Keiichi Furukawa

Infective endocarditis caused by Salmonella enteritidis in a dialysis patient: a case report and literature review.

BackgroundInfective endocarditis is significantly more common in haemodialysis patients as compared with the general population, the causative pathogen is generally Staphylococcus aureus; there have been no previously reported cases of infective endocarditis caused by a Salmonella species in haemodialysis patients.Case PresentationWe report the case of a 68 year-old woman on haemodialysis who developed infective endocarditis as a result of Salmonella enteritidis. Although we treated the patient with ceftriaxone combined with ciprofloxacin, infective endocarditis was not detected early enough and unfortunately developed into cerebral septic emboli, which ultimately resulted in death.ConclusionAlthough there are several reports that Salmonella endocarditis without cardiac failure can be successfully treated with antibiotics alone, early surgical intervention is essential for some cases to prevent life-threatening complications. Transesophageal echocardiography should be performed in any patient with high clinical suspicion of infective endocarditis. To the best of our knowledge, this is the first case-report of Salmonella endocarditis in a haemodialysis patient.

Listeria monocytogenes meningitis

Tumbling motility is one of the useful characteristics of Listeria monocytogenes. This can be helpful to identify the causative pathogen along with Gram staining before the confirmatory microbiological examination.

Catheter-free Period Over 2 Days Is Associated with Better Outcome in Catheter-related Bloodstream Infection due to Candida

Abstract Background Regardless of active antifungal drugs, mortality of candidemia remains high. Although it is well-known that central venous catheter (CVC) is one of the most important risk factors of candidemia and should be removed immediately, little is known about optimal timing of CVC replacement after removal. Here, we analyzed contributing risk factors associated with 30-day mortality for catheter-related bloodstream infection (CRBSI) due to candida and optimal timing of CVC replacement. Methods We conducted a retrospective cohort study at St. Luke#129; fs International Hospital between 2004 and 2015. We compared each clinical component in patients who died within 30 days and were alive at 30 days. Also, catheter-free period (from removal to replacement) was compared between group A and B. Fisher#129; fs exact test and Mann–Whitney U test were used in univariate analysis and multivariate linear regression was used for controlling confoundings. Results Among 228 patients (pts) with candidemia, 166 patients (73%) were on CVC at diagnosis. Of them, 144 patients (65%) removed CVC after the result of candidemia. Seventy-one patients (31%) replaced CVC. Fifteen patients (6%) died within 30 days (group A) and 56 patients (25%) were alive at 30 days (group B). Median age was 74 in group A and 72 in group B (P = 0.331) (Table 1). In univariate analysis, hematological malignancy (OR 6.75, 95% CI 1.01–44.9) and CVC replacement < 2-days after removal (OR 5.63, 95% CI 1.16–27.3) showed statistically significant increase in group A vs group B (Table 2). In multivariate analysis, CVC replacement < 2-days was independently associated with 30-day mortality (Table 3). Conclusion This is the first study to demonstrate the optimal timing of CVC replacement in CRBSI due to candida. CVC replacement < 2 days was an independent risk factor for 30-day mortality. Disclosures All authors: No reported disclosures.

Clinical Comparison between Native Vertebral Osteomyelitis with Abscess versus without Abscess in Clinical Features and Outcomes

Abstract Background It is well documented that native vertebral osteomyelitis (NVO) is accompanied by abscess formation (epidural, paravertebral, and psoas muscle) that is complicated by neurological deficit. There are few studies comparing between NVO with abscess and NVO without abscess in clinical features and outcomes. Methods We conducted a retrospective cohort study at St. Luke’s Intl. Hosp. in Tokyo, Japan (acute care hospital, 520 beds) from 2004 to 2015. Diagnosis of acute NVO was made by clinical signs and symptoms, and MRI. Clinical features and outcomes of NVO patients with abscess were compared with ones without abscess. Fisher’s exact test, Mann–Whitney U-test, and Kaplan–Meier curve with log-rank test were used in univariate analysis and the association to length of stay was analyzed by Cox-regression model controlling confounding. Results Among 122 patients with NVO, 83 patients (68%) had abscess (group A) and 39 patients (32%) had no abscess (group B). Median age: (group A: 69 vs. group B: 66, P = 0.641). Median length of stay (LOS) in hosp: (A: 48 vs. B: 43 days, 
P = 0.007) (Table 1). Group A had higher rate of neurological symptoms (16.9 vs. 2.6%, P = 0.035), blood cultures positivity (62.7 vs. 35.9%, P = 0.007), infective endocarditis (IE) (15.7 vs. 2.6%, P = 0.036), and longer duration of therapy (75 vs. 56 days, P = 0.025) than group B in univariate analysis. Also, group A had trend toward higher rate of methicillin-susceptible S. aureus (28.9 vs. 5.1%, P = 0.056). Kaplan–Meier analysis revealed LOS was significantly longer in group A (P = 0.013) (Figure 1). The result of Cox’s proportional hazards model suggested abscess was associated with longer LOS (Table 2). Blood culture positivity was independently associated with longer LOS. No statistically significant associations were observed between abscess and 90-day mortality (5.1 vs. 3.6%, P = 0.654), or neurological sequelae (6 vs. 0%, P = 0.227). Conclusion LOS of NVO patients with abscess was longer than those without abscess. In particular, LOS was significantly longer in patients with positive blood culture than those with negative results. Disclosures All authors: No reported disclosures.

Ocular involvement with secondary syphilis in a non-HIV infected man

A 65-year old human immunodeficiency virus (HIV)-uninfected man presented to the ophthalmology department with 3-week history of progressive deterioration of his right eyesight and a visual field abnormality. He also complained of 3-month of a painless ulcer on his dorsal penile shafts with 3-week of diffuse, symmetric skin erythema involving his entire trunk, bilateral palms and soles. His serum Venereal Disease Research Laboratory titer was 1:64 and Treponema Pallidum Hemagglutination (TPHA) titer was 1:5120. Examination of the cerebrospinal fluid revealed normal cell count of 3/μL, and glucose of 65 mg/dL, but slightly elevated protein of 52 mg/dL and positive TPHA of 1:8. Ophthalmologic examination demonstrated right papilledema and optic disk hemorrhage with leakage of contrast medium that was compatible with optic neuritis (Fig. 1). In addition, magnetic resonance imaging showed edema of his right optic nerve (Fig. 2). Optic neuropathy can occur in secondary syphilis, although it is likely underestimated as it may be overlooked [1]. Ocular syphilis is less common in HIV-uninfected healthy patients compared to those with HIV infection [2], but clinicians should be aware that the presence of diminished visual acuity in syphilitic patients is strongly suggestive of central nervous system involvement [3]. Syphilic optic neuritis can proceed to rapid visual dysfunction [4]. Our patient was treated with penicillin G 4 million units intravenously every 4 h for 14 days along with oral prednisolone 1 mg/kg daily, and his skin lesions and visual disturbance gradually improved. As delayed diagnosis can lead to irreversible visual loss, early assessment and treatment is of paramount importance [5].

Vertebral osteomyelitis as a rare manifestation of Lemierre's syndrome

A 55-year-old man without a significant past medical history presented to an emergency department with the symptoms of right neck pain for 2 weeks and high-grade fever up to 38 °C for 10 days, followed by acute onset of dyspnea on exertion. On admission, computed tomography (CT) scan with contrast revealed a 4cm-diameter of retropharyngeal abscess (Fig. 1A), right internal jugular vein thrombosis (Fig. 1B) and bilateral multiple septic pulmonary emboli. He was diagnosed as Lemierre’s syndrome accompanied by retropharyngeal abscess and underwent urgent surgical drainage on the same day. Blood culture revealed Streptococcus anginosus group sensitive to penicillin (MIC, 0.064 μg/mL: E test) and drained pus culture revealed Streptococcus anginosus group and Fusobacterium nucleatum. We started ampicillin IV 2 g every 4 h and clindamycin IV 600 mg every 8 h. Enhanced magnetic resonance imaging revealed vertebral osteomyelitis on the 2nd cervical spine (Fig. 2). The patient was treated with the combination therapy for 6 weeks, followed by oral amoxicillin/clavulanate 1.5 g per day for four weeks without any adverse event. Lemierre’s syndrome accompanied by vertebral ostemomyelitis is uncommon [1]. In this case, poor oral hygiene was associated with retropharyngeal abscess and eventually spreaded directly to the cervical spine. Duration of therapy for Lemierre’s syndrome is not well established, ranging from 4 to 112 days depending on severity and patient response [2]. Evaluating the presence of vertebral osteomyelitis is important because optimal duration of antibacterials differs accordingly [3]. Shorter duration of antibiotics can result in treatment failure.

Varicella-zoster virus myeloencephalitis

A 47-year-old woman with history of systemic lupus erythematous on prednisolone presented to our emergency department with fever and back pain for 5 days along with progressive muscle weakness on left lower leg. Cerebrospinal fluid (CSF) revealed pleocytosis with mononuclear leukocyte predominance. Brain and spine Magnetic Resonance Imaging (MRI) revealed multiple high intensity areas on cerebral white matter (Fig. 1A), cerebellum, pons, temporal lobe (Picture 1B), medulla oblongata and center of spinal cord on 8–12th thoracic spine (Fig. 2A, B). Based on MRI, transverse myelitis associated myeloencephalitis was suspected. Differential diagnoses were central nervous system lupus, neuromyelitis optica and infection-related myeloencephalitis including herpes simplex virus, varicella-zoster virus and human immunodeficiency virus. We empirically started acyclovir because she developed a small vesicle below her nose for which we strongly suspected Varicella-zoster (VZV) myeloencephalitis, and her neurological symptoms gradually improved. Eventually VZV-PCR of CSF became positive. VZV myeloencephalitis is uncommon and causes poor outcome with delayed diagnosis [1]. VZV-PCR is useful for confirming myeloencephalitis [2]. We should take it into consideration for transverse myelitis in cell-mediated immunity depleted patients.