Search

Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is the leading cause of bacteremia and meningitis in neonates; however, it also causes meningitis in adults, although much less frequently. After the detection of penicillin-non-susceptible GBS (PRGBS) for the first time in 2008 by Japanese researchers, clinical PRGBS isolates have been reported worldwide. These isolates need to be given due attention for being non-susceptible to multiple drugs. Herein, we present the first clinical report of meningitis caused by PRGBS. A 41-year-old Japanese male receiving an immunosuppressant visited hospital complaining of fever. Although he did not have meningitis-related symptoms or physical findings, determination of the cause of fever by Gram-staining of the spinal fluid revealed gram-positive cocci in pairs and chains. Initially, he was hospitalized on the diagnosis of cerebral meningitis caused by Streptococcus pneumoniae. However, culture of the spinal fluid revealed the β-hemolytic colonies on blood agar. Biochemical testing and mass spectrometry revealed the isolated organism as GBS (serotype Ib). The minimum inhibitory concentration (MIC) of penicillin G for the isolated strain was 0.5 μg/mL, which is greater than the MIC criteria for “susceptibility” to penicillin G for beta-hemolytic streptococci according to Clinical and Laboratory Standards Institute standards. The isolated strain was also resistant to macrolide (MIC ≥ 8 μg/mL) and fluoroquinolone (MIC ≥ 8 μg/mL). The patient recovered without neurologic sequelae upon treatment with ceftriaxone, vancomycin, and corticosteroids for 4 days, and subsequently with ampicillin for 17 days. The rate of isolation of PRGBS in the clinics has gradually increased, particularly in Japan. Although PRGBS isolated in the present case was susceptible to ampicillin and cephalosporins, strains not susceptible to ampicillin, cefotaxime, and ceftriaxone have already been isolated, indicating the prospects for limited range of effective antibiotics against PRGBS infections, including meningitis, in the near future.

Hypervirulent Klebsiella pneumoniae (HV-KP) typically causes pyogenic liver abscess and bacteremia with metastatic infections. Community-acquired pneumonia (CAP) due to HV-KP is uncommon and details of its clinical and microbiological features are limited. We report the first case of CAP due to capsular genotype K2-ST86 HV-KP in Okinawa, Japan and review infections caused by the K2-ST86 strain. A 79-year-old woman presenting with fever and productive cough persisting for the past three days was admitted to hospital. Her vital signs indicated septic shock. Lung examination by auscultation revealed holo-crackle and lobar pneumonia in chest radiography, and Streptococcus pneumoniae was suspected. However, sputum and blood cultures revealed Gram-negative coccus identified as K. pneumoniae. Genetic analysis identified the isolated strain as the K2 serotype harboring rmpA, iutA, entB, and mrkD. Therefore, we identified the isolated strain as hypervirulent. The isolate belonged to ST86 as determined by multilocus sequence typing. The case was not complicated by predisposing factors such as diabetes mellitus and malignancy related to HV-KP infection; thus, this CAP-causing HV-KP strain may differ from the typical HV-KP strain that induces liver abscess. A literature review identified only nine cases with CAP due to HV-KP. In all cases, the disease mainly occurred in older males with diabetes mellitus, which makes the present case unusual, and had high rates of septic shock and death. No case, including ours, was complicated by metastatic infection, suggesting that CAP due to HV-KP poses little distant metastasis risk, even in patients with bloodstream infection. In our review, consistent with our case, K2-ST86 was the most common strain of HV-KP in patients with CAP. Therefore, studies are needed to elucidate the clinical and microbiological features of HV-KP CAP, with a focus on the K2-ST86 strain. Physicians should always consider K. pneumoniae in cases of sepsis CAP with lobar pneumonia.

Hypervirulent Klebsiella pneumoniae (HV-KP) is typically associated with community-acquired liver abscess and bacteremia with metastatic infection; however, primary lung abscess (PLA) caused by HV-KP is rare, with only one such case report to date. A 69-year-old man with a history of diabetes mellitus (DM) was admitted to hospital complaining of slight bloody sputum. Chest imaging showed multiple consolidations with cavities in both lung fields. A culture of bronchoalveolar lavage fluid confirmed the presence of K. pneumoniae. Genetic analyses identified the isolate as serotype K2 and sequence type 375 (K2-ST375), and that it harbored the rmpA gene. The patient was an Asian middle-aged male with DM, all of which are risk factors for HV-KP infection. Although complicating DM and the presence of the rmpA gene are more likely to induce disseminated infection, metastatic infections were not found in this patient. The clinical and microbiological characteristics of our patient were different from those of a previous reported case, although in both cases the patient was from Asia and had DM. Therefore, DM appears to be one of the predisposing factors for HV-KP lung abscesses and physicians should pay attention to emerging HV-KP lung abscess infection, particularly in Asian countries. Previous studies have also revealed that K2-ST375 is one of the major clones causing HV-KP infection, and that it is mainly isolated from patients with liver abscess. Interestingly, including the present case, most of the infectious cases caused by K2-ST375 have been reported from Okinawa Prefecture in Japan. Therefore, the trend of the K2-ST375 strain should be carefully monitored, particularly in Okinawa, Japan. The serotype of HV-KP that causes PLA is still unknown and further study is needed to elucidate the etiology of PLA due to HV-KP and the relationship between the strain K2-ST375 and PLA.

Jun Hirai, Takeshi Kinjo, Shusaku Haranaga, Jiro Fujita Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, JapanCorrespondence: Jun Hirai Email j.eichi419@gmail.comAbstract: Streptococcus agalactiae, also known as Group B Streptococcus (GBS), is the leading cause of bacteremia and meningitis in neonates; however, it also causes meningitis in adults, although much less frequently. After the detection of penicillin-non-susceptible GBS (PRGBS) for the first time in 2008 by Japanese researchers, clinical PRGBS isolates have been reported worldwide. These isolates need to be given due attention for being non-susceptible to multiple drugs. Herein, we present the first clinical report of meningitis caused by PRGBS. A 41-year-old Japanese male receiving an immunosuppressant visited hospital complaining of fever. Although he did not have meningitis-related symptoms or physical findings, determination of the cause of fever by Gram-staining of the spinal fluid revealed gram-positive cocci in pairs and chains. Initially, he was hospitalized on the diagnosis of cerebral meningitis caused by Streptococcus pneumoniae. However, culture of the spinal fluid revealed the β-hemolytic colonies on blood agar. Biochemical testing and mass spectrometry revealed the isolated organism as GBS (serotype Ib). The minimum inhibitory concentration (MIC) of penicillin G for the isolated strain was 0.5 μg/mL, which is greater than the MIC criteria for “susceptibility” to penicillin G for beta-hemolytic streptococci according to Clinical and Laboratory Standards Institute standards. The isolated strain was also resistant to macrolide (MIC ≥ 8 μg/mL) and fluoroquinolone (MIC ≥ 8 μg/mL). The patient recovered without neurologic sequelae upon treatment with ceftriaxone, vancomycin, and corticosteroids for 4 days, and subsequently with ampicillin for 17 days. The rate of isolation of PRGBS in the clinics has gradually increased, particularly in Japan. Although PRGBS isolated in the present case was susceptible to ampicillin and cephalosporins, strains not susceptible to ampicillin, cefotaxime, and ceftriaxone have already been isolated, indicating the prospects for limited range of effective antibiotics against PRGBS infections, including meningitis, in the near future.Keywords: adult, meningitis, Streptococcus agalactiae, PRGBS, serotype Ib, corticosteroids

Jun Hirai,1,2 Daisuke Sakanashi,3 Masashi Momose,1 Tomomi Koga,4 Takeshi Kinjo,2 Shusaku Haranaga,5 Eiji Motonaga,6 Jiro Fujita2 1Department of Internal Medicine, Okinawa Miyako Hospital, Okinawa 906-0012, Japan; 2Department of Infectious, Respiratory and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa 903-0215, Japan; 3Department of Infection Control and Prevention, Aichi Medical University Hospital, Aichi 480-1195, Japan; 4Department of Radiology, Graduate School of Medicine, University of the Ryukyus, Okinawa 903-0215, Japan; 5Comprehensive Health Professions Education Center, University of the Ryukyus Hospital, Okinawa 903-0215, Japan; 6Department of General Medicine, Okinawa Miyako Hospital, Okinawa 906-0012, JapanCorrespondence: Jun Hirai Email j.eichi419@gmail.comAbstract: Hypervirulent Klebsiella pneumoniae (HV-KP) is typically associated with community-acquired liver abscess and bacteremia with metastatic infection; however, primary lung abscess (PLA) caused by HV-KP is rare, with only one such case report to date. A 69-year-old man with a history of diabetes mellitus (DM) was admitted to hospital complaining of slight bloody sputum. Chest imaging showed multiple consolidations with cavities in both lung fields. A culture of bronchoalveolar lavage fluid confirmed the presence of K. pneumoniae. Genetic analyses identified the isolate as serotype K2 and sequence type 375 (K2-ST375), and that it harbored the rmpA gene. The patient was an Asian middle-aged male with DM, all of which are risk factors for HV-KP infection. Although complicating DM and the presence of the rmpA gene are more likely to induce disseminated infection, metastatic infections were not found in this patient. The clinical and microbiological characteristics of our patient were different from those of a previous reported case, although in both cases the patient was from Asia and had DM. Therefore, DM appears to be one of the predisposing factors for HV-KP lung abscesses and physicians should pay attention to emerging HV-KP lung abscess infection, particularly in Asian countries. Previous studies have also revealed that K2-ST375 is one of the major clones causing HV-KP infection, and that it is mainly isolated from patients with liver abscess. Interestingly, including the present case, most of the infectious cases caused by K2-ST375 have been reported from Okinawa Prefecture in Japan. Therefore, the trend of the K2-ST375 strain should be carefully monitored, particularly in Okinawa, Japan. The serotype of HV-KP that causes PLA is still unknown and further study is needed to elucidate the etiology of PLA due to HV-KP and the relationship between the strain K2-ST375 and PLA.Keywords: hypervirulent Klebsiella pneumoniae, primary lung abscess, serotype K2, sequence type 375, Okinawa, Japan

Example weeks from dataset 1 and dataset 2 post-alignment. Sample weeks shown here are to serve as a visual representation of the method outlined to evaluate age distribution. Dataset 1 (left) and dataset 2 (right) were combined and aligned following the selection of “epidemic weeks”. A week in which influenza A or B cases accounted for more than 90 % of all positive influenza cases was defined as an epidemic week. In the year 2007, you see an example of a defined influenza A epidemic week, whereas the year 2011 is a representative influenza B epidemic week. The week from 2013 displays a typical week which was removed from our age distribution analysis because neither influenza A nor B was dominant (>90 %). (PPTX 66 kb)

Example weeks from dataset 1 and dataset 2 post-alignment. Sample weeks shown here are to serve as a visual representation of the method outlined to evaluate age distribution. Dataset 1 (left) and dataset 2 (right) were combined and aligned following the selection of “epidemic weeks”. A week in which influenza A or B cases accounted for more than 90 % of all positive influenza cases was defined as an epidemic week. In the year 2007, you see an example of a defined influenza A epidemic week, whereas the year 2011 is a representative influenza B epidemic week. The week from 2013 displays a typical week which was removed from our age distribution analysis because neither influenza A nor B was dominant (>90 %). (PPTX 66 kb)