Search

Background: Student-run free clinics provide an opportunity to shape medical student practices with and attitudes towards the medically underserved. Previous literature has shown mixed results on how student attitudes change over the course of medical education. The purpose of this mixed-method study is to determine the effect that participation in a student-run free clinic has on medical student attitudes towards the underserved as compared to attitudes of non-participating students. Methods: The validated Medical Attitudes Towards the Underserved (MSATU) survey was administered in cross-sectional study to student participants in a student-run free clinic and to non-participating medical students (n = 122). Additionally, first and fourth year participant students were interviewed via semi-structured interviews about results. Results: There was no statistically significant difference in overall MSATU scores between participant and non-participant medical students using Mann Whitney tests. In sub-score analyses, Mann Whitney tests demonstrated significantly higher scores among participants in the total services score (U = 1344.0, df = 115, p = 0.013) and the expensive procedures services sub-score (U = 1401.0, df = 115, p = 0.019). Interviews revealed that positive attitudes towards the underserved are not specific to student-run free clinic participants. Participants did not describe changes in their attitude from clinic participation, believing all medical students had a baseline positive attitude towards the underserved. They did, however, highlight that witnessing the reality of these patients influenced their perspective and future practice. Conclusions: There were limited significant differences in MSATU survey scores between participant and non-participant students. Interview results suggest that the survey tool was unable to capture changes in the perspectives of participant medical students or the changes in their projected practices but that, participation in a student-run free clinic had an overall positive effect on understanding of the barriers to care and empathy towards the underserved.

BackgroundInfection is the most common predisposing factor for diabetic ketoacidosis (DKA); however, studies are rare that have investigated the clinical outcomes of septic patients with infection-precipitated DKA.MethodsA retrospective cohort study was conducted at a tertiary hospital from 2004 to 2013. Patients with DKA in whom the presence of a predisposing infection was confirmed were enrolled. Characteristics at initial presentation, primary infection sources, and causative microorganisms were compared between the nonacute kidney injury (non-AKI) group and acute kidney injury (AKI) group at each stage. Risk factors for the development of failure-stage AKI and its outcomes were also analyzed.ResultsOne hundred and sixty DKA episodes were assessed. The most common infection sites were the urinary and respiratory tracts. The leading causative microorganism was Escherichia coli, followed by Klebsiella pneumoniae. A complicated/severe infection state [odds ratio (OR), 15.27; p

BackgroundThe Mycobacterium abscessus complex is a common cause of pulmonary nontuberculous mycobacteria infections in Taiwan. We examined the risk factors associated with treatment outcome in Taiwanese adults with pulmonary disease caused by the M. abscessus complex.MethodsWe retrospectively reviewed the records of all patients from a southern Taiwan medical center from 2006 to 2012 who had respiratory specimens identified as M. abscessus complex and met the American Thoracic Society criteria for pulmonary disease.ResultsOf the 106 included patients, females (58.5%) and nonsmokers (79.2%) predominated. The mean age of patients was 64.8 years. Sixty-three patients (59.4%) had pre-existing lung disease. Previous mycobacterial pulmonary disease (34.9%) was the most common underlying disorder. Chest radiography indicated that bronchiectasis was common (47.2%) and that cavitations were less common (14.2%). Fifty-six patients received antibiotic treatment. Clinicians were more likely to prescribe antibiotics if the initial sputum acid-fast staining was positive (p 1 year. Previous mycobacterial pulmonary disease (p = 0.011) and cavitary lesion (p = 0.034) are risk factors for persistence of M. abscessus complex.ConclusionWith antimicrobial therapy, previous mycobacterial disease, and cavitary lesion are associated with microbiologic failure in Taiwanese adults with M. abscessus complex pulmonary disease.

Background/Purpose Stenotrophomonas maltophilia has been recognized as an important nosocomial pathogen, but few reports have discussed S. maltophilia infection in the community settings. This study aimed to reveal characteristics of patients with community-onset S. maltophilia bloodstream infection (SMBSI), to specify the subgroup of healthcare-associated (HCA) infection in the community-onset group and to compare them with hospital-acquired (HA) SMBSI patients. Materials and methods Medical charts of adult patients with SMBSI presenting to a medical center in southern Taiwan from May 2008 to October 2011 were reviewed and analyzed retrospectively. Results Among 153 patients, we observed a high percentage (38.6%) of SMBSI to be community onset. Among community-onset SMBSI, 45.8% were community-acquired (CA) and 54.2% were HCA. The crude mortality rates were 11.1%, 18.8%, and 60.6% in the CA, HCA, and HA groups, respectively. Structural/mechanical abnormalities were observed in 32.7% of all cases, and 60% of those were related to malignancy. Independent risk factors for mortality in community-onset SMBSI were liver cirrhosis, liver metastasis, and a high Pitt bacteremia score, whereas structural/mechanical abnormalities and a high Pitt bacteremia score related to increased mortality in HA SMBSI. Conclusion Community-onset S. maltophilia infection deserves attention. Patients with community-onset SMBSI have reduced disease severity and lower mortality rate when compared to HA SMBSI. Underlying structural/mechanical abnormalities, especially those caused by malignancies, are common in SMBSI cases and should be investigated when bacteremia occurs.

Background/Purpose(s) In 2008, the Dengue NS1 Ag STRIP (Bio-Rad Laboratories, Marnes-la-Coquette, France) was introduced to routine dengue diagnostics in Taiwan, in addition to real-time reverse-transcription polymerase chain reaction (PCR), virus isolation, and capture immunoglobulin (Ig)M/IgG enzyme-linked immunosorbent assay (ELISA). This study aimed to evaluate the benefit of this assay and factors influencing the results of these diagnostic tests. Methods Retrospectively, the authors enrolled laboratory-confirmed adult dengue patients from July 2008 to January 2012 in a tertiary hospital. The sensitivities of each test alone and in combination were analyzed by the duration of illness (early stage: day 0-day 3 and late stage: day 4-day 8). The factors influencing sensitivity of the Dengue NS1 Ag STRIP were examined. Results There were 392 patients enrolled. The overall sensitivity of the Dengue NS1 Ag STRIP was 68.37% and PCR was 71.94%. With the assistance of the Dengue NS1 Ag STRIP, a diagnosis was made in 10.97% of patients without the need for second convalescent samples, and 4.34% more cases were detected. Independent factors for reduced Dengue NS1 Ag STRIP sensitivity were dengue virus (DENV) IgG seropositivity and a sample taken after the fifth day of illness. At the early stage, the PCR and the Dengue NS1 Ag STRIP combination had the highest sensitivity rate than other combinations. At the late stage, a combination of the Dengue NS1 Ag STRIP and capture IgM/IgG ELISA had better sensitivity rates. PCR and capture IgM/IgG ELISA in combination had sensitivity above 90% through the course of illness. Conclusion Dengue NS1 Ag STRIP is a useful tool for early dengue diagnosis. Its use can increase the diagnostic sensitivity and decrease the need of convalescent samples. Seeking treatment late (days postonset > 4) and DENV IgG seropositivity independently decrease the sensitivity of the Dengue NS1 Ag STRIP.

We investigated the impacts of introducing an expedited acid-fast bacilli (AFB) smear laboratory procedure and an automatic, real-time laboratory notification system by short message with mobile phones on delays in prompt isolation of patients with pulmonary tuberculosis (TB).We analyzed the data for all patients with active pulmonary tuberculosis at a hospital in Kaohsiung, Taiwan, a 1,600-bed medical center, during baseline (January 2004 to February 2005) and intervention (July 2005 to August 2006) phases.A total of 96 and 127 patients with AFB-positive TB was reported during the baseline and intervention phases, respectively. There were significant decreases in health care system delays (ie, laboratory delays: reception of sputum to reporting, P.001; response delays: reporting to patient isolation, P = .045; and interval from admission to patient isolation, P.001) during the intervention phase. Significantly fewer nurses were exposed to each patient with active pulmonary TB during the intervention phase (P = .039).Implementation of expedited AFB smear laboratory procedures and an automatic, real-time laboratory mobile notification system significantly decreased delays in the diagnosis and isolation of patients with active TB.

Extensively drug-resistant Acinetobacter baumannii (XDRAb) emerges as an important pathogen of health care–associated infections and outbreaks worldwide. During January and February 2006, there was a hospital-wide outbreak of XDRAb at a medical center in Taiwan. Without limiting the usage of carbapenems or the closure of any ward, this outbreak was effectively controlled. We investigated the molecular epidemiology and reported the infection control experiences. XDRAb is defined as A baumannii that is resistant to multiple antibiotics but susceptible to tigecycline and polymyxin B. During the outbreak, the clinical and environmental XDRAb isolates were collected and studied by antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and polymerase chain reaction for Verona integron-encoded metallo-beta-lactamases, imipenemases, and oxacillinases (OXA). Our measures to control the outbreak included private room isolation of patients until there were three successive negative cultures, reinforcement of contact precautions, daily environmental cleansing with room-dedicated cleaning tools and sodium hypochlorite, and careful auditing of adherence. During the outbreak, 32 clinical XDRAb isolates came from 13 patients who were hospitalized in four intensive care units and three wards. Most (7 of 13, 53.8%) cases were associated with a surgical intensive care unit. The results from pulsed-field gel electrophoresis study indicated that all isolates were of one genotype. All 32 isolates harbored IS Aba 1- bla OxA-51-like and bla OxA-72 genes. After this outbreak till August 2010, further incidences of XDRAb were sporadic cases of XDRAb with different clones and did not reach the level of outbreak. To our knowledge, this is the first reported hospital-wide outbreak caused by OXA-72 carbapenemase–producing A baumannii in the Asia-Pacific region, with successful and sustained control. Although the source or vehicle of the outbreak was not identified, our results suggest that a hospital-wide outbreak can be successfully managed with strict infection control measures, and that the limitation of the use of carbapenems and closure of wards may not be necessary.

BACKGROUND: Bacterial contamination of platelet (PLT) products is one of the most serious complications of transfusion. Culturing PLT components may detect the presence of bacteria, thus reducing the risk of a septic result after transfusion. Streptococcus bovis has previously been reported as a contaminating microorganism in PLT products. Here we report an asymptomatic donor diagnosed with occult colon malignancy after positive isolation of S. bovis from his apheresis PLTs (APs). We also review previous cases. CASE REPORT: The PLT donor was a 50-year-old man with more than 150 prior plateletpheresis or whole blood donations. Bacterial culture of his AP components yielded two positive results: group D Streptococcus was isolated in July 2008 and S. bovis was reported in April 2010. The donor received further testing, and colonofibroscopic examination revealed colonic neoplasm. Pathologic examination of the biopsied tissue led to a diagnosis of invasive adenocarcinoma. He underwent a left hemicolectomy in July 2010. Examination of the resection specimen confirmed adenocarcinoma, Stage III with regional lymph node metastatic adenocarcinoma. CONCLUSION: Donated AP products positive for S. bovis should not be presumed to be due to contamination during collection. This bacteremia originating from donor factors needs to be carefully evaluated. Colonofibroscopic examination is recommended for these donors to detect colonic malignancy as early as possible.

Extensively drug-resistant Acinetobacter baumannii (XDRAB) is a growing and serious nosocomial infection worldwide, such that developing new agents against it is critical. The antimicrobial activities of the rhizomes from Zingiber officinale, known as ginger, have not been proven in clinical bacterial isolates with extensive drug-resistance. This study aimed to investigate the effects of four known components of ginger, [6]-dehydrogingerdione, [10]-gingerol, [6]-shogaol and [6]-gingerol, against clinical XDRAB. All these compounds showed antibacterial effects against XDRAB. Combined with tetracycline, they showed good resistance modifying effects to modulate tetracycline resistance. Using the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging method, these four ginger compounds demonstrated antioxidant properties, which were inhibited by MnO₂, an oxidant without antibacterial effects. After the antioxidant property was blocked, their antimicrobial effects were abolished significantly. These results indicate that ginger compounds have antioxidant effects that partially contribute to their antimicrobial activity and are candidates for use in the treatment of infections with XDRAB.

Background/Purpose The early diagnosis and appropriate management of spinal tuberculosis (TB) is challenging for clinicians. This study aimed to characterize the clinical features and factors affecting treatment outcomes. Methods A retrospective study of patients with spinal TB over a 7-year period at a medical center in southern Taiwan was conducted. Clinical features, underlying diseases, laboratory results, imaging findings, therapy, treatment duration and outcomes were analyzed. Results Forty-eight patients (24 men and 24 women) were diagnosed with spinal TB. Their mean age was 64.3 years. The most common presenting symptoms were backache, neurological deficits, and fever. The most common vertebral area involved was lumbar spine (41.7%). The mean number of vertebra involved was 2.46. Surgery was carried out on 30 patients (62.5%). Patients who had a longer duration of symptoms prior to diagnosis were more likely to have surgery ( p = 0.03), and patients who received surgery had a more favorable outcome ( p = 0.063). The mean treatment course was 11.4 ± 3.7 months. A long course treatment did not contribute to favorable outcomes. Twenty-six patients had a favorable outcome and 11 had an unfavorable outcome. Factors associated with an unfavorable outcome included older age, limb weakness, incontinence, spinal kyphotic deformity, and spinal cord compression. Conclusion For elderly patients with chronic back pain in Taiwan, the differential diagnosis of spinal TB should be considered. Image studies and computed tomography-guided aspiration are helpful for early detection. Combined surgical intervention tended to have a more favorable outcome and longer treatment periods had no additional benefit.

Water assisted injection molding (WAIM) has gradually become one of the most important polymer processing methods for making hollowed parts. This study examined the morphological development in water assisted injection molded high density polyethylene (HDPE)/polyamide-6 (PA-6) blends. Samples for microscopic observation were prepared by an 80-ton injection-molding machine equipped with a tube cavity and with a water injection unit. A distinct skin layer, core region, and channel layer were observed across the thickness. The shape and size of the dispersed phase depended on the position both across the part thickness and along the flow direction. Small and large particles coexisted in the skin and channel layers, indicating that both coalescence and disintegration of the dispersed phase occurred in these layers. High water pressures were found to mold parts with smaller polyamide particle distributions. Additionally, the morphology of water assisted injection molded parts was compared to that of gas assisted injection molded products. It was found that water molded parts exhibit a smaller polyamide particle distribution than their gas counterparts. Copyright © 2010 John Wiley & Sons, Ltd.

SummaryBackgroundThe major sources of Legionnaires’ disease (LD) are the potable water systems of large buildings including hospitals, nursing homes, and hotels. Culturing the hospital water system for Legionella allows a preventive approach for hospital-acquired LD. However, hospital-acquired LD is rarely reported in Taiwan, and environmental cultures of Legionella in hospital water systems in Taiwan have never been systematically performed.ObjectiveThe objective of this study was to determine if Legionella is present in hospital water systems in Taiwan. Water quality analysis was also performed to determine if geographic differences in water quality result in different Legionella positivity rates.MethodThe water systems of 16 hospitals throughout Taiwan were tested for Legionella by culture. Standardized culture procedures were followed.ResultsLegionella pneumophila was isolated from 63% (10/16) of the hospital water systems; 19% (3/16) of the hospitals had an L. pneumophila positive rate greater than 30%. L. pneumophila serogroups 1 and 6 (strains that are most responsible for Legionella infections) were isolated from 80% (8/10) and 60% (6/10), respectively, of the hospitals that yielded L. pneumophila in their water distribution systems.ConclusionAs was shown in epidemiological studies in the USA and Spain, hospital-acquired legionellosis may be prevalent but underdiagnosed in Taiwan.

Many potential vaccine candidates for serogroup B Neisseria meningitidis (NMB) have been identified by reverse vaccinology, a genome-based approach. However, some candidates may be unseen owing to uncertain annotation or their peculiar properties. In this study, we describe the preparation and identification of a novel lipoprotein expressed in all meningococcal strains tested. mAb were first prepared from mice immunized with a meningococcal B strain isolated in Taiwan. Total proteins from the immunizing strain were separated by 2-DE in duplicate. Clone 4-7-3, which crossreacted to 174 tested meningococcal isolates, was used as the primary antibody for Western blotting. The immunoreactive spot was identified by LC-mass spectrometric analysis of the corresponding spot from the silver-stained gel and confirmed by molecular biology approach to be a novel lipoprotein encoded by the hypothetical NMB1468 gene. The potential use of this protein, designated Ag473/NMB1468, as a vaccine component was evaluated using the recombinant protein produced in Escherichia coli. Immunized mice were found to be protected from developing meningococcal disease after intraperitoneal inoculation with a lethal dose of meningococcal strain Nm22209, suggesting that Ag473/NMB1468 may be a promising vaccine candidate. This study also demonstrates the usefulness of the immunoproteomic approach in identification of novel vaccine candidates.

Hemophagocytic syndrome is a rare complication of acute Q fever. We reported the case of 26-year-old man with fever, chills, severe headache, non-productive cough and progressive thrombocytopenia. Bone marrow aspirate revealed hemophagocytosis. We discussed the differences among the three previous reported cases and the possible mechanisms of hemophagocytic syndrome.

Angiostrongylus cantonensis is the most common cause of eosinophilic meningitis worldwide. Human infection occurs after ingestion of the worms in raw snails or fish that serve as intermediate hosts. Two outbreaks of central nervous system infection with A. cantonensis occurred in Kaoshiung, Taiwan, during 1998 and 1999 among Thai laborers who ate raw snails. A detailed clinical studies of 17 of these patients was conducted, including study of 13 patients who underwent magnetic resonance imaging (MRI) scans of the brain. The MRI scans revealed high signal intensities over the globus pallidus and cerebral peduncle on T1-weighted imaging, leptomeningeal enhancement, ventriculomegaly, and punctate areas of abnormal enhancement within the cerebral and cerebellar hemisphere on gadolinium-enhancing T1 imaging, and a hyperintense signal on T2-weighted images. There was a significant correlation between severity of headache, cerebrospinal fluid (CSF) pleocytosis, and CSF and blood eosinophilia with MRI signal intensity in T1-weighted imaging (P < 0.05). Eosinophilic meningitis produced by A. cantonensis needs to added to the list of causes of hyperintense basal ganglia lesions found on T1-weighted MRI scans in tropical countries.

Peptostreptococcus sp., which are normal flora of human mucocutaneous surfaces, can be recovered in mixed infections involving the skin, soft tissue, respiratory tract, gastrointestinal tract and genitourinary tract. Peptostreptococci are rarely reported to be the cause of infective endocarditis. Because of their fastidiousness, peptostreptococci are difficult to isolate and are often overlooked. The authors report a case of Peptostreptococcus infective endocarditis of a native mitral valve complicated by splenic infarction. The authors also review the literature to identify features of infective endocarditis caused by Peptostreptococcus anaerobius.

Background Dengue fever, rickettsial diseases, and Q fever are acute febrile illnesses with similar manifestations in tropical areas. Early differential diagnosis of scrub typhus, murine typhus, and Q fever from dengue fever may be made by understanding the distinguishing clinical characteristics and the significance of demographic and weather factors. Methods We conducted a retrospective study to identify clinical, demographic, and meteorological characteristics of 454 dengue fever, 178 scrub typhus, 143 Q fever, and 81 murine typhus cases in three Taiwan hospitals. Results Case numbers of murine typhus and Q fever correlated significantly with temperature and rainfall; the scrub typhus case number was only significantly related with temperature. Neither temperature nor rainfall correlated with the case number of dengue fever. The rarity of dengue fever cases from January to June in Taiwan may be a helpful clue for diagnosis in the area. A male predominance was observed, as the male-to-female rate was 2.1 for murine typhus and 7.4 for Q fever. Multivariate analysis revealed the following six important factors for differentiating the rickettsial diseases and Q fever group from the dengue fever group: fever ≥8 days, alanine aminotransferase > aspartate aminotransferase, platelets >63,000/mL, C-reactive protein >31.9 mg/L, absence of bone pain, and absence of a bleeding syndrome. Conclusion Understanding the rarity of dengue in the first half of a year in Taiwan and the six differentiating factors may help facilitate the early differential diagnosis of rickettsial diseases and Q fever from dengue fever, permitting early antibiotic treatment.

Purpose To describe two outbreaks of Angiostrongylus cantonensis infection that occurred in Kaohsiung, Taiwan, during 1998 and 1999, and to characterize the source of the outbreaks and the clinical manifestations of the disease. Subjects and methods We performed a retrospective cohort study among Thai laborers with eosinophilic meningitis who ate raw snails ( Ampullarium canaliculatus ), as well as an environmental surveillance of larvae in snails. Results We enrolled 17 Thai laborers in whom severe headache and eosinophilia developed within 4 to 23 days after eating raw snails. Twelve (71%) developed eosinophilic meningitis. Third-stage larvae were found in the cerebrospinal fluids of 2 patients and in all 12 tested snails. Specific antibodies to A. cantonensis were detected in serum from 16 of the patients and in cerebrospinal fluid from 5 of the patients. Central nervous system manifestations included headache (n = 17 [100%]), fever (n = 11 [65%]), Brudzinski's sign/stiff neck (n = 11 [65%]), hyperesthesia (n = 3 [18%]), cranial nerve palsy (n = 2 [12%]), diplopia (n = 2 [12%]), and ataxia (n = 1 [6%]). Laboratory findings included peripheral eosinophilia (n = 15 [88%]) and cerebrospinal fluid eosinophilia (n = 12 [71%]); elevated immunoglobulin (Ig) E levels (n = 13 [100%]); and transient increases in white blood cell count (n = 7 [41%]) and in serum levels of creatine kinase (n = 7 [41%]), transaminase (n = 3 [18%]), and lactate dehydrogenase (n = 2 [12%]). The severity of illness and eosinophilia were correlated with the number of ingested snails. Meningeal and basal ganglion enhancement was noted on magnetic resonance imaging in several patients. Treatment with mebendazole combined with glucocorticosteroids appeared to shorten the course of the infection, but not the number of relapses. The eosinophil count fell to normal within 3 months, but IgE levels remained elevated for as long as 6 months. All patients recovered with minimal neurologic sequelae. Conclusion Eosinophilic meningitis caused by A. cantonensis should be considered in patients who have headache or central nervous system manifestations after eating raw snails.

Pseudomembranous colitis (PMC) is known to develop after antibiotic treatment, but is rarely associated with antituberculosis (anti-TB) agents. We report a 28-year-old woman without underlying diseases developing PMC after 126 days of anti-TB treatment. Severe diarrhea and abdominal cramping pain were experienced. Colonoscopic biopsy proved the diagnosis of PMC. Her symptoms improved after discontinuing the anti-TB agents but recurred shortly after challenging with rifampin and isoniazid. Metronidazole administration and replacement of rifampin with levofloxacin successfully cured the PMC. Our report supports the notion that rifampin can induce PMC.

The aim of this study is to explore the prevalence of hepatitis C virus (HCV) infection among injection drug users (IDUs) with and without human immunodeficiency virus (HIV) infection in southern Taiwan. For 562 IDUs (265 anti-HIV negative, 297 anti-HIV positive), we analyzed liver function, anti-HIV antibody, anti-HCV antibody, HCV viral loads, and hepatitis B surface antigen (HBsAg). HIV RNA viral loads and CD4 cell count for anti-HIV-seropositive IDUs and the HCV genotype for HCV RNA-seropositive IDUs were measured. The seroprevalence rates of anti-HIV, anti-HCV, and HBsAg were 52.8%, 91.3%, and 15.3%, respectively. All the anti-HIV-seropositive IDUs were positive for HIV RNA. Anti-HCV seropositivity was the most important factor associated with HIV infection (odds ratio [OR], 25.06; 95% confidence intervals [CI], 8.97–74.9), followed by male gender (OR, 6.12; 95% CI, 4.05–9.39) and HBsAg seropositivity (OR, 1.90; 95% CI, 1.11–3.34). Among IDUs positive for anti-HCV, 80.7% had detectable HCV RNA. HCV viremia after HCV exposure was strongly related to HIV infection (OR, 6.262; 95% CI, 1.515–18.28), but negatively correlated to HBsAg seropositivity (OR, 0.161; 95% CI, 0.082–0.317). HCV genotype 6 was the most prevalent genotype among all IDUs (41.0%), followed by genotypes 1 (32.3%), 3 (12.8%), and 2 (5.6%). In conclusion, about half IDUs were infected with HIV and >90% with HCV infection. Male and seropositivity for HBsAg and anti-HCV were factors related to HIV infection among our IDUs. HIV was positively correlated, whereas hepatitis B co-infection was negatively correlated with HCV viremia among IDUs with HCV exposure. Different HCV molecular epidemiology was noted among IDUs.

Phaeohyphomycosis of the central nervous system is rare but typically associated with high mortality. Treatment has not been standardized, but the combination of antifungal chemotherapy with surgical debridement is recommended. We report a 73-year-old, retired, male timber merchant with acute meningitis caused by Cladosporium sphaerospermum. The patient, who had well-controlled type 2 diabetes mellitus, presented with fever and weakness of the lower limbs. No brain abscess was apparent by cranial computed tomography. C. sphaerospermum was isolated from the cerebral spinal fluid and identified based on both morphology and DNA sequencing. He was treated with combination antifungal chemotherapy with amphotericin B and voriconazole for 28 days, followed by voriconazole monotherapy for 46 days. To date, the patient has recovered without significant sequelae. This patient represents the first reported case of cerebral phaeohyphomycosis caused by C. sphaerospermum. Moreover, the therapy was successful for totally less than 3 months of treatment duration.

Background Non-steroidal anti-inflammatory drugs (NSAIDs), the most widely prescribed drugs in the world, can cause gastrointestinal damage, including colitis. However, the prevalence of NSAID-induced colitis is unknown because the disease is often asymptomatic. Case presentation We report the case of a 64-year-old female patient with a history of long-term NSAID use, who was hospitalized with septic shock caused by Klebsiella pneumoniae bacteremia. Computed tomography revealed multiple renal and splenic abscesses with diffuse colon wall thickening. A colonoscopy confirmed colitis with diffuse ulcers. NSAIDs were discontinued after this hospitalization. The abscesses improved after antibiotic treatment. A short course of balsalazide treatment was given under the suspicion of ulcerative colitis. Balsalazide was discontinued four months later due to a non-compatible clinical course. A follow-up colonoscopy two years later revealed a normal colon mucosa, and NSAID-induced colitis was diagnosed. Conclusion This is the first reported case of combined bacterial splenic and renal abscesses without intestinal manifestations as the initial presentation of NSAID-induced colitis. In contrast to cases of K. pneumoniae bacteremia with primary liver abscesses in patients with diabetes mellitus in Taiwan, we presented the first case with abscesses caused by community-acquired K. pneumoniae in the kidneys and spleen without liver invasion. In conclusion, our case report alerts clinicians to the possibility that K. pneumoniae bacteremia combined with multiple abscesses can be associated with severe NSAID-induced colitis.

Clinical information regarding murine typhus in Taiwan is limited. In this study, 81 cases of serologically documented murine typhus during 1992-2009 at four referral hospitals in southern Taiwan were analyzed. There was a significant correlation between average environmental temperature and case numbers of murine typhus (r = 0.747, P = 0.005). Acute hepatitis was found in 67% of cases, and hyperbilirubinemia (serum total bilirubin ≥ 23.9 μmol/L) was found in 38%. The intervals between the initiation of appropriate therapy to defervescence were longer in patients with hyperbilirubinemia than those without hyperbilirubinemia (6.1 versus 4.1 days; P = 0.015). Nine (11.1%) showed development of severe illnesses such as acute respiratory distress syndrome (2 patients), aseptic meningitis (3), and acute renal failure (4). Only one died of acute respiratory distress syndrome. Cases of murine typhus were often found during the summer and had acute febrile hepatitis. Those patients with hyperbilirubinemia tended to have a delayed recovery even with appropriate therapy.

Mucormycosis is an invasive fungal infection associated with a high mortality rate, especially in immunocompromised hosts. Mucormycosis rarely occurs in cirrhotic patients. Here, we report a case of mucormycosis with underlying liver cirrhosis and diabetes mellitus. The patient suffered from maxillary sinusitis and osteomyelitis, and the infection was successfully treated with antifungal agents, surgical debridement, and hyperbaric oxygen therapy. The antifungal treatments used were liposomal amphotericin B, itraconazole, and posaconazole. Although our patient had liver cirrhosis (Child-Pugh classification B), no hepatic decompensation was developed during the treatment course of posaconazole. This is the first report of the safe and effective use of posaconazole for the treatment of mucormycosis in a cirrhotic patient.

Background/Purpose Proteus mirabilis is a common pathogen responsible for complicated urinary tract infections (UTIs) that sometimes causes bacteremia. Most cases of P. mirabilis bacteremia originate from a UTI; however, the risk factors for bacteremia and mortality rates from P. mirabilis UTI have not been determined. Methods A retrospective, case-control study was performed between May 2008 and November 2010 to identify the risk factors and markers for P. mirabilis bacteremic UTI. Each subject in the case group (all patients were diagnosed with P. mirabilis bacteremia from a urinary tract source) was matched by age and gender to two subjects in the control group (patients diagnosed with P. mirabilis UTI but with negative blood culture results). Clinical presentation and laboratory data were analyzed to determine the risk factors and markers of P. mirabilis bacteremic UTI. Results Sixty-seven bacteremic UTIs and 124 nonbacteremic UTIs were included in this study. Community-acquired infection ( p =0.017), hydronephrosis ( p =0.017), band neutrophils accounting for >10% of the white blood cell count ( p =0.001), hyperthermia or hypothermia ( p =0.047), and a serum C-reactive protein concentration >100mg/L ( p =0.002) were identified as independent risk factors for P. mirabilis bacteremic UTI. Seventeen patients died in hospital, including 11 in the bacteremic group and 6 in the nonbacteremic group. The bacteremic group had a higher mortality rate ( p =0.016). Bacteremic UTI ( p =0.049), shock ( p =0.014), and a low body mass index (BMI) 2 ( p =0.033) were identified as independent risk factors for mortality. Conclusion Because bacteremic P. mirabilis UTIs are associated with higher mortality, clinicians should carefully manage cases that present with the risk factors for bacteremia, including community-acquired infection, hydronephrosis, band neutrophils accounting for >10% of the white blood cell count, hyperthermia or hypothermia, and a high level of C-reactive protein.

Bacterial contamination of platelet (PLT) products is one of the most serious complications of transfusion. Culturing PLT components may detect the presence of bacteria, thus reducing the risk of a septic result after transfusion. Streptococcus bovis has previously been reported as a contaminating microorganism in PLT products. Here we report an asymptomatic donor diagnosed with occult colon malignancy after positive isolation of S. bovis from his apheresis PLTs (APs). We also review previous cases.The PLT donor was a 50-year-old man with more than 150 prior plateletpheresis or whole blood donations. Bacterial culture of his AP components yielded two positive results: group D Streptococcus was isolated in July 2008 and S. bovis was reported in April 2010. The donor received further testing, and colonofibroscopic examination revealed colonic neoplasm. Pathologic examination of the biopsied tissue led to a diagnosis of invasive adenocarcinoma. He underwent a left hemicolectomy in July 2010. Examination of the resection specimen confirmed adenocarcinoma, Stage III with regional lymph node metastatic adenocarcinoma.Donated AP products positive for S. bovis should not be presumed to be due to contamination during collection. This bacteremia originating from donor factors needs to be carefully evaluated. Colonofibroscopic examination is recommended for these donors to detect colonic malignancy as early as possible.

Healthcare system delays in the diagnosis of tuberculosis can increase the risk of its nosocomial transmission. We aimed to determine whether different physicians' specialties and experience influenced this diagnostic delay.We retrospectively reviewed the cases of 167 patients with smear-positive pulmonary tuberculosis who were hospitalized from September, 2004, to August, 2006, for 5 components of healthcare system delays according to the World Health Organization definitions and analyzed the impact of physicians' specialties and their experience (annual number of patients treated for tuberculosis) on these delays.The median suspicion delay was significantly longer for patients in surgical departments than those in medical departments (4 days versus 1 day, P = 0.001) and for patients treated by nontuberculosis specialists than those treated by tuberculosis specialists (including pulmonologists, infectious diseases specialists and thoracic surgeons; 3 days versus 1 day, P0.001). Both were independent factors related to suspicion delay examined by multivariate analysis. The annual number of tuberculosis patients in each department had a significant negative correlation with suspicion delay (r = -0.303, P0.001).Patients treated by surgeons and nontuberculosis specialists who were inexperienced in treating tuberculosis experienced a longer suspicion delay. Enhancing knowledge about tuberculosis among all physicians in the hospital, encouraging staff to consult tuberculosis specialists to confirm a diagnosis and implementing early alarm systems are crucial to improving the correct diagnosis of tuberculosis and to reducing delays in treatment.

Myocarditis is defined clinically as inflammation of the heart muscle, which can be caused by infectious agents, toxins or immunologic reactions. Most recognized cases of acute myocarditis are secondary to cardiotropic viral infections. Escherichia coli rarely cause myocarditis. The authors report a 25-year-old woman with E coli-induced acute pyelonephritis and septic shock that was complicated with acute myocarditis. Her symptoms mimicked acute myocardial infarction. The authors discuss the possible mechanism of bacterial sepsis-induced myocarditis.

Extensively drug-resistant Acinetobacter baumannii (XDRAB) is a growing and serious nosocomial infection worldwide, such that developing new agents against it is critical. The antimicrobial activities of the rhizomes from Zingiber officinale, known as ginger, have not been proven in clinical bacterial isolates with extensive drug-resistance. This study aimed to investigate the effects of four known components of ginger, [6]-dehydrogingerdione, [10]-gingerol, [6]-shogaol and [6]-gingerol, against clinical XDRAB. All these compounds showed antibacterial effects against XDRAB. Combined with tetracycline, they showed good resistance modifying effects to modulate tetracycline resistance. Using the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging method, these four ginger compounds demonstrated antioxidant properties, which were inhibited by MnO₂, an oxidant without antibacterial effects. After the antioxidant property was blocked, their antimicrobial effects were abolished significantly. These results indicate that ginger compounds have antioxidant effects that partially contribute to their antimicrobial activity and are candidates for use in the treatment of infections with XDRAB.