Satoshi Kodera

Efficacy of empirical therapy with non-carbapenems for urinary tract infections with extended-spectrum beta-lactamase-producing Enterobacteriaceae

OBJECTIVES Carbapenems are first-line agents for severe infections with extended-spectrum beta-lactamase (ESBL)-producing bacteria. The use of carbapenems, however, is associated with the emergence of resistant organisms. We investigated the effects of empirical therapy with non-carbapenems on urinary tract infections (UTIs) with ESBL-producing Enterobacteriaceae in a hospital where antimicrobial stewardship has been established. METHODS This retrospective chart review was undertaken at a tertiary care hospital where antimicrobial stewardship and restriction of carbapenems has been established. Patients with a UTI with ESBL-producing Enterobacteriaceae were stratified into susceptible and non-susceptible therapy groups according to the susceptibility of the causative organism to the initial antimicrobial therapy. Outcome measures were the duration of antimicrobial therapy, 14-day mortality, infection-related mortality, and clinical cure. RESULTS Of 90 patients, 30 (33.3%) exhibited susceptible therapy. However, no significant difference was observed in the duration of antimicrobial therapy, 14-day mortality, infection-related mortality, or clinical cure between the susceptible and non-susceptible groups. Multivariate analyses revealed that the independent risk factor for 14-day morality was the use of immunosuppressive agents (odds ratio 5.23, 95% confidence interval 1.26-24.04; p=0.023). CONCLUSIONS Non-carbapenem therapy against UTIs with ESBL-producing Enterobacteriaceae does not pose a significant risk to patients who are not taking immunosuppressive agents.

Eosinopenia as a Predictive Factor of the Short-Term Risk of Mortality and Infection after Acute Cerebral Infarction

BACKGROUND Eosinopenia has been shown to be a prognostic factor in bacteremia, chronic obstructive pulmonary disease, and myocardial infarction, but studies focusing on cerebral infarction are lacking. METHODS We conducted a retrospective study of 405 patients admitted to the Asahi General Hospital from June 2011 to September 2014 with a diagnosis of cerebral infarction within 24 hours after symptom onset. Differences in mortality, mortality associated with infection, and the prevalence of infection within 2 months of hospital admission were assessed between patients with and without eosinopenia at presentation. RESULTS Patients with eosinopenia had a significantly higher mortality rate (hazard ratio (HR) 2.54, 95% confidence interval (CI) 1.17-5.21, P = .01), mortality associated with infection (HR 28.7, 95% CI 4.9-542.2, P <.0001), and an increased prevalence of infection (HR 1.83, 95% CI 1.12-2.89, P = .01) than patients without eosinopenia. Patients with neutrophilia and eosinopenia showed a significantly higher mortality rate than patients without neutrophilia (HR 3.15, 95% CI 1.40-6.92, P = .007), whereas patients with neutrophilia without eosinopenia showed no significant difference in mortality compared with patients without neutrophilia (HR 1.57, 95% CI .56-3.93, P = .37). Eosinopenia was a significant risk factor in 2-month mortality rate in multivariate analyses (HR 2.34, 95% CI 1.05-4.95, P = .04). CONCLUSIONS Eosinopenia is a novel predictive factor for complications after acute cerebral infarction. Stroke patients with eosinopenia should be monitored carefully for infection.

Isolated deep T-wave inversion on an electrocardiogram with normal wall motion.

The electrocardiogram (ECG) of a 73‐year‐old, asymptomatic woman showed deep T‐wave inversion. The complete workup was negative. Ten years later, she developed takotsubo cardiomyopathy with abnormal ECG again. Isolated deep T‐wave inversion might be an aftereffect of takotsubo cardiomyopathy that does not warrant an invasive workup.

Arrhythmogenic right ventricular cardiomyopathy in a patient with schizophrenia

People with schizophrenia are at greater risk of cardiovascular morbidity and mortality than the general population. Arrhythmogenic right ventricular cardiomyopathy is a recognized cause of sudden cardiac death in young people. This report discusses the necessity for close cardiac evaluation to reduce incidence of sudden death in people with schizophrenia.

Thiamine-responsive pulmonary hypertension

The aim of this report is to call attention to a poorly recognised cause of pulmonary hypertension, thiamine deficiency. A 78-year-old woman without alcoholism or malabsorption presented with progressive dyspnoea and generalised oedema. Echocardiography showed signs of right ventricular overload with an estimated systolic pulmonary artery pressure of 50 mm Hg. Increased lactate concentrations prompted us to investigate thiamine deficiency. A 3-month history of picky eating, relying exclusively on white rice as the staple food, and low blood concentrations of thiamine confirmed the diagnosis. She recovered fully after 12 days of intravenous thiamine administration. Thiamine deficiency should be considered in all patients with pulmonary hypertension of unknown origin.

A case of congestive heart failure caused by secondary hypocortisolism

Congestive heart failure caused by secondary hypocortisolism is rare but clinically significant, because its appropriate treatment is effective. Severe hyponatremia with indefinite complaint resembling depression or persisting fever despite antibiotics may be important for establishing this diagnosis.

Fulminant Bacillus cereus septicaemia with multiple organ ischaemic/haemorrhagic complications in a patient undergoing chemotherapy for acute myelogenous leukaemia

Bacillus cereus is a Gram-positive spore-forming rod widely found in the environment and is thought to be a frequent source of contamination. This micro-organism is reportedly a significant pathogenic agent among immunocompromised individuals. Furthermore, multiple cases of fulminant septicaemia have been reported among individuals receiving chemotherapy for acute myelogenous leukaemia. In some cases, B. cereus septicaemia was associated with multiple haemorrhages. We, herein, describe a patient with an extremely acute course of B. cereus septicaemia characterised by haemorrhage and infarction of multiple organs, which led to his death. Our findings suggest that delayed treatment of B. cereus in patients with haematologic malignancies undergoing chemotherapy may result in extremely poor outcomes; thus, immediate empirical treatment with vancomycin should be considered.

Left ventricle Subepicardial aneurysm following asymptomatic myocardial infarction

An asymptomatic 75-year-old female with past medical history of percutaneous coronary intervention for angina pectoris was referred to our department for the management of left ventricular aneurysm which was pointed out on the follow-up echocardiography. Coronary angiography revealed no restenosis of the stent site, but 100% stenosis of a distal segment of the left circumflex artery that had not been detected previously. Transthoracic echocardiography indicated a defect of the myocardium 2cm in diameter in the posterior wall Aneurysmectomy and patch closure was performed successfully before rupture and the lesion was diagnosed as subepicardial aneurysm. Correspondence to: Junichi Shimamura, Department of Cardiac Surgery, Asahi General Hospital, I-1326 Asahi-shi, Chiba-ken 289-2511 Japan, Tel: +81-47963-8111; Fax: 81-479-63-8580; E-mail: junichi.shimamura@gmail.com

Inactive cardiac sarcoidosis with characteristic findings on cardiac MRI

Sarcoidosis has an active inflammatory phase and an inactive fibrotic phase. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and gallium (67Ga) scintigraphy are known to be useful for detecting its active phase1 but not its inactive phase. Delayed enhancement with gadolinium during cardiac MRI is a useful modality for detecting cardiac sarcoidosis2 and can reveal inactive fibrotic lesions.3 In this case, a 66-year-old woman had gradually decreased her ejection fraction (<50%) with regional dyskinesia on …

Cardiac Pacing Suppressed Macroscopic T Wave Alternans in a Patient with Heart Failure Caused by Non-ischemic Cardiomyopathy

A 67‐year‐old male with dilated cardiomyopathy and chronic renal failure who received chronic hemodialysis for 9 years admitted with pulmonary edema. Three days after admission, electrocardiogram showed transient prolongation of QT interval which was followed by macroscopic T wave alternans (TWA) and ventricular fibrillation (VF). Temporary pacing from right ventricular apex suppressed TWA and VF effectively. Combined cardiac resynchronization therapy and implantable cardioverter defibrillator device was implanted for the secondary prevention of VF. Both prolongation of QT interval and TWA disappeared for 10 days after therapy and no arrhythmic event occurred since then.