Objective Many patients on hemodialysis for chronic renal failure suffer from progressive anemia. In hemodialysis patients with gastrointestinal bleeding, endoscopic examination often fails to identify hemorrhagic lesions. We surveyed hemodialysis patients with obscure gastrointestinal bleeding (OGIB) for the presence of intestinal lesions by capsule endoscopy (CE).
Methods Among 90 patients who underwent CE, 13 had hemodialysis-related anemia (8 men and 5 women, age 66.5±7.9 years, Hb 8.8±1.9 g/dL, mean ± SD) and 77 had non-hemodialysis anemia (47 men and 30 women, age 55.7±19.9 years, Hb of 11.9±3.1 g/dL). The types and distribution of hemorrhagic lesions were investigated by CE. All patients had signs or symptoms of gastrointestinal bleeding but no active bleeding site was detected by endoscopy. The CE-observed lesions were classified into reddening, erosions/ulcers, vascular lesions, and tumors. The characteristic features of each lesion and patient demographic data were compared.
Results Vascular lesions were significantly more frequent in the hemodialysis group than in the controls (p<0.001). Reddening was observed in all patients of the hemodialysis group and mainly found in the ileum. Erosions/ulcers were observed in 4 patients (30.7%) and were more frequent in the jejunum. Vascular lesions were observed in 8 patients (61.5%) and they were more frequent in the ileum. A submucosal tumor was seen in one patient. There were no significant differences in demographic factors between patients with erosions/ulcers and those with a vascular lesion.
Conclusion Vascular lesions are common in anemic hemodialysis patients with OGIB and should be considered in the differential diagnosis of anemia in patients on hemodialysis with OGIB.

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Objective Early detection of gastric cancer by screening endoscopy facilitates endoscopic treatment in place of open surgery. The aim of this study was to evaluate whether 2 years intensive training improved the detection of gastric cancer by screening endoscopy.
Methods An endoscopist who had trained for 6 years as a general physician, performed screening endoscopy at Imari Arita Kyoritsu Hospital before (group I) and after (group II) intensive training in the diagnosis of early gastric cancer in consecutive patients.
Results Background characteristics, including age (61.6 vs. 62.2 years) and sex, did not differ between the groups. Before training, 10 gastric neoplasms were detected in 937 patients in group I: four early gastric cancers, one gastric adenoma, and five advanced gastric cancer. After training, 36 gastric neoplasms were detected in 937 patients in group II: 18 early gastric cancers, 11 gastric adenoma, five advanced gastric cancer, and one each of gastric carcinoid and malignant lymphoma. The detection rate for early gastric cancer was significantly improved by training [group I: 4/937 (0.4%) vs. group II: 18/937 (1.9%)], although the detection rate for advanced gastric cancer did not differ before and after training. The proportion of early gastric cancer + adenoma to advanced cancer was higher in group II (5/5 vs. 29/5 in group I).
Conclusion Intensive training in upper gastrointestinal endoscopy screening dramatically improved the detection rate for early gastric cancer, although the detection rate for advanced gastric cancer was not affected.

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Objective The purpose of this study was to investigate the relationship between the new onset of atrial fibrillation (AF) and inflammation in the early phase of acute myocardial infarction (AMI).
Background Serial interaction between inflammation and the incidence of AF is not fully understood in the early phase of AMI.
Methods Two hundred fifty-nine consecutive patients with AMI were studied. electrocardiogram monitoring was recorded continuously for >7 days. Serial inflammation markers, cardiac enzymes, coronary angiogram and echocardiography were obtained in all patients.
Results One hundred seventy-six patients were enrolled. AF was present in 24 patients (14%), and occurred on day 2.7±1.4 after admission. Serial measurements of WBC and C-reactive protein (CRP) with/without AF were as follows. WBC levels of day 5-7 were 9.3±3.5 vs. 7.5±2.4×10³/μL, p=0.04, and CRP levels of day 2-4, 5-7, 8-14 were 12.6±9.4 vs. 4.7±5.3 mg/dL, p<0.001, 12.3±10.4 vs. 5.2±5.2 mg/dL, p=0.01, and 8.5±7.7 vs. 2.7±4.2 mg/dL, p=0.005, respectively. Those were significantly higher in the patients with AF. In multivariate logistic regression analysis, CRP levels of day 2-4 were independently higher in the patients with AF (odds ratio (OR) 1.15, 95% confidence (CI) 1.04-1.27).
Conclusion AF in the early phase of AMI occurs a few days after the onset of AMI, which is independently related to the activated inflammation. AF in this period persists for only a short duration.

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Objective Hypertension guidelines recommend strict blood pressure (BP) control to less than 130/80 mmHg in patients complicated with chronic kidney disease (CKD). However, it is unclear whether this target BP level is applicable to the elderly hypertensive patients. The aim of this study was to assess the prevalence of CKD and BP control status in elderly hypertensive patients.
Methods Subjects were 675 hypertensive patients (65.5±11.7 years, 290 males and 385 females). Prevalence of CKD and BP control status were compared between elderly and young/middle-age patients.
Results Average BP of elderly and young/middle-age patients were 134±10/71±9 mmHg and 131±11/78±9 mmHg, respectively. CKD was more prevalent in the elderly than in the young/middle-age patients (35.5% and 24.5%, respectively). The elderly patients with CKD were more likely to be males and older. They also required a greater number of antihypertensive drugs than those without CKD (2.4±1.2 vs. 2.0±1.1, p<0.01). Elderly patients without CKD who achieved a target BP of <140/90 mmHg were 73.2%. Similarly, 78.5% of the patients with CKD achieved BP of <140/90 mmHg, while those who achieved <130/80 mmHg were only 29.6%.
Conclusion Our results suggest that CKD is frequently complicated in elderly hypertensive patients, and many of them failed to achieve strict BP goal in spite of the average use of 2.4 antihypertensive drugs.

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Objective An enlarged left atrium (LA) has recently been identified as a risk factor for adverse cardiovascular outcomes in various pathologic conditions. However, few studies have evaluated its prognostic value in hemodialysis (HD) patients.
Methods We conducted an observational study to investigate whether an enlarged LA predicted all-cause mortality in 174 HD patients. Patients were stratified into two groups based on the LA volume index (LAVI) value of 32 mL/m².
Results An increased left atrial volume index (LAVI >32 mL/m²) was present in 28 (16.1%) of the HD patients. During the follow-up period (50.1±22.4 months), 77 patients (44.3%) died. A Kaplan-Meier analysis revealed that the 7-year survival rate was significantly lower in the group whose LAVI was >32 mL/m² than in the group whose LAVI was ≤32 mL/m² (p=0.0033). Multivariate analyses adjusted for echocardiographic parameters and clinical and laboratory data showed that increased LAVI was an independent predictor of all-cause mortality (hazard ratio 1.030, 95% confidence interval 1.004-1.056, p=0.0260). Moreover, increased LAVI had a higher predictive value for all-cause mortality (area under the receiver operating characteristic curve=0.612, p=0.0059) among the measured echocardiographic parameters.
Conclusion The results of the present study suggested that measurement of LAVI may be helpful in the risk stratification of HD patients and in providing therapeutic direction for their management.

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Objective The prognosis of idiopathic pulmonary fibrosis (IPF) patients with acute exacerbation (AE) is reported to be extremely poor. Several clinical studies suggest that direct hemoperfusion with polymyxin B-immobilized fiber (PMX) may have beneficial effects on AE in patients with interstitial pneumonia (IP). The aim of this multicenter retrospective analysis was to investigate whether PMX treatment could provide improvement of oxygenation and survival benefits in IPF patients with AE.
Methods We conducted a retrospective study of 160 IP patients (including 73 IPF) with AE treated by PMX at 18 institutions in Japan. PMX treatment was carried out twice. The total hemoperfusion time of PMX treatment was, on average, 12 hours. Data concerning oxygenation on PMX treatment and survival after AE were collected and analyzed.
Results In IPF patients with AE, arterial oxygen tension (PaO₂)/inspiratory oxygen fraction (FiO₂), (P/F) ratio was significantly improved at the end of the 2nd treatment with PMX (173.9±105.4 to 195.2±106.8 Torr, p=0.003). White blood cell count was significantly reduced at the end of the 2nd treatment (13,330±7,002 to 9,426±5,188 /mm³, p<0.001). These clinical changes were also observed on analysis of all 160 IP patients with AE. The one- and three-month survival rates of IPF patients after AE were 70.1% and 34.4%, respectively.
Conclusion PMX treatment may improve oxygenation and survival in IPF patients with AE. Prospective, controlled trials of PMX treatment for IPF with AE are warranted to verify this potential benefit.

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Background Neuralgic amyotrophy (NA) is a distinct peripheral nervous system disorder characterized by attacks of acute neuropathic pain and rapid multifocal weakness and atrophy unilaterally in the upper limb. The current hypothesis is that the episodes are caused by an immune-mediated response to the brachial plexus, however, therapeutic strategies for NA have not been well established.
Methods and Results We retrospectively reviewed 15 case series of NA; 10 of the 15 patients received intravenous immunoglobulin (IVIg) with methylprednisolone pulse therapy (MPPT) and 9 of these10 patients showed clinical improvement of motor impairment.
Conclusion Our clinical observations do not contradict the possibility that IVIg with MPPT may be one of the potential therapeutics for NA, however the efficacy remains to be established. Further confirmatory trials are needed in patients with various clinical severities and phases of NA. Further basic research and confirmatory trials should be performed to survey the efficacy of such immunomodulation therapy for NA.

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Objective Previous studies have reported distinct serological profiles of lipid, urate and ferritin in Western patients with amyotrophic lateral sclerosis (ALS). We aimed to examine the levels of these serological factors and their relationship to disease progression in Japanese ALS patients.
Methods Ninety-two patients with definite or probable ALS who fulfilled the revised El Escorial criteria were analyzed for clinical and serological variables. Serological data at the time diagnosed with ALS were compared to those of 92 age/sex/body mass index-matched healthy controls.
Results Compared to controls, urate and creatinine (Cr) levels were decreased and ferritin levels were increased significantly in sera of male and female patients with ALS. Significant increases of serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and triglyceride levels were found in female ALS patients. The annual decline of ALS Functional Rating Scale-Revised (ALS-FRS) and forced vital capacity (FVC) were inversely correlated with serum TC, LDL-C, Cr and urate levels, and were positively correlated with serum ferritin levels. Multivariate analysis showed that the rapid worsening of annual ALS-FRS and FVC was associated with serum levels of TC, LDL-C, Cr, urate and ferritin.
Conclusion The present study indicated that serum levels of TC, LDL-C, Cr, urate and ferritin were correlated with clinical deterioration in ALS patients. These results are similar to those in Western patients. Metabolic and nutritional conditions of lipid, urate and iron could contribute to disease progression in ALS patients. Further studies investigating high nutrition diets and iron chelation for the treatment of ALS are warranted.

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Objective We aimed to compare the cumulative efficacy and resistance of ADV monotherapy, ADV add-on LAM (ADV + LAM), ADV and ETV (ADV + ETV) combination therapy in LAM-resistant patients.
Methods Ninety-one adult CHB patients with LAM-resistance mutations (YMDD) were identified. Of these 91, 29 patients were treated with ADV monotherapy, 30 were treated with ADV + LAM and 32 were treated with ADV + ETV combination therapy, for at least 24 months.
Results The mean serum HBV-DNA decreases from baseline at 3, 6, 12, and 24 months were -3.23, -4.41, -5.32, and -5.58 log₁₀IU/mL in the ADV + ETV combination therapy groups, respectively; the most significant among the three treatment groups (p<0.01). The rate of HBV-DNA PCR undetectability (<60 IU/mL) at 6 months in ADV + ETV combination therapy was 78.1%; also the most significant among the three treatment groups (p=0.024). Viral breakthrough and genotypic mutations were detected in 8 (27.6%) and 4 (13.3%) patients in the ADV monotherapy and ADV+LAM therapy groups, respectively; whereas no case of viral breakthrough and genotypic resistance was detected in the ADV+ETV combination therapy group after 24 months (p<0.05).
Conclusion ADV + ETV combination therapy demonstrated faster and significantly greater suppression of HBV DNA compared with ADV add-on LAM combination therapy for patients with LAM-resistance mutations. ADV + ETV was superior to ADV + LAM in achieving initial virological response and long-term suppression activity against HBV. ADV + ETV combination therapy was the most effective to refrain from selecting HBV strains with cross-resistance to three NAs (LAM, ADV and ETV) for LAM-resistance patients.

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Objective The present study was undertaken to determine the characteristics and outcome of in-hospital cardiac arrests and the effectiveness of BVM ventilation with airway adjuncts including the oropharyngeal airways and nasopharyngeal airways.
Methods Information about in-hospital cardiac arrests over a period of 6 years was retrospectively collected, and the effectiveness of BVM ventilation with airway adjuncts was analyzed using a multivariate logistic regression model.
Results During the study period, 105 (male, n=70; age, 68.6±14.2 years) cardiac arrests occurred, of which 95.2% developed among inpatients and 21.0% of them were witnessed. The initial rhythm of cardiac arrests was pulseless electrical activity in 63.8% (67/105) and respiratory failure (44.8%) was the most common cause. Overall, a return of spontaneous circulation occurred in 76.2% of in-hospital cardiac arrests, 31.4% survived to discharge, and the neurological outcome was good (cerebral performance category-1) in 66.7% of them. Bag-valve-mask ventilation with airway adjuncts improved the neurological outcome (OR 3.52, 95%CI 1.07, 11.5).
Conclusion Bag-valve-mask ventilation with airway adjuncts improved neurological outcomes.

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Intramyocardial calcification is a very rare condition. We report a case of a 72-year-old man with apical hypertrophic cardiomyopathy, who was initially suspected of having a thrombus in the left ventricular apex on echocardiography, but was finally diagnosed as having apical intramyocardial calcification on multidetector computed tomography. The mechanism of developing intramyocardial calcification remains to be elucidated, but the patient has been stable for more than 2 years.

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A 78-year-old man had right foot ulceration. The skin perfusion pressure (SPP) at the dorsum was 12 mmHg. Angiography revealed right iliac artery occlusion and diffuse stenosis of right superficial femoral artery. After stenting of the iliac arteries, the SPP was still 23 mmHg. Hence, we also inserted stents in the right superficial femoral artery. The anterior tibial artery remained stenosed, and the posterior tibial and fibular arteries were occluded. However, as the SPP had increased to 46 mmHg the treatment was discontinued. The ulcers improved. Measurement of SPP during a procedure may be useful in determining the treatment endpoint.

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Neurofibromatosis type 1 (NF1) is associated with benign and malignant neoplasms, but the coincidence of abdominal neoplasms is rare. A 65-year-old woman with NF1 had episodes of nausea, tachycardia, hypertension, and loss of consciousness. Bilateral adrenal tumors were detected by abdominal computed tomography, and plasma and urinary catecholamine levels were elevated. Open bilateral adrenalectomy and histological findings revealed bilateral pheochromocytomas (PCCs). Furthermore, malignant peripheral nerve sheath tumor (MPNST) and multiple gastrointestinal stromal tumors (GISTs) were incidentally found in the abdominal cavity. Early diagnosis of abdominal neoplasms in NF1 patients is important because of the risk of malignancy, organic complications and hemorrhagic-obstructive complications.

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We report two cases of membranoproliferative glomerulonephritis, involved in Castleman's disease of hyaline vascular variant and mixed variant, respectively. The diagnoses were confirmed by cervical lymph node and renal biopsy. Both cases were sensitive to chemotherapy with cyclophosphamide, vindesine and prednisone (COP). With the experience from treating case 1, which was misdiagnosed 9 years previously, we followed a more vigilant approach toward case 2 and achieved a more timely diagnosis. Finally, we reviewed pertinent literature of diagnosis and therapy to facilitate an early diagnosis of rare cases in the future.

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This report presents a human immunodeficiency virus (HIV) patient that developed a slowly progressive renal impairment over years under highly active antiretroviral therapy (HAART). The renal biopsy showed diffuse tubulointerstitial nephritis accompanied by crystal formations that were surrounded by multinuclear giant cells. Furthermore, rod-like crystals were detected in the urinary sediments. Tenofovir and Atazanavir were thought to be the causative drugs for the renal injury. Therefore, the possibility of HARRT-induced nephrotoxicity should be considered in HIV-infected patients, even though the activity of HIV is controlled by such therapies.

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Gitelman's syndrome (GS), an inherited disorder due to loss of function of ion channels and transporters such as Na-Cl co-transporter (NCCT) in distal convoluted tubules, is characterized by hypokalemia, hypomagnesemia, hypocalciuria, metabolic alkalosis and hyperreninemic-hyperaldosteronism. A 39-year-old man was admitted to our hospital because of muscle weakness with such intractable disorders. We performed a thiazide-loading test, which revealed a poor response of the fractional excretion rate of chloride compared to healthy subjects. Based on these data, the clinical diagnosis of GS was made. Gene-sequencing analysis revealed compound heterozygous mutations of c.539C > A and c.1844C > T in SLC12A3, which is newly reported in Japanese GS.

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We encountered an unusual and rare case of 59-year-old woman with Churg-Strauss syndrome (CSS) showing myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA)-related acute renal insufficiency accompanied by eosinophilic tubulointerstitial nephritis. To date, reports in English of CSS presenting with rapidly progressive/acute renal insufficiency and biopsy-proven renal lesions have been uncommon. Here, we discuss this unusual case and review the previously reported CSS cases. The complication of eosinophilic tubulointerstitial nephritis in CSS cases with acute renal insufficiency might be higher than generally thought. Furthermore, the presence of eosinophilic infiltration and eosinophilic tubulointerstitial nephritis might be associated with the good renal outcome in CSS patients.

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Extra-gastrointestinal stromal tumors (EGISTs) are rare. We describe a 69-year-old man with a 9-year history of hemodialysis. This patient was diagnosed as having peritoneal tumors measuring over 10 cm in length. Histologically, the tumors were composed of monomorphic spindle cells. The number of mitotic figures was 5 per 50 high-power fields. Immunohistochemical analysis revealed strong positivity for c-KIT and MIB-1. He was treated with imatinib mesylate with no recurrences 20 months later. We present this first case of EGIST in a hemodialysis patient in which imatinib mesylate had a favorable outcome and also discuss the rarity of this case.

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Two patients with anti-centromere antibody (ACA), hypertensive emergency, and acute renal failure, mimicking scleroderma renal crisis, without Raynaud's phenomenon and typical skin manifestations of systemic sclerosis (SSc), are reported. A review of 26 ACA-positive patients between March 2003 and March 2011 in Yokosuka Kyosai Hospital identified four additional patients with similar manifestations. All patients were Japanese women between 41 and 84 years of age at presentation. Human leukocyte antigen (HLA) genotyping tests revealed the absence of the HLA-DQB1*0501 and DRB1*0101 alleles, which are associated with disease susceptibility to ACA-positive SSc among Japanese. These subjects' manifestations may represent a novel entity.

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Splenic abscess is a rare clinical condition with a high mortality rate. Multiple splenic abscesses, rather than a solitary abscess, are present in immunocompromised states including hematological malignancies. As symptoms of splenic abscesses, fever and abdominal pain, are non-specific, timely and adequate use of imaging studies is crucial for early diagnosis. We report the cases of 2 patients with myelodysplastic syndrome and multiple splenic abscesses. Notwithstanding the higher mortality rate of patients with multiple splenic abscesses as compared with those with a solitary splenic abscess, we successfully treated the 2 patients by using antibiotic therapy and fine needle aspiration.

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Myelodysplastic syndromes (MDS) with pure red cell aplasia (PRCA) have been shown to be a rare form of MDS. A 35-year-old man presented with pancytopenia: hemoglobin 59 g/L, reticulocytes 2×10⁹/L, platelets 33×10⁹/L, and leukocytes 1.8×10⁹/L with 1% blasts. Bone marrow was hypercellular with 50.4% myeloid cells, 0.0% erythroblasts, 25.4% basophils, and 5.6% myeloblasts. Dysplastic changes including pseudo-Pelger-Huët anomaly of neutrophils and mononuclear micromegakaryocytes were found. Immunohistochemistry with glycophorin C confirmed erythroid aplasia. Cytogenetic analysis showed 46,XY,i(17)(q10)[18]/47,XY,+8[2]. Considering two reported cases, these findings indicate that isolated i(17q) may be implicated in the pathogenesis of MDS with PRCA as a recurrent cytogenetic aberration.

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We report the case of a young woman with anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis, without tumor, who was successfully treated with rituximab. Because conventional immunotherapy, including corticosteroids, immunoglobulin (IVIg), and plasma exchange showed little improvement in our patient, we introduced another treatment using rituximab. A week after the first administration of rituximab, her symptoms improved gradually and significantly. This case provides in vivo evidence that rituximab is an effective agent for treating anti-NMDAR encephalitis, even in those cases where conventional immunotherapies have been ineffective. Rituximab should be regarded as a beneficial therapeutic agent for this disease.

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A 67-year-old Japanese woman without contributory medical history developed acute onset of left-sided trochlear nerve palsy (TNP) with persistent and severe periorbital pain. There were no other neurological abnormalities. Funduscopic findings were normal. Cranial and orbital magnetic resonance (MR) imaging, and cranial MR angiography demonstrated no abnormalities. By administration of prednisolone 40 mg/day from the day after onset, periorbital pain was resolved within 24 hours, and TNP within 5 days. Thereafter, prednisolone was gradually tapered off. She remained asymptomatic under no medication. In the English language literature, this is the first reported case of Tolosa-Hunt syndrome presenting with isolated TNP.

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A 36-year-old man was admitted to our hospital because of urinary retention and muscle weakness affecting all 4 limbs after receiving a H1N1 09 influenza vaccination. Magnetic resonance imaging demonstrated multiple lesions in his brain and spinal cord. Furthermore, nerve conduction study showed acute sensorimotor neuropathy, and anti-GM2 antibodies were detected in his serum. Based on the temporal association and exclusion of alternative etiologies, we made a diagnosis of acute disseminated encephalomyelitis (ADEM) and Guillain-Barré syndrome (GBS). To our knowledge, this is the first case of co-morbid ADEM and GBS after influenza vaccination with positive anti-ganglioside antibodies.

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We describe a non-alcoholic diabetic patient with central pontine myelinolysis (CPM) and Wernicke encephalopathy (WE). A 69-year-old man developed consciousness disturbance after parenteral hyperalimentation for liver abscess and sepsis. Neurological examination revealed drowsiness and no articulation. MRI disclosed T2-hyperintense lesions in the dorsal medulla oblongata and dentate nuclei, and symmetric enhancement in the inferior colliculus. Thiamine treatment (1,000 mg/day, div) attenuated neurological deficits. Seven days later, WE-related lesions were markedly regressed and a central pontine T2-hyperintensity lesion appeared. Serum sodium levels were normal. Physicians should pay more attention to rapid development of normonatremic CPM under thiamine supplementation in non-alcoholic WE patients.

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Six days after the onset of influenza B symptoms, a 14-year-old Japanese boy presented with encephalopathy-like symptoms, somnolence, irritability, and childishness, which we first considered was an atypical type of influenza-associated encephalopathy because the infection symptoms disappeared by day 4. His encephalopathy-like symptoms gradually improved, although he had repetitive hypersomnia attacks. Owing to the patient's clinical presentation and normal interleukin-6 levels in the cerebrospinal fluid during the first period of hypersomnia, we diagnosed him with Kleine-Levin syndrome (KLS) triggered by influenza B. The preceding influenza infection was not only a diagnostic clue of KLS but also a diagnostic confounding factor.

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A familial aggregation of Behçet's disease (BD) has long been noted. These studies have supported the direct role of HLA-B5 in the pathogenesis of BD. Despite the fact that familial clustering is characterized by genetic anticipation, accounting for the earlier disease onset in successive generations, we present two brothers and two cousins from the same family who were diagnosed when they were over twenty years old.We report these young adult patients to introduce the characteristics of familial aggregation of BD. In this article HLA-B*51 and Cw*16 positivities with adult onset were demonstrated.

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Interstitial lung disease (ILD) frequently accompanies polymyositis (PM) and dermatomyositis (DM) and is a major cause of mortality. The rapid diagnosis of ILD is paramount. However, the early changes of presymptomatic ILD are difficult to detect. We present a patient with DM who had positive uptake in the lung of FDG-PET/CT as well as 'mechanic's hands' appearance, increased serum ferritin and serum anti-CADM-140 antibody, all before the detection of ILD by CT. Although aggressive treatment was initiated, the patient died of diffuse alveolar damage. These observations suggest that the pulmonary uptake of ¹⁸F-FDG predicts rapidly progressive ILD in DM.

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We present a rare case of infectious endocarditis caused by Lactobacillus acidophilus in a patient on long-term steroid use for autoimmune hepatitis. In vitro susceptibility-guided antibiotics with benzylpenicillin plus clindamycin and successive mitral annuloplasty resulted in a favorable outcome. Infectious endocarditis was suspected to be a complication of mistreated periodontal infection. Maintenance of oral hygiene is important in immunocompromised patients.

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A 39-year-old man presented a CD4 T cell count of 78/μL and HIV-RNA at 6.6×10⁵ copies/mL at his first medical examination. After the 58th day, we initiated HBV-active antiretroviral therapy. Three months after the start of antiretroviral therapy, he was diagnosed with hepatic flare on the basis of elevated AST and ALT levels without detecting HBV-DNA. Although after continuing the medication his AST and ALT levels increased to 700 IU/L and 1,400 IU/L, respectively, he showed improvement following a natural course and was discharged from hospital after the 169th day. This is a case of hepatic flare likely caused by immune reconstitution associated with resolved HBV infection.

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Warfarin is widely used in clinical practice all over the world. We report a man in whom prominent eosinophilia appeared after the initiation of warfarin administration following aortic valve replacement. Laboratory data following the administration and discontinuation of warfarin suggested that this drug was responsible for the eosinophilia. It is important to recognize the possibility of warfarin-induced hypereosinophilia as a latent adverse effect even when there are no clinical signs or symptoms.

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People living in Japan were affected in various ways after the Great East Japan earthquake of March 11, 2011. A 52-year-old female asthma patient not directly affected by the disaster experienced a decrease in peak expiratory flow (PEF) immediately after the earthquake. Despite increasing the inhaled and oral corticosteroid doses, her PEF did not recover. One month later, her PEF level abruptly returned to normal with minimal medications, which were previously ineffective, and the asthma-related symptoms vanished. The stabilization of her state of mind and actual social state seemed to be a part of the reason for the patient's recovery.

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This is an unusual case of invasive lobular carcinoma of the breast presenting as an orbital metastasis. A 70 year-old female presented with a gradually worsening blurred vision, periorbital swelling and ascites. The biopsy of the eyelid demonstrated dense fibrosis with neoplastic cells and the diagnosis of carcinoma was made; however, the site of origin of carcinoma was difficult to determine. The histopathologic characteristics of the carcinoma in the orbit and ascites fluid combined with the immunophenotypic features helped determine the primary site of the malignancy. Subsequently, the primary malignancy was identified by examination of the patient's breast.

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