Low-dose trimethoprim-sulfamethoxazole treatment for pneumocystis pneumonia in non-human immunodeficiency virus-infected immunocompromised patients: A single-center retrospective observational cohort study

BACKGROUND/PURPOSE

The efficacy of low-dose trimethoprim-sulfamethoxazole (TMP-SMX) may be acceptable for the treatment of pneumocystis pneumonia (PCP) in non-human immunodeficiency virus (HIV)-infected patients, with a low incidence of adverse reactions. This study is aimed to evaluate the efficacy and safety of such a regimen for the treatment of non-HIV PCP.

METHODS

We retrospectively enrolled 24 consecutive patients diagnosed with non-HIV PCP who were treated with low-dose TMP-SMX (TMP, 4-10 mg/kg/day; SMX, 20-50 mg/kg/day). Data of the conventional-dose treatment were used as reference. The primary endpoints were the 30- and 180-day survival rates from the day of treatment, and secondary endpoints were the incidence of each adverse reaction and dropout rate from the initial TMP-SMX regimen. The survival rate was estimated using the Kaplan-Meier method with 95% confidence interval (CI).

RESULTS

The median age of patients was 72 years (54.2% men), and connective tissue disease was the most frequent underlying disease (66.7%) in the low-dose group. The 30- and 180-day survival rates were 95.8% (95% CI: 88.2-100.0%) and 91.0% (95% CI: 79.9%-100.0%), respectively, in the low-dose group and 69.0% (95% CI: 54.0%-88.0%) and 51.5% (95% CI: 36.1%-73.4%), respectively, in the conventional-dose group. The total adverse reaction rate was 58.3% in the low-dose group and 72.4% in the conventional-dose group. A total of 75.0% of patients in the low-dose group and 31.0% in the conventional-dose group completed treatment with the initial regimen.

CONCLUSION

Low-dose TMP-SMX may be a treatment option for patients with non-HIV PCP.

A 10-year profile of enterococcal bloodstream infections at a tertiary-care hospital in Japan

OBJECTIVES

The first aim of this study is to characterize the epidemiology of enterococcal bloodstream infections (BSIs) at a Japanese tertiary-care hospital. The second aim is to identify predictive factors for 30-day mortality.

METHODS

We conducted a single center retrospective observational study. All patients with enterococcal BSI between 2005 and 2014 were enrolled. Univariate and multivariate analysis were performed to evaluate predictive factors for 30-day mortality.

RESULTS

A total of 410 patients with enterococcal BSI were enrolled. Enterococcus faecalis was identified in 200 patients (48.8%) and Enterococcus faecium in 124 patients (30.2%). Isolates were susceptible to ampicillin and vancomycin (67.3% and 97.8%, respectively). Isolates that were not susceptible to vancomycin were either Enterococcus casseliflavus or Enterococcus gallinarum. All strains of E. faecalis and 10.8% of E. faecium strains were susceptible to ampicillin. Thirty-day mortality was 24.8%. Predictive factors for 30-day mortality were Charlson Comorbidity Index (CCI) 1-2 (adjusted odds ratio [OR] 6.07, 95% confidence interval [CI]: 1.22-30.2), CCI 3-4 (adjusted OR 8.79, 95% CI: 1.70-45.4), CCI ≥5 (adjusted OR 17.6, 95% CI: 3.52-88.2), E. faecium bacteremia (adjusted OR 2.19, 95% CI: 1.27-3.76), Pitt Bacteremia Score (PBS) ≥5 (adjusted OR 15.1, 95% CI: 6.41-35.6), and source control (adjusted OR 0.39, 95% CI: 0.22-0.72).

CONCLUSION

Vancomycin-resistant strains of E. faecalis and E. faecium were not seen in this cohort. In addition, all strains of E. faecalis and 10.8% of E. faecium strains were susceptible to ampicillin. Predictive factors for 30-day mortality were CCI score, E. faecium bacteremia, PBS score, and source control.

Immunogenicity of trivalent influenza vaccine in patients with lung cancer undergoing anticancer chemotherapy

Lung cancer is a leading cause of cancer-related death, and patients with lung cancer are a priority group for influenza vaccination. However, few studies have assessed the immunogenicity of the influenza vaccine in these patients. Here, we performed a prospective study to evaluate the immunogenicity of the influenza vaccine in patients with lung cancer undergoing anticancer chemotherapy. Twenty-five patients with lung cancer undergoing anticancer chemotherapy and 26 patients with chronic obstructive pulmonary disease (COPD) as controls were enrolled. A trivalent influenza vaccine containing inactivated A/California/7/2009 (H1N1) pdm09, A/Texas/50/2012 (H3N2), and B/Massachusetts/2/2012 was administered as a single subcutaneous injection. Serum samples were collected before vaccination, and at 4-6 weeks after vaccination. Levels of serum antibody to hemagglutinin were measured. Among patients with lung cancer, the seroprotection rate (postvaccination titer > 1:40) was 84% for both A(H1N1) and A(H3N2), similar to the levels observed in patients with COPD. However, the seroprotection rate for the B strain was significantly lower in patients with lung cancer than in patients with COPD (64% versus 92%). Even after adjustment for potential confounders, patients with lung cancer had a significantly lower odds ratio for seroprotection against the B strain than patients with COPD. Moreover, in patients with lung cancer, those receiving the platinum doublet treatment tended to exhibit a lower seroprotection rate than those receiving a single agent. Thus, patients with lung cancer undergoing anticancer chemotherapy showed acceptable immune responses to a trivalent influenza vaccine, supporting the recommendation for annual influenza vaccination in these patients.

Pyelonephritis with bacteremia caused by Listeria monocytogenes: A case report

Listeria monocytogenes is a well-known cause of meningitis, colitis, and bacteremia; however, obstructive pyelonephritis caused by L. monocytogenes has never been reported. We herein report on a 90-year-old Japanese woman with obstructive pyelonephritis and bacteremia due to uterus carcinoma invading the ureter. She was admitted to our hospital complaining of fever and chills, and her physical examination revealed left costovertebral angle tenderness. Computed tomography showed hydronephrosis and complete ureteral obstruction due to tumor invasion. Blood and urine cultures upon nephrostomy revealed the growth of L. monocytogenes. We treated the patient with two weeks of intravenous ampicillin and an additional one-week treatment of oral sulfamethoxazole/trimethoprim. This case shows the importance to recognize L. monocytogenes as a potential causative agent of urinary tract infection.

[Training of Medical Technologists Who Will Be Able to Contribute to Emergency Medical Care]

Although health care is provided by many different medical professionals, medical technologists are usually not present in emergency care settings. Kameda Medical Center has established and been implementing a system of in-house certification as emergency medical care examiners. Medical technologists who have undergone seven-month-or-longer in-house and emergency medical care training and passed the final screening are certified as emergency medical care examiners, and their presence in critical care centers for 24 hours a day has improved the quality and safety of medicine. [Review].

Bloodstream infections caused by Streptococcus anginosus group bacteria: A retrospective analysis of 78 cases at a Japanese tertiary hospital

OBJECTIVES

To investigate the characteristics of Streptococcus anginosus group (SAG) bacteremia in recent years, we conducted a retrospective cohort study and compared its findings with the data from previous studies.

METHODS

All patients with positive blood cultures from May 2005 to September 2014 in a tertiary care center with 925 beds were included.

RESULTS

There were 78 cases of SAG bacteremia (51 cases men; median age, 68 years) during the study period. The most common comorbidities were solid tumors in 32.1% of the patients. The most common infection source was hepatobiliary in one-third of all cases. Other infection sites included the following: intra-abdominal (12.8%), thoracic (10.3%), musculoskeletal (9%), urinary tract (7.7%), soft tissues (7.7%), and cervicofacial (6.4%). Susceptibility to penicillin, clindamycin and erythromycin were 100% (78/78), 95% (70/74) and 85% (39/46), respectively. Surgery along with systemic antibiotic treatment was administered in 53% of the cases. In-hospital mortality was 14.1%.

CONCLUSION

The clinical sources of the SAG bacteria were diverse, and hepatobiliary infection was the most common source of infection. In more than half of the patients, surgical treatment was performed. Susceptibility to penicillin was 100%, but susceptibility to erythromycin was lower than that reported in previous studies.

Clinical Features of Community-Acquired Helicobacter cinaedi Bacteremia

BACKGROUND

There are growing numbers of reports concerning the clinical and pathological features of Helicobacter cinaedi (H. cinaedi) bacteremia; however, few reports have discussed the features of this condition in healthy individuals.

PATIENTS AND METHODS

A retrospective observational study was conducted at a Japanese tertiary care hospital to assess the clinical features of community-acquired H. cinaedi. All patients in whom H. cinaedi was isolated between January 2009 and March 2014 were identified from the hospital database.

RESULTS

Of the 28 patients included in the study, 12 had community-acquired H. cinaedi bacteremia. The most common clinical feature was cellulitis (n = 17). However, nearly half of the patients with healthcare-associated or nosocomial-associated bacteremia displayed no symptoms with the exception of fever. Most patients were successfully treated with a 14-day regime of third-generation cephalosporins or tetracycline.

CONCLUSIONS

Our results show that H. cinaedi infections are quite common in immunocompetent community-dwelling individuals.

Effective treatment by glycolic acid peeling for cutaneous manifestation of familial generalized acanthosis nigricans caused by FGFR3 mutation

BACKGROUND

Acanthosis nigricans (AN) can occur as a cutaneous manifestation of genetic diseases, one of which is associated with activating mutations of the fibroblast growth factor receptor 3 gene (FGFR3).

OBJECTIVE

We explored familial AN patients with FGFR3 mutations and examined the effectiveness of glycolic acid (GA) peeling in improving their skin manifestations.

METHODS

Sanger sequencing was performed for the genomic DNA extracted from leucocytes of the family members involving familial AN. GA peeling was carried out for the two patients of familial AN once every 2 weeks.

RESULTS

Heterozygous c.1949A>C (p.K650T) mutation in FGFR3 was identified for the affected family members examined, whereas the wild-type sequence was found for two unaffected individuals. Hyperpigmentation and coarseness of the skin were improved by GA peeling at regular intervals with few adverse effects.

CONCLUSION

We diagnosed our cases as familial generalized AN caused by heterozygous c.1949A>C (p.K650T) mutation of FGFR3. We propose that GA peeling is a useful and safe therapeutic option to treat familial AN.

Rice-Field Drowning-Associated Pneumonia in which Pseudomonas spp., Aspergillus fumigatus, and Cunninghamella sp. Are Isolated

We herein report the case of an 84-year-old who developed pneumonia after drowning in a rice field. Besides Aspergillus fumigatus, many pathogens previously not reported in drowning-associated pneumonia (such as Pseudomonas fluorescens, Pseudomonas putida, Nocardia niigatensis, and Cunninghamella sp.) were isolated from his sputum. He received sulbactam/ampicillin, trimethoprim/sulfamethoxazole, voriconazole, levofloxacin and liposomal amphotericin B, but died due to respiratory failure. Because the patient had drowned in a contaminated stagnant rice field and had multiple lung cavities, zygomycosis was suspected. This report provides invaluable information for the consideration of zygomycosis after an individual drowning in a rice field, even in an immunocompetent patient.

Cytomegalovirus Colitis in a Critically Ill Patient Following Severe Legionella Pneumonia with Multiple Organ Failure

A 68-year-old man visited an emergency department complaining of dyspnea. He was diagnosed to have Legionella pneumonia with multiple organ failure. Although his multiple organ failure improved, he suffered from persistent abdominal pain and diarrhea with continuous minor bleeding. Colonoscopy revealed a longitudinal ulcer of the rectum, below the peritoneal reflection. He was diagnosed with cytomegalovirus (CMV) colitis. Antiviral therapy with ganciclovir was initiated. He finally underwent a colostomy after a bowel stricture caused an intestinal outlet obstruction, which made oral intake impossible. Based on the present case, we believe that CMV colitis must be considered as one of the differential diagnoses when critically ill patients develop continuous diarrhea and abdominal pain.

[A Case of Osteomyelitis with a Granulomatous Lesion Caused by Salmonella Infantis]

We report herein on a case of osteomyelitis with a granulomatous lesion caused by Salmonella enterica subsp. enterica serovar Infantis (Salmonella Infantis). A 30-year-old Japanese man presenting with a 3-week history of left ankle pain was suspected to have either a tumor or osteomyelitis, on the basis of imaging study findings. He underwent a surgical resection of the lesion. Histopathological examination revealed a granuloma. However, S. Infantis was cultured from the biopsy sample. Cefazolin was initially administered as empirical therapy. We switched the antibiotic to ampicillin on the basis of the anitibiotic-susceptibility test results. Six weeks after intravenous ampicillin therapy, we switched to oral ciprofloxacin. He has had no recurrence in the 3 years after treatment completion. Salmonella osteomyelitis is rare and this pathogen seldom causes a granulomatous lesion. According to the findings in our case, Salmonella spp. should be considered as one of the differential diagnoses for granulomatous lesions in the bone.

Phase II study of the immune-checkpoint inhibitor ipilimumab plus dacarbazine in Japanese patients with previously untreated, unresectable or metastatic melanoma

PURPOSE

Ipilimumab (IPI), a monoclonal antibody against immune-checkpoint receptor cytotoxic T lymphocyte antigen-4, is designed to enhance antitumor T cell function. IPI 10 mg/kg plus dacarbazine (DTIC) significantly improved overall survival in a phase 3 study involving predominantly Caucasian patients, with an adverse event (AE) profile similar to that of IPI monotherapy. We conducted a single-arm, phase 2 study to evaluate the safety and efficacy of IPI plus DTIC in Japanese patients.

METHODS

Previously untreated patients with unresectable stage III or IV melanoma received IPI 10 mg/kg plus DTIC 850 mg/m(2) every 3 weeks for four doses (q3w × 4), followed by DTIC q3w × 4 and then IPI every 12 weeks until disease progression or intolerable toxicity.

RESULTS

All 15 treated patients reported drug-related AEs, the most common of which were increases in alanine aminotransferase (n = 12, 80 %) and aspartate aminotransferase (n = 11, 73 %). Treatment-related serious AEs were reported in 11 (73 %) patients. Nine patients (60 %) discontinued treatment due to drug-related toxicities. Immune-related AEs (irAEs) were reported in 14 patients (93 %). The most frequent irAEs were liver (n = 12, 80 %) and skin (n = 10, 67 %) toxicities. Five deaths were reported; all were caused by progressive disease. Efficacy evaluation showed one complete response, one partial response and four patients with stable disease. Best overall response rate was 13 % (2/15), and the disease control rate was 40 % (6/15). The study was terminated early due to frequent, high-grade liver toxicities.

CONCLUSIONS

IPI 10 mg/kg plus DTIC 850 mg/m(2) was not considered tolerable in the Japanese patient population. ClinicalTrials.gov identifier: NCT01681212.

Surface Modifications and Their Effects on Titanium Dental Implants

This review covers several basic methodologies of surface treatment and their effects on titanium (Ti) implants. The importance of each treatment and its effects will be discussed in detail in order to compare their effectiveness in promoting osseointegration. Published literature for the last 18 years was selected with the use of keywords like titanium dental implant, surface roughness, coating, and osseointegration. Significant surface roughness played an important role in providing effective surface for bone implant contact, cell proliferation, and removal torque, despite having good mechanical properties. Overall, published studies indicated that an acid etched surface-modified and a coating application on commercial pure titanium implant was most preferable in producing the good surface roughness. Thus, a combination of a good surface roughness and mechanical properties of titanium could lead to successful dental implants.

Profile of infective endocarditis at a tertiary-care hospital in Japan over a 14-year period: characteristics, outcome and predictors for in-hospital mortality

OBJECTIVES

The aims of this study were to describe the epidemiological features and clinical characteristics of infective endocarditis (IE) at a tertiary-care hospital in Japan and to identify the factors associated with in-hospital mortality.

METHODS

A retrospective observational study was conducted at a 925-bed tertiary-care teaching hospital in Japan. All adult patients diagnosed with definite IE between August 2000 and July 2014 according to the modified Duke criteria were included.

RESULTS

A total of 180 patients (60.6% men; mean age, 69.1 years) with definite IE were included. The most common pathogen was Staphylococcus aureus (27.2%). Nine patients (5.0%) had culture-negative IE. Transthoracic and transoesophageal echocardiography were performed in 180 (100%) and 132 patients (73.3%), respectively, and vegetations were detected in 128 patients (71.1%). Surgical therapy was performed in 31 patients (17.2%). Overall, the in-hospital mortality rate was 26.1%. The independent predictors of in-hospital mortality were methicillin-resistant S. aureus (MRSA), vascular phenomena, health care-associated IE and heart failure.

CONCLUSIONS

MRSA, vascular phenomena, health care-associated IE and heart failure were independent predictors of in-hospital mortality. The unique characteristics in our cohort were the very high mean age, low rate of culture-negative IE, high rate of definite IE without detected vegetations and predominance of S. aureus.

Cytogenetic, crossing and molecular evidence of two cytological forms of Anopheles argyropus and three cytological forms of Anopheles pursati (Diptera: Culicidae) in Thailand

Nine and 11 isolines of Anopheles argyropus and Anopheles pursati, respectively, were established from individual females collected from cow-baited traps, and the characteristics of metaphase chromosomes were investigated in their F1-progenies. As determined by the different amounts of extra heterochromatin on sex chromosomes, 2 types of X (X1, X2) and Y (Y1,Y2), and 2 types of X (X1, X2) and 3 types of Y (Y1, Y2, Y3) chromosomes were obtained from An. argyropus and An. pursati, respectively. These types of sex chromosomes comprised 2 [Forms A (X1, Y1) and B (X1, X2, Y2)] and 3 [Forms A (X1, X2, Y1), B (X1, X2, Y2) and C (X2, Y3)] karyotypic forms of An. argyropus and An. pursati, respectively. All karyotypic forms acquired from An. pursati are new one that were discovered in this study, of which Forms A, B and C were found generally in Chiang Mai Province, while only 1 isoline of Form B was obtained in Ratchaburi Province. Form A was recovered from An. argyropus only in Ubon Ratchathani Province, whereas Form B from that species was found commonly in both Ubon Rathchathani and Nakhon Si Thammarat Provinces. Crossing experiments among the 2 and 3 isolines representing 2 and 3 karyotypic forms of An. argyropus and An. pursati, respectively, indicated genetic compatibility in yielding viable progenies and synaptic salivary gland polytene chromosomes through F2-generations. The conspecific natures of these karyotypic forms in both species were further supported by very low intraspecific sequence variations (average genetic distance: An. argyropus = 0.003-0.007, An. pursati = 0-0.005) of ribosomal DNA (ITS2) and mitochondrial DNA (COI and COII).

Search for bosonic superweakly interacting massive dark matter particles with the XMASS-I detector

Bosonic superweakly interacting massive particles (super-WIMPs) are a candidate for warm dark matter. With the absorption of such a boson by a xenon atom, these dark matter candidates would deposit an energy equivalent to their rest mass in the detector. This is the first direct detection experiment exploring the vector super-WIMPs in the mass range between 40 and 120 keV. With the use of 165.9 day of data, no significant excess above background was observed in the fiducial mass of 41 kg. The present limit for the vector super-WIMPs excludes the possibility that such particles constitute all of dark matter. The absence of a signal also provides the most stringent direct constraint on the coupling constant of pseudoscalar super-WIMPs to electrons. The unprecedented sensitivity was achieved exploiting the low background at a level 10(-4)  kg-1 keVee-1 day-1 in the detector.

Loop-mediated isothermal amplification method for diagnosing Pneumocystis pneumonia in HIV-uninfected immunocompromised patients with pulmonary infiltrates

Loop-mediated isothermal amplification (LAMP) is becoming an established nucleic acid amplification method offering rapid, accurate, and cost-effective diagnosis of infectious diseases. We retrospectively evaluated 78 consecutive HIV-uninfected patients who underwent LAMP method for diagnosing Pneumocystis pneumonia (PCP). Diagnosis of PCP was made by the detection of Pneumocystis jirovecii (P. jirovecii) with positive LAMP or conventional staining (CS) (Grocott methenamine silver staining or Diff-Quick™) on the basis of compatible clinical symptoms and radiologic findings. Additionally, we reviewed HIV-uninfected immunocompromised patients who underwent subcontract PCR as a historical control. LAMP was positive in 10 (90.9%) of 11 positive-CS patients. Among 13 negative-CS patients with positive LAMP, 11 (84.6%) had PCP, and the remaining 2 were categorized as having P. jirovecii colonization. LDH levels in negative-CS PCP were higher than in positive-CS PCP (p = 0.026). (1 → 3)-β-D-glucan levels in negative-CS PCP were lower than in positive-CS PCP (p = 0.011). The interval from symptom onset to diagnosis as PCP in LAMP group (3.45 ± 1.77 days; n = 22) was shorter than in subcontract PCR group (6.90 ± 2.28 days; n = 10; p < 0.001). As for patients without PCP, duration of unnecessary PCP treatment in LAMP group (2; 2-3 days; n = 10) was shorter than in subcontract PCR group (7; 7-12.25 days; n = 6; p = 0.003). LAMP showed higher sensitivity (95.4%) and positive predictive value (91.3%) than subcontract PCR did. Pneumocystis LAMP method is a sensitive and cost-effective diagnostic method and is easy to administer in general hospitals. In-house LAMP method would realize early diagnosis of PCP, resulting in improving PCP prognosis and reducing unnecessary PCP-specific treatment.

Zoonotic onchocerciasis caused by a parasite from wild boar in Oita, Japan

Histological examination of a nodule removed from the back of the hand of a 58-year-old woman from Oita, Kyushu, Japan showed an Onchocerca female sectioned through the posterior region of the worm (ovaries identifiable) and young (thin cuticle). Six Onchocerca species are enzootic in that area: O. gutturosa and O. lienalis in cattle, O. suzukii in serows (Capricornis crispus), O. skrjabini and an Onchocerca sp. in Cervus nippon nippon, and O. dewittei japonica in wild boar (Sus scrofa leucomystax). Diagnostic characters of female Onchocerca species, such as the cuticle and its ridges, change along the body length. Tables of the histologic morphology of the mid- and posterior body-regions of the local species are presented. In addition, it was observed that transverse ridges arose and thickened during the adult stage (examination of fourth stage and juvenile females of O. volvulus). The specimen described in this report, with its prominent and widely spaced ridges, was identified as O. d. japonica. Four of the 10 zoonotic cases of onchocerciasis reported worldwide were from Oita, three of them being caused by O. d. japonica, the prevalence of which in local wild boar was 22 of 24 (92%).

Antibiotic susceptibility survey of blood-borne MRSA isolates in Japan from 2008 through 2011

We conducted an antibiotic susceptibility survey of 830 blood-borne methicillin resistant Staphylococcus aureus collected from nationwide hospitals in Japan over a three-year period from January 2008 through May 2011. Antibiotic susceptibility was judged according to the criteria recommended by the Clinical Laboratory Standard Institute. Over 99% of the MRSA showed to be susceptible to teicoplanin, linezolid, sulfamethoxazole/trimethoprim and vancomycin, and over 97% of them were susceptible to daptomycin, arbekacin and rifampin. The majority of the MRSA strains showed resistant to minocycline, meropenem, imipenem, clindamycin, ciprofloxacin, cefoxitin, and oxacillin in the rates of 56.6, 72.9, 73.7, 78.7, 89.0, 99.5, and 99.9%, respectively. Among the MRSA strains, 72 showed reduced susceptibility to vancomycin, including 8 strains (0.96%) of vancomycin-intermediate S. aureus (VISA), 54 (6.51%) of heterogeneous vancomycin-intermediate S. aureus (hVISA), and 55 (5.63%) of β-lactam antibiotics-induced vancomycin resistant S. aureus (BIVR). Unexpectedly, among the 54 hVISA and 55 BIVR, 45 isolates (83.3% and 81.8%, respectively) showed both hVISA and BIVR phenotypes. A new trend of vancomycin resistance found in this study was that VISA strains were still prevalent among the bacteremic specimens. The high rates of the hVISA/BIVR two-phenotypic vancomycin resistance, and the prevalence of VISA in the bloodborne MRSA call attention in the MRSA epidemiology in Japan.

[A case of osteomyelitis caused by mixed infection by Aggregatibacter aphrophilus and Staphylococcus aureus]

A 46-year-old man presented with a 10-day history of progressive weakness and numbness in both his legs. The spinal MRI and abdominal CT revealed discitis of L4/L5 and multiple epidural abscesses. The blood culture tested positive for methicillin sensitive Staphylococcus aureus (MSSA). The Gram stain of sample from abscess drainage showed Gram-positive cocci in clusters and small Gram-negative rods. The Gram-positive cocci in clusters were identified as MSSA using a general culture method and the small Gram-negative rods were identified as Aggregatibacter aphrophilus using a 16s ribosomal RNA sequencing method. The patient was treated four times with surgical abscess drainages and a long course of intravenous antibiotics therapy following which he recovered. No case of mixed infection by A. aphrophilus and S. aureus has been reported in MEDLINE; therefore, our case should be the first case report. Since we confirmed not only Gram-positive cocci in clusters but also Gram-negative rods in the abscess sample, we did not stop the identification procedure at the point when MSSA was identified and finally identified A. aphrophilus with 16s ribosomal RNA sequencing. Especially, in a mixed infection with organisms whose growth speed is different, an organism with slow growth might be missed if the Gram stain of sample were skipped. This case implies the significance of Gram staining as the identification procedure for organisms.

Effects of curcumin supplementation on exercise-induced oxidative stress in humans

The purpose of this study was to investigate the effects of curcumin supplementation on exercise-induced oxidative stress in humans. 10 male participants, ages 26.8±2.0 years (mean±SE), completed 3 trials in a random order: (1) placebo (control), (2) single (only before exercise) and (3) double (before and immediately after exercise) curcumin supplementation trials. Each participant received oral administration of 90 mg of curcumin or the placebo 2h before exercise and immediately after exercise. Each participant walked or ran at 65% of V˙2max on a treadmill for 60min. Blood samples were collected pre-exercise, immediately after exercise and 2h after exercise. The concentrations of serum derivatives of reactive oxygen metabolites measured immediately after exercise were significantly higher than pre-exercise values in the placebo trial (308.8±12.9 U. CARR, P<0.05), but not in the single (259.9±17.1 U. CARR) or double (273.6±19.7 U. CARR) curcumin supplementation trials. Serum biological antioxidant potential concentrations measured immediately after exercise were significantly elevated in the single and double curcumin supplementation trials compared with pre-exercise values (P<0.05). These findings indicate that curcumin supplementation can attenuate exercise-induced oxidative stress by increasing blood antioxidant capacity.

A case of novel swine influenza A (H1N1) pneumonia complicated with virus-associated hemophagocytic syndrome

Influenza related to complications such as pneumonia and encephalitis have sporadically been reported. However, influenza A (H1N1)-virus-associated hemophagocytic syndrome (VAHS) has rarely been reported. A 39-year old woman complained of high fever and was referred to us. Chest infiltrations in both lungs and a positive polymerase chain reaction (PCR) for novel swine-origin influenza A (H1N1) in bronchial alveolar lavage fluid (BALF) specimen was confirmed and she was diagnosed with influenza A (H1N1) pneumonia. Pancytopenia was found, and hemophagocytic syndrome (HPS) was diagnosed by bone marrow aspiration. Following intravenous administration of antiflu drug and combination therapy of steroid pulse and erythromycin IV, the patient’s respiratory dysfunction and lab data gradually improved and she was discharged on day 21. Whereas secondary HPS related to viral infections such as Epstein–Barr virus, cytomegalovirus, and human herpesvirus type 6 are commonly seen, H1N1 pneumonia complicated with secondary VAHS is rare.

Metaphase karyotypes of Anopheles paraliae (Diptera:Culicidae) in Thailand and evidence to support five cytological races

Sixteen isoline colonies of Anopheles paraliae were established from wild-caught females collected from cow-baited traps at 4 locations in Thailand. They showed 3 types of X (X1, X2, X3) and 5 types of Y (Y1, Y2, Y3, Y4, Y5) chromosomes based on the number and amount of major block(s) of heterochromatin present in the heterochromatic arm, and were designated as Forms A (X3, Y1), B (X1, X2, X3, Y2), C (X3, Y3), D (X1, X2, X3, Y4) and E (X3, Y5). Form A was found in Songkhla Province, Form B was obtained in Ratchaburi, Nakhon Si Thammarat and Songkhla Provinces, Form C was acquired in Chanthaburi Province, Form D was recovered in Ratchaburi and Songkhla Provinces, and Form E was encountered in Ratchaburi Province. Hybridization experiments among the 7 isoline colonies, which represented the 5 karyotypic forms of An. paraliae, revealed genetic compatibility in providing viable progenies and synaptic salivary gland polytene chromosomes through F2-generations, and thus suggest the conspecific nature of these karyotypic forms. These results were supported by the very low intraspecific sequence divergence (mean genetic distance = 0.000-0.002) of the nucleotide sequences in ribosomal DNA (ITS2) and mitochondrial DNA (COI and COII) of the 5 forms.

Burkholderia contaminans: unusual cause of biliary sepsis

We report a case of biliary tract infection caused by a strain of Burkholderia contaminans, a member of the Burkholderia cepacia complex. The patient developed sepsis after endoscopic retrograde cholangiopancreatography (ERCP). Gram-negative bacilli were isolated from blood and bile cultures. Automated bacterial identification systems identified the organism as Burkholderia cepacia, whereas DNA sequence analysis revealed that the recA gene isolate was identical to that of B. contaminans. The patient responded to therapy with the antibiotics trimethoprim/sulfamethoxazole and biliary tract decompression. This case suggests that B. contaminans can be a causative agent of healthcare-associated biliary tract infections such as ERCP-related cholangitis.

Blackfly vectors of zoonotic onchocerciasis in Japan

Studies of blackfly vectors of Onchocerca dewittei japonica Uni, Bain & Takaoka (Spirurida: Onchocercidae), a parasite of wild boar implicated in the aetiology of zoonotic onchocerciasis in Japan, and six other zoonotic Onchocerca species of this country are reviewed. Molecular identification of infective larvae found in wild-caught female blackflies showed that Simulium bidentatum (Shiraki) (Diptera: Simuliidae) is a natural vector of O. dewittei japonica, and also Onchocerca sp. sensu Fukuda et al., another parasite of wild boar. Inoculation experiments demonstrated that Simulium arakawae Matsumura and four other Simulium species are putative vectors. Similarly, S. arakawae, S. bidentatum and Simulium oitanum (Shiraki) are putative vectors of Onchocerca eberhardi Uni & Bain and Onchocerca skrjabini Rukhlyadev, parasites of sika deer. Morphometric studies of infective larvae indicated that Onchocerca lienalis Stiles, a bovine species, is transmitted by S. arakawae, Simulium daisense (Takahasi) and Simulium kyushuense Takaoka, and that Onchocerca sp. sensu Takaoka & Bain, another bovine species, is transmitted by S. arakawae, S. bidentatum, S. daisense and S. oitanum. Prosimulium sp. (Diptera: Simuliidae) and Simulium japonicum Matsumura are suspected vectors of Onchocerca suzukii Yagi, Bain & Shoho and O. skrjabini [Twinnia japonensis Rubtsov (Diptera: Simuliidae) may also transmit the latter], parasites of Japanese serow, following detection of the parasites' DNA genes in wild-caught blackflies.

Simulium (Nevermannia) chomthongense, a new species of black fly (Diptera: Simuliidae) from Chiang Mai, Thailand

Simulium (Nevermannia) chomthongense sp. nov. is described from female, male, pupal and larval specimens collected from Doi Inthanon National Park and Doi Phahompok National Park, Chiang Mai, Thailand. This new species, first reported as S. (Eusimulium) sp. A, and later regarded as S. (N.) caudisclerum Takaoka & Davies, described from peninsular Malaysia, is distinguished from S. (N.) caudisclerum in the male by the number of enlarged upper-eye facets and the relative size of the hind basitarsus against the hind tibia and femur, and in the pupa by the relative length of the stalks of paired filaments against the common basal stalk and the color of the dorsal surface of abdominal segments 1- 3 (or 4). Taxonomic and molecular notes are provided to separate this new species from four other known species of the vernum species-group, which share an accessory sclerite on the larval abdomen, a rare characteristic in this species-group.

Should Blood Cultures be Performed in Terminally Ill Cancer Patients?

Background:

No evidence-based guidelines or protocols to treat the infection-related symptoms in cancer patients with terminal stages have been established.

Materials and Methods:

We retrospectively analyzed all the patients with terminal stage cancer who died between April 2009 and March 2010. The patients’ background, the prevalence of infection and clinical outcomes, pathogens isolated, antibiotics used, and whether blood cultures and some of examinations were performed or not were evaluated.

Results:

A total of 62 (44 males and 18 females) patients were included in this study. The median age was 73 years (35–98 years). The most common cancer was that of the lung (n =59, 95.2%). A total of 32 patients were diagnosed with the following infections: Infection of respiratory tract in 27 (84.4%), of urinary tract in 4 (12.5%), and cholangitis in 1 (3.1%). Two cases (6.3%) had pneumonia complicated with urinary tract infection. Blood cultures and antibiotic therapies were performed in 28 and 30 cases, respectively. Four (14.3%) positive cultures were isolated from the blood obtained from 28 individual patients. As for clinical course, 3 (10%) of them experienced improved symptoms after antibiotic therapy. Twenty-seven (90%) patients were not confirmed as having any symptom improvement.

Conclusions:

Blood cultures and antibiotic therapy were limited, and might not be effective in terminally ill cancer patients with lung cancer. We suggest that administering an antibiotic therapy without performing a blood culture would be one of choices in those with respiratory tract infections if patients’ life expectancy is short.

Non-HIV Pneumocystis pneumonia: do conventional community-acquired pneumonia guidelines under estimate its severity?

Background: Non-HIV Pneumocystis pneumonia (PCP) can occur in immunosuppressed patients having malignancy or on immunosuppressive agents. To classify severity, the A-DROP scale proposed by the Japanese Respiratory Society (JRS), the CURB-65 score of the British Respiratory Society (BTS) and the Pneumonia Severity Index (PSI) of the Infectious Diseases Society of America (IDSA) are widely used in patients with community-acquired pneumonia (CAP) in Japan. To evaluate how correctly these conventional prognostic guidelines for CAP reflect the severity of non-HIV PCP, we retrospectively analyzed 21 patients with non-HIV PCP. Methods: A total of 21 patients were diagnosed by conventional staining and polymerase chain reaction (PCR) for respiratory samples with chest x-ray and computed tomography (CT) findings. We compared the severity of 21 patients with PCP classified by A-DROP, CURB-65, and PSI. Also, patients’ characteristics, clinical pictures, laboratory results at first visit or admission and intervals from diagnosis to start of specific-PCP therapy were evaluated in both survivor and non-survivor groups. Results: Based on A-DROP, 18 patients were classified as mild or moderate; respiratory failure developed in 15 of these 18 (83.3%), and 7/15 (46.7%) died. Based on CURB-65, 19 patients were classified as mild or moderate; respiratory failure developed in 16/19 (84.2%), and 8 of the 16 (50%) died. In contrast, PSI classified 14 as severe or extremely severe; all of the 14 (100%) developed respiratory failure and 8/14 (57.1%) died. There were no significant differences in laboratory results in these groups. The time between the initial visit and diagnosis, and the time between the initial visit and starting of specific-PCP therapy were statistically shorter in the survivor group than in the non-survivor group. Conclusions: Conventional prognostic guidelines for CAP could underestimate the severity of non-HIV PCP, resulting in a therapeutic delay resulting in high mortality. The most important factor to improve the mortality of non-HIV PCP is early diagnosis and starting of specific-PCP therapy as soon as possible.

Non-HIV Pneumocystis pneumonia: do conventional community-acquired pneumonia guidelines under estimate its severity?

Background

Non-HIV Pneumocystis pneumonia (PCP) can occur in immunosuppressed patients having malignancy or on immunosuppressive agents. To classify severity, the A-DROP scale proposed by the Japanese Respiratory Society (JRS), the CURB-65 score of the British Respiratory Society (BTS) and the Pneumonia Severity Index (PSI) of the Infectious Diseases Society of America (IDSA) are widely used in patients with community-acquired pneumonia (CAP) in Japan. To evaluate how correctly these conventional prognostic guidelines for CAP reflect the severity of non-HIV PCP, we retrospectively analyzed 21 patients with non-HIV PCP.

Methods

A total of 21 patients were diagnosed by conventional staining and polymerase chain reaction (PCR) for respiratory samples with chest x-ray and computed tomography (CT) findings. We compared the severity of 21 patients with PCP classified by A-DROP, CURB-65, and PSI. Also, patients’ characteristics, clinical pictures, laboratory results at first visit or admission and intervals from diagnosis to start of specific-PCP therapy were evaluated in both survivor and non-survivor groups.

Results

Based on A-DROP, 18 patients were classified as mild or moderate; respiratory failure developed in 15 of these 18 (83.3%), and 7/15 (46.7%) died. Based on CURB-65, 19 patients were classified as mild or moderate; respiratory failure developed in 16/19 (84.2%), and 8 of the 16 (50%) died. In contrast, PSI classified 14 as severe or extremely severe; all of the 14 (100%) developed respiratory failure and 8/14 (57.1%) died. There were no significant differences in laboratory results in these groups. The time between the initial visit and diagnosis, and the time between the initial visit and starting of specific-PCP therapy were statistically shorter in the survivor group than in the non-survivor group.

Conclusions

Conventional prognostic guidelines for CAP could underestimate the severity of non-HIV PCP, resulting in a therapeutic delay resulting in high mortality. The most important factor to improve the mortality of non-HIV PCP is early diagnosis and starting of specific-PCP therapy as soon as possible.

Diffuse tract damage in the hemispheric deep white matter may correlate with global cognitive impairment and callosal atrophy in patients with extensive leukoaraiosis

BACKGROUND AND PURPOSE

Patients with extensive leukoaraiosis are at high risk for vascular dementia. However, these patients exhibit variable severity of global cognitive impairment correlating with callosal atrophy. We hypothesized that callosal atrophy may reflect the severity of HDWM tract damage, which may explain global cognitive impairment. The purpose of this study was to evaluate HDWM tract damage by DTI and to investigate whether HDWM tract damage is associated with callosal atrophy and global cognitive impairment, in patients with extensive leukoaraiosis.

MATERIALS AND METHODS

Twenty-four consecutive outpatients with extensive leukoaraiosis were enrolled prospectively. The patients underwent cognitive evaluation and 3T MR imaging. The intercorrelation between cognitive score, DA of the HDWM, callosal DA, and callosal volume was analyzed statistically. The correlation of the cognitive score with DA of the HDWM and the corpus callosum was also evaluated by voxel-based analyses by using TBSS.

RESULTS

The patients' MMSE scores varied from 10 to 30 (mean, 25.1 ± 6.0). Reduced DA of the HDWM, reduced callosal DA, and callosal atrophy intercorrelated significantly. All of these parameters showed a significant correlation with global cognitive impairment. TBSS analyses showed a significant correlation between MMSE score decline and reduced DA in the diffuse HDWM and the corpus callosum.

CONCLUSIONS

In patients with extensive leukoaraiosis, atrophy and reduced DA of the corpus callosum may indicate diffuse HDWM tract damage, which may explain global cognitive impairment and development of vascular dementia.

Zoonotic onchocerciasis in Hiroshima, Japan, and molecular analysis of a paraffin section of the agent for a reliable identification

Japan is a country of high specific diversity of Onchocerca with eight species, the adults of two not yet known. Onchocerca dewittei japonica, a common filarial parasite of wild boar, had been proved to be the agent of five zoonotic onchocerciasis in Kyushu island with morphological and molecular studies. The sixth case, at Hiroshima in the main island, was identified to the same Onchocerca species, based on adult characters observed on histological sections. To consolidate the identification, mitochondrial cytochrome c oxidase subunit 1 (CO1) gene analysis was attempted with the formalin-fixed, paraffin-embedded parasite specimen. The sequence (196 bp) of a CO1 gene fragment of the parasite successfully PCR-amplified agreed well with those of O. dewittei japonica registered in GenBank, confirming the morphological identification. Moreover a comparison with the CO1 gene sequences of six other Onchocerca species in GenBank excluded the possibility that Onchocerca sp. from wild boar and Onchocerca sp. type A from cattle in Japan, were the causative agents in this case. Mitochondrial DNA analysis proved to be a valuable tool to support the morphological method for the discrimination of zoonotic Onchocerca species in a histological specimen.