Non-severe Serovar Type E Capnocytophaga canimorsus Infection in a Post-splenectomy Male: A Case Report.

Capnocytophaga canimorsus (CP) causes severe infections in immunocompromised individuals. Three serovars (A, B, and C) are known to be responsible for more than 90% of infections associated with dog bites, although these three constitute only 8% of the serovars carried by dogs. We experienced a post-splenectomy non-severe case of CP withserovar type E, which has never been isolated in Japan. The prognosis of type E CP infections may be better than that of types A, B, and C infections because of the disproportion of serovars between clinical human isolates and dog oral isolates.

Effect of Past Chlamydophila pneumoniae Infection on the Short-Time Mortality of COVID-19: A Retrospective Cohort Study.

BACKGROUND: Although Chlamydophila pneumoniae (CP)is known to play a role in atherosclerosis and endothelial injury, its past infection on the mortality of coronavirus disease 2019 (COVID-19), which was also reported to be a vascular disease, remains unknown. METHODS: In this retrospective cohort study, we examined 78 COVID-19 patients and 32 bacterial pneumonia patients who visited a tertiary emergency center in Japan between April 1, 2021, and April 30, 2022. CP antibody levels, including IgM, IgG, and IgA, were measured. RESULTS: Among all patients, the CP IgA-positive rate was significantly associated with age (P = 0.002). Between the COVID-19 and non-COVID-19 groups, no difference in the positive rate for both CP IgG and IgA was observed (P = 1.00 and 0.51, respectively). The mean age and proportion of males were significantly higher in the IgA-positive group than in the IgA-negative group (60.7 vs. 75.5, P = 0.001; 61.5% vs. 85.0%, P = 0.019, respectively). Smoking and dead outcomes were significantly higher both in the IgA-positive group and IgG-positive group (smoking: 26.7% vs. 62.2, P = 0.003; 34.7% vs. 73.1%, P = 0.002, dead outcome: 6.5% vs. 29.8%, P = 0.020; 13.5% vs. 34.6%, P = 0.039, respectively). Although the log-rank test revealed higher 30-day mortality in the IgG-positive group compared to the IgG-negative group (P = 0.032), Cox regression analysis demonstrated no significant difference between the IgG-positive and negative groups (hazard ratio (HR) = 4.10, 95%CI = 0.94-18.0, P = 0.061). CONCLUSION: The effect of past CP infection on 30-day mortality in COVID-19 patients was not obvious.

Insertion site of central venous catheter among hospitalized adult patients: A systematic review and network meta-analysis.

Introduction: Central venous catheterization is a commonly performed procedure, accounting for approximately 8% of hospitalized patients. Based on the current literatures, the most acceptable site for central venous catheterization is inconclusive, considering various complications in hospitalized patients. Herein, we conducted a network meta-analysis to assess the clinically important complications among internal jugular, subclavian, femoral, and peripheral insertion. Materials and methods: The Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science, Ichushi databases, Clinicaltrials.gov, and International Clinical Trials Registry Platform were searched. Studies including adults aged ≥ 18 years and randomized control trials that compared two different insertion sites (internal jugular, subclavian, femoral, and peripheral vein) were selected. The primary outcomes were clinically important infectious, thrombotic, and mechanical complications. Results: Among the 5,819 records initially identified, 13 trials (6,201 patients) were included for a network meta-analysis. For clinically important infectious complication, subclavian insertion decreased the complication risk, compared with internal jugular [risk ratio (RR), 0.30; 95% confidence interval (CI), 0.11-0.81; moderate certainty], and femoral insertion increased than subclavian insertion (RR 2.56; 95% CI, 1.02-6.44; moderate certainty). Peripheral insertion was also significantly associated with a lower risk compared with internal jugular (RR 0.06; 95% CI, 0.01-0.32; low certainty); subclavian (RR 0.21; 95% CI, 0.05-0.77; moderate certainty); and femoral insertion (RR 0.08; 95% CI, 0.02-0.40; low certainty). For clinically important thrombotic complication, we did not find significant differences between insertion sites. For clinically important mechanical complication, femoral insertion decreased the complication risk, compared with internal jugular (RR 0.42; 95% CI, 0.21-0.82; moderate certainty) and subclavian insertion (RR 0.33; 95% CI, 0.16-0.66; moderate certainty). Peripheral insertion was also associated with the lower complication risk compared with internal jugular (RR 0.39; 95% CI, 0.18-0.85; low certainty) and subclavian insertion (RR 0.31; 95% CI, 0.13-0.75; moderate certainty). Conclusion: The insertion site of the central venous catheter, which is most likely to cause the fewest complications, should be selected. Our findings can provide the rationale for deciding the insertion site for a central venous catheter. Systematic review registration: [www.protocols.io], identifier [61375].

Lemierre's Syndrome as a Sexually Transmitted Disease Due to Porphyromonas asaccharolytica Suspected to Be Caused by Pharyngitis Due to Mycoplasma pneumoniae and Epstein-Barr Virus.

Porphyromonas asaccharolytica rarely causes Lemierre's syndrome (LS), which is characterised by sepsis and thrombophlebitis of the internal jugular vein. An 18-year-old man presented with fever and a sore throat after sexual contact containing oral sex, and his blood sample was positive for atypical lymphocytes. Infectious mononucleosis was suspected initially. However, laboratory data showed elevated D-dimer and procalcitonin levels, and a computed tomography scan showed a thrombus in the internal jugular vein leading to the diagnosis of LS. The Mycoplasma pneumoniae (MP) IgM titre was 1:640 (normal, ≦1:40), and the Epstein-Barr nuclear antigen titre (taken 59 days after admission) was 1:10 (normal, <1:10). It was assumed that LS developed after infection with Epstein-Barr virus (EBV) and MP. LS should be suspected in young patients with fever and sore throat with a history of recent sexual contact. As pharyngitis was considered the cause of LS, evaluation of the preceding infection such as MP or EBV leading to pharyngitis should also be considered.

Methylprednisolone pulse therapy for critically ill patients with coronavirus disease 2019: A single-center retrospective observational study.

Aim: This study compared the clinical outcomes of critically ill patients with coronavirus disease (COVID-19) pneumonia treated with high-dose methylprednisolone and other steroids. Methods: This retrospective observational study included critically ill COVID-19 pneumonia adult patients with tracheal intubation treated between April 1, 2020, and September 15, 2021. Of the 46 patients who met the inclusion criteria, 36 received steroid pulse therapy (Group P) and 10 received steroids without pulse therapy (Group NP). Subgroup analyses in Group P by methylprednisolone dose of 1000 or 500 mg for 3 days during intensive care unit stay were carried out. The primary and secondary outcomes were 28-day mortality and steroid-associated complications, respectively. Results: In the Kaplan-Meier curve analysis, there was no difference in the 28-day survival between P and NP groups (log-rank P = 0.046). Univariate Cox proportional hazard model also showed that Group P had a decreased 28-day mortality (hazard ratio 0.30; [95% confidence interval, 0.20-0.44]; P < 0.01). After adjusting for covariates (age, sex, remdesivir, baricitinib, and favipiravir), using the multivariate Cox proportional hazards model, Group P had improved 28-day mortality (0.50 [0.30-0.85], P = 0.01). Conclusion: Steroid pulse therapy might improve the 28-day and in-hospital mortality in critically ill patients with COVID-19 pneumonia.

Chronic Pulmonary Aspergillosis During Convalescence From Severe COVID-19 Treated With Oral Itraconazole: A Report of Two Cases.

Invasive pulmonary aspergillosis (IPA) has been reported to occur secondary to coronavirus disease 2019 (COVID-19), and the condition has been termed COVID-19-associated pulmonary aspergillosis (CAPA). We diagnosed two severe COVID-19 cases with multiple cavitary lung lesions and chronic pulmonary aspergillosis (CPA) on days 58 and 48 of admission, respectively, with gradual improvement in the respiratory status. Both patients were positive for Aspergillus-precipitating antibodies (APAb). We chose oral itraconazole (ITCZ) for both patients because of its convenience in terms of long-term treatment. Cavitary lesions diminished after ITCZ administration. The risk factors for pulmonary aspergillosis in both patients were determined to be steroid pulse therapy, use of baricitinib, diabetes mellitus (DM), ICU admission, long hospital stay, and the use of broad-spectrum antibiotics. Pulmonary aspergillosis must be suspected in patients with severe COVID-19, even if they are asymptomatic, because not only IPA but also CPA can occur following COVID-19. Therefore, oral ITCZ may be a treatment option for CPA following COVID-19.

Awake intubation with videolaryngoscopy and fiberoptic bronchoscope.

By combining video laryngoscopy and fiberoptic bronchoscopy, awake intubation can be performed more safely.

A Case of Central Pontine Myelinolysis Occurred During Treatment of Hyperosmolar Hyperglycemic Syndrome.

Central pontine myelinolysis (CPM) is a rare demyelinating condition which has been reported to occur in a variety of clinical settings, but most commonly in association with a rapid rise in plasma osmolality during correction of chronic hyponatremia. The clinical consequences can vary from a mild motor weakness that resolves completely over time to the devastating locked-in syndrome. In this presentation, we report a case of hyperosmolar hyperglycemic syndrome (HHS) with ponto-occipital disintegration. A 71-year-old female was transferred to our ER by an ambulance due to consciousness disorder and continuous fever for 10 days. We diagnosed septic shock caused by urinary tract infection (UTI), cerebral multiple infarctions, acute kidney injury (AKI) and HHS without treatment for diabetes. Then, we started therapeutic interventions for them based on the guideline with severe control for blood sugar (BS; primary 1635 mg/dl) under insulin therapy and hypernatremia (primary 153 mEq/l) under crystal infusion control in advanced care unit, apparently on routine lab data. However, the initial serum sodium value of 153 mEq/l was slowly compensated to 148 mEq/l in 60 hours under guideline on routine lab data, the initial compensated sodium value with osmolality was changed from 178 mEq/l to 150 mEq/l in the period. She recovered from her primary diagnosis and unconsciousness. After stabilized sepsis and HHS, we detected CPM on brain MRI due to following up multiple cerebral infarctions with left leg paralysis and verbal disorder. She gradually recovered over several months with intensive rehabilitation and eventually regained near normal functional capacity with stabilized BS. When we consider HHS with hypernatremia, it may be necessary to pay attention to not only to BS control and sodium control according to the guideline but also to osmolality changes to prevent CPM.

Veno-venous extracorporeal membrane oxygenation for severe pneumonia: COVID-19 case in Japan.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is one of the ultimate treatments for acute respiratory failure. However, the effectiveness of ECMO in patients with novel coronavirus disease (COVID-19) is unknown. CASE PRESENTATION: A 72-year-old woman who was a passenger of a cruise ship tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) while in quarantine on board using throat swab. Three days after admission, her condition deteriorated, and she was subsequently intubated. On day 6, VV-ECMO was introduced. Lopinavir/ritonavir was given; continuous renal replacement therapy was also introduced. On day 10, her chest radiography and lung compliance improved. She was weaned off ECMO on day 12. CONCLUSION: Treatment of severe pneumonia in COVID-19 by ECMO should recognize lung plasticity considering time to ECMO introduction and interstitial biomarkers. In Japan, centralization of ECMO patients has not been sufficient. Thus, we suggest nationwide centralization and further research to respond to the crisis caused by COVID-19.

Quantitative capillary refill time predicts sepsis in patients with suspected infection in the emergency department: an observational study.

BACKGROUND: Outcomes in emergent patients with suspected infection depend on how quickly clinicians evaluate the patients and start treatment. This study was performed to compare the predictive ability of the quantitative capillary refill time (Q-CRT) as a new rapid index versus the quick sequential organ failure assessment (qSOFA) score and the systemic inflammatory response syndrome (SIRS) score for sepsis screening in the emergency department. METHODS: This was a multicenter, observational, retrospective study of adult patients with suspected infection. The area under the curve (AUC) of receiver operating characteristic curve analyses and multivariate analyses were used to explore associations of the Q-CRT with the qSOFA score, SIRS score, and lactate concentration. RESULTS: Of the 75 enrolled patients, 48 had sepsis. The AUC, sensitivity, and specificity of Q-CRT were 0.74, 58%, and 81%, respectively; those for the qSOFA score were 0.83, 66%, and 100%, respectively; those for the SIRS score were 0.61, 81%, and 40%, respectively, for SIRS score; and those for the lactate concentration were 0.76, 72%, and 81%, respectively. We found no statistically significant differences in the AUC between the scores. We then combined the Q-CRT and qSOFA score (Q-CRT/qSOFA combination) for sepsis screening. The AUC, sensitivity, and specificity of Q-CRT/qSOFA combination were 0.82, 83%, and 81%, respectively. CONCLUSIONS: In this study, Q-CRT/qSOFA combination had better sensitivity than the qSOFA score alone and better specificity than the SIRS score alone. There was no significant difference in accuracy between Q-CRT/qSOFA combination and the qSOFA score or lactate concentration. The ability of the Q-CRT to predict sepsis may be similar to that of the qSOFA score or serum lactate concentration; therefore, measurement of the Q-CRT may be an alternative for invasive measurement of the blood lactate concentration in evaluating patients with suspected sepsis.