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Peel J, Blazos M, Manuchehri H, Fish C, Griffin DWJ. Frontal Lobe Lesion Masquerades as Meningioma. Clin Infect Dis 2023; 77:1733-1735. [PMID: 38102806 DOI: 10.1093/cid/ciad521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Affiliation(s)
- Joanne Peel
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Australia
| | - Mitsi Blazos
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Australia
| | - Hossein Manuchehri
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, Australia
| | - Charles Fish
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
| | - David W J Griffin
- Department of Infectious Diseases, Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
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Kanayama S, Nagata S, Akiyama Y, Miyazato Y, Ishikane M, Inoue M, Ohmagari N, Hara T. Cerebral syphilitic Gumma in the modern era: a report of an unusual case and brief review of recent published reports. Br J Neurosurg 2022:1-6. [PMID: 36564899 DOI: 10.1080/02688697.2022.2159923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/21/2021] [Accepted: 09/08/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Cerebral syphilitic gummas are rare. However, numerous case reports on them have been published recently, consistent with the resurgence of syphilis and its accompanying atypical manifestations. We here present a patient with a cerebral syphilitic gumma and an unusual clinical course and review recent case reports. CASE PRESENTATION A 49-year-old woman had a generalised seizure and was found by computed tomography and magnetic resonance imaging to have a brain mass that mimicked a brain abscess or malignant tumour. Further imaging with magnetic resonance spectroscopy and positron emission tomography did not contribute further to the differential diagnosis. Because treatment with ceftriaxone was ineffective, the lesion was resected. Serological tests on serum and cerebrospinal fluid were positive for syphilis and histopathological examination of the operative specimen revealed a syphilitic gumma. Antibiotic treatment is preferred over invasive interventions for cerebral syphilitic gumma. However, as in our case, radical resection is required when antibiotic treatment is ineffective. CONCLUSIONS It has recently been reported that the prevalence of syphilis is increasing in older individuals, including in patients without HIV infection or prior treatment for early syphilis. Though advanced imaging and molecular biological techniques are often used to help make a diagnosis, they are of limited value. Because the clinical and imaging features are nonspecific, some neurosurgeons do not include cerebral syphilitic gummas in their differential diagnoses. It is vital that this possibility be considered when a patient has a tumour-like cerebral mass and serum positivity for syphilis.
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Affiliation(s)
- Seisaku Kanayama
- Department of Neurosurgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
| | - Soudai Nagata
- Department of Neurosurgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
| | - Yutaro Akiyama
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yusuke Miyazato
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiro Ishikane
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masato Inoue
- Department of Neurosurgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Tetsuo Hara
- Department of Neurosurgery, Center Hospital of National Center for Global Health and Medicine, Tokyo, Japan
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Niimura M, Imai H. Multiple Spinal Syphilitic Gummas Diagnosed by Postoperative Histopathology and Antibiotic Responsiveness: A Case Report. NMC Case Rep J 2022; 8:637-643. [PMID: 35079528 PMCID: PMC8769426 DOI: 10.2176/nmccrj.cr.2021-0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/01/2021] [Indexed: 11/20/2022] Open
Abstract
Neurosyphilis is an infection of the central nervous system by Treponema pallidum. Gummatous neurosyphilis, especially spinal syphilitic gumma, is an exceedingly rare manifestation and may be misdiagnosed as other tumors due to its rarity. A 42-year-old man with a medical history of treatment for syphilis presented with rapidly progressive leg paralysis, leg sensory disturbance, and bladder and rectal disturbance. Spinal MRI demonstrated an intradural extramedullary lesion strongly compressing the spinal cord at the T6/7 level, which was accompanied with dural tail sign and perilesional meningeal thickening at the T6–T8 levels. Small intradural extramedullary lesions were also detected at the T1 and T8 levels. Serological and cerebrospinal fluid examinations for syphilis were both positive. In the treatment of spinal syphilitic gumma, the decompression of the spinal cord by lesionectomy followed by postoperative antibiotic treatment is considered to be an optimal procedure in patients with rapid progression of neurological deterioration. In the present case, the symptomatic main lesion that was compressing the thoracic cord was excised by surgery and analyzed by histopathological examination, and another small asymptomatic lesion was resolved by postoperative antibiotic treatment. Spinal syphilitic gumma was diagnosed using both histopathological findings of the surgically resected lesion and another residual lesion that was resolved by postoperative antibiotic treatment.
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Affiliation(s)
- Manabu Niimura
- Department of Neurosurgery, Shinagawa Shisyokai Hospital, Tokyo, Japan.,Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Hideaki Imai
- Department of Neurosurgery, Japan Community Healthcare Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
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Koh PX, Neo SX, Chiew HJ, Singh DR, Saini M, Chen Z. Syphilitic Spinal Disease: An Old Nemesis Revisited. A Case Series and Review of Literature. Sex Transm Dis 2021; 48:e126-e131. [PMID: 33512899 DOI: 10.1097/olq.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Syphilitic spinal disease is a rare condition caused by the spirochete Treponema pallidum, either from direct spirochete involvement of the cord or as a consequence of indirect spirochete involvement of the meninges, blood vessels, or the vertebral column. After the introduction of penicillin therapy in the 1940s, it has become an increasingly rare condition. We report 3 challenging cases of syphilitic spinal disease presenting as myelopathy-1 with an extra-axial gumma of tertiary syphilis causing cord compression and 2 with tabes dorsalis complicated by tabetic spinal neuroarthropathy-each presenting a diagnostic dilemma to their treating physicians. We also review the literature for updates on modern investigative modalities and discuss pitfalls physicians need to avoid to arrive at the diagnosis.
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Affiliation(s)
- Pei Xuan Koh
- From the Department of Neurology, National Neuroscience Institute, Singapore
| | - Shermyn Xiumin Neo
- From the Department of Neurology, National Neuroscience Institute, Singapore
| | - Hui Jin Chiew
- From the Department of Neurology, National Neuroscience Institute, Singapore
| | | | - Monica Saini
- From the Department of Neurology, National Neuroscience Institute, Singapore
| | - Zhiyong Chen
- From the Department of Neurology, National Neuroscience Institute, Singapore
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Pham K, Gottesdiener L, Simon MS, Trzebucki A, Maldarelli GA, Cisse B, Lieberman J, DeHaan E, Pisapia D. Meningovascular Syphilis Presenting as a Brain Mass in an Immunocompetent Male. Open Forum Infect Dis 2021; 8:ofab455. [PMID: 34557566 PMCID: PMC8454516 DOI: 10.1093/ofid/ofab455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/30/2021] [Indexed: 11/14/2022] Open
Abstract
We present a case of a human immunodeficiency virus-negative man with syphilitic meningovascular disease with subjacent involvement of brain parenchyma leading to a mass-forming inflammatory lesion that was pathologically distinct from a typical gumma. Syphilis was diagnosed after tissue obtained from a brain biopsy demonstrated spirochetes consistent with Treponema pallidum and confirmed by 16S ribosomal RNA sequencing.
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Affiliation(s)
- Khanh Pham
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA,Correspondence: Khanh Pham, MD, New York–Presbyterian Hospital, Weill Cornell Medical Center, 1300 York Ave, A-421, New York, NY 10021, USA ()
| | - Lee Gottesdiener
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Matthew S Simon
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Alex Trzebucki
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Grace A Maldarelli
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA
| | - Babacar Cisse
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA,Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Joshua Lieberman
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Elliot DeHaan
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David Pisapia
- New York–Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, USA,Department of Pathology, Weill Cornell Medicine, New York, New York, USA
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Abstract
PURPOSE OF REVIEW This article focuses on the epidemiology, clinical presentation, diagnosis, and management of neurosyphilis, with an emphasis on clinically relevant issues faced by the practicing neurologist. RECENT FINDINGS The incidence of primary and secondary syphilis, the sexually transmissible stages of infection, has been on the rise for the past 2 decades. A concerning recent trend is the surge in cases of syphilis in women and of congenital syphilis. Neurosyphilis remains a relatively common complication that can occur at any stage of syphilis. Along with meningitis, meningovascular syphilis, which has been historically described as a late presentation of neurosyphilis, now frequently occurs as a manifestation of early infection. Late forms of neurosyphilis, including tabes dorsalis and general paresis, are less prevalent in the era of widespread penicillin use. As more laboratories adopt the reverse-sequence algorithm for syphilis testing, patients with serodiscordant results (ie, a reactive serum treponemal test with a nonreactive nontreponemal test) may present an increasingly encountered diagnostic challenge for neurologists. Although the CSF Venereal Disease Research Laboratory (VDRL) remains a mainstay of diagnostic testing for neurosyphilis, using a higher titer cutoff (greater than 1:320) for the Treponema pallidum particle agglutination assay (TPPA) from the CSF may improve the utility of the TPPA as a supporting criterion for the diagnosis of neurosyphilis. Penicillin G is the treatment of choice for neurosyphilis, although ceftriaxone may be a reasonable alternative therapy. SUMMARY A high index of suspicion and awareness of the variable clinical presentations of neurosyphilis are essential to the approach to this treatable infection. Neurologists should be mindful of the limitations of serologic testing in the diagnosis of neurosyphilis and exercise clinical judgment to determine the likelihood of the diagnosis.
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Worku D, Houston A, Cosgrove C, Byrne L. Spinal Syphilitic Gumma: A Rare Presentation of an Old Disease. Case Rep Infect Dis 2021; 2021:5533686. [PMID: 34188963 PMCID: PMC8192201 DOI: 10.1155/2021/5533686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022] Open
Abstract
Syphilis is an ancient condition which still is of global concern today. Despite better awareness amongst clinicians and improving diagnostics, it remains likely underdiagnosed in part because of its namesake the 'great imitator.' While many patients suffer primary or secondary disease, tertiary syphilis characterised by gumma is rare, especially in the context of neurosyphilis. Here, we report a rare case of a well-controlled human immunodeficiency virus- (HIV-) positive gentleman with a history of previous syphilis and epilepsy who presented with progressive left leg weakness leading to immobility and altered bowels and, on neurological examination, Brown-Sequard syndrome. Magnetic resonance imaging (MRI) of the spine revealed two peripherally enhancing cavitating lesions at T4-T5 with associated meningeal thickening and cord oedema. Cerebrospinal fluid (CSF) analysis revealed high protein (3.07 g/dL) and white cell count (7 × 109/L) with negative cryptococcal antigen, tuberculosis molecular testing (GeneXpert), microscopy and culture, and viral polymerase chain reaction (PCR). CSF serology was positive for Treponema pallidum particle agglutination (TPPA) 10240 and RPR 1 in 2 suggesting active disease. While TB treatment had been started prior to these investigations on day 11, 14-day high-dose benzylpenicillin therapy commenced. Repeat MRI of the spine at days 12 and 22 showed incremental improvements in all parameters which correlated with improving functionality and neurology. According to our literature search, this represents the 13th case recorded for spinal syphilitic gumma and the only case recorded in a HIV-positive individual and adds to the evidence that, in the absence of rapidly changing neurology, medical management can lead to good clinical outcomes.
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Affiliation(s)
- Dominic Worku
- Clinical Infection Unit, St. George's Hospital, BlackshawRoad, Tooting, London SW17 0QT, UK
| | - Angela Houston
- Clinical Infection Unit, St. George's Hospital, BlackshawRoad, Tooting, London SW17 0QT, UK
| | - Catherine Cosgrove
- Clinical Infection Unit, St. George's Hospital, BlackshawRoad, Tooting, London SW17 0QT, UK
| | - Laura Byrne
- Clinical Infection Unit, St. George's Hospital, BlackshawRoad, Tooting, London SW17 0QT, UK
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Barthel L, Hetze S, Teuber-Hanselmann S, Chapot V, Sure U. Syphilitic Gummata in the Central Nervous System: A Narrative Review and Case Report about a Noteworthy Clinical Manifestation. Microorganisms 2021; 9:906. [PMID: 33922782 PMCID: PMC8145658 DOI: 10.3390/microorganisms9050906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022] Open
Abstract
Infection with Treponema pallidum is on the rise. In this narrative literature review, we show that the incidence of rare manifestations of syphilis, such as intracerebral gummata, is increasing and should be considered in the differential diagnosis of intracerebral lesions. With the exemplary case that we present here, we aim to raise awareness of the resurgence of this disease, which should be considered in the differential diagnosis of intracerebral lesions, especially for patients who have a risk profile for syphilis, and serological testing for T. pallidum prior to surgery should be discussed in order to avoid an unnecessary operation.
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Affiliation(s)
- Lennart Barthel
- Department of Neurosurgery, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Susann Hetze
- Department of Neurosurgery, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
- Institute of Medical Psychology and Behavioral Immunobiology, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Sarah Teuber-Hanselmann
- Institute of Neuropathology, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Valérie Chapot
- Institute of Medical Microbiology, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery, University Hospital of Essen, Hufelandstraße 55, 45147 Essen, Germany
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Abstract
PURPOSE OF REVIEW In the context of a resurgence of syphilis worldwide, it can be anticipated that a rise in cases of ocular, otic, and neurosyphilis will also be seen. This article reviews the current epidemiology, manifestations, and approach to management and treatment. RECENT FINDINGS Although studies continue investigating alternate approaches and new diagnostic tests for ocular and neurosyphilis, few data exist to change current diagnostic algorithms and approaches to diagnosis, management, or follow up. SUMMARY The diagnosis of neurologic and eye/ear involvement with syphilis may be delayed because of a lack of specificity of findings, low suspicion for syphilis, fluctuation in symptoms, and/or similarities in presentation to other diseases. A high index of suspicion for syphilis and re-education about the protean manifestations of syphilis by all clinicians is required provide timely diagnosis and management of ocular, otic, and neurosyphilis.
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Imoto W, Arima H, Yamada K, Kanzaki T, Nakagawa C, Kuwabara G, Yamairi K, Shibata W, Oshima K, Watanabe T, Asai K, Kaneko Y, Kawaguchi T, Goto T, Kakeya H. Incidental finding of neurosyphilis with intracranial hemorrhage and cerebral infarction: A case report. J Infect Chemother 2020; 27:521-525. [PMID: 33067106 DOI: 10.1016/j.jiac.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023]
Abstract
Syphilis has recently increased in prevalence in Japan. Neurosyphilis is a special pathological condition of syphilis well known to cause cerebral vasculitis and ischemic stroke. Neurosyphilis in the meningovascular stage rarely causes caliber irregularity of the cerebral blood vessels or cerebral hemorrhage. We describe the case of a 49-year-old Japanese man with neurosyphilis. Cerebral hemorrhage, multiple cerebral infarctions, and caliber irregularity of the cerebral blood vessels were observed, the patient underwent surgery for cerebral hemorrhage on the day of admission, all of which were suspected to be caused by syphilis. He was started on an antibacterial treatment of penicillin on the day of admission and was diagnosed with neurosyphilis the following week based on his serum and spinal fluid test results. His condition improved, and he was transferred to another hospital after 4 weeks of treatment consisting of 3 weeks of infusion treatment with benzylpenicillin followed by oral treatment with amoxicillin. To the best of our knowledge, this is a rare case of neurosyphilis in conjunction with cerebral hemorrhage and cerebral infarction. Clinicians should consider syphilis in the differential diagnosis of cerebral hemorrhage and cerebral infarction and test patients for sexually transmitted diseases, in addition to cerebrospinal fluid testing, when cerebral hemorrhage occurs with an unknown cause. This is especially pertinent when patients present with cerebral infarction or caliber irregularity of the cerebral blood vessels.
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Affiliation(s)
- Waki Imoto
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Hironori Arima
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Koichi Yamada
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Toshiyuki Kanzaki
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Chihiro Nakagawa
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Gaku Kuwabara
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Kazushi Yamairi
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Wataru Shibata
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Kazuhiro Oshima
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Tetsuya Watanabe
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yukihiro Kaneko
- Department of Bacteriology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Tomoya Kawaguchi
- Department of Respiratory Medicine, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Takeo Goto
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Hiroshi Kakeya
- Department of Infection Control Science, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan; Department of Infectious Disease Medicine, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-5-7 Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan.
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