Treatment of portosystemic shunt-borne hepatic encephalopathy in a 97-year-old woman using balloon-occluded retrograde transvenous obliteration: A case report.

BACKGROUND: Hyperammonemia and hepatic encephalopathy are common in patients with portosystemic shunts. Surgical shunt occlusion has been standard treatment, although recently the less invasive balloon-occluded retrograde transvenous obliteration (B-RTO) has gained increasing attention. Thus far, there have been no reports on the treatment of portosystemic shunts with B-RTO in patients aged over 90 years. In this study, we present a case of hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins, successfully treated with B-RTO. CASE SUMMARY: A 97-year-old woman with no history of liver disease was admitted to our hospital because of disturbance of consciousness. She had no jaundice, spider angioma, palmar erythema, hepatosplenomegaly, or asterixis. Her blood tests showed hyperammonemia, and abdominal contrast-enhanced computed tomography revealed a portosystemic shunt running between the left common iliac vein and the inferior mesenteric vein. She was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt. The patient did not improve with conservative treatment: Lactulose, rifaximin, and a low-protein diet. B-RTO was performed, which resulted in shunt closure and improvement in hyperammonemia and disturbance of consciousness. Moreover, there was no abdominal pain or elevated levels of liver enzymes due to complications. The patient was discharged without further consciousness disturbance. CONCLUSION: Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.

The first case report of septic abortion resulting from ß-lactamase-negative ampicillin-resistant non-typeable Haemophilus influenzae infection.

Introduction. This is the first case report of septic abortion due to ß-lactamase-negative ampicillin-resistant (BLNAR) non-typeable Haemophilus influenzae infection. In Japan, BLNAR H. influenzae is widespread and has become a clinical concern, especially in paediatrics and otolaryngology, but H. influenzae has not been previously recognized as a causative agent of obstetric or gynaecological infection. Case presentation. A 31-year-old pregnant woman presented at 17 weeks and 6 days of gestation with a high fever; she was admitted with a diagnosis of threatened premature delivery. Despite tocolytic treatment, she aborted spontaneously 2 h after admission and then entered septic shock. BLNAR H. influenzae was detected in both blood and vaginal cultures. Her condition gradually improved after several days of treatment with cefotaxime, and she was ultimately discharged without sequelae or complaints. Conclusion. Although penicillin with a ß-lactamase inhibitor is currently recommended for the treatment of septic abortion, this combination will probably lead to treatment failure in the case of BLNAR H. influenzae infection. As this study reveals, H. influenzae can cause septic abortion; hence, future efforts should be undertaken to detect and therapeutically target this pathogen during pregnancy.

[A case of osteomyelitis caused by mixed infection by Aggregatibacter aphrophilus and Staphylococcus aureus].

A 46-year-old man presented with a 10-day history of progressive weakness and numbness in both his legs. The spinal MRI and abdominal CT revealed discitis of L4/L5 and multiple epidural abscesses. The blood culture tested positive for methicillin sensitive Staphylococcus aureus (MSSA). The Gram stain of sample from abscess drainage showed Gram-positive cocci in clusters and small Gram-negative rods. The Gram-positive cocci in clusters were identified as MSSA using a general culture method and the small Gram-negative rods were identified as Aggregatibacter aphrophilus using a 16s ribosomal RNA sequencing method. The patient was treated four times with surgical abscess drainages and a long course of intravenous antibiotics therapy following which he recovered. No case of mixed infection by A. aphrophilus and S. aureus has been reported in MEDLINE; therefore, our case should be the first case report. Since we confirmed not only Gram-positive cocci in clusters but also Gram-negative rods in the abscess sample, we did not stop the identification procedure at the point when MSSA was identified and finally identified A. aphrophilus with 16s ribosomal RNA sequencing. Especially, in a mixed infection with organisms whose growth speed is different, an organism with slow growth might be missed if the Gram stain of sample were skipped. This case implies the significance of Gram staining as the identification procedure for organisms.

[Plasmodium malariae malaria with more than a 4-month incubation period: difficult to distinguish from a relapse of Plasmodium vivax malaria].

We report herein on a case of Plasmodium malariae malaria with more than a 4-month incubation period. A 35-year-old Japanese man who first presented to our clinic with fever and history of travel to Papua New Guinea was suspected of having Plasmodium vivax malaria based on peripheral smear results. We admitted him and initiated treatment with mefloquine. After two days of therapy, he became afebrile. We discharged him, and P. vivax was later confirmed with PCR. We started mefloquine prophylaxis for a planned trip to Papua New Guinea. After his return, a standard dose of primaquine (15 mg x 14 days) was prescribed for a radical cure of P. vivax. About 4 months after his last visit to Papua New Guinea, he returned to our clinic with fever. We suspected a relapse of P. vivax malaria and admitted him for a second time. After two days of mefloquine therapy, his symptoms improved. We discharged him and restarted a higher dose of primaquine (30 mg x 14 days) therapy for a radical cure of P. vivax. Subsequently, the PCR test revealed the parasite was P. malariae and not P. vivax. Only 13 cases of Plasmodium malariae malaria have been reported in Japan during the past 10 years. Blood-stage schizonticides such as mefloquine is not active against the liver stage. Therefore, the use of these drugs for prophylaxis will not be effective for prevention of malaria if its liver stage is longer than the duration of effective chemoprophylaxis. Although the incubation period of P. malariae is typically 13 to 28 days, it occasionally lasts for months or even years. Careful attention should be given to the possibility that P. malariae occasionally has a long incubation period even in the absence of the hypnozoite stage.

Urosepsis caused by Globicatella sanguinis and Corynebacterium riegelii in an adult: case report and literature review.

We report an extremely rare case of urosepsis caused by Globicatella sanguinis and Corynebacterium riegelii coinfection in a 94-year-old Japanese man with nephrolithiasis. Prompt identification of this coinfection is important so that effective antimicrobial coverage can be initiated.

Impact of infectious diseases service consultation on diagnosis of infective endocarditis.

BACKGROUND: The infectious diseases (ID) consultation service is a new clinical entity in Japan. We examined the impact of ID consultation on the diagnosis of infective endocarditis (IE) at a large teaching hospital in Japan. METHODS: Routine consultation with an ID service for cases of positive blood culture was implemented at Kameda Medical Center in November 2004. In addition, ID service doctors started to give lectures on ID to doctors and also provided local guidelines on ID. We compared the incidence of IE during a 3-y and 10-month period before intervention with that during a 5-y and 2-month period after intervention. The modified Duke criteria were used to confirm the diagnosis of definite IE. Patients who fulfilled the criteria for definite IE were included in the analysis. RESULTS: Twenty-seven cases of IE were diagnosed before the implementation of routine consultation, and 76 cases after. The respective incidences of IE were 48.7 and 84.8 per 100,000 patients discharged from the hospital (p = 0.01). The relapse rate of IE within 6 months was significantly lower in patients who underwent routine consultation (22.2% vs 2.2%; p = 0.02). CONCLUSION: Routine consultation with an ID service for cases of positive blood culture, together with consecutive lecturing and local guidelines by ID specialists, resulted in improved detection of IE and a reduced relapse rate within 6 months. Timely consultation with an ID specialist in bacteraemia cases may be beneficial for improving the outcomes of patients in this setting.