Objective Hepatic encephalopathy (HE) is a serious adverse event associated with lenvatinib (LEN) that requires discontinuation of the medication. We investigated the risk factors for HE in patients with hepatocellular carcinoma (HCC) who received LEN. We also explored the usefulness of rifaximin in preventing HE and LEN.

Methods We enrolled 216 patients with HCC who had undergone LEN. The incidence of HE was evaluated [observational period 171 (1-2,079) days]. LEN dosage was assessed using the relative dose intensity (RDI). A decision-tree algorithm was constructed to reveal the profiles associated with HE.

Results The incidence rate of HE was 8.8%. There were no significant differences in the age, sex, body mass index, or tumor stage between the HE and non-HE groups. A splenorenal shunt (≥8 mm in diameter) was identified as an independent risk factor for HE (hazard ratio 7.653, 95% confidence interval 2.489-23.535, p<0.001). A decision-tree analysis revealed that, in patients with splenorenal shunt and ALBI grade 2, HE occurred in 66.6% of patients with no refaxmin. In contrast, 16.6% developed HE in patients treated with rifaximin. Furthermore, the prevalence of RDI >70% was 20.0% and 66.7% in patients who did not receive rifaximin and rifaximin, respectively.

Conclusion Splenorenal shunt placement is an independent risk factor for HE in patients with HCC receiving LEN. Furthermore, rifaximin prevented HE and contributed to a sufficient dose of LEN in patients with HCC, splenorenal shunts, and ALBI grade 2. Thus, rifaximin may be beneficial for the management of patients with HCC receiving LEN, especially those with HCC with splenorenal shunt and hepatic dysfunction.

Objective This study investigated the association between the phase angle (PhA), a marker of cellular health and body composition quality, and hemoglobin A1c (HbA1c), an indicator of glycemic control, in non-elderly (<65 years old) patients with type 2 diabetes mellitus (T2DM).

Methods This cross-sectional study included 167 non-elderly T2DM patients. The participants were categorized into tertiles (low, middle, and high) based on their PhA values. A multiple logistic regression analysis was performed to examine the association between PhA tertiles and controlled HbA1c levels (defined as <7.0%) after adjusting for potential confounders, such as the age, sex, body mass index, waist circumference, and number of anti-diabetic medications used by the study participants.

Results HbA1c levels were significantly lower in the middle (8.41%±2.06%) and high (8.35%±1.77%) PhA tertiles than in the low tertile (9.58%±2.86%). After adjusting for confounders, the odds ratios for achievement of controlled HbA1c in the middle and high PhA tertiles, compared with the low tertile, were 2.338 (95% confidence interval 1.006-5.432) and 2.666 (1.071-6.636), respectively. Furthermore, when analyzed as a continuous variable, PhA remained a significant and independent predictor of controlled HbA1c level.

Conclusion PhA appears to be a useful independent indicator of glycemic control in non-elderly patients with T2DM. This non-invasive marker could contribute to the development of personalized therapeutic strategies that consider the cellular health and muscle quality.

An 88-year-old man presented with epigastric pain 14 years after a pancreaticoduodenectomy. A migrated stent was found in the pancreatic duct and encased in hard pancreatic stones. Double-balloon endoscopy was used to successfully remove the stent using a biopsy forceps. The procedure was challenging because of the stone formation and narrow pancreatic duct.

An 82-year-old man presented with weight loss was being treated with methotrexate (MTX) for rheumatoid arthritis. Computed tomography revealed sigmoid colonic wall thickening and multiple liver masses. Although we initially considered sigmoid colon cancer with liver metastases, the patient was diagnosed with MTX-associated lymphoproliferative disorder (MTX-LPD) based on histopathological findings and clinical course. All the lesions improved after MTX discontinuation. MTX-LPD rarely affects the gastrointestinal tract, particularly the colon. However, our case suggests that MTX-LPDs should be considered when gastrointestinal lesions are observed in patients receiving MTX.

We herein report a kidney transplant recipient with recurrent bleeding due to multiple ileal ulcerations associated with mycophenolate mofetil (MMF). Symptoms persisted despite surgical resection and embolization. Double-balloon enteroscopy revealed multiple ulcerations, and a biopsy helped exclude other causes. The discontinuation of MMF led to rapid symptom resolution and healing of the ulceration. Intestinal complications after renal transplantation vary, and MMF-induced enteritis, although rare, should be considered. This case highlights the diagnostic value of enteroscopy in identifying drug-induced small intestinal injuries and underscores the importance of including MMF in the differential diagnosis of post-transplant gastrointestinal bleeding.

A man in his 60s developed epigastric pain and anorexia due to pyloric obstruction caused by a retained mochi that had formed a large mass. Without endoscopic tools, conservative treatment with prokinetics and acid suppression leads to symptom resolution. This case highlights the gastrointestinal risks of mochi ingestion in elderly individuals, and suggests that conservative management may be effective in selected cases.

Corynebacterium striatum, which inhabits the human skin and mucous membranes, is generally considered to have low pathogenic potential. It rarely causes infectious endocarditis in immunocompetent hosts without underlying cardiac disease. We report a case of infectious endocarditis caused by multidrug-resistant Corynebacterium striatum in a 75-year-old man with no history of cardiac disease or other predisposing conditions following endoscopic mucosal resection of the rectum.

When C. striatum is isolated from blood cultures, careful evaluation of potential underlying risk factors is essential to distinguish true infection from contamination.

A 30-year-old woman with cutaneous lupus erythematosus, Kikuchi disease, and anti-ribonucleoprotein (RNP)/SS-A antibodies presented with fever and anterior chest pain. Initial echocardiography showed no pericardial effusion; however, follow-up revealed pericardial effusion, thus leading to a diagnosis of systemic lupus erythematosus (SLE)-associated acute pericarditis. Anti-RNP/SS-A antibodies are associated with serositis and elevated type I interferon (IFN) activity. Despite treatment with prednisolone, her condition persisted, thus prompting the administration of anifrolumab (300 mg), a monoclonal antibody that targets the type I IFN receptor. Following treatment, both pericardial effusion and the C-reactive protein levels promptly improved. This case highlights the fact that anifrolumab is a promising therapy for steroid-resistant SLE-associated pericarditis.

A 39-year-old man with asthma and chronic sinusitis presented with nocturnal chest pain and a loss of consciousness. Blood tests showed elevated myocardial enzyme levels and eosinophilia, but the coronary angiography results were unremarkable. Although the patient was treated with vasodilators, chest pain with ST elevation recurred, leading to a diagnosis of refractory coronary spastic angina (CSA) with hypereosinophilia. Prednisolone (PSL) was initially effective, but symptoms recurred during dose reduction. After initiation of mepolizumab, an interleukin-5 (IL-5) inhibitor, his symptoms improved, allowing tapering of PSL. This case indicates that IL-5 inhibitors can be useful glucocorticoid-sparing agents for recurrent CSA associated with eosinophilia.

A 65-year-old woman diagnosed with group A streptococcal vaginosis was admitted to our hospital with pyothorax. Abscess drainage was performed, and antimicrobial agents were administered; however, hematuria, proteinuria, hemolytic anemia, thrombocytopenia, and renal dysfunction developed. Conservative management did not improve kidney or systemic conditions. A renal biopsy confirmed post-infectious glomerulonephritis (PIGN). Glucocorticoid treatment improved the kidney and systemic findings. Bacterial vaginosis rarely causes PIGN. Hemolytic anemia and thrombocytopenia are infrequent complications of PIGN, and glucocorticoids may be effective for their treatment.

Mycobacterium kyorinense is a rare mycobacterium. A 58-year-old man presented with sputum production and left-sided chest pain. Thickened left pulmonary cyst and pleural effusion were observed. A culture of the pleural fluid was negative, but the adenosine deaminase level was elevated. The patient was clinically diagnosed with M. kyorinense infection because this mycobacterium was identified in sputum samples on two occasions. The effusion and chest pain improved following treatment with levofloxacin, clarithromycin, and streptomycin. Identification of M. kyorinense is clinically significant because of its drug resistance. To our knowledge, this is the first reported case of pleuritis caused by a pulmonary M. kyorinense infection.

We report the case of a 38-year-old woman who visited our hospital because of persistent bloody stool one month after starting treatment with dupilumab, an anti-interleukin-4 receptor subunit α monoclonal antibody, for bronchial asthma. Based on the lower gastrointestinal endoscopy findings, the patient was diagnosed with ulcerative colitis. Despite medication, the patient's bloody stool was not well controlled; however, the situation improved after discontinuation of dupilumab. Based on the patient's clinical course, drug-induced ulcerative colitis due to dupilumab was diagnosed. Careful monitoring of the symptoms associated with the development of enteritis is necessary after dupilumab administration.

Inhaled treprostinil is the first-choice drug for the treatment of Group 3 pulmonary hypertension (PH) associated with chronic lung disease. A 72-year-old man was diagnosed with interstitial pneumonia, and his respiratory symptoms had gradually worsened. Echocardiography revealed a maximum tricuspid regurgitation pressure gradient (TRPG) of 64 mmHg, and the patient was diagnosed with Group 3 PH. Subsequently, he was admitted to the hospital with acute heart failure. Inhaled treprostinil was prescribed, his B-type natriuretic peptide level and maximum TRPG subsequently improved, and his oxygen requirement decreased. Treprostinil inhalation may be effective in treating patients with severe respiratory symptoms of interstitial pneumonia.

We report the first pathologically confirmed case of drug-induced interstitial lung disease (DI-ILD) with hypersensitivity pneumonitis (HP). A 63-year-old woman with triple-negative breast cancer developed a fever and cough 1 week after starting neoadjuvant pembrolizumab plus epirubicin and cyclophosphamide (EC). Chest computed tomography revealed diffuse centrilobular ground-glass opacities, and a cryobiopsy confirmed non-fibrotic HP. Although Krebs von den Lungen-6 levels were normal, surfactant protein-D levels were elevated. The patient's condition improved with drug discontinuation and brief corticosteroid therapy, enabling curative surgery. This presentation may represent a distinct phenotype of EC-induced ILD, underscoring the importance of an early diagnosis.

Endotracheal and endobronchial metastases from peripheral lung adenocarcinoma are rare, and optimal clinical management remains unclear. We herein report a 60-year-old woman with epidermal growth factor receptor (EGFR) exon 19 deletion-positive early-stage lung adenocarcinoma who underwent surgical resection followed by osimertinib treatment for recurrence. She later developed oligoprogressive disease with airway metastases. Bronchoscopic tumor removal was performed, and next-generation sequencing of the resected specimen revealed an acquired EGFR C797S mutation, along with exon 19 deletion. Gefitinib treatment was initiated, which led to a partial response. This case underscores the utility of repeated molecular profiling and local intervention in managing acquired resistance in EGFR-mutant non-small-cell lung cancer.

We herein report a case of the leukemic phase of chronic lymphocytic leukemia (CLL)-type lymphoma that abruptly developed 12 months after the initial diagnosis of autoimmune hemolytic anemia (AIHA), in which retrospective immunohistochemistry and next-generation sequencing (NGS) revealed that (1) lymphoma with a CLL-type immunophenotype underlay the development of secondary AIHA, (2) complete loss of TP53 function by double-hit TP53 abnormalities (TP53 deletion and mutation) was secondarily acquired, and (3) complete loss of TP53 function could have contributed to clinical manifestation of transformed lymphoma. Immunohistochemistry for LEF1 and an NGS analysis may help physicians precisely diagnose CLL-type lymphoproliferation-associated AIHA.

The association between paroxysmal nocturnal hemoglobinuria (PNH) and systemic lupus erythematosus (SLE) remains unclear. A 34-year-old woman undergoing treatment for SLE developed progressive direct Coombs-negative hemolytic anemia due to PNH, as revealed by flow cytometric analysis. Anemia worsened, accompanied by elevated lactate dehydrogenase (LDH) levels and severe fatigue. Administration of the C5 inhibitor crovalimab resulted in improvement of anemia, reduction in LDH levels, and rapid clinical improvement, without major adverse effects. To the best of our knowledge, this is the first reported case of SLE complicated by PNH that was successfully and safely treated with crovalimab.

Chronic active Epstein-Barr virus (CAEBV) infection is a rare and potentially fatal condition involving EBV-infected T or natural killer cells. We herein report a 46-year-old man with CAEBV complicated by cardiomyopathy. Imaging and a biopsy revealed EBV-positive CD3⁺ T cell infiltration in the myocardium. The patient was treated with high-dose cytarabine-based chemotherapy followed by cord blood transplantation using reduced-intensity conditioning, resulting in complete donor chimerism. Although transient cardiac dysfunction and post-transplant EBV reactivation occurred, the patient remained in remission for five years. This case underscores the importance of a myocardial biopsy and long-term monitoring of CAEBV with cardiac involvement.

A 42-year-old woman was diagnosed with monomorphic epithelial-type intestinal T-cell lymphoma (MEITL) following small bowel endoscopy. The patient subsequently underwent a small bowel resection to prevent perforation. Bowel lesions progressed shortly after completion of first-line chemotherapy. Although four different salvage regimens were attempted, they were refractory, and both bowel and ovarian lesions progressed. Partial jejunal resection was performed during the fifth salvage regimen, followed by oophorectomy. After achieving complete remission, she underwent cord blood transplantation and remained alive 37 months after the diagnosis. Integration of elective surgery and allogeneic transplantation may be a treatment option for relapsed or refractory MEITL.

A 76-year-old man was admitted to our hospital with progressive dysphagia. His physical and neurological examination results were normal, except for dysphagia. Videofluoroscopy of swallowing demonstrated a cricopharyngeal bar, a highly specific finding for inclusion body myositis (IBM). A cricopharyngeal muscle specimen was obtained during cricopharyngeal myotomy to improve his symptoms. Muscle histopathology successfully led to the diagnosis of IBM. Dysphagia can occasionally precede limb weakness in IBM, and an early histopathological diagnosis using limb muscles is challenging. In such cases, a histopathological evaluation via myotomy may be useful for making an early diagnosis and facilitating appropriate treatment.

Cryptogenic new-onset refractory status epilepticus (C-NORSE) is a rare, severe condition characterized by refractory status epilepticus without identifiable causes. It is often unresponsive to first-line immunotherapy. The C-NORSE score is a useful diagnostic tool, but in the early phase, when the score remains low and antibody test results are unavailable, it is difficult to initiate second-line immunotherapy, including cyclophosphamide. We report a 27-year-old man with C-NORSE who achieved early recovery and favorable outcome following administration of intravenous cyclophosphamide, despite a low C-NORSE score on admission, suggesting the importance of repeated assessment using the C-NORSE score and early administration of cyclophosphamide.

This case report describes the case of an 80-year-old man with ocular myasthenia gravis, who developed microscopic polyangiitis with alveolar hemorrhage. This rare co-occurrence of the two autoimmune diseases presented significant diagnostic and therapeutic challenges. Despite the initial improvement with glucocorticoids, the patient relapsed and died before receiving additional immunosuppressive agents. Thus, the balance between therapeutic efficacy and adverse effects, such as infections, must be carefully considered, especially in elderly patients. This case underscores the importance of recognizing rare overlaps of autoimmune diseases and highlights the need for individualized treatment strategies, especially in older individuals, in whom aggressive immunosuppression carries additional risks.

Immunoglobulin G4-related disease (IgG4-RD) presenting with isolated nasopharyngeal involvement is rare. A 51-year-old man presented with left-sided otalgia and temporal tingling. Magnetic resonance imaging showed a 2.5-cm infiltrative soft tissue lesion in the left nasopharynx, initially suspected of being nasopharyngeal carcinoma. Serum IgG4 levels were normal. The first biopsy was inconclusive; however, a second, deeper biopsy confirmed IgG4-RD based on storiform fibrosis, dense lymphoplasmacytic infiltration, and increased IgG4-positive plasma cells. The patient responded well to moderate-dose glucocorticoids and azathioprine. IgG4-RD should be considered in the differential diagnosis of mass-forming lesions in the nasal cavity, even in the absence of elevated serum IgG4 levels.

Bladder rupture is a rare but potentially fatal condition that is often difficult to diagnose because of its nonspecific symptoms. A 75-year-old woman with a history of remote pelvic radiotherapy presented with abdominal pain, renal dysfunction, and ascitic fluid. Initially, NSAID-induced renal injury was suspected, and her condition improved after drug discontinuation. Recurrent symptoms led to the suspicion of bladder rupture, confirmed by elevated ascitic creatinine levels and cystography. Her serum ascites albumin gradient (SAAG) exceeded 3.0 g/dL. Although elevated SAAG levels are theoretically expected in patients with bladder rupture, this association remains hypothetical, and further investigation is warranted to clarify its diagnostic utility.