The cardiac involvement of sarcoidosis causes progressive heart failure symptoms and is a life-threatening condition; thus, an early and appropriate diagnosis of this condition is crucial. On the other hand, the decline in the cardiac function is rapid; therefore, patients usually have moderate-severe left ventricular dysfunction when diagnosed with cardiac sarcoidosis, which may decrease the effectiveness of therapies. We herein report three illustrative cases of heart failure due to cardiac sarcoidosis in patients who were or were not diagnosed with preceding systemic sarcoidosis. We also discuss the currently available diagnostic modalities and possible biomarkers for the diagnosis of cardiac sarcoidosis.
Objective Spinal cord injury (SCI) can lead to significant cardiac arrhythmia. However, P-wave, QT dispersion, and risk factors in these patients have not been widely investigated. In this study, we assessed whether there is a relationship between electrocardiogram (ECG) parameters and risk factors in SCI patients. Methods The study population consisted of 85 SCI patients and 38 control subjects. P-wave durations were measured using 12 leads of the surface ECG. P-wave dispersion was defined as the difference between the P-wave maximum and P-wave minimum duration. QT dispersion was defined as the difference between the largest and smallest QT interval for any of the 12 leads (QTmax-QT-min). QT intervals were also corrected (QTc) in accordance with the heart rate using Bazett's formula (QT Interval/√[RR interval]). We also evaluated the independent risk factors for P-wave dispersion and QT dispersion in SCI patients. Results The P-wave minimum, P-wave maximum, QT minimum, and dispersion were significantly different between the control and SCI groups. There was no significant difference in P-wave dispersion, QT maximum, or QTc. Multivariate regression analysis showed that disease duration, glucose and high-density lipoprotein cholesterol (HDL-C) levels, and systolic tension were independent risk factors for P-wave dispersion. Conclusion Our results demonstrate that QT dispersion is related to SCI and that P-wave dispersion was linked to the duration of SCI, HDL-C and glucose levels, and arterial tension in SCI patients.
Objective In Japan, the number of elderly people who have difficulties performing the activities of daily living (ADLs) is increasing. The objective of this study was to assess the relationship between ADL and the clinical characteristics of pneumonia. Methods We conducted a retrospective study of 219 adult patients hospitalized due to pneumonia [151 patients with community-acquired pneumonia (CAP) and 68 patients with healthcare-associated pneumonia (HCAP)]. CAP, HCAP, and all the patients were stratified into two groups using a modified version of the Katz index of five ADLs as follows: independent in all ADLs or dependent in one to three ADLs (CAP-A, HCAP-A, and All-A groups) and dependent in four or five ADLs (CAP-B, HCAP-B, and All-B groups). Disease severity, microbiological findings, and mortality were compared between the groups. Results As the ability to perform ADLs declined, A-DROP scores (the CAP severity measurement index) increased significantly in CAP (CAP-A: 1.1±1.1, CAP-B: 2.6±1.1), HCAP (HCAP-A: 2.0±1.0, HCAP-B: 2.8±1.0), and all patients (All-A: 1.3±1.1, All-B: 2.8±1.0). Thirty-day mortality was higher in the CAP-B (23.1%) and All-B (19.2%) groups than in the CAP-A (0.7%) and All-A (1.8%) groups, respectively. A multivariate Cox proportional hazards analysis showed an ADL score ≥ four to be a significant predictor of 30-day mortality in CAP patients [hazard ratio (HR), 19.057; 95% confidence interval (CI), 1.930-188.130] and in all patients (HR, 8.180; 95% CI, 1.998-33.494). Conclusion A functional assessment using a modified version of the Katz index is useful for the management of CAP and HCAP patients.
Objective The Japanese translation of the Berg balance scale (BBS) has previously been published; however, its reliability has not yet been validated. This study aimed to evaluate its reliability. Methods Patients took the BBS test three times; two neurologists monitored the results. The intraclass correlation coefficients (ICCs) and Cronbach's alpha (α) coefficients were calculated, and the inter-rater and intra-rater reliability were determined. Patients Thirty-three patients with balance disturbance were recruited. Results The study participants included 15 men and 18 women with a mean age of 62.8 years (SD, 14.8). For the total BBS score, the inter-rater ICC and Cronbach's α coefficient were 0.9337 and 0.9493, respectively, while the intra-rater ICC and Cronbach's α coefficient were 0.9772 and 0.9416, respectively. Most items had a relatively high ICC. The Cronbach's α coefficients were more than 0.9 for all items. Conclusion The Japanese version of the BBS was found to have a high inter-rater and intra-rater reliability and internal consistency.
A 70-year-old man with a gastric lesion was referred to our hospital because of an unusual pedunculated lesion in the gastric body. Endoscopic ultrasound showed scattered cystic lesions within a heterogeneous area confined to the submucosal layer. Endoscopic mucosal resection was performed to obtain a precise diagnosis, as well as for removal. The lesion was histopathologically diagnosed as a heterotopic submucosal gland. We herein describe this rare type of gastric polyp and provide a literature review.
A 64-year-old woman underwent a coronary flow reserve evaluation using intracoronary-administered papaverine into the left anterior descending artery. Her baseline electrocardiogram (ECG) was normal, but toward the end of papaverine administration, the QTU intervals were excessively prolonged and torsade de pointes occurred, leading to ventricular fibrillation. Ten months previously, the patient's ECG showed mildly prolonged QTc (480 ms1/2), which normalized after the cessation of bepridil. This case report suggests that a history of drug-induced QT prolongation can be a risk factor for papaverine-induced fatal ventricular arrhythmia.
We herein describe the case of a 68-year-old man who developed overt diabetes mellitus following the topical administration of dexamethasone 0.1%-containing ointment over a five-month period to treat oral lichen planus. The topical dexamethasone therapy was discontinued gradually, and the patient was subsequently treated with insulin for one month without clinical signs of overt adrenal insufficiency. An oral glucose tolerance test revealed impaired glucose tolerance after the treatment. The potential for the deterioration of glucose metabolism must be considered when patients with impaired glucose tolerance are treated with relatively low doses of topical corticosteroid ointment on the oral mucosa, even for short periods.
A 44-year-old man with type 2 diabetes of five years' duration was admitted for the management of poor glycemic control despite the administration of insulin therapy. On admission, he received vigorous treatment for a 28-year history of Crohn's disease and a 14-year history of a psychiatric disorder. His glycosylated hemoglobin A1c (HbA1c) level was 11.3%, his fasting blood glucose level was 567 mg/dL and his C-peptide level was 1.0 ng/mL. His quality of life (QOL) was severely impaired as a result of frequent episodes of hyperglycemia and hypoglycemia. Treatment with liraglutide was commenced in place of insulin, which improved the patient's glycemic control to an HbA1c level of 5.5% and markedly increased his QOL score with no hypoglycemia.
A 51-year-old man was transferred to our hospital due to acute respiratory failure that had progressed over four days. A chest X-ray and thoracic computed tomography scan showed multiple faint micronodules randomly distributed throughout both lungs with ground glass opacity, suggesting miliary tuberculosis or Pneumocystis jirovecii pneumonia with acute respiratory distress syndrome. Six hours after admission, the patient died of septic shock. Later, the cryptococcal antigen titer was found to be markedly elevated (1/65,536), with a positive result for anti-human immunodeficiency virus and a low CD4 cell count (12/μL). The present case is reminder that disseminated cryptococcosis with HIV infection can be misdiagnosed as miliary tuberculosis based on radiological findings.
A 37-year-old woman had undergone bilateral living-donor lobar lung transplantation 11 years previously for idiopathic pulmonary arterial hypertension. Her father donated the right lobe and her brother donated the left lobe. She subsequently developed progressively worsening respiratory dysfunction due to pneumonia. CT showed left dominant pulmonary artery dilatation, bronchial wall thickening and airway stenosis, followed by sudden death. An autopsy showed marked pathologic left dominant rejection of the pulmonary artery, small airway and large airway. Notably, only the left lung showed C4d vascular deposition, thus suggesting that antibody-mediated lung rejection may have occurred.
We evaluated a serial change in peripheral neuropathy (PN) severity during treatment with bortezomib (Bor) or lenalidomide (Len) using the Functional Assessment of Cancer Therapy scale/Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx). The patient suffered from grade 2 PN and exhibited a dramatic decrease in FACT/GOG-Ntx score after intravenous and subcutaneous Bor therapy. Thereafter, he received seven cycles of Len therapy, which exacerbated existing PN; he experienced mild numbness and exhibited a transient decrease in FACT/GOG-Ntx score. Interestingly, FACT/GOG-Ntx score increased to baseline and numbness was ameliorated during the Len washout period in every cycle.
We herein describe a Japanese family with distal hereditary motor neuropathy carrying a K141Q mutation of small heat shock protein HSPB1. Two patients among them had late onset disease (older than 50 years). The muscles of the distal legs were weak and atrophic. Sensory and autonomic dysfunction were not seen. Even eight years after onset, one patient could still walk without support. A nerve conduction study revealed axonal degeneration of the motor nerves of the legs. A heterozygous K141Q mutation was detected in the affected patients. The late onset and mild clinical phenotype might reflect the mild biochemical alteration of HSP27 induced by the K141Q mutation.
A 56-year-old man was admitted to our hospital due to periodic episodes of acute pericarditis. These episodes occurred monthly along with a high fever and elevation of the C-reactive protein (CRP) level. The patient became afebrile and his CRP level decreased following the administration of a non-steroidal anti-inflammatory drug. A mutation analysis revealed the heterozygote of the familial Mediterranean fever (FMF) gene (E84K, G304R). This finding confirmed our diagnosis, and we treated the patient with colchicine. He responded to treatment and has been visiting our hospital without disease recurrence. FMF should be included in the differential diagnosis of repeated episodes of pericarditis.
The formation of spinal epidural abscess following acupuncture is very rare. We herein report the case of a 54-year-old woman who presented with progressive low back pain and fever with a root sign. She underwent surgical decompression, with an immediate improvement of the low back pain. A culture of the epidural abscess grew Serratia marcescens. One year postoperatively, magnetic resonance imaging revealed the almost complete eradication of the abscess. This case is the first case of Serratia marcescens-associated spinal epidural abscess formation secondary to acupuncture. The characteristics of spinal epidural abscess that develop after acupuncture and how to prevent such complications are also discussed.
We herein report a clinical pitfall regarding the treatment of a case of pulmonary tuberculoma in a patient with chronic hepatitis C. The patient presented with both chronic hepatitis C and pulmonary tuberculoma, and we initiated treatment of the chronic hepatitis C first due to the potential for liver injury; however, the patient's condition worsened in terms of the pulmonary tuberculosis. This case highlights the need to select the initial treatment for pulmonary tuberculoma, not chronic hepatitis C. In addition, we report that, although the administration of anti-tuberculosis chemotherapy regimens containing pyrazinamide (PZA) substantially increases the incidence of drug-induced hepatitis in patients with chronic hepatitis, we were fortunately able to use PZA without observing drug-induced hepatitis in this case because we closely monitored the patient's liver function.
We herein describe a case of community-acquired pneumonia caused by macrolide-resistant Mycoplasma pneumoniae (MRMP) in an adult who responded poorly to macrolide antibiotics, progressively deteriorated to acute respiratory failure and then responded effectively to a fluoroquinolone. In a series of 14 patients with M. pneumoniae pneumonia, 11 were infected with MRMP. In seven of the eight cases of MRMP initially treated with macrolides, the patients did not improve, and a marked improvement was observed only after the antibiotic regimen was modified to include fluoroquinolones or tetracyclines. Nationwide surveillance should provide important information regarding the prevalence and empirical treatment of MRMP infection in adults.
Mycoplasma pneumoniae typically causes respiratory tract infections, including pneumonia. We herein report the case of a 30-year-old Japanese woman with hemophagocytic lymphohistiocytosis (HLH), which is rarely caused by bacteria, secondary to Mycoplasma pneumoniae infection and ensuing hypercytokinemia without pneumonia who was successfully treated with a combination of antibiotics and corticosteroids. Therefore, Mycoplasma pneumoniae infection, which is treatable with antibiotics, should be considered a possible trigger of HLH in patients who present with a viral-like illness without pneumonia.
Impaired cellular-mediated immunity is a known risk factor for both tuberculosis and cryptococcosis. However, pulmonary cryptococcosis associated with pulmonary tuberculosis is rare. We herein describe three cases of concurrent infection with Mycobacterium tuberculosis and Cryptococcus neoformans. All patients had underlying diseases; all three had uncontrolled diabetes mellitus, and other underlying diseases were liver cirrhosis, malignancy, and rheumatoid arthritis requiring long-term steroid use. We also review other relevant reports.
We describe a rare case of recurrent Stenotrophomonas maltophilia bacteremia in a previously healthy 45-year-old man. The infection was caused by osteomyelitis at the site of an iliac crest bone graft harvest. A genetic analysis using enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR) revealed that the blood isolates and pathogens obtained from the surgical wound were identical. Initial treatment with levofloxacin and cefozopran was ineffective, but the patient's infection was successfully treated by long-term administration of latamoxef and trimethoprim-sulfamethoxazole. The present case suggests that attention should be given to the possibility of S. maltophilia infection in any situations.
Liver abscesses secondary to Salmonella species are rarely described in the general population. We herein describe a case of a liver abscess caused by CTX-M-55-type extended-spectrum β-lactamase (ESBL)-producing Salmonella enteritidis, which has not been reported in the literature. A 54-year-old male was admitted due to a high fever and was clinically diagnosed with a liver abscess. Culture of the fluid from the liver abscess revealed CTX-M-55-type ESBL-producing S. enteritidis. Although the patient underwent percutaneous transhepatic abscess drainage and antibiotic therapy, he died one month later. It should be noted that liver abscesses are potentially fatal depending on the causative pathogen.
We herein report the case of a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome who was diagnosed with drug-induced pure red cell aplasia consequent to lamivudine treatment. The patient was admitted to our hospital for treatment of increasing shortness of breath following physical effort. Upon admission, routine blood tests revealed a hemoglobin level of 7.6 g/dL and a hematocrit proportion of 21.2%, with normal leukocyte and platelet counts. After stopping the lamivudine treatment, the patient's hemoglobin concentration and hematocrit level returned to normal. A bone marrow examination showed an exclusive reduction in erythrocyte formation. This case indicates that lamivudine can induce severe anemia without the influence of zidovudine.