Objective To clarify the relationship between the shape and circumferential location of non-circumferential short-segment Barrett's esophagus (SSBE).
Methods We examined 3,788 subjects (2,497 males, 1,291 females; mean age 52.4 years) who underwent upper GI endoscopy as part of a detailed medical checkup. The presence of columnar-appearing mucosa ≥10 mm long in the distal esophagus was diagnosed as BE and then divided into circumferential and non-circumferential localized types. Localized SSBE was further divided into round and sharp types based on the shape of the proximal margin.
Results SSBE was endoscopically observed in 197 subjects (5.2%). The numbers of patients with circumferential SSBE, round localized SSBE, and sharp localized SSBE were 38, 114 and 69, respectively. Round and sharp types of localized SSBE were simultaneously observed in 25 patients. Reflux esophagitis was more frequently observed in subjects with BE, regardless of type, in comparison to those without BE. Round localized SSBE was found mainly in the left posterior wall of the esophagus in a location similar to the main area of the esophageal cardiac glands. In contrast, sharp localized SSBE was observed mainly in the right anterior wall of the esophagus in a location similar to that of esophageal mucosal injury caused by mild type reflux esophagitis.
Conclusion The location differs between round and sharp localized SSBE, possibly due to differences in the process of BE development.
Objective The aims of the present study were to determine the proportions of hepatitis B surface antigen (HBsAg)-positive and anti-hepatitis C virus (HCV)-positive patients, and identify the characteristics that influenced referral to a hepatologist.
Methods The present study included patients who were positive for HBsAg (n=153) or anti-HCV (n=574); their viral status was tested by non-hepatologists between January 2008 to December 2012. We performed a multivariate analysis to investigate the factors associated with the referral of patients to hepatologists.
Results The rates of hepatitis B virus (HBV) and the percentage of suspected HCV carriers at the hospital were 1.4% and 3.5%, respectively. Among the 727 patients who were seropositive for HBV or HCV, 107 (14.7%) were referred to a hepatologist. A multivariate analysis to investigate the factors contributing to referral revealed that (i) an alanine aminotransferase (ALT) level of >30 IU/L [odds ratio (OR), 3.24; 95% confidence interval (CI), 2.10-5.03; p<0.001]; (ii) undergoing testing at an internal medicine department (OR, 2.79; 95% CI, 1.80-4.38; p<0.001); and (iii) HBsAg-positivity (OR, 2.22; 95% CI, 1.35-3.61; p=0.002) were factors that significantly influenced referral.
Conclusion Hepatologists must educate non-hepatologists, especially non-internists, to promote the referral of hepatitis-virus carriers, especially HCV carriers, even in patients with ALT levels of <30 IU/L.
Objective The 6-min walk test (6MWT) is a simple test that is used to examine the exercise tolerance and outcomes in patients with chronic obstructive pulmonary disease (COPD). Although the 6MWT is useful for assessing exercise tolerance, it is difficult to evaluate time-dependent parameters such as the walking pattern. A modified 6MWT has been devised to assess the walking pattern by calculating the number of steps per second (NSPS). This study was performed to investigate walking pattern of COPD patients in the modified 6MWT before and after a single inhalation of the short-acting β2-agonist procaterol.
Methods Nine male COPD patients participated in this study. The 6MWT was performed before and after the inhalation of procaterol hydrochloride. A digital video recording of the 6MWT was made. After the 6MWT, the number of steps walked by the subject in each 5-s period was counted manually with a hand counter while viewing the walking test on the video monitor.
Results After the inhalation of procaterol, the 6-min walking distance increased significantly in comparison to baseline (p<0.01). The mean NSPS was also significantly increased after the inhalation of procaterol in comparison to baseline (p<0.01). The walking pattern was displayed on a graph of time versus NSPS, and the walking pace was shown by a graph of time versus cumulative steps.
Conclusion The analysis of the COPD patients' walking test performance and their walking pattern and pace in the 6MWT may help to evaluate the effects of drug treatment.
Objective For lung cancer complicated with sarcoidosis, there are no exact features that indicate whether lymphadenopathy is metastatic. This makes the validity of surgery uncertain for clinicians. The aim of this study was to clarify the clinical features of pulmonary sarcoidosis complicated by lung cancer, especially from the viewpoint of evaluating lymphadenopathy.
Methods We retrospectively reviewed medical records from 2004 to 2013 at our institution, and 18 patients who were diagnosed with sarcoidosis and lung cancer were thus found to be eligible. We investigated the relationship between the clinical and pathological findings of their swollen lymph nodes.
Results Of 18 patients, 11 conducted surgery, and the postoperative pathological evaluation of swollen lymph nodes was done in 8 of the patients. Postoperative N factor in all these patients was 0, even though lymphatic metastasis had been suspected preoperatively because of the unbalanced distribution of lymphadenopathy or the accumulation of fluorodeoxyglucose.
Conclusion In patients with lung cancer complicated by sarcoidosis, the clinical assessment of the state of lymphadenopathy is difficult to make. However, as many of them tend to be benign, we suggest that surgical resection should be considered for a complete cure in the absence of any remote metastasis.
Objective Parkinson's disease (PD) is a common, progressive, neurodegenerative disorder. With progression of PD, the wearing-off phenomenon occurs more frequently as a motor complication, decreasing the patient's quality of life. The aim of this study was to investigate the risk factors for the wearing-off phenomenon in Japanese PD patients.
Methods All of the study participants were clinically diagnosed as having PD. Each patient was assessed for the wearing-off phenomenon based on the findings of clinical assessments and interviews that were conducted during a single visit. The risk factors for wearing-off were analyzed by univariate and multivariate logistic regression analyses.
Results Wearing-off was observed in 101 of the 180 (56.1%) patients who were enrolled in this study. The multivariate logistic regression analysis revealed that the onset of PD at ≥69 years of age (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.05-0.88; p=0.032), female sex (OR, 6.49; 95% CI, 2.34-17.99; p<0.001), catechol-O-methyltransferase (COMT) inhibitor treatment (OR, 19.59; 95% CI, 3.55-108.11; p<0.001) and a high daily levodopa dosage (≥600 mg/day) (OR, 7.69; 95% CI, 1.41-41.84; p=0.018) were independent predictive factors for wearing-off in Japanese PD patients.
Conclusion Age at the symptomatic disease onset, female sex, COMT inhibitor treatment, and a high daily levodopa dose were associated with the occurrence of wearing-off in Japanese PD patients. Physicians need to consider the risk factors and carefully choose medications for PD patients to postpone the occurrence of this phenomenon for as long as possible.
A 68-year-old man with occult hepatitis B virus (HBV) infection was diagnosed with malignant lymphoma and achieved complete remission after treatment with a chemotherapy regimen including rituximab for 5 months. Entecavir (ETV) was also used during and after chemotherapy and was ended at 14 months after chemotherapy. However, reactivation of HBV was observed in blood tests, which showed not only elevation of HBV-DNA but also HBsAg and HBeAg, at 27 months after the end of chemotherapy. After restarting ETV, the HBV-DNA levels immediately subsided. In addition, anti-HBs became and remained positive at 31 months after chemotherapy. ETV was re-discontinued at 36 months after chemotherapy.
A 74-year-old man was admitted to our hospital with chest pain and dyspnea associated with ST elevation in leads II, III and aVF. An echocardiogram showed an enlarged mass lesion measuring nearly 80 mm. Coronary angiography showed two giant coronary artery aneurysms (CAAs) in the right coronary artery (RCA). CAAs were also seen in the left main trunk and left anterior descending artery. Computed tomography showed the CAA in the RCA was ruptured into the right atrium. We therefore diagnosed this patient with multiple CAAs, myocardial infarction and coronary artery rupture. He underwent successful surgical excision and coronary bypass surgery.
Patients with persistent atrial fibrillation (AF) and a large left atrium are at a high risk for thromboembolisms. Recently, direct oral anticoagulants (DOACs) have mainly been used for the prevention of cardiac embolisms caused by AF. Transesophageal echocardiography (TEE) is performed in order to exclude any left atrial appendage (LAA) thrombi. We herein report two cases of persistent AF, both of which were treated with rivaroxaban for more than two years. Since TEE identified mobile LAA thrombi with this treatment, we switched from rivaroxaban to the direct thrombin inhibitor dabigatran. Dabigatran resolved the LAA thrombi that had been refractory to rivaroxaban.
The delayed diagnosis of adrenal insufficiency is relatively common because its symptoms are non-specific. One of the causes of adrenal insufficiency is isolated adrenocorticotropic hormone deficiency (IAD), which is sometimes caused by traumatic brain injury. Indeed, severe head trauma is considered to contribute to the incidence of this disease. However, the relationship between milder head trauma—such as chronic subdural hematoma — and the occurrence of hormonal deficiency is uncertain. We herein report the case of a 79-year-old man with IAD who presented with leg edema and pain in his extremities following a recent history of chronic subdural hematoma.
Werner syndrome is a rare genetic disease characterized by progeria, diabetes mellitus, cataracts and various types of malignancy. However, there are few reports showing adrenal cortex cancer in subjects with Werner syndrome. We herein report an extremely rare case of Werner syndrome accompanied by adrenal cortex cancer. Based on the data obtained from blood samples, computed tomography, magnetic resonance imaging and 131I adosterol scintigraphy, we diagnosed this subject with adrenal cortex cancer and Cushing's syndrome. Since the prognosis of adrenal cancer is very poor, we should be aware of the possibility of adrenal cancer occurring in subjects with Werner syndrome.
A 65-year-old Japanese man with advanced chronic kidney disease (CKD) developed acute-onset type 1 diabetes mellitus (T1D) that was associated with severe acute kidney injury and was manifested by generalized tonic-clonic status epilepticus. His seizures resolved without recurrence after correcting the diabetic ketoacidosis. Although hyperglycemia is an important cause of acute symptomatic seizure (ASS), patients with ketotic hyperglycemia develop ASS less frequently. In this T1D case with CKD, severe hyperglycemia in conjunction with other metabolic insults, such as uremia, hyponatremia, and hypocalcemia, probably provoked his seizure despite the severe ketonemia.
A 26-year-old Japanese man without hypouricemia and with 3 previous episodes of seizures concurrent with acute kidney injury (AKI) was admitted due to an epileptic seizure, lower back pain and AKI. His creatinine kinase levels were slightly elevated. Patchy renal ischemia on contrast-enhanced computed tomography and persistent residual contrast medium was observed, consistent with acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE). Diffusion-weighted imaging (DWI) demonstrated signal changes in the corresponding area. ALPE should be considered a cause of AKI following seizures. We recommend DWI as an alternative diagnostic modality.
A 62-year-old man exhibiting nasal obstruction and glomerulonephritis with proteinase 3-antineutrophil cytoplasmic antibodies (PR3-ANCAs) was diagnosed with extranodal NK/T-cell lymphoma, nasal type (ENKL) with infiltration of neutrophils with apoptosis. Chemoradiotherapy reduced the tumor, improved the renal function, and decreased the PR3-ANCA levels. ANCA-positivity is observed in immunoinsufficient diseases, in which neutrophils lead to apoptosis and translocate intracellular granules, such as PR3, to the cell surface, triggering the production of ANCAs. In our case, the PR3-ANCA production was derived from the expression of PR3 on the cell surface of apoptotic neutrophils. This is the first report on ENKL describing the mechanism of ANCA development.
We herein report a 58-year-old Japanese woman who survived 14 years after surgery for lung adenocarcinoma harboring an epidermal growth factor receptor (EGFR) exon 19 deletion. She developed recurrence, for which she underwent multimodal therapy, including EGFR-tyrosine kinase inhibitor (TKI) administration. She ultimately died from a rapidly progressive right lung tumor that was resistant to EGFR-TKI. According to the autopsy findings, she had combined large-cell neuroendocrine carcinoma (LCNEC) and adenocarcinoma in the right lung, which retained an EGFR exon 19 deletion in both components. Therefore, the histological transformation to LCNEC can be a mechanism of acquired EGFR-TKI resistance.
An 83-year-old man was admitted with a chief complaint of exacerbation of dyspnea. His blood oxygen saturation was 90% in the recumbent position despite oxygen therapy, and it dropped to less than 80% when the patient attempted to sit upright. A computed tomography scan revealed a giant hepatic cyst compressing the right atrium and the inferior vena cava. After percutaneous drainage, the oxygen saturation improved and did not change with alteration of the patient's positions from recumbent to sitting or standing. This case report describes a patient with the platypnea-orthodeoxia syndrome due to a giant hepatic cyst successfully managed by percutaneous drainage.
A 58-year-old woman was referred to our hospital with a chief complaint of exertional dyspnea. Bronchoscopy failed to establish a diagnosis, and the patient subsequently died suddenly due to respiratory insufficiency because of advanced pulmonary hypertension (PH). The pathological diagnosis at autopsy was pulmonary veno-occlusive disease (PVOD). PVOD is difficult to diagnose antemortem and has a poor prognosis. Lung transplantation is the only curative treatment for PVOD.
Chest wall tumors are relatively rare, and hematogenous metastasis to the chest wall is very rare. We herein describe a rare case of occult thyroid carcinoma as metastasis to the chest wall in an 80-year-old woman. The patient received detailed examinations of the chest wall tumor, and the results suggested that she had occult thyroid carcinoma. Surgery was then performed to remove all of her thyroid. As a result, she was diagnosed with follicular carcinoma of the thyroid. We report an extremely rare case of occult thyroid carcinoma diagnosed as hematogenous metastasis to the chest wall.
A single dose of pegfilgrastim or the daily administration of colony-stimulating factors can be used to prevent febrile neutropenia. This may delay the detection of rapidly progressive infections among cancer patients undergoing chemotherapy. We report a case of Pseudomonas aeruginosa bacteremic pneumonia that occurred in a patient receiving pegfilgrastim.
Primary superior vena cava lymphoma originating from the endothelium of a large vein is very rare. A 70-year-old man was admitted to the hospital; computed tomography showed a tumor limited to the inside of the superior vena cava, completely occluding the vessel. A transjugular biopsy confirmed the diagnosis of diffuse large B-cell lymphoma, which was diffusely positive for CD30. Rituximab monotherapy followed by five courses of R-CHOP chemotherapy induced a complete remission. There was no recurrence after two years. The pathophysiology of lymphoma derived from large vessels may be different from intravascular large B-cell lymphoma, which usually involves small vessels.
Sarcoidosis predominantly affects the lungs, intrathoracic lymph nodes, and eyes; it less frequently affects the musculoskeletal system. We herein report a case of paraneoplastic sarcoidosis in a patient presenting with multiple myeloma. The patient developed ocular sarcoidosis and showed an increased 18F-fluorodeoxyglucose uptake in the mediastinal lymph nodes and vertebral column. A lymph node specimen showed the histological features of sarcoidosis, while an examination of the vertebral tumor revealed myeloma. Although the simultaneous occurrence of sarcoidosis and myeloma is extremely rare, our case indicates the importance of exculing any underlying malignancies before establishing a diagnosis of skeletal sarcoidosis when bone lesions are observed at unusual sites.
Neuromuscular disorders associated with hyperthyroidism have several variations in their clinical phenotype, such as ophthalmopathy, periodic paralysis, and thyrotoxic myopathy. We herein report an unusual case of thyrotoxic myopathy presenting as unilateral drop foot. Histopathological examinations of the left tibialis anterior muscle showed marked variation in the fiber size, mild inflammatory cell infiltration, and necrotic and regenerated muscle fibers with predominantly type 1 fiber atrophy. Medical treatment with propylthiouracil resulted in complete improvement of the left drop foot. This case expands the phenotype of thyrotoxicosis and suggests that thyrotoxicosis be considered as a possible cause of unilateral drop foot.
We herein report the case of a 44-year-old woman who developed protein-losing gastroenteropathy (PLGE) with hypoalbuminemia as the first manifestation of mixed connective tissue disease (MCTD). Albumin leakage from the stomach and intestinal tract was demonstrated by 99mTc-labeled human serum albumin scintigraphy. The patient's response to prednisolone therapy was insufficient; therefore, additional cyclosporin A (CsA) treatment was administered, and clinical remission was achieved. We concluded that although PLGE is a rare complication of MCTD, it may manifest as an initial clinical episode of MCTD. Furthermore, CsA can be a useful treatment option for refractory PLGE related to MCTD.
A 68-year-old man presented with polyarthritis, proximal muscle weakness, and erythema of the face, arms, neck, and anterior chest that resembled the V-neck sign. Initially, dermatomyositis (DM) was considered because of the erythema, polyarthritis, and muscle weakness. He also had mediastinal and hilar lymphadenopathy on contrast-enhanced computed tomography. Unexpectedly, a biopsy of the forehead skin revealed numerous multinucleated giant cells. A biopsy of a solitary nodule on the dorsum of his right middle finger revealed similar multinucleated giant cells with ground-glass cytoplasm, leading to the diagnosis of multicentric reticulohistiocytosis (MRH). Although MRH is rare, it should be remembered that MRH can mimic DM.
The incidence of co-infection with Treponema pallidum and human immunodeficiency virus (HIV) is increasing in developing and developed countries. The neurological complications of both infections occasionally occur simultaneously during a clinical course. We herein report the case of an HIV carrier with syphilitic meningomyelitis and subclinical optic neuropathy. The patient presumably had latent syphilis and slowly developed longitudinally extensive transverse myelitis (LETM). A cerebrospinal fluid examination confirmed the diagnosis of active neurosyphilis based on an elevated T. pallidum hemagglutination assay index. A change in the patient's immune status, possibly due to HIV, might have converted the syphilis from latent to active, leading to LETM of the spinal cord.