Imported Melioidosis in South Korea: A Case Series with a Literature Review

Objectives

Melioidosis is a potentially fatal infectious disease caused by the environmental anaerobic Gram-negative bacillus Burkholderia pseudomallei. Melioidosis is endemic to areas of northern Australia and Southeast Asia. With increasing international travel and migration, imported cases of melioidosis are being reported regularly. Here, we summarize the 11 cases of melioidosis reported in South Korea from 2003 to 2014.

Methods

Tracing epidemiological investigations were performed on every patient reported to the National Surveillance System since 2011. A systematic literature search was performed to identify melioidosis cases that occurred prior to 2011.

Results

The overall fatality rate was 36.4%. All the patients had visited Southeast Asia where melioidosis is endemic. The stay in the endemic region ranged from 4 days to 20 years. Of the seven patients who developed initial symptoms after returning to South Korea, the time interval between returning to South Korea and symptom onset ranged from 1 day to 3 years. The remaining four patients developed symptoms during their stay in the endemic region and were diagnosed with melioidosis in South Korea. Seven (63.6%) patients possessed at least one risk factor, all of whom were diabetic. Pneumonia was the most frequent clinical manifestation, but the patients showed a wide spectrum of clinical features, including internal organ abscesses, a mycotic aneurysm of the aorta, and coinfection with tuberculosis.

Conclusion

An early diagnosis and initiation of the appropriate antibiotics can reduce the mortality of melioidosis. Consequently, increased awareness of the risk factors and clinical features of melioidosis is required.     

Case Report and Literature Review on Good's Syndrome,a Form of Acquired Immunodeficiency Associated with Thymomas

Thymoma is an uncommon and slow-growing neoplasm that usually presents with mass-associated respiratory symptoms, superior vena cava syndrome or parathymic syndromes. We present a patient with thymoma and hypogammaglobulinemia who had recurrent sinopulmonary infections and diarrhea, recognized to be Good''s syndrome. A 75-year old male with thymoma was admitted in our institution due to severe dehydration secondary to a 2-week history of non-bloody watery diarrhea refractory to anti-motility medications. His condition started 3 years ago when he had repeated outpatient visits and hospital admissions either from diarrhea or respiratory tract infections. Workup was essentially unremarkable except for low serum IgM and IgG, lymphocytopenia, and a low absolute CD4 T cell count of 94. A diagnosis of Good''s syndrome was made. Patients with Good''s syndrome usually have low to absent B cells in the peripheral blood, hypogammaglobulinemia, and cell-mediated immunity defects. Immunologic investigations, T cell subsets, B cell, and quantitative immunoglobulins should be considered a part of diagnostic search in patients with thymoma with recurrent infections or diarrhea. Thymectomy has favorable effects on other parathymic syndromes but is ineffective in improving immunologic deficiencies in this syndrome. Immunoglobulin replacements have been reported to decrease infections, reduce hospitalizations, and decrease antibiotic use in these patients. Clinical outcomes depend on the severity of infections, associated hematologic and autoimmune diseases rather than the thymoma itself.     

Cefepime MIC as a predictor of the extended-spectrum beta-lactamase type in Klebsiella pneumoniae, Taiwan

To guide selection of carbapenems or fourth-generation cephalosporins as therapy, 110 Klebsiella pneumoniae isolates with extended-spectrum beta-lactamases from Taiwan were characterized by phenotypic (MICs), molecular, and chemical methods. MIC patterns of ceftazidime and cefepime clearly differentiate strains treatable by cefepime and those capable of efficiently hydrolyzing available cephalosporins (CTX-M series and SHV-types). Continued use of cefepime appears to be a treatment option in cases for which MIC results are available and interpreted by the criteria presented.     

TEM and SHV Genes in Klebsiella pneumoniae Isolated from Cockroaches and Their Antimicrobial Resistance Pattern

Objectives

Klebsiella pneumoniae is a gram-negative rod bacterium, a known cause of community-acquired bacterial pneumonia and is an important hospital-acquired pathogen that causes severe morbidity and mortality. The aim of this study was to identify the TEM and SHV genes in K. pneumoniae isolated from cockroaches obtained from hospitals.

Methods

In this study, 250 cockroaches were collected from different hospitals in the province of Chaharmahal Va Bakhtiari, which is located in southwest Iran. The samples were examined for the presence of K. pneumoniae by plating onto a combination of culture media, and the antimicrobial susceptibility patterns of isolated K. pneumoniae from samples were evaluated using the disk diffusion test. In addition, from the culture, genomic bacterial DNA was extracted, and sequence-specific targets (TEM and SHV genes) were amplified using the polymerase chain reaction (PCR) method.

Results

Out of 250 cockroach samples collected from various hospitals, 179 samples (71.60%) were positive for K. pneumoniae. PCR reaction was performed using specific oligonucleotide primers (TEM-F, TEM-R and SHV-F, SHV-R) for the amplification of each gene, and amplified products were visualized on 1% agarose gel electrophoresis. Of all the specimens amplified by PCR in this research, 32 samples (17.87%) were positive for TEM and 15 samples (8.37%) were positive for SHV.

Conclusion

Detection of TEM and SHV genes using molecular methods and their pattern of antimicrobial resistance can provide useful information about the epidemiology of and risk factors associated with K. pneumoniae infection.     

Congenital Epulis in a Newborn: A Case Report,Immunoprofiling and Review of Literature

Background

Congenital epulis is a rare lesion of the newborn, presenting as mass in the oral cavity which can interfere with respiration and feeding. It should be distinguished from other lesions which can occur in newborns, both clinically and histopathologically.

Case Details

Here, we report a case of congenital epulis in a newborn female on the right alveolar ridge, along with an extensive review of literature and discuss the immunoprofiling.

Conclusion

Early diagnosis of CE in a newborn is of paramount importance in the successful management of these rare cases.     

Virulence characteristics of Klebsiella and clinical manifestations of K. pneumoniae bloodstream infections

We studied 455 consecutive episodes of Klebsiella pneumoniae bacteremia occurring in 7 countries. Community-acquired pneumonia and an invasive syndrome of liver abscess, meningitis, or endophthalmitis occurred only in Taiwan and South Africa. Infections by K1 and K2 capsular serotype, the mucoid phenotype, and aerobactin production were important determinants of virulence. The mucoid phenotype was seen in 94% of isolates in patients with community-acquired pneumonia and in 100% of isolates that caused the invasive syndrome in Taiwan and South Africa, compared with only 2% of isolates elsewhere. Mortality of mice injected with mucoid strains (69%) was strikingly higher than that occurring in mice injected with nonmucoid strains (3%, p < 0.001). Differences in clinical features of bacteremic infection with K. pneumoniae are due to the virulence factors expressed by the organism.     

Challenges in the Management of Mucopolysaccharidosis Type II (Hunter's Syndrome) in a Developing Country: a Case Report

Background

Mucopolysaccharidosis type II (Hunter''s syndrome) is an X-linked chromosomal storage disorder due to deficiency of the lysosomal enzyme iduronate-2-sulfatase with patients rarely living till adulthood. Failure to identify patients early could contribute to an increased morbidity as identified in this case report.

Case Details

An eight year old patient with Hunter''s syndrome identified five years after disease onset with severe cardiovascular complications exemplifies the challenges faced in resource-limited countries towards making diagnosis and treatment of rare conditions. Elevated urinary glycosaminoglycans levels or a strong clinical suspicion of Hunter''s syndrome, as identified in the index case, is a prerequisite for enzyme activity testing. Urinary mucopolysaccharide(MPS) level was 69.6mg/mmol(normal range is 0.0 – 11.6mg/mmol), and the confirming MPS electrophoresis analysis showed elevated heparan sulphate in the urine sample. Enzyme activity testing, with absent or very low iduronate-2-sulfatase activity, is diagnostic. However, the scarce availability and high cost of these tests is another constraint in making a diagnosis.

Conclusion

Identification and management of mucopolysaccharidosis type II pose a problem in resource-constrained countries due to late presentation, lack of facility for diagnosis and treatment, cost and expertise required for the management.     

Kartagener's Syndrome: A Classical Case

Background

Recurrent lower respiratory tract infection (LRTI) is a very common problem we encounter in our clinical practice. Failure to recognize the specific cause of this condition may subject the patients to unnecessary and inappropriate treatment.

Case Details

among the various causes of recurrent LRTI, the most frequent causes are abnormalities of general or local impairment of immune mechanism and abnormalities of cilia or mucus of respiratory tract. We report an adult case of recurrent upper and lower respiratory tract infections since childhood along with situs inversus totalis which was diagnosed as Kartagener''s syndrome. He had all the classical clinical and radiological features of Kartagener''s syndrome which is a rare inherited disorder which is seen in nearly half of the cases of primary cilliary dyskinesia (PCD).

Conclusion

One should always keep in mind the possibilities of Kartagener''s syndrome in patients presenting with recurrent upper and lower respiratory tract infections, sinusitis or bronchiectasis. Inability to diagnose this condition may subject the patient to unnecessary and repeated hospital admissions, investigations and treatment failure.     

Human Linguatulosis Caused by Linguatula serrata in the City of Kerman,South-eastern Iran- Case Report

Human linguatulosis poses an important medical and veterinary concern in endemic countries. Animals, as reservoir host, play a major role in transmission of infestation and epidemiology of the disease. This study reports a case of human linguatulosis caused by Linguatula serrata in the city of Kerman, South-eastern Iran. A woman suffering from upper respiratory symptoms is presented. The patient consumed raw liver of sheep who was admitted to the Afzalipour University Hospital in Kerman for the symptoms of upper respiratory tract. In microscopic examination of the nasopharyngeal discharge, L. serrata was detected. This report has future medical implication in precise diagnosis of L. serrata in patients with complaints of nasopharyngeal symptoms.     

Characterization of Plasmid-Mediated AmpC and Carbapenemases among Iranain Nosocomial Isolates of Klebsiella pneumoniae Using Phenotyping and Genotyping Methods

Objectives

Plasmid-mediated AmpC β-lactamases (PMABLs) and carbapenemases are emerging groups of antimicrobial-resistance determinants. The aims of the study were to evaluate the occurrence of PMABLs and carbapenemases in clinical isolates of Klebsiella pneumoniae and compare the test performance of various phenotypic methods for detection of these enzymes in Iran.

Methods

A total of 100 K. pneumoniae isolates were collected from clinical specimens obtained in Valiasr Hospital. AmpC production in all isolates was determined using the AmpC disk test, the cephamycin Hodge test, the AmpC Etest, and the boronic acid combined-disk test. In addition, carbapenemase production was determined using the modified Hodge test, the EDTA disk synergy test, and the boronic acid combined-disk test. The performances of various phenotypic methods were evaluated by the comparison of their results with polymerase chain reaction (PCR) method as the gold standard.

Results

Of the 100 isolates, 19 (19%) were demonstrated to harbor the PMABL-resistance gene by the multiplex PCR method. The PCR result indicated the presence of carbapenemase genes in 12 isolates. The performance of various phenotypic tests carried out for detection of carbapenemase-producing isolates varied widely, ranging in sensitivity from 30% to 100% and in specificity from 90.8% to 100%.

Conclusion

This is the first report of MOX-type AmpC β-lactamase and bla_GES in K. pneumoniae in Iran. A comparison of the phenotypic methods showed that a combination of cefoxitin plus boronic acid is optimal for detecting plasmid-mediated AmpC enzymes in K. pneumoniae, whereas the implementation of molecular methods is often complex, requires specially trained personnel, and is associated with higher costs.     

Risk factors and clinical significance of ertapenem-resistant Klebsiella pneumoniae in hospitalised patients

Ertapenem-resistant Klebsiella pneumoniae (ER-Kp) is an emerging healthcare-associated pathogen. In order to identify risk factors associated with ER-Kp acquisition, the records of 100 patients from whom K. pneumoniae had been isolated between July 2008 and December 2009 were reviewed. These comprised 38 with ER-Kp (28 infected, 10 colonised) and 62 with ertapenem-susceptible K. pneumoniae (ES-Kp) (43 infected, 19 colonised). Multilocus sequence typing (MSLT) and porin gene investigation performed on 25 ER-Kp strains showed that 24 belonged to the ST37 lineage, expressing a novel OmpK36 variant and not expressing OmpK35. Breakthrough bacteraemia occurred in 13 (52%) of 25 bloodstream infections (BSIs). Among nine ER-Kp BSIs, five were complicated by breakthrough bacteraemia, of which four developed during carbapenem therapy. Among 16 ES-Kp BSIs, breakthrough bacteraemia developed in eight patients (50%), but only one occurred (12%) during carbapenem therapy. Logistic regression analysis showed that carbapenems (odds ratio: 12.9; 95% confidence interval: 3.09-53.7; P < 0.001), second generation cephalosporins (11.8; 1.87-74.4; P < 0.01), endoscopy (5.59; 1.32-23.6; P < 0.02), acute renal failure (5.32; 1.13-25.1; P=0.034) and third generation cephalosporins (4.15; 1.09-15.8; P < 0.01) were independent risk factors for acquisition of ER-Kp. Our findings confirm that prior use of certain antimicrobials, specifically carbapenems and cephalosporins, are primary independent risk factors for colonisation or infection with ER-Kp.     

Antibiotic selection pressure and resistance in Streptococcus pneumoniae and Streptococcus pyogenes

We correlated outpatient antibiotic use with prevalence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP), macrolide-resistant S. pneumoniae (MRSP), and macrolide-resistant S. pyogenes (MRGAS) in 20 countries. Total antibiotic use was correlated with PNSP (r = 0.75; p < 0.001), as was macrolide use with MRSP (r = 0.88; p < 0.001) and MRGAS (r = 0.71; p = 0.004). Streptococcal resistance is directly associated with antibiotic selection pressure on a national level.     

Resistance to Fluoroquinolone by a Combination of Efflux and Target Site Mutations in Enteroaggregative Escherichia coli Isolated in Korea

ObjectivesEnteroaggregative Escherichia coli (EAEC) was recently reported as a major diarrheagenic pathogen in infant and adult travelers, both in developing and developed countries. EAEC strains are known to be highly resistant to antibiotics including quinolones. Therefore in this study we have determined the various mechanisms of quinolone resistance in EAEC strains isolated in Korea.MethodsFor 26 EAEC strains highly resistant to fluoroquinolone, minimal inhibitory concentrations for fluoroquinolones were determined, mutations in the quinolone target genes were identified by PCR and sequencing, the presence of transferable quinolone resistance mechanism were identified by PCR, and the contribution of the efflux pump was determined by synergy tests using a proton pump inhibitor. The expression levels of efflux pump-related genes were identified by relative quantification using real-time PCR.ResultsApart from two, all tested isolates had common mutations on GyrA (Ser83Leu and Ser87Gly) and ParC (Ser80Gln). Isolates EACR24 and EACR39 had mutations that have not been reported previously: Ala81Pro in ParC and Arg157Gly in GyrA, respectively. Increased susceptibility of all the tested isolates to ciprofloxacin and norfloxacin in the presence of the pump inhibitor implies that efflux pumps contributed to the resistance against fluoroquinolones. Expression of the efflux pump-related genes, tolC, mdfA, and ydhE, were induced in isolates EACR 07, EACR 29, and EACR 33 in the presence of ciprofloxacin.ConclusionThese results indicate that quinolone resistance of EAEC strains mainly results from the combination of mutations in the target enzyme and an increased expression of efflux pump-related genes. The mutations Ala81Pro in ParC and Arg157Gly in GyrA have not been reported previously; the exact influence of these mutations should be investigated further.     

巨大子宫内膜息肉自行脱落一例报告并文献复习

回顾分析1例黄体期子宫内膜巨大息肉(4 cm×2 cm×1 cm)自行剥脱临床资料,并对国内外子宫内膜息肉的相关文献进行归纳总结。子宫内膜息肉发病率高,但直径大于4 cm的子宫内膜息肉临床少见。绝大多数患者无临床症状,直径小于1 cm的子宫内膜息肉多为功能性息肉,有月经期自行剥脱的可能。子宫内膜息肉病因及发病机制不明确,其形成可能与雌孕激素受体失调、感染、炎症、氧化应激、细胞因子表达异常、细胞增殖与凋亡失衡有关。宫腔镜检查及宫腔镜下息肉切除术是目前治疗子宫内膜息肉最简单、有效的方法,临床上直径小于0.7 cm的息肉可期待治疗,药物治疗(雌孕激素或孕激素)及左炔诺孕酮宫内缓释系统(LNG-IUS)多用于宫腔镜术后复发的预防。     

Emergence of ceftriaxone-resistant Salmonella isolates and rapid spread of plasmid-encoded CMY-2-like cephalosporinase,Taiwan

Of 384 Salmonella isolates collected from 1997 to 2000 in a university hospital in Taiwan, six ceftriaxone-resistant isolates of Salmonella enterica serovar Typhimurium were found in two patients in 2000. The resistance determinants were on conjugative plasmids that encoded a CMY-2-like cephalosporinase. During the study period, the proportion of CMY-2-like enzyme producers among Escherichia coli increased rapidly from 0.2% in early 1999 to >4.0% in late 2000. Klebsiella pneumoniae isolates producing a CMY-2-like beta-lactamase did not emerge until 2000. The presence of bla(CMY)-containing plasmids with an identical restriction pattern from Salmonella, E. coli, and K. pneumoniae isolates was found, which suggests interspecies spread and horizontal transfer of the resistance determinant. Various nosocomial and community-acquired infections were associated with the CMY-2-like enzyme producers. Our study suggests that the spread of plasmid-mediated CMY-2-like beta-lactamases is an emerging threat to hospitalized patients and the public in Taiwan.