The Tokyo subway sarin attack--lessons learned

The sarin gas attack in the Tokyo subway system is reviewed from a clinical toxicology perspective. Based on the lessons learned from this attack, the following areas should be addressed on a global scale. First, an adequate supply of protective equipment is required, including level B protective equipment with a pressure demand breathing apparatus. In addition, a system should be established that enables a possible cause to be determined based on symptoms, physical findings, general laboratory tests, and a simple qualitative analysis for poisonous substances. If an antidote is needed, the system should enable it to be administered to the victims as quickly as possible. Preparation for a large-scale chemical attack by terrorists requires the prior establishment of a detailed decontamination plan that utilizes not only mass decontamination facilities but also public facilities in the area. A system should be established for summarizing, evaluating, and disseminating information on poisonous substances. Finally, a large-scale scientific investigation of the Tokyo sarin attack should be conducted to examine its long-term and subclinical effects and the effects of exposure to asymptomatic low levels of sarin.

[Studies of anti-cytomegalovirus IgG antibody positive rate and cytomegalovirus mononucleosis in adults]

We analyzed anti-Cytomegalovirus (CMV) IgG and IgM antibody (EIA) and anti-Epstein-Barr virus (EBV) viral capsid antigen (VCA) IgG and IgM antibody (FA) in adults during 1994-1999. We examined these IgM sero-positive patient's medical records, and diagnosed CMV mononucleosis and EBV mononucleosis. Anti-CMV antibody positive rates decreased from 87.6% in 1994 to 77.8% in 1999. Especially in twenties, anti-CMV antibody positive rates decreased from 65.2% in 1994 to 53.3% in 1999. On the other hand, anti-EBV VCA antibody positive rates were not changed (91-94%). Number of cases of CMV mononucleosis increased from 2 cases in 1994 to 16 cases in 1999, but EBV mononucleosis was not changed. These results suggested that increasing cases of CMV mononucleosis was influenced by decreasing anti-CMV antibody positive rate.

Aspergilloma: comparison of treatment methods and prognoses

We report five cases of aspergilloma. Three patients had a previous history of tuberculosis, including one who fully recovered after resection of the right lower lobe. Four patients were treated mainly with oral itraconazole. Two of these four patients, died, one of massive hemosputa, and one of heart valve disease, while two had a good outcome, although one of them has since developed respiratory insufficiency and has received oxygen therapy. In itraconazole therapy, the daily dose may be 200 mg or more, and the duration of treatment may be 1 year or more. Percutaneous intracavitary instillation of amphotericin B, performed in one patient, showed no efficacy. The efficacy of this treatment may depend on the width and number of drainage bronchi, and on the mechanism of acceleration of degradation of the fungus ball. It is important to carefully choose the therapy for aspergilloma, with due consideration being given to the patient's pulmonary function and general status.

[Comparison between cytomegalovirus hepatitis and Epstein-Barr virus hepatitis in healthy adults]

In order to determine the factors responsible for the differentiation of cytomegalovirus (CMV) hepatitis and Epstein-Barr virus (EBV) hepatitis in previously healthy adults, the clinical features and laboratory data of both types of hepatitis were retrospectively analyzed. CMV hepatitis showed a tendency to increase in our department. In comparison with EBV hepatitis, CMV hepatitis occurred in significantly older hosts than EBV hepatitis. We found that lymphadenopathy, cough and sore throat was more common in EBV hepatitis than in CMV hepatitis. The number of peripheral white blood cell count and atypical lymphocytes, and serum GOT, GPT, LDH and CRP levels of CMV and EBV hepatitis showed no significant differences.

[A case of endophthalmitis and abscesses in the liver and the lung caused by Klebsiella pneumoniae]

[Case report] A 65-year-old male war admitted to a local hospital because of fever. He was treated with piperacillin and clindamycin without noticeable effect. He began to complain of loss of vision on the third hospital day and culture of the blood specimen yielded Klebsiella pneumoniae. He was diagnosed as endophthalmitis and referred to our hospital for further examination. The hematological laboratory test showed leukocytosis (12,700/microliter) and increased CRP (20.4 mg/dl). A computed tomographic (CT) scan of the thorax revealed multiple lung abscesses. An abdominal ultrasonographic scan and a CT scan of the abdomen revealed multiple liver abscesses. We drained the abscess in the liver and Klebsiella pneumoniae was detected from the sample of aspirated fluid and his sputum. Meropenem was administered intravenously. Fever started to improve on the tenth hospital day and the size of both liver and lung abscesses were reduced. He has lost vision of his right eye. He was discharged after sixty days. He did not have any immunosuppressive underlying disease including HIV infection and diabetes mellitus which cause these lesions.

Lung abscess: analysis of 66 cases from 1979 to 1991

Sixty-six patients with bacterial lung abscess were treated between 1979 and 1991 in our hospital. Among these patients, death occurred in one of the 42 cases of community-acquired infection (mortality rate: 2.4%) and in 16 of the 24 cases of nosocomial infection (mortality rate: 66.7%). Of all 66 cases, 55 were culture-positive, and the etiologic agents isolated from 24 of the culture-positive cases were found to be anaerobic bacteria. The most common aerobes isolated from the foci were identified as Staphylococcus aureus, Klebsiella spp. and Pseudomonas aeruginosa, while the most common anaerobes were Bacteroides spp., Peptostreptococcus, Fusobacterium spp., microaerophilic Streptococcus and Veillonella. The mortality was higher in the cases with P. aeruginosa, Klebsiella spp. and Candida spp. than in those with other bacteria. The prognosis of lung abscess patients proved to depend on the presence of underlying diseases and on superinfection with aerobes.

Periodic fever compatible with familial Mediterranean fever

A 55-year-old male presented with a recurrent fever of over 38 degrees C, occurring at irregular intervals 1-6 times a month with chest, back or abdominal pain. After admission to our hospital, we found the following characteristics: 1) the febrile attacks were accompanied by obvious inflammatory findings and pleuritis or peritonitis; 2) the patient's elder sister had a similar periodic fever; and 3) there were no apparent causative factors responsible for his symptoms. Therefore, we diagnosed this as a case compatible with familial Mediterranean fever. The febrile attacks have been completely suppressed by daily colchicine. This is the seventh case of familial Mediterranean fever reported in Japan.

[Asporogenic anaerobic empyema--clinical and bacteriological investigations of 31 patients with anaerobic empyema]

The author reviewed the records of 31 patients with asporogenic anaerobic empyema mostly seen in the wards of Internal Medicine, Juntendo University Hospital during the 27 years between 1961 and 1988, and obtained the following results. 1. There were 25 males and 8 females with an average age of 57.8 and 51.0 y/o (range, 25 to 79 y/o), respectively males more than forty years old occupied 74.2 percent of all cases. 28 patients (90%) had underlying conditions. 2. The cases of mixed infections with anaerobes and aerobes were only 22.6%. 3. The isolated bacteria were microaerophilic streptococcus, Bacteroides spp., Peptostreptococcus spp., Fusobacterium spp. etc. in this order. 4. There were no relationships between anaerobic infections with or without aerobes and putrid odor of pleural effusion. 5. Bacteroides spp. were isolated most in the group with putrid pleural effusion, however, they were not isolated in the group without putrid pleural effusion at all. This fact suggests that there is an intimate relationship between putrid odor and Bacteroides spp. 6. There was no deceased case which pleural effusion had been drained sufficiently with open or closed drainage. It suggests that sufficient drainage is the most important in therapeutic procedures of asporogenic anaerobic empyema.

[Eight cases of diphyllobothriasis]

Eight cases of diphyllobothriasis have been experienced in the Juntendo University Hospital. Seven of the 8 patients excreted tapeworm fragments. Eggs of Diphyllobothrium latum were found in the feces in 5 cases. One patient had a history of ingestion of raw trout (Sushi), and 2 raw salmon. One might have been infected in foreign countries, and 3 could not tell the source of infection. Bithoinol was administered orally to 7 patients. Four of the 7 excreted the worm and the scolex was recognized in three of the four. Neither recurrence nor abnormal findings have been recognized so far.

[Fluconazole treatment of systemic mycoses]

Efficacies of fluconazole, a new triazole antifungal agent, were evaluated in 11 cases of systemic mycoses (1 case each of candiduria, pulmonary cryptococcosis, pulmonary aspergillosis, pulmonary penicilliosis and suspected fungal pulmonary infection, and 3 cases each of candidemia and Candida endophthalmitis). The clinical efficacies were excellent or good in 8 out of 9 cases and poor in 1. Side effects observed were mild with 1 incident each of gastrointestinal symptom and reversible leukopenia. This drug appears to be promising in treatment of systemic mycoses.