Case: The patient was a 19-year-old male. The patient presented anaphylaxis after the administration of phosphomycin. Adrenaline (1 mg) was intravenously administered to treat his anaphylaxis. Immediately after the injection of adrenaline, the patient lost pulse and the monitor showed ventricular tachycardia (VT). Spontaneous circulation returned 21 minutes after the onset of VF. Outcome: We did not observe arrhythmia on the patient’s monitor during the course of his hospitalization. The cause of this pulseless VT was determined to be an iatrogenic overdose of adrenaline. After 13 days, he was discharged without hypoxic encephalopathy. Conclusion: Safety measures to prevent the incorrect administration of adrenaline are required as soon as possible. First, medical practitioners need to attend study meetings to address their lack of knowledge in relation to the usage of adrenaline. Second, most emergency carts have adrenaline products (1 mg/ml) for CPA, not for anaphylaxis. An epinephrine autoinjector (EpiPen®) for anaphylaxis should be put into emergency carts.

Introduction: Inflammation and coagulation are closely interrelated processes in the pathogenesis of sepsis. This study aimed to determine whether intravenous immunoglobulin (IVIg) could improve the hyperinflammatory state and coagulation/fibrinolysis abnormalities in patients with sepsis.Methods: Forty-one patients with sepsis were included. Nineteen patients were treated with IVIg (IVIg group; 5.0 g daily for 3 days within 2 days after hospitalization), and 22 patients were not (non-IVIg group). Inflammatory and coagulation/fibrinolysis molecular markers, Japanese Association for Acute Medicine disseminated intravascular coagulation score, and the Sequential Organ Failure Assessment score were evaluated in each group.Results: On admission, patients in the IVIg group had a significantly more severe condition. In the IVIg group, after treatment, C-reactive protein, procalcitonin, and interleukin-6 levels significantly decreased relative to values on admission. Also, compared with admission, the various coagulation/fibrinolysis molecular markers decreased after treatment. Moreover, the Japanese Association for Acute Medicine disseminated intravascular coagulation score and the Sequential Organ Failure Assessment score also significantly decreased after treatment. In contrast, in the non-IVIg group, only interleukin-6 level and thrombin-antithrombin complex levels significantly decreased. The 28-day mortality rate of the IVIg group was approximately one third of the value of the non-IVIg group (IVIg: 5.3% vs non-IVIg: 18.2%).Conclusions: Intravenous immunoglobulin treatment significantly improved hemostatic abnormalities along with the hyperinflammatory state in patients with sepsis. Accordingly, IVIg treatment should be classified as an adjunctive therapy for patients complicated with sepsis-induced coagulopathy. (C) 2015 Elsevier Inc. All rights reserved.

Introduction: There are few investigations regarding the relationships between procalcitonin (PCT) and the acute kidney injury (AKI) in the diagnosis of sepsis. The purpose of this study was to clarify the diagnostic accuracy of the use of PCT levels in patients with or without AKI.Methods: This study was conducted as a single-center retrospective study. We enrolled 393 patients in whom PCT were measured on admission. We grouped the patients into non-AKI and AKI, and those with AKI were classified according to the RIFLE criteria (Risk, Injury, Failure). The patients in each group were further classified into the sepsis and the non-sepsis group. We subsequently investigated the diagnostic accuracy of the PCT for detecting sepsis in these groups.Results: The levels of PCT were significantly higher in the sepsis group than in the non-sepsis group among the non-AKI and each AKI patients (p<0.0001). The diagnostic accuracy of the POT for detecting sepsis was determined according to a ROC analysis; AUC value was 0.958 in the non-AKI group, in the Risk, Injury and Failure groups were 0.888 and 0.917, 0.857, respectively. AUC value for non-AKI group was significantly different from that of Failure group (p<0.05).Conclusions: In Failure AKI patients, the diagnostic accuracy of the PCT level is significantly lower than non-AKI patients. It is therefore suggested that we should be careful in using per value to diagnose sepsis in patients with Failure under RIFLE criteria. (C) 2014, Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

症例は43歳の女性。30歳時に神経性食思不振症と診断され，精神科への入退院を繰り返していた。今回，自宅にて意識レベルが低下したため，救急車で近医へ搬送された。脱水と低栄養状態であり，低血圧，低血糖に対して高カロリー輸液による水分栄養補給が開始された。しかし，多臓器不全を呈したため，第13病日に当センターへ転院となった。臨床経過から，本患者は慢性の半飢餓状態の代謝に適合しており，低リン血症を補正しないまま糖負荷を行ったことによるrefeeding syndromeと診断した。血清リン濃度（IP）0.5mg/dlと著明な低リン血症を呈していたため，直ちにリンの補充を行い，輸液は低カロリーから開始した。低リン血症改善後，ショックから離脱し多臓器不全も改善傾向を示した。しかし，第27病日に敗血症性ショックを合併し呼吸不全の増悪から，第60病日に死亡退院となった。近年，救急・集中治療の領域においても栄養管理の重要性が認識されているものの，依然としてrefeeding syndromeの存在は広く認知されているとは言い難い。神経性食思不振症患者の栄養管理に際しては，refeeding syndromeを念頭に置き，微量元素を含めた低カロリーから開始する栄養補給により臓器不全を回避しなければならない。

Vancomycin has been the drug of choice for the treatment of serious methicillin-resistant Staphylococcus aureus (MRSA) infections for over 5 decades. It demonstrates slower bactericidal activity in comparison to the results seen with antistaphylococcal beta-lactams against S. aureus (1). Moise et al. showed that 30-day mortality was related to the in vitro bactericidal activity of vancomycin (3). This study sought to determine whether the in vitro bactericidal activity of vancomycin, as well as other MRSA strain-specific characteristics, such as a polymorphism at accessory gene regulator (agr) locus (4, 5) and vancomycin MIC (2, 7), impacts the mortality associated with MRSA bacteremia. A total of 129 consecutive MRSA blood isolates recovered from patients with MRSA bacteremia admitted to the First Department of Internal Medicine (52 beds) and Emergency Medical Care Center (32 beds), Fukuoka University Hospital, from 1991 through 2004 were identified. This study focused on 66 isolates recovered from the 66 patients initially treated with glycopeptides (vancomycin [n = 42 patients] or teicoplanin [n = 24 patients]) after the onset of bacteremia. Bactericidal assays were performed over 72 h as reported by Sakoulas et al., using a concentration of 16 μg/ml against MRSA at an initial inoculum of approximately 108 CFU/ml (6). The clinical data were extracted from patients' medical records, and mortality that occurred within 30 days after the onset of bacteremia was examined. The in vitro bactericidal activity of vancomycin showed high heterogeneity among the isolates, with reduction in viable bacteria at 72 h ranging from 2.5 log10 to 7.2 log10 CFU/ml. The median (interquartile range) bactericidal activity was 4.4 (3.8 to 5.4) log10 CFU/ml. Overall, 26 (39.4%) of the 66 patients died during the first 30 days after the onset of MRSA bacteremia. There was no difference in the 30-day mortality between the patients treated with vancomycin and those treated with teicoplanin (42.9% versus 33.3%, P = 0.45). Univariate analysis indicated a statistically significant relationship between mortality and the in vitro bactericidal activity of vancomycin (P = 0.017), renal failure indicated by the necessity for dialysis (P = 0.025), the Acute Physiological and Chronic Health Evaluation II (APACHE II) score (P = 0.007), and the presence of shock (P = 0.005), while agr group (P = 0.36), agr function (P = 0.07), and vancomycin MIC (P = 0.13) were not significant. Multivariate logistic regression analysis with forward stepping on mortality using independent variables, with a P value of <0.2 in the univariate analysis, showed that decreased in vitro bactericidal activity of vancomycin (odds ratio [OR], 2.04; P = 0.021), APACHE II score (OR, 1.16; P = 0.018), and the presence of shock (OR, 6.56; P = 0.025) were predictors of mortality. In addition, a Hill-type mathematical model (Fig. ​(Fig.1)1) identified a very close relationship between vancomycin bactericidal activity and mortality in patients with MRSA bacteremia (R2 = 0.983), with a 3.8-log reduction in bacteria necessary to achieve a 50% probability of survival. FIG. 1. Vancomycin pharmacodynamics showing the relationship between the probability of survival and bactericidal activity, which was fit to a Hill-type mathematical model (R2 = 0.983). The probability of survival based on the 30-day mortality data for ... Although previous studies have examined the relationship of vancomycin killing activity and treatment failure (3, 6), this current study is the first to demonstrate a relationship with attenuated vancomycin bacterial killing and an increased probability of mortality in the multivariate analysis. In addition, the attenuated vancomycin bactericidal activity was more frequently observed in isolates from endovascular sources than in other sources (P = 0.043). This result demonstrates that reduced vancomycin killing in vitro could therefore be a surrogate marker of high-risk sources of bacteremia. Although performing vancomycin bactericidal assays over 72 h may be too labor-intensive to successfully implement in clinical microbiological analyses, this study highlights the potential problems associated with suboptimal vancomycin killing. These findings suggest that the evaluation of this characteristic may therefore be useful through other phenotypic markers of tolerance, such as those measured by minimal bactericidal concentration (MBC)/MIC and serum bactericidal assays, when considering antimicrobial therapies that can be used as alternatives to either vancomycin or teicoplanin for the treatment of MRSA bacteremia.

症例は84歳の女性。認知症と脳梗塞後遺症のリハビリテーションのため入院加療中であった。食事は常に全量摂取で，嘔吐や嚥下困難は認められなかった。食後1時間後より突然の呼吸困難と吸気性喘鳴が出現し，胸部X線検査にて上縦隔の拡大を認めた。4日前に転倒による胸部打撲があることから縦隔血腫が疑われ，加療目的で当センターへ転院となった。入院時，頻脈と不整脈，頻呼吸，吸気性喘鳴，頸静脈怒張を認めた。胸腹部CT検査では，食道の異常拡張と大量の内容物貯留を認め，食道アカラシアと診断した。食道の異常拡張による気管圧排に起因した気道閉塞と判断し，気管挿管を実施したところ，心室細動が生じ胸骨圧迫を実施した。約1分後に自己心拍は再開し，気道圧迫解除目的で緊急上部消化管内視鏡検査を行った。食道から約600gの食物残渣を吸引し，その後不整脈は消失しショック状態から離脱した。以後，全身状態は安定し，2週間後に前医へ転送した。食道アカラシアは，心停止を来しうる疾患であることを認識し，的確な診断と迅速な対応を心掛けなければならない。

Methicillin-resistant Staphylococcus aureus (MRSA) infections have been the most common cause of nosocomial infections in Japan, but their genetic characteristics related to bloodstream infections have not been well studied. The aim of this study was to investigate a comprehensive molecular characterization of MRSA blood isolates during the historical 18-year study period between 1987 and 2004 in a tertiary care university hospital. A total of 137 MRSA isolates recovered from the blood of inpatients at Fukuoka University Hospital were analyzed. Clinical information and antimicrobial susceptibility profiles were reviewed, and staphylococcal chromosomal cassette mec (SCCmec), accessory gene regulator (agr), and a battery of bacterial genes were tested by PCR-based assays. The relatedness of these isolates was determined by the repetitive sequence-based PCR (rep-PCR) and pulsed-field gel electrophoresis (PFGE). Although low numbers of agr type III/SCCmec type IV isolates circulated between 1987 and 1992, agr type II/SCCmec type II isolates started circulating in 1993 and were responsible for the increased MRSA isolates until 2004. The rep-PCR and PFGE identified 104 epidemic and 33 sporadic isolates. Among the 104 epidemic isolates, six major rep-PCR/PFGE types were identified, which occupied 67.3% of epidemic isolates. The SCCmec type II and agr type II isolates were observed in significantly higher proportion in epidemic isolates than in sporadic isolates (P=0.0318, P=0.0123, respectively). In contrast, SCCmec type IV strains were observed in significantly higher proportion in sporadic isolates than in epidemic isolates (P=0.0494). Although isolates with sec were detected in higher rates in epidemic isolates (P=0.0397), seh was detected in higher rates in sporadic isolates (P=0.0350). Multivariate logistic regression analysis with forward stepping revealed that SCCmec type II was independently associated with epidemic isolates (P=0.0067; odds ratio, 1.75; 95% confidence interval, 1.17–2.64). These data indicated that SCCmec type II MRSA isolates were responsible for the increased MRSA bloodstream infections for inpatients during the 18-year study period in the hospital.