Coinfection of Severe Fever With Thrombocytopenia Syndrome Virus and Coxiella burnetii in Developmental Stage of Hard Ticks in Subtropical Region of Korea

Background@#Severe fever with thrombocytopenia syndrome virus (SFTSV) is transmitted through tick bites. Ticks are potential vectors for the bacterium Coxiella burnetii that causes Query fever. Here, we analyzed SFTSV and C. burnetii co-infection rates in ticks in rural areas of Jeju Island, South Korea. @*Methods@#Free ticks were collected from the natural environment of the island between 2016 and 2019, and SFTSV RNA was extracted. Additionally, ribosomal RNA gene sequencing was used to identify Coxiella species. @*Results@#Haemaphysalis longicornis was the most common tick species followed by H. flava. Tick number gradually increased from April, peaked in August, and was lowest in March. Of all the collected ticks, 82.6% (2,851/3,458) were nymphs, 17.9% (639/3,458) adults, and 0.1% (4/3,458) larvae. SFTSV-infected ticks comprised 12.6% of all ticks; their numbers were the lowest in November–December, increased from January, and were mostly identified in the adult stage during June–August. C. burnetii infections were detected in 4.4% of the SFTSVinfected H. longicornis ticks. C. burnetii co-infection was mainly observed in the nymph stage of H. longicornis, with the highest infection rate in January, followed by December and November. @*Conclusion@#Our findings suggest that Jeju Island has a high SFTSV and potential C. burnetii infection in ticks. This study provides important insights regarding SFTS and Q fever risk to humans in South Korea.

First Report of Tenosynovitis Caused by Mycobacterium virginiense in Korea

No abstract available.

Phylogenetic Analysis for the Origin of Typhoid Fever Outbreak on Jeju Island, Korea, in 2017

In June 2017, on Jeju Island, six patients were diagnosed with typhoid fever. All six patients were admitted to our hospital with fever, all of them had been working at the same hotel.The gyrA and gyrB genes of four out of six Salmonella typhi cases were amplified by polymerase chain reaction. The phylogenetic tree of the genes showed that the S. Typhi isolates from Jeju Island in 2017 had the same genotype and were similar to isolates from the United Kingdom.The origin of the isolates of the outbreak was the same, and the disease strain may have been imported from outside of Korea.

Acute Cholangitis Caused by Boryong Strain of Orientia tsutsugamushi

Scrub typhus present with a variety clinical manifestations caused by Orientia tsutsugamushi, it is sometimes accompanied by severe complications. The clinical course of this complication is not well clear. Herein, we first report a case with acute cholangitis and acalculous cholecystitis caused by the Boryong genotype of O. tsutsugamushi. A 82-year-old woman presented with fever and acute abdominal pain on the right upper quadrant. Initially, the patient showed an abnormality of liver enzymes of cholestatic pattern. An acute cholangitis and cholecystitis were suspected on the enhanced computed tomography (CT), and emergent endoscopic retrograde cholangiopancreatography (ERCP) performed. However, neither ERCP nor CT detected common bile duct stones or sludge. The patient's illness progressed despite bile drainage and antibiotic therapy. On the fifth day in hospital, an immunofluorescence IgG assay for O. tsutsugamushi was positive, and the patient newly developed a skin rash and an eschar lesion on the right abdomen. The polymerase chain reaction amplification of Orientia genes from blood and bile was positive, genotype of both samples was identified the Boryong type. The presentation of scrub typhus as an acute cholangitis is not reported till now. In endemic areas, scrub typhus would be considered a rare etiology of acute cholangitis.

Acute Cholangitis Caused by Boryong Strain of Orientia tsutsugamushi

Scrub typhus present with a variety clinical manifestations caused by Orientia tsutsugamushi, it is sometimes accompanied by severe complications. The clinical course of this complication is not well clear. Herein, we first report a case with acute cholangitis and acalculous cholecystitis caused by the Boryong genotype of O. tsutsugamushi. A 82-year-old woman presented with fever and acute abdominal pain on the right upper quadrant. Initially, the patient showed an abnormality of liver enzymes of cholestatic pattern. An acute cholangitis and cholecystitis were suspected on the enhanced computed tomography (CT), and emergent endoscopic retrograde cholangiopancreatography (ERCP) performed. However, neither ERCP nor CT detected common bile duct stones or sludge. The patient's illness progressed despite bile drainage and antibiotic therapy. On the fifth day in hospital, an immunofluorescence IgG assay for O. tsutsugamushi was positive, and the patient newly developed a skin rash and an eschar lesion on the right abdomen. The polymerase chain reaction amplification of Orientia genes from blood and bile was positive, genotype of both samples was identified the Boryong type. The presentation of scrub typhus as an acute cholangitis is not reported till now. In endemic areas, scrub typhus would be considered a rare etiology of acute cholangitis.

Invasive Pneumococcal Disease Caused by Non-Vaccine Type Multidrug-Resistant Streptococcus pneumoniae Transmitted by Close Contact in a Healthy Adult

The incidence of vaccine-type Streptococcus pneumoniae carriage and disease have declined in vaccinated children as well as in unvaccinated children and adults. However, diseases caused by non-vaccine type (NVT) S. pneumoniae are increasing. In this study, we report an invasive pneumococcal disease (IPD) caused by NVT multidrug-resistant (MDR) S. pneumoniae transmitted from a vaccinated infant to an unvaccinated healthy woman, and the clinical characteristics of this serotype. A 29-year-old previously healthy woman visited our hospital with fever and headache. She had been breastfeeding her baby for 8 months. She was diagnosed with brain abscess and sinusitis caused by S. pneumoniae. Although the patient had no previous exposure to antibiotics, antibiotic susceptibility test identified the pathogen as MDR. The patient's family members were examined using nasopharyngeal swabs for bacterial culture. The serotype of S. pneumoniae identified from the blood, abscess, and sputum of the patient was 15B/C. After investing the patient's family members, we found that the serotype from nasopharyngeal specimen of her baby was the same. We described an invasive MDR pneumococcal disease in an immunocompetent young adult in the community. IPD likely spread to the patient by close contact with her baby, who harbored S. pneumoniae of NVT. The spread of NVT S. pneumoniae in the post-vaccine era has increased in the community, and resistance pattern for S. pneumoniae of 15B/C changed compared to the pre-pneumococcal conjugate vaccine era. The spread of MDR pathogens causing IPD among family members should be monitored.

Application of therapeutic plasma exchange in patients having severe fever with thrombocytopenia syndrome

BACKGROUND/AIMS@#Severe fever with thrombocytopenia syndrome (SFTS) is a viral hemorrhagic fever with a high fatality rate. However, effective treatments for SFTS cases not responded to supportive therapy have not been established. Herein, we introduced the therapeutic plasma exchange (TPE) in SFTS patients in a tertiary hospital between 2013 and 2015.@*METHODS@#TPE was performed in patients with rapidly progressing SFTS. Clinical, laboratory, and virological parameters were compared before and after TPE.@*RESULTS@#Among 27 confirmed SFTS patients, two patients were treated with TPE and ribavirin combination in May 2013, then, 14 patients with rapidly progressing SFTS patients were treated with only TPE from June 2013 to September 2015: their median age was 58 years (interquartile range, 50 to 70) and eight (57.1%) were male. Body temperature, pressure-adjusted heart rate, white blood cell and platelet counts, coagulation profile, serum creatinine, and multiple organ dysfunction score improved immediately after TPE. In addition, the mean cyclic threshold value of real-time reverse transcriptase polymerase chain reaction for SFTS virus after TPE (mean ± standard deviation, 31.3 ± 2.9) was significantly higher than that before TPE (26.5 ± 2.9; p < 0.001), indicating that serum viral loads decreased after TPE. Finally, 13 of 14 TPE-treated patients (92.8%) recovered from rapidly progressing SFTS without sequelae.@*CONCLUSIONS@#SFTS patients treated with TPE showed improvements in clinical, laboratory, and virological parameters. These results suggest that TPE would be a therapeutic modality as rescue therapy in patients with rapidly progressing SFTS.

Changes in Serotype of Streptococcus pneumoniae After the Introduction of the 13-Valent Pneumococcal Vaccine in a Homogenous Population on Jeju Island

We compared the serotypes of Streptococcus pneumoniae between the pre-pneumococcal conjugate vaccine (PCV)13 era and post-PCV13 era among homogenous inhabitants of an isolated South Korean island. A total of 325 S. pneumoniae strains were isolated. In the pre-PCV13 era, 19A/F, 15A/F, 19B, and 23A serotypes were identified. In the post-PCV13 era, 15 serotypes were identified. The 19F and 23A serotypes showed the highest prevalence in the pre- and post-PCV13 era, respectively. After PCV13 introduction, the PCV 13 serotype coverage rate was decreased (80.0% and 30.5% in the pre- and post-PCV13 eras, respectively), while the proportion of non-PCV 13 serotypes increased.

Seroprevalence of Severe Fever with Thrombocytopenia Syndrome in the Agricultural Population of Jeju Island, Korea, 2015–2017

BACKGROUND@#Severe fever with thrombocytopenia syndrome (SFTS) is a tick-borne zoonotic disease that is caused by the SFTS virus (SFTSV), and exhibits an overall mortality rate of approximately 20.0% in Korea. Most cases of this disease have been reported in Korea, East China, and Japan, and it mostly affects outdoor workers and farmers. This study aimed to investigate the seroprevalence of SFTSV among healthy farmers on Jeju Island, Korea.@*MATERIALS AND METHODS@#In this prospective cross-sectional study, we analyzed 421 blood samples obtained from 254 farmers (mean age, 59.9 years; 68.9% male) to determine the seroprevalence of SFTSV in 16 rural areas of the Jeju Special Self-Governing Province over a period of 3 years (January 2015–December 2017). We used an enzyme-linked immunosorbent assay to detect immunoglobulin (Ig) G antibodies against SFTSV in the collected samples.@*RESULTS@#The seroprevalence of the SFTSV IgG among farmers on Jeju Island was observed to be 2.4%. One subject showed seropositivity over the entire 3-year study period. The areas with the highest SFTSV IgG seropositivity rates were Seonheul-ri in Jocheon-eup, followed by Namwon-eup. Fruit farmers were at a higher risk of exposure to SFTSV than other farmers.@*CONCLUSION@#The seroprevalence of SFTSV in the healthy agricultural population of Jeju Island was not high. However, personal hygiene management should be implemented for the agricultural population in the endemic areas. Surveillance of mild or asymptomatic infections is required in the endemic regions.

First Case of Necrotizing Fasciitis Caused by Skermanella aerolata Infection Mimicking Vibrio Sepsis

No abstract available.

Patterns of rpoC Mutations in Drug-Resistant Mycobacterium tuberculosis Isolated from Patients in South Korea / 결핵및호흡기질환

BACKGROUND: Rifampicin (RFP) is one of the principal first-line drugs used in combination chemotherapies against Mycobacterium tuberculosis, and its use has greatly shortened the duration of chemotherapy for the successful treatment of drug-susceptible tuberculosis. Compensatory mutations have been identified in rpoC that restore the fitness of RFP-resistant M. tuberculosis strains with mutations in rpoB. To investigate rpoC mutation patterns, we analyzed 93 clinical M. tuberculosis isolates from patients in South Korea. METHODS: Drug-resistant mycobacterial isolates were cultured to determine their susceptibility to anti-tubercular agents. Mutations in rpoC were identified by sequencing and compared with the relevant wild-type DNA sequence. RESULTS: In total, 93 M. tuberculosis clinical isolates were successfully cultured and tested for drug susceptibilities. They included 75 drug-resistant tuberculosis species, of which 66 were RFP-resistant strains. rpoC mutations were found in 24 of the 66 RFP-resistant isolates (36.4%). Fifteen different types of mutations, including single mutations (22/24, 91.7%) and multiple mutations (2/24, 8.3%), were identified, and 12 of these mutations are reported for the first time in this study. The most frequent mutation involved a substitution at codon 452 (nt 1356) resulting in amino acid change F452L. CONCLUSION: Fifteen different types of mutations were identified and were predominantly single-nucleotide substitutions (91.7%). Mutations were found only in dual isoniazid- and RFP-resistant isolates of M. tuberculosis. No mutations were identified in any of the drug-susceptible strains.

Clinical Characteristics of Macrolide-Resistant Mycoplasma pneumoniae from Children in Jeju

Mycoplasma pneumoniae is the major pathogen of community-acquired pneumonia in children. The prevalence of macrolide-resistant M. pneumoniae (MRMP) is important owing to the limited alternative therapies for children. We analyzed 111 M. pneumoniae obtained from 107 children admitted for lower respiratory tract infection at Jeju National University Hospital between 2010 and 2015. Macrolide resistance of M. pneumoniae was searched for using polymerase chain reaction (PCR) and sequencing. Of 107 clinical M. pneumoniae, 11 (10.3%) carried macrolide resistance mutations in the 23S rRNA gene. All macrolide resistance mutations were A2063G transitions. We found an acquired A2063G mutation of M. pneumoniae from a patient during macrolide treatment. Patients' characteristics and clinical severity did not differ between those with MRMP and macrolide-sensitive M. pneumoniae, with the exception of frequent pleural effusion in the MRMP group. The prevalence of MRMP (10.3%) in Jeju Island was relatively lower than those of surrounding countries in East Asia. Previous antimicrobial usage and timing of diagnostic test should be considered when determining of macrolide resistance of M. pneumoniae.

Outbreak of Zika Virus

Zika virus (ZIKV) is a vector-borne flavivirus. It was initially identified in Uganda in 1947, and the first human infection was reported in Nigeria in 1953. Since 2015, ZIKV has been spreading rapidly in Brazil and the Americas. Given its general symptoms, ZIKV is considered to be a mild, febrile illness, although it is associated with severe neurologic complications. On February 1, 2016, the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC). We conducted a review of the literature on the epidemiology and transmission, clinical manifestations, and diagnosis of ZIKV. Additionally, we introduce original literature on the current ZIKV outbreak in this review.

The Influence of Genotype Polymorphism on Morphine Analgesic Effect for Postoperative Pain in Children

BACKGROUND: Although opioids are the most commonly used medications to control postoperative pain in children, the analgesic effects could have a large inter-individual variability according to genotypes. The aim of this study was to investigate the association between single nucleotide polymorphisms and the analgesic effect of morphine for postoperative pain in children. METHODS: A prospective study was conducted in 88 healthy children undergoing tonsillectomy, who received morphine during the operation. The postoperative pain score, frequency of rescue analgesics, and side effects of morphine were assessed in the post-anesthesia care unit. The children were genotyped for OPRM1 A118G, ABCB1 C3435T, and COMT Val158Met. RESULTS: Children with at least one G allele for OPRM1 (AG/GG) had higher postoperative pain scores compared with those with the AA genotype at the time of discharge from the post-anesthesia care unit (P = 0.025). Other recovery profiles were not significantly different between the two groups. There was no significant relationship between genotypes and postoperative pain scores in analysis of ABCB1 and COMT polymorphisms. CONCLUSIONS: Genetic polymorphism at OPRM1 A118G, but not at ABCB1 C3435T and COMT Val158Met, influences the analgesic effect of morphine for immediate acute postoperative pain in children.

The First Case of Non-retrospective Clinical Identification of Severe Fever with Thrombocytopenia Syndrome Patient in 2013 in South Korea

In this study, we report the first clinically identified case of severe fever with thrombocytopenia syndrome (SFTS) in a 73-year old man from Jeju Island, South Korea. Although his initial manifestation suggested tsutsugamushi disease with cutaneous lesion, later the patient presented with symptoms characteristic of SFTS. Despite intensive medical therapies upon the clinical diagnosis of SFTS, patient's condition rapidly deteriorated. SFTS is a fatal disease that requires early diagnosis and appropriate supportive treatment.

Association between Polymorphisms in Toll-like Receptor 9 Gene and Outcomes after Ischemic Stroke

Several evidences suggested that Toll-like receptor 9 (TLR9) plays an important role in atherosclerosis and neuroprotection but the association between the TLR9 and risk for stroke or outcomes after stroke has not been investigated. The aim of the present study was to investigate the association between TLR9 polymorphisms and the risk for ischemic stroke using a case-control study design. We also explored the correlation between the polymorphisms and outcomes after stroke. We enrolled consecutive Korean stroke patients and controls without history of stroke. Four polymorphisms, namely c.-1486T>C, c.-1237C>T, c.1174A>G, and c.2848G>A were examined using polymerase chain reaction followed by direct sequencing. Initially we examined 193 stroke patients and the same number of healthy adults who had no history of stroke as controls. Due to deviation from Hardy-Weinberg equilibrium of initial controls, we performed genetic analysis of two polymorphisms (c.1174A>G and c.2848G>A) for additional 165 controls. The genotype frequency of four polymorphisms did not differ significantly between stroke patients and controls in unadjusted analysis. The variant allele (C) in c.-1486 locus was associated with significantly increased chance of favorable functional outcome at three month after stroke (OR 2.32, 95% CI 1.02~5.26, p = 0.043).

The 2013-2015 Ebola outbreak in West Africa

Zaire Ebola virus (EBOV) is a fatal human pathogen, with a high case fatality rate (CFR) averaging up to 78%. In March 2014, the World Health Organization (WHO) was made aware of a ZEBOV outbreak in rural Guinea, West Africa. Epidemiologic investigation linked the clinical and laboratory confirmed cases with the presumed first fatality of the outbreak in December 2013. EBOV from Guinea is a separate clade from other ZEBOV strains reported from the Democratic Republic of Congo (DRC) and Gabon. Since the outbreak in March, ZEBOV was also reported in Conakry, Guinea's capital and spread to other neighboring countries. In its largest outbreak, ZEBOV disease expanded through Guinea, Liberia, Sierra Leone, and Nigeria and to Spain, the USA, and the UK. The WHO declared the 2013-2015 West African Ebola epidemic a public health emergency of international concern considering its presumable capacity for further international spread. Early manifestations of EVD (Ebola virus disease) include a high fever, body aches, malaise, and fatigue. Severe diarrhea and other gastrointestinal manifestations such as vomiting were common, while bleeding was a more sporadic finding. The fatality rate was 43% and highest in patients aged > or = 45 years and the overall fitted mean incubation period was 10.3 days (95% CI 9.9~10.7). We present a review of the literature on the emergence of Ebola, and the epidemiologic, clinical, and laboratory records of patients in whom EVD was diagnosed in Sierra Leone, Guinea, Liberia, Mali, the USA, and Spain, its zoonotic origin, and the transmission of ZEBOV, as well as presenting original literature on the current Ebola outbreak.

Japanese Cedar (Cryptomeria japonica) Pollinosis in Jeju, Korea: Is It Increasing?

Jeju is an island in South Korea located in a temperate climate zone. The Japanese cedar tree (JC) has become the dominant tree species while used widely to provide a windbreak for the tangerine orchard industry. An increase in pollen counts precedes atopic sensitization to pollen and pollinosis, but JC pollinosis in Jeju has never been studied. We investigated JC pollen counts, sensitization to JC pollen, and JC pollinosis. Participants were recruited among schoolchildren residing in Jeju City, the northern region (NR) and Seogwipo City, the southern region (SR) of the island. The JC pollen counts were monitored. Sensitization rates to common aeroallergens were evaluated by skin prick tests. Symptoms of pollinosis were surveyed. Among 1,225 schoolchildren (49.6% boys, median age 13 years), 566 (46.2%) were atopic. The rate of sensitization to Dermatophagoides pteronyssinus (35.8%) was highest, followed by D. farinae (26.2%), and JC pollen (17.6%). In the SR, 156 children (23.8%) were sensitized to JC pollen; this rate was significantly higher than that in the NR (59 children, 10.4%, P<0.001). A significant increment in the sensitization rate for JC pollen with increasing school level was observed only in the SR. JC pollen season in the SR started earlier and lasted longer than that in the NR. JC pollen season in Jeju was defined as extending from late January to mid-April. The prevalence of JC pollinosis was estimated to be 8.5%. The prevalence differed significantly between the NR and SR (5.3% vs 11.3%, P<0.001), mainly due to the difference in sensitization rates. JC pollen is the major outdoor allergen for early spring pollinosis in Jeju. JC pollen season is from late January to mid-April. Warmer weather during the flowering season scatters more JC pollen in the atmosphere, resulting in a higher sensitization rate in atopic individuals and, consequently, making JC pollinosis more prevalent.

A Cross-sectional Epidemiological Study on Trends in the Prevalence of Allergic Diseases among Children and Adolescents in the Jeju Area in 2008 and 2013

PURPOSE: This study was to find epidemiological trends in the prevalence of allergic diseases among children and adolescents in Jeju Province, Korea. METHODS: Two questionnaire surveys of the same method were conducted, respectively, in 2008 and in 2013 with five years' interval with 1,296 participants in 2008 and 878 in 2013 who were elementary and secondary students sampled at random from the same five schools. 'International Study of Asthma and Allergies in Childhood (ISAAC)' was applied to the parents with their written consent to the survey. RESULTS: The results of analysis showed an increasing trend in the prevalence of lifetime asthma (8.6% in 2008 and 10.4% in 2013) and in the prevalence of lifetime allergic rhinitis (25.3% in 2008 and 31.1% in 2013) (p=.003), and a decreasing trend in the prevalence of lifetime atopic dermatitis (32.0% in 2008 and 26.8% in 2013) (p=.011). CONCLUSION: This research showed an increasing trend in the prevalence of asthma and allergic rhinitis among children and adolescents in Jeju Province compared to that 5 years ago, but represented a declining trend in the prevalence of atopic dermatitis.

Severe Fever with Thrombocytopenia Syndrome Mimicking Scrub Typhus: Three Case Reports

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease in South Korea with clinical features similar to those of scrub typhus. Infected patients with these two diseases usually visited the emergency department (ED) complaining of fever that was not responsive to treatment in a local clinic. Aggressive management of SFTS is required in order to prevent rapid progression and human-to-human transmission, thus rapid and accurate differential diagnosis of the two diseases in the ED is important. We reported three laboratory confirmed cases of SFTS during 2013-2014 in a single center, with fever, skin lesions, and history of outdoor activities in order to help in differential diagnosis between SFTS and scrub typhus in the ED.