We report a patient with candidemia, and remote organ infection, who underwent surgical treatment of aortic valvular stenosis. The patient was a 77-year-old man. Candida glabrata was detected in a blood culture during pharmacological treatment for pyelonephritis associated with vesicoureteral transition stenosis. A ureteral stent had been placed to preserve urine outflow, and vesicoureteral surgery had been scheduled. However, the urological surgery had to be performed first because of severe aortic valvular stenosis. After long-term (5 months) of antifungal treatment, Candida was no longer detected in the urine or blood cultures, but the serum β-D-glucan level did not fall below the reference value (21.6 pg/ml at the last measurement). It was difficult to control the infection further, and we decided to perform aortic valve replacement. There was no evidence of endocarditis at surgery, but pathological examination revealed traces of the fungus in the tissue of the aortic valve. The post-operative course was uneventful, and urological surgery was carried out 45 days later. Infection recurred when the antifungal medication was temporarily discontinued. The infection was then controlled by resumption of the antifungal medication. The patient has been free of recurrence for the past year since the aortic valve replacement. In the present case, in which a mycosis from a remote source was not readily eradicated prior to valve replacement, we were able to obtain good results by first administering long-term antifungal medication to quell the inflammation as much as possible.

We herein report a 79-year-old man who developed anaphylactoid purpura after thoracic endovascular aortic repair, which he underwent for a distal aortic arch aneurysm of saccular type. On the third postoperative day he had purpura over his lower legs and abdomen accompanied by intermittent fever. His serum C-reactive protein concentration reached a maximum of 12 mg/dl, and remained at around 4 mg/dl thereafter. A dermatologist diagnosed anaphylactoid purpura ; this gradually improved with topical steroid and the nature and dosage of the oral medication. We suspected the presence of malignancy ; however, appropriate investigations failed to identify a cause for the purpura. During 6 months of outpatient follow up he has been free of recurrence. Anaphylactoid purpura occurs most frequently in childhood, often after an upper respiratory tract infection, whereas this condition is rare in adults. Triggers for anaphylactoid purpura include surgery, infection, certain medications, chronic lung, liver, or renal failure, and malignancy. We believe that the stress of undergoing thoracic endovascular aortic repair was the trigger in this case. Anaphylactoid purpura may be complicated by arthritis, gastrointestinal involvement and renal manifestations. There were no such complications in this case.

Background : A vitamin K₂ agent has recently been approved and is going to be marketed for the treatment of osteoporosis. Since vitamin K₂ agents are known to cause rebound of blood coagulation capacity lowered by an anticoagulant warfarin, a great caution is necessary for the concomitant use of these agents.
Objective and Design : A drug utilization survey to examine the use of warfarin and drugs for osteoporosis.
Methods : Fukui Medical School Database was surveyed to identify patients who used warfarin and/or drugs for osteoporosis during the period between January 1, 1988 and July 31, 1995. Patients with a diagnosis osteoporosis made between December 1, 1983 and July 31, 1995, were also identified and their prescription data were extracted to examine the combined use of warfarin and drugs for osteoporosis. In addition, 53 outpatients with cardiovascular diseases were interviewed to know the treatments and medications given by other clinics.
Results : Concomitant drug therapy for osteoporosis was given to 6.9% (56/813) of warfarin users. The proportion of concomitant use was 15% (36/234) in women, much higher than 3.5% (20/579) in men. More than 10% of the interviewed patients were receiving some treatments in other orthopedic clinics for osteoporosis or other diseases but few patients were aware of their medication.
Conclusion : Old female users of warfarin, especially those having osteoporosis concomitantly, are likely to berome a high risk group for the possible interaction between warfarin and the vitamin K₂ agent. Useful information on the safety associated with the interaction between these two drugs should be given to this group of patients as well as to the prescribers and dispensers.