Internal Medicine
Online ISSN : 1349-7235
Print ISSN : 0918-2918
ISSN-L : 0918-2918
Volume 58 , Issue 3
Showing 1-30 articles out of 30 articles from the selected issue
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ORIGINAL ARTICLES
  • Fumio Tanaka, Kazunari Tominaga, Yoshiko Fujikawa, Tamami Morisaki, Ko ...
    2019 Volume 58 Issue 3 Pages 321-328
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    Objective The association between functional dyspepsia (FD) and endoscopic findings has not been fully elucidated. Helicobacter pylori infection is considered a key factor in the pathophysiology of FD. The Kyoto Classification of Gastritis (KCG) was proposed in 2014 to evaluate endoscopic findings based on the H. pylori status. We investigated the endoscopic findings associated with FD according to the KCG.

    Methods This cross-sectional study included subjects who underwent esophagogastroduodenoscopy during a medical health check-up. We compared the endoscopic findings between subjects with FD and healthy controls (HCs) according to the KCG.

    Results A total of 456 subjects were analyzed. Among them, the detection rate of FD was 5.5% (25/456 persons). In a univariate analysis of the endoscopic findings, a significantly lower proportion of subjects with FD had gastric red streak in comparison to HCs (0% vs. 18.6%, respectively; p=0.0124). Subjects with FD were more likely to have gastric depressive erosion (20.0% vs. 7.9%; p=0.0522). A higher proportion of the erosion-positive subjects had FD in comparison to erosion-negative subjects (12.8% vs. 4.8%). There were no significant differences in the other endoscopic findings, including gastric atrophy, intestinal metaplasia, enlarged fold, nodularity, and diffuse redness. A multivariate analysis revealed that gastric depressive erosion was significantly and independently associated with FD (odds ratio, 2.92; 95% confidence interval, 1.03-8.26; p=0.0436). In contrast, gastric red streak was not associated with FD (p=0.989).

    Conclusion Gastric depressive erosions may be associated with dyspepsia.

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  • Masanori Kobayashi, Shomei Ryozawa, Ryuichiro Araki, Koji Nagata, Yuki ...
    2019 Volume 58 Issue 3 Pages 329-335
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    Objectives While bile duct brush cytology during endoscopic retrograde cholangiopancreatography (ERCP) is a well-established procedure for detecting malignant biliary stricture, its sensitivity is reportedly low. We aimed to determine the pre-ERCP factors affecting brush cytology sensitivity.

    Methods We retrospectively analyzed 185 patients who underwent brush cytology during the first ERCP for undiagnosed biliary stricture at our institution between January 2014 and December 2016. We analyzed the relationship of age, sex, final diagnosis, stricture location, tumor size, stricture length, total bilirubin level, white blood cell count, and C-reactive protein level with brush cytology sensitivity.

    Results The following conditions were established as final diagnoses: benign disease, 19 cases (10.3%); intrahepatic cholangiocarcinoma, 10 cases (5.4%); hilar cholangiocarcinoma, 38 cases (20.5%); extrahepatic cholangiocarcinoma, 44 cases (23.8%); pancreatic cancer, 55 cases (29.7%); other malignant tumors, 19 cases (10.3%). The sensitivity and specificity of brush cytology were 60.8% and 94.7%, respectively. The stricture length, total bilirubin level, and white blood cell count in true-positive cases were significantly higher than those in false-negative cases. Furthermore, a stratified analysis of the bilirubin levels demonstrated that sensitivity was highest in patients with moderate jaundice (80% for a total bilirubin level of 10-20 mg/dL), but significantly lower in patients with severe jaundice (total bilirubin level ≥20 mg/dL).

    Conclusion While the sensitivity of brush cytology increases with bilirubin levels of up to 20 mg/dL, severe jaundice has a negative effect on sensitivity, warranting additional pathological examinations according to the pre-ERCP bilirubin level.

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  • Masaru Ishida, Tomonori Itoh, Satoshi Nakajima, Yu Ishikawa, Yudai Shi ...
    2019 Volume 58 Issue 3 Pages 337-343
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    Objective In patients with acute coronary syndrome (ACS), low high-density lipoprotein cholesterol (HDL-C) levels in samples collected after an overnight fast are diagnostic indicators and well-established predictors of adverse outcomes. However, the relationship between the HDL-C levels in samples collected just after arrival (early HDL-C) and in-hospital mortality remains unknown. The purposes of the present ACS study were to (1) evaluate the association between the early HDL-C levels of patients and in-hospital mortality and (2) compare the early HDL-C level with other well-known determinants associated with in-hospital mortality.

    Methods This retrospective study surveyed 638 consecutive ACS patients and then assessed the possible determinants of in-hospital mortality. All initial blood samples, including that for early HDL-C, were drawn within one hour of arrival.

    Results In the present study, the overall in-hospital mortality was 5.9%. A multivariable analysis showed that a low early HDL-C [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.14-5.62], elevated troponin T (OR 4.40, 95% CI 1.26-15.29) and high Killip class (OR 15.41, 95% CI 7.29-32.59) were independent predictors of in-hospital mortality. A Kaplan-Meier survival analysis indicated that there the in-hospital outcome for the low early HDL-C group was significantly worse than that for the high early HDL-C group (age- and gender-adjusted hazard ratio 2.40, 95% CI 1.15-5.00, p=0.02).

    Conclusion ACS patients with low early HDL-C levels had higher in-hospital mortalities than those who did not have low early HDL-C levels. In addition to the already well-known determinants, low early HDL-C should also be considered as an independent predictor of in-hospital mortality in ACS patients who present to a cardiac care unit.

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  • Daisuke Ueshima, Shunji Yoshikawa, Taro Sasaoka, Yu Hatano, Ken Kuriha ...
    2019 Volume 58 Issue 3 Pages 345-353
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS
    Supplementary material

    Objective The aim of this study was to assess the relationship between hypercholesterolemia (HC) and clinical events through a percutaneous coronary intervention (PCI) registry. HC is a well-known independent risk factor for long-term cardiovascular events after PCI. However, it has been reported to be associated with a lower risk of adverse events in patients with cancer or acute coronary syndrome.

    Methods We analyzed the relationship between HC and adverse events in patients treated with everolimus-eluting stents (EESs) through the Tokyo-MD PCI study (an all-comer, multicenter, observational registry). The propensity score method was applied to select two groups with similar baseline characteristics.

    Results The unadjusted population included 1,536 HC patients and 330 non-HC patients. Propensity score matching yielded 314 matched pairs. After baseline adjustment, the outcomes of HC patients were significantly better than those of the non-HC patients with respect to the primary endpoint, which was a combination of mortality from all causes, nonfatal myocardial infarction (MI), nonfatal neurological events, and major bleeding [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.39-0.81; p=0.002], and the secondary endpoints, which included a combination of mortality from all causes, nonfatal MI, and nonfatal neurological events (HR 0.59, 95% CI 0.39-0.88; p=0.01), and major bleeding (HR 0.42, 95% CI 0.20-0.88; p=0.02). A subgroup analysis showed age as an interaction factor for the primary endpoint (interaction p=0.035).

    Conclusion HC was associated with better outcomes in patients who underwent EES implantation, even after baseline adjustment.

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  • Kensuke Matsuda, Junji Koya, Shunya Arai, Kumi Nakazaki, Fumihiko Naka ...
    2019 Volume 58 Issue 3 Pages 355-360
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    Objective The therapeutic approach for transfusion-independent non-severe aplastic anemia (NSAA) is undetermined. This study aimed to investigate the efficacy of immunosuppressive therapy (IST) for NSAA.

    Methods We retrospectively reviewed 42 consecutive patients with transfusion-independent NSAA. NSAA was further divided into two stages according to the degree of cytopenia. Progression was defined as transition to a transfusion-dependent state.

    Results Twelve (29%) patients received IST with cyclosporine A (CsA). Eleven (26%) patients became transfusion-dependent. In all patients, a univariate analysis revealed that a low hemoglobin level (p=0.006) and low reticulocyte count (p=0.005) were associated with a high probability of progression. The estimated transfusion-free survival (TFS) was significantly prolonged by IST among patients with advanced-stage NSAA (p=0.002), while IST did not reduce the incidence of progression in the overall cohort (p=0.349). In the non-IST group, an advanced clinical stage was significantly associated with progression (p=0.003). In contrast, the clinical stage was not related to progression in the IST group (p=0.318). None of the patients had to discontinue treatment with CsA due to renal failure.

    Conclusion IST is expected to be effective in patients with advanced-stage NSAA.

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  • Makio Takahashi, Hayato Tabu, Akihiko Ozaki, Toshiaki Hamano, Takao Ta ...
    2019 Volume 58 Issue 3 Pages 361-368
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    Objective Depression, apathy, and gait instability are cardinal symptoms in patients with Parkinson's disease (PD). Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are used for treating the psychiatric symptoms of PD. This is the first prospective randomized study to compare the efficacy of an SNRI (duloxetine) with SSRIs (paroxetine, escitalopram) in improving depressive symptoms and apathy (primary) and freezing of gait (FOG; secondary) in patients with PD.

    Methods In this prospective, multicenter, open-label, randomized study, Japanese PD patients with a Quick Inventory of Depressive Symptomatology-Japanese (QIDS-J) score ≥6 were randomly assigned to receive an SSRI (27 enrolled, 25 analyzed) or duloxetine (28 enrolled, 27 analyzed) and were assessed at 6 and 10 weeks.

    Results The mean change (SD) in the QIDS J [SSRI -2.4 (3.6), p=0.015; SNRI -2.3 (3.9), p=0.029] and FOG-Questionnaire [SSRI -2.9 (4.2), p=0.012; SNRI -3.4 (4.7), p=0.010] scores (from baseline) at 10 weeks was statistically significant, while the mean change in the Apathy Scale scores was not [SSRI -2.7 (5.4), p=0.054; SNRI -1.5 (3.7), p=0.109]. No significant differences were observed between the SSRI and SNRI groups. The treatments were well-tolerated; however, gastrointestinal events were more common with SSRIs. Two SNRI-treated patients reported an exacerbation of tremor.

    Conclusion SSRIs and SNRIs improve the depressive symptoms and FOG in PD patients with mild to severe depressive symptoms. However, their effectiveness in treating apathy remains to be elucidated.

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CASE REPORTS
  • Suguru Ito, Masaaki Higashiyama, Kazuki Horiuchi, Akinori Mizoguchi, S ...
    2019 Volume 58 Issue 3 Pages 369-374
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    We herein report a 44-year-old man suffering from systemic edema due to protein-losing enteropathy (PLE) with superior mesenteric vein (SMV) obstruction and development of collateral veins, which subsequently proved to be a chronic result of thrombosis and a complication of Crohn's disease (CD). PLE was supposedly induced by both intestinal erosion and thrombosis-related lymphangiectasia, which was histologically proven in his surgically-resected ileal stenosis. Elemental diet and anti-TNFα agent improved his hypoalbuminemia after surgery. The rarity of the simultaneous coexistence of SMV obstruction and PLE and the precedence of these complications over typical abdominal symptoms of CD made the clinical course complex.

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  • Manabu Hayashi, Kazumichi Abe, Masashi Fujita, Ken Okai, Atsushi Takah ...
    2019 Volume 58 Issue 3 Pages 375-380
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    Hepatitis B virus (HBV) reactivation occasionally occurs long after immunosuppressive therapy. The characteristics of late HBV reactivation remain unclear. We herein present a case of HBV reactivation in a patient with nonalcoholic steatohepatitis (NASH) more than 3 years after rituximab-containing chemotherapy for diffuse large B-cell lymphoma. Increased transaminase levels, which were induced by NASH, were observed after chemotherapy and were alleviated with statin treatment. HBV reactivation was identified incidentally. The patient developed hepatitis that improved with entecavir therapy. Our case might indicate that the presence of NASH is associated with HBV reactivation long after treatment and that statins, as immune-modulatory agents, affect HBV reactivation.

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  • Takeshi Yagyu, Maiko Naito, Masahiro Kumada, Tsutomu Nakagawa
    2019 Volume 58 Issue 3 Pages 381-385
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    An aortic mural thrombus (AMT) on a non-atherosclerotic wall is a rare but important cause of arterial thromboembolism. We herein report two cases of AMT in the thoracic aorta. Both showed multiple hypercoagulable factors (case 1: protein S deficiency and positive finding of anti-cardiolipin antibody; case 2: protein C deficiency, gastric cancer, and cisplatin-based chemotherapy) and were successfully treated with anticoagulation. Hypercoagulable states, including malignancy, can influence the formation of AMT; therefore, the accurate assessment of a hypercoagulable condition is necessary when we encounter patients with AMT.

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  • Yasunori Inoguchi, Bunji Kaku, Naotaka Kitagawa, Shoji Katsuda
    2019 Volume 58 Issue 3 Pages 387-393
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    A 52-year-old man with recurrent epistaxis and palpebral conjunctival telangiectasia visited our hospital for a follow-up checkup for gastrointestinal polyposis. At 48 years of age, he underwent Y-graft replacement for an abdominal aortic aneurysm. Arteriovenous malformation was detected in his lungs, and a genetic test revealed an SMAD4 mutation. Eventually, he was diagnosed with juvenile polyposis-hereditary hemorrhagic telangiectasia (JP-HHT) syndrome. In addition, fatty degeneration of the left ventricle and a coronary aneurysm were detected. This is the first report suggesting the possibility of an association between these manifestations and JP-HHT due to SMAD4 mutations. Examining cardiovascular disorders in JP-HHT patients is imperative.

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  • Kayo Misumi, Takeshi Ogo, Jin Ueda, Akihiro Tsuji, Sigefumi Fukui, Nao ...
    2019 Volume 58 Issue 3 Pages 395-399
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    Pulmonary arterial hypertension (PAH) is a rare, devastating disease, characterized by elevated pulmonary arterial pressure due to pulmonary microvascular obstruction, which can result in heart failure and death. PAH can be associated with exposure to certain drugs or toxins. We herein report a case in which PAH developed in a patient with refractory ulcerative colitis during treatment with "Qing-Dai," a Chinese herbal medicine. The patient's PAH improved after the discontinuation of Qing-Dai.

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  • Miho Miyoshi, Hidekazu Kondo, Tetsuji Shinohara, Kunio Yufu, Mikiko Na ...
    2019 Volume 58 Issue 3 Pages 401-404
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    We herein report a case of a 53-year-old man who survived cardiac arrest due to ventricular fibrillation (VF). When admitted to the hospital, his 12-lead electrocardiogram did not show Brugada-like ST elevation, early repolarization or delta-wave, in any leads. During the treatment of hypothermia, the manifestation of delta-wave was documented, which disappeared after the cessation of this treatment. A cardiac evaluation showed no structural heart disease, and electrophysiology studies did not demonstrate conduction via accessary pathway. Although the etiology of VF could not be determined, the most probable diagnosis was idiopathic VF. The patient was fitted with an implantable cardioverter-defibrillator.

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  • Toshihiro Kobayashi, Hitomi Imachi, Seisuke Sato, Tomohiro Ibata, Kens ...
    2019 Volume 58 Issue 3 Pages 405-409
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    We herein present the case of a 27-year-old woman with clinical and biochemical features of virilism. Imaging studies revealed the presence of a bilateral adrenal tumor. Although the secretion of androgens was remarkable, the autonomous production of cortisol was also evident because of a loss of circadian rhythm and the absence of cortisol suppression by dexamethasone. The surgical excision of both adrenal tumors was performed, and the histological examination showed no malignancy. We also report the successful pregnancy and delivery of the patient who showed evolving adrenocortical insufficiency along with virilization and Cushing's syndrome and who continued to receive glucocorticoid replacement therapy during pregnancy.

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  • Yosuke Hirakawa, Rika Miura, Yuji Sasaki, Yui Yoshida, Imari Mimura, M ...
    2019 Volume 58 Issue 3 Pages 411-414
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    A 21-year-old woman was referred to our hospital because of proteinuria and hematuria. She had occasional flank pain. A renal biopsy was performed and revealed a thin basement membrane. Therefore, she was diagnosed with thin basement membrane disease. However, the frequency of her flank pain increased. Since her left kidney was slightly larger than the right, nutcracker syndrome (NCS) was suspected. Renal vein ultrasonography and venography were performed, and NCS was confirmed. Her hematuria was multifactorial, and NCS can go unnoticed if there is a comorbidity that also causes hematuria.

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  • Shinichi Morita, Takeshi Suda, Chiyumi Oda, Masaaki Kobayashi, Takahir ...
    2019 Volume 58 Issue 3 Pages 415-418
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    We encountered a small cell lung cancer (SCLC) patient with intertrabecular vertebral metastasis (IVM). A 59-year-old man was admitted to our hospital with weight loss. 18F-fluorodeoxyglucose positron emission tomography (FDG PET)-CT demonstrated the uptake of fluorodeoxyglucose in the hilum of the left lung and whole-body bones. Despite intensive support, the patient died within a month. Subsequent autopsy revealed a small lesion consisting of small round cells in the left lung. The cancer cells were found to have spread through the replacement of the bone marrow cells while sparing the trabecular bone. This case demonstrated the potential of 18F-FDG PET for detecting IVM in SCLC patients.

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  • Nobuhiro Kanaji, Nariyasu Nakashima, Takuya Inoue, Emi Ibuki, Makiko M ...
    2019 Volume 58 Issue 3 Pages 419-422
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    A 34-year-old Japanese woman exhibited a 35×25-mm solitary multiloculated mass shadow in the left lower lobe mimicking lung adenocarcinoma. On computed tomography, the mass resembled a lotus torus. A transbronchial lung biopsy and mediastinal lymph node biopsy led to the diagnosis of sarcoidosis. This lotus torus-like mass regressed spontaneously. This is the second reported case of pulmonary cavitary sarcoidosis with a 'lotus torus-like' appearance. We propose several findings regarding the lotus torus-like appearance by comparing the findings to those of lung adenocarcinoma. Knowledge of this unique sign may be helpful for the differential diagnosis of pulmonary sarcoidosis from lung adenocarcinoma.

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  • Takeshi Saraya, Masachika Fujiwara, Sunao Mikura, Nozomi Fukuda, Haruy ...
    2019 Volume 58 Issue 3 Pages 423-425
    Published: February 01, 2019
    Released: February 01, 2019
    JOURNALS OPEN ACCESS
    Supplementary material

    A 51-year-old woman presented with dyspnea that had progressed over the previous year. On a physical examination, harsh, hollow breath sounds with a high-pitched timbre, termed "amphoric breathing", were identified during inspiration and expiration. Chest radiography and thoracic computed tomography performed over the previous three years revealed an enlarging cyst in the right lung arising from an area of consolidation. Pulmonary adenocarcinoma (T4 N0 M1a, stage IV) was diagnosed and considered a possible cause of the cyst, resulting in amphoric breathing.

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  • Takafumi Aritomi, Takashi Kido, Kazuhisa Nakano, Yurie Satoh, Shingo N ...
    2019 Volume 58 Issue 3 Pages 427-431
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    We herein report a 63-year-old woman with small-cell lung cancer (SCLC) who developed dermatomyositis (DM) after initial chemoradiotherapy despite tumor reduction. Serum anti-transcriptional in termediary factor (TIF) 1γ antibody was detected before the development of DM, and its levels increased over time. She died five months after the diagnosis of SCLC. Anti-TIF1γ antibody is known to be a marker for cancer-associated DM (CAM); however, the present case indicates that the antibody can be found in cancer patients without DM. This case is also unusual, as DM developed later despite successful chemoradiotherapy.

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  • Joe Senda, Kunihiko Araki, Yasushi Tachi, Hazuki Watanabe, Yuichi Kaga ...
    2019 Volume 58 Issue 3 Pages 433-436
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    An otherwise healthy 44-year-old woman exhibited isolated unilateral oculomotor nerve palsy accompanied by an influenza A infection. An intra-orbital MRI scan revealed that her right third intracranial nerve was enlarged and enhanced. She recovered completely during the first month after treatment with oseltamivir phosphate. Although intracranial nerve disorders that result from influenza infections are most frequently reported in children, it is noteworthy that influenza can also cause focal intracranial nerve inflammation with ophthalmoparesis in adults. These disorders can be diagnosed using intra-orbital MRI scans with appropriate sequences and through immunological assays to detect the presence of antiganglioside antibodies.

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  • Ryo Sasaki, Yasuyuki Ohta, Yoshiaki Takahashi, Keiichiro Tsunoda, Koh ...
    2019 Volume 58 Issue 3 Pages 437-440
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: September 12, 2018
    JOURNALS OPEN ACCESS

    Klinefelter syndrome is a chromosomal disorder with a typical karyotype of 47, XXY, accompanied by various neurological symptoms. We herein report the first case of Klinefelter syndrome with a rare mosaic form of 47, XXY and 48, XXXY, combined with both spastic paraplegia and peripheral motor neuropathy. This case showed spasticity and hyperreflexia with pathological reflexes and ankle clonus as well as muscle weakness in all extremities. A motor nerve conduction study and the magnetic motor evoked potential suggested motor axonal neuropathy and corticospinal tract disorders. The present case suggests that Klinefelter syndrome can present with both upper and lower motor neuron degeneration.

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  • Toshimasa Shimizu, Naoki Iwamoto, Momoko Okamoto, Yushiro Endo, Sosuke ...
    2019 Volume 58 Issue 3 Pages 441-445
    Published: February 01, 2019
    Released: February 01, 2019
    [Advance publication] Released: August 24, 2018
    JOURNALS OPEN ACCESS

    A 44-year-old Japanese man with a 14-year history of limited cutaneous systemic sclerosis (SSc) was admitted with a fever, hypertension, anemia, thrombocytopenia, and renal dysfunction. On admission, hypertension, hyperreninemia, acute renal dysfunction, hemolytic anemia, and thrombocytopenia led to the diagnosis of scleroderma renal crisis (SRC) complicated with thrombotic microangiopathy (TMA). The patient had also been infected with influenza B virus almost six days before admission. Following treatment with plasma exchange, an angiotensin-converting enzyme inhibitor, and an anti-virus agent, his general condition improved. He had no risk factors for SRC. In SSc patients, an influenza virus infection might trigger SRC complicated with TMA.

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