Internal Medicine
Online ISSN : 1349-7235
Print ISSN : 0918-2918
ISSN-L : 0918-2918
Volume 57 , Issue 12
Showing 1-30 articles out of 30 articles from the selected issue
ORIGINAL ARTICLES
  • Kenichiro Suzuki, Kimiaki Komukai, Kotaro Nakata, Ryeonshi Kang, Yuhei ...
    2018 Volume 57 Issue 12 Pages 1673-1680
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    Objective This study was carried out to examine the usefulness of point-of-care (POC) cardiac troponin in diagnosing acute coronary syndrome (ACS) and to understand the limitations of a POC cardiac troponin I/T-based diagnoses.

    Methods Patients whose cardiac troponin levels were measured in the emergency department using a POC system (AQT System; Radiometer, Tokyo, Japan) between January and December 2016 were retrospectively examined (N=1,449). Patients who were < 20 years of age or who were admitted with cardiopulmonary arrest were excluded. The sensitivity and specificity of the POC cardiac troponin levels for the diagnosis of ACS were determined.

    Result One hundred and twenty of 1,449 total patients had ACS (acute myocardial infarction, n=88; unstable angina n=32). On comparing the receiver operating characteristic (ROC) curves, the area under the curve (AUC) values for POC cardiac troponin I and cardiac troponin T were 0.833 and 0.786, respectively. The sensitivity and specificity of POC cardiac troponin I when using the 99th percentile (0.023 ng/mL) as the diagnostic cut-off value were 69.0% and 88.1%, respectively. The sensitivity of POC cardiac troponin I (99th percentile) was higher in the patients sampled > 3 hours after symptom onset (83.3%) than in those sampled ≤ 3 hours after symptom onset (58.8%, p < 0.01).

    Conclusion When sampled > 3 hours after the onset of symptoms, the POC cardiac troponin I level is considered to be suitable for use in diagnosing ACS. However, when sampled ≤ 3 hours after the onset of symptoms, careful interpretation of POC cardiac troponins is therefore required to rule out ACS.

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  • Shin Kawasoe, Takuro Kubozono, Satoko Ojima, Masaaki Miyata, Mitsuru O ...
    2018 Volume 57 Issue 12 Pages 1681-1688
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
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    Objective An increased red cell distribution width (RDW) has been reported to be associated with adverse outcomes in patients with heart failure (HF). This study aimed to evaluate the prognostic power of the combined measurement of RDW and B-type natriuretic peptide (BNP) concentrations in patients with HF.

    Methods and Results We retrospectively studied 116 patients (mean age, 63.7±14.3 years) who were admitted for the treatment of HF. Data including demographic information, vital signs, and laboratory and echocardiographic measurements at admission were collected from medical records. The observational period was defined as the number of days from hospitalization, and the study endpoint was defined as cardiovascular death. The mean RDW and BNP concentration at admission were 14.5±2.0% and 626±593 pg/mL, respectively. During a median observation period of 1,046 days, 22 patients died of cardiovascular disease. A univariate Cox proportional hazard analysis revealed that both RDW [hazard ratio (HR) 1.252, p = 0.0391] and BNP (HR 1.001, p = 0.0445) were significant prognostic indices for cardiovascular death. A receiver operating characteristic curve analysis revealed that the optimal cut-off RDW and BNP values for cardiovascular death were 14.9% and 686 pg/mL, respectively. The Kaplan-Meier survival curve revealed that the survival rate of patients with both RDW ≥ 14.9% and BNP ≥ 686 pg/mL showed the poorest prognosis in comparison to the patients in the other groups.

    Conclusion The combined assessment of the RDW and BNP concentrations may be useful for predicting mortality in patients with HF.

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  • Mariko Kogo, Kazuma Nagata, Takeshi Morimoto, Jiro Ito, Daichi Fujimot ...
    2018 Volume 57 Issue 12 Pages 1689-1695
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
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    Objective A severely altered level of consciousness (ALC) is considered to be a possible contraindication to non-invasive ventilation (NIV). We investigated the association between mild ALC and NIV failure in patients with hypoxemic respiratory failure.

    Methods A retrospective study was conducted by reviewing the medical charts of patients with de novo hypoxemic respiratory failure who received NIV treatment. The clinical background and the outcomes of patients with and without ALC were compared.

    Patients Patients who were admitted to our hospital for acute hypoxemic respiratory failure between July 2011 and May 2015 were included in the present study.

    Results Sixty-six of the 148 patients had ALC. In comparison to the patients without ALC, the patients with ALC were older (median: 72 vs. 78 years, p=0.02), had a higher Acute Physiology and Chronic Health Evaluation II score (18 vs. 19, p=0.02), and received a higher level of inspiratory pressure (8 cmH2O vs. 8, p<0.01). The median Glasgow Coma Scale score of the patients with ALC was 14 (interquartile range, 11-14). There were no significant differences between the groups in the rates of NIV failure (24% vs. 30%, p=0.4) and in-hospital mortality (13% vs. 16%, p=0.3).

    Conclusion NIV may be successfully applied to treat acute hypoxemic respiratory failure with mild ALC. NIV may be performed, with careful attention to the appropriate timing for intubation.

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  • Yoshihito Morimoto, Hidefumi Takei, Keisei Tachibana, Yoko Nakazato, R ...
    2018 Volume 57 Issue 12 Pages 1697-1702
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
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    Objective In Japan, pleurodesis is often performed using OK-432. However, OK-432 may cause severe chest pain and fever. The risk factors for these complications are unclear. The aim of this study was to identify the risk factors for chest pain and fever caused by pleurodesis with OK-432.

    Methods The clinical data of 94 patients who underwent pleurodesis with OK-432 were retrospectively analyzed. Patients who developed chest pain (indicated by a record of rescue pain medication) and/or fever (a recorded temperature of >38°C) were identified. A logistic regression analysis was performed to determine the risk factors for these complications.

    Results Rescue medication for chest pain was required by 43.6% of the patients and 40.4% developed pyrexia after pleurodesis with OK-432. The univariate analysis showed that the likelihood of requiring rescue medication for chest pain was significantly increased in patients of <70 years of age (p=0.028) and in those who were not premedicated with a nonsteroidal anti-inflammatory drug (NSAID; p=0.003). Age <70 years (adjusted odds ratio 2.97, 95% confidence interval 1.10-8.00, p=0.031) and a lack of premedication with an NSAID (adjusted odds ratio 4.21, 95% confidence interval 1.47-12.04, p=0.007) remained significant factors in a multivariate analysis. The absence of NSAID premedication was the only statistically significant risk factor for fever in the univariate analysis (p=0.034). The multivariate analysis revealed no significant risk factors for fever.

    Conclusion The results of the present study suggest that premedication with an NSAID might be useful for preventing the chest pain caused by pleurodesis with OK-432. Furthermore, caution is advised when managing chest pain in adults of <70 years of age. Prospective studies should be performed to further investigate this issue.

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  • Takuya Fukuoka, Yoshihiko Nakazato, Hitoshi Kawasaki, Kei Ikeda, Tomot ...
    2018 Volume 57 Issue 12 Pages 1703-1706
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    Objective The purpose of this study was to clarify the clinical features of ischemic patients for whom cigarette smoking was the sole risk factor for ischemic stroke.

    Methods Among the 1,329 patients (male, n=833; female, n=496) with acute ischemic stroke who were admitted to our hospital between April 2005 and September 2016, 346 (26%) were smokers [male, n=308 (36.9%); female, 38 (7.6%)]. In 42 (3.1%; male, n=41; female, n=1) cases, cigarette smoking was considered to be the sole risk factor for ischemic stroke. Data regarding gender, age, the clinical type of ischemic stroke, the National Institutes of Health Stroke Scale (NIHSS) score at the admission, the modified Rankin scale (mRS) scores before the onset and at discharge, the progression of symptoms, and the recurrence of infarction were investigated.

    Results The mean age of the 42 patients was 63.2±12.4 years (range, 26-86 years). The clinical types of ischemic stroke included atherothrombosis (n=19), lacunar (n=17), other type (n=2) and undetermined type (n=4). The median NIHSS score at the time of admission for ischemic stroke was 2 (interquartile range: IQR 1-4.25). The median mRS scores before the onset and at the discharge were 0 (IQR 0-0) and 1 (IQR 0-2), respectively. One patient had symptoms of progression; no patients had recurrence of infarction.

    Conclusion Our findings suggest that cigarette smoking alone may induce ischemic stroke; moreover, patients for whom smoking was the sole risk factor for ischemic stroke showed milder symptoms in comparison to patients with other risk factors; however, ischemic stroke was induced from youth. Since cigarette smoking has detrimental effects on the central nervous system, we suggest that people be encouraged to quit smoking in order to maintain good health.

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CASE REPORTS
  • Hiroaki Saito, Junji Shiode, Shogen Ohya, Atsushi Yao, Shunsuke Saito, ...
    2018 Volume 57 Issue 12 Pages 1707-1713
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 72-year-old man presented with anorexia and 15-kg weight loss over 3 years. Endoscopy revealed yellow, shaggy mucosa alternating with erythematous, eroded mucosa in the duodenum. Biopsy specimens showed massive infiltration of periodic acid-Schiff-positive macrophages in the lamina propria, consistent with Whipple's disease. The patient was treated with intravenous ceftriaxone for four weeks, followed by oral trimethoprim-sulfamethoxazole. His condition improved, and he gradually gained weight. Although the endoscopic findings improved with continuous trimethoprim-sulfamethoxazole administration, macrophage infiltration of the duodenal mucosa persisted. However, the patient has been symptom-free for eight years.

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  • Atsushi Takagi, Hideki Ozawa, Masayuki Oki, Hidetaka Yanagi, Kazuhito ...
    2018 Volume 57 Issue 12 Pages 1715-1718
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    The incidence of Helicobacter pylori-negative gastric cancer is very low. A 60-year-old man was referred to Tokai University Hospital from a local clinic because of eosinophilia. The laboratory data revealed prominent eosinophilia, with a white blood cell count of 7,900 /μL and increased eosinophil granulocyte level of 1,659 /μL. After an examination for secondary eosinophilia, esophagogastroduodenoscopy showed an enlarged gastric fold in the corpus, suggesting type 4 gastric cancer. Repeated esophagogastroduodenoscopy (EGD) and a re-biopsy demonstrated poorly differentiated adenocarcinoma and signet ring cell carcinoma. The patient was negative for Helicobacter pylori infection according to the serum anti-Helicobacter pylori antibody, culture and histopathological findings.

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  • Mami Tokunaga, Sohachi Nanjo, Hiroki Yoshita, Haruka Fujinami, Tohru W ...
    2018 Volume 57 Issue 12 Pages 1719-1723
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 77-year-old patient was admitted to our hospital for the further examination of melena. A computed tomography scan detected two submucosal tumors (SMTs) in the stomach and jejunum. Double-balloon endoscopy revealed the presence of a delle on the jejunal SMT, suggesting that the SMT was the origin of the gastrointestinal bleeding. Both tumors were surgically resected and subsequently diagnosed via histology as gastrointestinal stromal tumors (GISTs). Furthermore, the two GISTs had different mutations in the c-kit gene, suggesting that they were derived from different clonal origins. This report depicts an extremely rare case of multiple synchronous sporadic GISTs in the stomach and jejunum.

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  • Michihiro Yoshida, Yoshiaki Marumo, Itaru Naitoh, Kazuki Hayashi, Kats ...
    2018 Volume 57 Issue 12 Pages 1725-1732
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: December 21, 2017
    JOURNALS OPEN ACCESS

    Type 1 autoimmune pancreatitis (AIP) is a pancreatic manifestation of IgG4-retated disease that is often associated with IgG4-related sclerosing cholangitis (IgG4-SC). Autoimmune hemolytic anemia (AIHA) is an immune-related disease that causes hemolytic anemia. Although type 1 AIP/IgG4-SC and AIHA have a shared etiology as a presumed autoimmune disease, they rarely overlap, and their association has not been clarified. Secondary AIHA might not be diagnosed appropriately because the obstructive jaundice observed in type 1 AIP/IgG4-SC can obscure the presence of hemolytic jaundice. We herein report a case of type 1 AIP/IgG4-SC overlapping with secondary AIHA along with a review of the literature.

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  • Yutaka Shimada, Makoto Fujimoto, Tatsuya Nogami, Hidetoshi Watari, Hid ...
    2018 Volume 57 Issue 12 Pages 1733-1740
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
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    A 67-year-old woman experiencing coughing visited a clinic and was prescribed drugs, including shosaikoto extract, for 4 days. She subsequently suffered from liver injury, but her condition improved after the discontinuation of all medications. Approximately 1 year later, she experienced fatigue, consulted another clinic, and received saikokeishikankyoto extract for 21 days. She subsequently suffered liver injury again. Both shosaikoto and saikokeishikankyoto contain Scutellariae Radix. This case is thought to be one of recurrent drug-induced liver injury caused by the incidental readministration of a Kampo formula containing Scutellariae Radix. An awareness of adverse drug events caused by Kampo formulas, especially those containing Scutellariae Radix, is essential.

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  • Nobuyuki Torii, Atsuhiro Ichihara, Yuki Mizuguchi, Yasufumi Seki, Etsu ...
    2018 Volume 57 Issue 12 Pages 1741-1745
    Published: June 15, 2018
    Released: June 15, 2018
    JOURNALS OPEN ACCESS

    The patient was a 23-year-old man who was diagnosed with severe hypoxemia and liver dysfunction after suffering from sudden difficulty breathing. At 2 years of age, he had been diagnosed with hypopituitarism, and had received hormone-replacement until he was 18 years of age. Echocardiography using micro bubbles and pulmonary scintigraphy indicated intrapulmonary shunt and a liver biopsy showed steatohepatitis. He was diagnosed with hepatopulmonary syndrome associated with nonalcoholic steatohepatitis. Hormone-replacement therapy was re-started. After 5 months, a second liver biopsy revealed the amelioration of nonalcoholic steatohepatitis, which improved his respiratory condition. This case suggested that early effective therapy for chronic liver diseases might improve the pathological and clinical conditions of hepatopulmonary syndrome.

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  • Chiaki Kishida, Ryo Naito, Hiroki Kasuya, Tomohiro Kaneko, Kosuke Yabe ...
    2018 Volume 57 Issue 12 Pages 1747-1749
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 35-year-old Japanese man was emergently admitted to our hospital with chief complaints of palpitation and dyspnea. He has been treated for Basedow's disease. He was diagnosed with acute decompensated heart failure, atrial fibrillation and thyrotoxicosis. We started anti-thyroid agents and a treatment for heart failure with beta blockers and diuretics under anti-coagulation therapy. His B-type natriuretic peptide levels remained high, although the heart failure had been compensated and the heart rate was well controlled while hyperthyroidism still existed. We should bear in mind that a discrepancy can exist between the clinical course and the B-type natriuretic peptide level in heart failure patients complicated with hyperthyroidism.

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  • Katsunori Matsueda, Tatsuya Toyokawa, Masahiro Sakata, Isao Fujita, Jo ...
    2018 Volume 57 Issue 12 Pages 1751-1755
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    Mantle cell lymphoma (MCL) is a malignant lymphoma of the gastrointestinal tract that mostly presents as multiple lymphomatous polyposis (MLP); however, MLP with intussusception is rarely reported in MCL. Furthermore, a single protruding lesion with intussusception has never been reported in primary small intestinal MCL. A 70-year-old man presented with pain in the right lower abdomen. Computed tomography and colonoscopy revealed ileocecal intussusception. Ileocecal resection was performed. Histology and immunohistochemistry of the resected specimen showed MCL with a single protruding lesion. The patient was successfully treated with surgery alone and remains in complete remission at the three-year follow-up.

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  • Chikayuki Morimoto, Yoshihide Fujigaki, Yoshifuru Tamura, Tatsuru Ota, ...
    2018 Volume 57 Issue 12 Pages 1757-1762
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: December 21, 2017
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    A 67-year-old woman presented with hematuria and proteinuria 16 and 11 months ago, respectively. She had been followed up as mixed connective tissue disease and Sjögren's syndrome for over 19 years. Blood chemistry showed no elevated serum creatinine or C-reactive protein but did reveal myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) of 300 U/dL. A kidney biopsy showed pauci-immune focal necrotizing glomerulonephritis. She was treated with prednisolone and rituximab, resulting in normal urinalysis and decreased MPO-ANCA. The complication of ANCA-associated glomerulonephritis should not be overlooked when abnormal urinalysis findings appear in the course of connective tissue disease, irrespective of the presence of rapidly progressive glomerulonephritis.

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  • Haruhi Yamada, Yukiko Katsumori, Miki Kawano, Shumpei Mori, Ryo Takesh ...
    2018 Volume 57 Issue 12 Pages 1763-1767
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 73-year-old man, with congestive heart failure due to combined valvar disease, underwent curative surgery. Although the surgery was successful, his clinical course was eventful because of pulmonary complications, and he began to deteriorate mentally. Quetiapine was prescribed, which appeared to effectively settle his mental status. Following the administration of quetiapine, however, he developed acute kidney injury (AKI) that required continuous hemodiafiltration. Subsequent to discontinuation of quetiapine, his renal function gradually improved. Atypical antipsychotic drugs, including quetiapine, are frequently used to treat delirium in elderly patients in the intensive-care setting. This case highlights a potential risk of quetiapine-related AKI.

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  • Tetsuaki Shoji, Hidenori Mizugaki, Yasuyuki Ikezawa, Megumi Furuta, Yu ...
    2018 Volume 57 Issue 12 Pages 1769-1772
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
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    This report describes the case of a 66-year-old man with non-small cell lung cancer and venous thromboembolism (VTE). Unfractionated heparin (UFH) was initially used to control VTE before chemotherapy. However, switching UFH to warfarin or edoxaban, a novel oral anticoagulant (NOAC), failed. Chemotherapy was then administered to control the tumor which was thought to have been the main cause of VTE, which had been treated by UFH. After tumor shrinkage was achieved by chemotherapy, we were able to successfully switch from UFH to edoxaban. Controlling the tumor size and activity enabled the use of edoxaban as maintenance therapy for VTE.

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  • Mieko Ochi, Shingo Miyamoto, Yuriko Terada, Yoshiaki Furuhata, Nobuyas ...
    2018 Volume 57 Issue 12 Pages 1773-1777
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    We report the case of a 60-year-old Japanese man with a metastatic brain tumor that caused ataxia. As a consequence of resection of a cerebellar tumor, the tumor was diagnosed as a poorly differentiated adenocarcinoma with choriocarcinomatous features. The patient underwent bronchoscopy, leading to a diagnosis of the same histology as the brain tumor. After the administration of first-line chemotherapy and maintenance therapy due to progressive disease, he was given nivolumab and obtained a partial response; however, 11-months later, computed tomography showed tumor progression. Our experience suggests that nivolumab has strong activity, even in patients with a rare form of lung cancer.

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  • Mayumi Hatayama, Katsuya Ikuta, Masatomo Ishioh, Takeshi Saito, Yasumi ...
    2018 Volume 57 Issue 12 Pages 1779-1782
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 67-year-old man with relapsed anaplastic large cell lymphoma received salvage chemotherapy, and pegfilgrastim was used to prevent febrile neutropenia. On day 18 of chemotherapy, he developed a pseudogout attack. Although the first symptoms improved, another pseudogout attack occurred when he received the second course of chemotherapy and pegfilgrastim. Filgrastim was then used for the third course of chemotherapy, and a pseudogout attack did not occur. The serum granulocyte-stimulating factor (G-CSF) level was extremely elevated only when pegfilgrastim was used, suggesting a relationship between pseudogout and G-CSF. Pseudogout should be recognized as an adverse effect of pegfilgrastim.

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  • Yuya Fujita, Shoichi Fukui, Yushiro Endo, Sosuke Tsuji, Ayuko Takatani ...
    2018 Volume 57 Issue 12 Pages 1783-1788
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: January 11, 2018
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    A 67-year-old Japanese man was diagnosed with granulomatosis with polyangiitis based on the presence of right maxillary sinusitis, proteinase 3 antineutrophil cytoplasmic antibody positivity, and right scleritis. A conjunctival biopsy specimen showed neutrophil-predominant infiltration around the vessels without granuloma. Because there was a risk of blindness, pulsed methylprednisolone and intravenous cyclophosphamide pulse therapy (IVCY) were started. However, it was ineffective, and peripheral ulcerative keratitis newly emerged. We promptly switched the treatment from IVCY to rituximab, and ophthalmologists performed amniotic membrane transplantation, which avoided blindness. The close and effective working relationship between physicians and ophthalmologists improved our patient's ocular prognosis.

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  • Tokuhiro Matsubara, Tsutomu Nishida, Yu Higaki, Ryo Tomita, Hiromi Shi ...
    2018 Volume 57 Issue 12 Pages 1789-1792
    Published: June 15, 2018
    Released: June 15, 2018
    [Advance publication] Released: February 09, 2018
    JOURNALS OPEN ACCESS

    A 42-year-old man was diagnosed with cStage IIIb malignant melanoma and underwent resection. After interferon-beta therapy, 18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) showed multiple lung metastases, and he received nivolumab (2 mg/kg) every 3 weeks, resulting in a total of 17 cycles. After treatment, 18F-FDG PET/CT showed a significant decrease in the size of the metastases, but he had a Grade 4 alanine aminotransferase (ALT) elevation. Liver histology revealed drug-induced liver damage. Therefore, we performed steroid half-pulse therapy followed by oral methylprednisolone, but his ALT level did not completely recover to the normal range even after five months. We herein report a case with specific, sustained liver injury induced by nivolumab as an immune-related adverse events.

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