Perforation of the hypopharynx after transesophageal echocardiography.

A 65-year-old obese woman with an oversized neck and dysphagia underwent transesophageal echocardiography (TEE). The procedure was complicated by difficulty in insertion from the pharynx to esophagus, and her head and neck gradually swelled. Computed tomography (CT) revealed extensive emphysema from the neck to superior mediastinum, which suggested pharyngeal perforation. A nasogastric tube was inserted, and the patient received antibiotics to prevent secondary mediastinitis. CT performed 1 week later showed improvement of emphysema and no evidence of mediastinitis. Perforation along the orogastric pathway during TEE is a rare but life-threatening complication to which physicians performing TEE should pay attention.

Complete genome sequence of the incompatibility group I1 plasmid R64.

A streptomycin and tetracycline resistance plasmid R64 isolated from Salmonella enterica serovar Typhimurium belongs to the incompatibility group I1 (IncI1). The DNA sequence of the R64 conjugative transfer region was described previously (Komano et al., 2000). Here, we report the complete genome sequence of R64. In the circular double-stranded R64 genome with 120,826bp, 126 complete ORFs are predicted. In addition, 2 and 6 different kinds of proteins are produced by translational reinitiation and shufflon multiple inversions, respectively. The genome consists of five major regions: replication, drug resistance, stability, transfer leading, and conjugative transfer regions in clockwise order. The nucleotide sequence essential for autonomous replication of R64 is completely identical to that of IncI1 colicinogenic plasmid ColIb-P9, an indication that these two plasmids share the same mechanisms for replication and copy number control. Tetracycline and streptomycin resistance genes are encoded in transposons Tn10 and Tn6082, respectively. These transposons and two insertion elements, IS2 and IS1133, were inserted stepwise into the arsenic-resistant gene, arsA1, present in the drug resistance region. The stability and transfer leading regions contain various important genes such as parAB, resD, ardA, psiAB, or ssb for plasmid maintenance, recombination and transfer reactions. When the genome of R64 was compared with those of other plasmids, varying levels of similarity were observed. It is suggested that genetic recombinations including the site-specific rfsF-ResD system have played an important role in diversity of genomes related to R64. It was found that R64 exhibits highly organized genome structure.