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Aspergillus udagawae and A. fumigatus share similar morphological features but they differ genetically. There is also an important clinical distinction as A. udagawae is less sensitive to amphotericin B than A. fumigatus. We encountered a rare case of bronchial infection due to A. udagawae that was successfully treated with voriconazole. An 82-year-old woman with diabetes mellitus complained of bloody sputum. Bronchoscopy revealed a white plugged region at the origin of the right bronchi B5. Cytological study revealed a clot composed of filamentous fungi and Aspergillus spp. was detected by culture. Molecular analysis revealed that the causative agent was A. udagawae, and voriconazole was used for the treatment. In comparison to A. fumigatus, the A. udagawae strain isolated in this case was less sensitive to amphotericin B, less virulent in immunosuppressed mice, and more sensitive to hydrogen peroxide, features that are almost identical to those of the previously reported isolates of the fungus. We should be aware of the emergence of new Aspergillus species that might pose a clinical threat.

Although the diagnostic significance of isolating Aspergillus spp. from respiratory cultures has been studied in immunocompromised hosts with invasive pulmonary aspergillosis (IPA), little is known of such infections in immunocompetent patients with other forms of aspergillosis. In this study of adult pneumology ward patients, we examined the association between Aspergillus spp. and disease prevalence. Laboratory records from April 1998 to March 2009 were reviewed to identify patients with Aspergillus spp. in respiratory samples. Correlations between the isolated species and clinical characteristics of patients were evaluated. During the study period, 165 Aspergillus spp. isolates were detected in the respiratory cultures of 139 patients. Of these patients, 62 (45%) were colonized with Aspergillus spp. and displayed no clinical symptoms of aspergillosis, while 77 (55%) had a form of pulmonary aspergillosis, characterized as either chronic necrotizing pulmonary aspergillosis (CNPA) (48%), aspergilloma (29%), IPA (13%), or allergic bronchopulmonary aspergillosis (ABPA) (10%). The dominant species were Aspergillus fumigatus (41%), A. niger (32%), and A. versicolor (12%). A. fumigatus was most commonly isolated in patients with IPA, aspergilloma, and CNPA, whereas A. niger was the dominant species in colonized patients and those with ABPA. Isolation of an Aspergillus spp. from respiratory samples does not confirm it as the etiologic pathogen because airway colonization by Aspergillus spp. is a common feature in several chronic lung diseases. Repeated isolation of the identical Aspergillus species and detection of anti-Aspergillus antibodies and/or Aspergillus antigens in sera are needed to determine the isolate represents the etiologic agent of disease., (© 2011 ISHAM)

Lemierre's syndrome is characterized by a primary oropharyngeal infection in a young healthy person who subsequently develops septic thrombophlebitis of the internal jugular vein and metastatic abscesses. We here report an uncommonly severe case of Lemierre's syndrome with acute respiratory distress syndrome (ARDS), in which polymyxin B-immobilized fiber (PMX) was used as supportive therapy. A 30-year-old, previously healthy man presented with sore throat, fever, rigor, and dyspnea. Chest computed tomography scan revealed multiple bilateral peripheral pulmonary nodules with small bilateral pleural effusions. The patient's condition rapidly deteriorated into ARDS after admission. Intubation followed by mechanical ventilation was required, and hemoperfusion with PMX was useful in alleviating the patient's condition. Isolation of Fusobacterium necrophorum from the blood culture and the contrast-enhanced scan revealed thrombosis and thrombophlebitis in the left internal jugular vein. The patient was diagnosed with Lemierre's syndrome, and an alternative treatment regimen with prolonged administration of ampicillin, clindamycin, and metronidazole resulted in improvement of the patient's respiratory function and general condition. Our case indicated that PMX might be an effective supportive therapy in severe cases of Lemierre's syndrome with ARDS that possessed no indication of surgical interventions.

Cryptococcal pleuritis is rare in individuals with no underlying disease. We report a case of pulmonary cryptococcosis followed by pleuritis in a patient on fluconazole treatment. Biopsy of the pleura revealed a granuloma and a cryptococcal body, while PCR and sequence analysis of extracted DNA from the pleura proved the presence of Cryptococcus species, most likely C. neoformans. Voriconazole with flucytosine and drainage of the pleural effusion were effective in treating the patient.

We report a rare case of Legionella pneumophila pneumonia followed by invasive aspergillosis (IA). Legionellosis was ameliorated by the administration of ciprofloxacin, erythromycin, and corticosteroid as adjunctive therapy. Although intravenous administration of the corticosteroid was effective at reducing severe inflammation due to legionellosis, IA occurred at 12 days after admission. Combination therapy with micafungin and voriconazole was effective in this case; however, it remains necessary to exercise caution when making decisions regarding indications for corticosteroid use and observation in the treatment of severe pneumonia patients.

Amyopathic dermatomyositis (ADM) is a clinical subtype of dermatomyositis, characterized by the absence of motor weakness and the presence of normal muscle enzyme levels. ADM is sometimes accompanied by interstitial pneumonia that shows a rapid progressive course associated with a poor prognosis. We describe a 70-year-old man who presented rapidly progressive interstitial pneumonia associated with clinically ADM (C-ADM); he was successfully treated with polymyxin B-immobilized fiber column (PMX) hemoperfusion.

A 58-year-old man was admitted to our hospital with fever. The vegetation was confirmed by echocardiography on the tricuspid valve and Erysipelothrix rhusiopathiae was isolated by blood culture. The patient died due to heart failure, and tricuspid valve vegetation was confirmed on autopsy and the sample of Gram's staining showed gram-positive microcolonies. Although about 60 cases of E. rhusiopathiae endocarditis have been reported, Japanese cases are extremely rare.