Systemic Antifungal Agents and Clinical Application / 대한의진균학회지

In the past, even two decades ago, it was not easy for the physicians to diagnose the systemic fungal infection especially in immuno-compromised host. However, as malignant neoplasm and organ transplantation increased, the incidence of fungal infection became heightened. Also the development of newer technique of microbiology and computerized imaging methods made it relatively easy to diagnose the fungal infection. Several new antifungal agents developed recently. It is necessary for us to prescribe the antifungal agents optimally. We summarized amphotericin B lipid formulations, newer triazoles, echinocandins.

Meningococcal Disease in the Republic of Korea Army: Incidence and Serogroups Determined by PCR

This study was performed to determine the incidence and serogroups of meningococcal disease in the Korean Army. From August 2000 to July 2001, we identified prospective cases in the Korean Army. Meningococcal disease was confirmed by isolation of Neisseria meningitidis or detection of its antigen by latex agglutination from cerebrospinal fluid (CSF) or blood. Polymerase chain reactions (PCRs) were performed in the crgA gene to identify N. meningitidis regardless of its serogroup, and then in orf-2 (serogroup A) and siaD (serogroups B, C, Y, and W135) respectively for serogroup prediction. During the study period, twelve patients (four meningitis and eight septicaemia) were identified. The annual incidence was 2.2 per 100,000 (95% confidence interval, 1.3-3.8) among 550,000 private soldiers. Latex agglutinations were positive to A/C/Y/W135 polyvalent latex, but not to B latex in all patients. PCRs of crgA gene were positive in ten patients, whose samples (2 isolates from CSF, 2 CSFs, and 6 sera) were stored. In PCRs for serogroup prediction, one isolate was serogroup A, and one isolate and two sera were serogroup C. The need for meningococcal vaccination would be considered in the Korean Army through the cost-benefit analysis based on the result of this study.

Clinical characteristics and outcome of invasive Prevotella infection / 대한내과학회지

BACKGROUND: Prevotella species is one of the major microoranism responsible for invasive anaerobic bacterial infection. This study was performed to investigate the clinical characteristics and outcome of invasive Prevotella infection in a University affiliated, tertiary care Hospital. METHODS: We obtained the information from the computerized data base of the clinical microbiology laboratory from January 1997 to December 2000, and identified patients whose sterile clinical specimen culture had yielded Prevotella species. We then reviewed the patients' medical records, and studied demographic, clinical, and microbiologic data. RESULTS: The total of 34 patients with invasive Prevotella infection were enrolled for the analysis. Seventeen strains were isolated from blood, 13 from the pleural fluid, 5 from the ascites, and 1 from both the ascites and blood. Half of the cases of Prevotella infection were mixed-infection and 22 cases (64.7%) were of community origin. Twenty-six patients (76%) were men and the mean age was 59 years. Most common underlying disease was malignant neoplasms (19/34, 55.9%). A portal of entry could be determined in 29 patients (85.3%) with the most common being the respiratory tract (12/34, 35.3%), followed by the gastrointestinal tract (6/34, 14.4%), and the wound site (6/34, 14.4%). Surgical procedure was necessary for 21 cases (63.5%). One-month mortality was 32.3%. The mortality was significantly associated with the underlying chronic renal failure (p=0.028) and ICU care (p=0.002). Surgical therapy had a protective effect (54% vs 14%, p=0.022) CONCLUSION: Invasive Prevotella Infections were more prevalent among old age patients with underlying malignancy than younger people and frequently necessitated surgical procedure. Early surgical treatment would decrease mortality.

Invasive Aspergillosis and the Clinical Management / 대한의진균학회지

Invasive aspergillosis remains a major cause of morbidity and mortality in immunocompromised patients. And there has been substantial increase in the number of cases documented at autopsy in all developed nations. There are probably many factors responsible for this substantial increase, but they include the following: greater numbers of transplantation patients; more aggressive chemotherapy for such conditions as myeloma, breast cancer, and certain lymphomas; more aggressive immunosuppressive regimens for patients with autoimmune disease; and the emergence of AIDS. The use of hepafiltration and, in particular, laminar air flow reduces the risk of invasive aspergillosis. The portal of entry for Aspergillus include the respiratory tract, damaged skin or other operative wounds, the cornea, and the ear. The majority of patients (80~90%) have pulmonary disease, but some have other manifestations of disease, including aspergillus rhinosinusitis. Prognosis of invasive aspergillosis has in general relied on making a prompt diagnosis of infection, and early treatment. Unfortunately, the rapid diagnosis of invasive aspergillosis is difficult, as no rapid methods to establish definitely the diagnosis of infection are available in most clinical settings. An ELISA for detecting Aspergillus galactomannan is used to establish an early diagnosis in Western Europe. Invasive aspergillosis carries a nearly 100% mortality if untreated. There are currently two antifungal agents with activity against Aspergillus-amphotericin B and itraconazole. Several novel agents are under investigation, including Liposomal nystatin (Nyotran), Voriconazole, Posaconazole, Caspofungin. The most advanced azole is the voriconazole, which has shown good clinical efficacy and tolerability among immunocompromised patients with invasive aspergillosis.

A Case of Candida parapsilosis Arthritis / 대한의진균학회지

Candida parapsilosis was not considered pathogenic, until it had been reported as the cause of the fatal case of infective endocarditis in intravenous narcotic addicts in 1940. More recently this species has emerged as an important nosocomial pathogen in many clinical infections, such as fungemia, endocarditis, endophthalmitis, septic arthritis, and peritonitis. Among them C. parapsilosis arthritis is still very rare, which is mainly caused by invasive procedures such as prosthetic arthroplasty, intraarticular steroid injection and contamination of hyperalimentation solutions. We experienced a 53 year-old male patient who had chronic elbow pain and was diagnosed as the first case of C. parapsilosis arthritis in Korea. Herein we report the case with a review of the literature.

Clinical Evaluation of Tc-99m Ciprofloxacin for the Diagnosis of Infectious Disease / 감염

BACKGROUND: For the evaluation of infectious or inflammatory disease, Tc-99m HMPAO WBC scan has been used. But techniques involving radiolabelled leukocytes scan were difficult, and have failed to distinguish between bacterial infection and non-bacterial inflammation. To overcome this difficulty, we evaluated Tc-99m Ciprofloxacin in clinically suspected bacterial infection. METHODS: We used this agent for 31 patients who had suspected sites of infection. And then we compared the imaging results of these patients with those of radiolabelled leukocyte scan. RESULTS: There was no adverse effect. 29 patients was involved for the interpretation. Infective spondylitis was the most common suspected disease (41%). Bateriologic culture was positive in 10 patients. The most common organism was meticillin-susceptible S. aureus (5 cases). The sensitivity and specificity of Tc- 99m Ciprofloxacin was 83.3% and 66.6%, and those of Tc-99m HMPAO WBC was 62.5% and 83.3%, repectively. For the diagnosis of infective spondylitis the sensitivity of Tc-99m Ciprofloxacin was 80.0% and that of Tc-99m HMPAO WBC was 40.0%. CONCLUSOIN: Tc-99m Ciprofloxacin shows relatively high sensitivity and specificity. Tc-99m Ciprofloxacin was superior to Tc-99m HMPAO WBC for the diagnosis of infection in axial skeleton.

A Case Report of Factitious Fever / 감염

Factitious fever has been a rare cause of fever of unknown origin. We herein report a case of a young soldier, who presented with persistent fever of unusual pattern and bullae on both palms. After numerous investigations had excluded organic diseases, factitious fever was diagnosed with measurement of the freshly voided urine temperatures and body temperatures while directly observed. Biopsy of skin lesions revealed friction blister. Early recognition of this cause of fever is needed to avoid the unnecessary investigation and prolonged hospitalization.

A Case of Syphilitic Aortitis with Aortic Insufficiency and Aortic Aneurysm / 감염

Syphilitic aortitis, passing out of our mind, is the most common systemic manifestation of late syphilis and is more typically manifestated 10 to 30 years afterward. This diagnosis has been made less frequently in recent decades than in the past, because of public awareness of syphilis and screening program. Treponema pallidum lodge within vasa vasorum, especially ascending aorta cause the histologic changes, which are responsible for the three major forms of symptomatic cardiovascular syphilis, including aortic insufficiency, coronary ostial stenosis, and aortic aneurysm. We experienced a case of syphilitic aortitis with aortic insufficiency and aortic aneurysm in a 48-year-old man presented with progressive dyspnea. Echocardiography, chest CT, and later surgical correction were performed and surgical specimen revealed the histologic finding consistent with syphilitic aortitis. We report this case with a review of the literature.

Hepatic and small bowel mucormycosis after chemotherapy in a patient with acute lymphocytic leukemia

Mucormycosis is a rare but invasive opportunistic fungal infection with increased frequency during chemotherapy-induced neutropenia. The clinical infections due to Mucor include rhinocerebral, pulmonary, cutaneous, gastrointestinal and disseminated diseases. The first two are the most common diseases and all entities are associated with a high mortality rate. Still hepatic involvement of Mucor is rarely reported. We experienced a case of hepatic and small bowel mucormycosis in a 56-year-old woman after induction chemotherapy for B-cell acute lymphocytic leukemia. Initial symptoms were a high fever unresponsive to broad spectrum antibiotics and pain in the left lower abdominal quadrant. It was followed by septic shock, deterioration of icterus and progressively elevated transaminase. An abdominal CT demonstrated multiple hypodense lesions with distinct margins in both lobes of liver and pericolic infiltration at small bowel and ascending colon. Diagnosis was confirmed by biopsy of the liver. The histopathology of the liver showed hyphae with the right-angle branching, typical of mucormycosis. The patient was managed with amphotericin B and operative correction of the perforated part of the small bowel was performed. However, the patient expired due to progressive hepatic failure despite corrective surgery and long-term amphotericin B therapy.

Microbial Features and Antibiotic Prophylaxis of Prosthetic Joint Infection / 감염

BACKGROUND: Success in orthopedic implant surgery relies on reducing infection by preventive methods including antibiotic prophylaxis. The lack of published data on orthopedic implant infections with methicillin-resistance Staphylococcus aureus (MRSA) and methicillin-resistance coagulase-negative staphylococcus (MRCNS) makes it difficult to choose correct prophylactic antibiotics. We therefore reviewed the etiology of prosthetic joint infection and the effectiveness of current antibiotic prophylaxis. METHODS: We reviewed retrospectively the clinical notes and microbial records of patients with prosthetic joint infection who had admitted in Asan Medical Center from June 1989 to July 1999. RESULTS: During a eleven-year period, prosthetic joint infections occurred in 18 (0.9%) of 2,028 patients who received a total hip or total knee arthroplasty at Asan Medical Center (AMC). The cephalosporins were administered to most of patients before surgery for prophylaxis. Twenty two patients were referred to our institution because of prosthetic joint infection. Thirty five patients had positive bacteriological cultures from tissue removed at the time of surgery or joint aspiration. Staphylococci were the most common pathogens and accounted for twenty four (68.8%) of the 35 isolates. Seven (50%) of the fourteen isolates of coagulase-negative staphylococci were MRCNS. Eight (80 %) of the ten ioslates of S. aureus were MRSA. Gram-negative bacilli accounted for five (14.3%) of the isolates and included Escherichia coli, Serratia marcescens, Pseudomonas aeruginosa. CONCLUSION: First-or second-generation cephalosporins were effective prophylatic antibiotics in total hip or total knee arthroplasty because the rate of prosthetic joint infections was low (0.9%). But the prevalence of MRCNS or MRSA prosthetic joint infection was high, we must consider glycopeptides prophylaxis if there is, or has been, infection or carriage with MRCNS or MRSA.

Antimicrobial resistance in Korea / 대한내과학회지

No abstract available.

Pulmonary Inflammatory Pseudotumor Presenting as Fever of Unknown Origin / 감염

Inflammatory pseudotumor (IPT) is an uncommon benign neoplasm of unknown etiology presenting as an incidental mass, fever, malaise, anemia, and weight loss. Generally, IPT in the lung is asymptomatic. A case of pulmonary IPT presenting as prolonged fever in a 59 year old man is presented with clinicopathological findings. The patient had been febrile for three months before admission. Five months before admission, a chest X-ray showed a small left pulmonary mass which was regarded as old tuberculosis. An chest X-ray taken on admission revealed a left pulmonary mass two times the size of the one on the first x-ray. Percutaneous needle aspiration and biopsy were performed, and the microscopic examination revealed a plasma cell reaction with myofibroblastic proliferation, consistent with IPT. As prolonged unexplained fever is a frequent symptom in patients with IPTs, this disease entity should be included in the differential diagnosis of fever of unknown origin.

Pulmonary Inflammatory Pseudotumor Presenting as Fever of Unknown Origin / 감염

Inflammatory pseudotumor (IPT) is an uncommon benign neoplasm of unknown etiology presenting as an incidental mass, fever, malaise, anemia, and weight loss. Generally, IPT in the lung is asymptomatic. A case of pulmonary IPT presenting as prolonged fever in a 59 year old man is presented with clinicopathological findings. The patient had been febrile for three months before admission. Five months before admission, a chest X-ray showed a small left pulmonary mass which was regarded as old tuberculosis. An chest X-ray taken on admission revealed a left pulmonary mass two times the size of the one on the first x-ray. Percutaneous needle aspiration and biopsy were performed, and the microscopic examination revealed a plasma cell reaction with myofibroblastic proliferation, consistent with IPT. As prolonged unexplained fever is a frequent symptom in patients with IPTs, this disease entity should be included in the differential diagnosis of fever of unknown origin.

A case report of suprerior mesenteric vein thrombosis associated with diverticulitis / 대한내과학회지

Mesenteric vein thrombosis is a rare disease that can be fatal, as it can cause ischemia or infarction of bowels. The mortality rate is 13~50%. The predisposing factors of mesenteric vein thrombosis are numerous, and one of them is diverticulitis. Diverticulitis is a rare disease and mesenteric vein thrombosis caused by diverticulitis has not been reported in Korea. We report a patient with superior mesenteric vein thrombosis associated with diverticulitis of ascending colon, and it was diagnosed by computed tomography and barium enema. After antibiotic therapy, the thrombosis was resolved and the patient was completely recovered.

Vancomycin-Gentamicin Synergism against Methicillin-resistant Staphylococcus aureus : Relationship with Gentamicin Susceptibility / 감염

BACKGROUND: Vancomycin is the drug of choice for the treatment of infections caused by methicillin- resistant Staphylococcus aureus(MRSA). However, vancomycin monotherapy of deep-seated staphylococcal infection may be associated with poor bacteriological response. Limited data suggest that vancomycin- gentamicin combination therapy is effective against MRSA. In this study, we evaluated the vancomycin- gentamicin synergism against MRSA and also investigated whether gentamicin susceptibility may affect the synergism. MATERIALS AND METHODS: The 51 strains of MRSA were obtained from patients at the Asan Medical Center from 1995 to 1996. The minimal inhibitory concentrations(MICs) of gentamicin were determined by the agar dilution method. The 25 strains with various levels of gentamicin MICs were chosen for time-kill studies. The MICs and minimal bactericidal concentrations(MBCs) of vancomycin were defined to determine vancomycin tolerance. Time-kill curves were established with vancomycin, gentamicin, and a combination of both. RESULTS: Gentamicin MICs ranged from 4 to 512microgram/mL. Only 7 of the 51 strains were gentamicin-susceptible and 44 were resistant. All of the 25 strains chosen were susceptible to vancomycin, but 16 of them showed tolerance. Vancomycin-gentamicin synergism was demonstrated in 5 of the 18 strains, in which the analysis of drug interaction was possible. In the remaining 13 strains, vancomycin and gentamicin interacted in a nonsynergistic manner. In all strains that showed synergism, the MICs of gentamicin were below 32microgram/mL. No synergism was demonstrated in strains with gentamicin MICs above 64microgram/mL. CONCLUSIONS: Although most of MRSA strains are resistant to gentamicin, synergistic interaction between vancomycin and gentamicin may be expected when the MIC of gentamicin is below 32 microgram/mL.

Pathogenesis, Causes and management of Fever

No abstract available.

Clinical Characteristics of Malaria in Korean Patients / 감염

BACKGROUND: Vivax malaria has been a reemerging disease since 1993 in Korea, and the number of cases are rapidly increasing. Clinical manifestations of malaria are affected by genetic factors and individual patient's characteristics. In this study, we evaluated clinical manifestations and prognosis of malaria in Korean patients. METHODS: Medical records of the patients confirmed as malaria by peripheral blood smear in Asan Medical Center from June, 1989 to October, 1997 were reviewed retrospectively. The patients with vivax malaria and falciparum malaria were compared with respect to clinical manifestations, complications, and prognosis. We also compared our data to meta-analysis reports from western countries. RESULTS: Twenty-eight cases of malaria were included. The number of cases increased by year. Seventeen of them were diagnosed as vivax malaria, and 11 as falciparum malaria. Fifteen indigenous malaria were all vivax malaria, 9 of which had finished the military service in the border between North and South Korea several months before the onset. Eleven of 13 imported malaria were falciparum malaria, 8 of which were acquired in Africa. All 28 patients had fever, but cyclic pattern was shown only in 6 patients of vivax malaria. Hematologic abnormalities were the most common laboratory findings, and there were no significant differences in the frequency of thrombocytopenia, anemia, and leukopenia between vivax malaria and falciparum malaria. Altered mentality, elevated transaminase, total bilirubin, and serum creatinine were more frequent in falciparum malaria than in vivax malaria. Korean patients showed anemia, thrombocytopenia, leukopenia, and elevation of transaminase more frequently than western patients. CONCLUSION: The number of malaria cases has been increasing by year. All Korean patients with malaria had fever, and the most common laboratory findings were thrombocytopenia, anemia, and leukopenia.

Two Cases of Salmonella typhi Liver Abscess after Transarterial- Chemoembolization / 감염

Hepatocellular carcinoma (HCC) is one of the most common malignancies in Korea. Transarterial chemoembolization (TACE) is an effective modality for treating HCC with a few complications. Liver abscess is most common infectious complication during post-TACE period. However, liver abscess caused by Salmonella typhi has never been reported. We experienced two cases of liver abscess following TACE, caused by S. typhi. Th clinical manifestations of S. typhi liver abscess are similar with other pyogenic liver abscesses. The CT scans showed liver abscesses mixed with necrotic materials after TACE, and the cultures of blood and abscess aspirates yielded S. typhi. The patients did not respond well only with the antibiotic treatment and was controlled after percutaneous drainage. A possible pathogenesis of these liver abscesses is considered as secondary infection in the necrotic liver tissues in biliary carrier of S. typhi.

Clinical Characteristics of Bacteremic Pneumococcal Diseases Due to Penicillin-Resistant Streptococcus pneumoniae / 감염

BACKGROUND: The emergence of penicillin-resistant Streptococcus pneumoniae (PRSP) poses serious therapeutic problem in clinical practice, especially in cases with bacteremia or meningitis. METHODS: To investigate clinical characteristics of bacteremic pneumococcal diseases due to PRSP, we retrospectively analyzed 41 cases with documented bacteremic diseases seen in a tertiary care hospital between 1989 and 1994. RESULTS: Agar dilution test of 41 strains isolated showed that 68.3% of S. pneumoniae were PRSP [high-level resistance(R) 56.1%, intermediate resistance (I) 12.2%]. High-level resistant strains were not susceptible to other beta-lactam agents, whereas isolates of penicillin-susceptible S. pneumoniae (PSSP) were uniformly susceptible to all beta-lactam agents. Predominant serogroup of PRSP were 19, 23, and 6. Bacteremic diseases caused by PRSP included pneumonia (22), meningitis (5), peritonitis (3), acute otitis media (2), acute tonsillitis (2), endocarditis (1), pyelonephritis (1), and primary bacteremia (5). Children were more likely to be infected with PRSP with high-level or intermediately resistant strains than were adults (P=0.0001), but no differences were seen between PRSP and PSSP regarding sex, previous antibiotic history, previous hospitalization, and underlying immunocompromised conditions. Most cases were community-acquired (R 78.3%, I 60%, S 61.5%). Fatality rates of patients infected with PRSP were not different significantly from PSSP (22.6% vs. 30%). However, most fatal cases had underlying immunocompromised conditions. CONCLUSION: PRSP is widely prevalent in Korea and shows resistance to most antibiotics. It causes community-acquired bacteremic diseases with poor outcomes, but there was no difference in mortality between patients infected with PRSP and PSSP. Pediatric age was the only risk factor for penicillin resistance.

Sensitivity of Laboratory-based Surveillance for Detecting Nosocomial Infections / 병원감염관리

BACKGROUND: Laboratory-based surveillance is an effective method' to detect nosocomial infections with limited personnel and time, and also can be used to identify clusters of organisms by unit and site. However it will fail to detect a significant number of infections because of cultures being negative or not submitted at all. This study was performed to determine the sensitivity of laboratory-based surveillance method in detecting nosocomial infections. METHODS: Four nursing units, two each of medical and surgical units, of Asan Medical Center were chosen and surveillance for nosocomial infections was performed with the total surveillance method for the 6-month period from July to December of 1995 by an infection control nurse. Proportion of the nosocomial infections that would have been detected by culture results alone was identified to determine the sensitivity of the laboratory-based surveillance method. RESULTS: A total of 164 cases of nosocomial infections were identified by the total surveillance method. Of these, 119 (72.6%) cases would have been detected by the laboratory-based surveillance method alone. Sensitivities were 100% in urinary tract infection and bacteremia, and 44.7%, 52.6% and 54.8% in lower respiratory tract, surgical site and other site infections, respectively. The 45 cases of infections that would have been undetected by microbiology data alone included 30 cases with culture negatives and 15 cases in which cultures were not submitted. CONCLUSIONS: The laboratory-based surveillance revealed different sensitivities depending on the sites of infections and patient services. The method is efficient with an acceptable level of sensitivities, but infection control teams should be aware of its shortcoming by a periodic monitoring of its sensitivity in the detection of nosocomial infections at their own hospitals.