False-positive fourth-generation HIV test result in a woman with Plasmodium malariae malaria

BACKGROUND

False positive results on fourth-generation human immunodeficiency virus (HIV) diagnostic tests have previously been reported in infections with Plasmodium falciparum and Plasmodium ovale but not with Plasmodium malariae.

METHODS

We report a false positive fourth-generation HIV test result in a patient with P. malariae infection. The patient's symptoms improved rapidly with antimalarial treatment and the confirmatory and repeated HIV tests were eventually negative.

RESULTS

False positive results may add a variety of unnecessary burden.

CONCLUSIONS

One must be aware of false positive results even with fourth-generation tests in patients with malaria, including P. malariae malaria.

A case of Shewanella algae-induced bacteremia in Japan: Case report and literature review

Shewanella algae (S. algae) is a rare bacterium that causes infectious diseases in humans. Herein, we present a case of an 84-year-old man with S. algae-induced bacteremia and performed a review of 12 cases identified via a literature search and this case. Literature review of previous reports in Japan have revealed that 69.2% of patients with S. algae-induced bacteremia had a history of contact with fresh fish. Appropriate interviews of patients, especially in the hot season, and the accurate identification of the causative bacterium, by using techniques such as MALDI-TOF-MS and genetic testing, are necessary if S. algae or other bacteria from the genus Shewanella are detected in blood-culture tests.

Clinical characteristics of elderly pulmonary tuberculosis in an acute-care general hospital in Tokyo, Japan: A 12-year retrospective study

OBJECTIVE

A significant feature of tuberculosis (TB) in Japan is the fact that a high proportion of cases belong to the elderly population. Furthermore, previous reports have pointed out the delayed diagnosis of pulmonary TB in acute-care settings. We aimed to examine the clinical characteristics of pulmonary TB patients in an acute-care general hospital, particularly focusing on the elderly population.

METHODS

We retrospectively reviewed the medical records of patients with pulmonary TB who presented at our institution between May 2005 and December 2016. We described the overall clinical characteristics of these patients and compared them according to age.

RESULTS

Overall, 289 patients were eligible for the analysis, with a median age of 58 [42-73] years, and 29.4% being older than 70 years. Among the elderly patients, 42.4% were characterized by atypical presentation.

CONCLUSION

Our findings suggest that the elderly population tends to present as atypical cases lacking respiratory complaints, thereby being at a risk of misdiagnosis.

Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae ST258 isolated from a Japanese patient without a history of foreign travel - a new public health concern in Japan: a case report

Background

Thus far, studies on Klebsiella pneumoniae carbapenemase (KPC)-producing organisms have only been reported in those with a history of foreign travel, and a specific Japanese KPC-producing isolate has not yet been reported.

Case presentation

We describe a Japanese patient, with no history of travel to foreign countries, admitted due to aspiration pneumonia, and a KPC-producing isolate detected in his sputum. Fortunately, his pneumonia resolved. His close contacts did not have a history of foreign travel, and the isolate was not detected in other patients.

Conclusions

The potential for KPC-producing organisms to become endemic in Japan is currently of great concern.

Prevalence of Chronic Kidney Disease and Poor Diagnostic Accuracy of Dipstick Proteinuria in Human Immunodeficiency Virus-Infected Individuals: A Multicenter Study in Japan

Background

Chronic kidney disease (CKD) has become one of the common comorbid conditions affecting the human immunodeficiency virus (HIV) population. Human immunodeficiency virus-infected individuals are at increased risk of developing CKD, and they are likely to experience faster progression of renal dysfunction compared with HIV-uninfected individuals. Albuminuria represents not only kidney damage but also manifests metabolic syndrome and vascular dysfunction.

Methods

We conducted a multicenter, cross-sectional study involving 2135 HIV-infected individuals in Japan to test the prevalence of CKD and proteinuria/albuminuria. Urine sample was analyzed by both dipstick test and albumin-to-creatinine ratio (ACR) assay. Chronic kidney disease was classified according to the Kidney Disease Outcomes Quality Initiative (K/DOQI) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. The diagnostic performance of dipstick test to detect albuminuria (ACR ≥30 mg/g) was evaluated.

Results

The prevalence of CKD, evaluated by K/DOQI and KDIGO guidelines, was 15.8% and 20.4%, respectively. Age, total cholesterol level, prevalence of hypertension, diabetes mellitus, and hepatitis C infection tended to increase, whereas levels of hemoglobin, serum albumin, and CD4 cell count tended to decrease as CKD risk grades progressed. Proteinuria and albuminuria were present in 8.9% and 14.5% of individuals, respectively. Dipstick test ≥1+ to detect albuminuria had an overall sensitivity of 44.9% and specificity of 97.2%.

Conclusions

The KDIGO guideline may enable physicians to capture HIV-infected patients at increased risk more effectively. The sensitivity of dipstick proteinuria to detect albuminuria is so poor that it may not serve as an alternative in HIV-infected individuals.

Unique characteristics of community-onset healthcare- associated bloodstream infections: a multi-centre prospective surveillance study of bloodstream infections in Japan

BACKGROUND

Analysis of bloodstream infections (BSIs) is valuable for their diagnosis, treatment and prevention. However, limited data are available in Japan.

AIM

To investigate the characteristics of patients with bacteraemia in Japan.

METHODS

This study was conducted in five hospitals from October 2012 to September 2013. Clinical, demographic, microbiological and outcome data for all blood-culture-positive cases were analysed.

FINDINGS

In total, 3206 cases of BSI were analysed: 551 community-onset healthcare-associated (CHA)-BSIs, 1891 hospital-acquired (HA)-BSIs and 764 community-acquired (CA)-BSIs. The seven- and 30-day mortality rates were higher in patients with CHA- and HA-BSIs than in patients with CA-BSIs. The odds ratios (ORs) for seven-day mortality were 2.56 [95% confidence interval (CI) 1.48-4.41] and 2.63 (95% CI 1.64-4.19) for CHA- and HA-BSIs, respectively. The ORs for 30-day mortality were 2.41 (95% CI 1.63-3.57) and 3.31 (95% CI 2.39-4.59) for CHA- and HA-BSIs, respectively. There were 499 cases (15.2%) of central-line-associated BSI and 163 cases (5.0%) of peripheral-line-associated BSI. Major pathogens included coagulase-negative staphylococci (N = 736, 23.0%), Escherichia coli (N = 581, 18.1%), Staphylococcus aureus (N = 294, 9.2%) and Klebsiella pneumoniae (N = 263, 8.2%). E. coli exhibited a higher 30-day mortality rate among patients with HA-BSIs (22.3%) compared with patients with CHA-BSIs (12.3%) and CA-BSIs (3.4%). K. pneumoniae exhibited higher 30-day mortality rates in patients with HA-BSIs (22.0%) and CHA-BSIs (22.7%) compared with patients with CA-BSIs (7.8%).

CONCLUSION

CHA- and HA-BSIs had higher mortality rates than CA-BSIs. The prognoses of E. coli- and K. pneumonia-related BSIs differed according to the category of bacteraemia.

Multicenter Study of the Clinical Presentation of Staphylococcus lugdunensis Bacteremia in Japan

Staphylococcus lugdunensis (SL) is a bacterium with a highly pathogenicity than most other coagulase-negative Staphylococcus spp. (CoNS). In Japan, data on this pathogen are sparse, and the current prevalence of SL bacteremia is unknown. Therefore, we investigated the prevalence of SL in blood culture specimens in a prospective multicenter study across 5 facilities. A total of 3,284 patients had positive blood cultures, and 2,478 patients had bacteremia. Among the patients with bacteremia, 7 patients (0.28%) had SL bacteremia. A total of 281 patients had CoNS bacteremia, with SL accounting for 2.49% of these cases. Of the 7 patients with SL bacteremia, 1 patient (14.3%) had infective endocarditis, and 1 patient (14.3%) died within 30 days. In this study, SL resulted in the development of bacteremia in select patients. Clinicians in Japan should be aware of the prevalence of SL and the complications of SL bacteremia.

Pulmonary Histoplasmosis in a Japanese Man Infected During Travel to Mexico and Management of His Wife's Condition: A Case Report

We report herein on the case of a 33-year-old Japanese man in whom an abnormal shadow was detected on chest radiography during a medical checkup after a 1-year-stay in Mexico. Chest computed tomography showed a nodule in the left lower lobe adjacent to the visceral pleura. Histopathologic examination of a thoracoscopic partial pulmonary resection specimen showed coagulation necrosis with a number of yeast-like forms on Grocott staining. In addition, serum anti-Histoplasma antibody positivity was detected with an enzyme-linked immunosorbent assay, and Histoplasma-specific nested real-time polymerase chain reaction results were positive in the pulmonary region. Finally, pulmonary histoplasmosis was diagnosed, and treatment with itraconazole was initiated. The patient's wife who had accompanied him to Mexico was asymptomatic and was not found to have histoplasmosis based on diagnostic imaging and serological findings. Although rare in Japan, histoplasmosis should be considered in the differential diagnosis of pulmonary lesions in patients who have returned from travel to endemic areas.

Edwardsiella tarda bacteremia. A rare but fatal water- and foodborne infection: Review of the literature and clinical cases from a single centre

BACKGROUND

Edwardsiella tarda bacteremia (ETB) can be a fatal disease in humans.

OBJECTIVES

To determine the significant risk factors associated with death caused by ETB, and to examine the geographical, seasonal, environmental and dietary factors of the disease.

METHODS

A retrospective, observational, case control study was performed. The PubMed MEDLINE and Japanese Medical Abstract Society (www.jamas.or.jp) databases were searched for ETB case reports and meeting abstracts. In additon, retrospective chart reviews of patients with ETB at the Tokyo Women's Medical University Hospital (Tokyo, Japan) were conducted to evaluate the risk factors associated with death using multivariate analyses.

RESULTS

The literature search yielded 46 publications, comprising 72 cases from the English (n=30), French (n=1), Spanish (n=1) and Japanese (n=14) literature. Five cases at the Tokyo Women's Medical University Hospital were also included. Of the included 77 cases, the mean age was 61 years and 39% of patients were female; 77.2% of the cases occurred between June and November, and 45.5% were reported in Japan. Dietary factors (raw fish/meat exposure) were reported for 10.4% of patients and 12.9% reported environmental (ie, brackish water) exposure. The overall mortality rate was 44.6%; however, this rate increased to 61.1% for ETB patients with soft tissue infections. Liver cirrhosis was determined to be an independent risk factor associated with death (OR 12.0 [95% CI 2.46 to 58.6]; P=0.00213) using multivariate analyses.

DISCUSSION

To our knowledge, the present analysis was the first and largest multi-language review of ETB. Clinical characteristics of ETB resemble those of Aeromonas, typhoid fever and Vibrio vulnificus infections, in addition to sharing similar risk factors.

CONCLUSION

ETB should be categorized as a severe food- and waterborne infection, which results in high mortality for patients with liver cirrhosis.

Perianal tuberculosis: A case report and review of the literature

Tuberculosis (TB) is still a major health problem worldwide. We present a rare case of an immuno-competent patient with perianal TB. A 38-year-old man visited a clinic with pain, swelling, and redness in the perineum. He had been persistently coughing for the past 6 mo. The abscess had formed a fistula to the perianal region, indicating perianal abscess. Mycobacterium tuberculosis was found in sputum and perianal abscess. Surgical drainage was performed, and oral anti-tuberculous drugs were administered for 6 mo. The patient’s clinical course was favorable. On review of the literature on 58 cases of perianal TB, we found that the duration of persistent perianal lesion was much longer in patients without active pulmonary TB (APTB) than in those with APTB (66.4 mo vs 8.3 mo; confidence interval, 0.0760-0.9620, P = 0.0380). Thus, in cases of non-healing or recurrent perianal lesions, TB should be considered.

Gram-negative rod bacteremia after cardiovascular surgery: Clinical features and prognostic factors

BACKGROUND/PURPOSE

Our aim was to describe the clinical features and prognostic factors of Gram-negative rod bacteremia (GNRB) after cardiovascular surgery (CVS).

METHODS

This retrospective observational study included adults with GNRB onset within 100 days after CVS at a single institution from April 2004 to May 2013. Clinical data regarding episodes of GNRB were collected from patients' medical charts. Those having polymicrobial bacteremia with a bacterium other than a GNR were excluded.

RESULTS

Among 2017 CVS patients, GNRB occurred in 78. Klebsiella, Pseudomonas aeruginosa, Enterobacter, and Escherichia coli were the most commonly isolated organisms. Graft replacement was the most common surgical procedure in patients with GNRB after CVS (44.9%). Prophylaxis antibiotics were ampicillin/sulbactam (76.9%), and vancomycin (12.8%). The crude 90-day mortality rate was 21.8%, and the mean Acute Physiology and Chronic Health Evaluation II score was 15.6 (range, 3-39). In 34.6% of patients, the same GNR species were isolated from other samples within 30 days of GNRB occurrence. Multivariate analysis indicated that P. aeruginosa bacteremia [odds ratio (OR), 175; confidence interval (CI), 2.40-1270; p = 0.0182], Acute Physiology and Chronic Health Evaluation II scores of ≥ 25 (OR 76.2; CI 1.04-5580; p = 0.0479), and vancomycin for prophylaxis (OR 45.4; CI 1.02-202; p = 0.0488) were significant independent prognostic factors associated with death due to GNRB after CVS.

CONCLUSION

Graft replacement was the most common surgical procedure in patients with GNRB after CVS. Empirical antibiotics covering Gram-negative rods including P. aeruginosa should be considered if bacteremia is suspected in unstable patients after CVS.

Risk factors for recurrent hospital-acquired Clostridium difficile infection in a Japanese university hospital

Background

Clostridium difficile infection (CDI) is a highly prevalent hospital-associated infection. Although most patients respond well to discontinuation of antibiotics, 20%–30% of patients relapse. To initiate early therapeutic measures, the risk factors for recurrent CDI must be identified, although very few Japanese studies have used standard surveillance definitions to identify these risk factors.

Methods

We retrospectively reviewed the medical records of patients with health care facility-onset CDI between August 2011 and September 2013. Patients with diarrhea who were positive for Clostridium difficile (via an enzyme immunoassay) were defined as having CDI. Clinical data (eg, demographics, comorbidities, medication, laboratory results, and clinical outcomes) were evaluated, and multivariate analysis was used to identify risk factors that were associated with recurrent CDI.

Results

Seventy-six health care facility-onset CDI cases were identified, with an incidence rate of 0.8 cases per 10,000 patient-days. Fourteen cases (18.4%) were recurrent, with 13 patients having experienced a single recurrent episode and one patient having experienced three recurrent episodes. The 30-day and 90-day mortality rates were 7.9% and 14.5%, respectively. Multivariate analysis revealed that recurrent patients were more likely to have underlying malignant disease (odds ratio: 7.98; 95% confidence interval: 1.22–52.2; P=0.03) and a history of intensive care unit hospitalization (odds ratio: 49.9; 95% confidence interval: 1.01–2,470; P=0.049).

Conclusion

Intensive care unit hospitalization and malignancy are risk factors for recurrent CDI. Patients with these factors should be carefully monitored for recurrence and provided with appropriate antimicrobial stewardship.

Candidemia Diagnosed from Peripheral Blood Smear: Case Report and Review of Literature 1954-2013

BACKGROUND

Yeast with pseudohyphae or those that have been phagocytized by white blood cells are coincidentally found in peripheral blood smears. The clinical diagnostic value and outcome of candidaemia diagnosed from peripheral blood smears (CPBSs) are unclear.

CASE PRESENTATION

A 45-year-old man with diabetes and panhypopituitarism for 20 years received 10 mg of hydrocortisone and 100 μg of levothyroxine sodium hydrate daily. He has been admitted seven times because of adrenal failure triggered by infections and was admitted for pneumonia. On day 56, some budding yeast was found microscopically in a peripheral blood smear with May-Giemsa staining. Some of them were phagocytized by white blood cells. The two blood cultures yielded Candida parapsilosis. Despite antifungal treatment and removal of an intravenous catheter, on day 98 (42 days after the candidaemia diagnosis), the patient died.

CONCLUSION

We analysed 36 cases including the present case. Almost all CPBS patients (96.5 %, n = 29) were using an intravenous catheter. The most frequently isolated species was C. parapsilosis (35.1 %), followed by C. albicans (29.7 %). The overall mortality rate was 53.6 % (n = 28). The time from the discovery of yeast-like pathogens using peripheral blood smears to death ranged from a few hours to 93 days (median 19 days). The present results suggest that intravenous catheter use and the underlying conditions of patients are responsible for CPBSs. The detection of yeast in peripheral blood smears suggests advanced infections with uncontrollable complications, which means a poor prognosis. Rapid detection methods besides blood culture are needed.

Evaluation of an automated rapid diagnostic assay for detection of Gram-negative bacteria and their drug-resistance genes in positive blood cultures

We evaluated the performance of the Verigene Gram-Negative Blood Culture Nucleic Acid Test (BC-GN; Nanosphere, Northbrook, IL, USA), an automated multiplex assay for rapid identification of positive blood cultures caused by 9 Gram-negative bacteria (GNB) and for detection of 9 genes associated with β-lactam resistance. The BC-GN assay can be performed directly from positive blood cultures with 5 minutes of hands-on and 2 hours of run time per sample. A total of 397 GNB positive blood cultures were analyzed using the BC-GN assay. Of the 397 samples, 295 were simulated samples prepared by inoculating GNB into blood culture bottles, and the remaining were clinical samples from 102 patients with positive blood cultures. Aliquots of the positive blood cultures were tested by the BC-GN assay. The results of bacterial identification between the BC-GN assay and standard laboratory methods were as follows: Acinetobacter spp. (39 isolates for the BC-GN assay/39 for the standard methods), Citrobacter spp. (7/7), Escherichia coli (87/87), Klebsiella oxytoca (13/13), and Proteus spp. (11/11); Enterobacter spp. (29/30); Klebsiella pneumoniae (62/72); Pseudomonas aeruginosa (124/125); and Serratia marcescens (18/21); respectively. From the 102 clinical samples, 104 bacterial species were identified with the BC-GN assay, whereas 110 were identified with the standard methods. The BC-GN assay also detected all β-lactam resistance genes tested (233 genes), including 54 bla_CTX-M, 119 bla_IMP, 8 bla_KPC, 16 bla_NDM, 24 bla_OXA-23, 1 bla_OXA-24/40, 1 bla_OXA-48, 4 bla_OXA-58, and 6 bla_VIM. The data shows that the BC-GN assay provides rapid detection of GNB and β-lactam resistance genes in positive blood cultures and has the potential to contributing to optimal patient management by earlier detection of major antimicrobial resistance genes.

Nosocomial Candida parapsilosis candidaemia: risk factors, antifungal susceptibility and outcome

A retrospective analysis was undertaken from 2000 to 2010 to show the risk factors associated with death within 30 days in patients with C. parapsilosis candidaemia (CPC). Fifty-one cases of nosocomial CPC were included in the analysis. All isolates from blood cultures were susceptible to micafungin and fluconazole. The overall mortality rate was 23.5%, and the most severe complications were endocarditis (5.9%) and endophthalmitis (5.9%). On multi-variate analysis, APACHE II score >25 (odds ratio 43.9) and retained cardiovascular prosthetic materials (RCPM) (prosthetic valve or graft) (odds ratio 14.6) were found to be risk factors associated with death. Prompt surgical removal should be considered in CPC patients with RCPM.

Leptospirosis in a Japanese urban area: a case report and literature review

Leptospirosis is not a major disease in urban areas of Japan. We describe a 49-year-old man with leptospirosis, who lived in an urban area and had no history of living in endemic area of leptospirosis. As he worked at a fish market infested with rats, he was suspected of having contracted leptospirosis and received antimicrobial agent treatment. Serum and urinary tests confirmed the diagnosis of leptospirosis. Although it took six days from the onset until treatment initiation, the patient improved in response to receiving ceftriaxone for seven days. Analyzing past reports of Japanese patients with leptospirosis who had no history of overseas travel, we identified 90 patients with courses similar to that of our patient, and the period from onset to treatment initiation was about six days on average (described in 46 cases). Health care providers as well as patients need to recognize that even people with no history of being in an endemic area of leptospirosis may still be at risk of developing this disease depending on occupations and activities.

Analysis of clinical features of non-HIV Pneumocystis jirovecii pneumonia

Pneumocystis jirovecii pneumonia (PCP) is classified as PCP with human immunodeficiency virus (HIV) and non-HIV PCP, and the two forms differ in progression and prognosis. Although early treatment is necessary, the diagnosis of non-HIV PCP is often difficult because of the underlying diseases. However, the outcome with treatment delay remains unclear because there are no concrete data indicating a worsened clinical situation or increased complications related to delayed therapy initiation. We retrospectively examined patients with non-HIV PCP admitted to Tokyo Women's Medical University Hospital from November 2008 to October 2010. The relationship between intubation with mechanical ventilation (within 1 week after starting treatment) and treatment delay was investigated. Treatment delay was defined as the period, in days, from onset to therapy initiation. In total, 24 confirmed non-HIV PCP cases were included. Median treatment delay was 7 ± 4.83 days (1-20 days). Twelve of 24 cases (50 %) were intubated, and 11 (45.8 %) died of their underlying diseases within 90 days. Treatment delay was more than 7 days in the intubation group, but was within 7 days in 9 of 12 nonintubation cases. The difference in treatment delay was significant (p = 0.0071) between the intubation and nonintubation groups, but there were no significant differences in survival rate at 90 days or other findings. We conclude that starting treatment within 7 days after onset is important because intubation and mechanical ventilation may be avoided in many cases.