A 62-year-old woman was admitted to the hospital for acute pancreatitis and underwent sustained intraarterial infusion therapy and drainage for pseudocyst of the pancreas. She needed fasting and long term central venous nutrition and was administered MVI as a multivitamin.On 4th month after admission, she developed pancytopenia. Since the origin was obscure at first, she was treated with blood transfusion, infusion of platelets, and G-CSF but in vain. When serum level of folic acid was measured, the level was as low as 0.8ng/ml. At this time, pancytopenia due to folic acid deficiency was diagnosed . Percutaneous injection of folic acid everyday provided a rapid improvement.We have to give a multivitamin containing folic acid for patients who require long-term central venous nutrition more then three months like this case. In addition macrocytic anemia had appeared prior to pancytopenia due to folic acid deficiency in this case, and at that time we had to suspect folic acid deficiency. We regret not to do so in this case.

It has been proved that antibiotics binding to penicillin-binding protein 3 (PBP3) are associated with the greater release of endotoxin than those that bind to PBP2 in both in vitro and animal models. The aim of this study is to evaluate the potential clinical implications of antibiotic-induced endotoxin release after hepatic resection. Forty-five patients who underwent hepatic resection in our clinic were enrolled. The patients were divided into two groups. Group A (n = 26): antibiotics that bind primarily to PBP3, including cefmetazole (CMZ), latamoxef (LMOX), flomoxef (FMOX), were used. Group B (n = 19); antibiotics that bind to both PBP2 and PBP3, including cefazolin (CEZ), cefoperazone (CPZ), cefotiam (CTM). Postoperative complications, liver functional tests, and chemical mediators [endotoxin, interleukins (IL-6, IL-8), tumor necrosis factor alpha (TNFalpha), granulocyte colony-stimulating factor (G-CSF), hepatotrophic growth factor (HGF) were examined after hepatic resection. There were no significant differences in the backgrounds of the two groups. Eight patients in each group developed postoperative complications; in particular, 9 of 13 patients with biliary tract carcinoma developed postoperative complications. No significant elevation of peripheral blood endotoxin was noted by the endospecy method, in any of the patients, although six died following sepsis. Pre- and postoperative levels of cytokines showed no significant difference between the two groups. Our data suggest that clinical antibiotic-induced endotoxin release would not occur after hepatic resection regardless of the antibiotic, probably owing to continuous scavenging of endotoxin from peripheral blood.

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