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Coinfection with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) is common worldwide. The current guidelines for the treatment of HIV infection recommend that HIV patients coinfected with HBV receive antiretoroviral therapy (ART) with two nucleoside analogs against HBV. However, an increase in liver enzymes that is usually attributed to HBV immune reconstitution inflammatory syndrome (IRIS) sometimes occurs in HBV/HIV-coinfected patients after the commencement of ART. We report a case of HBV/HIV-coinfection in which the chronic hepatitis B was successfully treated using interferon (IFN) therapy followed by ART without the development of IRIS. A Japanese man in thirties was referred to our hospital because of an acute HIV infection two months after the diagnosis of an acute HBV infection, which had progressed to a chronic HBV infection. The laboratory test results were as follows:hepatitis B surface antigen (HBsAg) positive, hepatitis B e antigen (HBeAg) positive, HBV DNA level of 8.8 Log copies/mL, HBV genotype A, alanine aminotransferase of 834 IU/L, HIV RNA level of 5 Log copies/mL, and a CD4+ T cell count of 437/microL. The initial treatment was natural IFNalpha therapy for chronic hepatitis B, and HBeAg seroclearance was achieved 20 weeks after the start of therapy. Four months after the end of IFN therapy for 24 weeks, ART including tenofovir and emtricitabine against HBV was commenced. Six months after starting ART, the patient's serum HBV DNA level had decreased and become undetectable and HBsAg seroclearance was achieved without an elevation in liver enzymes. The present case suggests that IFN therapy prior to ART contributes to a successful outcome for chronic hepatitis B patients coinfected with HIV, if the HIV status does not require the immediate start of ART.

Kaposi's sarocoma (KS) is a well-known complication of the acquired immunodeficiency syndrome (AIDS). A 23-year-old man with AIDS complicated by multiple KS seen in January 2008 for anorexia and 10 kg weight loss had a CD4 cell count of 7/microL and a serum HIV RNA level of 29,000 copies/mL. Computed tomography (CT) and endoscopy showed multiple KS lesions in both lungs, the duodenum, small intestine, colon, liver, and both kidneys but not of the skin. Despite the administration of pegylated liposomal doxorubicin (PLD) and highly active antiretroviral therapy, he died in disease progression, unable to complete PLD, KS-related respiratory failure.

Highly active antiretroviral therapy (HAART) has dramatically decreased the incidence of HIV-1-associated morbidity and mortality. During the initial months of HAART, immune reconstitution inflammatory syndrome (IRIS), an adverse consequence of restoration of the pathogen-specific immune response, often occurred in terminal-stage in patients, with MAC infection the most frequently implicated in IRIS. In August 2004, a 26-year-old Japanese woman with fever and general lymphadenopathy was diagnosed with AIDS (HIV-1 RNA 5.7 x 10(5) copies/mL, CD4+ T cell count 10/microL) and disseminated Mycobacterium avium (M. avium) infection, for which antimycobacterial treatment was initiated. The M. avium infection responded well to two months of this treatment, and HAART was begun. Despite good virologic response to HAART (HIV-1 RNA <50 copies/mL), she contracted pulmonary disease with parenchymal lung changes, endobronchial lesions, and localized supraclavicular lymphadenitis, which are M. avium-associated IRIS. Good immunological response (CD4+ T cell count 136/microL) and a stronger antimycobacterial treatment helped her overcoming M. avium-associated IRIS without systemic corticosteroids or the discontinuation of HAART. The possibility of IRIS should always be watched for when treating AIDS patients with HAART and an antimycobacterial treatment regimen formulated that considers potential drug interactions with HAART.

A 39-year-old man with a high fever, headache, and stiff neck, and Kernig and Brudzinski signs admitted in June 2004 had a WBC of 10,680/microL and CRP of 10.5mg/dL. Streptococcus pneumoniae was detected in blood and spinal fluid culture, but brain CT was normal. Meningitis was diagnosed and antibiotics and corticosteroids begun. After four days of treatment, his blood test and spinal fluid data had improved, but his consciousness had deteriorated. ADEM was diagnosed by the clinical course and brain MRI (T2-weighted image) that showed high-intensity lesions in the white cerebral matter, and steroid pulse treatment was begun on day 4 after admission. His consciousness disturbance rapidly disappeared and brain MRI showed that the multiple high-intensity lesions had ameliorated. The patient was released after 40 days of treatment.

A 69-year-old woman with gastritis was prescribed a 1-week triple regimen therapy of Amoxicillin, Clarithromycin, and Lansoprazole to eradicate Helicobacter pylori (H. pylori) starting on March 7, 2005. H. pylori was detected on the gastric mucosa by the urease test. Twenty days after eradication therapy, she began to suffer from profuse watery diarrhea. Colonoscopy on April 12 showed multiple pseudomembranes in the cecum and the transverse colon, leading to a diagnosis of pseudomembranous colitis. Because she had not taken Vancomycin (VCM) (500 mg/day) as directed, she had a relapse of watery diarrhea and was admitted on April 30. A stool test for Clostridium difficile (CD) toxin was positive, although colonoscopy showed only a few aphthoid erosions in the cecum and the transverse colon on May 6. She was treated with oral VCM (2000 mg/day) from May 6, and diarrhea disappeared by May 11. The stool test for CD toxin was negative, so VCM was discontinued. Care must thus be taken in H. pylori eradication to ensure that the triple regimen therapy does not lead to pseudomembranous colitis.

In March 2003, a 34-year-old man with left facial palsy, dysphagia, and hoarseness treated with acyclovir suffered worsened dermatological and neurological problems. A routine blood test in early April showed the patient to be HIV-antibody positive, so he was transferred to our hospital. Blood analysis showed serum HIV-RNA at 96,000 copies/mL and a CD 4 count of 170/microL. Brain MRI taken on admission showed a T 2 high lesion in their left medulla. Acyclovir was thought to be ineffective due to reduced cell-mediated immunity because of the HIV infection, and HAART therapy was begun. After two months of HAART, skin lesions and the T 2 high lesion in left medulla improred. HIV-RNA became undetectable and the CD 4 count exceeded 500/microL. Intracellular cytokine analysis by flow cytometry showed a shift from Th 2 to Th 1 dominance. The elimination of VZV may thus have been promoted by the combination of acyclovir and HAART.

We assessed the sensitivity and specificity of the Capilia Flu AB rapid diagnosis kit for influenza that utilizes the immunochromatography method. Tested were 114 influenza like illness patients in the 2001/2002 influenza season. We used Capilia Flu AB and Infu A . B Quick, a rapid diagnosis kit based on enzyme immunoassay. As laboratory confirmation tests, influenza virus isolation and polymerase chain reaction (PCR) were done. Those patients with positive results from virus isolation or PCR were regarded as influenza patients. The sensitivities of nasal swab, pharyngeal swab, and nasal wash specimens were 82.8%, 80.0%, and 75.0%, respectively. The specificities of nasal swab, pharyngeal swab, and nasal wash specimens were 95.3%, 93.9%, and 100%, respectively. A total of 20 patients displayed different results in comparison of their nasal and pharyngeal swabs: 15 patients were positive with the nasal swab but negative with the pharyngeal swab and 5 patients were negative with the nasal swab but positive with the pharyngeal swab. Nasal swab would seem to be preferable in terms of sensitivity. The sensitivity and specificity of Capilia Flu AB were a little higher than those of Influ A . B Quick, but with no significant difference. The one-step operation of Capilia Flu AB is easier than the four steps required by Influ A . B Quick, but the time required to make a diagnosis is the same. No significant age related difference in the effectiveness of the kits was found. The Capilia Flu AB rapid diagnosis kit is useful in clinical practice because it has good sensitivity (about 80%) and specificity (about 90%), and it is easy to use.

A 33 year-old female was admitted with facial, trunk and limb eruptions, conjunctiva intrahemorrhage, Koplik's spots in the pharynx and severe hypoxemia after fever and upper respiratory tract symptom. Infiltrative shadow of the whole right lung was seen on chest radiography. Fine crackles were seen in the lower left lung and in the whole right lung. Severe inflammation and liver dysfunction were indicated by blood test. Measles antibody IgM was high. The abnormal interstitial shadows were confirmed in greater detail by chest computed tomography. Her condition was diagnosed as measles pneumonia. A combination therapy with steroid pulse, high dose vitamin A, and gamma globulin was started, after which the patient gradually improved, indicating the effectiveness of this combination therapy for severe adult measles pneumonia.

To investigate the mechanism of hypergammaglobulinemia in HIV infected patients, the effect of highly active antiretroviral therapy (HAART) on the hypergammaglobulinemia was analyzed. Involved in this study were 34 untreated, 21 HAART-effective (complete response) and 14 HAART-non-effective (partial response) patients. Serum levels of HIV-RNA and gammaglobulin and immunoglobulin (Ig) isotypes were measured. Mean HIV-RNA levels of untreated and partial response patients were 1.6 x 10(4) copies/ml and 0.4 x 10(4) copies/ml, respectively. HIV-RNA levels of all complete response patients were below 4.0 x 10(2) copies/ml. Mean gammaglobulin percentages of untreated, partial response and complete response patients were 24.4%, 21.8% and 17.9%, respectively (p < 0.01 in untreated vs complete response patients). Mean IgG levels in the three groups were 2,489 mg/dl, 1,947 mg/dl and 1,618 mg/dl, respectively (p < 0.001 in untreated vs complete response patients). IgA levels were high in some untreated patients and lower in complete response patients. IgE levels were increased in some untreated and partial response patients, but there was no significant difference among the three groups. These results suggested that the hypergammaglobulinemia found in HIV infected patients was associated with HIV replication. The activation mechanism might differ by Ig isotypes.

An outbreak of an influenza like illness was found in a nursing home in Fukuoka in January, 1999. Results of hemagglutinin inhibition tests with paired sera of patients and rapid diagnosis kit for influenza A indicated that an influenza A (H3N2) outbreak had occurred. A total of 15 patients with influenza like illness from one residential area of the nursing home were administered amantadine, 100 mg per day for five days. Clinical records of 264 residents were surveyed retrospectively from the tenth to the thirty-first of January, 1999. Influenza like illness was found in 112 residents (42.4%). The incidence of influenza like illness differed by residential area, ranging from 27.6% to 54.0%. The mean duration of fever was 3.6 days among patients administered amantadine. The mean duration was 4.4 days for patients not administered amantadine. The incidence of influenza like illness decreased rapidly after amantadine administration in the residential area where amantadine administration was done. These results suggest that amantadine is effective in mitigating influenza symptoms in the elderly. Amantadine may be useful for diminishing the influence of influenza A outbreaks in nursing homes.

Institutionalized elderly patients are at risk of nosocomial infection because of their compromised status by aging. To clarify the relationship between fever and disease in elderly patients, we analyzed 1,105 febrile episodes, the etiology of which were already diagnosed, of 443 patients (136 men, 307 women). All patients who were 65 years of age or older and who had been admitted to the hospital for more than 7 days had fevers above 37.5 degrees C recorded. The etiologies of the 1,105 febrille episodes were respiratory tract infection in 381 (34.5%), urinary tract infection in 263 (23.8%), other diseases in 164 (14.8%) and in 297 (26.9%) unknown. The episodes were categorized into two groups by the degree of initial fever: group A, 559 episodes (50.6%) of 37.5-38.0 degrees C and group B, 546 episodes (49.4%) of above 38.0 degrees C. Of the episodes, 41.0% were one-day fevers, 21.4% two-day fevers, and 14.0% three-day fevers. The frequency of two-or-more-day fevers was significantly higher in group B (69.0%) than in group A (49.2%) (p < 0.001). In group B, respiratory tract infection (44.3%) was more frequent than urinary tract infection (16.1%) (p < 0.001). Of the respiratory tract infections, 63.5% were in group B and, in contrast, 66.5% of the urinary tract infections were in group A. The white blood cell count and C-reacting protein levels were significantly higher in group B than in group A (p < 0.001). The degree of initial fever is an important predictive marker of severity of disease in elderly patients.

To investigate the efficacy of influenza vaccine in the elderly, hemagglutination inhibition (HI) antibody titer for the three types of influenza viruses were measured and the influenza infection rate was determined serologically in geriatric inpatients. Influenza vaccination was done for inpatients. For patients who had influenza vaccination in the year prior to the study, influenza vaccine was administered once or twice, and the number of injections were determined randomly. Influenza vaccine was injected twice to those had not received influenza vaccine in the previous year. Serum samples were collected from 166 vaccinated and 104 unvaccinated patients before and after 1996/1997 influenza season. In the vaccinees who had been vaccinated the previous year, 56 patients were injected once and 58 patient were injected twice. Fifty-two patients had not been vaccinated the previous year. Serologically diagnosed influenza infection rate in the 104 unvaccinated patients was 16.3% for influenza A/H3N2 and 8.7% for influenza B. The infection rate was 3.0% for influenza A/H3N2 and 0.6% for influenza B in the 166 vaccinated patients. The infection rates were significantly lower in the vaccinees than in the unvaccinated patients (p < 0.001 with A/H3N2 and p < 0.01 with B). There was no significant difference in the infection rate among the three vaccinated groups. These results suggest that the influenza vaccination had significant protective efficacy for influenza infection in the elderly. Prior vaccination did not diminish the efficacy of the influenza vaccine. The efficacy of a single influenza vaccine injection was equivalent to that of two injection.

Fungal infection is a major opportunistic infection in AIDS. Histoplasmosis is often seen in American AIDS, but only one case has been reported in Japan. We report a AIDS case of with histoplasmosis in Japan. The patient was a forty year old male living in the U.S from 1987 to 1990. He was diagnosed as candidial esophagitis in July, 1994, and human immunodeficiency virus type 1 (HIV) antibody positive led to a diagnosis of AIDS. He was admitted to our hospital with fever and lymphadenopathy (neck, abdomen) in August. The therapy for candidial esophagitis was successful and he was recovering, but he was newly diagnosed as atypical mycobacteriosis and Kaposi's sarcoma. Though the fever was slight, it persisted. He was discharged from our hospital in October. He was readmitted for a high fever and dehydration in December, but died after a week from disseminated intravascular coagulation (DIC). Histoplasma capsulatum was found by blood and ascites cultures on second admission. Many yeast like histoplasma cells in granuloma of the liver were found at autopsy. For moderate or severe histoplasmosis, amphotericin B is generally used as the first induction therapy. Fluconazole (FLCZ) is used as a maintenance therapy. We did not use amphotericin B, but used FLCZ because we did not diagnose histoplasmosis before death, and his general condition became worse. The effect of FLCZ therapy was unclear in our case because he had other infections. We expect that AIDS with histoplasimosis will increase in Japan through HIV infected patients infected in the U.S.A.

Directigen Flu A, an enzyme immunoassay membrane test for the detection of influenza A virus, was compared with serum hemagglutinine inhibition assay in adult and elderly patients. Throat specimens were collected by vigorous swabbing from febrile patients who were suspect for influenza by clinical symptoms and tested with Directigen Flu A. Serum samples were collected from the patients at onset of illness and two to eleven weeks later and tested for antibody titer to influenza A/H1N1, A/H3N2, and B. A total of 57 patients were involved in this study; 32 under 59 years of age and 25 over 60 years of age. Influenza was diagnosed in 42 patients by HI titer elevation (73.7%). Directigen Flu A was positive in 25 patients. Results of Directigen Flu A and HI test agreed in 40 patients. Sensitivity and specificity of Directigen Flu A were 59.5% (25/42) and 100% (15/15), respectively. There was no significant difference in sensitivity between the two age groups. These results indicate the potential usefulness of Directigen Flu A in the surveillance of influenza A infection in the geriatric population. Directigen Flu A gives results within 15 minutes without expensive equipment. Use of Directigen Flu permits the timely administration of antiviral therapy and infection control among hospitalized and institutionalized geriatric patients.

To investigate the effect of previous influenza vaccination and the difference in antibody induction by single and twice injection of influenza vaccine in the elderly, hemagglutination inhibition (HI) antibody titers of the three types of influenza viruses were measured. Influenza vaccination was done for 217 inpatients. For the patients who had influenza vaccination in the year prior to the study, influenza vaccine was administered once to 77 patients and twice to another 70 patients. Influenza vaccine was injected twice to 70 patients who had not received influenza vaccine in the previous years. The influenza vaccine induced an increase in HI titer in almost all patients. The geometric mean of the HI titer and the frequency of patients with HI titers over 128x were similar after vaccination in the groups of patients who were injected twice, irrespective of whether or not influenza vaccination was given in the year prior to the study. The geometric means of the HI titers for influenzas A/H3N2 and B and the frequency of HI titers over 128x for influenza A/H3N2 after vaccination were lower in the patients who received vaccine once than in the patients vaccinated twice. These results suggest that prior vaccination does not diminish antibody response to influenza vaccine significantly in the elderly when influenza vaccine is injected twice. Although single injection is inferior to twice injection in antibody induction with some vaccine virus strains, induction of HI titers over 128x is found in more than 70% of elderly. Single injection of influenza vaccine may be practically effective and useful for protection of influenza infection in the elderly.

To determine the efficacy of a single influenza vaccine administration in the elderly receiving annual influenza vaccination, antibody response to influenza vaccine was compared between once and twice injections in a geriatric cohort. Influenza vaccination had been done for 69 inpatients in the year prior to the study, and was administered twice for 34 of them and once for the other 35 during the study period. Influenza vaccine was injected twice to 77 inpatients who had not received influenza vaccine in the year prior to the study. Hemoagglutination inhibition (HI) antibody titer for influenza A/H1N1, A/H3N2, and B was measured before vaccination, after the first vaccination, after the second vaccination, and after the epidemic period, September 1995 to April 1996. HI antibody titer prior to vaccination was significantly higher in the patients who had received influenza vaccination the previous year. The influenza vaccine induced an increase in HI titer in almost all subjects, and the geometric mean of the HI titer after vaccination in the patients who received vaccine once was comparable to that of the patients injected vaccine twice. The number of patients with HI titers of over 128x increased, and the frequency ranged from 60.0% to 97.1% for the influenza viruses of the three subtypes. The frequency of HI titers over 128x was not significantly different among the three groups. The second vaccination did not increase the number of patients with HI titers over 128x when compared with the number after the first injection in the patients who had received influenza vaccine the previous year. These results suggest that prior vaccination does not diminish the antibody response to influenza vaccine in the elderly. The efficacy of a single influenza vaccination is comparable to that achieved by twice injections in the elderly receiving annual influenza vaccination.

A 42-year-old male type A hemophiliae who been using coagulates since 1971 was diagnosed Human Immunodeficiency Virus (HIV) positive in 1993. Medical history included liver disfunction in 1987, with chronic hepatitis C (CHC) diagnosed in 1989. He was admitted to the hospital in October, 1994 because of general fatigue. Serum transaminase was elevated, CD4 was 221/micro L, and CD8 was 990. CD4/CD8 ratio was 0.2. HCV was of genotype 2b and 10(6) copies/50 microL, 8 week-Interferon (IFN)-beta treatment was started. HCV RNA was eliminated by week 8 and was sustained for one year with no severe side effects. With careful patient screening, IFN therapy for CHC with HIV may be an effective treatment.

To determine the cause of nosocomial infections, all febrile episodes of hospitalized elderly patients aged 65 and older at a hospital in Fukuoka City were categorized between April 15 1994 and April 14 1995. A febrile episode was a temperature above 37.5 degrees C after 7 consecutive days of normal body temperature (below 37.5 degrees C). Various clinical tests including blood examination, urinalysis, chest radiography and bacterial culture were done on the first and 7th day of the fever. A total of 1105 episodes in 443 patients (male 136, female 307) fulfilled this criteria for fever. The fevers were mainly due to respiratory tract (381 cases, 34.5%) and urinary tract infections (263 cases, 23.8%). There were 135 infections (12.2%) of other kinds and 297 cases (26.9%) that were classified as unknown. Approximately 70% of the febrile episodes were caused nosocomial infections, suggesting increased risk of infection in the hospitalized elderly and the importance of early detection of febrile changes in elderly inpatients.

To determine the impact of influenza epidemics among geriatric inpatients and to monitor the clinical efficacy of influenza vaccination, the influenza infection rate in non-vaccinated inpatients was determined serologically and the incidence of febrile episodes and death were compared between the vaccinees and non-vaccinees hospitalized in the referred hospital from January through September, 1995. Three influenza subtypes, influenza A/H1N1, A/H3N2, and B, were endemic simultaneously from January to March in 1995. The pattern of incidence of febrile episodes varied for each ward. A total of 123 non-vaccinated inpatients were tested for elevation of serum hemagglutination inhibition titer to the three subtypes of influenza virus. Of these, 58 (47.2%) patients were infected with at least one of the influenza viruses during the epidemic of 1995. No patient with pre-existing HI titer over 128X was infected with any of three types of influenza, indicating that HI titer over 128X is the protective level. The febrile episode frequency was significantly higher in the non-vaccinees than in the vaccinees (49.6% vs. 32.6%), but it was quite comparable in the two groups after the influenza epidemic (34.9% vs. 35.8%). The number of observed deaths from January to September of 1995 was 4 (4.9%) in the vaccinee group and 12 (9.8%) in the non-vaccinee group. These results suggest that influenza epidemics have a striking impact on geriatric inpatients and that influenza vaccination has significant efficacy for the reduction of harmful events associated with influenza infection.

In order to investigate the effects of prior influenza vaccination on subaequent annual influenza vaccination in the geriatric population, we analyzed serum hemagglutinine inhibition antibody tirers (HI titer) before and after vaccination with inactivated influenza vaccine in elderly inpatients. A total of 163 inpatients of 60 years or older were enrolled with informed consent. They were classified by vaccination status in the previous year, 53 patients had inactivated vaccine (inactivated). 52 patients had genetically assorted cold-adapted influenza live attenuated vaccine (cold-adapted), and 53 had no influenza vaccine history during the past year. The HI titer was higher in the inactivated group than in the cold-adapted and non-vaccinated groups, suggesting residual immunological effects of inactivated influenza vaccine from the previous year vaccination. The HI titer after the inactivated vaccine in 1993 was higher in both the inactivated and cold-adapted groups than in the non-vaccinated group. The number of patients with HI titers of 2(7) or higher, which is the putative protective HI titer level for influenza infection, was significantly higher in both the inactivated and cold-adapted groups than the non-vaccinated group. These results suggest that continuous annual influenza vaccination does not impair the effects of vaccination, and may actively promote elevated HI titers.

We report a case of progressive dementia and prolonged gait disturbance correlated with influenza A/H3N2 infection in 91-year-old female patient, admitted because of in ability to take care of herself due to aging and cerebral infarction. At admission, conversation and comprehension were not significantly impaired, and she was able to walk by herself. Flu symptoms such as high grade fever, chills, arthralgia, and cough appeared after a short stay at home. Influenza A/ H3N2 was confirmed serologically. Delirium occurred on the sixth day after influenza onset, persisted for three weeks, followed by recovery. Dementia symptoms such as memory defects and disorientation continued and did not improve. Due to this febrile episode, she was unable to walk unassisted. The results of computed tomography performed before and after the influenza episode were unremarkable for additional cellebro-vascular events during the observed period. Influenza infection may be an important risk factor for reducing the quality of life in the elderly. In geriatric cases, influenza should not be treated as a mere transient illness, but rather one which has important consequences for the elderly population, including the possibility of life threatening complications.

To investigate the clinical implication of peak body temperature, peripheral blood white blood cell (WBC) count, and serum C-reactive protein (CRP) level in febrile symptoms among geriatric hospitalized patients, they were analyzed in 968 febrile episodes obtained from 433 hospitalized patients in the referred hospital. Episodes of one day duration were most frequent (41.6%). WBC count was elevated over 8000/microliters in 475 episodes (49.1%) and CRP exceeded 1.0 mg/dl in 770 episodes (79.5%). Frequency of WBC elevation decreased and frequency of CRP elevation increased according to the time course. The mean value of CRP increased significantly according to the time course. The frequency of WBC count increase and CRP elevation and their averages correlated to the peak body temperature. The peak body temperature displayed the most striking correlation to the length of febrile episodes among three clinical indicators, peak body temperature, WBC count, and CRP level. These results indicate that the elevation of WBC count and/or CRP level is frequent in geriatric patients with febrile symptoms. Peak body temperature may serve as a clinical indicator of the severy of the febrile disease occurring in geriatric patients.

Psoas abscess is relatively rare and often difficult to make early diagnosis. We treated a patient suffering from hepatocellular carcinoma due to hepatitis C virus infection who was admitted to our hospital complaining of right inguinodynia and a high fever. Positive CRP test were seen. Staphylococcus aureus was detected from blood culture and he was treated for sepsis with antibiotic therapy. After starting treatment, his inguinodynia continued and abscesses were demonstrated in the right psoas muscle by pelvic computed tomography (CT). The abscesses were drained and a specimen yielded S. aureus on culture. After drainage, the symptoms improved and the abscesses disappeared on pelvic CT. Pelvic CT can be successfully used to diagnose psoas abscess and to monitor the efficiency of the treatment.

To investigate the relationship between serum albumin level and incidence of febrile episodes and mortality in the elderly, we studied 748 patients hospitalized for over one year. The subjects included 123 males and 355 females with a mean age 81.2 years. The average serum albumin level was 3.79 g/dl and levels of serum albumin decreased with advancing age. The incidence of febrile episodes was 1.8 per year in patients with serum albumin levels over 4.1 g/dl, increasing with decline of serum albumin levels. The incidence of febrile episodes was 5.3 per year in patients with serum albumin levels under 3.0 g/dl. Patients with serum albumin levels under 3.0 g/dl displayed a high incidence of febrile episodes irrespective of age. Age adjusted in-hospital mortality was 40.4% during the observed period in patients with serum albumin levels under 3.0 g/dl, significantly higher than that of the patients with serum albumin levels over 3.1 g/dl. Relative risk of febrile episode and mortality calculated using the patients with serum albumin levels over 4.1 g/dl as a control was 2.9 and 2.1, respectively, in the patients with serum albumin levels under 3.0 g/dl. These results indicate that serum albumin level is a simple, but strong, predictor of susceptibility of febrile episode and death. Patients with serum albumin levels under 3.0 g/dl may constitute a high risk group for febrile episode and death.

Fever is a common and important clinical symptom observed among hospitalized geriatric patients. To investigate the frequency and duration of fever episodes, we surveyed fever episodes in a hospital where the frequency of patients over 60 years of age exceeds 90 per cent of the patients. Fever episodes with body temperature of over 37.5 degrees C were registered from May in 1991 to December in 1994, and 6809 episodes were subjected to analysis. The average incidences per month were 157.1, 165.3, 158.0, and 139.3 in 1991, 1992, 1993, and 1994, respectively. The numbers of episodes per month did not show any significant correlation with temperature or humidity. Average duration of the episodes were 8.0, 6.5, 7.6, and 6.7 days for 1991, 1992, 1993, and 1994, respectively. Episodes of one day duration were the most frequent in all months, and the frequencies of that ranged from 37.1% to 58.6% with a mean of 47.8%. The average duration of episodes and the frequency of one day episodes did not change significantly irrespective of a notable decrease in the total incidence. The high frequency of one day episodes and their consistency through the observed period suggest that fevers with one day duration are one of the characteristic features of the febrile symptoms in geriatric patients. Causality and prevention methods for these one day fever episodes should be investigated.

An outbreak of influenza A (H3N2) in a hospital where almost 90% of the inpatients are aged over 70 years is described. An increase of febrile episodes was seen during the period from January 29th to March 17th, 1992 in two of six wards paired sera, at the onset of fever and more than two weeks later, were obtained from patients in sixty-five episodes. Serum antibody titer to influenza A (H3N2) elevated over four times in 39 (60%) of 65. Influenza A (H3N2) virus was also isolated from seven patients. These results indicated an outbreak of influenza A (H3N2) in this population. Maximum body temperature was over 39 degrees C in 18 patients (46.2%) with influenza, and were significantly higher than that of the non-influenza patients. The duration of fever in 12 patients of 39 was longer than 8 days in 12 patients, and significantly longer than that of non-influenza cases. Bronchopneumonia was found in ten patients (25.6%). These results suggest that the influenza infection causes a high grade fever in geriatric patients and lasts longer than is commonly seen in patients with fever not associated with influenza. Influenza infection also frequently induces bronchopneumonia and may contribute to increase mortality in the elderly, especially in patients over 70 years old.

A 40-year-old male was admitted to the hospital with acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia (PCP). Two months before admission the patient had a high fever, general fatigue and mild epigastic tenderness. On admission, physical examination revealed numerous small tumors on the head, gingiva, neck, nasal ala, anterior forehead, anterior thoracic, bilateral sole and bilateral lower limbs. At that time, the CD4 cell count was 130/microliters. Upper GI endoscopy was performed because of sever epigastralgia and hematemesis. The gastric mucosa was diffusely nodular and erythematous with bleeding. This biopsy showed Kaposi's sarcoma, and the same findings were obtained from the duodenum, rectum and skin, AIDS with related cutaneous and gastrointestinal KS and PCP was diagnosed. We performed a combination of chemotherapy and Interferon-alpha therapy, and the KS almost completely disappeared within 3 months.

We report a case of dermatomyositis (DM) in a 15-year-old female with toxoplasmosis after ingestion of raw bovine liver. Facial erythema and cervical lymphadenopathy preceded myalgia and muscle weakness of the extremities. The diagnostic criteria of DM was fulfilled because of symmetrical and proximal dominant muscle weakness, elevation of myogenic enzyme (CPK, GOT, LDH, myoglobin, aldorase), myogenic pattern of electromyogram, skeletal muscle biopsy showing interstitial myositis with mild destruction of muscle fiber, and facial erythema. Immunological findings showed IgG anti-toxoplasma antibody to be 1340 IU/ml and IgM to be 7.0 (Cut off index 0.7), suggesting acute toxoplasmosis. Treatment with prednisolone for DM and acetylspiramycin for toxoplasmosis was successful. Toxoplasmosis should be considered as a possibility in patients with myositis.

A new immunochromatography assay (Dainascreen Ausab Dainabot) has been recently introduced for the detection of the presence of antibody to HBsAg. To evaluate the feasibility of using the Dainascreen Ausab, we carried out comparison tests with this method and PHA. In the test of 439 sera from HB vaccinees, inhabitants in Iki Island, Nagasaki Pref., patients with autoimmune diseases and with acute hepatitis B, 154 (31.2%) were positive by Dainascreen Ausab, 145 (29.4%) were positive by PHA and 145 (29.4%) were positive by both Dainascreen Ausab and PHA. Nine (1.8%) were positive by only Dainascreen and there were none positive by only PHA. A good correlation was observed between the titer of the antibody by this method and IMx. The anti-HBs assay by this method was able to be completed within 15 minutes and the procedure was very simple. The results indicate that the sensitivity of Dainascreen is superior to PHA and that it is easy to use.

In order to evaluate the feasibility for the detection of antibody to hepatitis C (anti-HCV), the first generation assay (c100-3 Ab) and two second generation assays (2nd EIA and 2nd PHA) were used to test 477 individuals who visited the medical hospital or clinics in Iki Island, Nagasaki Prefecture. HCV RNA, antibody titer by 2nd PHA and four kinds of antibody to epitope of HCV by RIBA II were also surveyed to determine their association with these three assays. Prevalence of anti-HCV was 26.6% by c100-3, 38.8% by 2nd PHA and 39.6% by 2nd EIA, indications that the 2nd generation assays are much more sensitive than c100-3. Prevalence of HCV RNA was 82.1% among 190, anti-HCV positive individuals; 100% among 52 individuals with liver disease, but only 75.4% in those without liver disease. HCV antibody titer, over 2(11) was higher among those who were positive for HCV RNA than those negative for HCV RNA. Four antibodies by RIBA II were all positive and reacted strongly when they were positive for HCV RNA, but only antibody to core antigen was observed among those negative for HCV RNA, suggesting that only antibody to core antigen remains in those with past HCV infection.

A case of a HIV infected 61-year-old bisexual male with dilated cardiomyopathy (DCM) is reported. The death was originally recorded as from undetermined causes, but on autopsy, his heart showed left ventricular dilatation macroscopically, variety in size and vacuolation of cardiomyocyte, partial deciduation of cardiac muscle and diffuse perivascular fibrosis microscopically. These findings were compatible with DCM which was compounded by excessive weight loss. The further data indicated that the etiology of DCM in this case was directly related to the HIV infection.

To determine the efficacy of an additional low dose of intradermal injection of recombinant HB vaccine administered to nonresponders in addition to the standard three injections, we investigated the anti-HBs positive rate and titer of anti-HBs after four years among 58 subjects who did not develop antibodies after three doses of subcutaneous injections and who did develop the antibody after an additional low dose intradermal injection (Nonresponders), and compared them with 150 subjects who developed anti-HBs after three doses of subcutaneous injections (Responders). Fifty four subjects who were negative after four years were revaccinated with one or three doses of the subcutaneous injection. Anti-HBs positive rates after four years were 56.0 percent in Responders and 56.9 percent in Nonresponders, showing no differences. Eighty eight percent of 54 subjects who were given one or three doses of the vaccine developed anti-HBs. There were no differences in the antibody rates or titer of the antibody between the one and three doses groups. The decrease in titer of antibody was related to the levels initially having the most marked decrease in the level four years later. From these findings, we concluded that there were no differences of anti-HBs positive rates or antibody titer after four years in Responders and Nonresponders, and that one additional dose of the vaccine may be effective four years after initial administration among both groups.

A new immunochromatography assay technique (DAINASCREEN HBsAg, Dainabot) has been recently introduced for the detection of the presence of hepatitis B surface antigen (HBsAg). To evaluate the feasibility of using the DAINASCREEN HBsAg, we carried out comparison tests with this method and RPHA. Results obtained were as follows: In a test of 692 sera from inhabitants in Iki island, Nagasaki Prefecture, 24 (3.5%) were positive for HBsAg by both DAINA and RPHA. Twenty-four patients with hepatitis B were all positive in both methods. Thirty patients with autoimmune diseases and eight who had accidental needle exposure to the blood of patients with HBV infection were negative by both methods. Six individuals were followed over a period of 10 years and all eventually eliminated HBsAg from their sera. In four patients, HBsAg remained positive by DAINA at one yearly check after it had become negative by RPHA. In five patients, HBsAg remained positive by RIA and IMs after DAINA and RPHA had become negative. A good correlation was observed between DAINA and RPHA with a concordance rate of 99.5%. A good correlation of HBsAg titer between the two methods was observed and found to be significant (r = 0.87, p < 0.001). HBsAg assay was able to be completed within 15 minutes by DAINA and the procedure was simple. These results indicate that the sensitivity of DAINA is superior to RPHA and it is easy to use.

Two cases of Acquired Immune Deficiency Syndrome (AIDS) with disseminated non-tuberculous mycobacterial infection are reported. Both patients had hemophilia and were infected with Human Immunodeficiency Virus type 1 (HIV) by antihemophilic factor infusion. In case 1, a 44-year-old male, Mycobacterium marinum, which ordinarily causes cutaneous infection, was isolated from sputum before death and from the lung, spleen, bone marrow, liver and lymph node at autopsy. This is the first report of disseminated M. marinum infection with AIDS. In case 2, a 25-year-old male, Mycobacterium avium complex, which is the most common strain in non-tuberculous mycobacterial infection among patients with HIV, was isolated from the lung by TBLB and at autopsy from the lung, liver, spleen, bone marrow, lymph node, stomach, small intestine and testis. He also had a giant intraabdominal lymphadenopathy, associated with the M. avium complex infiltration. In conclusion, non-tuberculous mycobacteria can be easily disseminated in patients with AIDS because of dysfunction of cellular immunity, even when their primary lesions are not severe.

To evaluate the immunogenicity of the Chinese hamster ovary cell derived HB vaccine (CHB), CHB and yeast derived HB vaccine (YHB) were given to 110 medical students divided into four groups. CHB was given to group A subcutaneously (0.5 ml, 3 times) and to group B intradermally (0.125 ml, 3 times). YHB was given to group C (Y company) and to group D (Z company) subcutaneously (0.5 ml, 3 times). The anti-HBs positive rate at 7 months was 85.7% in group A, 95.8% in group B, and 100% in groups C and D. The percentage responding with high anti-HBs concentration (> or = 100 mIU/ml by RIA) at 7 months was 67.9% in group A, 79.2% in group B, 58.3% in group C and 63.3% in group D. Thus, although the anti-HBs positive rate was rather low when CHB was given subcutaneously, it was almost the same as YHB when given intradermally. The percentage of high responders to CHB given both subcutaneously and intradermally was high compared to YHB. These data suggest that CHB has almost the same immunogenicity to the conventional YHB.

A new micro particle enzyme immunoassay technique (MEIA, IMx HAVAB, Abbott) has been recently introduced for the detection of antibody to hepatitis A virus (anti-HA). To evaluate the feasibility of the IMx HAVAB, we carried out comparison tests between MEIA, RIA and EIA. Furthermore, we investigated the prevalence of anti-HA in Fukuoka City and Yonaguni Island, Okinawa, Japan using this method. Results obtained were as follows: In the test of 514 sera, 254 (49.0%) were positive by the three methods, and the remaining 260 (50.6%) were negative by the three methods. Examination of diluted sera using IMx revealed that IMx can be used as efficiently as RIA and EIA. Quantitative linear correlations were found between IMx and RIA (r = 0.973), and IMx and EIA (r = 0.969). Anti-HA was assayed within 45 minutes by IMx, and the procedure was simple because of the auto analyser used in this method. On Yonaguni Island, a significant decrease in the overall prevalence of anti-HA from 75.2% in 1980 to 61.1%, in 1990 (p less than 0.05) was found, the prevalence of anti-HA on Yonaguni Island in 1990 was significantly higher than in Fukuoka City (p less than 0.001). These results indicate that the sensitivity of IMx is equivalent to those of RIA and EIA, that it is easier to use than either RIA or EIA and that hepatitis A virus infection in Okinawa, has significantly decreased during the past 10 years, but is still significantly more frequent than in Fukuoka City.

A fully automated microparticle enzyme immunoassay (IMx AUSAB, Abbott) has been recently introduced for the detection of the presence of antibody to hepatitis B surface antigen (anti-HBs). The present trial was carried out to determine the feasibility of using the IMx AUSAB with sera and plasma, and for comparison with RIA (AUSAB, Abbott) and EIA (AUSAB EIA, Abbott). According to the kinds of vaccines used and locations of residents, the subjects were divided into six groups. Results obtained were as follows; In the test of 642 sera from 446 vaccines and 196 other inhabitants of Okinawa and Miyazaki prefectures, 388 (87.0%) were found positive for anti-HBs using IMx, 392 (87.9%) with RIA and 359 (80.5%) with EIA. Among those vaccinated with recombinant vaccines, 96.6% were found positive with IMx, 96.2% with RIA and 89.4% with EIA. Among subject vaccinated with plasma derived vaccines, 72.9% were found positive with IMx, 75.7% with RIA, and 68.5% EIA. Quantitative agreement between IMx and RIA among the six groups gave linear correlation coefficients ranging from 0.459 to 0.821. In the group vaccinated with the recombinant vaccine by K company (r = 0.459), anti-HBs was confirmed in many sera by IMx compared to that confirmed by RIA and EIA. In addition, anti-HBs was assayed within one hour by IMx and the procedure was simplified by autoanalyser equipped for this method. The results indicate that the sensitivity of IMx is equal to that of RIA and more than that of EIA, and that quantitative linear correlations were obtained between IMx and RIA, and IMx and EIA.

The new Micro Particle Enzyme Immunoassay technique (MEIA, IMx HBc-M, Abbott) had been recently introduced for the detection of IgM class antibody to hepatitis B core antigen (IgM anti-HBc). To evaluate the feasibility of using the IMx HBc-M, we carried out comparison tests between this method. RIA and EIA using sera from acute hepatitis B and type B chronic liver disease. Results obtained were as follows: In the test of 98 sera from acute hepatitis B patients, 92 (93.9%) were positive for IgM anti-HBc by IMx HBc-M, 96 (98.0%) by RIA and 82 (83.7%) by EIA. The four sera which were positive by RIA, but not by IMx were ones obtained from 5 to 12 month after onset. In the test of 267 sera from B type chronic liver disease patients, 93 (34.8%) were positive by IMx HBc-M, 109 (40.8%) by RIA and 23 (8.6%) by EIA. There was a difference in the positive rate between IMx HBc-M and RIA among type B chronic liver disease: the positive rate was higher in RIA than in IMx HBc-M among type B active chronic hepatitis, but only a little higher in IMx HBc-M than RIA among hepatocellular carcinoma. IgM anti-HBc titer was significantly higher in acute hepatitis type B than in chronic liver disease, and was so even in the phase of HBsAg negative in acute hepatitis. IgM anti-HBc was assayed within 45 minutes by IMx, and the procedure was simple because of the auto analyser used in this method.(ABSTRACT TRUNCATED AT 250 WORDS)

The new Micro Particle Enzyme Immunoassay technique (MEIA, IMx HBc, Abbott) has been recently introduced for the detection of the antibody to hepatitis B core antigen (anti-HBc). To evaluate the feasibility of using the IMx-HBc, we carried out comparison tests with this method and RIA using various sera. Results obtained were as follows: In the test of 813 sera, 427 (52.3%) were positive by both IMx and RIA, two (0.2%) were positive by RIA only, and the remaining 384 (47.3%) were negative by both methods. A good correlation between IMx and RIA was observed with a coincidence rate of 99.8% and a correlation coefficient of 0.969. Examination of diluted sera using IMx revealed that IMx can be used as efficiently was RIA: high anti-HBc titer was found among HBsAg carriers, but not among non HBsAg carriers. Anti-HBc was assayed within 45 minutes by IMx, and the procedure was simple because of the auto analyser used in this method. These results indicate that the sensitivity of IMx is equivalent to that of RIA, and that it is easier to use than RIA.

The new Micro Particle Enzyme Immunoassay technique (MEIA, IMx HBsAg, Abbott) has been recently introduced for the detection of the presence of hepatitis B surface antigen (HBsAg). The present trial was carried out to determine the feasibility of using the IMx HBsAg with sera and plasma, and for comparison with RIA (Ausria II, Abbott) and RPHA (Reversecell, Megroken). Results obtained were as follows: In the test of 622 sera from inhabitants in Okinawa, 455 (73.1%) using IMx were positive for HBsAg, 454 (73.0%) with RIA, and 330 (53.0%) with RPHA. Five of the 179 tests using plasma from hemodialysis patients were positive for HBsAg with both IMx and RIA. One of these 5 was negative for HBsAg with RPHA. The difference of HBsAg positive rates between IMx and both RIA and RPHA increased with advancing age. Twenty four individuals were followed up from three to ten years and had had it confirmed that HBsAg had become negative in their sera, HBsAg was still positive from one to four years in both IMx and RIA after HBsAg became negative in RPHA. It was noted that HBsAg was assayed within one hour by IMx, and that the procedure was simple because of the autoanalyser equipped for this method. The results indicate that the sensitivity of IMx might be equal to that of RIA more than that of RPHA, and easier to measure than either of the others.

HTLV-I seroprevalence in the southern part of Miyazaki prefecture was reported to be high in many seroepidemiological surveys. In order to determine the distribution of antibody to Human T-cell lymphotropic virus type I (anti-HTLV-I) in the Kushima district of Miyazaki prefecture and evaluate the relation between the HLTV-I carrier and disease, determination of anti-HTLV-I status of patients in a hospital in Kushima City, Miyazaki prefecture was carried out from March to July, 1985. Sera from 542 patients was tested for presence of anti-HTLV-I by particle agglutination (PA) and indirect immunofluorescence (IF). Results obtained area as follows 1) Overall prevalence of anti-HTLV-I was 31.2 per cent (169 of 542 individuals). It increased gradually with age and elevated remarkably in the 60-69 age group, showing the highest rate of 39.6 per cent. 2) Prevalence of anti-HTLV-I was 28.6 per cent (65 of 227) in males and 33.0 per cent (104 of 315) in females. A significant difference by sex was not recognized. 3) No significant difference was found in the geographical distribution of anti-HTLV-I, but prevalence in the Toi area was relatively low. 4) Anti-HTLV-I was prevalent in the patients with tuberculosis (46.2 per cent), most of whom had a history of blood transfusion. In this study, the relation between HTLV-I carriers and diseases was not analysed. 5) Seroprevalence of anti-HTLV-I in the patients who had had blood transfusions was significantly higher than that of those who had not had blood transfusions (p less than 0.01).

The Kyusyu district is known as an endemic area of HTLV-I. But the prevalence of anti-ATLA in Saga prefecture was reportedly relatively low. In this study, in order to determine the distribution of antibody to ATL-associated antigen (anti-ATLA) in the Karatsu and Higashimatsuura districts of the northern Kyusyu, the determination of anti-ATLA status of patients in Karatsu Red Cross Hospital was carried out from September to October, 1985. Sera from 757 patients were tested for presence of anti-ATLA by Enzyme immunoassay (EIA) prepared by Eisai Co., Ltd. Tokyo, Japan. Results obtained are as follows: 1) Overall prevalence of anti-ATLA was 13.7 per cent (104 of 757 individuals). Prevalence of anti-ATLA increased with age, reaching a maximum of 21.1 per cent for people from 60 to 69 years old. 2) Prevalence of anti-ATLA was 9.5 per cent (36 of 376) in males and 17.8 per cent (68 of 381) in females. A significant difference by sex was recognized. (p less than 0.001) 3) The positive rates of patients with non-malignant diseases were high in the Chinzei, Hizen, and Hamatama areas facing the Sea of Genkai. The positive rate of the seaside area was significantly higher than that of the mountain area. (p less than 0.001). 4) Anti-ATLA was most prevalent in the patients with neoplasms (26.1%). The positive rate of ATL patients was 100 per cent, and that of patients with malignancies other than ATL was 25.9 per cent. These results suggest that HTLV-I infection is likely to increase the incidence of other types of malignancy.

Sera from 69 adult prostitutes, 139 juveniles in the reformatory for boys, and 63 juveniles in the reformatory for girls, were collected between 1986 and 1987 in Fukuoka City. These samples were tested for the presence of antibody to human T-cell leukemia virus type-I (anti-HTLV-I), for hepatitis B surface antigen (HBsAg), and for antibody to hepatitis B core antigen (anti-HBc). The juveniles in the reformatory for girls were surveyed for the incidence of venereal diseases (VD) and for a history of intravenous drug use. Anti-HTLV-I was detected in 5.8% of the prostitutes, 0.7% of the boys, and 1.6% of the girls. Prevalence of anti-HTLV-I among the prostitutes was higher than that among the controls, but no significant difference was recognized. HBsAg was detected in 7.2% of the prostitutes, but was absent in the boys and girls. Prevalence of HBsAg among the prostitutes was higher than that among the controls, but no significant difference was recognized. Anti-HBs was detected in 39.1% of the prostitutes, 10.1% of the juvenile boys, and 17.5% of the juvenile girls. In each group prevalence of anti-HBc was higher than that in the controls. Especially between the prostitutes and the controls a significant difference was recognized (p less than 0.005). In the reformatory for girls anti-HBc was detected in 40.0% of 11 girls who were exposed to VD and in 7.0% of 43 girls who were not exposed to VD. Prevalence of anti-HBc among the exposed group was significantly higher than that among the non-exposed group (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)