter- nal Medicine and Pediatrics. 2. Patients with erythromycin resistant Streptococcis pneumoniae were treated with macrolide antibiotics frequently in the respiratory unit of Internal Medicine and Pediatrics. 3. MIC90 of EM, CLDM, MINO and ABPC for Streptococcus pneumoniae was 8.0, 8.0, 8.0 and 1.0 micrograms/ml, respectively, indicating moderate resistance to penicillin derivatives and high resistance to macrolides, particularly EM; some strains showed high levels of MIC over 400 micrograms/ml. 4. Investigations on biological properties using VITEK GPI cards revealed that some erythromycin resistant strains showed less responsiveness to DEX, LAC, PUL and MEL. 5. The survival rate of mice infected with erythromycin resistant strains was longer than that with erythromycin sensitive strains. These findings suggested that the prolonged administration of erythromycin causes a virulence reduction of the organism.

[A case of the greater omentum abscess due to Peptostreptococcus ssp]

A case of the greater omentum abscess due to Peptostreptococcus ssp. is reported. A 63-year-old male was admitted to Heisei Memorial Hospital with a complaint of abdominal pain. An intraperitoneal mass measuring 6 cm in diameter was detected by CT and ultrasonogram. He was diagnosed as having an intraperitoneal abscess. After antibiotics therapy by cefotiam, laparotomy was performed and an abscess about 7 cm in diameter at the edge of the greater omentum was found. There was no evidence of perforation in the intestine wall. The abscess was removed and Peptostreptoccocus spp. was isolated from the dark red pus drained from the abscess.

[A case of amoebiasis as a latent infection]

A 69-year-old male was admitted because of constipation and abdominal distension. A colon fiberscopic examination revealed the formation of ulceration. The trophozite of Entamoeba histolytica was detected from from the specimens of colon mucosal biopsy of the ulcer. The stool was positive for the cysts of E. histolytica too. He had been in China and Southeast Asia during World War II. He returned home and experienced amoebic dysentry, and was treated with Emethin hydrochlolide. He suffered from amoebic disentry in 1970 and was treated with Emethine hydrochrolide again. After the War he had not gone abroad, and was not a homosexual. So this case was considered a latent infection of E. histolytica from the War. This time he was treated with metronidazol and minocycline. After the therapy, cysts were negative in the stool and the ulcer was cured on the colon fiberscopic examination.

Clinical aerosol inhalation cine-scintigraphy to evaluate mucociliary transport system in diffuse panbronchiolitis

This study evaluates the mucociliary transport system in patients with diffuse panbronchiolitis using aerosol inhalation cine-scintigraphy (AICS).

METHODS

Forty-one subjects, 10 healthy controls and 31 patients with diffuse panbronchiolitis, were studied. In addition, the mucociliary transport system was evaluated in 11 patients who had received erythromycin therapy for 3-8.3 yr. Following inhalation of 99mTc-human serum albumin aerosol for 3-5 min in a sitting position, the subjects were placed on the imaging table in the supine position and posterior images were obtained dynamically for 20 sec/frame over 2 hr with a gamma camera linked to a digital computer. The 360 20-sec serial frames were edited into a cinematographic presentation at 200-msec intervals. Clinical evaluation of the mucociliary transport system was based on the bolus movement of radioactive aerosol from the main bronchi to the trachea and the movement patterns, which were divided into four types using the movement in the controls as a standard (type I): type I, rapid and smooth movement; type II, slow movement; type III, stagnation at the carina; and type IV, complete stasis.

RESULTS

All patients with diffuse panbronchiolitis had types III and IV, indicating that mucociliary transport system was severely impaired. Of the 11 patients on erythromycin therapy, 8 had movement pattern type IV and 3 had movement pattern type III before erythromycin therapy. In eight patients (72.7%), movement pattern was improved to type I or II after therapy.

CONCLUSION

Aerosol inhalation cine-scintigraphy helps evaluate the clinical usefulness of erythromycin therapy in diffuse panbronchiolitis.

Murine tumorlytic factor, immunologically distinct from tumor necrosis factor-alpha and -beta, induced in the serum of mice treated with a T-cell mitogen of Corynebacterium kutscheri

Murine tumorlytic factor (TF), immunologically distinct from murine tumor necrosis factor (TNF)-alpha and -beta, was purified to a homogeneity from the serum of mice injected with a T-cell mitogen of Corynebacterium kutscheri. The treated mouse serum was purified by Lentil lectin-Sepharose chromatography, DEAE-cellulose chromatography, preparative isoelectric focusing, and high-pressure liquid chromatography to the specific activity of 1.5 x 10(6) U/mg protein. TF was 42 kDa in its oligomeric form and 14 kDa in its monomeric form. TF activity was not impaired with hamster monoclonal antibody (mAb) to recombinant murine TNF-alpha and -beta and, reciprocally, rabbit antibody to TF neutralized the bioactivity of neither murine TNF-alpha nor -beta. TF was not precipitated with the mAb to murine TNF-alpha and -beta in Western blot analysis. The partial amino acid sequence of TF was at most 33% homologous to the 46-63 sequence of mouse TNF-beta. Thus, these results suggest that TF might be a novel tumorlytic factor which is immunologically distinct from mouse TNF-alpha and -beta.

The high hepatocarcinogen susceptibility of LEC rats is genetically independent of abnormal copper accumulation in the liver

We previously reported that LEC rats, which show a spontaneous occurrence of liver injury and hepatocellular carcinoma (HCC), are highly susceptible to chemical carcinogens such as diethylnitrosamine (DEN). Since abnormal copper accumulation in the liver of LEC rats was found to be a cause of liver injury, it is necessary to elucidate whether the carcinogen susceptibility of LEC rats is related to the accumulation of copper in the liver. In this study we have examined the relationship between the susceptibility of FI [LEC x LEA or LEC x Fischer 344 (F344)] and FI backcross rats to DEN and hepatic copper concentration, as copper accumulation has been demonstrated to be inherited as an autosomal recessive trait. The groups of F1 and F1 backcross rats were given a single intraperitoneal injection of DEN (20 mg/kg wt) and subjected to a modified Solt-Farber protocol for assaying glutathione S-transferase placental form (GST-P)-positive foci. The hepatic copper concentration was examined by atomic absorption. Although no F1 rats showed a high copper concentration in the liver, the numbers of foci were as high as those in LEC rats which accumulate copper. Backcross rats separated into high and low copper concentration groups at an almost 1:1 ratio, but there was no significant difference in the mean numbers of foci between these two groups. The results clearly indicate that the high susceptibility of LEC rats to DEN is genetically independent of copper accumulation in the liver. A possible dominant inheritance of this high carcinogen susceptibility was suggested. Biochemical measurement of cytochromes P450 and b5 in the liver of F1 rats indicated that alterations in drug metabolizing enzymes may be partially responsible for the high carcinogen susceptibility of LEC rats.

[A case of sepsis due to Escherichia coli isolated from blood, transtracheal aspiration and urine]

We reported a 53-year-old female who was admitted due to partial loss of consciousness. She had been diagnosed as old pulmonary tuberculosis and diabetes mellitus. She was diagnosed as diabetic keto-acidosis on admission. We isolated Escherichia coli in the blood, transtracheal aspiration (TTA) and from the urine. We have experienced 6 cases where the same bacteria was isolated from the blood and TTA at the same time. In all 6 cases, we have found single bacteria in the blood and a few other bacteria in TTA. Blood culture is the most certain method to detect the origin of infectious diseases. But the compromised host, as in this case, has multifocal infections in many cases. In order to understand the pathological aspects of the infection, we must obtain many kinds of samples and as many as possible.