Objective To analyze the clinical characteristics and endoscopic features of patients with lanthanum deposition in the stomach.

Patients We retrospectively reviewed seven patients with lanthanum deposition in the stomach who were diagnosed at Okayama Saiseikai General Hospital. We investigated the patient sex, age at diagnosis, medical and medication histories, gastrointestinal symptoms, complications, presence or absence of gastric atrophy, and outcome. We also investigated any changes in the endoscopic features if previous endoscopic images were available.

Results Seven patients (six males and one female) had lanthanum deposition. The median age was 65 years (range, 50-79 years). All patients had been undergoing dialysis (continuous ambulatory peritoneal dialysis in one patient, hemodialysis in six patients). The dialysis period ranged from 16 to 73 months (median, 52 months). The patients had all been taking lanthanum carbonate for a period ranging from 5 to 45 months (median, 27 months). Gastric atrophy was noted in 6 patients (85.7%). One patient had difficulty swallowing, and 1 other patient had appetite loss. The other 5 patients were asymptomatic. Endoscopic features included annular whitish mucosa (n = 4), diffuse whitish mucosa (n = 3), and whitish spots (n = 2). Five patients underwent multiple esophagogastroduodenoscopy. The endoscopic features were unchanged in 2 patients, whereas the whitish mucosa became apparent and spread during the course in 3 patients.

Conclusion We identified 7 patients with lanthanum deposition in the stomach. All patients showed whitish lesions macroscopically. Although the pathogenicity of gastric lanthanum deposition is uncertain, lanthanum-related lesions in the stomach progressed during continuous lanthanum phosphate intake in several patients.

Objective High-sensitivity cardiac troponin T (hs-cTnT) is widely used for the diagnosis of acute myocardial infarction (AMI). The current cut-off value of 0.014 ng/mL was determined based on the 99th percentile of a normal reference population; however, little data exist regarding the appropriate cut-off value in the elderly (≥75 years). Accordingly, we aimed to investigate the accuracy of the current cut-off value in an elderly population.

Methods We assessed 355 consecutive patients (mean age =66.7±16.1 years, male =210) whose hs-cTnT levels were measured at Kanazawa University Hospital from January 2014 to July 2015. Twenty-six patients were eventually diagnosed with AMI. Hs-cTnT was measured during a visit to the emergency or outpatient department. Receiver operating characteristic (ROC) curves were assessed to determine the appropriate cut-off levels, yielding the maximum sensitivity and specificity while dividing the subjects into two groups according to ages (≥75 or ≤74 years).

Results The appropriate overall cut-off value was 0.038, the sensitivity and specificity of which were 85% and 89%, respectively, with an area under the ROC curve (AUC) of 0.945 overall. The conventional cut-off value (99th percentile: 0.014 ng/mL) provided low specificity, particularly in the elderly or those with renal dysfunction. In contrast, a calculated appropriate cut-off provided higher sensitivity with significantly larger c-statistics in the elderly (0.940 vs. 0.629, p<0.001).

Conclusion When measuring hs-cTnT, careful assessments are needed in elderly subjects.

Objective A low ankle-brachial index (ABI) is a known predictor for future cardiovascular events and mortality in patients with chronic kidney disease (CKD). While most prior studies have defined CKD as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², recent reports have suggested that the cardiovascular risk may be increased even in early stages of renal insufficiency. We hypothesized that a low ABI may predict future cardiovascular morbidity and mortality in patients with mild impairment of the renal function.

Methods The IMPACT-ABI study was a retrospective, single-center, cohort study that enrolled and obtained ABI measurements for 3,131 patients hospitalized for cardiovascular disease between January 2005 and December 2012. From this cohort, we identified 1,500 patients with mild renal insufficiency (eGFR =60-89 mL/min/1.73 m²), and stratified them into 2 groups: ABI ≤0.9 (low ABI group; 9.2%) and ABI >0.9 (90.8%). The primary outcome measured was the cumulative incidence of major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke).

Results Over a mean follow-up of 5.0 years, 101 MACE occurred. The incidence of MACE was significantly higher in patients with low ABI than in those with ABI >0.9 (30.2% vs. 14.4%, log rank p<0.001). A low ABI was associated with MACE in a univariate Cox proportional hazard analysis. A low ABI remained an independent predictor of MACE in a multivariate analysis adjusted for cardiovascular risk factors (hazard ratio (HR): 2.27; 95% confidence interval (CI): 1.33-3.86; p=0.002).

Conclusion Low ABI was an independent predictor for MACE in patients with mild renal insufficiency.

Objective To identify the prehospital factors predicting the performance of tracheal intubation (TI) at the emergency department (ED) in patients with convulsive seizure or epilepsy.

Methods We performed a retrospective analysis of seizure patients who underwent TI at the ED soon after arrival. The clinical variables obtained in the prehospital setting were reviewed.

Patients The study population included consecutive adult patients who were transported to an urban tertiary care ED due to convulsive seizure between August 2010 and September 2015.

Results Among the 822 eligible patients, 59 patients (7.2%) underwent TI at the ED. Four independent prehospital predictors were identified using multivariate analysis: age ≥50 years (+1 point), meeting the definition of convulsive status epilepticus (+4 points), and an on-scene heart rate of ≥120 bpm (+1 point) led to a higher likelihood of TI, while a higher on-scene (alert or confused) level of consciousness (-3 points) led to a lower likelihood of TI. The derived prediction rule (the sum of all points) had good predictive performance with an area under the curve of 0.88 (95% confidence interval: 0.79-0.97), a sensitivity of 0.62, a specificity of 0.91, and a positive likelihood ratio of 10.6, when the cut-off value was set to 5 points.

Conclusion We constructed a simple prehospital prediction rule to help predict the need for TI in seizure patients, even in the prehospital phase. This may possibly lead to the more effective management of seizure patients in the ED.

Objective We attempted to clarify the factors related to the aggravation of depression in patients with subacute myelo-optico-neuropathy (SMON) caused by clioquinol intoxication more than 35 years previously.

Methods We investigated changes in the depressive mental states that occurred with aging in 19 Japanese SMON patients (mean age, 78.3 years; range, 66-89 years) according to their scores on the Japanese version of the Zung Self-rating Depression Scale (SDS), which were obtained 3-10 years previously and their current scores. The depressive state was further evaluated using simultaneous semi-structured interviews.

Results The depressive mental states of 6 patients, whose current total SDS scores had increased by ≥10% in comparison to the previous score, were considered to have been aggravated with aging. The mean current total SDS score of these six patients was significantly higher than the mean score of the 13 patients whose conditions were not aggravated. Among the 20 SDS questionnaires, the patients whose conditions were aggravated showed significantly higher scores in diurnal variation, sleep disturbance and weight loss. The semi-structured interviews revealed that physical disabilities due to the sequelae of SMON, a lack of acceptance of SMON, and a decline in social activities were important factors in the aggravation of their depressive mental states with aging.

Conclusion The maintenance of social activities with public support was important for coping among Japanese SMON patients with a depressive mental state, especially those who could not walk independently or who could not go outside freely without assistance.

Objective We examined the general characteristics, survival rate, and most common reasons for visiting the emergency department (ED) among colorectal cancer patients in Taiwan. We performed a population-based retrospective study and used data sourced from the National Health Insurance Research Database (NHIRD).

Methods The colorectal cancer patient population, their diagnosis, and their medical management at the ED were identified using the Longitudinal Health Insurance Database 2000 (HV) codes and International Classification of Diseases, Ninth Revision, Clinical Modification system. We investigated their reasons for visiting the ED and the medications used there, analyzed their cumulative survival curves using the Kaplan-Meier method, and compared the survival curves with other colorectal cancer patients who had never visited the ED.

Results Between 2000 and 2012, there were 6,532 ED visits by 3,347 colorectal patients, and the number per year increased gradually. The top three most common reasons for visiting ED were ill-defined conditions, abdominal pain, and intestinal obstruction. The overall survival rates of colorectal patients in the ED visit group at 3, 5, and 10 years, were 0.65, 0.56, and 0.47, respectively, without significant differences from the rates among colorectal cancer patients who did not visit the ED (p=0.2072).

Conclusion We described the circumstances of ED visitation by colorectal cancer patients in Taiwan. Health care providers and researchers should pay more attention to improve medical care quality and investigate more details to predict the outcome among colorectal cancer patients.

A 66-year-old man presented to his previous physician with epigastric discomfort in 2014. He was then referred to our hospital due to suspected primary malignant melanoma of the esophagus (PMME). A biopsy showed atypical cells containing melanin granules. A diagnosis of PMME was thus made. We investigated the endoscopic findings of the previous physician, which revealed a black point-like pigmentation at the same site since 2009. In 2010, black pigmentation was also observed at the same site. Although esophageal melanosis was suspected, no biopsy was performed. This case demonstrates the process by which esophageal melanomas develop into malignant melanomas.

We herein report a child case of autoimmune hepatitis (AIH) accompanied with Graves' disease. Elevated aminotransferase levels were found in a 12-year-old Japanese girl with Graves' disease. In her first liver biopsy, necrosis and inflammation was limited to the centrilobular area, while the second biopsy showed different findings. Namely, portal injury newly appeared, including interface hepatitis, which represents the histological characteristics of AIH. As the histological findings at the onset of AIH do not always show typical findings, a re-biopsy is considered to be important in individuals suspected to have AIH. AIH should be included in the differential diagnosis of liver dysfunction in Graves' disease, even in children.

The patient was a 39-year-old man hospitalized due to the presence of a cardiac mass and heart failure. Emergency tumor resection and mitral valve replacement were performed. The pathological findings of the tumor led to a diagnosis of cardiac leiomyosarcoma. After the operation, multiple metastases were found. The patient underwent three courses of chemotherapies: adriamycin, ifosfamide, dacarbazine, and mesna (MAID therapy), gemcitabine plus docetaxel, and sunitinib. During MAID therapy, the patient underwent resection of gastrointestinal metastases twice due to gastrointestinal hemorrhaging. Although he died 27 months after the initial treatment, use of multimodal therapy was effective in achieving a longer survival for the patient.

We herein report the total course and autopsy findings of a woman who complained of chest discomfort and had plasma B-type natriuretic peptide 43 pg/mL and left ventricular outflow tract obstruction (with a resting pressure gradient of 181 mmHg) due to sigmoid septum at 73 years of age. Betaxolol and verapamil decreased her pressure gradient to 14 mmHg, but the pressure gradient (101 mmHg) again worsened. The betaxolol dose was increased and cibenzoline was added, resulting in a pressure gradient ≤21 mmHg. An autopsy was performed after death from a urinary tract infection at 80 years of age. The absence of any disarray of cardiac myocytes was confirmed.

A 58-year-old man with a recent history of generalized myalgia and muscle weakness was transferred to our hospital because of acute progressive dyspnea. The patient underwent left ventricular (LV) assist device (LVAD) implantation due to cardiogenic shock with a LV ejection fraction (LVEF) of 6%. The histological findings obtained from LV apex showed the infiltration of multinucleated giant cells and severe myocardial contusion. Combining this histological finding with our experienced neurologists comments, resulted in a final diagnosis of fulminant giant cell myocarditis associated with polymyositis. A day after LVAD implantation, the patient received corticosteroid and immunosuppressive therapy, and the LVEF recovered to 68%.

A 79-year-old woman was admitted with a left femoral neck fracture and she immediately developed circulatory shock. Echocardiography showed a markedly enlarged right ventricle (RV) with systolic ballooning of the mid-ventricular wall and preserved contractility of the apex. The left ventricular (LV) motion was normal. Multi-detector-row computed tomography showed severe congestion of the contrast media in the right atrium with no forward flow to RV, but no pulmonary embolism. She was successfully treated with percutaneous veno-arterial extracorporeal membrane oxygenation. This case presented with acute, profound, but reversible RV dysfunction triggered by acute stress in a manner similar to that seen in LV stress cardiomyopathy.

A 50-year-old man presented with exertional dyspnea and orthopnea. An electrocardiogram showed a delta wave and a wide QRS complex, similar to left bundle branch block. Cardiac echocardiography revealed diffuse severe hypokinesis and dyssynchrony. The patient was diagnosed with congestive heart failure. We considered that the patient's condition was caused by an accessory pathway-induced cardiomyopathy after heart failure compensation with guideline-oriented medical therapy. We therefore performed catheter ablation for right-sided pre-excitation syndrome as cardiac resynchronization therapy. The left ventricular dyssynchrony was resolved immediately after the procedure, and the patient's ventricular contraction improved, with a reduced cardiac volume at 6 months after the procedure-thus suggesting that the accessory pathway had affected the patient's cardiac function.

Purulent pericarditis is a life-threatening disorder, even in the modern antibiotic era. Although diabetes mellitus is known to be associated with an increased risk of multiple types of infections, purulent pericarditis is extremely rare. We herein report an unusual case of pericarditis caused by Salmonella enterica subspecies arizona that was not associated with any evident underlying immunosuppressive disorder apart from uncontrolled type 2 diabetes mellitus. Because a pet snake was suspected as being the source of infection in the present case, patient education and a detailed review of exposure history could play an important role in treating patients with diabetes mellitus.

We herein report the case of a Japanese woman with familial dysalbuminemic hyperthyroxinemia (FDH) who was initially diagnosed with Graves' disease. Direct genomic sequencing revealed a guanine to cytosine transition in the second nucleotide of codon 218 in exon 7 of the albumin gene, which then caused a proline to arginine substitution. She was finally diagnosed with FDH, which did not require treatment. FDH is - superficially - an uncommon cause of syndrome of inappropriate secretion of thyrotropin (SITSH) in Japan. A misdiagnosis of pseudo-hyperthyroidism will lead to inappropriate treatment. Thus, physicians should strongly note the possibility of FDH as a differential diagnosis of SITSH.

A 66-year-old woman, who was diagnosed with iritis, visited our hospital due to general malaise. A blood analysis revealed hypercalcemia. Computed tomography revealed mediastinal and hilar lymph node hyperplasia. Moreover, ⁶⁷Gallium scintigraphy demonstrated strong accumulation in the lesions, suggesting sarcoidosis. A core needle biopsy (CNB) of the hypoechoic areas of the thyroid was performed because the patient refused to undergo a bronchoscopic examination. The scattering of slightly acidophilic epithelioid cell granulomas was observed in the pathological examination of the biopsy specimen. Based on this finding, the patient was diagnosed with sarcoidosis. Although sarcoidosis rarely involves the thyroid gland, in the present case, thyroid CNB was an alternative diagnostic method that allowed a pathological diagnosis to be obtained.

For the first time, a 15-year-old boy was found to have a slight degree of proteinuria and microscopic hematuria during annual school urinalysis screening. His kidney function had already severely deteriorated. A kidney biopsy revealed tubulointerstitial nephritis (TIN) with diffuse inflammatory cell infiltration. His medical records showed his serum creatinine level to be 0.98 mg/dL two years ago, which was abnormally high considering his age. Although the etiology of slowly progressive TIN was unclear, glucocorticoid and immunosuppressant therapy improved his kidney function. This case report suggests that all doctors should recognize the reference range for the serum creatinine level in teenagers.

We herein report a case of congestive heart failure which developed during osimertinib treatment. A 78-year-old woman presented with mild exertional dyspnea three weeks after starting osimertinib for the treatment of epidermal growth factor receptor (EGFR) T790M-positive non-small cell lung cancer. She was diagnosed with congestive heart failure caused by the osimertinib. In contrast to trastuzumab, a human epidermal growth factor receptor 2 (HER2) monoclonal antibody that often causes cardiac dysfunction, the causal relationship between osimertinib and cardiotoxicity has so far received little attention and thus remains unclear. However, it inhibits HER2 in addition to mutant EGFR, thereby potentially causing cardiotoxicity.

Although anti-neutrophil antibodies (ANAs) often exist and immunoreaction may be involved in agranulocytosis, few reports have so far described ANA-positive cases of agranulocytosis with an unknown etiology. We herein describe the case of a 69-year-old woman who presented with ANA-positive agranulocytosis. In this case, both the withdrawal of the drugs that had possibly caused neutropenia and the use of granulocyte-colony stimulating factor (G-CSF) were ineffective treatment measures. Approximately 2 weeks after the discontinuation of the suspected drugs, we initiated corticosteroid pulse therapy; the neutrophil count recovered by day 19 of steroid therapy. High-dose methylprednisolone therapy should thus be considered for patients demonstrating ANA-positive agranulocytosis with an unknown etiology that is refractory to G-CSF treatment.

TAFRO syndrome is a rare systemic inflammatory disease characterized by thrombocytopenia, pleural effusion, fever, renal dysfunction, reticulin fibrosis of the bone marrow, and organomegaly. The clinical course varies significantly among patients. However, the prognosis is usually dismal in patients with severe TAFRO syndrome, and no optimal treatment has yet been established. We herein describe the first case of TAFRO syndrome, which was successfully treated with combination therapy consisting of tocilizumab, prednisone, and cyclophosphamide.

We herein describe a 37-year-old man who developed cervical flexion myelopathy 11 years after suffering a cervical spinal cord injury. Cervical magnetic resonance imaging 11 years after the accident demonstrated atrophy and hyperintense lesions at the C6 and C7 levels in the cervical cord with an abnormal alignment of the vertebrae. In the neck flexion position, an anterior shift of the cervical cord was evident. Our patient's condition suggests that an abnormal alignment of the cervical spine and spinal cord injury due to a traumatic accident could be risk factors in the subsequent development of cervical flexion myelopathy.

Kawasaki disease (KD) is an acute, self-limited vasculitis of unknown etiology that occurs predominantly in young children (≤5 years of age). We herein report the case of an 18-year-old Japanese man with a history of incomplete KD during infancy; later, despite an initial diagnosis of retropharyngeal abscess, he was ultimately diagnosed with retropharyngeal edema associated with recurrent KD. Adult-onset or recurrent KD is an uncommon event, and retropharyngeal edema is a rare manifestation of this disease. Internists should be aware of the possibility of KD that mimics a retropharyngeal abscess, even in adult patients.

We herein report the case of a 41-year-old Japanese man with well-controlled HIV who presented with diagnostically difficult acute necrotizing ulcerative gingivitis (ANUG). After diet-induced weight loss, he developed oral pain and disturbance of mouth opening, and was admitted to our hospital. Based on preconceptions of HIV-associated diseases, fluconazole was initiated for candidiasis. However, no improvement was seen and ANUG was finally diagnosed. This case suggests that physicians should consider ANUG in HIV-infected individuals when several risk factors are present, even if CD4+ T-lymphocyte counts have remained stable owing to long-term anti-retroviral therapy.

A 56-year-old Japanese man diagnosed with acquired immunodeficiency syndrome, Pneumocystis jirovecii pneumonia and cytomegalovirus infection presented with thrombocytopenia after starting antiretroviral therapy, which included dolutegravir (DTG). Although good control of the human immunodeficiency virus and cytomegalovirus infections was achieved, the patient's thrombocytopenia persisted. The patient's platelet count decreased to ≤50,000/μL even after the cessation of valganciclovir, which can cause bone marrow suppression. At five months after starting antiretroviral therapy, DTG was replaced by ritonavir-boosted darunavir. Soon after, his platelet count improved and was maintained at a level of >100,000/μL. This is the first reported case of severe thrombocytopenia during DTG-containing antiretroviral therapy.

Familial Mediterranean fever (FMF) is a genetic autoinflammatory disease characterized by recurrent fever with serosal inflammation. We experienced a 53-year-old male who had been suffering from periodic attacks with slight fever and myalgia which were mainly triggered by cold exposure in winter. Although his clinical course did not satisfy the criteria for familial Mediterranean fever, heterozygous E148Q/M694I mutation in the Mediterranean fever (MEFV) gene was detected. Further attacks were prevented by treatment with colchicine. Attention should therefore be paid to the possibility of atypical FMF symptoms, which should be accurately diagnosed by genetic analyses to prevent the development of amyloidosis.