Hsing-Chun Chung

Bacteremia Caused by Extended-Spectrum-β-Lactamase-Producing Escherichia coli Sequence Type ST131 and Non-ST131 Clones: Comparison of Demographic Data, Clinical Features, and Mortality

ABSTRACT Escherichia coli producing the highly virulent, multidrug-resistant, CTX-M-15 extended-spectrum β-lactamase (ESBL), sequence type 131 (ST131), has emerged on three continents since the late 2000s. We described the molecular epidemiology, clinical features, and outcome of ESBL-producing E. coli bacteremia in Taiwan from 2005 to 2010. This study aims to determine whether the risk factors, clinical features, and outcomes of the ST131 isolate differ from those of non-ST131 isolates. From 2005 to 2010, we collected 122 nonduplicated, consecutive, ESBL-producing E. coli isolates from bloodstream infections in a 1,200-bed hospital in Taiwan. Isolates were characterized using multilocus sequence typing. Demographic data, clinical features, and outcomes were collected from medical chart records. Thirty-six (29.5%) patients with bacteremia with ESBL-producing E. coli ST131 were identified. Patients with clone ST131 were more likely to have secondary bacteremia and noncatheterized urinary tract infections (P < 0.05). Secondary bacteremia (odds ratio [OR], 5.05; 95% confidence interval [CI], 1.08 to 23.56) and urinary catheter nonuse (OR, 3.77; 95% CI, 1.17 to 12.18) were independent risk factors for the ST131 clone after adjustment. Mortality rates at day 28 were similar in ST131 and non-ST131 populations. Independent risk factors predicting mortality at day 28 included malignancy, shock, and hospital-acquired bacteremia. In ESBL-producing E. coli bloodstream infections, the ST131 clone was not associated with health-care-associated risk factors, such as urinary catheter use or antibiotic exposure. Although highly virulent and multidrug resistant, the ST131 clone was not associated with higher mortality than non-ST131 clones.

Sphingomonas paucimobilis Bacteremia in Humans: 16 Case Reports and a Literature Review

BACKGROUND/PURPOSE Sphingomonas paucimobilis is a glucose-nonfermenting Gram-negative bacillus that is widely distributed in both natural environment and hospitals. Various infections in humans have been reported, but most have been limited to sporadic case reports. The aim of this study was to describe the clinical characteristics and manifestations of S. paucimobilis bacteremia. We also reviewed the literature on S. paucimobilis bacteremia. METHODS Cases of S. paucimobilis bacteremia were identified retrospectively at a university-affiliated hospital in Taiwan. In addition, relevant case reports were identified through PubMed and reviewed. RESULTS From April 2004 to April 2008, 42 cases of S. paucimobilis bacteremia were identified in this study. Among them, 16 cases were identified from E-Da hospital, Kaohsiung, Taiwan and 26 cases from the literature review. The median age of patients was 48.5 years and 57.1% were male. The most common comorbidities included malignancy (57.1%), immunosuppressant use (40.5%), and diabetic mellitus (11.9%). Hospital-acquired bacteremia accounted for 69.0% of infections. Primary bacteremia and catheter-related bloodstream infection were found in 35.7% and 33.3% respectively. The most effective antibiotics were fluoroquinolones, carbapenems, and beta-lactam/beta-lactamase inhibitor combinations. All 42 patients survived the S. paucimobilis bacteremic episodes, but three patients experienced septic shock. CONCLUSION S. paucimobilis can cause infections in healthy as well as immunocompromised individuals. Although it is an organism of low clinical virulence, infection caused by S. paucimobilis can lead to septic shock. Further clinical research is required to characterize this infection.

Risk factors of isolated antibody against core antigen of hepatitis B virus: association with HIV infection and age but not hepatitis C virus infection.

Background:Isolated antibody to hepatitis B core antigen (anti-HBc) is defined as seropositivity for anti-HBc in the absence of hepatitis B surface antigen (HBsAg) and antibody to HBsAg (anti-HBs). It is commonly found in HIV-infected persons or hepatitis C virus (HCV)-infected persons, but the risk factors for isolated anti-HBc remain uncertain, especially in regions that are hyperendemic for hepatitis B virus (HBV) infection. Methods:This cross-sectional study included a cohort of 955 nonhemophiliac, HIV-infected patients, diagnosed between 1988 and 2009, and 643 HIV-uninfected injection drug users (IDUs) attending the methadone clinic between August 2007 and May 2009, with available HBV serological data. The medical records were reviewed to identify the risk factors associated with seropositivity of isolated anti-HBc. Results:The overall seroprevalence of isolated anti-HBc was 12.1% (193 of 1598), in which occult HBV infection accounted for 1.6% (3 of 185) and the majority (91.2 %, 176 of 193) had low titers of anti-HBs (3.6 ± 2.9 IU/L). Subjects with isolated anti-HBc were significantly older (40.7 ± 9.3 versus 36.9 ± 8.0, respectively, P < 0.0001). There was a significantly increasing trend in the prevalence of isolated anti-HBc with age, from 4.0% in those younger than 30 years to 22.5% after 50 years of age (test for trend, P < 0.0001). A significantly higher prevalence of isolated anti-HBc was observed in HIV-infected subjects [14.0% (134 of 955) versus 9.2% (59 of 643), adjusted odds ratio, 1.64; P < 0.01], but not in those with HCV infection (P = 0.18). Conclusions:Isolated anti-HBc seropositivity was significantly associated with HIV infection, and older age. HCV infection was not associated with isolated anti-HBc in a country hyperendemic with HBV infection, even in populations with a high prevalence of HCV infection. The majority was not attributable to occult HBV infection, but rather, low level of anti-HBs, suggesting that HBV vaccination may not be required.

Acute Q Fever Hepatitis in Patients with and without Underlying Hepatitis B or C Virus Infection

BACKGROUND Although hepatitis is one of the major presentations of acute Q fever, the possible influence of viral hepatitis in Q fever has, to our knowledge, never been investigated. It is an important issue in regions where Q fever hepatitis and viral hepatitis are prevalent, such as Taiwan. We conducted a study to investigate the possible influence of viral hepatitis in cases of acute Q fever hepatitis. METHODS Cases of acute Q fever confirmed by serologic examination were included in the study. All patients who were found to be positive for Q fever were tested for hepatitis B surface antigen and antibody to hepatitis C virus, and those with positive results had their viral loads determined. Demographic data, clinical manifestations, results of laboratory and imaging examinations, and responses to treatment were recorded retrospectively from charts. RESULTS A total of 58 patients with acute Q fever hepatitis were studied, of whom 16 (27.6%) had viral hepatitis (hepatitis B virus infection in 12 and hepatitis C virus infection in 4). Patients with and patients without viral hepatitis did not differ with regard to clinical manifestations and responses to treatment, except that chills (100% vs. 73.8%; P=.02) and nausea and/or vomiting (18.8% vs. 2.4%; P=.03) were significantly more common among patients with viral hepatitis. The change in hepatitis B and C virus loads between the acute and convalescent phase was <1.0 log(10). CONCLUSIONS The clinical manifestations of acute Q fever hepatitis differ little in patients with and patients without underlying viral hepatitis, and replication of hepatitis virus is not influenced by acute Q fever hepatitis.

Endometriosis Presenting as Bloody Ascites and Shock

Endometriosis is defined as the presence of ectopic foci of endometrial tissue outside the uterine cavity. Many patients are asymptomatic, but others present protean symptoms, including headache, cyclic hemoptysis, pleural effusion, and ascites depending on the endometrial implantation sites. Although massive ascites has been reported as a manifestation of endometriosis, hypovolemic shock is unusual. We report a case of endometriosis presenting as shock and bloody ascites to show that endometriosis can result in acute abdomen with shock. A 29-year-old female presented to our Emergency Department (ED) complaining of light-headedness and palpitations. Examination suggested hypovolemic shock. Ultrasonography revealed massive ascites and paracentesis showed bloody ascites. Exploratory laparoscopy showed endometriosis over the left broad ligament. After fluid resuscitation and electrocauterization of the endometriosis, the patients condition stabilized, and she was discharged 5 days after admission. This case is presented to raise awareness that endometriosis can present with hypovolemic shock.

Myoclonic jerks due to acute bromovalerylurea intoxication

Background. Bromides are still sold as sedatives, antitussives, and anticonvulsants in many countries. Bromovalerylurea is a bromide-containing sedative-hypnotic that is occasionally combined with non-steroidal anti-inflammatory drugs in over-the-counter products. Chronic intake of excessive bromovalerylurea can produce bromide intoxication, but acute bromovalerylurea intoxication presenting with myoclonic jerks has never been described. Case report. A 23-year-old woman was brought to our emergency department with unusual drowsiness. Her physical examination was normal except for frequent myoclonic jerks in all extremities that could be triggered by moving the patient or by noxious stimuli. Initial blood tests results were normal; the serum bromide concentration was 81.0 mg/L (reference <10 mg/L). Treatment with intravenous normal saline and furosemide resulted in gradual improvement in her drowsiness and myoclonic jerks. By the second hospital day, she was normal. A brain magnetic resonance imaging (MRI) was normal. At a 2-month follow-up visit, the patient had no neurological sequelae. Discussion. Chronic bromide intoxication caused by long-term abuse of bromovalerylurea may present as psychiatric or neurologic abnormalities. Our case of acute bromovalerylurea intoxication presented with severe myoclonic jerks and lethargy. The serum bromide concentration was similar to the reported concentrations in acute bromide intoxications. Treatment with normal saline and diuretics results in increased clearance of bromide and an improvement in clinical effects. Conclusion. Myoclonic jerks may be one of the major presentations of acute bromovalerylurea intoxication. Physicians should consider bromide intoxication in the differential diagnosis of the causes of myoclonic jerks.

Gas forming liver abscess caused by Klebsiella pneumoniae

A 71-year-old man presented to the emergency department with fever and chill for 3 days. He had type 2 diabetes mellitus for 2 years. On arrival, his vital signs were stable and his physical examination was unremarkable except for mild right upper quadrant tenderness. The patient’s white blood cell count was 18580/mm3; aspartate aminotransferase and alanine aminotransferase …

Salmonella Infection after Surgery of Small Intestine Foreign Bodies

Objective: To report the first case of Salmonella enterica serotype choleraesuis infection after surgery for small intestine foreign bodies. Clinical Presentation and Intervention: A 52-year-old woman presented to our hospital with the chief complaint of left abdominal pain for 1 day. The plain kidney-ureter-bladder film and abdominal computed tomography scan showed foreign bodies in the peritoneum. Metallic foreign bodies in the jejunum were found during surgery. Following surgery, the patient developed fever, and blood culture yielded Salmonella enterica serotype choleraesuis. The patient recovered smoothly after antibiotic therapy. Conclusion:Salmonella enterica serotype choleraesuis is a highly invasive serotype of nontyphodial Salmonella. In addition to gastroenteritis, bacteremia, or extraintestinal localized infections, physicians should know that it could complicate intestinal surgery.