Masashi Haraoka

Suppression of renal scarring by prednisolone combined with ciprofloxacin in ascending pyelonephritis in rats

To prevent renal scarring, which occurs at the end stage of chronic pyelonephritis due to vesicoureteral reflux of infected urine, immediate antimicrobial treatment is reported to be essential. When treatment is delayed, the antimicrobial agent is believed to be effective only in eliminating bacteria, not in preventing scar formation. Using the ascending pyelonephritis model in rats, we investigated the effect of immediate or delayed treatment with ciprofloxacin and that of delayed treatment with a combination of ciprofloxacin and prednisolone in preventing renal scarring following infection. An inoculum of 1 x 10(9) colony forming units (cfu)/0.1 ml. of the HM32 strain of Escherichia coli, which was isolated from a patient with a urinary tract infection, was injected directly into the rat bladder, and the urethra was clamped for 4 hours in each rat. Treatment by ciprofloxacin (15 mg./kg., twice a day for 5 days) alone or in combination with prednisolone (2 mg./kg., once a day for 4 days) was initiated 6 or 72 hours after bacterial inoculation. The kidneys of each rat were examined 6 weeks later. Immediate treatment by ciprofloxacin significantly inhibited renal scarring (no scarring was seen in any of the 8 rats), but delayed treatment had no effect on scarring (4 of 8 rats showed scarring) when compared with the untreated controls (7 of 8 rats showed scarring). However, the addition of prednisolone to the delayed treatment with ciprofloxacin significantly inhibited renal scarring (only 1 of 10 rats showed scarring) when compared with the untreated controls (7 of 8 rats showed scarring). These data suggest that prednisolone is effective in preventing renal scarring which occurs due to vesicoureteral reflux when the initiation of antimicrobial treatment is delayed.

Elevated Interleukin-8 Levels in the Urine of Children with Renal Scarring and/or Vesicoureteral Reflux

PURPOSE Elevation of urinary levels of interleukin-6 and 8 has been observed in patients with acute urinary tract infections. However, to our knowledge there have been no studies concerning the secretion of interleukin-6 and 8 into the urine after acute inflammation has resolved and renal scarring has occurred. On the other hand, it is well known that cytokines are variously related to glomerular diseases and, thus, it is possible that the progression of reflux nephropathy depends on interleukin-6 or 8. Therefore, we assessed urinary levels of interleukin-6 and 8 in children with vesicoureteral reflux and/or renal scarring. MATERIALS AND METHODS We evaluated interleukin-6 and interleukin-8 levels in the urine of 32 children without a urinary tract infection who presented or were admitted to our hospital because of vesicoureteral reflux between April and December 1994. Interleukin-6 and 8 were determined using a commercially available human enzyme-linked immunosorbent assay kit and the 2-step sandwich method. RESULTS Urinary interleukin-6 levels were below the lower detection limit (less than 10 pg./ml.) in all samples. There were statistically significant differences between urinary interleukin-8 levels in children with and without renal scarring (p = 0.001), and with and without vesicoureteral reflux (p = 0.0246). CONCLUSIONS Urinary interleukin-8 is an effective marker for renal scarring and vesicoureteral reflux.

Susceptibilities of Neisseria gonorrhoeae Isolates Containing Amino Acid Substitutions in GyrA, with or without Substitutions in ParC, to Newer Fluoroquinolones and Other Antibiotics

ABSTRACT We examined the antimicrobial susceptibilities of 85Neisseria gonorrhoeae isolates, classified according to the presence of amino acid substitutions in the GyrA and ParC proteins, to 12 fluoroquinolones and 7 other antibiotics. Sitafloxacin and HSR-903 showed excellent activity against N. gonorrhoeae, including strains with both GyrA and ParC substitutions. Among the strains with various GyrA substitutions, strains with a serine-91-to-phenylalanine mutation required the highest MICs of all of the fluoroquinolones tested and were cross-resistant to structurally unrelated β-lactams.

RETROPERITONEAL LAPAROSCOPIC ADRENALECTOMY IN A PREGNANT WOMAN WITH CUSHING’S SYNDROME

A 31-year-old woman presented at gestational week 26 with facial edema and hypertension. On physical examination she had features typical of Cushing’s syndrome and blood pressure of 184/104 mm. Hg. Laboratory examination demonstrated hypokalemia (potassium 2.9 mEq./l., normal 3.6 to 4.9) and mild anemia (hemoglobin 9.5 gm./dl., normal 12.0 to16.0). Plasma cortisol was 58.6 mg./dl (normal 5.5 to17.0), adrenocorticotropic hormone 5.5 pg./ml. (normal 8.2 to 54.8) and urinary cortisol excretion 1,860 mg./24 hours (normal 30 to 100). Furthermore, plasma cortisol was not suppressed with high dose (8 mg.) dexamethasone. Ultrasonography and magnetic resonance image showed a 3 cm. mass in the left adrenal gland. However, the sella turcica was normal size on magnetic resonance imaging. These findings prompted the diagnosis of Cushing’s syndrome due to left adrenal adenoma. Although hypertension was treated with methyldopa, blood pressure had not decreased by gestational week 31. Retroperitoneoscopic adrenalectomy was successfully performed with the patient in the right full lateral position, and under general and epidural anesthesia (figs. 1 and 2). Pneumoperitoneum was created with carbon dioxide insufflation at 10 mm. Hg. Operating time was 125 minutes and estimated blood loss was 250 ml. Convalescence was uneventful. Pathological examination confirmed the diagnosis of Cushing’s syndrome due to an adrenocortical adenoma. Postoperatively, temporary pulmonary edema developed but the remainder of the pregnancy was uneventful. At gestational week 40 a healthy 2,470 gm. male neonate was delivered via a normal vaginal delivery without any complications.

Testicular Injury Induces Cell-Mediated Autoimmune Response to Testis

Studies on testis autoimmunity are needed for a better understanding of immunological male infertility. Evidence has accumulated that the delayed type hypersensitivity (DTH) response plays a key role in the induction and/or maintenance of experimental autoimmune orchitis (EAO), an animal model for human immunological male infertility or aspermatogenesis. We report here that an antigen-specific DTH response to autologous testicular cells (TC) could be induced by bilateral testicular injury (trauma) in mice. Pretreatment of traumatized mice with a high dose of cyclophosphamide (CY) enhances the DTH response in a dose-dependent manner. The DTH response induced by testicular injury reaches its peak on the ninth day. We have shown that the local passive transfer of the footpad reaction to normal recipients by T cells further defines the DTH reaction. These characteristics resemble those of the previously reported DTH response to syngeneic TC induced by subcutaneous immunization with viable syngeneic crude TC. Our present injury model mimics clinical testicular trauma; therefore, this testicular injury model can be very useful in studying the immunological mechanism of EAO and of human immunological male infertility.

Enhanced chemiluminescence response of polymorphonuclear leukocytes by new quinolone antimicrobials.

Some of the many antimicrobial agents (beta-lactams, macrolides, aminoglycosides, tetracyclines, new quinolones; NQs) were reported to have a bactericidal or bacteriostatic effect cooperating with host defense mechanisms including polymorphonuclear neutrophils (PMNs). We investigated the effect of new quinolone antimicrobials on chemiluminescence (CL) response of human PMNs. Among many NQs, we chose ofloxacin, lomefloxacin, fleroxacin, sparfloxacin, AM-1155, NM-394, Q-35, Y-26611 and T-3761. Twenty-five or 100 micrograms/ml of fleroxacin and ofloxacin enhanced luminol-dependent CL response of PMNs up to 1.5-2.0 times compared to the drug free condition. Other antimicrobial agents, however, inhibited CL response. This suggested that fleroxacin and ofloxacin were more efficient in the treatment of bacterial infections with respect to the interaction between antimicrobials and PMNs.

Clitoral involvement by neurofibromatosis: a case report and review of the literature.

We report a case of clitoral involvement by neurofibromatosis in which the clitoris resembled a phallus. The patient was treated successfully by clitoroplasty. This is the seventh such case reported in the English literature.

Analysis of quinolone resistance mechanisms in a sparfloxacin-resistant clinical isolate of Neisseria gonorrhoeae

Background and Objectives: Recently, a reduction in the susceptibility of clinical isolates of Neisseria gonorrhoeae to newer fluoroquinolones including sparfloxacin in vitro has been recognized in Japan. The quinolone resistance mechanisms in gonococcal isolates from a patient with clinical failure of sparfloxacin treatment was investigated. Goal: To report a man with gonococcal urethritis in whom clinical failure of sparfloxacin treatment occurred and to examine the quinolone resistance mechanisms in gonococcal isolates from the patient. Study Design: A man with gonococcal urethritis was treated with oral 100 mg sparfloxacin three times daily for 5 days. However, clinical failure of the sparfloxacin treatment was observed. The antimicrobial susceptibilities of pretreatment and posttreatment isolates to sparfloxacin and other agents were measured. To analyze quinolone resistance mechanisms in the set of isolates, DNA sequencing of the genes corresponding to the quinolone resistance‐determining regions within the GyrA and ParC proteins was performed. We also assayed the intracellular sparfloxacin accumulation level in these gonococcal cells. Moreover, we performed pulsed‐field gel electrophoresis analysis to determine whether the pretreatment and posttreatment isolates were isogenic. Results: The minimum inhibitory concentration of sparfloxacin for the posttreatment isolate (4 μg/ml) was 16 times higher than that for the pretreatment isolate (0.25 μg/ml). The pretreatment isolate contained three mutations, including a Ser‐91 to Phe mutation and an Asp‐95 to Asn mutation in GyrA and a Ser‐88 to Pro mutation in ParC. The posttreatment isolate had four mutations, including the same three mutations and an additional Glu‐91 to Gly mutation in ParC. The sparfloxacin accumulation level within 30 minutes in the posttreatment isolate was four times less than that in the pretreatment isolate. There were no differences in the pulsed‐field gel electrophoresis patterns between the pretreatment and posttreatment isolates from the patient. Conclusions: The emergence of a fluoroquinolone‐resistant N. gonorrhoeae isolate with multiple mutations involving GyrA and ParC reduced the response to sparfloxacin treatment. Multiple dosing and long‐term treatment with sparfloxacin seems to induce a mutation in ParC and an alteration leading to reduced drug accumulation that contribute to increasing the fluoroquinolone resistance level.

Evaluation of a new amplified enzyme immunoassay (EIA) for the detection of Chlamydia trachomatis in male urine, female endocervical swab, and patient obtained vaginal swab specimens.

Aims—To compare the performance of a new generation dual amplified enzyme immunoassay (EIA) with a molecular method for the diagnosis of Chlamydia trachomatis, using a range of urogenital samples, and to assess the reliability of testing self collected vaginal specimens compared with clinician collected vaginal specimens. Methods—Two population groups were tested. For the first population group, first void urine samples were collected from 193 male patients with urethritis, and endocervical swabs were collected from 187 high risk commercial sex workers. All urine and endocervical specimens were tested by a conventional assay (IDEIA chlamydia), a new generation amplified immunoassay (IDEIA PCE chlamydia), and the Amplicor polymerase chain reaction (PCR). Discrepant results obtained among the three sample types were confirmed using a nested PCR test with a different plasmid target region. For the second population group, four swab specimens, including one patient obtained vaginal swab, two clinician obtained endocervical swabs, and one clinician obtained vaginal swab, were collected from 91 high risk sex workers. Self collected and clinician collected vaginal swabs were tested by IDEIA PCE chlamydia. Clinician obtained endocervical swabs were assayed by IDEIA PCE chlamydia and Amplicor PCR. Results—The performance of the IDEIA PCE chlamydia test was comparable to that of the Amplicor PCR test when male urine and female endocervical swab specimens were analysed. The relative sensitivities of IDEIA, IDEIA PCE, and Amplicor PCR on male first void urine specimens were 79.3%, 91.4%, and 100%, respectively. The relative sensitivities of the three tests on female endocervical specimens were 85.0%, 95.0%, and 100%, respectively. The positivity rates for patient collected vaginal specimens and clinician collected vaginal specimens by IDEIA PCE were 25.2% and 23.1%, respectively, whereas those for clinician collected endocervical swabs by PCR and IDEIA PCE were both 27.5%. Conclusions—IDEIA PCE chlamydia is a lower cost but sensitive alternative test to PCR for testing male urine samples and female endocervical swabs. In addition, self collected or clinician collected vaginal specimens tested by IDEIA PCE chlamydia are a reliable alternative to analysing endocervical specimens.

Preventive Effect of Ulinastatin on Renal Scarring in Rat Model of Pyelonephritis Induced by Direct or Ascending Infection with Serratia marcescens or Escherichia coli

Renal scarring is considered to be a characteristic of reflux nephropathy. The effects of ulinastatin, a strong inhibitor of polymorphonuclear leukocyte elastase, on renal scarring following direct parenchymal or intravesical ascending infection by Serratia marcescens or Escherichia coli were determined. Four days of treatment with ulinastatin initiated 2 or 5 days after infection prevented renal scarring. Doses of 1,000-4,000 units/kg inhibited renal scar formation, but 8,000 units/kg did not. These results suggest that it may be possible to limit renal scar formation in pyelonephritis by the use of an appropriate pharmacologic agent.