Cumulative antibiogram preparation among hospitals participating in the Japan Surveillance for Infection Prevention and Healthcare Epidemiology

BACKGROUND

The cumulative antibiogram is essential to guide empirical therapy for infectious diseases and monitor the trend of antimicrobial resistance. However, the status of antibiogram generation at medical institutions in Japan is uncertain.

METHODS

A web-based questionnaire survey was conducted in February 2023 on the status of antibiogram preparation among facilities participating in the Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE), an infection control surveillance system in Japan.

RESULTS

The questionnaire collection rate was 19.6% (379/1931). Of all facilities, 47% (178/379) performed microbiological tests mainly in-house, while 53% (201/379) performed microbiological tests mainly outsourced. Of all facilities, 78% (296/379) prepared antibiograms. Of those without antibiograms, 33% (27/83) were considering the development in the future. Some facilities cited staff shortage as a barrier to preparing antibiograms. Of the 214 facilities with antibiograms that could use the J-SIPHE system to prepare antibiograms, 19% (41/214) were using the J-SIPHE system to prepare their antibiograms.

CONCLUSIONS

One-quarter of the facilities that responded to the survey had not prepared antibiograms. Technical support for surveillance and awareness activity for using cumulative antibiograms might promote antibiogram preparation in Japan, which may improve antimicrobial stewardship and antimicrobial resistance measures.

Extracorporeal membrane oxygenation may decrease the plasma concentration of remdesivir in a patient with severe coronavirus disease 2019

Remdesivir is an antiviral drug that results in clinical improvement after five days of treatment and accelerates recovery by 31%. No studies have discussed the pharmacokinetic analysis of remdesivir in patients with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO). A 63-year-old American man who underwent mechanical ventilation and ECMO for severe COVID-19 was administered remdesivir for ten days. The loading dosage was 200 mg at 7 PM on day 12 and 100 mg daily at 0:00 PM from day 13–21, administered within 1 h. The pharmacokinetic analysis was performed. The serum creatinine concentration was within the normal range of 0.5–0.7 mg/dL during treatment. According to the pharmacokinetic analysis, the plasma concentrations of remdesivir and GS-441524 4 h after administration (C₄) were 662 ng/mL and 58 ng/mL, respectively, and the concentrations 18 h after administration (C₁₈) were 32 ng/mL and 44 ng/mL, respectively. Therefore, the half-life of remdesivir and GS-441524 was 3.2 and 35.1 h, respectively. Monitoring the plasma concentrations of remdesivir and GS-441524 in patients undergoing ECMO may be necessary.

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A COVID-19 patient undergoing ECMO was administered remdesivir.

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The loading dosage was 200 mg at 7:00 PM on day 12.

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From days 13–21, it was 100 mg daily at 0:00 PM administered within 1 h.

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The half-lives of remdesivir and GS-441524 were 3.2 and 35.1 h, respectively.

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Plasma concentrations of remdesivir and GS-441524 must be monitored during ECMO.

Reduced Cardiac Index Reserve and Hypovolemia in Severe Falciparum Malaria

BACKGROUND

Impaired microvascular perfusion is central to the development of coma and lactic acidosis in severe falciparum malaria. Refractory hypotension is rare on admission but develops frequently in fatal cases. We assessed cardiac function and volume status in severe falciparum malaria and its prognostic significance.

METHODS

Patients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography.

RESULTS

Patients with severe malaria had 38% shorter left ventricular (LV) filling times and 25% shorter LV ejection times than healthy participants because of tachycardia; however, stroke volume, LV internal diameter in diastole (LVIDd), and LV internal diameter in systole (LVIDs) indices were similar. A low endocardial fraction shortening (eFS) was present in 17% (9 of 52) of severe malaria patients. Adjusting for preload and afterload, eFS was similar in health and severe malaria. Fatal cases had smaller baseline LVIDd and LVIDs indices, more collapsible inferior vena cavae (IVC), and higher heart rates than survivors. The LVIDs and IVC collapsibility were independent predictors for mortality, together with base excess and Glasgow Coma Scale.

CONCLUSIONS

Patients with severe malaria have rapid ejection of a normal stroke volume. Fatal cases had features of relative hypovolemia and reduced cardiac index reserve.

Associations Between Restrictive Fluid Management and Renal Function and Tissue Perfusion in Adults With Severe Falciparum Malaria: A Prospective Observational Study

Background

Liberal fluid resuscitation has proved harmful in adults with severe malaria, but the level of restriction has not been defined.

Methods

In a prospective observational study in adults with severe falciparum malaria, restrictive fluid management was provided at the discretion of the treating physician. The relationships between the volume of fluid and changes in renal function or tissue perfusion were evaluated.

Results

A total of 154 patients were studied, 41 (26.6%) of whom died. Median total fluid intake during the first 6 and 24 hours from enrollment was 3.3 (interquartile range [IQR], 1.8–5.1) mL/kg per hour and 2.2 (IQR, 1.6–3.2) mL/kg per hour, respectively. Total fluid intake at 6 hours was not correlated with changes in plasma creatinine at 24 hours (n = 116; r_s = 0.16; P = .089) or lactate at 6 hours (n = 94; r_s = −0.05; P = .660). Development of hypotensive shock or pulmonary edema within 24 hours after enrollment were not related to the volume of fluid administration.

Conclusions

Restrictive fluid management did not worsen kidney function and tissue perfusion in adult patients with severe falciparum malaria. We suggest crystalloid administration of 2–3 mL/kg per hour during the first 24 hours without bolus therapy, unless the patient is hypotensive.

Septic shock with emphysematous cholecystitis and disseminated infection caused by hypervirulent Klebsiella pneumoniae capsular genotype K2-ST65 in a Japanese man with diabetes mellitus: A case report

Hypervirulent Klebsiella pneumoniae capsular genotypes K1 and K2 are common pathogens responsible for community-acquired liver abscesses and invasive infections especially in East Asia. We report a Japanese man with diabetes mellitus who rapidly developed emphysematous cholecystitis and fulminant disseminated infection with life-threatening multiple organ-system failure due to K. pneumoniae K2 strains belonging to sequence type 65. In East Asia, clinicians should be aware of fulminant infections caused by hypervirulent K2 strains in patients with community-acquired K. pneumoniae infections. Further epidemiological studies are warranted to elucidate the clinical features associated with the virulence K. pneumoniae K2 strains.

Cell-Free Hemoglobin Is Associated With Increased Vascular Resistance and Reduced Peripheral Perfusion in Severe Malaria

BACKGROUND

In severe falciparum malaria, unlike sepsis, hypotension on admission is uncommon. We hypothesized that low nitric oxide bioavailability due to the presence of cell-free hemoglobin (CFH) increases vascular tone in severe malaria.

METHODS

Patients with severe malaria (n = 119), uncomplicated malaria (n = 91), or suspected bacterial sepsis (n = 56), as well as healthy participants (n = 50), were recruited. The systemic vascular resistance index (SVRI) was estimated from the echocardiographic cardiac index and the mean arterial pressure.

RESULTS

SVRI and hematocrit levels were lower and plasma CFH and asymmetric dimethylarginine levels were higher in patients with malaria, compared with healthy participants. In multivariate linear regression models for mean arterial pressure or SVRI in patients with severe malaria, hematocrit and CFH but not asymmetric dimethylarginine were significant predictors. The SVRI was lower in patients with suspected bacterial sepsis than in those with severe malaria, after adjustment for hematocrit and age. Plasma CFH levels correlated positively with the core-peripheral temperature gradient and plasma lactate levels and inversely with the perfusion index. Impaired peripheral perfusion, as reflected by a low perfusion index or a high core-peripheral temperature gradient, predicted mortality in patients with severe malaria.

CONCLUSIONS

CFH is associated with mean arterial pressure, SVRI, and peripheral perfusion in patients with severe malaria. This may be mediated through the nitric oxide scavenging potency of CFH, increasing basal vascular tone and impairing tissue perfusion.

Challenges in treatment of disseminated nocardiosis in an elderly patient with renal failure on corticosteroids: a case report

We report the case of a 71-year-old Japanese man with a history of chronic kidney disease and sarcoidosis receiving chronic corticosteroids who presented with disseminated Nocardia brasiliensis infection. He initially showed improvement with empiric antimicrobial therapy including trimethoprim-sulfamethoxazole. However, he deteriorated after modifying the empiric regimen due to complicated hyperkalemia and ultimately died. In general, elderly patients have decreased renal function. Standard therapy for nocardiosis with trimethoprim-sulfamethoxazole may not be used for a prolonged period of time. This case emphasizes the challenges and importance of prudent selection of empiric antimicrobial therapy for disseminated nocardiosis in elderly patients with underlying kidney disease.

Clinically Infrequent Arcanobacterium haemolyticum Bacteremia Complicated by Foot Decubitus Ulcer: An Educational Reminder for Primary Care Physicians

An 81-year-old Japanese man with no history of diabetes mellitus was admitted to our hospital for a fever with a new ulcerative lesion on the left heel. Blood cultures on admission grew Arcanobacterium haemolyticum in aerobic bottles. He was therefore diagnosed with A. haemolyticum bacteremia and osteomyelitis complicated with foot decubitus ulcer. He was successfully treated with intravenous antibiotic therapy and debridement of the left heel. Our case and literature review show that it is important to recognize that A. haemolyticum is a systemic causative pathogen in immunocompetent patients in primary care practice.

Outbreak of Trichinella T9 Infections Associated with Consumption of Bear Meat, Japan

An outbreak of trichinellosis occurred in Japan in December 2016. All case-patients had eaten undercooked bear meat, from which Trichinella larvae were subsequently isolated. DNA sequencing analysis of the mitochondrial genes cytochrome c-oxidase subunit 1 and internal transcribed spacer 2 confirmed that Trichinella T9 had caused the outbreak.

Does reduced oxygen delivery cause lactic acidosis in falciparum malaria? An observational study

Background

Lactic acidosis with an elevated lactate–pyruvate ratio suggesting anoxia is a common feature of severe falciparum malaria. High lactate levels are associated with parasitized erythrocyte sequestration in the microcirculation. To assess if there is an additional contribution to hyperlactataemia from relatively inadequate total oxygen delivery, oxygen consumption and delivery were investigated in patients with malaria.

Methods

Adult Bangladeshi and Indian patients with uncomplicated (N = 50) or severe (N = 46) falciparum malaria or suspected bacterial sepsis (N = 27) and healthy participants as controls (N = 26) were recruited at Chittagong Medical College Hospital, Chittagong, Bangladesh and Ispat General Hospital, Rourkela, India. Oxygen delivery (DO₂I) was estimated from pulse oximetry, echocardiographic estimates of cardiac index and haematocrit. Oxygen consumption (VO₂I) was estimated by expired gas collection.

Results

VO₂I was elevated in uncomplicated median (IQR) 185.1 ml/min/m² (135–215.9) and severe malaria 192 ml/min/m² (140.7–227.9) relative to healthy persons 107.9 ml/min/m² (69.9–138.1) (both p < 0.001). Median DO₂I was similar in uncomplicated 515 ml/min/m² (432–612) and severe 487 ml/min/m² (382–601) malaria and healthy persons 503 ml/min/m² (447–517) (p = 0.27 and 0.89, respectively). The VO₂/DO₂ ratio was, therefore, increased by similar amounts in both uncomplicated 0.35 (0.28–0.44) and severe malaria 0.38 (0.29–0.48) relative to healthy participants 0.23 (0.17–0.28) (both p < 0.001). VO₂I, DO₂I and VO₂/DO₂ did not correlate with plasma lactate concentrations in severe malaria.

Conclusions

Reduced total oxygen delivery is not a major contributor to lactic acidosis in severe falciparum malaria.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2733-y) contains supplementary material, which is available to authorized users.

Acetaminophen as a Renoprotective Adjunctive Treatment in Patients With Severe and Moderately Severe Falciparum Malaria: A Randomized, Controlled, Open-Label Trial

Background

Acute kidney injury independently predicts mortality in falciparum malaria. It is unknown whether acetaminophen's capacity to inhibit plasma hemoglobin-mediated oxidation is renoprotective in severe malaria.

Methods

This phase 2, open-label, randomized controlled trial conducted at two hospitals in Bangladesh assessed effects on renal function, safety, pharmacokinetic (PK) properties and pharmacodynamic (PD) effects of acetaminophen. Febrile patients (>12 years) with severe falciparum malaria were randomly assigned to receive acetaminophen (1 g 6-hourly for 72 hours) or no acetaminophen, in addition to intravenous artesunate. Primary outcome was the proportional change in creatinine after 72 hours stratified by median plasma hemoglobin.

Results

Between 2012 and 2014, 62 patients were randomly assigned to receive acetaminophen (n = 31) or no acetaminophen (n = 31). Median (interquartile range) reduction in creatinine after 72 hours was 23% (37% to 18%) in patients assigned to acetaminophen, versus 14% (29% to 0%) in patients assigned to no acetaminophen (P = .043). This difference in reduction was 37% (48% to 22%) versus 14% (30% to -71%) in patients with hemoglobin ≥45000 ng/mL (P = .010). The proportion with progressing kidney injury was higher among controls (subdistribution hazard ratio, 3.0; 95% confidence interval, 1.1 to 8.5; P = .034). PK-PD analyses showed that higher exposure to acetaminophen increased the probability of creatinine improvement. No patient fulfilled Hy's law for hepatotoxicity.

Conclusions

In this proof-of-principle study, acetaminophen showed renoprotection without evidence of safety concerns in patients with severe falciparum malaria, particularly in those with prominent intravascular hemolysis.

Clinical Trials Registration

NCT01641289.

Campylobacter fetus meningitis associated with eating habits of raw meat and raw liver in a healthy patient: A case report and literature review

Meningitis caused by the zoonotic pathogen Campylobacter fetus in immunocompetent adults is rare. We report a 48-year-old Japanese woman with no underlying disease who was found to have meningitis caused by C. fetus. Both C. fetus subsp. fetus and C. fetus subsp. venerealis were isolated from the cerebrospinal fluid culture. The mode of infection in our patient was considered to be associated with the consumption of raw beef and raw cattle liver on a regular basis. Public awareness and education to avoid the consumption of raw or undercooked meat might help prevent C. fetus meningitis.

Disease Severity and Effective Parasite Multiplication Rate in Falciparum Malaria

Patients presenting with severe falciparum malaria in a Bangladeshi tertiary hospital had higher total parasite burden, estimated by parasitemia and plasma PfHRP2, than uncomplicated malaria patients despite shorter fever duration. This suggests that higher parasite multiplication rates (PMR) contribute to causing the higher biomass found in severe disease. Compared with patients without a history of previous malaria, patients with previous malaria carried a lower parasite biomass with similar fever duration at presentation, suggesting that host immunity reduces the PMR.

Cell-free hemoglobin mediated oxidative stress is associated with acute kidney injury and renal replacement therapy in severe falciparum malaria: an observational study

BACKGROUND

Intravascular hemolysis is an intrinsic feature of severe malaria pathophysiology but the pathogenic role of cell-free hemoglobin-mediated oxidative stress in severe malaria associated acute kidney injury (AKI) is unknown.

METHODS

As part of a prospective observational study, enrolment plasma cell-free hemoglobin (CFH), lipid peroxidation markers (F₂-isoprostanes (F₂-IsoPs) and isofurans (IsoFs)), red cell deformability, and serum creatinine were quantified in Bangladeshi patients with severe falciparum malaria (n = 107), uncomplicated malaria (n = 80) and sepsis (n = 28). The relationships between these indices and kidney function and clinical outcomes were examined.

RESULTS

AKI was diagnosed at enrolment in 58% (62/107) of consecutive patients with severe malaria, defined by an increase in creatinine ≥1.5 times expected baseline. Severe malaria patients with AKI had significantly higher plasma cell-free hemoglobin (geometric mean CFH: 8.8 μM; 95% CI, 6.2-12.3 μM), F₂-isoprostane (56.7 pg/ml; 95% CI, 45.3-71.0 pg/ml) and isofuran (109.2 pg/ml; 95% CI, 85.1-140.1 pg/ml) concentrations on enrolment compared to those without AKI (CFH: 5.1 μM; 95% CI, 4.0-6.6 μM; P = 0.018; F₂-IsoPs: 27.8 pg/ml; 95% CI, 23.7-32.7 pg/ml; P < 0.001; IsoFs: 41.7 pg/ml; 95% CI, 30.2-57.6 pg/ml; P < 0.001). Cell-free hemoglobin correlated with markers of hemolysis, parasite burden (P. falciparum histidine rich protein 2 (PfHRP2)), and F₂-IsoPs. Plasma F₂-IsoPs and IsoFs inversely correlated with pH, positively correlated with creatinine, PfHRP2 and fractional excretion of sodium, and were higher in patients later requiring hemodialysis. Plasma F₂-IsoP concentrations also inversely correlated with red cell deformability and were higher in fatal cases. Mixed effects modeling including an interaction term for CFH and time showed that F₂-IsoPs, IsoFs, PfHRP2, CFH, and red cell rigidity were independently associated with increasing creatinine over 72 h. Multivariable logistic regression showed that admission F₂-IsoPs, IsoFs and red cell deformability were associated with the need for subsequent hemodialysis.

CONCLUSIONS

Cell-free hemoglobin and lipid peroxidation are associated with acute kidney injury and disease severity in falciparum malaria, suggesting a pathophysiological role in renal tubular injury. Evaluation of adjunctive therapies targeting cell-free hemoglobin-mediated oxidative stress is warranted.

Genotypic and phenotypic characterization of G6PD deficiency in Bengali adults with severe and uncomplicated malaria

BACKGROUND

Control of malaria increasingly involves administration of 8-aminoquinolines, with accompanying risk of haemolysis in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Few data on the prevalence and genotypic basis of G6PD deficiency are available from Bangladesh, where malaria remains a major problem in the South (Chittagong Division). The aim of this study was to determine the prevalence of G6PD deficiency, and associated G6PD genotypes, in adults with falciparum malaria in southern Bangladesh.

METHODS

G6PD status was assessed via a combination of fluorescent spot testing (FST) and genotyping in 141 Bengali patients admitted with falciparum malaria to two centres in Chittagong Division from 2012 to 2014. In addition, an analysis of genomic data from 1000 Genomes Project was carried out among five healthy Indian subcontinent populations.

RESULTS

One male patient with uncomplicated malaria was found to have G6PD deficiency on FST and a genotype associated with deficiency (hemizygous Orissa variant). In addition, there were two female patients heterozygous for deficiency variants (Orissa and Kerala-Kalyan). These three patients had a relatively long duration of symptoms prior to admission compared to G6PD normal cases, possibly suggesting an interaction with parasite multiplication rate. In addition, one of 27 healthy local controls was deficient on FST and hemizygous for the Mahidol variant of G6PD deficiency. Examination of 1000 Genomes Project sequencing data across the Indian subcontinent showed that 19/723 chromosomes (2.63%) carried a variant associated with deficiency. In the Bengali from Bangladesh 1000 Genomes population, three of 130 chromosomes (2.31%) carried deficient alleles; this included single chromosomes carrying the Kerala-Kalyan and Orissa variants.

CONCLUSIONS

In line with other recent work, G6PD deficiency is uncommon in Bengalis in Bangladesh. Further studies of particular ethnic groups are needed to evaluate the potential risk of wide deployment of primaquine in malaria control efforts in Bangladesh.

Bacteremic renal stone-associated urinary tract infection caused by nontypable Haemophilus influenzae: A rare invasive disease in an immunocompetent patient

Haemophilus species are known to colonize the upper respiratory tract and can cause infections. However Haemophilus influenzae has been rarely described as a cause of genitourinary tract infection. We report a 44-year-old nonimmunocompromised Japanese man with bacteremic pyelonephritis caused by a nontypable H. influenzae associated with a left ureteral calculus. The organism was isolated from both blood and urine cultures. Treatment consisted of 14 days of intravenous ceftriaxone and oral amoxicillin one after than other and insertion of a left ureteral stent. After discharge, he underwent extracorporeal shock wave lithotrity for the left ureteral calculus. He had no recrudescence of the symptoms. H. influenzae should be considered as a genitourinary pathogen among patients with certain risk factors such as anatomical or functional abnormality of genitourinary tract. Collaboration between clinicians and microbiology laboratory personnel is essential for correct identification of the organism and appropriate therapy for genitourinary tract infections due to this organism.

Refractory to treat Helicobacter cinaedi bacteremia with bilateral lower extremities cellulitis in an immunocompetent patient

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The patient had bacteremia and cellulitis due to Helicobacter cinaedi.

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This reports an immunocompetent patient with bilateral cellulitis in the lower extremities.

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This patient had recurrent symptoms required a twelve week prolonged antimicrobial therapy.

Helicobacter cinaedi is known to cause bacteremia with multi-focal cellulitis, usually, among immunocompromised patients. We report here a 54-year-old Japanese man who was found to have bacteremia complicated with bilateral lower extremities cellulitis due to H. cinaedi. This patient did not have any immunocompromised conditions including Human Immunodeficiency Virus infection. In this patient, the cellulitis was multi-focal which is rare among immunocompetent patients. In addition, interestingly, the cellulitis was symmetrically on the both sides on the lower dorsal part of the extremities. The patient was treated with meropenem, which was considered as one of the best available agents, however, he required a prolonged antimicrobial treatment. During the admission, he underwent colonoscopy which was unremarkable, and his stool culture was also negative while on meropenem. Subsequently, he developed recurrent symptoms of the right lower extremity twice and each time he was treated with intravenous meropenem followed by oral minocycline. After the total of 12 weeks of antimicrobial treatment, his symptoms subsided. Clinicians should be aware of this organism when treating multi-focal, or symmetrical cellulitis even if the patients are immunocompetent.

[A Patient with a Wedge-shaped Pulmonary Lesion Associated with Streptococcus parasanguinis]

An 84-year-old man was admitted to our hospital with bloody sputum. He was found to have a right lower lobe wedge-shaped nodular lesion with chest X-ray and computed tomography of the chest. Ceftriaxone and minocycline were started empirically based on a working diagnosis of community-acquired pneumonia. Streptococcus parasanguinis was isolated with sputum cultures obtained on three consecutive days and was identified based on its biochemical properties. S. parasanguinis is a member of the sanguinis group of viridans Streptococci. It is known as a causative pathogen for endocarditis. There are very few reports of S. parasanguinis associated with pulmonary infections. The present report describes the association of S. parasanguinis with a wedge-shaped nodular lesion in the lungs.

Sequestration and Red Cell Deformability as Determinants of Hyperlactatemia in Falciparum Malaria

Background. Hyperlactatemia is a strong predictor of mortality in severe falciparum malaria. Sequestered parasitized erythrocytes and reduced uninfected red blood cell deformability (RCD) compromise microcirculatory flow, leading to anaerobic glycolysis.

Methods. In a cohort of patients with falciparum malaria hospitalized in Chittagong, Bangladesh, bulk RCD was measured using a laser diffraction technique, and parasite biomass was estimated from plasma concentrations of Plasmodium falciparum histidine-rich protein 2 (PfHRP2). A multiple linear regression model was constructed to examine their associations with plasma lactate concentrations.

Results. A total of 286 patients with falciparum malaria were studied, of whom 224 had severe malaria, and 70 died. Hyperlactatemia (lactate level, ≥4 mmol/L) was present in 111 cases. RCD at shear stresses of 1.7 Pa and 30 Pa was reduced significantly in patients who died, compared with survivors, individuals with uncomplicated malaria, or healthy individuals (P < .05, for all comparisons). Multiple linear regression analysis showed that the plasma PfHRP2 level, parasitemia level, total bilirubin level, and RCD at a shear stress of 1.7 Pa were each independently correlated with plasma lactate concentrations (n = 278; R² = 0.35).

Conclusions. Sequestration of parasitized red blood cells and reduced RCD both contribute to decreased microcirculatory flow in severe disease.

Low prevalence of active cytomegalovirus infection in a cardiovascular intensive care unit

Active cytomegalovirus infection is not uncommon in critically ill non-immunosuppressed patients. We conducted a preliminary observational study to determine the prevalence of active cytomegalovirus infection in cardiovascular surgical patients. One hundred patients admitted to the intensive care unit following cardiovascular surgery were enrolled between January 2010 and May 2010. Four patients (4%) were positive for serum pp65 antigens, though cytomegalovirus-positive serology (immunoglobulin G, IgG) was found in 98 patients (98%) including those four patients. Active cardiac diseases and their operative procedures including cardiopulmonary bypass may not be significant risk factors for active cytomegalovirus infection unless systemic derangements are also present.

Synovitis of the wrist caused by Mycobacterium florentinum

Mycobacterium florentinum is a newly identified, rare, slow-growing species of nontuberculous mycobacteria (NTM). Here, we report a case of M. florentinum-induced synovitis of the wrist in an immunocompromised Japanese patient. M. florentinum was identified by sequence analysis of the rpoB, hsp65, and 16S rRNA genes. The M. florentinum strain in this study could not be differentiated from certain M. triplex strains by the hsp65 or 16S rRNA sequences alone, because they occasionally shared more than 99 % sequence identity. The isolated M. florentinum strain was only susceptible to clarithromycin and amikacin. Initially, the patient was treated with clarithromycin, levofloxacin, and ethambutol, and then with clarithromycin, levofloxacin, and rifampicin. To our knowledge, M. florentinum-induced synovitis has not been previously reported. Our results suggest that, in addition to other well-known pathogenic NTM, the recently identified M. florentinum strain should be considered as a possible cause of synovitis. Moreover, we should be cautious when identifying M. florentinum because this strain closely resembles M. triplex in genotype.

A cross-sectional study of the association between circulating 25-hydroxyvitamin D levels and predicted operative mortality of patients with cardiovascular disease

Recent studies have suggested that low levels of 25-hydroxyvitamin D (25OHD) are associated with cardiovascular risks in medical patients. However, these associations have not been well documented in high risk surgical patients. We hypothesized that serum 25OHD, 1,25-dihydroxyvitamin D (1,25OHD) would be associated with the cardiac operative risk stratification score. The study was conducted with a cross-sectional design at a single academic medical center in Japan. Two hundred five adult patients scheduled for major cardiovascular surgery were included consecutively. Cardiac operative risk was evaluated with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) scoring system. Correlations between 25OHD and 1,25OHD, and EuroSCORE were assessed using simple and multiple linear regression models. Mean 25OHD and 1,25OHD were 20.1 ± 7.1 ng/mL and 51.2 ± 19.2 pg/mL, respectively. Half and 88% of the study population showed deficient (<20 ng/mL) and insufficient (<30 ng/mL) 25OHD levels, respectively. In contrast, only 3% showed 1,25OHD levels lower than normal (<20 pg/mL). Circulating 25OHD levels, but not 1,25OHD levels, were negatively correlated with EuroSCORE (p=0.005) even after adjusted for body mass index, albumin, hypertension, dyslipidemia, diabetes mellitus, creatinine, use of statin, high sensitive C-reactive protein, and intact parathyroid hormone. These results suggest that serum 25OHD levels are inversely associated with operative risk severity of patients undergoing major cardiovascular surgery.

Fulminant amebic colitis in an HIV-infected homosexual man

We present a case of fulminant amebic colitis in a human immunodeficiency virus (HIV)-infected homosexual man. The patient developed colonic perforation over a short time despite empirical therapy with metronidazole, and underwent right hemicolectomy. Amebic colitis was pathologically diagnosed by identifying invasive trophozoites of Entamoeba in a surgical specimen. Amebic colitis is one of the important differential diagnoses of acute abdomen in HIV-infected patients and/or homosexual men, especially in East Asia. Although fulminant amebic colitis is a rare manifestation of amebiasis, early diagnosis and treatment are thought to be important to improve the outcome of this highly fatal complication.

Intracranial hemorrhage associated with cerebrospinal fluid drainage during thoraco-abdominal aortic surgery

A 69-year-old woman underwent thoraco-abdominal aortic aneurysm repair with cerebrospinal fluid drainage (CSFD). The initial CSF pressure was elevated to approximately 25 cmH(2)O, and clear CSF was continuously drained at a rate of 30 ml/h with the drainage level at 10-20 cmH(2)O. The CSF became bloody when cardiopulmonary bypass was terminated. The total volume of CSF drained was approximately 300 ml at the conclusion of the 638 min operation. Three hours later, she suffered a series of generalized seizures because of intracranial hemorrhage (ICH). It was suggested that excessive drainage of CSF was associated with ICH. Meticulous control of drainage volume combined with standard pressure-based management may be the key to avoiding these complications.

Group G streptococcal bacteremia and vertebral osteomyelitis in a homosexual man with amebic colitis

We present a case of bacteremia caused by group G streptococci (GGS) and vertebral osteomyelitis in a homosexual man with amebic colitis. The organism likely entered the blood via the inflamed intestinal mucosa resulting from amebiasis. Arthritis of both hands, which probably represented poststreptococcal reactive arthritis, was also observed. We should be aware that diseases caused by GGS appear to be increasing in recent years, and a potential for serious infection exists with regard to GGS as well as group A streptococci.

Malignant fibrous histiocytoma of soft tissue producing granulocyte colony-stimulating factor

We treated a rare case of malignant fibrous histiocytoma (MFH) of soft tissue that produced granulocyte colony-stimulating factor (G-CSF). The patient, an 80-year-old woman, was admitted because of a feeling of abdominal fullness and leg edema. An elastic, hard, tender tumor was palpated in the right thigh. Histopathological examinations of the tumor revealed atypical and prominent pleomorphic spindle-shaped cells with funicular arrangement, which were compatible with the diagnosis of MFH. Prominent leukocytosis (up to 84,300/microl), a high serum G-CSF concentration (82 pg/ml) and positive immunohistochemical staining of the tumor tissue for G-CSF indicated that G-CSF was produced by the MFH.

Diagnostic usefulness of diffusion-weighted magnetic resonance imaging in influenza-associated acute encephalopathy or encephalitis

A magnetic resonance imaging (MRI) study was performed for a 20-month-old girl with an influenza type A infection who presented acute encephalopathy. Conventional MRI performed 8 days after the onset of encephalopathy, including T1-weighted, T2-weighted, and fluid-attenuated inversion recovery imaging, revealed only vague lesions in the right frontal, temporal, and parietal lobes. In contrast, diffusion-weighted imaging (DWI) then demonstrated the lesions much more intensively. On the 26th day, the lesions previously observed on DWI had become less discernible. The hyperintensity observed on DWI might reflect cytotoxic edema. Thus, DWI may be useful for evaluation of acute influenzal encephalopathy/encephalitis.

Possible role of an endovascular provocative test in the diagnosis of glossopharyngeal neuralgia as a vascular compression syndrome

We utilized endovascular provocative techniques to identify the indications for microvascular decompression surgery in a serious case of glossopharyngeal neuralgia. This is the first reported case in which an endovascular provocative test was applied for diagnosis of glossopharyngeal neuralgia as a vascular compression syndrome. A 68-year-old woman presented with severe paroxysmal facial pain which could not be controlled by medical therapy. Partial effectiveness to carbamazepine led us to wonder whether or not the selection of microvascular decompression surgery would be appropriate. Pre-operative angiography was performed. During the examination a microcatheter was inserted into the right posterior inferior cerebellar artery (PICA), and an attack of typical glossopharyngeal neuralgia occurred. The patient thus underwent microvascular decompression surgery. The PICA was verified to compress the glossopharyngeal nerve and therefore was moved to induce decompression. The patient has since experienced no further pain for one year postoperatively. The diagnosis of glossopharyngeal neuralgia is sometimes complex and it is difficult to select the most appropriate surgical modality. In such cases this endovascular provocative technique may thus be useful for making a definitive decision or microvascular decompression surgery.

[Schizencephaly: clinical and MRI features]

We report the clinical and neuroimaging features of 4 cases with schizencephaly. Case 1 had bilateral schizencephaly with open-lip on the right and closed-lip on the left. Case 2 had unilateral schizencephaly with closed-lip on the left and subcortical heterotopia on the right. Case 3 had unilateral schizencephaly with closed-lip on the left. Case 4 had bilateral closed-lip schizencephaly. Although all cases except for Case 3 had bilateral lesions, neurodevelopmental outcome was generally good; Case 1 and 3 had mild hemiparesis. All patient have epilepsy which are well-controlled with antiepileptic drugs. Thus, the clinical presentation of schizencephaly, even if bilateral lesions, are quite variable.

The role of ATP-sensitive potassium channels in the mechanism of ischemic preconditioning

We clarified the role of K(ATP) channels in the mechanism of ischemic preconditioning by using K(ATP) channel opener, nicorandil, and K(ATP) channel inhibitor, glibenclamide. Forty anesthetized dogs were divided into five groups: (a) control (C), (b) ischemic preconditioning (PC), (c) intravenous infusion of nicorandil before PC (Ni), (d) glibenclamide pretreated with PC (Gl + PC), and (e) glibenclamide pretreated with Ni (Gl + Ni). All groups were followed by 60-min ischemia and 60-min reperfusion and analyzed by the biochemical procedures. At the end of 60-min reperfusion, percentage of segment shortening in C indicated paradoxic bulging. This value was significantly recovered in PC and Ni, but it was still negative in Gl + PC and Gl + Ni. Ca2+ -adenosine triphosphatase (ATPase) activity of sarcoplasmic reticulum (SR) was significantly decreased in C. In PC and Ni, this activity was significantly maintained; however, in Gl + PC and Gl + Ni, it was similar to that in C. State III respiration of mitochondria showed similarity to the changes in SR. These results indicated that the K(ATP) channel opener enhanced the effects of ischemic preconditioning, and its blockade abolished these phenomena. We conclude that the ATP-sensitive potassium channel may play one of key roles in the mechanisms of ischemic preconditioning in the dog model.

[Usefulness of T2* weighted magnetic resonance image in the diagnosis of head injury on chronic stage]

T2* weighted gradient echo image has heightened diagnostic sensitivity to hemorrhage, which is attributed to magnetic susceptibility-induced static field inhomogeneities arising from paramagnetic blood breakdown products such as hemosiderin, which shorten T2*. We examined 4 cases of head injury in chronic stage by T2* weighted images and assessed the clinical application of this sequence for diagnosis of the intracranial lesion. All patients underwent CT scan on acute stage and long-term follow up was performed. In all cases, abnormally low signals in the brain and subarachnoid space were more conspicuous with the T2* weighted image than with any of the conventional sequences. In 2 cases with diffuse axonal injury, of which lesions were not detected on acute stage CT scan, hypointensity area was clearly demonstrated in the cerebral peduncle and corpus callosum on T2* weighted images. Selection of T2* weighted image into the routine MR examination of patients with chronic stage of the head injury is recommended.

Generation of free radicals and the damage done to the sarcoplasmic reticulum during reperfusion injury following brief ischemia in the canine heart

Free radical generation was studied by the electron spin resonance (ESR) technique using alpha-phenyl N tert butyl nitrone (PBN) in a brief ischemia-reperfusion model of the canine heart, and correlated with biochemical changes of the sarcoplasmic reticulum (SR). ESR spectra (aH=0.3-0.4mT, aN=1.43-1.58mT) were observed as PBN spin adducts, which peaked at levels 5-fold above the control levels at 5 min after reperfusion. The simulated coupling constants of PBN spin adducts suggested that the sample should contain at least 2 carbon-centered radicals at 5 min after reperfusion (radical A: aH=0.350mT, aN=1.485mT; radical B: aH=0.370mT, aN=1.615 mT). At this time point, a significant reduction in Ca-ATPase activity of the SR was found without degradation of the major ATPase protein. Superoxide dismutase (SOD) significantly reduced the intensity of the PBN spin adduct signals and preserved the Ca-ATPase activity of the SR to 80% of the control level. Reperfusion injury after brief ischemia may be the result of inactivation of intracellular Ca-ATPase by free radicals generated during reperfusion, and SOD contributes to the protective effect by scavenging the radicals.

Biochemical and ultrastructural evaluations of the effect of ischemic preconditioning on ischemic myocardial injury--role of the adenosine triphosphate-sensitive potassium channel

The aim of this study was to clarify the role of the adenosine triphosphate (ATP)-sensitive potassium channel on the mechanism of ischemic preconditioning (IP). Thirty-five anesthetized dogs were divided into 5 groups: (1) Control (C), (2) IP, (3) intravenous infusion of nicorandil (Ni) prior to IP, (4) glibenclamide (G1) pretreated with IP (G1+IP), and (5) G1 pretreated with Ni (G1+Ni). All groups had 60 min ischemia followed by 60 min reperfusion, and were analyzed by biochemical and morphological procedures. At the end of the 60-min reperfusion, %segment shortening in C indicated paradoxical bulging. This value had significantly recovered in IP and Ni groups, but it was still negative in the G1+IP and G1+Ni groups. Ca++-ATPase activity of the sarcoplasmic reticulum (SR) was significantly decreased in C. In the IP and Ni groups, this activity was significantly maintained; however, in the G1+IP and G1+Ni groups it was similar to that in C. State 3 respiration of mitochondria showed similar changes in the SR. In the ultrastructural observations, severely damaged cells were not observed in the IP and Ni groups. These results indicated that an ATP-sensitive potassium channel opener enhanced the effects of IP and its blockade abolished these phenomena. It was conclude that the ATP-sensitive potassium channel may play a key role in the mechanism of IP.

Protective effect of captopril on ischemic myocardium

The protective effect and mechanism of action of the angiotensin-converting enzyme inhibitor (ACE-I) captopril was investigated in organelles from ischemic myocardial cells in a canine coronary ligation model. Sarcoplasmic reticulum (SR) and mitochondrial fractions were extracted from ischemic and nonischemic myocardial cells from captopril- and saline-treated (control) hearts. Heart rate, cardiac output, and right ventricular systolic blood pressure were similar in the captopril-treated and control groups. Left ventricular systolic blood pressure (LVPs) decreased gradually to 89% of the baseline value after captopril administration, and to 78% of the baseline value after ligation. Ca-ATPase activity in the SR, the respiratory control ratio (RCR) in the mitochondria, and dinitrophenol (DNP)-stimulated ATPase activity were significantly higher in ischemic myocardium from the captopril-treated group than from the saline-treated (control) group. The SH group content of both organelles was higher in the captopril-treated group. Our results suggest that, in addition to their hemodynamic effects, ACE-I agents containing SH groups protect the myocardium from ischemic damage by preventing enzyme oxidation.

Effect of mammalian growth hormone on amino nitrogen mobilization in the eel

Hypophysectomy decreased plasma amino nitrogen (PAN) levels of Japanese eels. In contrast, administration of bovine or ovine growth hormone (GH; 2 micrograms/g) produced a delayed increase in PAN levels of both intact and hypophysectomized eels 48 hr after GH injection. The minimum dose of GH required to elevate PAN levels was found to be 0.1-1 micrograms/g body wt. The fact that GH treatment also increased PAN of hepatectomized eels indicates that the increased PAN was at least partly caused by the increased mobilization of amino nitrogen from body protein. GH also increased plasma free fatty acid content of intact and hypophysectomized eels 48 hr after GH injection in one experiment of the present study, but this effect was not reproducible in other experiments. No effect of GH administration was observed either in plasma glucose and lipid of intact and hypophysectomized eels 48 hr after the injection.

In vivo and in vitro effects of growth hormone on the incorporation of [14C]leucine into protein of liver and muscle of the eel

In vivo administration of ovine GH (2 micrograms/g body wt) increased [14C]leucine incorporation into protein of the liver, skeletal muscle, and opercular muscle of hypophysectomized eels. Addition of ovine GH into the medium (5 micrograms/ml) slightly increased [14C]leucine incorporation into protein of liver slices during 5 hr in vitro incubation, but did not affect protein synthesis from [14C]leucine in opercular muscle. In vivo pretreatment with ovine GH (2 micrograms/g body wt) 48 hr prior to tissue preparation clearly increased [14C]leucine incorporation into protein of liver slices in vitro. However, no statistically significant change was observed for in vitro incorporation of [14C]leucine into protein of opercular muscle of hypophysectomized eels which had been previously treated with ovine GH (2 micrograms/g body wt). These results indicate that ovine GH has a protein anabolic action in the liver and muscle of the eel and that compared to mammals a rather long lag period is needed to elicit such protein anabolic actions of GH in these animals.

Catecholamines in experimental spinal cord lesions associated with spinal arachnoiditis

Catecholamines in the spinal cord and cerebrospinal fluid of dogs with arachnoiditis induced by cisternal kaolin injection were measured by radioenzymatic assay. The levels of noradrenaline in the gray matter of the cervical cord and the cerebrospinal fluid were highest in 1st week (mean values, 127.8 ng/g and 856.0 pg/ml), whereas those in the gray matter of the thoracic and thoracolumbar cord increased to 175.0 and 210.0 ng/g in average respectively in 12th week. The increase in the level of noradrenaline in the gray matter seemed to be related with degenerative cord lesions in almost all segments, while most segments with cavitation indicated low noradrenaline level.

Effects of insulin and glucagon on amino acid transport into the liver and opercular muscle of the eel in vitro

Effects of insulin and glucagon on amino acid transport in vitro into liver slices and the opercular muscle of the eel were studied using a labeled nonmetabolizable amino acid analog, alpha-[1-14C]aminoisobutyric acid (AIB). Addition of insulin (0.1 IU/ml) to the medium increased the radioactivity in the deproteinized fractions of both the liver slices and opercular muscle, indicating an accelerated movement of this amino acid analog into these tissues. Glucagon (5 micrograms/ml) also enhanced the entry of [14C]AIB into the liver slices; however, treatment of opercular muscle with glucagon did not alter the radioactivity in the deproteinized fraction. These findings clearly indicate that the entry of amino acids into eel tissues independent of protein synthesis can be altered by insulin and glucagon.

Effects of insulin and glucagon on the incorporation of [14C]glycine into the protein of the liver and opercular muscle of the eel in vitro

Effects of insulin and glucagon on the incorporation of [14C]glycine into the protein of liver slices and the opercular muscle of the eel were studied in vitro. Addition of insulin (0.1 IU/ml) to the medium increased the radioactivity both of the trichloroacetic acid (TCA)-soluble fraction and of the protein of the opercular muscle, indicating an acceleration by the hormone both of entry of the amino acid into the tissue and of protein synthesis. Insulin also increased the incorporation of [14C]glycine into the liver protein, while a decrease in the radioactivity of the TCA-soluble fraction was observed. These findings suggest that the hormone accelerated protein synthesis at the expense of an intracellular amino acid pool. In contrast, glucagon (5 micrograms/ml) did not affect the radioactivity either of the TCA-soluble fraction or of protein for either the opercular muscle or the liver. Thus, the present results highlight the importance of insulin in the regulation of protein synthesis in the eel both in muscle and in liver.