Masashi Narita

Chromobacterium haemolyticum-induced bacteremia in a healthy young man

BackgroundThe genus Chromobacterium consists of 7 recognized species. Among those, only C. violaceum, commonly found in the soil and water of tropical and subtropical regions, has been shown to cause human infection. Although human infection is rare, C. violaceum can cause life-threatening sepsis, with metastatic abscesses, most frequently infecting those who are young and healthy.Case presentationWe recently identified a case of severe bacteremia caused by Chromobacterium haemolyticum infection in a healthy young patient following trauma and exposure to river water, in Japan. The patient developed necrotizing fasciitis that was successfully treated with a fasciotomy and intravenous ciprofloxacin and gentamicin.ConclusionsC. haemolyticum should be considered in the differential diagnosis of skin lesions that progressively worsen after trauma involving exposure to river or lake water, even in temperate regions. Second, early blood cultures for the isolation and identification of the causative organism were important for initiating proper antimicrobial therapy.

Presence of periaortic gas in Clostridium septicum-infected aortic aneurysm aids in early diagnosis: a case report and systematic review of the literature

BackgroundClostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates.Case presentationA 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death.ConclusionsIn this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy.A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases.Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy).We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.

High positivity of blood cultures obtained within two hours after shaking chills

OBJECTIVE To determine whether the time lag between blood culture draw and the start of shaking chills is associated with blood culture positivity. METHODS A prospective observational study was undertaken from January 2013 to March 2015 at a referral center in Okinawa, Japan. All enrolled patients were adults with an episode of shaking chills who were newly admitted to the division of infectious diseases. The study exposure was the time lag between blood culture draw and the most recent episode of shaking chills. RESULTS Among patients whose blood cultures were obtained within 2h after shaking chills started, the blood culture positivity was 53.6% (52/97), whereas among patients whose blood cultures were obtained after more than 2h, the positivity was 37.6% (44/117) (p=0.019). The adjusted odds ratio of blood culture positivity for samples drawn within 2h after shaking chills was 1.88 (95% confidence interval 1.01-3.51, p=0.046). Escherichia coli were the most frequently detected bacteria (58/105). CONCLUSIONS The positivity of blood cultures obtained within 2h after the start of the most recent shaking chills was higher than that for blood cultures obtained after 2h.

A case of typhoidal tularemia in a male Japanese farmer

In Japan, most tularemia cases occur after contact with hares (hunting, cooking) and involve the glandular or ulceroglandular form. Here, we present a case of typhoidal tularemia in a 72-year-old Japanese male farmer who presented with fever, fatigue, and right lower abdominal pain. Computed tomography revealed intestinal wall thickening at the ascending colon, pleural effusion, and ascites. Following an initial diagnosis of bacterial enteric infection, his symptoms deteriorated after a week-long cephalosporin treatment course. The patient lived in an area endemic for scrub typhus; the antibiotic was changed to a tetracycline on suspicion of scrub typhus infection. His symptoms rapidly improved after initiation of minocycline treatment. Later, blood tests revealed marked increases in serological tests against Francisella tularensis exclusively, and the patient was diagnosed with typhoidal tularemia. Typhoidal tularemia may be characterized by any combination of general symptoms, but does not exhibit the local manifestations associated with other forms of tularemia. The patient, in this case, had no direct contact with hares or other wild animals and did not present with local manifestations of tularemia. Physicians should consider this disease, especially when tick-borne disease is suspected in the absence of local wounds, eschar, ulcers, or lymphadenopathy.

Where’s the Eschar?: Non-eschar cases and Eschar Distribution between the serotypes of Karp, Irie/Kawasaki and Hirano/Kuroki Causing Scrub Typhus in Fukushima, Japan

Abstract Background Scrub typhus (ST) is endemic in Fukushima, where the highest number has been reported from 2006 to 2011 in Japan. Lack of the triad (fever, rash and eschar) in the clinical features of ST makes the diagnosis difficult especially without eschar. Although genitalia or axillae must be examined carefully as overlooked part of physical examination, the distributions of eschars in the serotypes of ST remain unclear. Methods We reviewed the clinical features of the patients diagnosed as ST in adults from 2008 to 2016 at Ohta Nishinouchi General Hospital, a major teaching hospital in Fukushima, Japan. Results Total 51 cases (serotype Karp 24, Irie/Kawasaki 19, Hirano/Kuroki 8) of ST were confirmed by elevated specific IgM and IgG in the paired sera and the positivity by real-time PCR analysis of eschars. Non-eschar cases were found in 5/51 (9.8%): one of Karp, one of Irie/Kawasaki and three of Hirano/Kuroki. Two eschars were found in a case of Irie/Kawasaki. Total 47 eschars were found in the diagnosed cases. In terms of sex differences, eschars from abdomen to thighs including genitalia were found 4/17 (24%) in men and 17/30 (57%) in women, which is more than twice as high than men. In contrast, eschars in lower extremities from calves to feet were found 5/17(29%) in men and 1/30 (3%) in women. There was no eschar in genitalia and hips in men. In terms of serological type differences, eschars of Karp were found in all of parts of bodies (head, neck, upper extremities, chest, back, abdomen, genitalia, hips, knees/popliteal fossae, and feet). In contrast, no eschar was found in genitalia and hips in Irie/Kawasaki and Hirano/Kuroki. No eschar was found in head, neck and feet in Hirano/Kuroki as well. The contact body sites by vectors, behavior pattern of the patients (passage in women, etc.) and preference to human, such as slow-biter with migration to genitalia or axillae as Leptotrombidium pallidum (L. pallidum; vector of Karp) or quick-biter as L. scutellare (vector of Irie/Kawasaki and Hirano/Kuroki) would be the causes of eschar distribution. Conclusion Eschar is the key feature of ST, so we should not be missed the finding with the high index of suspicion in regards to eschar distribution of the sexes and the serotypes. Atypical presentation such as eschar negative ST should be concerned in this endemic area. Disclosures All authors: No reported disclosures.