Vasculitis is pathologically identified as specific cellular inflammation, vessel destruction, and tissue necrosis. Current classifications of vasculitis such as the Chapel Hill Classification (CHCC) and American College of Rheumatology (ACR) guidelines are not sufficiently adequate for clinicians to diagnose vasculitis. The biomarkers that are currently in clinical use such as PR3-ANCA and MPO-ANCA, only help in diagnosing small vessel vasculitis and their sensitivity and specificity are not sufficient. However, recent developments related to the pathogenesis and etiopathogenesis of vasculitis have the potential to contribute to new and improved biomarkers. The determination of diverse roles of ANCA and synergistic effects of infection, genetic, environmental factors and drugs on pathogenesis is quite important. The demonstration of a new autoantibody directed to hLAMP-2 and the resemblance to some microbial structures, in addition to the determination of the possible roles of hepatitis B and C on vasculitis are important findings. These hints may lead to new biomarker developments, providing a better method to diagnose vasculitis. The evidence on T cell immunity as circulatory and lesional will likely contribute to the development of new drugs for vasculitis.

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Objective To evaluate the possible therapeutic effect of ambroxol on pulmonary fibrosis induced by paraquat.
Methods Adult male Sprague-Dawley rats (n=144, 200-250 g) were divided into four groups (Control, Ambroxol, Paraquat, and Paraquat+Ambroxol group) and sacrificed on day 1, 3, 5, 7, 14 and 28. Several significant oxidant stress markers (MDA, SOD and GSH-PX), MPO activity, cytokines (TNF-α, MCP-1, TGF-β1, MMP-2 and TIMP-1), total inflammatory cell count, hydroxyproline content, collagen I and III mRNA were analyzed.
Results In Paraquat group, the MDA, MPO activity, hydroxyproline contents, the mRNA expression of TNF-α, MCP-1, TGF-β1, MMP-2, TIMP-1, collagen I, collagen III and the number of total inflammatory cells were up-regulated in lung tissue, but SOD and GSH-PX activity were down-regulated in lung tissue compared with Control group (p<0.05). In paraquat+ambroxol group, the MDA, MPO activity, hydroxyproline content, the mRNA expression of TNF-α, MCP-1, TGF-β1, MMP-2, TIMP-1 collagen I, collagen III and the number of total inflammatory cells were significantly decreased, while the SOD and GSH-PX activities in lung tissue were increased compared with Paraquat group (p<0.05). Histological examination of paraquat-treated rats showed lung injury with interstitial edema and widespread inflammatory cell infiltration in the alveolar space and septum, as well as pulmonary fibrosis. Ambroxol could markedly reduce such damage in lung tissue and prevent pulmonary fibrosis.
Conclusion The results of this study indicated that ambroxol could reduce lung damage and prevent pulmonary fibrosis induced by paraquat.

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Objective Recent evidence has strongly suggested that atherosclerosis is an angiogenic disease, and PEDF may play a significant role in determining the balance of angiogenesis/antiangiogenesis during atherogenesis. Therefore, we assessed the associations among plasma levels of pigment epithelium-derived factor (PEDF), high-sensitivity C-reactive protein (hsCRP), the lipid profile and tissue characteristics of coronary plaque as assessed by integrated backscatter intravascular ultrasound (IB-IVUS).
Methods Fifty-two consecutive patients with stable coronary artery disease who underwent percutaneous coronary intervention were enrolled. Non-target coronary lesions with mild to moderate stenosis were measured by IB-IVUS. A total of 20 IB-IVUS images were recorded at an interval of 0.5 mm for a length of 10 mm in each plaque.
Results Although the percentage of plaque volume (%PV, 100×total PV/total vessel volume), percentage of lipid volume (%LV, 100×LV/PV) and percentage of fibrous volume (%FV, 100×FV/PV) were not associated with plasma log[PEDF] levels in the overall patients, in the patients without statin treatment %LV and %FV were correlated with plasma log[PEDF] levels (r=0.525, p=0.021 and r=-0.498, p=0.030, respectively).
Conclusion The plasma level of PEDF may be a useful biomarker for predicting the tissue characteristics of coronary plaque using IB-IVUS.

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Objective Sleep-disordered breathing (SDB) is a potential risk factor for cardiac sudden death. Recent studies have reported that patients with type 2 diabetes mellitus (T2DM) frequently suffer from SDB. Although the roles of hyperglycemia, disturbances of the autonomic nervous system and obesity have been postulated, the factors related to SDB in T2DM, especially those related to improvement of SDB remain unknown. We investigated the significance of waist circumference (WC), representing excess visceral fat, body mass index (BMI), glycemic control and other clinical parameters on SDB in T2DM.
Methods and Subjects Forty inpatients received treatment for T2DM. Overnight cardiorespiratory monitoring and laboratory tests were conducted before and after treatment of T2DM.
Results The apnea-hypopnea index (AHI) at admission correlated positively with BMI, neck circumference, WC, and systolic and diastolic blood pressures, but not with Log 1,5-anhydro-D-glucitol (1,5-AG) and presence or absence of diabetic neuropathy. Stepwise multiple regression analysis identified BMI and WC as significant determinants of AHI. After 2 or 3 weeks of glucose-lowering therapy, hyperglycemia was controlled and significant reductions in AHI, BMI, WC, 1,5-AG, leptin, high-sensitivity C-reactive protein (hs-CRP), and an oxidative stress marker, thiobarbituric acid reactive substances (TBARS) were observed. The fall in AHI correlated significantly with changes in WC independent of BMI, 1,5-AG, leptin, hs-CRP, and TBARS.
Conclusion Our results demonstrated that reduction of WC correlated with improvement in SDB independent of glycemic control in T2DM, and that abdominal obesity might be a target for the treatment of SDB and prevention of potential cardiovascular diseases in T2DM.

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Objective The optimal therapeutic approach to patients with idiopathic membranous nephropathy (IMN) remains controversial. In this study, we assessed the efficacy of single daily dose cyclosporine (CsA) combined with low-dose prednisolone (PSL) and an angiotensin II receptor blocker (ARB) in patients with IMN.
Methods We studied 13 nephrotic patients (8 men, 5 women) with IMN diagnosed on biopsy. An initial single daily dose of 2 mg/kg, but not exceeding 150 mg, CsA was given for 12 months, tapered by a 25 mg reduction every 2 months. An initial twice-daily dose of 0.5 mg/kg PSL was given for 2 months and was also tapered. An ARB was given to all patients and the same dosage was used throughout the study. Patients were followed up for 6 to 66 months.
Results Nine patients achieved complete remission at 6.7±2.9 months, and incomplete remission was obtained in the remaining patients. After a follow-up period of 32.7±20.0 months, their serum creatinine and estimated glomerular filtration rate values were similar to baseline levels. The 9 patients who completed the treatment course have not relapsed. Moreover, there were no adverse effects requiring discontinuation of this triple therapy.
Conclusion A single daily dose of CsA combined with a low dose of PSL and an ARB in new-onset nephrotic patients with IMN induced a high remission rate of nephrotic syndrome, with a low incidence of relapse and a low risk of adverse effects. The triple therapy and prospective follow-up shows potential as a treatment approach for patients with IMN.

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Background Despite the use of inhaled corticosteroid (ICS) becoming increasingly widespread, many problems related to asthma management still need to be addressed. One of them, obesity, has been reported to exert a harmful influence on asthma control. However, there have been few reports focusing not only on both obesity and its influence on Japanese asthma patients but also on the Japanese definition of obesity, as defined by the Japan Society for the Study of Obesity (JASSO).
Aims & Methods The aim of this study was to confirm the influence of obesity, as defined by the JASSO, on asthma management in Japanese asthmatic patients. Using data from the Niigata Asthma Treatment Study Group 2008 questionnaire survey, differences between the "normal" group (18.5 kg/m² ≤ BMI <25 kg/m²) and the "obese" group (25 kg/m² ≤ BMI) were analyzed.
Results There was a significantly lower step 1 rate (19.4% v.s. 26.8%) and a higher proportion of patients using inhaled salmeterol (43.6% v.s. 35.8%) and leukotriene receptor antagonist (49.8% v.s. 40.8%) in the obese group relative to the normal group, although there were no significant differences in indicators of asthma control, including asthma control test scores.
Conclusion This study investigated influences of JASSO-defined obesity on asthma severity and management in a clinical setting in Japan. It is possible that there are strong interactions between asthma and obesity, such as obesity causing decreased ICS therapy efficacy and leukotriene (LT)-related inflammation, although further investigation is necessary.

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Objective Several scoring systems have been derived to identify patients with severe community-acquired pneumonia (CAP). Recently, España et al (Am J Respir Crit Care Med 174:1249-1256, 2006) developed a clinical prediction rule that predicts hospital mortality, the need for mechanical ventilation, and risk for septic shock. We assessed the performance of this rule and compared it with other published scoring systems.
Methods A prospective study was conducted of patients with CAP who were hospitalized at our hospital from April 2007 till May 2009. Clinical and laboratory features at presentation were recorded and used in order to calculate España rule, the pneumonia severity index (PSI), CURB-65, A-DROP, the 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) prediction rule and SMART-COP. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were compared for adverse outcomes. We also assessed the association of the España rule criteria and adverse outcomes.
Results A total of 505 patients were enrolled in the study. The overall in-hospital mortality rate was 6.5%, and 6.3% of patients were admitted to the intensive care unit (ICU). Sixty-two (12.3%) patients were defined as having severe CAP (in-hospital death or need for mechanical ventilation or septic shock). España rule achieved highest sensitivity and NPV in predicting severe CAP. When ICU admission was the outcome measure, the IDSA/ATS rule and SMART-COP were regarded to be good predictors.
Conclusion España rule performed well in identifying patients with severe CAP. As a result, each of the severity scores has advantages and limitations for predicting adverse outcomes.

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Objective Barometric pressure has been reported as a triggering and exacerbating factor in migraine headaches, although there are few reports concerning the association of weather change and migraine headache. The relationship between barometric pressure changes and migraine headaches was prospectively examined.
Methods A total of 28 migraine patients who lived within 10 km of the Utsunomiya Local Meteorological Observatory kept a headache diary throughout the year. Daily and monthly mean barometric pressure data of the Utsunomiya Local Meteorological Observatory were obtained via the homepage of the Meteorological Office.
Results The correlation between headache frequency obtained by the headache diaries for 1 year and changes in the barometric pressure during the period of 2 days before and 2 days after the headache onset were evaluated. The frequency of migraine increased when the difference in barometric pressure from the day the headache occurred to the day after was lower by more than 5 hPa, and decreased when the difference in barometric pressure from the day the headache occurred to 2 days later was higher by more than 5 hPa. Of 28 patients, weather change was associated with migraine headache development in 18 (64%) patients, 14 of which reported low barometric pressure to be a cause of headache. There was no association between the monthly mean barometric pressure and headache frequency throughout the year.
Conclusion Barometric pressure change can be one of the exacerbating factors of migraine headaches.

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Background/Aims Erythropoietin (EPO) has been widely used for the treatment of anemia in chronic kidney disease (CKD). A growing body of evidence indicates that the therapeutic benefits of EPO could extend beyond the improvement of anemia. The aim of the present study was to determine whether EPO affects renovascular and oxidative stress biomarkers in pre-dialysis CKD patients with anemia.
Methods The study was a single-arm prospective study. Fifteen CKD patients (9 males and 6 females, mean age 63 years) with anemia (mean Hb: 8.1 g/dL) were treated with recombinant human EPO; 12,000 U administered subcutaneously once every 2 weeks. Various parameters were measured before and 6 months after treatment. These included serum hemoglobin (Hb), creatinine, estimated glomerular filtration rate (eGFR), proteinuria, urinary liver-type fatty acid binding protein (L-FABP - a biomarker of renal injury), urinary 8-hydroxydeoxyguanosine (8-OHdG - a marker of oxidative stress), serum asymmetrical dimethylarginine (ADMA), carotid artery intima-media thickness (IMT) and brachial-ankle pulse wave velocity (baPWV) as vascular markers and plasma brain natriuretic peptide (BNP) levels and left ventricular ejection fraction (LVEF) as cardiac function markers and cardio-thoracic ratio (CTR) and inferior vena cava dimension (IVCS) as extra fluid retention markers.
Results After 6 months, serum Hb was significantly increased (p<0.001) and urinary levels of protein, L-FABP and 8-OHdG, carotid IMT, baPWV, plasma BNP and serum ADMA levels were significantly decreased (p<0.001). Serum creatinine, eGFR, LVEF, CTR and IVCS showed little difference throughout the experimental period.
Conclusion These data suggest that recombinant human EPO may ameliorate renal injury, oxidative stress and progression of atherosclerosis in addition to improving anemia in CKD patients.

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Objective Candiduria is a common finding in the growing population of very old patients that has not been previously studied. The objective was to study candiduria in the population aged 85 and over, including an estimation of the incidence, factor of acquisition, and evaluation of treatment and mortality.
Methods retrospective monocentric study.
Materials medical charts of patients aged of 85 and over who have candiduria diagnosed at Nimes University Hospital.
Results The prevalence of candiduria in the hospitalized very old patients was 8.9%. More than half of strains isolated were C. albicans (59%). Mean age was 89.7 years old with 53 women and 20 men. Urinary catheter (55%) and prior antibiotic use (67%) were commonly found. Fifteen patients with candiduria were treated, consistently with fluconazole. Patients treated had higher Mini Mental Test score than the others. A high C-reactive protein level, Mac Cabe score or Charlson's score >7 were associated with 6 months mortality.
Conclusion Episodes of candiduria in oldest old were associated with frailty and vulnerability of the patient. The medical decision for antifungal treatment is usually difficult to make but it did not seem to influence mortality.

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A 57-year-old man was admitted to another hospital for hematemesis due to heavy drinking. A Sengstaken-Blakemore tube was inserted and the patient was transferred to our hospital. The patient's ensuing movements inadvertently caused an esophageal rupture 2.5 cm in size. Since the patient's condition was stable, treatment via endoscopic repair using metallic clips was chosen over emergency surgery. Two hemoclips were fixed at the ends of the ruptured area; by employing an endoscopic detachable snare, the ruptured area was carefully repaired with 10 metallic clips. As a result, the esophageal rupture could be successfully repaired by endoscopic procedure rather than performing surgery.

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An epithelial cyst in an intrapancreatic accessory spleen (ECIAS) is a rare disease that is commonly misdiagnosed preoperatively. To identify the clinical and imaging features of ECIAS, we reviewed the relevant medical literature. Twenty-one cases of ECIAS were identified, including our own. The cases were mainly diagnosed as mucinous cystic neoplasm (MCN) preoperatively based on clinical and imaging features, such as, a woman in middle age; elevation of serum CA19-9 levels; location in the tail of the pancreas; and a solid component resembling a mural nodule. ECIAS is another lesion to be considered in the differential diagnosis of MCN.

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A 38-year-old man presented to our hospital with abdominal pain and melena. Gastrointestinal endoscopy revealed a large gastric ulcer, and the pathological diagnosis of diffuse large B-cell lymphoma (DLBCL) was made based on immunohistochemical findings. Left diplopia developed soon after commencement of chemotherapy. Despite normal findings from head MRI, orbital involvement in DLBCL was detected with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). The patient was treated with salvage chemotherapy with success. Treatment analysis using FDG-PET for patients with DLBCL, especially for those with clinical symptoms and negative findings on conventional modalities, may be useful for assessing disease status and adjusting treatments.

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We describe a case of advanced atrioventricular (AV) block, in which treatment with cilostazol was effective in recovering the AV conduction. The patient was referred to our hospital for close examination of the advanced AV block and permanent pacemaker implantation. Although the patient had experienced third-degree AV block with occasional AV synchrony for more than two days, the AV conduction completely recovered after treatment with oral cilostazol at 200 mg/day. Here we discuss the possible mechanism of the improvement in the AV conduction by cilostazol.

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A young woman who was experiencing repeated convulsions was admitted. The patient's brain magnetic resonance image revealed reversible posterior leukoencephalopathy. Blood pressure fluctuated at times to more than 200 mmHg, and the measurement of the right and left upper arms differed by approximately 70 mmHg. Enhanced computed tomography revealed stenotic lesions of some arteries including the left renal artery. Such findings led to an initial diagnosis of Takayasu arteritis and hypertensive encephalopathy caused by renovascular hypertension. A percutaneous transluminal renal angioplasty was successfully performed. The patient's blood pressure returned to normal value without the use of antihypertensive drugs.

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Acute myocardial infarction is a life-threatening condition. Coronary dissection after blunt chest trauma is a rare event. Chest pain is a common symptom after chest trauma, which may relate to chest contusion without cardiac injury or myocardial infarction. Differentiation between minor cardiac contusion and significant cardiac injury is difficult and it is a challenge for physicians to diagnose traumatic cardiac injury early. We report a case of a 40-year-old man suffering from coronary artery dissection after a blunt chest trauma and intracranial hemorrhage after percutaneous coronary intervention.

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Propylthiouracil (PTU) is an antithyroid drug which is known to cause drug-induced vasculitis. PTU is implicated in 80-90% of cases of anti-neutrophil cytoplasm circulating antibody (ANCA)-associated vasculitis caused by anti-thyroid drugs which induce ANCA production. Sweet's syndrome is characterized by fever, leucocytosis, neutrophilia and the sudden onset of painful skin lesions. The pathology of the disease is still unclear. Cytokine dysregulation including interleukin-6 and endogenous granulocyte colony-stimulating factor (G-CSF) are thought to play a role in the pathogenesis of Sweet's syndrome. PTU and G-CSF are known to cause Sweet's syndrome and other neutrophilic dermatosis. The presence of ANCA can have a diagnostic value in Sweet's syndrome. Systemic corticosteroids are the first-line therapy for both diseases. Here we report a female patient with Graves' disease who developed ANCA and Sweet's syndrome after using PTU and G-CSF.

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Resistance to thyroid hormone (RTH) is characterized by elevated serum levels of thyroid hormones and normal or slightly increased serum thyrotropin (TSH) levels. Recently it has been suggested that chronic TSH stimulation in RTH activates intrathyroidal lymphocytes, leading to thyroid damage and autoimmune thyroid disease (AITD). Therefore, individuals with RTH have an increased likelihood of AITD compared to unaffected relatives. We here report a 33-year-old woman in whom we diagnosed Graves' disease and treated her with thiamazole (MMI). For two years, her TSH levels were suppressed when thyroid hormones were elevated and conversely they were increased when thyroid hormones levels were decreased. These findings were common for a clinical course during treatment for Graves' disease with anti-thyroid drug. However, three years after the initiation of MMI therapy, she had a normal or gradually elevated serum TSH level even though the level of thyroid hormones never decreased, indicating inappropriate secretion of TSH. We concluded she had RTH clinically, and we demonstrated by direct sequence analysis a mutation of the TRβ gene, causing replacement of a glycine (G) with arginine (R) at codon 251. The finding of an elevated TSH level without decreased thyroid hormones should suggest the presence of RTH during therapy of Graves' disease.

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Women with congenital adrenal hyperplasia (CAH) caused by steroid 21-hydroxylase deficiency show reduced fertility, especially with the salt-wasting form. A 27-year-old pregnant woman with this disease underwent laparotomy and oophorectomy to remove a multilocular ovarian tumor at 14 weeks of pregnancy. This proved to be a mucinous cystadenoma. Toward the third trimester, she presented with marked elevations of 17α-hydroxyprogesterone and plasma renin activity. Careful management of endocrine and body fluid homeostasis allowed her to give birth to a healthy female infant with normal external genitalia. This case illustrates endocrinological parameters during pregnancy in a woman with classical salt-wasting CAH.

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We herein describe the case of a 47-year-old woman with pre-clinical Cushing's syndrome caused by a left adrenal adenoma, which was diagnosed 6 years after trans-sphenoidal selective removal of a pituitary adenoma for acromegaly at age 35. The patient was started on bromocriptine and then somatostatin analogues after the surgery; however, since her serum insulin-like growth factor-1 (IGF-1) values remained above the age-adjusted normal range, the treatment for acromegaly was switched from somatostatin analogues to pegvisomant (10 mg daily), before a left laparoscopic adrenalectomy. After the subsequent adrenalectomy, the dose of pegvisomant could be reduced gradually to once every 4 days without any increase in the serum IGF-1 values. This is the first report describing the need for a different dose of pegvisomant for the treatment of acromegaly before and after adrenalectomy for pre-clinical Cushing's syndrome.

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Bezoars are concretions of foreign matter in the gastrointestinal tract which may cause nonspecific symptoms, including epigastric discomfort, early satiety, and constipation, and rarely gastrointestinal obstruction. We report a case in which the migration of bezoars led to secondary gastrointestinal obstruction. With endoscopy manipulation and chemical dissolution, such as with Coca-Cola, to disintegrate the gastric bezoars, the possibility that fragmented residuals may coalesce in the small intestine causing ileus should be considered when a patient presents with abdominal obstruction symptoms after these procedures. In this condition, abdominal plain film X-ray and computer tomography play important roles in timely diagnosis.

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A 34-year-old woman visited our hospital with chest pain and was diagnosed with acute myocardial infarction (AMI) on admission. Echocardiography imaging revealed the presence of complex masses in the aortic valve. As serum tumor marker CA19-9 was elevated, she was screened for malignant disease. A computed tomography (CT) scan revealed a solitary pulmonary nodule, but because the nodule was small and non-specific, CT follow-up was considered appropriate. However, she developed hemorrhagic stroke in the short term and was subsequently diagnosed with lung adenocarcinoma. Clinicians should be on alert for the occurrence of AMI in patients with small-size lung cancer.

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A 67-year-old man was referred to our hospital for a detailed medical examination of a bronchial polyp that was detected during chest computed tomography. Bronchoscopic examination revealed a tumor that almost occluded the main left bronchus. Nd-YAG laser treatment and tumor removal with biopsy forceps were conducted. On the basis of the histopathological and immunohistochemical features, large cell neuroendocrine carcinoma (LCNEC), T2aN0M0, stage IB was diagnosed. After induction chemotherapy with a combination of cisplatin and etoposide, a sleeve resection of the left main bronchus with telescoping bronchial anastomosis was performed. LCNEC typically occurs in the peripheral lung field, but here, we report a rare case of LCNEC arising from the left main bronchus.

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We report a 59-year-old man with intravascular large B-cell lymphoma (IVLBCL) associated with hemophagocytic syndrome, disseminated intravascular coagulopathy, and lung involvement. G-banding analysis of the metaphase spreads obtained from the bone marrow showed that the lymphoma cells were near-tetraploid and included two homologues of the 14q+ chromosome. Spectral karyotyping revealed that complex translocations occurred among chromosomes 3, 12, 14, and 19, and additional materials of 14q+ were from chromosome 19 with the breakpoint at 14q32 and 19q13. To the best of our knowledge, this is the first report describing t(14;19)(q32;q13) in IVLBCL.

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We report a case of Good's syndrome-associated pure red cell aplasia (PRCA) with myelodysplastic syndrome (MDS). In this case, effector memory T (T_EM) cells were expanded in the bone marrow. It remains uncertain whether the development of MDS was caused by the basic marrow defects or radiation therapy. However, since CD8⁺ perforin⁺ T_EM cells expanded in the bone marrow, as was previously described for 3 of our patients with thymoma-associated PRCA, it is highly possible that the pathogenic mechanism of PRCA that is accompanied by thymoma is related to the expanded CD8⁺ perforin⁺ T_EM cells in this MDS-complicated case.

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We report the case of a 68-year-old man who was diagnosed with Fournier's gangrene (FG), which developed during immunosuppresive treatment for idiopathic thrombocytopenic purpura (ITP). The patient was administered steroids for ITP but on the 36th day, he developed FG and septic shock. We initiated antibiotic treatment and drained a periproctal abscess immediately. On day 53, extensive drainage to progressive FG and a splenectomy was performed, following which both FG and thrombocytopenia improved. This is the first case of FG has developing in a ITP patient. It appears that high-dose immunoglobulin therapy and splenectomy should be considered earlier especially for a patient complicated with FG.

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A 40-year-old man presented with weakness of neck extensor muscles. Cervical magnetic resonance imaging showed high-intensity areas in muscles of the left lateral cervical region on T2-weighted images. Fluorodeoxyglucose-positron emission tomography scan demonstrated striking fluorodeoxyglucose uptake by multiple skeletal muscles of the neck, chest, and abdominal region. Muscle biopsy demonstrated peripheral T-cell lymphoma, unspecified. The diagnosis was primary skeletal muscle peripheral T-cell lymphoma. Primary skeletal muscle non-Hodgkin's lymphoma of T-cell immunophenotype is extremely rare and fluorodeoxyglucose-positron emission tomography demonstrated striking fluorodeoxyglucose uptake in multiple skeletal muscles and served as a quite useful modality for the diagnosis of this patient.

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A 66-year-old man was admitted to our hospital with muscle pain, fatigue and appetite loss that had lasted for a month. The patient was somnolent and had nuchal stiffness with a high fever. Cerebrospinal fluid (CSF) tests demonstrated lymphocytic pleocytosis with a decreased CSF-blood glucose ratio. The tests for tuberculous, fungal and carcinomatous meningitis and herpetic meningoencephalitis were negative. Endocrinological exams showed hypopituitarism and diabetes insipidus. A pituitary MRI showed an enlargement of the pituitary stalk. A diagnosis of lymphocytic hypophysitis with aseptic meningitis was made after the exclusion of secondary hypophysitis. Lymphocytic hypophysitis with aseptic meningitis can mimic subacute meningoencephalitis.

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Intracranial tuberculoma and neurocysticercosis (NCC) are the most frequent granulomatous infections in the central nervous system. Here we report a 41-year-old man with disseminated intracranial tuberculoma mimicking NCC. The patient complained of relapsing vertigo and vomiting consistent with Bruns syndrome. Serum antibodies against cysticercosis were positive. Magnetic resonance imaging (MRI) of the brain showed multiple disseminated ring-enhanced lesions. An initial diagnosis of NCC was made based on clinical signs and MRI. However, during antiparasitic treatment, the patient exhibited fever, meningitis signs, and positive cerebrospinal fluid findings for tuberculosis. The diagnosis was therefore corrected as tuberculoma. After three months of antituberculous treatment, the patient recovered clinically and on MRI. Our results highlight the importance of differential diagnosis of these two diseases in the early stage.

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A 50-year-old man with a 30-year occupational history of welding presented with low-grade fever, fatigue and persistent dry cough. Computed tomography (CT) of the chest revealed interlobular septal thickening and bilateral non-segmental patchy ground-glass opacities except in the sub-pleural zone. He revealed that he had inhaled nickel fumes 3 days previously at work. These findings suggested a diagnosis of pneumonitis induced by inhalation of nickel fumes. Fewer reports describe pneumonitis associated with the inhalation of nickel compared with zinc fumes. Although nickel compounds are particularly pernicious among the transition metals and more toxic than zinc compounds, nickel fume inhalation rarely induces lethal acute respiratory distress syndrome. Our patient was successfully treated with corticosteroid.

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Disseminated gonococcal infection (DGI) is quite a rare condition, especially in the Japanese population; only 10 cases have been reported in case notes and minutes. We describe a man in which Neisseria gonorrhoeae was suspected to have infected the patient through his pharynx. He developed chills, fever, tonsillitis, papules, tenosynovitis and migratory polyarthralgia without genitourinary symptoms. After conducting a literature review, we suggest that being male is a possible risk factor and that blood culture can be used for diagnosing DGI in Japan. DGI should be considered as a diagnosis for patients with fever, dermatitis and joint pain in Japan.

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