Jeong-Hwan Hwang

Clinical significance of hypoalbuminemia in outcome of patients with scrub typhus

BackgroundThis study was designed to investigate the clinical significance of hypoalbuminemia as a marker of severity and mortality in patients with Scrub typhus.MethodsThe patients with scrub typhus were divided into two groups based on the serum albumin levels; Group I (serum albumin <3.0 g/dL) and Group II (serum albumin ≥3.0 g/dL). The outcome of patients with hypoalbuminemia was compared with that of normoalbuminemia.ResultsOf the total 246 patients who underwent the study, 84 patients (34.1%) were categorized as Group I and 162 patients were (65.9%) as Group II. Group I showed significantly higher incidence of confusion (24.6% vs. 5.3%, p < 0.001), pulmonary edema (15.8% vs. 3.2%, p = 0.002), pleural effusion (22.8% vs. 11.1%, p = 0.03), arrhythmia (12.3% vs. 2.6%, p = 0.008) and non-oliguric acute renal failure (40.4% vs. 11.1%, p < 0.001) compared to group II. Hypoalbuminemic group had a higher APACHE II score (11.37 ± 5.0 vs. 6.94 ± 4.2, p < 0.001), longer hospital stay (19.9 ± 42.1 days vs 7.5 ± 13.8 days, p = 0.012), and higher hospital cost compared to Group II.ConclusionsThis study showed hypoalbuminemia in scrub typhus was closely related to the frequency of various complication, longer hospital stay, consequently the higher medical cost, necessitating more efficient management of patients, including medical resources.

Severe Fever with Thrombocytopenia Syndrome in South Korea, 2013-2015

Background Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease that was recently identified in China, South Korea and Japan. The objective of the study was to evaluate the epidemiologic and clinical characteristics of SFTS in South Korea. Methods/Principal Findings SFTS is a reportable disease in South Korea. We included all SFTS cases reported to the Korea Centers for Disease Control and Prevention (KCDC) from January 2013 to December 2015. Clinical information was gathered by reviewing medical records, and epidemiologic characteristics were analyzed using both KCDC surveillance data and patient medical records. Risk factors for mortality in patients with SFTS were assessed. A total of 172 SFTS cases were reported during the study period. SFTS occurred throughout the country, except in urban areas. Hilly areas in the eastern and southeastern regions and Jeju island (incidence, 1.26 cases /105 person-years) were the main endemic areas. The yearly incidence increased from 36 cases in 2013 to 81 cases in 2015. Most cases occurred from May to October. The overall case fatality ratio was 32.6%. The clinical progression was similar to the 3 phases reported in China: fever, multi-organ dysfunction, and convalescence. Confusion, elevated C-reactive protein, and prolonged activated partial thromboplastin times were associated with mortality in patients with SFTS. Two outbreaks of nosocomial SFTS transmission were observed. Conclusions SFTS is an endemic disease in South Korea, with a nationwide distribution and a high case-fatality ratio. Confusion, elevated levels of C-reactive protein, and prolonged activated partial thromboplastin times were associated with mortality in patients with SFTS.

Hepatitis A antibody seroprevalence among medical school students

A total of 324 first- to third-year medical school students were examined for anti-hepatitis A virus IgG. Of these 324 students, 37 were found to be anti-hepatitis A virus IgG positive (11.4%). Mass screening of medical students for seropositivity and vaccination of nonimmune students should be considered before starting medical clerkships.

Impact of Vancomycin MIC on Treatment Outcomes in Invasive Staphylococcus aureus Infections

ABSTRACT There are conflicting data on the association of vancomycin MIC (VAN-MIC) with treatment outcomes in Staphylococcus aureus infections. We investigated the relationship between high VAN-MIC and 30-day mortality and identified the risk factors for mortality in a large cohort of patients with invasive S. aureus (ISA) infections, defined as the isolation of S. aureus from a normally sterile site. Over a 2-year period, 1,027 adult patients with ISA infections were enrolled in 10 hospitals, including 673 (66%) patients with methicillin-resistant S. aureus (MRSA) infections. There were 200 (19.5%) isolates with high VAN-MIC (≥1.5 mg/liter) by Etest and 87 (8.5%) by broth microdilution (BMD). The all-cause 30-day mortality rate was 27.4%. High VAN-MIC by either method was not associated with all-cause 30-day mortality, and this finding was consistent across MIC methodologies and methicillin susceptibilities. We conclude that high VAN-MIC is not associated with increased risk of all-cause 30-day mortality in ISA infections. Our data support the view that VAN-MIC alone is not sufficient evidence to change current clinical practice.

Peritonitis in patients with scrub typhus.

Various complications have been reported in scrub typhus cases including acute respiratory distress syndrome, encephalitis, pneumonia, pericarditis, acute renal failure, and acute hepatic failure. Few studies have reported on the gastrointestinal manifestations of scrub typhus. Typical gastrointestinal manifestations in patients with scrub typhus include abdominal pain, nausea, vomiting, hematemesis, melena, and diarrhea. The two cases presented in this study are the first reported cases of peritonitis associated with scrub typhus. This study shows that scrub typhus should also be included in the differential diagnosis of peritonitis in areas where Orientia tsutsugamushi is endemic.

Splenic infarction associated with acute infectious mononucleosis due to Epstein–Barr virus infection

The purpose of this study was to report a case of a previously healthy 20‐year‐old woman diagnosed with splenic infarction following infectious mononucleosis (IM) by Epstein–Barr virus (EBV) infection and to perform the first systematic review of the clinical characteristics of splenic infarction associated with IM. A systematic review was conducted using English, French, and Japanese literatures of splenic infarction associated with IM due to EBV infection published between 1961 and 2015 in PubMed Medline. A total of 19 cases were extracted from the collected articles. Left upper quadrant (LUQ) pain was observed in 15 (79%) patients. Splenectomy was performed in five (26%) cases, among which four patients presented with stable vital signs. Splenic rupture was accompanied in two (10%) patients. The median time from the onset of IM symptoms to the diagnosis of splenic infarction was 5 days (range, 1–25 days). Fourteen (74%) of 19 patients experienced improvement through medical treatment, and there were no deaths. Splenic infarction associated with IM due to EBV infection can show a favorable clinical outcome after medical treatment. Clinicians should consider the possibility of splenic infarction when patients with IM experience LUQ pain. J. Med. Virol. 89:332–336, 2017.

Comparison of Arbekacin and Vancomycin in Treatment of Chronic Suppurative Otitis Media by Methicillin Resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of ear infections. We attempted to evaluate the clinical usefulness of arbekacin in treating chronic suppurative otitis media (CSOM) by comparing its clinical efficacy and toxicity with those of vancomycin. Efficacy was classified according to bacterial elimination or bacteriologic failure and improved or failed clinical efficacy response. Ninety-five subjects were diagnosed with CSOM caused by MRSA. Twenty of these subjects were treated with arbekacin, and 36 with vancomycin. The bacteriological efficacy (bacterial elimination, arbekacin vs. vancomycin: 85.0% vs. 97.2%) and improved clinical efficacy (arbekacin vs. vancomycin; 90.0% vs. 97.2%) were not different between the two groups. However, the rate of complications was higher in the vancomycin group (33.3%) than in the arbekacin group (5.0%) (P=0.020). In addition, a total of 12 adverse reactions were observed in the vancomycin group; two for hepatotoxicity, one for nephrotoxicity, eight for leukopenia, two for skin rash, and one for drug fever. It is suggested that arbekacin be a good alternative drug to vancomycin in treatment of CSOM caused by MRSA.

Malaria-Induced Splenic Infarction

Splenic infarction is a rare complication of malaria. We report two recent cases of splenic infarction after Plasmodium vivax infection. No systematic review of malaria-induced splenic infarction was available, therefore we conducted a systematic review of the English, French, and Spanish literature in PubMed and KoreaMed for reports of malaria-associated splenic infarction from 1960 to 2012. Of the 40 cases collected on splenic infarction by Plasmodium species, 23 involved P. vivax, 11 Plasmodium falciparum, one Plasmodium ovale, and five a mixed infection of P. vivax and P. falciparum. Of the 40 cases, 2 (5.0%) involved splenectomy and 5 (12.5%) were accompanied by splenic rupture. The median time from symptom onset to diagnosis was 8.5 days (range, 3-90 days). Improved findings after treatment were observed in 8 (88.9%) of 9 patients with splenic infarction on follow-up by computed tomography or ultrasonography. All patients survived after treatment with the exception of one patient with cerebral malaria. Clinicians should consider the possibility of splenic infarction when malaria-infected patients have left upper quadrant pain.

Successfully Managed Acute Transverse Myelitis Related to Scrub Typhus and Serial Image Findings

Central nervous system involvement manifesting as meningitis or meningoencephalitis is a known complication of scrub typhus, but very few spinal cord lesions such as acute transverse myelitis (ATM) have been reported in association with this disease. Scrub typhus patients with a spinal lesion present with neurologic symptoms including dysuria, motor, and sensory weakness. Herein, we describe a rare case of ATM associated with scrub typhus. Clinical characteristics, cerebrospinal fluid cytology, Orientia tsutsugamushi serum antibody titer, and serial magnetic resonance imaging scans resulted in a diagnosis of ATM associated with scrub typhus.

Incidentally Discovered Splenic Infarction Associated with Scrub Typhus

A 46-year-old woman was transferred to our emergency room (ER) from another hospital because of pleural effusion and general weakness. Five days before admission to our ER, oral doxycycline treatment was begun on clinical suspicion of scrub typhus. On physical examination by emergency medical services personnel, the patient did not exhibit a skin rash, and eschar was observed on the right posterior thigh aspect (Figure 1 ). No abdominal tenderness was observed. On arrival to our ER, transthoracic echocardiography was performed because of both pleural effusion and general weakness, and the results were within normal limits. On laboratory testing, complete blood count was within normal range, as were other chemical profiles except for the following: alkaline phosphatase 229 IU/L, gamma-glutamyl transferase 153 IU/L, aspartate aminotransferase 110 IU/L, and alanine aminotransferase 190 IU/L. Peripheral blood smear showed normal finding. Coagulopathy testing did not reveal disseminated intravascular coagulation, with negative results for lupus anticoagulant and anticardiolipin antibody. Serology for Epstein–Barr virus was also negative. The Orientia tsutsugamushi antibody titer using the indirect immunofluorescent antibody test was 1:5,120. Abdominal computed tomography was performed because of abnormal liver function test results, which revealed a wedge-shaped hypoperfusion area, suggesting splenic infarction (Figure 2 ). During hospitalization, blood culture did not yield any organism. Oral doxycycline was maintained for more than 7 days. The patients clinical course improved, and 2 weeks after discharge, the patient was stable without abdominal tenderness. Figure 1. Eschar on the posterior aspect of the right thigh. Figure 2. Abdominal computed tomography with enhancement shows a low-attenuated, wedge-shaped lesion consistent with splenic infarction as well as splenomegaly in the arterial phase (A) and portal phase (B). Focal or disseminated vasculitis is the major pathogenesis of complications following scrub typhus.1 Scrub typhus can lead to the involvement of various intra-abdominal organs.1 However, the pathogenesis of splenic infarction associated with scrub typhus has not been previously documented, and splenic complications such as splenic infarction may be extremely rare and underreported.1,2