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Immunomodulators (tocilizumab/baricitinib) improve outcomes of coronavirus disease 2019 (COVID-19) patients, but the synergistic effect of remdesivir is unknown. The effect of combination therapy with remdesivir, immunomodulators, and standard treatment in COVID-19 patients was investigated. This retrospective, single-center study included COVID-19 patients who were treated with tocilizumab or baricitinib. The severity of respiratory status in the two groups on Days 14 and 28 and the duration to respiratory recovery in both groups were compared, and the effect of remdesivir use on respiratory status was examined in a multivariate analysis. Ninety-eight patients received tocilizumab or baricitinib; among them, 72 used remdesivir (remdesivir group) and 26 did not (control group). The remdesivir group achieved faster respiratory recovery than the control group (median 11 vs. 21 days, p = 0.033), faster weaning from supplemental oxygen (hazard ratio [HR]: 2.54, 95% confidence interval [CI]: 1.14-5.66, p = 0.021). Age, body mass index, diabetes mellitus, and time from onset to oxygen administration were independent prognostic factors. The remdesivir group achieved better severity level at Days 14 and 28 (p = 0.033 and 0.003, respectively) and greater improvement from baseline severity (p = 0.047 and 0.018, respectively). Remdesivir combination therapy did not prolong survival (HR: 0.31, 95% CI: 0.04-2.16, p = 0.23). Among severely ill COVID-19 patients who received immunomodulator, remdesivir contributed to a shorter respiratory recovery time and better respiratory status at Days 14 and 28. Concomitant remdesivir with immunomodulators and standard treatment may provide additional benefit in improving respiratory status of COVID-19 patients.

The clinical importance of Mycobacterium abscessus species (MABS) infections has been increasing. However, the standard treatment regimens recommended in the current guidelines often result in unfavorable outcomes.

Background Mycobacterium abscessus subsp. massiliense (MMA) comprises a group of non-tuberculous, rapidly growing mycobacteria. Although MMA can cause pulmonary diseases, surgical site infections, and disseminated diseases, aortic endograft infection has not been reported. Here, we describe the first case of aortic endograft infection caused by MMA. Case presentation Two months after stent-graft insertion for an abdominal aortic aneurysm, an 85-year-old man was admitted with fever and abdominal pain and was diagnosed with aortic endograft infection. Despite 14 days of meropenem and vancomycin intravenous administration, periaortic fluid pooling increased as compared to that before antibiotic administration. The abscess was drained, and fluorescent acid-fast staining of the abscess fluid revealed bacilli. The organism was identified as MMA by genetic testing. Intravenous imipenem–cilastatin (IPM/CS), amikacin (AMK), and oral clarithromycin (CAM) were administered. After 2 months, oral CAM and sitafloxacin were administered because the abscess had decreased in size. However, after 6 weeks, the abscess increased in size again. Antimicrobial susceptibility testing of the drainage fluid from the abscess resulted in the isolation of an MMA strain that had acquired resistance to CAM. Intravenous IPM/CS, AMK, and oral linezolid were added to the treatment regimen along with oral CAM and STFX. However, he was not fully cured and died 6 months later. Neither the full-length erythromycin ribosome methyltransferase (erm)(41) gene nor the rrl or rpIV gene mutations were found by Sanger sequencing in the pre- and post-treatment strains. Whole-genome sequence analysis of the post-treatment strain revealed mutations in genes with no previous reports of association with macrolide resistance. Conclusions Aortic endograft infection caused by MMA strain is extremely rare; nonetheless, MMA should be suspected as the causative microorganism when broad-spectrum antimicrobials are ineffective.

Immunoglobulin G4-related disease (IgG4-RD) can affect various organs, including the cardiovascular system. In this study, we described the case of a 72-year-old man with periaortitis both in the ascending and terminal aorta related to IgG4-RD. He presented with swelling in the left leg. Computed tomography (CT) showed increased wall thickness of the ascending aorta and retroperitoneal fibrosis, which, in turn, caused deep vein thrombosis. Using positron emission tomography-computed tomography, the patient was diagnosed with IgG4-RD in the aorta. Although it was difficult to distinguish intramural hematoma (IMH) from IgG4-related periaortitis, treatment with steroids has dramatically improved his periaortitis. IgG4-related periaortitis should be differentiated from IMH due to their similar morphologies.

Background The impact of the outbreak of COVID-19 on the work of respiratory physicians in Japan has not yet been evaluated. The study investigates the impact of the outbreak on respiratory physicians’ work over time and identifies problems to be addressed in the future. Methods We conducted a web-based survey of respiratory physicians in 848 institutions. The survey comprised 32 questions and four sections: Survey 1 (April 20, 2020), Survey 2 (May 27, 2020), Survey 3 (August 31, 2020), and Survey 4 (December 4, 2020). Results The mean survey response rate was 24.9%, and 502 facilities (59.2%) participated in at least one survey. The proportion of facilities that could perform PCR tests for diagnosis and more than 20 tests per day gradually increased. The percentage capable of managing extracorporeal membrane oxygenation (ECMO) or more than five ventilators did not increase over time. The proportion that reported work overload of 150% or more, stress associated with lack of personal protective equipment (PPE), and harassment or stigma in the surrounding community did not sufficiently improve. Conclusion While there was an improvement in expanding the examination system and medical cooperation in the community, there was no indication of enhancement of the critical care management system. The overwork of respiratory physicians, lack of PPE, and harassment and stigma related to COVID-19 did not sufficiently improve and need to be addressed urgently.

Mycobacteriosis is mainly caused by two groups of species: Mycobacterium tuberculosis and non-tuberculosis mycobacteria (NTM). The pathogens cause not only respiratory infections, but also general diseases. The common problem in these pathogens as of today is drug resistance. Tuberculosis (TB) is a major public health concern. A major challenge in the treatment of TB is anti-mycobacterial drug resistance (AMR), including multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. Recently, the success rate of the treatment of drug-resistant tuberculosis (DR-TB) has improved significantly with the introduction of new and repurposed drugs, especially in industrialized countries such as Japan. However, long-term treatment and the adverse events associated with the treatment of DR-TB are still problematic. To solve these problems, optimal treatment regimens designed/tailor-made for each patient are necessary, regardless of the location in the world. In contrast to TB, NTM infections are environmentally oriented. Mycobacterium avium-intracellulare complex (MAC) and Mycobacterium abscessus species (MABS) are the major causes of NTM infections in Japan. These bacteria are naturally resistant to a wide variation of antimicrobial agents. Macrolides, represented by clarithromycin (CLR) and amikacin (AMK), show relatively good correlation with treatment success. However, the efficacies of potential drugs for the treatment of macrolide-resistant MAC and MABS are currently under evaluation. Thus, it is particularly difficult to construct an effective treatment regimen for macrolide-resistant MAC and MABS. AMR in NTM infections are rather serious in Japan, even when compared with challenges associated with DR-TB. Given the AMR problems in TB and NTM, the appropriate use of drugs based on accurate drug susceptibility testing and the development of new compounds/regimens that are strongly bactericidal in a short-time course will be highly expected.

We provide the details of the successful management of a patient with active Cushing’s disease complicated with coronavirus disease 2019 (COVID-19) pneumonia. The patient was a 27-year-old Japanese female healthcare worker who was scheduled to undergo pituitary surgery for Cushing’s disease. She had been in close contact with an undiagnosed patient infected with COVID-19 and then developed COVID-19 pneumonia. Despite a lack of known risk factors associated with severe COVID-19 infection, the patient’s dyspnea worsened and her respiratory condition deteriorated, as indicated by the need for 7 L/min oxygen supply by mask to maintain her oxygen saturation at >90%. Medical treatment was initiated to control hypercortisolism by the ‘block and replace’ regimen using steroidogenesis inhibitors and hydrocortisone. The COVID-19 pneumonia improved with multi-modal treatment including antiviral therapy. One month later, after a negative severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) test result and with appropriate protection against virus transmission to medical staff in the operating room and daily medical care nurses, trans-sphenoidal surgery was performed by our highly experienced pituitary surgeon. One month after the surgery, the patient’s basal ACTH and cortisol levels and urinary free cortisol were all under the detection limit. Surgical remission was expected. Since hypercortisolism due to active Cushing’s disease may worsen a COVID-19 infection, multi-disciplinary management that includes appropriate and prompt treatment strategies is mandatory in such cases.

Background: Although immunomodulators (tocilizumab or baricitinib) have been shown to improve outcomes in patients with coronavirus disease (COVID-19), the additive effect of remdesivir is unknown. We retrospectively tested the effect of remdesivir in combination with immunomodulators and standard treatments in COVID-19 patients.Methods: A retrospective, single-center study was conducted on patients with COVID-19 admitted to the Hokkaido University Hospital between April 2020 and September 2021, who were treated with either tocilizumab or baricitinib. The duration to achievement of oxygen-free in both groups was compared, and the effect of remdesivir use on respiratory status was examined through multivariate analysis. The severity of respiratory status in the two groups on day 14 and day 28 was compared. A sensitivity analysis using propensity score was also performed.Results: We enrolled 98 patients who received either tocilizumab or baricitinib. Of these, 72 patients used remdesivir (remdesivir group) and 26 did not (control group). Most cases were severe and treated with concomitant steroids. The remdesivir group had faster recovery of respiratory status compared to the control group (11 days vs. 26 days, P=0.033). Multivariate analysis showed that remdesivir use contributed to shorter time to being oxygen-free (hazard ratio [HR] = 2.33, 95 % confidence interval [CI] 1.17 – 4.46, P=0.016). Age, body mass index, diabetes mellitus, and time from onset to oxygen administration were independent prognostic factors. The remdesivir group achieved higher rate of oxygen free than the control group at days 14 and 28 after treatment (P=0.033, P=0.003, respectively). The degree of improvement from baseline severity was also higher in the remdesivir group (day 14; P=0.047, day 28; P=0.018). The survival time between two groups was not significantly different (HR = 0.55, 95 %CI 0.10 – 2.99, P=0.49). Similarly, the propensity score-matched patient groups showed the efficacy of remdesivir. Conclusions: Among patients with COVID-19 who used immunomodulator containing tocilizumab or baricitiib, remdesivir contributed to shorter respiratory recovery time and better respiratory status at days 14 and 28. Concomitant use of remdesivir may contribute to improved respiratory status in patients on immunomodulator and standard treatment.

We present three cases with an atypical clinical course of organizing pneumonia (OP) secondary to coronavirus disease 2019 (COVID-19). Three patients were discharged with satisfactory improvement after standard steroid therapy for COVID-19. Shortly after the completion of treatment, the patients experienced a flare-up of symptoms. Imaging results showed new lesions in the lungs. Transbronchial lung cryobiopsy showed histological findings consistent with OP in all cases. Steroids were administered, and a good therapeutic response was observed. This report is the first to describe pathologically confirmed OP that developed after recovery from COVID-19. Careful follow-up is advisable for patients who have recovered from COVID-19.

Comparisons of distal bypass outcomes between hemodialysis-dependent (HD) and renal transplant (RT) patients have been reported, but the influences of immunosuppressive therapy on the outcomes remain unclear because of the limited number of RT patients who underwent distal bypass or cohort heterogenicity. We compared outcomes of distal bypass for chronic limb-threatening ischemia (CLTI) with homogenous ischemic limb pathology.Between January 2014 and December 2019, we performed 334 infrapopliteal bypass procedures using vein grafts for 275 consecutive CLTI patients with tissue loss. Among them, there were 130 HD patients (47.3%) (163 limbs) and 11 RT patients (4%) (15 limbs), and 30-day mortality, 5-year primary and secondary patency (PP and SP), limb salvage (LS), amputation-free survival rates, and wound healing (WH) status were compared between the HD and RT patient groups.Nine HD patients died within 30 days after surgery (7%), whereas no deaths were observed among the RT patients. Five-year PP and SP rates in the RT group 39% and 41%, which were significantly worse compared to 64% and 82% in the HD group (P 0.01). Unsuccessful rate of revision surgery including hemodynamically failed grafts after revision reached over 80% in the RT group, which was technically unfeasible pathology for graft salvage (vs. 3% in the HD group), and WH, and LS rates were significantly worse in the RT group.In comparison with HD patients, RT patients showed a lower LS rate for CLTI. The lower LS rate was associated with a lower SP rate, which was caused by disease progression of distal arteries in the foot.

Background Although the biological agents tocilizumab and baricitinib have been shown to improve the outcomes of patients with COVID-19, a comparative evaluation has not been performed. The aim of our study was to evaluate the comparative effect of the use of tocilizumab and baricitinib on patient outcomes in COVID-19. Methods A retrospective, single-center study was conducted using the data of patients with COVID-19 admitted to Hokkaido University hospital between April 2020 and September 2021 and were treated with tocilizumab or baricitinib. The clinical characteristics of the patients who received each drug were compared. Univariate and multivariate logistic regression analyses were performed against the outcomes of all-cause mortality and the improvement in respiratory status. The development of secondary infection events was analyzed using the Kaplan–Meier method and the log-rank test. Results Among the 459 patients hospitalized with COVID-19 during the study, 64 received tocilizumab and 34 received baricitinib, and they were included in the study. Most patients were treated with concomitant steroids, and the severity of the disease at the time of initiation of biological agents was similar. The use of tocilizumab or baricitinib was not associated with all-cause mortality or the improvement in respiratory status within 28 days of drug administration. Age, chronic renal disease, and comorbid respiratory disease were independent prognostic factors for all-cause mortality, whereas anti-viral drug use and severity of COVID-19 at baseline were associated with the improvement in respiratory status. There was no significant difference in the infection-free survival rate between patients treated with tocilizumab and those with baricitinib. Conclusion There were no differences in efficacy and safety between tocilizumab and baricitinib in the treatment of COVID-19. Both these biological agents are expected to be equally safe and clinically effective.

ObjectiveMycobacterium tuberculosis(Mtb) H37Ra strain has been reported to rapidly enter the viable but non-culturable (VBNC) state following treatment with an NADH oxidase inhibitor (diphenyleneiodonium [DPI]) and to be reactivated by fetal bovine serum (FBS). However, the mechanism underlying FBS-induced reactivation is unclear. We tried to reveal the mechanism of FBS-induced reactivation usingM. tuberculosisH37Rv.MethodsFirst, we evaluated the effect of DPI on culturability, viability and changes of acid-fastness toward H37Rv. Secondly, we measured the reactivation-promoting effects of human serum albumin, egg-white albumin and antioxidative agents in DPI-induced VBNC cells. We also inhibited adenylyl cyclase and protein kinase which is the downstream of adenylyl cyclase to evaluate the influence to reactivation capacity of bovine serum albumin (BSA).ResultsDPI treatment induced VBNC state in H37Rv, resulting in a high proportion of viable cells but a low proportion of culturable cells, loss of acid-fastness and lipid-accumulation. Not only FBS but also BSA alone could reactivate H37Rv. Contrary to our expectation, only human serum albumin had a similar restorative effect to BSA. The inhibition of adenylyl cyclase by SQ22536 did not have a significant effect on reactivation; however, the inhibition of mycobacterial protein kinase by H89 and staurosporine strongly suppressed the BSA-induced reactivation.ConclusionDPI-induced VBNC Mtb cells may be reactivated via the activation of protein kinase-dependent cell division processes through interaction with BSA.

We prospectively compared the efficacy of PCR detection of SARS-CoV-2 between paired nasopharyngeal and saliva samples in nine COVID-19 patients. SARS-CoV-2 was detected in saliva in 8 of 9 (89%) patients and in all 11 samples taken within 2 weeks after disease onset. Viral load was equivalent at earlier time points but declined in saliva than nasopharyngeal samples. PCR negativity was also concordant in all 27 saliva samples from 24 patients between nasopharyngeal and saliva samples. These results suggest that saliva is a reliable noninvasive alternative to nasopharyngeal swabs and facilitate widespread PCR testing in the face of shortages of swabs and protective equipment without posing a risk to healthcare workers.

This study aimed to identify effective treatments against rapidly growing mycobacteria (RGM) infections by investigating the minimum inhibitory concentrations (MIC) of 24 antimicrobial agents and their molecular mechanisms of resistance. In total, 509 clinical RGM isolates were identified by analyzing the sequences of three housekeeping genes (hsp65, rpoB, and sodA), and their susceptibilities to 24 antimicrobial agents were tested. We also performed sequencing analysis of antimicrobial resistance genes (rrl, rrs, gyrA, and gyrB). To identify Mycobacteroides abscessus group subspecies, we performed PCR-based typing and determined the sequevar of erm(41). We identified 15 RGM species, most of which were susceptible to amikacin and linezolid. Among these species, arbekacin and sitafloxacin had the lowest MIC among the same class of antimicrobials. The MIC of rifabutin for M. abscessus subsp. abscessus (MAB) was lower than that for M. abscessus subsp. massiliense (MMA). The proportion of MAB isolates with MIC ≤ 2 mg/L for rifabutin was significantly higher than that of MMA [MAB: 50/178 (28.1%) vs. MMA: 23/130 (17.7%); p = 0.041]. In summary, our study revealed the antimicrobial susceptibility profile of 15 RGM species isolated in Japan and indicated that arbekacin, sitafloxacin, and rifabutin may be possible therapeutic options for RGM infections.

Mitocryptides are a novel family of endogenous neutrophil-activating peptides originating from various mitochondrial proteins. Mitocryptide-2 (MCT-2) is one of such neutrophil-activating peptides, and is produced as an N-formylated pentadecapeptide from mitochondrial cytochrome b. Although MCT-2 is a specific endogenous ligand for formyl peptide receptor 2 (FPR2), the chemical structure within MCT-2 that is responsible for FPR2 activation is still obscure. Here, we demonstrate that the N-terminal heptapeptide structure of MCT-2 with an N-formyl group is the minimum structure that specifically activates FPR2. Moreover, the receptor molecule for MCT-2 is suggested to be shifted from FPR2 to its homolog formyl peptide receptor 1 (FPR1) by the physiological cleavages of its C-terminus. Indeed, N-terminal derivatives of MCT-2 with seven amino acid residues or longer caused an increase of intracellular free Ca2+ concentration in HEK-293 cells expressing FPR2, but not in those expressing FPR1. Those MCT-2 derivatives also induced β-hexosaminidase secretion in neutrophilic/granulocytic differentiated HL-60 cells via FPR2 activation. In contrast, MCT-2(1–4), an N-terminal tetrapeptide of MCT-2, specifically activated FPR1 to promote those functions. Moreover, MCT-2 was degraded in serum to produce MCT-2(1–4) over time. These findings suggest that MCT-2 is a novel critical factor that not only initiates innate immunity via the specific activation of FPR2, but also promotes delayed responses by the activation of FPR1, which may include resolution and tissue regeneration. The present results also strongly support the necessity of considering the exact chemical structures of activating factors for the investigation of innate immune responses.

Infectious diseases caused by nontuberculous mycobacteria (NTM) are increasingly becoming a major global problem. Additionally, Mycobacteroides abscessus subsp. abscessus (MAB) infections are refractory to macrolides. This study was conducted to investigate the epidemiology of rapidly growing mycobacteria (RGM) species isolated from clinical specimens in Japan and assess differences in the regional distribution of lower respiratory specimens (LRS)- and non-lower respiratory specimens (NLRS)-derived species. 532 strains (427 LRS, 92 NLRS and 15 unknown specimens) were isolated in nine areas of Japan. We collected 418 specimens from Bio Medical Laboratories (BML), Inc., and 114 specimens from 45 hospitals in Japan. Their epidemiological differences were examined according to the specimen type, region, and climate. Fifteen species were identified. The proportion of M. abscessus group (MAG) strains was significantly lower in NLRS than in LRS (35.9% vs. 68.4%). The proportion of MAG strains was higher in northern Japan than in other regions (83.7% vs. 60.5%). Variations in strain abundance among RGM species was evident in regions with a mean annual temperature below 15 °C. We conclude that the proportions of MAG strains differed between NLRS and LRS in Japan. In addition, the mean annual temperature likely influenced the distribution of RGM species.

Japanese manufacturing companies have been expanding their production networks in Southeast Asia. Especially since the AEC was launched in 2015, they have been building supply chains in the ASEAN region, and their local production in those countries is increasing year by year. For Japanese SMEs in particular, aggressive overseas development of trade and investment have been progressing because such an approach could be one of the measures against market contraction in Japan due to population decline. That is also a growth strategy via development of sales channels to overseas markets where demand is set to increase. In “The Spatial Economy”, Paul Krugman argues that lower transportation costs as a result of reductions in custom duties will enable Japanese manufacturers to engage in geographically multi-polar development in their overseas business development. We outline that analysis assuming RCEP to be a very hopeful framework to expand economic welfare in the Asia Pacific.

Background Mycolicibacterium fortuitum is a species of the rapidly growing mycobacteria that can cause pulmonary infection. It is susceptible to multiple antibiotics both in vitro and in clinical practice, so that any combination of susceptible drugs is effective. However, we encountered a case of infection due to fluoroquinolone-resistant M. fortuitum. In this study, we report the case and describe the mechanism of resistance. Case presentation A 65-year-old man with a history of total gastrectomy and immunosuppressant treatment for rheumatoid arthritis developed a recurrence of pulmonary infection caused by M. fortuitum. He was treated with clarithromycin and levofloxacin as a first-line treatment, based on the favorable susceptibility at that time. After recurrence, a high minimum inhibitory concentration to fluoroquinolones was detected. DNA sequencing of the pathogen showed the substitution of serine for tryptophan at residue 83 in the gyrA gene. He was successfully treated with a combination of other antibiotics. Conclusion This is the first report on the treatment of fluoroquinolone-resistant M. fortuitum and investigation of the mechanism of resistance. We suggest that the susceptibility test remains effective for determining the next line of treatment after a pathogen has acquired resistance, and resistance to fluoroquinolones in M. fortuitum can be attributed to a single change of amino acid.

The darknet monitoring system consists of network sensors widely deployed on the Internet to capture incoming unsolicited packets. A goal of this system is to analyse captured malicious packets and provide effective information to protect regular nonmalicious Internet users from malicious activities. To provide effective and reliable information, the location of sensors must be concealed. However, attackers launch localisation attacks to detect sensors in order to evade them. If the actual location of sensors is revealed, it is almost impossible to identify the latest tactics used by attackers. Thus, in a previous study, we proposed a packet sampling method, which samples incoming packets based on an attribute of the packet sender, to increase tolerance to a localisation attack and maintain the quality of information publicised by the system. We were successful in countering localisation attacks, which generate spikes on the publicised graph to detect a sensor. However, in some cases, with the previously proposed sampling method, spikes were clearly evident on the graph. Therefore, in this paper, we propose advanced sampling methods such that incoming packets are sampled based on multiple attributes of the packet sender. We present our improved methods and show promising evaluation results obtained via a simulation.

A 51-year-old man with severe comorbidities required redo revascularization due to left chronic limb-threatening ischemia caused by a previous vein graft occlusion. The saphenous veins were not available due to previous surgeries. Femoro-posterior tibial artery bypass surgery was successfully performed using the basilic-cephalic loop vein under peripheral nerve blockades. This anesthesia allowed a series of surgical revascularizations without general anesthesia, and the postoperative courses were uneventful. The patient survived for 4 years with ambulatory status. In conclusion, loop graft can be an alternative single vein material for distal bypass when no saphenous veins are available.

Delayed cardiac tamponade (DCT) can be a fatal complication after cardiac surgery, but its early diagnosis and/or prediction is sometimes difficult. This study aimed to confirm the efficacy of postoperative computed tomography (CT) as routine examination compared with transthoracic echocardiography (TTE) for predicting DCT after cardiac surgery. This study was a retrospective single-center analysis of 485 consecutive patients undergoing cardiac surgery from January 2016 to July 2018 in our department. Among them, 237 patients were enrolled in this analysis after application of the exclusion criteria: minimally invasive surgery via small thoracotomy, death in the acute phase, and no CT 7 ± 3 days after surgery. Pericardial effusion (PE) was measured at the thickest part using CT and TTE. DCT was found in nine enrolled patients (3.8%). The mean PE on CT was 7.7 ± 5.5 mm in the no event group and 23.4 ± 5.7 mm in the DCT group (p = 0.026), whereas the mean PE on TTE was 6.2 ± 4.5 mm in the no event group and 10.8 ± 4.4 mm in the DCT group (p = 0.170). On multivariate analysis, PE greater than 20 mm on CT (Odds ratio, 13.93; 95% confidence interval 2.57–75.46; p = 0.002) was a significant predictor of DCT. The present study suggested that postoperative CT examination is superior to TTE for predicting DCT. If PE is less than 20 mm on CT, it could be treated conservatively; otherwise, preventive/therapeutic intervention should be considered.

Background Gemella bergeri is one of the nine species of the genus Gemella and is relatively difficult to identify. We herein describe the first case of septic shock due to a Gemella bergeri coinfection with Eikenella corrodens. Case presentation A 44-year-old Asian man with a medical history of IgG4-related ophthalmic disease who was prescribed corticosteroids (prednisolone) presented to our hospital with dyspnea. On arrival, he was in shock, and a purpuric eruption was noted on both legs. Contrast enhanced computed tomography showed fluid retention at the right maxillary sinus, left lung ground glass opacity, and bilateral lung irregular opacities without cavitation. Owing to suspected septic shock, fluid resuscitation and a high dose of vasopressors were started. In addition, meropenem, clindamycin, and vancomycin were administered. Repeat computed tomography confirmed left internal jugular and vertebral vein thrombosis. Following this, the patient was diagnosed with Lemierre’s syndrome. Furthermore, he went into shock again on day 6 of hospitalization. Additional soft tissue infections were suspected; therefore, bilateral below the knee amputations were performed for source control. Cultures of the exudates from skin lesions and histopathological samples did not identify any pathogens, and histopathological findings showed arterial thrombosis; therefore it was concluded that the second time shock was associated with purpura fulminans. Following this, his general status improved. He was transferred to another hospital for rehabilitation. The blood culture isolates were identified as Gemella bergeri and Eikenella corrodens. Gemella bergeri was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry and confirmed by 16S rRNA gene sequencing later. The primary focus of the infection was thought to be in the right maxillary sinus, because the resolution of the fluid retention was confirmed by repeat computed tomography. Conclusions Gemella bergeri can be the causative pathogen of septic shock. If this pathogen cannot be identified manually or through commercial phenotypic methods, 16S rRNA gene sequencing should be considered.