Objective Diffuse mucosal inflammation in the duodenum, distinct from peptic ulcer disease, has been repeatedly reported in patients with ulcerative colitis (UC). The pathogenesis of this complication remains uncertain; however, colectomy for medically refractory UC appears to trigger duodenitis. Cases in which colectomy was performed for UC were analyzed to characterize UC-related duodenitis after colectomy.

Methods A retrospective case-control study of UC-related duodenitis that developed after colectomy in medically refractory UC between January 2011 and June 2020 was conducted. UC-related duodenitis was diagnosed based on typical clinical, endoscopic, and histological findings, and no duodenitis was endoscopically defined by the normal duodenal mucosa. Clinical and laboratory data, disease severity, and medications used were collected and compared between the UC-related and non-duodenitis cases.

Results Ten UC-related duodenitis and 35 non-duodenitis cases were identified among 45 patients with UC who underwent esophagogastroduodenoscopy after colectomy. Disease severity, defined by the C-reactive protein level and partial Mayo score prior to colectomy, was significantly higher in duodenitis patients than in non-duodenitis patients. In comparison to non-duodenitis patients, duodenitis patients more frequently received rescue therapies with calcineurin inhibitors or anti-tumor necrosis factor (TNF)-α agents at the time of colectomy (100% vs. 65.7%).

Conclusion Patients with UC with higher disease activity, especially those who require rescue therapies with calcineurin inhibitors and anti-TNF-α agents, may be prone to developing UC-related duodenitis after colectomy.

Objective The daily step count is associated with mortality in idiopathic pulmonary fibrosis (IPF). However, the factors associated with this phenomenon are not yet fully understood. We therefore clarified its association with clinical parameters.

Methods Fifty-nine patients with IPF with available data for daily step counts; 6-minute walk distance (6MWD); chest, abdominal, and pelvic computed tomography (CT); pulmonary function; psychological evaluations; and sarcopenia assessments were prospectively enrolled. The daily step count was measured continuously for seven consecutive days. The cross-sectional areas of the erector spinae muscles at the level of the 12th vertebra (ESM_CSA) and psoas major muscle volume (PMV) obtained by CT were assessed.

Results The average age of the patients was 73.3±8.1 years old, and the percent predicted forced vital capacity was 81.6%±15.8%. The median daily step count was 4,258 (2,155-6,991) steps. The average 6MWD, ESM_CSA, and PMV were 413±97 m, 25.5±6.7 cm², and 270±75.6 cm³, respectively. A linear regression analysis for daily step count showed that the ESM_CSA and 6MWD were independent factors for the daily step count, whereas the PMV and skeletal muscle index were not. The daily step count, ESM_CSA, and 6MWD were lower in patients with sarcopenia than in those without sarcopenia.

Conclusion A lower daily step count was associated with a smaller erector spinae muscle area and sarcopenia in patients with IPF. Further studies are warranted to confirm the importance of physical therapy for muscle strengthening in patients with IPF.

Objective The changes in the prevalence of acute meningitis during the coronavirus disease 2019 (COVID-19) pandemic remain unclear. This study aimed to compare the prevalence of acute meningitis before and during the COVID-19 pandemic in Japan.

Methods We retrospectively reviewed the Japanese nationwide administrative medical payment system database, Diagnosis Procedure Combination (DPC), from 2016 to 2022. A total of 547 hospitals consistently and seamlessly offered DPC data during this period. The study period was divided into the following three periods: April 2016 to March 2018 (fiscal years 2016-2017), April 2018-March 2020 (2018-2019), and April 2020-March 2022 (2020-2021).

Results Among the 28,161,806 patients hospitalized during the study period, 28,399 were hospitalized for acute meningitis: 16,678 for viral/aseptic type, 6,189 for bacterial type, 655 for fungal type, 429 for tuberculous, 2,310 for carcinomatous type, and 2,138 for other or unknown types of meningitis. A significant decrease during the pandemic was confirmed in viral (n=7,032, n=5,775, and n=3,871 in each period; p<0.0001) and bacterial meningitis (n=2,291, n=2,239, and n=1,659; p<0.0001) cases. Meanwhile, no decrease was observed in fungal meningitis (n=212, n=246, and n=197; p=0.056) or carcinomatous meningitis (n=781, n=795, and n=734; p=0.27). The decrease in the number of tuberculous meningitis cases was equivocal (n=166, n=146, and n=117; p=0.014). The decrease during the pandemic was more remarkable in younger populations aged <50 years than in older populations, both for viral and bacterial meningitis.

Conclusion The number of hospitalized cases of acute meningitis clearly decreased during the COVID-19 pandemic, especially for viral and bacterial meningitis in younger populations aged <50 years.

Objective This study evaluated the implementation status of morbidity and mortality conferences in internal medicine specialty training programs in Japan.

Methods This cross-sectional study surveyed hospitals in Japan with certified internal medicine specialty training programs. Program directors or equivalently responsible physicians managing certified internal medicine training programs were invited to participate in this study (n=619).

Materials Data were collected using an online questionnaire that included questions about the number of morbidity and mortality conferences, types of cases covered, collaboration of the patient safety section and other health professions, and whether or not the conferences were conducted by a subspecialty department-led or program-based.

Results Responses were received from 123 hospitals (19.8% response rate), of which 59 (48%) had some form of internal medicine morbidity and mortality conference in place. The average number per year was 9.63 (standard deviation: 18.12). Hospitals with morbidity and mortality conferences in subspecialty departments held significantly more conferences. Furthermore, the involvement of the patient safety department tended to be associated with holding more conferences. Autopsy rates were significantly higher in hospitals with program-based internal medicine morbidity and mortality conferences than subspecialty-led.

Conclusion Internal medicine specialty training hospitals had more morbidity and mortality conferences than previously reported. Program-based morbidity and mortality conferences in internal medicine are associated with higher autopsy rates and may lead to an organizational reporting culture and lifelong learning attitudes that support patient safety. Collaboration with organizational management sections, such as patient safety, would be effective in implementing these conferences in internal medicine training programs.

A Japanese woman presented with gastric antral ulcers accompanied by erosion and edema, demonstrating a chronic pattern of improvement and recurrence for more than six years. The patient had no relevant treatment history, and Helicobacter pylori infection was ruled out. Other potential etiologies contributing to gastric ulcers were eliminated on the basis of endoscopic biopsy and blood laboratory findings. Consequently, the patient was diagnosed with idiopathic gastric antral ulcer. This disease is often overlooked, and the chronological endoscopic images provided in this report can be used as a reference.

A persistent left superior vena cava (PLSVC) is a commonly observed anatomical anomaly that is frequently detected incidentally via computed tomography (CT) imaging. However, the occurrence of a PLSVC with a right superior vena cava (RSVC) defect, also known as "isolated PLSVC," is a much rarer anomaly. This peculiar malformation can lead to sinoatrial dysfunction, thus necessitating pacemaker implantation, which requires delicate manipulation due to various anatomical complexities. We herein present a case of a sick sinus syndrome with this rare anomaly, which required special consideration when performing pacemaker lead placement.

A 90-year-old man experienced chest oppressive sensation at 12:30 AM for the first time. Electrocardiography showed a newly developed inversion of the terminal T-wave in the V_2-5 leads. A left coronary angiogram showed no significant atherosclerotic stenosis. A myocardial bridge was found in the mid-left anterior descending artery (LAD). Myocardial scintigraphy with ¹²³I beta-methyl 15-para-iodophenyl 3(R,S)-methylpentadecanoic acid revealed a reduced uptake in the apical and septal areas. Based on these findings, we suspected new-onset vasospastic angina complicated by a myocardial bridge in the territory of the LAD. He remained in good condition without recurrent anginal attacks after nifedipine was started before bedtime.

An 86-year-old man successfully underwent percutaneous coronary intervention (PCI), in which a drug-coated stent (DCS) was placed in the left anterior descending coronary artery. However, stent thrombosis occurred twice after eight and two months. After the second admission, the patient was tested for platelet aggregation activity using the platelet aggregation threshold index (PATI), and insufficient inhibition of platelet aggregation was observed. The patient's PATI improved to a satisfactory level using oral anticoagulants. At the six-month follow-up, clinical events were observed. Measuring the platelet aggregation ability can help clinicians understand the pathology of patients and determine treatment choices.

A 75-year-old man underwent chemoradiotherapy for advanced esophageal cancer. After nine years, he was hospitalized for left pyothorax. Consequently, the patient underwent drainage and window opening surgery. He experienced cardiopulmonary arrest but was resuscitated. Based on cardiac catheterization data, the patient was diagnosed with constrictive pericarditis. Unfortunately, extracorporeal circulation did not improve his condition, and he ultimately died. An autopsy revealed adhesion between the pericardium and pleura, especially the pericardium in contact with the left thoracic cavity, which was markedly thickened. This suggests that constrictive pericarditis, a latent complication of chemoradiotherapy, is aggravated by pyothorax.

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Nephrogenic diabetes insipidus (NDI) is characterized by excessive urination and an inability to concentrate urine. Lithium is the most common cause of acquired NDI. Treatment typically involves thiazide diuretics and nonsteroidal anti-inflammatory drugs (NSAIDs). However, the efficacy of desmopressin in NDI remains unclear. We herein report a case of lithium-induced NDI in a 71-year-old woman with lithium-induced NDI. Thiazide diuretics and NSAIDs reduced the urine output by approximately 40% compared to pretreatment, while the addition of desmopressin reduced it by approximately 70%. This case suggests that desmopressin can be a viable treatment option for lithium-induced NDI.

A 26-year-old woman experienced sudden loss of consciousness with respiratory arrest while engaged in a heated conversation shortly after consuming a carbohydrate-rich meal; she was resuscitated immediately. Severe hypokalemia became evident and was deemed to have caused lethal arrhythmia. She was diagnosed with a left aldosterone-producing adenoma and achieved remission following partial adrenalectomy. Primary aldosteronism is frequently complicated by hypokalemia; however, hypokalemia-induced lethal arrhythmias are rare. Clinicians should recognize that primary aldosteronism can potentially cause sudden death in apparently healthy individuals; hence, an early diagnosis and proper treatment are critical.

Neuroendocrine neoplasms can produce multiple hormones that are released into the bloodstream, causing symptoms that vary depending on the type and quantity of hormones involved. We herein report a 63-year-old asymptomatic patient with pancreatic insulinoma who showed marked elevations in circulating calcitonin and procalcitonin levels that returned to normal following surgery. Immunohistochemical analyses confirmed the co-staining of calcitonin and insulin immunoreactivity in the tumor cells, suggesting a calcitonin-producing insulinoma. This insulinoma released calcitonin and a considerable amount of its precursor peptide, procalcitonin, resulting in both hyperprocalcitoninemia and hypercalcitoninemia.

We herein report a case in which diazoxide was effective in treating reactive hypoglycemia caused by late dumping syndrome in a patient with end-stage renal disease (ESRD). A 50-year-old man with ESRD and a history of gastrectomy underwent hemodialysis. Although he was administered voglibose to treat recurrent reactive hypoglycemia caused by late dumping syndrome, he had difficulty continuing treatment because of gastrointestinal side effects. When he began diazoxide treatment, the reactive hypoglycemia improved. The dose was gradually increased with no apparent side effects, and the hypoglycemic attacks disappeared one year after the start of treatment.

A 35-year-old woman was admitted for the examination of lower leg edema and proteinuria. A kidney biopsy showed membranous nephropathy (MN) with fine granular deposits of IgG along the glomerular capillary and poor spike formation, differing from primary MN in the presence of positive IgG3 and C1q. Lupus nephritis was excluded because serum complement and anti-dsDNA antibody, anti-Smith antibody, and anti-cardiolipin antibody tests were negative. The serological test for syphilis was positive, as was the Treponema pallidum hemagglutination test. The patient was diagnosed with syphilis, and the proteinuria disappeared with antibiotic treatment. In MN with positive IgG3 and C1q, syphilis nephropathy may be a differential diagnosis.

Primary ciliary dyskinesia (PCD) is a genetic disease characterized by motile cilia dysfunction, mostly inherited in an autosomal recessive or X-linked manner. We herein report a 29-year-old woman with PCD caused by a heterozygous frameshift mutation due to a single nucleotide deletion in exon 3 of FOXJ1. Heterozygous de novo mutations in FOXJ1 have been reported as an autosomal-dominant cause of PCD. The patient had situs inversus, congenital heart disease, infertility, and hydrocephalus. However, the nasal nitric oxide level was normal. Long-term macrolide therapy was remarkably effective. This is the first case report of PCD caused by a FOXJ1 variant in Japan.

A case in which a foreign body located in the peripheral airway of the lung was removed by flexible bronchoscopy using a virtual bronchoscopy navigation (VBN) system has been reported. The patient was a 60-year-old man. Chest radiography revealed an incidental foreign body in the left lower lung. Chest computed tomography with 1.0-mm slices was used to create a VBN system and confirm the foreign body in left B⁹biiαy, which was removed by flexible bronchoscopy. Thus, peripheral foreign bodies can be safely removed using flexible bronchoscopy by creating a VBN system in advance.

Pulmonary vein stenosis (PVS) is a serious complication of catheter ablation (CA) for atrial fibrillation (AF). PVS generally occurs several months after CA and presents with non-specific symptoms and imaging findings. There have been reports of delayed diagnoses due to a misdiagnosis as infection, interstitial pneumonia, or organizing pneumonia. We introduced six cases of PVS after CA, all of which showed narrowing of the unilateral pulmonary vessels with or without lobar volume loss in the left lung on unenhanced computed tomography. We report these findings as important results indicating the possibility of PVS after CA for AF and contributing to the early diagnosis and management of PVS.

Pulmonary alveolar proteinosis (PAP) is characterized by an abnormal surfactant accumulation in peripheral air spaces. Autoimmune PAP (APAP) results from macrophage dysfunction caused by anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) autoantibodies, and the presence of antibodies more than the cutoff value is specific for APAP. In contrast, secondary PAP (SPAP) does not require anti-GM-CSF autoantibodies and is complicated by other diseases, including myelodysplastic syndrome (MDS). A 73-year-old man with anemia and thrombocytopenia was diagnosed with APAP and MDS simultaneously. The measurement of serum anti-GM-CSF autoantibodies is important for the correct diagnosis and management of PAP, even with an established diagnosis of underlying SPAP-suggestive disease.

We present the case of a 61-year-old man who developed coronavirus disease 2019 (COVID-19) and died during treatment for relapsing polychondritis. The patient was intubated and treated with steroid pulse therapy, remdecivir, antibacterial agents, baricitinib, and tocilizumab. However, his respiratory condition worsened, and he died 108 days after disease onset. An autopsy revealed diffuse alveolar damage in the fibrotic phase in all lung lobes, diffuse pulmonary ossification, and cytomegalovirus-infected cells in the middle lobe of the right lung. We herein discuss the clinical features and pathological findings of COVID-19 in immunosuppressed patients.

Scedosporium/Lomentospora infections are rare and are associated with a high mortality rate in immunocompromised patients. A 69-year-old man with nontuberculous mycobacteria (NTM) died during induction chemotherapy for acute myeloid leukemia because of multiple organ failure due to pneumonia. During an autopsy, Lomentospora prolificans was detected using a fungal gene analysis of the blood, lungs, spleen, kidneys, and intestines, and Scedosporium aurantiacum was detected in the lungs. NTM disease may predispose patients to Scedosporium/Lomentospora infections. Physicians should consider Scedosporium/Lomentospora spp. as an invasive fungal infection that occurs during myelosuppression, particularly when NTM is a complication.

Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive clinically amyopathic dermatomyositis (CADM) is a subtype of dermatomyositis without severe myositis but with characteristic cutaneous manifestations and severe interstitial lung disease. Joint symptoms can occur in patients with anti-MDA5 antibody-positive CADM. However, the treatment strategy and utility of ultrasound for treating joint symptoms remain unknown. We herein report an 85-year-old man with anti-MDA5 antibody-positive CADM who presented with ultrasound-confirmed synovitis that improved with medium-dose corticosteroid therapy.

A 75-year-old Japanese woman was admitted to our hospital and diagnosed with hemophagocytic syndrome secondary to severe fever with thrombocytopenia syndrome (SFTS). The patient recovered after steroid treatment and was discharged from the hospital. Two months after the onset of SFTS, the patient revisited our hospital with a fever and palpable purpura on the extremities and trunk. A histopathological examination of a punch skin biopsy specimen revealed leukocytoclastic vasculitis. Symptomatic treatment resolved the fever, and palpable purpura disappeared 14 days later. No other clinical symptoms or abnormal immunological findings contributed to the leukocytoclastic vasculitis. This is the first report to describe leukocytoclastic vasculitis secondary to SFTS, highlighting a potential association between the two conditions.

We herein report a case of immune-mediated necrotizing myopathy (IMNM) in a patient with microscopic polyangiitis (MPA). A 77-year-old Japanese woman presented with a 2-day history of proximal muscle weakness and myalgia, with elevated serum creatinine kinase (CK) levels. Findings of a muscle biopsy were compatible with IMNM; however, anti-signal recognition particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies were negative. She also had peripheral neuropathy with elevated serum myeloperoxidase anti-neutrophil cytoplasmic antibody titers, leading to a diagnosis of MPA. IMNM can be a pathological result of MPA muscle involvement.

Coronavirus disease 2019 (COVID-19) is a respiratory viral disease, and several cases of autoimmune diseases have been reported after infection. This report presents the case of a 38-year-old Japanese woman who developed systemic lupus erythematosus (SLE) following COVID-19. Clinical manifestations included dermatological complications, joint pain, and positive autoantibodies. The patient met the SLE classification criteria, and renal involvement was observed. Her symptoms improved with immunosuppressive therapy. A literature review identified 10 similar cases, those with lymphopenia and renal involvement. SLE should be considered in patients with persistent nonspecific symptoms after COVID-19 infection, particularly when hematologic and renal involvement are present.

We herein report a case of recurrent infection caused by Verruconis gallopava, which is known to cause fatal phaeohyphomycosis. A 71-year-old man presented with a fever, and computed tomography revealed right chest wall thickening. Eleven years earlier, he had undergone autologous peripheral blood stem cell transplantation for a hematological malignancy. One year earlier, he had undergone excision of a solitary pulmonary nodule, from which had been detected V. gallopava. On this occasion, right chest wall surgery was performed to investigate the cause of the fever, which led to the diagnosis of recurrent infection. Even if a localized lesion is excised, additional antifungal therapy should be performed.

Infected aortic aneurysms are rare, and have a high mortality rate. Although not a major pathogen, Streptococcus pyogenes has been reported to cause infected aortic aneurysms. In the present case, the patient was hospitalized for pyogenic flexor tenosynovitis with S. pyogenes bacteremia. Despite drainage of the abscess around the flexor tendon and effective antimicrobial therapy, infected aneurysms developed in the abdomen and ascending aorta. Because of their rapid enlargement, these aneurysms were treated with in situ reconstruction. Although rare, the possibility that S. pyogenes is the causative pathogen of infected aortic aneurysms should be considered.

Citrobacter koseri causes opportunistic infections in various organs. We herein report an 84-year-old man with diabetes mellitus who presented to our hospital with left hip pain and walking difficulty. Computed tomography showed an extensive abscess with gas production, mainly in the left retroperitoneal space, caused by C. koseri infection. Despite daily cleaning of the wound and antimicrobial therapy (with surgical drainage), the patient developed repeated pneumonia and small bowel hemorrhaging caused by disseminated intravascular coagulation and died on day 65 of hospitalization. Overall, retroperitoneal abscesses caused by C. koseri are rare, and multiple abscesses may show a poor prognosis.