An infantile late-onset case Group of B Streptococcus meningitis diagnosed with a rapid latex kit

Globally, vaccination has reduced the prevalence of meningitis caused by Streptococcus pneumoniae Neisseria meningitidis, and Haemophilus influenzae. However, neonatal Group B Streptococcus (GBS) meningitis continues to remain a problematic infection of the central nervous system. Here, we report a case of bacterial meningitis in a 34-day old male baby who presented with fever. A cerebrospinal fluid (CSF) test on the day of admission showed an increase in cell count with decreased glucose level. A rapid latex test of the CSF using a commercial kit diagnosed the causative pathogen as GBS. We administered the antibiotics ampicillin, cefotaxime, gentamicin and panipenem/betamipron to the patient for over 14 days. Partial seizures were frequently observed during the course and were well-controlled with midazolam and phenobarbital. Brain magnetic resonance imaging on day 17 showed subdural hygroma in the frontal region, and 99mTc ethyl-cysteinate dimer-single photon emission computed tomography confirmed a decreased cerebral blood flow predominantly in the left frontal region. After three years of follow-up, the condition of the patient improved without any neurological sequelae. Our report highlights that rapid identification of the causative organism is essential in infantile late-onset meningitis. In addition, we consider that the latex kit-based rapid testing of CSF is beneficial for identifying the causative agent of bacterial meningitis.

IgG4-related sclerosing cholangitis may be a risk factor for cancer

BACKGROUND/PURPOSE

The relationship between autoimmune pancreatitis (AIP) and malignancy has been reported. However, the potential risk for cancer in patients with immunoglobulin 4 (IgG4)-related sclerosing cholangitis (IgG4-SC) is unclear. The present study aimed to evaluate the incidence of cancer in IgG4-SC patients.

METHODS

We retrospectively collected clinical data for 121 patients diagnosed with IgG4-SC from 7 hospitals. We calculated the standardized incidence ratio (SIR) of cancer in IgG4-SC patients based on the national cancer rates. The SIR of the period after the diagnosis of IgG4-SC were calculated.

RESULTS

The mean follow-up period was 6.4 years, with 121 IgG4-SC patients. During the follow-up period, 26 patients had cancer, and 29 cancers were diagnosed. The SIR of cancer after the diagnosis of IgG4-SC was 1.90 (95% confidence interval [CI] 1.67-2.21). The SIR of pancreatic and bile duct cancer was 10.30 and 8.88, respectively. The SIR of cancer in <1 year, 1-5 years, and >5 years after diagnosis of IgG4-SC were 2.58, 1.01, and 2.44, respectively.

CONCLUSIONS

IgG4-SC patients have a high risk of cancer including pancreatic and bile duct cancer. The risk of cancer was high less <1 year and >5 years after diagnosis of IgG4-SC. Therefore, IgG4-SC patients may require careful long-term follow-up.

Protein-losing enteropathy in an infant with severe atopic dermatitis

Severe atopic dermatitis (AD) may lead to various complications such as hypoproteinaemia. We describe the case of a 7-month-old male infant with severe AD complicated with protein-losing enteropathy (PLE). He was diagnosed with AD at 2 months of age; however, because of familial steroid phobia, topical corticosteroids were not administered. At 7 months of age, he was admitted to our hospital for decreased feeding, diarrhoea, reduced urine volume and recurrent vomiting. Class 3 topical corticosteroid treatment was initiated. On day 3, eczema had almost resolved. However, serum protein levels had not improved; oliguria persisted and oedema worsened. Serum albumin scintigraphy revealed radioisotopes in the distal duodenum, leading to PLE diagnosis. Systemic prednisolone and albumin were administered, with no PLE relapse after discontinuation. To our knowledge, only two infant PLE cases associated with AD were reported to date. PLE should be considered in patients with severe AD and persistent hypoproteinaemia.

Effectiveness of Ursodeoxycholic Acid in the Treatment of Primary Sclerosing Cholangitis with Ulcerative Colitis: A Pediatric Case

Primary sclerosing cholangitis is a rare disease with poor prognosis that potentially leads to liver cirrhosis and is often complicated by inflammatory bowel disease. Although ursodeoxycholic acid is the most commonly used drug to treat primary sclerosing cholangitis, its effectiveness in treating primary sclerosing cholangitis has not yet been established. An 11-year-old girl had a fever, upper and lower abdominal pain, and bloody stools. Colonoscopy revealed ulcerative colitis. She also had elevated hepatobiliary enzyme levels and C-reactive protein levels, indicating cholangitis after starting food intake, and primary sclerosing cholangitis was diagnosed with endoscopic retrograde cholangiography. Her hepatobiliary enzyme levels gradually improved after ursodeoxycholic acid was started, and symptoms did not recur after food intake. Primary sclerosing cholangitis should be considered if patients, even children, with inflammatory bowel disease, have upper abdominal pain with elevated biliary enzyme levels. The clinical guidelines for primary sclerosing cholangitis treatment have recommended that ursodeoxycholic acid should not be actively used. However, there are some recent reports stating its effectiveness for primary sclerosing cholangitis. In this patient, ursodeoxycholic acid may have been effective for the normalization of the hepatobiliary enzymes. However, it is unknown whether ursodeoxycholic acid improves long-term prognosis. Hence, further evidence regarding the effectiveness of ursodeoxycholic acid in the treatment of primary sclerosing cholangitis needs to be established.

LC-MS/MS method for rapid and accurate detection of caffeine in a suspected overdose case

Excessive intake of caffeine, otherwise known to be a safe and mild central nervous system stimulant, causes nausea, vomiting, convulsions, tachycardia, and eventually fatal arrhythmias and death. Caffeine intoxication, a global problem, has been increasing in Japan since 2013. Thus, there is a need for rapid and accurate diagnosis of caffeine poisoning in forensic and clinical toxicology investigations. Herein, we demonstrate rapid and accurate caffeine quantitation by liquid chromatography tandem mass spectrometry using the standard addition method in a fatal case. Biological samples were diluted 500-100,000-fold and subjected to a simple pretreatment (adding caffeine standard and internal standard and passing through a lipid removal cartridge). The multiple reaction monitoring transitions were 195 → 138 for quantitation, 195 → 110 for the qualifier ion, and 204 → 144 for the internal standard (caffeine-d9). The standard plots were linear over 0-900 ng/mL (r² = 0.9994-0.9999) for biological samples, and the reproducibility (%RSD) of the method was 1.53-6.97% (intraday) and 1.59-10.4% (interday). Fatal levels of caffeine (332 μg/mL) and toxic to fatal levels of olanzapine (625 ng/mL), along with other pharmaceuticals were detected in the external iliac venous blood. The cause of death was determined to be multi-drug poisoning, predominantly caused by caffeine. Our method is useful for not only forensic cases but also the rapid diagnosis of caffeine overdose in emergency clinical settings.

Insulinoma induces a hyperinsulinemia-mediated decrease of GLUT2 and GLP1 receptor in normal pancreatic β-cells

There have been several clinical reports of transient postoperative hyperglycemia in patients with insulinoma, but the effect of insulinoma on normal β-cells has not been investigated. We examined the glucose transporter 2 (GLUT2) and glucagon-like peptide 1 receptor (GLP1R) expression in normal pancreatic β-cells of five patients with insulinoma and five patients with normal glucose tolerance (NGT) as controls. The positive rate of GLUT2-or GLP1R-positive islets in the nontumor area was calculated by the ratio with the analyzed islets. For functional in vitro analyses, q-PCR and Western blotting were performed after insulin loading on MIN6 cells. The expression rates of both GLUT2 and GLP1R were significantly lower in nontumor area islets of insulinoma patients than in patients with NGT (GLUT2: 31.6 ± 15.3% vs 95.9 ± 6.7%, p < 0.01, GLP1R: 66.8 ± 15.0% vs 96.7 ± 5.0%, p < 0.01). Exposure of MIN6 cells to high concentrations of insulin resulted in a significant decrease in GLUT2 protein for 12 h and GLP1R protein for 24 h (GLUT2; 1.00 ± 0.079 vs 0.81 ± 0.04. p = 0.02, GLP1R; 1.00 ± 0.10 vs 0.50 ± 0.24, p = 0.03) but not in those mRNAs. Our findings show that insulinoma is associated with the downregulation of GLUT2 and GLP1R expression in nontumor area islets. These phenomena may be caused by high levels of insulin.

Endotoxin contamination of single-use sterile surgical gloves

Aim: Strict endotoxin limits are enforced for implants and catheters inserted into the body. However, no standard limit has been set for single-use sterile surgical gloves. Materials & methods: Four types of gloves sold in Japan were dipped in saline and that endotoxin levels were measured. Cytokine producing activity of gloves in blood was also measured. Results: Three of the four types of gloves showed endotoxin contamination. We also confirmed an increase in cytokine production in these gloves except one glove in which anionic surfactants was found. Conclusion: The extent to which detected endotoxins enter the body during surgery is controversial, but strict endotoxin limits need to be established.

Prediction of the improvement of left ventricular wall motion after acute myocardial infarction by simultaneous dual-isotope imaging with 99mTc-sestamibi/123I-BMIPP using cadmium-zinc-telluride SPECT

Background/Introduction

Although both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in patients with acute myocardial infarction (AMI) are known to significant markers for predicting the improvement of left ventricular (LV) wall motion in the infarcted territory in chronic phase, few studies evaluated them by simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) imaging using cadmium-zinc-telluride (CZT) SPECT system.

Purpose

The purpose of this study was to evaluate whether the presence of 99mTc-sestamibi/123I-BMIPP mismatch or the reverse redistribution of 99mTc-sestamibi make better prediction of the improvement of LV wall motion in the infarcted territory.

Methods

We evaluated 30 consecutive patients with AMI who had undergone both dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Both 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were determined using traditional definition. The improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was assessed using QGS.

Results

Of 30 patients, the improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was found in 20 patients. Both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were significantly linked to predict the improvement of LV wall motion (p=0.0001, p=0.011, respectively). The respective sensitivities, specificities and accuracies in the prediction of the improvement of LV wall motion in the infarcted territory were 90%, 90% and 90% with 99mTc-sestamibi/123I-BMIPP mismatch, and 60%, 90%, 70% with reverse redistribution of 99mTc-sestamibi.

Conclusions

In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging using CZT SPECT system, both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in acute phase are useful for predicting the improvement of LV wall motion in chronic phase, but the presence of 99mTc-sestamibi/123I-BMIPP mismatch is superior to the reverse redistribution of 99mTc-sestamibi for it.

Funding Acknowledgement

Type of funding source: None

Prediction of myocardial viability in chronic phase in patients with acute myocardial infarction by simultaneous dual-isotope imaging with 99mTc-sestamibi/123I-BMIPP SPECT using CZT camera system

Objectives

The objective of this study was to determine the optimal cut-off value of % uptake of simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in patients with acute myocardial infarction (AMI) for prediction of myocardial viability in chronic phase.

Methods

We evaluated 30 consecutive patients with AMI who had undergone both dual-SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Regional % uptake with a 17-segment model was obtained using QPS software. The presence of myocardial viability was defined when regional % uptake ≥50% in 99mTc SPECT at rest in chronic phase was observed. Receiver operating characteristic (ROC) curves were analyzed to determine the optimal cutoff values of regional % uptake in both left anterior descending artery (LAD) territory and non-LAD coronary territory in acute phase to predict the myocardial viability in chronic phase.

Results

The cutoff values for prediction of viable myocardium were %uptake ≥47% for 99mTc-sestamibi, %uptake ≥31% for 123I-BMIPP in acute phase in LAD territory and %uptake ≥52% for 99mTc-sestamibi, %uptake ≥48% for 123I-BMIPP in non-LAD territory. The respective sensitivities, specificities and the area under the ROC curve (AUC) values in the prediction of myocardial viability were 92%, 92% and 0.94 with 99mTc-sestamibi, 90%, 85%, 0.92 with 123I-BMIPP in LAD territory, and 81%, 93% and 0.92 with 99mTc-sestamibi, 81%, 90%, 0.92 with 123I-BMIPP in non-LAD territory. There were no significant differences in AUC values between 99mTc-sestamibi and 123I-BMIPP in both LAD territory and non-LAD coronary territory.

Conclusions

In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging in patients with AMI, these results suggest that not only 99mTc-sestamibi SPECT, but also 123I-BMIPP SPECT may be possible to predict the presence of myocardial viability in chronic phase. But it should be noted that the optimal cutoff values of regional % uptake in acute phase to predict the myocardial viability may differ for LAD territory and non-LAD coronary territory.

Funding Acknowledgement

Type of funding source: None

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma

BACKGROUND/PURPOSE

Placement of uncovered self-expandable metallic stents (U-SEMSs) of patients with unresectable perihilar cholangiocarcinoma (UPHC) is recommended as the treatment of first choice to address bile stasis. The aim of this study was to determine which of the following two endoscopic stents might be the stent of first choice for the treatment of biliary stasis in patients with UPHC: plastic stents (PSs) or U-SEMSs.

METHODS

U-SEMSs, deployed as a stent-in-stent, were selected as the stents of first choice from 2013 and 2014, while PSs began to be selected as the stents of first choice from 2015 onward.

RESULTS

The median time to recurrent biliary obstruction were 66 days in the PS group (N = 38) and 105 days in the U-SEMS group (N = 37; P = .04). Emergency endoscopy was necessitated in 76.3% (29/38) of patients of the PS group and 54.1% (20/37) of patients of the U-SEMS group (P = .0434). The success rate of the first reintervention was 96.5% (27/29) in the PS group and 55% (11/20) in the U-SEMS group (P = .0002). Sustainable chemotherapy could be carried out in 55.2% of patients in the PS group and 32.4% of patients in the U-SEMS group (P = .0472). Multivariate analysis identified selection of U-SEMS as the stent of first choice as the only independent factor predictive of successful reintervention (P = .0016, odds ratio = 0.058). However, the stent selection was not an independent factor for feasible chemotherapy.

CONCLUSIONS

Plastic stent placement could enhance the success rate of reintervention in patients with UPHC and might be facilitated by sustainable chemotherapy. However, stent selection might not have an influence on the prognosis.

Japanese guidelines for atopic dermatitis 2020

Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion, which is frequently encountered in clinical practice. Skin barrier dysfunction leads to enhanced skin irritability to non-specific stimuli and epicutaneous sensitization. In the lesion site, a further inflammation-related reduction in skin barrier function, enhanced irritability and scratching-related stimuli deteriorate eczema, leading to vicious cycle of inflammation. The current strategies to treat AD in Japan from the perspective of evidence-based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.