Internal Medicine
Online ISSN : 1349-7235
Print ISSN : 0918-2918
ISSN-L : 0918-2918
Volume 56 , Issue 24
Showing 1-30 articles out of 30 articles from the selected issue
REVIEW ARTICLE
  • Kosaku Nitta, Aiji Yajima, Ken Tsuchiya
    2017 Volume 56 Issue 24 Pages 3271-3276
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Chronic kidney disease (CKD) patients with coexisting osteoporosis are becoming common. Many of the therapeutic agents used to treat osteoporosis are known to be affected by the renal function. It is generally thought that osteoporosis in G1 to G3 CKD patients can be treated as in non-CKD patients with osteoporosis. In stage 4 or more advanced CKD patients and CKD patients on dialysis with osteoporosis, however, bisphosphonates must be used with caution, bearing in mind the potential development of such disorders as adynamic bone disease. The use of vitamin D preparations in low doses is relatively safe. In postmenopausal women, raloxifene must be administered with caution. When using denosumab, the serum calcium concentrations should be monitored carefully to prevent the development of hypocalcemia, and active vitamin D preparations should be administered concomitantly. The present article provides an overview of the management of osteoporosis in CKD patients.

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ORIGINAL ARTICLE
  • Toshinori Tsukahara, Nobuyuki Horita, Ken Tashiro, Kenjiro Nagai, Masa ...
    2017 Volume 56 Issue 24 Pages 3277-3282
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Objective Onodera's Prognostic Nutritional Index (PNI), determined as "10× albumin (g/dL) + 0.005× lymphocyte count (/μL)," was originally designed to determine the risk of complications following gastrointestinal surgery. This single-center, retrospective observational study was designed to investigate whether or not the PNI can predict the treatment outcome.

    Methods We consecutively reviewed HIV-negative pulmonary tuberculosis adults in an isolation ward. Most patients were being treated with standard three- or four-drug regimens. Patients were discharged after consecutive negative smears/cultures were confirmed. The risk of all-cause death was assessed using a multivariable Cox proportional hazard model and a log-rank trend test.

    Results During the observation period, we observed 371 consecutive patients with a median age of 72 (interquartile range [IQR]: 54-82) years. In our cohort, 295 (79.5%) patients were discharged alive, and 76 (20.5%) died in-hospital. Patients who died in-hospital had a lower PNI [median 21.2 (IQR: 18.5-25.9)] than those who were discharged alive [median 35.1 (IQR: 28.0-43.3); p<0.001]. The area under the receiver operating characteristic curve was 0.87. After dividing the patients based on the baseline PNI quartile, those patients with a lower PNI showed a poorer survival than those with a higher PNI (log-rank trend p<0.001). After adjusting for other baseline variables, the baseline PNI was still associated with in-hospital death with a hazard ratio of 0.86 (95% confidence interval: 0.82-0.91, p<0.001).

    Conclusion Our results showed that a low PNI was clearly related to a poor survival prognosis in smear-positive HIV-negative pulmonary tuberculosis inpatients.

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CASE REPORTS
  • Katsuki Yaguchi, Makomo Makazu, Kingo Hirasawa, Makoto Sugimori, Ryosu ...
    2017 Volume 56 Issue 24 Pages 3283-3286
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Stomach cancer rarely develops in patients with familial adenomatous polyposis (FAP), and Helicobacter pylori infection may increase the risk of FAP-related gastric cancer. We describe the case of a 64-year-old woman who developed multiple synchronous early gastric cancers without H. pylori infection. Nine cancer lesions were successfully treated by endoscopic submucosal dissection. An immunohistochemical analysis revealed that the tumors were positive for mucin (MUC)2, MUC6, and CDX2, but negative for MUC5AC, suggesting that the tumors were gastrointestinal mixed type. Periodical endoscopic surveillance is important for the detection of cancers at an early stage.

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  • Masaya Iwamuro, Rika Omote, Takehiro Tanaka, Naruhiko Sunada, Takahiro ...
    2017 Volume 56 Issue 24 Pages 3287-3291
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
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    A 67-year-old Japanese man with neurofibromatosis type 1 underwent right hemicolectomy owing to abscess formation around the cecum. A pathological analysis revealed diffuse intestinal ganglioneuromatosis in the cecum and colon. Colonoscopy performed eight months after hemicolectomy revealed multiple ulcers throughout the colon and rectum. The colorectal ulcers failed to respond to conservative treatment and ultimately required surgical resection. Diffuse ganglioneuromatosis was observed again in the resected specimen. This report illustrates a rare manifestation of diffuse intestinal ganglioneuromatosis in a patient with neurofibromatosis type 1.

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  • Yuichi Miyashima, Michihiko Shibata, Yuichi Honma, Hidehiko Matsuoka, ...
    2017 Volume 56 Issue 24 Pages 3293-3297
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 49-year-old woman with a history of heavy alcohol drinking was admitted to our hospital due to jaundice and abdominal distention. A blood test showed leukophilia, mild hypoalbuminemia, hyperbilirubinemia, hepatobiliary injury and coagulopathy. Image studies showed an extremely enlarged fatty liver and splenomegaly. The Japan alcoholic hepatitis score and Maddrey's discriminant function were 10 and 54 points, respectively. We diagnosed her with severe alcoholic hepatitis and treated her with corticosteroids, but her liver function did not improve. We therefore administered the vitamin E product tochopheryl acetate (150 mg/day) as an add-on therapy, after which her leukophilia, liver enzymes and coagulopathy improved immediately.

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  • Naoki Tamada, Kazuhiko Nakayama, Yuto Shinkura, Kenichi Yanaka, Naoto ...
    2017 Volume 56 Issue 24 Pages 3299-3304
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    The patient was a 19-year-old woman who was diagnosed with patent ductus arteriosus complicating Eisenmenger syndrome at a previous medical institution. She was referred to our hospital and arranged for lung transplantation. She developed hemoptysis after the introduction of i.v. epoprostenol, which was administered as a bridging treatment while the patient awaited lung transplantation. She continued to suffer from recurrent hemoptysis, even after switching from i.v. epoprostenol to i.v. treprostinil. Angiography of the systemic and pulmonary arteries revealed the vessel responsible for the recurrent hemoptysis and pulmonary artery embolization was successfully performed. It is essential to identify the culprit vessel and physicians must not hesitate in performing embolization when patients develop lethal hemoptysis.

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  • Yasuaki Hada, Hiroyuki Fujii, Masato Shimizu, Noriyoshi Yamawake, Mits ...
    2017 Volume 56 Issue 24 Pages 3305-3309
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Coronary artery aneurysm (CAA) after sirolimus-eluting stent (SES) implantation is one of the most troublesome problems associated with first-generation drug-eluting stents. However, the natural course and standard therapy of CAA has been unknown. A 49-year-old man underwent SES implantation for the left anterior descending artery. Follow-up coronary angiography (CAG) revealed CAA in the SES. We performed bare metal stent (BMS) implantation for treatment of CAA. Ten months after the BMS implantation, the size of the CAA had diminished, and a very thin layer of endothelium on the BMS was observed by optical coherence tomography. CAG assessment revealed that the blood stream of the CAA had been obstructed. We herein report a case of CAA after SES implantation with eight years of follow-up and the findings of a multimodality imaging evaluation.

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  • Takashi Iijima, Junichi Hoshino, Kenmei Takaichi, Tadashi Kohno, Takes ...
    2017 Volume 56 Issue 24 Pages 3311-3316
    Published: December 15, 2017
    Released: December 15, 2017
    JOURNALS OPEN ACCESS

    A 48-year-old woman was admitted to our hospital to undergo evaluation for fatigue, severe weight loss, and nephrotic range proteinuria. Light microscopy of a renal biopsy specimen revealed class III (A) lupus nephritis, while immunofluorescence and electron microscopy only showed sparse immune deposits with findings that were not typical of lupus nephritis. Computed tomography revealed a mass in the anterior mediastinum, which was resected. The examination of the surgical specimen revealed type A noninvasive thymoma. In combination with thymomectomy, postoperative steroid therapy achieved the prompt remission of lupus nephritis. In this patient, thymoma-related autoimmunity may have contributed to the exacerbation of lupus nephritis.

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  • Hiroaki Myoga, Tetsu Akimoto, Naoko Mato, Takakiyo Nakaya, Takuya Mura ...
    2017 Volume 56 Issue 24 Pages 3317-3322
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 68-year-old man was admitted to our hospital to undergo an examination for nephrotic syndrome while concurrently complicated with recurrent thymoma in the parietal pleura and retroperitoneum. He had been diagnosed with invasive thymoma and had undergone thymo-thymectomy seven years previously. Based on the renal biopsy findings, his nephrotic syndrome was ascribed to minimal change disease. He was treated with corticosteroid monotherapy, which resulted in complete remission six months later, despite the fact that the recurrent thymoma remained. The role of thymoma in the pathogenesis of paraneoplastic glomerulopathy and the therapeutic concerns that emerged in this case are also discussed.

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  • Masaki Okamoto, Masaki Tominaga, Shigeki Shimizu, Chiyo Yano, Ken Masu ...
    2017 Volume 56 Issue 24 Pages 3323-3326
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 40-year-old female dental technician visited our hospital for the investigation of a chest X-ray abnormality. Chest computed tomography demonstrated centrilobular nodules and lung volume reduction, and her serum KL-6 level was elevated. A histological analysis of the specimens obtained on a surgical lung biopsy showed peribronchiolar fibrosis with pigmented macrophages and cholesterol clefts. An energy-dispersive X-ray analysis showed that these lung tissues contained some metals, including indium. The serum indium level was also elevated. We diagnosed this patient with pneumoconiosis caused by exposure to sandblasting certain dental metals. This is the first reported case of pneumoconiosis in a dental technician associated with exposure to indium.

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  • Masashi Namba, Takeshi Masuda, Takashi Nakamura, Yasushi Horimasu, Shi ...
    2017 Volume 56 Issue 24 Pages 3327-3331
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Recently, sirolimus, an inhibitor of mammalian target of rapamycin, was reported to decrease chylous effusion in patients with lymphangioleimyomatosis (LAM). We herein report a case of a 34-year-old woman with LAM who developed refractory chylothorax and chylous ascites during sirolimus therapy. In this case, to reduce chylous effusion, we administered octreotide, which is often used to control postoperative chylous effusion, in addition to the sirolimus therapy. This combination therapy reduced the chylothorax and chylous ascites. For patients with LAM, octreotide therapy in addition to sirolimus may be effective for treating sirolimus-refractory chylous effusion.

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  • Suya Hori, Motoko Tachihara, Daisuke Tamura, Kazuyuki Kobayashi, Kyosu ...
    2017 Volume 56 Issue 24 Pages 3333-3339
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 20-year-old Japanese woman with a history of pulmonary atresia was referred to our hospital after the detection of an abnormal mass in the right lung and mediastinal lymphadenopathy. A cytological specimen obtained by transbronchial brushing indicated that the pathological diagnosis was non-small cell lung cancer. During the follow-up period, the tumor spontaneously regressed. At four months after the diagnosis, she experienced sudden bleeding from the small intestine. The histological characteristics of the small intestine tumor were compatible with the cytological characteristics of the lung tumor. Detailed immunohistochemical analyses led to a final diagnosis of epithelial angiosarcoma of the small intestine, which might have formed metastatic lesions in the lung.

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  • Morihiro Inoue, Masao Hagihara, Tomoyuki Uchida, Jian Hua, Takeshi Nak ...
    2017 Volume 56 Issue 24 Pages 3341-3346
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 48-year-old man was admitted due to marked leukocytosis. Bone marrow examinations resulted in a diagnosis of Philadelphia (Ph) chromosome-positive chronic myeloid leukemia. One month later, massive muscle and bone invasion by leukemic cells was detected. After induction chemotherapy, he complained of a headache and visual loss, which was caused by a leukemic infiltration in the central nervous system. After temporary remission in response to chemotherapy, the disease relapsed in the form of an intracranial tumor. The unusual t(14;22)(q24;q11.2) translocation of the Ph-chromosome and the significant increase in monocytes observed might have contributed to the unique and aggressive clinical course.

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  • Yoshiki Nakae, Mizuki Hyuga, Yuta Terada, Wataru Kishimoto, Akiko Fuku ...
    2017 Volume 56 Issue 24 Pages 3347-3351
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Autoimmune autonomic ganglionopathy is an autonomic disorder that occurs as a symptom of paraneoplastic neurological syndrome. To date, there have been no reports on multiple myeloma with autoimmune autonomic ganglionopathy. A 37-year-old Japanese woman suffered from orthostatic hypotension was diagnosed with multiple myeloma (IgG kappa type), and a serological examination revealed the presence of anti-ganglionic nicotinic acetylcholine receptor (anti-gAChR) antibodies. She was treated for multiple myeloma, as a result, the autonomic disturbance improved and her anti-gAChR antibody titer decreased to undetectable levels, despite the fact that she only achieved a partial remission of multiple myeloma. Treatment for multiple myeloma may improve autoimmune autonomic ganglionopathy.

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  • Sakiko Itaya, Yasuhiro Ueda, Zen Kobayashi, Hiroyuki Tomimitsu, Daisuk ...
    2017 Volume 56 Issue 24 Pages 3353-3355
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A 61-year-old woman presented with a 1-month history of decreased activities of daily living. Magnetic resonance imaging revealed abnormal intensities of the bilateral frontal lobes and enhancement of the thickened dura matter. A biopsy of the dura mater revealed multinucleated giant cells. She had sinusitis and hematuria; she was diagnosed with granulomatosis with polyangiitis. Hypertrophic pachymeningitis (HPM) was considered to have interrupted the venous flow and caused vasogenic edema. Bilateral frontal lobe edema resulting from HPM due to granulomatosis with polyangiitis has not been reported. A biopsy and examination for other organ complications were useful for the diagnosis and treatment of our patient.

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  • Reina Kawamura, Eiichiro Nagata, Masako Mukai, Yoichi Ohnuki, Tomohiko ...
    2017 Volume 56 Issue 24 Pages 3357-3359
    Published: December 15, 2017
    Released: December 15, 2017
    JOURNALS OPEN ACCESS

    A 54-year-old woman with adenocarcinoma of the lung and lymph node metastasis experienced nystagmus and cerebellar ataxia 2 weeks after initiating nivolumab therapy. An evaluation for several autoimmune-related antibodies and paraneoplastic syndrome yielded negative results. We eventually diagnosed the patient with nivolumab-induced acute cerebellar ataxia, after excluding other potential conditions. Her ataxic gait and nystagmus resolved shortly after intravenous steroid pulse therapy followed by the administration of decreasing doses of oral steroids. Nivolumab, an immune checkpoint inhibitor, is known to induce various neurological adverse events. However, this is the first report of acute cerebellar ataxia associated with nivolumab treatment.

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  • Yoshiaki Takahashi, Toru Yamashita, Ryuta Morihara, Yumiko Nakano, Kot ...
    2017 Volume 56 Issue 24 Pages 3361-3364
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 16, 2017
    JOURNALS OPEN ACCESS

    We herein report the case of a 46-year-old pregnant woman with anti-muscle specific kinase (MuSK) antibody-positive myasthenia gravis (MG) who showed pregnancy-induced hypertension and developed respiratory failure at 30 weeks and 5 days of pregnancy, and who underwent an emergency caesarean section (CS). Her MG symptoms gradually improved in the subsequent weeks. The premature baby with positive MuSK antibodies was successfully delivered, but the male baby required temporary artificial ventilation. However, his condition also gradually improved over time. The present case suggests that an emergency CS could rescue both the mother, who was in critical condition, and the prematurely born baby, even when suffering from acute respiratory insufficiency.

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  • Yusuke Kobari, Tasuku Nagasawa
    2017 Volume 56 Issue 24 Pages 3365-3367
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    A previously healthy 77-year-old Japanese man presented with a 2-week history of daily fevers peaking at 38°C, chills, hearing loss, and almost 10 kg of unintentional weight loss over 2 months. Pure tone audiometry showed mixed conductive-sensorineural hearing loss: right, 63.6 dB, left, 80.0 dB. Blood tests after admission showed a high myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) level (>300 U/mL), so we suspected ANCA-related vasculitis. The Japanese Otorhinolaryngology Society has recently been advocating the concept of otitis media with ANCA-associated vasculitis (OMAAV). Our case met the criteria proposed, leading to our diagnosis.

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  • Daisuke Oryoji, Nobuyuki Ono, Daisuke Himeji, Kyoko Yoshihiro, Yasufum ...
    2017 Volume 56 Issue 24 Pages 3369-3372
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Relapsing polychondritis (RP) is a rare systemic autoimmune disease that affects cartilaginous structures. RP causes tracheobronchomalacia (TBM) by affecting the bronchial cartilage. TBM is a fatal condition characterized by excessive weakening of the walls of the trachea and bronchi. We herein report a case of a 73-year-old man who experienced sudden respiratory failure due to TBM caused by RP. Immunosuppressive treatment did not improve his respiratory failure. Multiple metallic stentings dramatically improved his severe airway symptoms. When the airway condition becomes lethal in RP patients, then metallic stenting can be a useful treatment option.

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  • Fumika Honda, Hiroto Tsuboi, Hirofumi Toko, Ayako Ohyama, Hidenori Tak ...
    2017 Volume 56 Issue 24 Pages 3373-3377
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    Kikuchi-Fujimoto disease (KFD) is a benign disease of unknown etiology characterized by lymphadenopathy and a fever. For the majority of patients with KFD, the course is self-limited; however, the optimum method of managing recurrent cases has not yet been established. We herein report a case of a 42-year-old Japanese woman with KFD (confirmed by a lymph node biopsy). Although high-dose prednisolone (PSL) rapidly induced remission, she experienced four recurrences on treatment tapering. Concomitant use of hydroxychloroquine (HCQ) with low-dose PSL induced continuous remission. This is the first case to suggest the effectiveness of HCQ for recurrent KFD in a Japanese patient.

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  • Yuki Otsuka, Haruki Watanabe, Yuzuki Kano, Noriko Tatebe, Katsue Sunah ...
    2017 Volume 56 Issue 24 Pages 3379-3383
    Published: December 15, 2017
    Released: December 15, 2017
    JOURNALS OPEN ACCESS

    We herein report a patient with breast cancer who developed dermatomyositis (DM) immediately after mastectomy. She had a history of severe drug eruption during neoadjuvant chemotherapy six months previously. Within a month after the operation, myalgia and rash, including Gottron's papules, developed, and skeletal-muscle enzymes elevated, so she was diagnosed with probable DM according to the Bohan and Peter criteria. In many neoplastic DM cases, the course of the disease parallels the course of the malignancy. Possible mechanisms were suggested to explain the development of DM in the present case and offer new insight into autoimmune diseases.

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  • Shota Kurushima, Yoshiro Horai, Ayuko Takatani, Ayako Nishino, Shin-ya ...
    2017 Volume 56 Issue 24 Pages 3385-3387
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    We herein report a woman in her 50s with systemic lupus erythematosus (SLE) who developed swelling and pain in her fingers; the symptoms were more prominent in winter. Magnetic resonance imaging (MRI) revealed bone edema in the phalanges of both hands, which was compatible with phalangeal microgeodic syndrome (PMS). This is the first reported case of PMS in a patient with SLE and suggests that performing MRI should be considered for patients with SLE in order to assess the nature of finger symptoms and signs more precisely.

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  • Kenya Watanabe, Yoshitaka Yamazaki, Mariko Sugawara
    2017 Volume 56 Issue 24 Pages 3389-3394
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: October 11, 2017
    JOURNALS OPEN ACCESS

    This is a rare case of tuberculosis (TB) complicated with pseudogout of the wrist joint in a non-immunocompromised 84-year-old female with a history of pulmonary tuberculosis. She was diagnosed with extrapulmonary tuberculosis of the wrist based on a polymerase chain reaction (PCR) study and synovial fluid aspiration in which the cytology was positive for acid-fast bacilli. Calcium pyrophosphate was also positive. We must be careful not to miss articular tuberculosis as it may mimic common inflammatory arthritis, such as pseudogout of the wrist. Even if the patient is positive for calcium pyrophosphate, this does not exclude the possibility of articular tuberculosis.

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  • Miho Fukui, Shunsuke Iwai, Ryunosuke Sakamoto, Hiroko Takahashi, Tsune ...
    2017 Volume 56 Issue 24 Pages 3395-3397
    Published: December 15, 2017
    Released: December 15, 2017
    [Advance publication] Released: September 25, 2017
    JOURNALS OPEN ACCESS

    We herein report a rare case of Clostridium paraputrificum bacteremia in an elderly (88-year-old) man without a predisposing medical condition. Although he had a history of anaerobic bacteremia approximately eight months prior to admission, no gastrointestinal disease was discovered. He was treated with intravenous ampicillin/sulbactam. This case suggests that C. paraputrificum bacteremia can result from only minor abnormalities in macroscopically normal mucosal barriers. To our knowledge, this is the first report of C. paraputrificum bacteremia in Japan.

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