Toyoichiro Kudo

Establishment of anti-Epstein–Barr virus (EBV) cellular immunity by adoptive transfer of virus-specific cytotoxic T lymphocytes from an HLA-matched sibling to a patient with severe chronic active EBV infection

We describe an experience of a specific immune transfer treatment in a patient with chronic active EBV infection. The patient had low anti‐EBV T cell‐mediated cytotoxic activity in his peripheral blood mononuclear cells (PBMC), which may have been the primary cause of the disease. An EBV‐specific cytotoxic T lymphocyte (CTL) line was established from PBMC obtained from the patient’s sister whose human leucocyte antigens (HLA) are identical to patients. The patient received three courses of intravenously administered CTL at 3‐week intervals. The number of the cells was increased with each course of treatment. After infusion of the T cell line, anti‐EBV CTL activity was detected in the patients PBMC. CTL activity increased markedly after the second course of immune transfer therapy. The amount of EBV DNA in the patients plasma showed transient but repeated decreases. Serum levels of tumour necrosis factor‐alpha (TNF‐α), which had elevated before treatment, began to decrease after initiation of treatment. No adverse effects were directly associated with CTL infusions. Despite having previously received a pneumococcal vaccine and prophylactic antibodies, the patient died of infection caused by Streptococcus pneumoniae bacteraemia 27 days after the third infusion. Although the long‐term efficacy and safety of this therapy remains to be established, our findings suggest that adoptive transfer of CTL specific for EBV obtained from an HLA‐matched donor might be a promising treatment for patients with chronic active EBV infection.

Clinical factors associated with fluconazole resistance and short-term survival in patients with Candida bloodstream infection

In a 1-year national surveillance program of Candida bloodstream infections in Japan, clinical factors predicting fluconazole resistance and survival of the patients were analyzed. Blood isolates and complete clinical histories were obtained from 326 patients. Fluconazole-resistant isolates were found in 15 (4.6%) of the cases. Univariate analysis of the demographic and clinical factors associated with fluconazole resistance revealed that age, hematologic malignancy, neutropenia, and immunosuppression were of statistical significance. A multiple logistic regression model showed that only hematologic malignancy as the underlying disease (odds ratio, 6.6; 95% confidence interval, 1.6–26.9; P=0.009) was independently associated with resistance. In 242 cases in which data regarding management and prognosis were available, the 30-day survival rate was 68.4%. In the univariate analysis of factors predicting survival, a significant association was found for Candida species, age of the patient, neutropenia, recent abdominal surgery, removal of the central venous catheter, and use of appropriate antifungal therapy. In the multivariate analysis, removal of the central venous catheter (odds ratio, 6.0; 95% confidence interval, 2.2–16.1; P<0.001) and the use of appropriate therapy (odds ratio, 2.1; 95% confidence interval, 1.1–4.1; P=0.03) were independent factors significantly associated with survival after the diagnosis of Candida bloodstream infection.

Serum amyloid A protein in acute viral infections.

Concentrations of serum amyloid A protein (SAA) were measured in 254 children with viral diseases, including measles, varicella, rubella, mumps, echo-30 meningitis, chronic hepatitis B and C, and in eight with Kawasaki disease. Latex agglutination nephelometric immunoassay was used for assaying SAA. In 191 out of 195 patients (98%), SAA concentrations became markedly raised in the acute phase of the viral disease: measles (97%), varicella (100%), mumps (95%), and echo-30 meningitis (99%) with mean titres of 82.4, 80.5, 60.2, 75.2, and 101.1 micrograms/ml respectively. This increase in SAA was followed by a rapid return to normal concentrations (< 5 micrograms/ml) during convalescence. Remarkably higher concentrations of SAA (mean 1630 micrograms/ml) were detected in the acute phase of patients with Kawasaki disease, but in most of the children with chronic hepatitis B or C, the titres of SAA remained normal. There was no close correlation between SAA and serum concentrations for alpha 1-acid glycoprotein, beta 2-microglobulin, transferrin, and IgG. There was a clear correlation between SAA and C reactive protein concentrations, although SAA showed a greater incremental change than C reactive protein in the acute phase. In the acute phase of these viral diseases, 56% of the patients had raised SAA concentrations (> or = 5 micrograms/ml) with normal C reactive protein concentrations (< 5 micrograms/ml). These results indicate that SAA could be useful as an inflammatory marker in children with acute viral infections.

Analysis of mother-to-infant transmission of hepatitis C virus: quasispecies nature and buoyant densities of maternal virus populations.

Mother‐to‐infant transmission of hepatitis C virus (HCV) was analyzed by sequencing of viral RNA and semiquantitative polymerase chain reaction following ultracentrifugation of maternal sera. In two mother‐infant pairs, the hypervariable region 1 (HVR1) and carboxyl terminus of envelope 1 (E1) were sequenced. Both viral sequences in the infants were less diverse than those of their mothers. Although the E1 sequences were almost identical in each mother‐infant pair, the HVR1 sequences of the infants were related, but not identical, to those of the mothers. Serial examinations of one infant revealed that the HVR1 nucleotide sequence did not change from 10 days to 3 months of age. In six mothers with uninfected infants, all of the dense fractions of sera contained significant amounts of HCV RNA, whereas in six mothers with infected infants, only two of those fractions contained significant amounts of HCV RNA. These results indicate that the strains of HCV detected in the infants were not dominant in the mothers, but were still transmissible to the infants. As dense fractions are known to contain antibody‐bound HCV particles, maternal antibodies against HCV may inhibit viral transmission. J. Med. Virol. 51:225–230, 1997.

Stool Color Card Screening for Early Detection of Biliary Atresia and Long-Term Native Liver Survival: A 19-Year Cohort Study in Japan

OBJECTIVE To evaluate the sensitivity and specificity of a stool color card used for a mass screening of biliary atresia conducted over 19 years. In addition, the age at Kasai procedure and the long-term probabilities of native liver survival were investigated. STUDY DESIGN From 1994 to 2011, the stool color card was distributed to all pregnant women in Tochigi Prefecture, Japan. Before or during the postnatal 1-month health checkup, the mothers returned the completed stool color card to the attending pediatrician or obstetrician. All suspected cases of biliary atresia were referred for further examination. Diagnosis was confirmed by laparotomy or operative cholangiography for high-risk cases before the Kasai procedure. Patients with biliary atresia were followed from the date of their Kasai procedure until liver transplantation, death, or October 31, 2013, whichever comes sooner. RESULTS A total of 313,230 live born infants were screened; 34 patients with biliary atresia were diagnosed. The sensitivity and specificity of stool color card screening at the 1-month check-up was 76.5% (95% CI 62.2-90.7) and 99.9% (95% CI 99.9-100.0), respectively. Mean age at the time of Kasai procedure was 59.7 days. According to Kaplan-Meier analysis, the native liver survival probability at 5, 10, and 15 years was 87.6%, 76.9%, and 48.5%, respectively. CONCLUSIONS The sensitivity and specificity of the stool color card have been demonstrated by our 19-year cohort study. We found that the timing of Kasai procedure and long-term native liver survival probabilities were improved, suggesting the beneficial effect of stool color card screening.

Prolonged use of dexmedetomidine in an infant with respiratory failure following living donor liver transplantation

We used dexmedetomidine for more than 2 months in a mechanically ventilated infant without serious adverse effects. An infant with liver cirrhosis of unknown cause underwent living donor liver transplantation at the age of 9 months. Long‐term mechanical ventilation was required postoperatively, and midazolam with fentanyl had been used to sedate the patient. They required increase to 1.7 mg·kg−1·h−1 and 3.5 μg·kg−1·h−1, respectively, which were still inadequate. On postoperative day 29, dexmedetomidine was added. The rate of dexmedetomidine infusion was increased gradually to 1.4 μg·kg−1·h−1. It was discontinued temporarily to exclude drug‐induced liver dysfunction. However, without dexmedetomidine, adequate sedation level was unattainable. Liver dysfunction was likely to be attributed to cytomegalovirus infection and after restarting dexmedetomidine, the respiratory condition improved. He was extubated 10 weeks after the operation. Dexmedetomidine was successfully tapered off over the following 2 weeks with no signs of withdrawal. Dexmedetomidine was a useful sedative for an infant who required mechanical ventilation for a prolonged period of time.

Significance of serial real-time PCR monitoring of EBV genome load in living donor liver transplantation.

Background: Quantitative analysis of the Epstein–Barr virus (EBV) genome has been recently reported to be helpful for early identification of EBV viremia which could reduce the risk of post‐transplantation lymphoproliferative disorder (PTLD).

Anaerobic bacteremia: the yield of positive anaerobic blood cultures: patient characteristics and potential risk factors.

Abstract The anaerobic blood culture (AN) bottle is routinely used in Japan with little discussion as to its justification or validity. We retrospectively studied the AN bottle yield of obligate anaerobes and the characteristics of, and potential risk factors in, patients with anaerobic bacteremia during a 2-year period (1999–2000) at four university hospitals and one community hospital. Thirty-four of 18310 aerobic and anaerobic blood culture sets from 6215 patients taken at the university hospitals, and 35 of 2464 samples taken from 838 patients at the community hospital, yielded obligate anaerobes. Bacteroides species and Clostridium species accounted for 60% of the isolates. Fifty-seven patients from 69 blood culture sets containing anaerobes had clinically significant anaerobic bacteremia. Among these 57 patients, 24 (49%) were oncology patients, 40 (70%) had an obvious source of anaerobic infection, 15 (26%) had recent surgery and/or were in an immunosuppressed state. We concluded that the recovery rate of obligate anaerobes isolated from AN bottles was low, and the patients with anaerobic bacteremia had limited number of underlying diseases or potential risk factors for anaerobic infections. Therefore, anaerobic blood cultures may be selectively used according to the potential risk for anaerobic infections.

Comparison of the BDProbeTec ET system with the Cobas Amplicor PCR for direct detection of Mycobacterium tuberculosis in respiratory samples.

In the study presented here, the performance of the BDProbeTec ET system (Becton Dickinson, USA) was compared with the Roche Cobas Amplicor-PCR (Roche, Switzerland) to detect Mycobacterium tuberculosis complex (MTB) in clinical respiratory samples. The Bactec MGIT 960 liquid culture system (Becton Dickinson) was used as a reference method. A total of 411 samples were tested. Of the 93 culture-positive samples, both the BDProbeTec ET system and the Cobas Amplicor-PCR detected 87 (sensitivity, 93.5%). When only smear-negative samples were considered, the BDProbeTec ET exhibited a sensitivity of 50% and the Cobas Amplicor-PCR 60%. Specificity was 99.7% for the BDProbeTec ET system and 100% for the Cobas Amplicor-PCR. Percent agreement between the two nucleic amplification methods was 98.7%. Inhibition occurred in three (0.7%) samples in the BDProbeTec ET system. The high sensitivity and specificity of the BDProbeTec ET system suggest it is a useful method for the rapid and direct detection of MTB in smear-positive respiratory samples.

Effects of interferon-alpha on serum hepatitis C virus in patients with chronic hepatitis C.

Interferon is beneficial in some patients with chronic hepatitis C. To assess the efficacy of interferon, we used the polymerase chain reaction (PCR) to measure HCV RNA in serial serum samples from 13 chronic hepatitis C patients who were treated with interferon-α. Serum alanine aminotransferase (ALT) values normalized in association with the disappearance of serum HCV RNA in nine cases during the therapy. Serum HCV remained negative after the therapy in the three patients who had no, relapse, while serum HCV RNA reappeared in the six patients with elevation of ALT values. The persistence of normal ALT levels appears to be correlated with the clearance of the serum HCV. There were two patients whose ALT became normal immediately after the cessation of interferon. Serum HCV was detectable at the end of treatment when serum ALT was elevated, and thereafter serum HCV disappeared. This result, suggests an immunomodulatory effect of interferon in the clearance of HCV in some cases. Furthermore, the semiquantitative PCR assay showed that all five patients in whom ALT values were normal at the end of follow-up without detectable serum HCV genome had lower HCV titers in the pretreatment sera than the other eight patients. The detection of HCV RNA by the PCR assay is useful in determining the efficacy of interferon and its mechanisms.