Objective Triple therapy with rabeprazole (RPZ), amoxicillin (AMPC) and metronidazole (MNZ) (RPZ+AMPC+MNZ therapy: RAM therapy) has been approved by the Japanese Ministry of Health, Labour and Welfare as a second-line therapy for Helicobacter pylori-positive gastric and duodenal ulcers in Japan. The present multicenter prospective observational study aimed to investigate the safety and efficacy of RAM therapy in clinical practice. Methods Patients with H. pylori-positive gastric or duodenal ulcers (including ulcer scars) in whom first-line therapy was unsuccessful were administered 10 mg of RPZ, 750 mg of AMPC and 250 mg of MNZ twice daily for seven days (total: 14 doses) based on an approved dose and regimen. Patient background factors, including complications, previous medical history, concomitant drugs, eradication results and adverse events were recorded by the investigator. Results The incidence of adverse drug reactions was 2.21% and the H. pylori eradication rate was 92.8%. Subgroup analyses performed to investigate the patient background factors affecting safety and efficacy revealed no factors that significantly affected the incidence of adverse drug reactions or the H. pylori eradication rate. Conclusion Amid reports of decreased eradication rates with clarithromycin-based first-line therapy, the >90%H. pylori eradication rate achieved in the present study demonstrates the clinical efficacy of RAM therapy in subjects in whom first-line therapy is unsuccessful.
Objective To investigate the influence of glycemic variability on the HbA1c level in elderly male patients with type 2 diabetes (T2DM). Methods The 24-h glucose profiles were obtained using a continuous glucose monitoring system in 291 elderly male type 2 diabetic patients. The relationship between the glycemic variability and HbA1c level was assessed in these patients. Results The mean amplitude of glycemic excursions (MAGE) in patients with HbA1c ≥7.0% was significantly higher than in patients with HbA1c <7.0% (4.33±1.67 vs. 3.48±1.46 mmol/L, p<0.001). A simple (Pearson's) correlation analysis indicated that the MAGE was significantly correlated with the HbA1c (r=0.229, p<0.001). Compared with the lowest quartile, the highest quartile of the MAGE was associated with a significantly increased risk of having a HbA1c ≥7.0% after multiple adjustments (p for trend <0.001). Conclusion The glycemic variability had a significant influence on the HbA1c level in elderly male patients with T2DM. The present data suggests that patients with higher glycemic variability might have higher HbA1c levels.
Objective The aim of this study was to determine the epidemiological characteristics of never-smoking patients with non-small cell lung cancer (NSCLC) detected with clinic-based screening programs, focusing on clinical risk factors and survival. Methods The medical records of NSCLC patients (n=285) diagnosed at Fujisawa City Hospital between April 2000 and December 2010 with lesions that were originally detected with clinic-based screening programs in Fujisawa City were reviewed to identify the clinicopathological variables and survival outcomes. Results Of the 285 NSCLC patients, 95 (33.3%) were never-smokers. A comparison between the never-smoking and ever-smoking patients revealed that the never-smokers included a significantly greater proportion of women and patients with adenocarcinoma (86.3% vs. 12.6%: p<0.001 or 94.7% vs. 55.8%: p<0.001, respectively). The overall survival rate of the never-smoking patients was significantly superior to that of the ever-smokers (p=0.004). In addition to smoking status, factors found to be significantly associated with the overall survival rate in univariate analyses were gender, stage, histology and first line treatment. A multivariate analysis revealed smoking status to be an independent prognostic factor in addition to stage and first line treatment. Conclusion The differences in the clinicopathological factors and survival outcomes between never-smoking and ever-smoking patients with NSCLC detected with clinic-based screening programs suggest that persuading people to never start smoking is important.
Objective There are many reports regarding the course of migraines during pregnancy. However, the prevalence and characteristics of migraines during the postpartum period have not been adequately investigated. We prospectively investigated the patients suffering from migraines over a long postpartum period in an obstetrics department in Japan. Methods We investigated the course of migraines experienced during the postpartum period by patients in a postnatal ward. The patients were surveyed during the first postpartum week and 1, 3, 6 and 12 months after delivery. The patients were provided a headache diary to assess medication use and migraine attack frequency, severity (the faces pain scale) and duration. Results The migraine remission rate was 63%, 83% and 85% during the first, second and third trimesters, respectively. No patient experienced a worsening of headaches during pregnancy. Headache recurrence during the first month after delivery was more frequent in the patients >30 years of age than in those ≤30 years of age (p<0.05). The percentage of women experiencing recurrence at 1, 3, 6 and 12 months after delivery was 63%, 75%, 78% (n=60) and 87.5% (n=40), respectively. In breastfeeding patients, the rates were 50%, 65.8%, 71.1% and 91.7% and in bottle feeding patients, the rates were 86.4%, 90.9%, 95.5% and 81.3%, respectively. Conclusion We found that 85% of the patients with migraines experience remission during pregnancy and that more than 50% experience recurrence during the first month after delivery. Until six months after delivery, breastfeeding is associated with a lower recurrence rate than bottle feeding.
The case of a patient with gastric adenosquamous carcinoma with positive cancer cells on intraperitoneal washing cytology (CY1) who achieved a long recurrence-free survival is herein reported. A 74-year-old man was found to have adenosquamous carcinoma of the stomach. Partial gastrectomy was performed, and a pathological examination confirmed a diagnosis of adenosquamous carcinoma with invasion into the serosa and lymph node metastasis. S-1 monotherapy was administered because a cytologic examination revealed that the patient's peritoneal washings were positive for cancer cells. The patient remains alive with no recurrence two years and 10 months after undergoing surgery. Postoperative chemotherapy with S-1 monotherapy is effective for treating adenosquamous carcinoma of the stomach with CY1 and might contribute to long-term survival.
Systemic lupus can involve any part of the gastrointestinal (GI) tract. Diarrhea generally results from complications arising from infection, drugs or pancreatitis. We herein report the case of a 40-year-old hypertensive man with a psychotic disorder in whom the evaluation of chronic diarrhea revealed a diagnosis of systemic lupus erythematosus (SLE), diffuse proliferative glomerulonephritis and protein-losing enteropathy that required treatment with both steroids and mycophenolate mofetil. Over the following year, the patient developed atrial fibrillation, miliary tuberculosis and generalized clonic tonic seizures. He is currently under regular follow-up care and receives antiepileptics, antihypertensives, diltiazem, amiodarone and warfarin.
We herein describe a rare case of ulcerative colitis associated with unilateral hypoglossal nerve palsy. A 64-year-old woman developed severe active ulcerative colitis and was treated with prednisolone. The dose of oral prednisolone was reduced to 7.5 mg/day, following which the patient noticed slight dysphagia and a speech disturbance. She was diagnosed with unilateral hypoglossal nerve palsy, which was thought to be caused by mononeuritis. She was treated with intravenous methylprednisolone at a dose of 500 mg/day, which improved the neuropathy. When the neuropathy occurred, the patient was in a mildly active stage of ulcerative colitis. We concluded that the mononeuritis observed in the present case was likely an extraintestinal manifestation of ulcerative colitis.
Giant-cell myocarditis is a fatal autoimmune disorder that is often associated with other autoimmune diseases. We herein describe a case of giant-cell myocarditis complicated by heparin-induced thrombocytopenia (HIT). A 71-year-old woman was admitted to our hospital due to palpitations and ptosis. Echocardiography revealed hypokinesis in the left basal ventricular walls. Heart failure gradually developed, and the condition was complicated by HIT. The patient died of cardiogenic and septic shock caused by agranulocytosis. An autopsy showed giant-cell myocarditis. When severe left ventricular dysfunction due to an unknown cause is complicated by HIT, potential diagnoses of giant-cell and other types of autoimmune myocarditis should thus be investigated.
Although rare, symptomatic hypocalcemia may develop after the administration of phospho-soda. We herein present the case of a patient with phospho-soda-induced hypocalcemia who was surprisingly diagnosed with multiple endocrine neoplasia type 1 (MEN1) caused by a heterozygous mutation in the MEN1 gene (c628_631delACAG), thus resulting in a frameshift mutation (210ThrfsX224). In addition to being the first report of phospho-soda-induced hypocalcemia in a patient with MEN1-associated primary hyperparathyroidism, our report highlights the complex nature of calcium balance in the human body and helps clinicians to appreciate how confounding factors might affect the presentation of endocrine disorders.
Immunoglobulin G4 (IgG4)-related lung diseases can occur in patients with autoimmune pancreatitis (AIP). However, the causal relationship between AIP and acquired hemophilia A (AH) is unknown. We herein report the first case of AH associated with IgG4-related lung disease that developed in a patient with AIP. A 65-year-old asymptomatic man with a history of AIP and sclerosing cholangitis diagnosed at the age of 57 was admitted to our hospital due to an abnormal reticulonodular shadow on chest X-ray. An examination of lung biopsy specimens revealed IgG4-positive plasma cell infiltration in the interstitium. The serum IgG4 level was elevated. One year later, the patient developed a progressive severe hematoma in the left femoral muscle. On admission, laboratory examinations revealed severe anemia with a markedly prolonged activated partial prothrombin time, a decreased level of factor VIII (FVIII) activity, and the existence of anti-FVIII antibodies. These findings were consistent with a diagnosis of AH. No relapse has been observed over the past 25 months, during which time, corticosteroid therapy has been continuously administered.
We present a case of organizing pneumonia complicated by pneumothorax in association with cyst formation that developed during corticosteroid treatment. Although it has been reported that the check-valve mechanism is a plausible cause of cyst and pneumothorax formation in patients with organizing pneumonia, the details of the corresponding pathological changes that occur in air-trapping have not been elucidated. A pathological examination of lung specimens obtained with video-assisted thoracoscopic surgery suggested that granulation tissues plugging the bronchiole lumens might be a potential cause of the check-valve mechanism in this case. In this report, we also reviewed eight other cases of organizing pneumonia with pneumothorax or cyst formation.
A 54-year-old alcoholic woman developed fulminant community-acquired pneumonia. Despite receiving intensive support measures, she died four days after admission. An autopsy revealed bronchopneumonia with clusters of pseudohyphae and yeast-like fungi, and Candida albicans was isolated from both tracheal aspiration specimens obtained on admission and the postmortem lungs. The absence of vessel invasion or any other organ involvement led to a diagnosis of primary Candida pneumonia secondary to aspiration, rather than pulmonary seeding from systemic infection. Candida species isolated from respiratory tract samples are usually regarded as originating from colonization; however, the possibility for true Candida pneumonia should be taken into account, even in the setting of community-acquired pneumonia.
Kimura's disease (KD) or eosinophilic lymphogranuloma is a rare chronic inflammatory disorder of unknown etiology that occurs primarily in Asians. A 51-year-old man diagnosed three years earlier with KD of a left neck nodule was admitted to our hospital with a productive cough and pulmonary infiltration. Bronchoscopy was performed, and a diagnosis of eosinophilic lung disease (ELD) was made. The patient's condition improved after receiving corticosteroid treatment. Complications such as nephrotic syndrome have been reported in patients with KD; however, ELD has not been previously described. To the best of our knowledge, this is the first report of ELD related to KD.
A 41-year-old woman with idiopathic thrombocytopenic purpura and dyslipidemia abruptly developed vertigo, truncal ataxia and divergence paralysis. Cranial magnetic resonance imaging demonstrated the presence of infarction in the left superior paramedian mesencephalic artery involving the vicinity of the periaqueductal gray matter. The symptoms rapidly resolved under the administration of anti-platelet agents. The precise location of the hypothetical divergence center of the ocular motor system remains unclear because the lesions responsible for divergence paralysis are rarely identified on neuroimaging. We emphasize that this is a first reported case of DP caused by acute midbrain infarction and speculate that the mesencephalic reticular formation may be partially involved.
Relapsing polychondritis (RP) is a rare disease involving cartilaginous structures, predominantly the ears, nose and laryngotracheobronchial tree. The eyes, cardiovascular system, peripheral joints, skin, and central nervous system may also be affected. Involvement of all ocular structures has been described. Non-granulomatous uveitis is a common feature; however hypopyon is uncommon. We herein present the case of a 42-year-old man who had been diagnosed with bronchial asthma for a long period; and who presented with recurrent hypopyon uveitis as a revealing manifestation of relapsing polychondritis. We emphasize that RP should therefore be considered in the differential diagnosis of sterile hypopyon uveitis.
A 63-year-old woman suddenly developed central retinal artery occlusion following a slight fever while being treated with methimazole (MMI) for hyperthyroidism. She was diagnosed to have anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) based on increased inflammatory reactions with positive myeloperoxidase-ANCA in the serum. Her visual acuity remained low despite immediate treatment with corticosteroids and cyclophosphamide after cessation of MMI, which may have played a role in the pathogenesis of AAV. Central retinal artery occlusion is a rare manifestation of AAV; however, it is important with regard to the possibility of serious sequelae.
A 59-year-old woman with a 10-year history of rheumatoid arthritis (RA) presented with chronic ulcers on both feet while undergoing treatment with etanercept. Rheumatoid vasculitis (RV) was diagnosed, and the patient was treated with immunosuppressant drugs and skin grafting. Although anti-tumor necrosis factor (TNF) agents are known to induce vasculitis, vasculitis can also be caused by active RA. Accordingly, the cause of vasculitis in RA patients receiving anti-TNF therapy must be evaluated carefully.
A 31-year-old woman who had developed systemic lupus erythematosus at 17 years of age was admitted to the hospital for suspected cellulitis in the lower extremities. A blood culture performed upon admission to the hospital detected Helicobacter cinaedi (H. cinaedi), which was also isolated in blood and fecal cultures obtained on the 42nd hospital day. Bacterial translocation of H. cinaedi present in the intestines may have led to the development of recurrent bacteremia and cellulitis. In cases such as this, appropriate antibiotics therapy might be needed for more than one month. Moreover, H. cinaedi, a cause of emerging infections, requires a long period of time to grow; therefore it is important to extend the culture duration when the presence of this bacterium is suspected.
Bacteroides fragilis is a rare causative agent of spondylodiscitis. The pathophysiology of B. fragilis in spondylodiscitis remains largely unclear because of its rare occurrence. We herein report a case of spondylodiscitis complicated by an epidural abscess and meningitis; B. fragilis was detected in the blood of the patient. Moreover, the patient had a splenic abscess that was confirmed on magnetic resonance imaging. The patient completely recovered with antimicrobial therapy alone.
Raoultella ornithinolytica is a Gram-negative aerobic bacillus reclassified in the new genus from the Klebsiella species based on new genetic approaches; however, human infections caused by R. ornithinolytica are rare. We herein report three cases of R. ornithinolytica bacteremia associated with biliary tract infections in cancer patients. R. ornithinolytica can be a causative pathogen of biliary tract infection in cancer patients.
As tuberculosis still exists in Japan, tuberculous pericarditis is a major health issue. Tuberculous pericarditis is difficult to diagnose and leads to poor outcomes when left untreated. We herein report the case of a patient who was admitted to the hospital after undergoing resuscitation for cardiopulmonary arrest. Mycobacterium tuberculosis was detected in his hemorrhagic pericardial fluid and tuberculous pericarditis was diagnosed. The administration of antituberculous medication resulted in marked improvements. A diagnosis of tuberculous pericarditis, in addition to other causes such as malignant tumors, should therefore be considered in the differential diagnosis for cases presenting with hemorrhagic pericardial effusion, even in those involving sudden cardiac arrest.
An 89-year-old man with advanced renal failure, polymyalgia rheumatica and a past history of tuberculosis was admitted with a high fever. Erythema and swelling appeared in the femoral region. Since the cellulitis failed to respond to antibiotic therapy, a skin biopsy was performed. The specimen showed the presence of epithelioid cell granuloma and panniculitis. Acid-fast organisms were found on Ziehl-Neelsen staining. A polymerase chain reaction test of tuberculosis was positive. Although a diagnosis of miliary tuberculosis was suggested, examinations of a bone marrow biopsy and fundoscopy revealed normal results. The patient's symptoms improved following treatment with isoniazid, rifampicin and ethambutol. This case represents an unusual presentation of tuberculous cellulitis in an immunocompromised patient.
We herein describe the successful treatment of a patient with possible Legionella pneumophila serogroup 6 infection complicated by pneumonia and myocarditis. A 32-year-old man presented with a five-day history of cough, dyspnea and chest pain. Chest radiography revealed patchy opacities in both lungs suggestive of bilateral pneumonia, and a urinary antigen test for Legionella pneumophila was positive. After admission, the patient developed congestive heart failure due to pathologically confirmed myocarditis. He was successfully treated with minocycline, macrolide, steroids and noninvasive positive-pressure ventilation (NPPV). He eventually recovered with a normalized cardiac function. L. pneumophila serogroup 6 was isolated from the bathwater in the patient's home.
A 72-year-old woman was referred to our hospital for palliative care. Fifteen years earlier, she had undergone total hysterectomy and radiotherapy for cervical cancer. One year before her referral, she visited a hospital due to a gait disturbance and was diagnosed with lymphangiosarcoma. The level of coagulation factor VIII plasma activity was >201% (normal range: 62-145%) and the immunohistochemical results were positive for factor VIII-related antigen in a tumor specimen. To the best of our knowledge, this is the first report of high coagulation factor VIII plasma activity in a patient with lymphangiosarcoma.