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Shunichi Koide,1 Yoshiro Hadano,2,3 Shinji Mizuochi,4 Hitoshi Koga,1 Hisashi Yamashita1 1Department of Emergency Medicine, St. Mary’s Hospital, Kurume, Japan; 2Department of Infection Control and Prevention, Tokyo Medical and Dental University Medical Hospital, Tokyo, Japan; 3Biostatistics Center, Kurume University School of Medicine, Kurume, Japan; 4Department of Pathology, Kurume University School of Medicine, Kurume, JapanCorrespondence: Shunichi KoideDepartment of Emergency Medicine, St. Mary’s Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka 830-8543, JapanTel +81-942-35-3322Fax +81-942-34-3115Email aquarium0131@gmail.comBackground: Pneumonitis and pneumonia after non-fatal drowning are common and the pathogens involved are numerous. However, invasive aspergillosis after non-fatal drowning in immunocompetent individuals is relatively rare. Here, we report a case of invasive aspergillosis complicated by pulmonary embolism after non-fatal drowning that proved fatal.Case Presentation: A 75-year-old Japanese man accidentally fell into a creek and was brought to a local hospital. His oxygenation steadily deteriorated to the point that he required intubation and mechanical ventilation. He was then transferred to the emergency department at our hospital. On arrival, he had severe respiratory dysfunction with diminished breath sounds. Radiography of the chest and computed tomography of the lungs showed diffuse bilateral infiltrates. The diagnosis was acute respiratory distress syndrome caused by aspiration pneumonitis as a result of non-fatal drowning and septic shock. Despite intensive care, the patient’s hypoxia continued to worsen and he died on day 7. Computed tomography scans obtained at autopsy showed that both lungs were extensively infiltrated with effusion. An embolus was also detected in the right pulmonary artery. Microscopic analysis revealed diffuse filamentous fungi throughout the lungs, heart, stomach, thyroid gland, and the pulmonary embolus, which were identified as Aspergillus fumigatus by culture.Conclusion: Invasive aspergillosis should also be considered in immunocompetent patients with severe respiratory failure after non-fatal drowning who do not respond to broad-spectrum antibiotics. Angioinvasive aspergillosis can even result in fatal pulmonary embolism; hence, early targeted testing for Aspergillus species and empiric intravenous voriconazole should be considered in such cases.Keywords: drowning, aspergillosis, pulmonary embolism, immunocompetent, acute respiratory distress syndrome

Yoshiro Hadano, Michinori Shirano, Tetsushi Goto Center for Infectious Diseases, Osaka City General Hospital, Osaka, Japan Abstract: We analyzed the travel-related health problems in persons returning to Japan from overseas. Data were extracted retrospectively for all patients visiting the infectious diseases department of Osaka City General Hospital, Osaka, Japan, between July 2012 and September 2013. There were 209 sick returning travelers during the period of the study. The median age of the subjects was 34.3 years, and the subjects consisted of 133 tourists (63.6%), 39 business travelers (18.7%), 17 expatriates (8.1%), 14 volunteer workers (6.7%), and four persons who visited friends and relatives (1.9%). The most visited destinations were Asia (n=162, 77.5%), including East Asia (n=26, 12.4%), Southeast Asia (n=116, 55.5%), South Asia (n=25, 12.0%), Central Asia (n=3, 1.4%), and Africa (n=30, 14.3%). The most commonly diagnosed diseases were gastrointestinal tract infection (n=81, 38.8%), dengue fever (n=26, 12.4%), and animal bites (n=26, 12.4%). Twenty-nine patients (13.8%) were hospitalized, mainly for dengue fever and gastrointestinal tract infection. Keywords: travel medicine, travel-related health problems, Japan

Yoshiro Hadano,1 Taro Shimizu,2 Shimon Takada,3 Toshiya Inoue,4 Sumire Sorano51Department of General Internal Medicine and Infectious Diseases, Rakuwakai Otowa Hospital, Yamashina-ku, Kyoto, Japan; 2Rollins School of Public Health, Emory University, Atlanta, GA, USA; 3Department of General Internal Medicine, Osaka City General Hospital, Miyakojima-ku, Osaka, Japan; 4Department of Emergency Medicine, Urasoe General Hospital, Urasoe-city, Okinawa, Japan; 5Kobe University School of Medicine, Kusunokicho, Chuoku, Kobe, JapanAbstract: Purple urine bag syndrome is characterized by the urinary drainage bag turning purple in patients on prolonged urinary catheterization, especially those in the bedridden state. It is associated with bacterial urinary tract infections caused by indigo-producing and indirubin-producing bacteria, usually affects women, and is associated with alkaline urine, constipation, and a high bacterial load in the urine. Almost all patients with purple urine bag syndrome are catheterized due to significant disability, and the urinary pH is 7.0 or more. In general, intensive treatment with antibiotics is not recommended. Purple urine bag syndrome per se almost always appears to be asymptomatic and harmless. However, caution is needed, because some cases have been reported to show progression to severe disease states, so further research into the morbidity and mortality of this infection is warranted.Keywords: purple urine, urinary catheterization, geriatrics, urinary tract infection

Yoshiro Hadano,1 Kenta Ito,1 Jun Suzuki,1 Ichiro Kawamura,1 Hanako Kurai,1 Kiyofumi Ohkusu21Division of Infectious Diseases, Shizuoka Cancer Center, Shizuoka; 2Department of Microbiology, Graduate Medical School of Medicine, Gifu University, Gifu, JapanAbstract: Moraxella osloensis is a rare causative organism of infections in humans, with most cases reported in cancer patients. We report the case of a 67-year-old Japanese man with advanced cancer of the pancreatic head and multiple liver metastases who developed fever with chills. Blood culture was found to be positive for Gram-negative bacilli that were aerobic, oxidase-positive, and catalase-positive. M. osloensis was identified by 16 rRNA gene sequencing. Prompt control of the infection was achieved by treatment with cefepime for 14 days, without the need for removal of the central venous catheter.Keywords: Moraxella osloensis, central venous catheter, infection, cancer