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Background Human granulocytic anaplasmosis (HGA) is a systemic inflammatory response caused by the rickettsial bacterium Anaplasma phagocytophilum. Rhabdomyolysis and acute kidney injury (AKI) are rare complications of HGA. Here, we report a case of HGA concurrent with rhabdomyolysis and AKI in an elderly patient. Case presentation An 84-year old woman with a medical history of hypertension was hospitalised after two days of fever, dizziness, whole body pain, and general weakness. Laboratory investigations showed severe thrombocytopenia, leukopenia, impaired renal function, and elevated cardiac enzyme and myoglobin levels. On the day after admission, peripheral blood smear revealed morula inclusions in neutrophils, a suggestive finding of HGA. Real-time polymerase chain reaction (PCR) results indicated the presence of A. phagocytophilum. Antibiotics were de-escalated to doxycycline monotherapy. After 10 days of antibiotic treatment, laboratory tests showed complete recovery from HGA complicated with rhabdomyolysis and AKI. Conclusions HGA can lead to serious complications in patients with associated risk factors. Therefore, in patients with HGA accompanied by rhabdomyolysis, management with antibiotics and hydration should be initiated immediately, and not delayed until diagnostic confirmation.

BACKGROUND Preanalytical errors cause a decrease in the accuracy of clinical laboratory results. We analyzed preanalytical errors (preAEs) made in the clinical laboratory of a university hospital. METHODS All samples received in a centralized laboratory from January 1, to December 31, 2018, were analyzed retrospectively. The categories of preAEs were improper request, incorrect labeling, improper collection/transport, inadequate sample volume, inappropriate container, hemolysis, and sample clotting. The rates of preAEs in these categories were calculated according to sample type, laboratory subunit, department, sampling place, sampling time, and patient age. RESULTS Of 1,082,014 samples received and analyzed by the laboratory, 6,848 (0.63%) were classified as having preAEs. The most frequent categories of preAE were hemolysis (44.6%), sample clotting (30.8%), and inadequate volume (16.7%). The most frequent preAE category for whole-blood and serum/plasma was clotting and hemolysis, respectively. The most frequent preAE category in the blood bank, clinical chemistry, immunology, and test referral service laboratory subunits was hemolysis, in the hematology subunit it was sample clotting, and in the microbiology and urinalysis subunits it was inadequate sample volume. Surgical departments had a higher rate of preAEs than did non-surgical departments (p < 0.0001). Samples drawn in the sampling room showed the lowest frequencies of preAEs (0.01%). Samples drawn on general wards from 5 pm to 5 am, when duty nurses perform sampling, showed a preAE rate of 2.80%. The rate of preAEs increased with patient age. CONCLUSIONS This analysis of preAEs is the most comprehensive to date. Our findings will promote the provision of high-quality laboratory services to clinicians and their patients.

Babesiosis is a tick-transmitted intraerythrocytic zoonosis. In Korea, the first mortalities were reported in 2005 due to Babesia sp. detection in sheep; herein we report epidemiological and genetic characteristics of a second case of babesiosis. Microscopic analysis of patient blood revealed polymorphic merozoites. To detect Babesia spp., PCR was performed using Babesia specific primers for β-tubulin, 18S rDNA, COB, and COX3 gene fragments. 18S rDNA analysis for Babesia sp., showed 98% homology with ovine Babesia sp. and with Babesia infections in Korea in 2005. Moreover, phylogenetic analysis of 18S rDNA, COB, and COX3 revealed close associations with B. motasi. For identifying the infectious agent, Haemaphysalis longicornis (296) and Haemaphysalis flava (301) were collected around the previous residence of the babesiosis patient. Babesia genes were identified in three H. longicornis: one sample was identified as B. microti and two samples were 98% homologous to B. motasi. Our study is the first direct confirmation of the infectious agent for human babesiosis. This case most likely resulted from tick bites from ticks near the patient house of the babesiosis patient. H. longicornis has been implicated as a vector of B. microti and other Babesia sp. infections.

Background Clinicians need to know timelines of requested laboratory tests to provide effective patient management. We developed a real‐time laboratory progress checking system and measured its effectiveness using appropriate indicators in an emergency room setting. Methods In our original in‐house health information system display, blank spaces, which were generated for test results when tests were ordered, remained empty until the final results reported. We upgraded the laboratory reporting system to show real‐time testing information. The stages included requests for test, label printing, sampling, laboratory receipts, performance of tests, verification of results, and interpretation of results and final report by laboratory physician. To assess the usefulness of the function, we measured the emergency department healthcare workers' satisfaction and compared the number of phone calls about test status before and after implementation. Results After the system upgrade, the healthcare workers' understanding of the testing process increased significantly as follows. More clinicians could estimate the time of final test results through the real‐time testing status information (61.9% and 85.7%, P = .002), and respondents reported that the upgraded system was more convenient than the original system (41.3% and 22.2%, respectively, P = .022). The number of phone calls about the test status decreased after implementation of the upgrade; however, the difference was not statistically significant (before, 0.13% [63 calls/48 637 tests] and after, 0.09% [42/46 666]; P = .066). Conclusions The real‐time display of laboratory testing status increased understanding of testing process among healthcare workers in emergency room, which ultimately may increase the usefulness and efficiency of the laboratory service use.

The purpose of this study was to describe and compare the duration of Staphylococcus aureus bacteremia (SAB) according to methicillin resistance and the primary foci of infection. We also aimed to newly define persistent SAB considering these results. Nonduplicated episodes of SAB in patients aged ≥15 years from 14 hospitals in the Republic of Korea were analyzed between January 2009 and February 2018. The duration of SAB was defined as the number of days from the time of administration of an antibiotic to which the isolate was susceptible after the onset of SAB to the last day of a positive blood culture for S. aureus. SAB durations were described and compared based on methicillin resistance and the primary foci of infection. Cases in the top quartile for the duration of bacteremia in the respective clinical context were classified as newly defined persistent SAB, and its association with in-hospital mortality was evaluated. A total of 1,917 cases were analyzed. The duration of SAB was longer in patients with methicillin-resistant SAB (MRSAB; n = 995) than in patients with methicillin-susceptible SAB (MSSAB; n = 922) (median duration, 1 day [interquartile range, 1 to 3 days] for MSSAB and 1 day [interquartile range, 0 to 5 days] for MRSAB; P

Purpose Neutrophil gelatinase-associated lipocalin (NGAL) is a useful biomarker for early diagnosis of acute kidney injury (AKI). However, the diagnostic value of NGAL for predicting AKI in sepsis patients is unclear. Methods MEDLINE, EMBASE, and Cochrane Library databases were searched to identify research publications. Results Twelve studies from 9 countries including a total of 1582 patients, of whom 315 (19.9%) developed AKI, were included in the study; plasma NGAL levels were significantly higher in adult sepsis patients with AKI than in those without AKI (mean difference, 274.65; 95% confidence interval [CI], 106.16-443.15; I 2 = 94%). Urine NGAL levels were not significantly different. The diagnostic odds ratio of plasma NGAL for predicting AKI in sepsis patients was 6.64 (95% CI, 3.80-11.58). The diagnostic accuracy of plasma NGAL was 0.881 (95% CI, 0.819-0.923) for sensitivity, 0.474 (95% CI, 0.367-0.582) for specificity, 0.216 (95% CI, 0.177-0.261) for positive predictive value and 0.965 (95% CI, 0.945-0.977) for negative predictive value. Conclusion Plasma NGAL has a high sensitivity and a high negative predictive value for detection of AKI in adult sepsis patients. However, its low specificity and low positive predictive value could limit its clinical utility. The usefulness of urine NGAL was not revealed in this study.

Summary Background Burkholderia cepacia is intrinsically resistant to certain antiseptics. The authors noted a sudden increase in the frequency of isolation of B. cepacia from blood cultures in a neonatal intensive care unit (NICU) of a university-affiliated hospital. Aim To identify the source and intervene in the ongoing infections. Methods The cases were defined as patients with positive blood cultures for B. cepacia in an NICU between November 2014 and January 2015. Medical records were reviewed and NICU healthcare workers were interviewed. Samples of suspected antiseptics, blood culture bottles, cotton balls, gauze and a needle used in the NICU were analysed microbiologically. Findings During the outbreak period, B. cepacia was identified in 25 blood cultures obtained from 21 patients. The clinical features of the patients were suggestive of pseudobacteraemia. Regarding environmental samples, B. cepacia was cultured from 0.5% chlorhexidine gluconate (CHG) solution products that had been used as a skin antiseptic during blood drawing in the NICU. The clinical B. cepacia isolate and two strains obtained from 0.5% CHG exhibited identical pulsed-field gel electrophoresis patterns. After the CHG products were withdrawn, the outbreak was resolved. Conclusions The pseudobacteraemia cases were caused by contaminated 0.5% CHG produced by a single manufacturer. Stricter government regulation is needed to prevent contamination of disinfectants during manufacturing. In addition, microbial contamination of antiseptics and disinfectants should be suspected when a B. cepacia outbreak occurs in hospitalized patients.

Morganella morganii is a facultative gram-negative and anaerobic rod. It may be a cause of devastating infections in neonates and immunocompromised hosts. Some bacterial infections such as Clostridium and Vibrio are associated with hemolysis. However, massive hemolysis caused by M. morganii sepsis has not yet been reported. We observed a 59-yr-old man who had chemotherapy-induced neutropenia and was found to have massive hemolysis and metabolic acidosis due to sepsis. He died 6 hr after admission in spite of aggressive treatment. Two sets of blood cultures revealed the growth of M. morganii. We report here that M. morganii sepsis can cause fatal massive hemolysis leading to death.

Introduction. Genetic testing services for disease prediction, drug responses, and traits are commercially available by several companies in Korea. However, there has been no evaluation study for the accuracy and usefulness of these services. We aimed to compare two genetic testing services popular in Korea with 23andMe service in the United States.Materials and Methods. We compared the results of two persons (one man and one woman) serviced by Hellogene Platinum (Theragen Bio Institute), DNAGPS Optimus (DNAlink), and 23andMe service.Results. Among 3 services, there were differences in the estimation of relative risks for the same disease. For lung cancer, the range of relative risk was from 0.9 to 2.09. These differences were thought to be due to the differences of applied single nucleotide polymorphisms (SNPs) in each service for the calculation of risk. Also, the algorithm and population database would have influence on the estimation of relative disease risks. The concordance rate of SNP calls between DNAGPS Optimus and 23andMe services was 100% (30/30).Conclusions. Our study showed differences in disease risk estimations among three services, although they gave good concordance rate for SNP calls. We realized that the genetic services need further evaluation and standardization, especially in disease risk estimation algorithm.

The optimal dose of the oral anticoagulant warfarin varies with polymorphisms of the vitamin K epoxide reductase complex subunit 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) genes. A fast and reliable method of warfarin dose adjustment is required to prevent serious hemorrhagic or thrombotic complications. The aim of this study is to develop and validate a new warfarin dose genotyping system with an automatic interpretation function.Four VKORC1 and two CYP2C9 SNPs were genotyped by real-time PCR using allele-specific primers and probes. Multiple reactions that included internal positive controls were performed in each well, and an automatic interpretative algorithm was developed. This system was validated using 82 clinical specimens previously genotyped by PCR-direct sequencing. The analytical time of the method was calculated.No interference was observed when multiple samples were included in each reaction, with all internal positive control reactions being successful. In the genotyping algorithm, Ct differences2 and ≥2 identified heterozygotes and homozygotes, respectively. All results obtained were concordant with those of the reference method. The overall analytical time for assay of 12 specimens was around 3 hours.This rapid, accurate, and user-friendly genotyping system improves the efficacy and safety of anticoagulation therapy in clinical practice.

Bacterial infection of biliary tract may cause severe inflammatory response or sepsis. An immediate bile culture and appropriate antibiotic administration are important to control the biliary tract infection. The objective of the study was to identify organisms in bile and the features of antibiotic susceptibility in patients with biliary tract infection.We retrospectively reviewed the clinical records of 212 patients whose bile had been cultured for variable biliary tract diseases at Inje University Ilsan Paik Hospital from Jan. 2000 to Feb. 2007. Bile samples were obtained from percutaneous transhepatic biliary drainage (PTBD, n=89), percutaneous transhepatic gallbladder drainage (PTGBD, n=14) or endoscopic naso-biliary drainage (ENBD, n=49).The overall positive rate of bile culture was 71.7% (152 cases). The organisms cultured were Escherichia coli (25.0%), Enterococcus spp. (13.4%), Klebsiella spp. (11.1%), Pseudomonas spp. (11.1%), and coagulase-negative Staphylococcus (9.7%) in decreasing order. Effective antibiotics for Gram-negative organisms were amoxicillin/clavulanic acid, amikacin, imipenem, and piperacillin/tazobactam in order of effectiveness. Of the cultured blood samples from 160 patients, fifty (31.2%) showed positive bacterial growth. The organisms isolated from blood were similar to those found in the bile.A broad spectrum penicillin/beta-lactamase inhibitor is a recommendable antimicrobial for empirical treatment for biliary tract infection. However, Gram-positive bacteria such as Enterococcus spp. or methicillin-resistant Staphylococcus aureus are emerging as causative microorganisms. If these organisms are isolated, antimicrobial drugs should be replaced by narrower-spectrum antimicrobials.

We report 45 pediatric cases of Yersinia pseudotuberculosis infection confirmed by stool culture between May 1993 and June 1994. In 41 (91.1%) cases there had been contact with untreated well or mountain water. Y. pseudotuberculosis was also isolated from 4 samples of mountain spring water thought to be the sources of infection. During the course of the illness, acute renal failure (ARF) developed in 6 patients (13.6%). The age distribution of the ARF group (12.3 +/- 1.2 years) was significantly different from the non-ARF group (8.0 +/- 3.2 years). The serogroups of Y. pseudotuberculosis isolates from stool samples were 5 (n = 30) and 4 (n = 15). Isolates from the water samples were all serogroup 5. The main symptoms of both groups were fever, rash, abdominal pain, and vomiting. ARF developed between the 2nd and 14th days (mean 6 days) after the onset of fever, and oliguria (< 400 ml/m2 per day) developed in 3 patients (3/6, 50%) immediately after their fevers had subsided. ARF underwent a benign course, with complete recovery within a maximum of 4 weeks (mean 10.2 days), with 1 exceptional patient requiring hemodialysis. Renal biopsy showed evidence of tubulointerstitial nephritis. Y. pseudotuberculosis should be included as one of the causes of acute interstitial nephritis causing ARF in children, especially when the children have histories of drinking untreated water in endemic areas.