Objective Sofosbuvir/velpatasvir (SOF/VEL) has been approved for various stages of hepatitis C virus (HCV) infection; however, real-world data on Japanese patients remain limited. We evaluated the efficacy of SOF/VEL treatment in Japanese patients with chronic hepatitis, compensated cirrhosis, decompensated cirrhosis, and direct-acting antiviral (DAA) retreatment.

Methods This multicenter prospective study enrolled 236 patients treated with SOF/VEL (with ribavirin for retreatment) at 21 Japanese institutions (chronic hepatitis, n=35; compensated cirrhosis, n=43; decompensated cirrhosis, n=134; undergoing DAA retreatment, n=24). The primary outcome was the sustained virologic response (SVR) rate at 24 weeks post-treatment (SVR24). In decompensated cirrhosis, liver function changes were assessed using the modified albumin-bilirubin (ALBI) score.

Results The overall SVR24 rate was 97%, with SVR24 achieved in 100% of the patients with chronic hepatitis and compensated cirrhosis, 96% of those with decompensated cirrhosis, and 92% of those undergoing DAA retreatment. In the decompensated cirrhosis group, a significant improvement in the modified ALBI scores was observed from baseline to SVR24, and this improvement was sustained for two years after treatment. The proportion of patients with modified ALBI grades 1 or 2a increased from 5.2% at baseline to 23% at the end of treatment, 31% at SVR12, 35% at SVR24, 37% at 1 year, and 44% at 2 years post-treatment.

Conclusion SOF/VEL has demonstrated high efficacy in all stages of hepatitis C, including patients with chronic hepatitis, compensated cirrhosis, decompensated cirrhosis, and prior DAA failure. The ability to achieve high efficacy at any stage of chronic hepatitis C is expected to improve the prognosis for a wide range of patients.

Objective Alcoholic liver disease is the leading cause of cirrhosis and liver failure in Japan. We assessed hepatologist-led interventions stratified using the alcohol use disorder identification test.

Methods This was a single-center, prospective study. Outcomes included total alcohol consumption, number of heavy drinking days, drinking risk level, and liver function over 24 weeks.

Patients Patients with chronic liver disease were stratified into three groups according to alcohol use disorder identification test scores: <10 (education only), 10-19 (hepatologist-led intervention), and ≥20 (psychiatric referral). Patients in the hepatologist-led group received drinking guidance, psychosocial support, and nalmefene, when indicated.

Results Between August 2022 and September 2025, 932 patients were screened; 823, 78, and 31 had alcohol use disorder identification test scores of <10, 10-19, and ≥20 points, respectively. Of the 78 patients in the hepatologist-led intervention group, 74 completed follow-up. In this group, median total alcohol consumption decreased from 63.1 to 35.1 g/day (p=0.001) and heavy-drinking days from 17.0 to 11.3 days/month (p=0.002). Drinking risk level downstaging was achieved in 52 patients (70.2%), who showed significant improvements in aspartate aminotransferase (p=0.027) and γ-GTP (p=0.014) levels and experienced fewer cirrhosis-related complications in comparison to patients without downstaging. Logistic regression identified baseline hepatocellular carcinoma as an independent predictor of drinking risk-level downstaging (odds ratio, 5.23; 95% confidence interval, 1.10-15.3).

Conclusion Hepatologist-led alcohol use disorder identification test-based management of alcoholic liver disease reduces alcohol intake. Drinking risk-level downstaging has been linked to improved liver biochemistry and clinical outcomes, offering a practical strategy in which psychiatric resources are limited.

A 72-year-old man was referred for the evaluation of multiple hepatic lesions incidentally detected on contrast-enhanced computed tomography during prostate cancer staging. Imaging could not exclude malignancy, but the tumor markers were within the normal limits, except for prostate-specific antigen, and endoscopic examinations revealed no primary malignancy. A percutaneous biopsy was not feasible because of the lesion size and location. Endoscopic ultrasound (EUS) revealed a 25-mm caudate lobe lesion, from which fine-needle biopsy (FNB) was performed without complications. A histopathological examination confirmed a diagnosis of hepatic sarcoidosis. This case highlights the utility of EUS-FNB for the diagnosis of hepatic sarcoidosis, especially when a conventional biopsy is impractical.

An enterovesical fistula (EVF) is an abnormal connection between the intestinal tract and urinary bladder, typically developing with symptoms of pneumaturia and fecaluria. We herein present the case of an 81-year-old man with 10-day watery diarrhea. After ineffective empiric antidiarrheal treatment, computed tomography and cystography revealed EVF and gas in the bladder lumen and within its wall. His diarrhea improved after urethral catheter placement. EVF can occasionally cause diarrhea in a delicate pressure balance between the bladder and intestine. Clinicians should be aware of this unusual condition and include "urinary diarrhea" in the differential diagnosis of diarrhea.

Budesonide is recommended for mild-to-moderate ulcerative colitis (UC); however, cytomegalovirus (CMV) colitis may still emerge during therapy. We report the case of a 69-year-old woman with left-sided UC who developed worsening diarrhea and hematochezia while receiving budesonide rectal foam and MMX. Colonoscopy revealed longitudinal, undermined, and "double-tracked" ulcers in the rectosigmoid. CMV pp65 antigenemia was positive, and immunohistochemical staining of a biopsy specimen revealed CMV-infected cells. Oral valganciclovir was initiated, leading to rapid improvement, with antigenemia converting to negative; follow-up endoscopy showed shallower ulcers. This case illustrates that locally acting budesonide MMX does not eliminate the risk of CMV colitis, and viral reactivation can occur even during its use. Accordingly, when clinical worsening occurs during budesonide MMX therapy, early CMV testing should be considered to avoid unnecessary escalation to systemic corticosteroids or advanced agents.

An intraductal papillary mucinous neoplasm (IPMN) was incidentally detected in a 91-year-old woman 12 years before her current admission. The patient declined additional examinations and surgical intervention. Over the subsequent years, she experienced recurrent acute pancreatitis and ultimately developed a gastrointestinal perforation due to the rupture of the IPMN. Considering her age, general condition, and personal wishes, conservative management was selected, which allowed her to successfully resume oral intake until death from cancer. This rare clinical course provides valuable insights into the management of older adults with IPMN, a condition that is likely to be frequently encountered as the population ages.

A 44-year-old man with suspected familial hypercholesterolemia underwent percutaneous coronary intervention (PCI) with bioresorbable polymer sirolimus-eluting stent implantation for unstable angina. A proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor was initiated post-procedure but it discontinued five months later due to financial constraints, leading to a loss to follow-up and cessation of optimal medical therapy, including antiplatelet therapy. Four years later, he developed stent thrombosis, presenting as ST-elevation myocardial infarction with cardiogenic shock. Emergency PCI with Impella support achieved successful revascularization. This case emphasizes that beyond clinical efficacy, attention to financial feasibility and shared decision-making is essential for the long-term success of therapies such as PCSK9 inhibitors.

Myelodysplastic syndrome (MDS) often coexists with systemic autoimmune diseases. Chronic myelogenous leukemia (CML) is an independent risk factor for intrarenal arterial hyalinosis. We describe a case of glomerulopathy that developed at the transition from CML with 5q deletion (relatively rare) to MDS with 5q and 13q deletion. Kidney histology showed glomerular hyalinosis due to intrarenal arterial changes from CML, in addition to podocytic infolding glomerulopathy (PIG) due to systemic immune responses from MDS or tyrosine kinase inhibitors, or which was coincidental. To our knowledge, this is the first case of PIG developing during the transition from CML to MDS.

Pulmonary sequestration is a congenital lung malformation involving the systemic arterial blood. Infection is a common complication; however, Nocardia infection is rare. We report the case of a 55-year-old immunocompetent male with recurrent infection of a pulmonary cyst in the left lower lobe. Despite the use of empirical antibiotics, the inflammation recurred. Contrast-enhanced computed tomography confirmed pulmonary sequestration, and bronchoscopy revealed Nocardia cyriacigeorgica. Although trimethoprim-sulfamethoxazole was effective, it was discontinued because of severe drug-induced rash. Surgical resection resolved the infection without the use of long-term antibiotics. Timely consideration of surgical intervention may be important for infection control in pulmonary sequestration complicated by Nocardia, especially when antibiotic management is difficult.

Multiple myeloma with central nervous system (CNS) involvement is rare and associated with a poor prognosis. Although the emergence of novel therapies, including chimeric antigen receptor T-cell therapy and bispecific antibodies, has made it possible to obtain long-term disease control in multiple myeloma, there is still no established standard treatment for cases with CNS involvement, and the efficacy of novel therapies remains unclear. To our knowledge, we herein report the first case of successful elranatamab treatment in Japan in a patient with refractory multiple myeloma showing impaired consciousness caused by CNS involvement.

A 94-year-old woman residing in a nursing home was admitted with aspiration pneumonia. A sputum culture yielded Klebsiella pneumoniae. Despite appropriate management, the patient's mental status deteriorated. Brain magnetic resonance imaging demonstrated high signal intensity in the right insular cortex on diffusion-weighted images, raising the suspicion of limbic encephalitis. A lumbar puncture revealed clear cerebrospinal fluid (CSF) with normal cell counts and protein levels. On hospital day 5, HSV-1 DNA was detected in the CSF, confirming herpes simplex encephalitis (HSE), and acyclovir was initiated. In elderly patients with unexplained altered consciousness, clinicians should not exclude HSE based on normal CSF findings.

Acyclovir (ACV) is the first-line agent for varicella zoster virus (VZV) encephalitis. Acute kidney injury (AKI) remains a clinical concern. We report the case of a sarcopenic obese woman with VZV encephalitis. She developed AKI 2 days after receiving intravenous ACV based on her actual body weight. After temporarily discontinuing ACV and confirming recovery of the renal function, ACV was restarted at a dose based on her ideal body weight. The patient recovered without any further complications. This case underscores the importance of dose adjustment of water-soluble medications, such as ACV, in obese patients, particularly in those with sarcopenic obesity.

Sporadic late-onset nemaline myopathy (SLONM) is a rare neuromuscular disorder often associated with monoclonal gammopathy of undetermined significance (MGUS). However, reports of SLONM without MGUS are limited, particularly in cases complicated by Sjögren's syndrome. We herein report the case of a 62-year-old woman with SLONM without MGUS, associated with Sjögren's syndrome. The patient presented with dropped head syndrome. A muscle biopsy confirmed SLONM, and Sjögren's syndrome was diagnosed. Treatment with intravenous immunoglobulin and corticosteroids improved her muscle strength. This case highlights the importance of considering SLONM in the differential diagnosis when dropped head is the predominant clinical presentation.

Idiopathic normal pressure hydrocephalus (iNPH) occasionally presents with parkinsonism, in addition to its classic triad of symptoms. However, it remains unclear whether such parkinsonism reflects an inherent manifestation of iNPH or comorbid Parkinson's disease, and whether it is levodopa-responsive. We report three patients exhibiting both hydrocephalus and parkinsonism. Two improved with both levodopa and shunt surgery; one improved only with levodopa and not with spinal tap. In one dual responder, dopamine transporter uptake improved postoperatively, and motor symptoms remained stable despite tapering levodopa. These cases highlight the heterogeneity of this overlapping condition, including a potentially reversible, levodopa-responsive parkinsonism due to hydrocephalus-induced dopaminergic dysfunction that can be ameliorated by shunt surgery.

Rituximab is frequently used to treat hematological and autoimmune diseases. Rituximab-induced acute thrombocytopenia (RIAT) is a rare adverse event associated with the use of this drug. In this report, we describe two cases of RIAT in patients with systemic sclerosis. Severe thrombocytopenia was observed in both patients following the second rituximab infusion. In addition, mild leukopenia, hypocomplementemia, and systemic inflammation were observed. Most previous reports have described RIAT in patients with hematological malignancies, but patients with autoimmune diseases may also develop this condition.

We report the first case of Vibrio vulnificus sepsis in a patient with vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome. A 76-year-old man was diagnosed with VEXAS and myelodysplastic syndromes. He was treated with tocilizumab, oral prednisolone, and regular blood transfusions. The patient presented with fever, chills, and vomiting and was subsequently diagnosed with sepsis. A blood culture confirmed V. vulnificus infection, which resolved after tazobactam/piperacillin treatment. V. vulnificus infections can be facilitated by iron overload resulting from frequent blood transfusions. Since patients with VEXAS syndrome often require regular transfusions, clinicians should monitor for this potentially fatal infection.

A 59-year-old woman developed a persistent dry cough one month after recovering from coronavirus disease 2019 (COVID-19). She subsequently developed fever and back pain, and a local doctor diagnosed suspected infection and prescribed antibiotics. However, her symptoms did not improve and she was referred to our department. No definitive etiology was identified based on the initial physical examination, blood tests, and non-contrast computed tomography (CT). Her symptoms persisted for another week, and contrast-enhanced CT revealed aortic wall thickening. The patient was then diagnosed with Takayasu arteritis. As only a few cases of Takayasu arteritis have been reported after COVID-19, this case is valuable.

Protein-losing enteropathy (PLE) is a rare complication of systemic lupus erythematosus (SLE). A 38-year-old woman with well-controlled SLE developed abdominal pain, lower-extremity edema, anemia, and hypoalbuminemia. The patient was then diagnosed with PLE. Despite treatment with glucocorticoids and cyclophosphamide, persistent hypoalbuminemia was observed. A biopsy was performed using double-balloon enteroscopy due to small bowel lesions, which confirmed the diagnosis of diffuse large B-cell lymphoma. To the best of our knowledge, this is the first reported case of diffuse large B-cell lymphoma mimicking PLE associated with SLE. The possibility of malignant lymphoma should be considered in cases of treatment-resistant PLEs associated with SLE.

A 50-year-old man with a history of bronchial asthma was admitted to our hospital with peripheral neuropathy, sinusitis, and eosinophilia. The patient was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). The symptoms partially improved with a combination of prednisolone and mepolizumab. However, nasal mucosal biopsy revealed a complication due to eosinophilic sinusitis. The addition of dupilumab resulted in the improvement of sinusitis. Few reports exist on the combination of these two drugs for EGPA, and no case reports exist on the addition of dupilumab in patients with residual eosinophilic sinusitis after treatment with prednisolone and mepolizumab. This case is valuable for future consideration in cases involving combination therapy.

Eosinophilic granulomatosis with polyangiitis (EGPA), a subtype of antineutrophil cytoplasmic antibody (ANCA)-related vasculitis, is rarely reported as an immune-related adverse event. We herein present the case of a 61-year-old woman with non-small cell lung cancer treated with durvalumab after definitive chemoradiotherapy. Following durvalumab treatment initiation, she experienced numbness in her hands and feet, and drop foot in her right ankle. She was subsequently diagnosed with peripheral neuropathy, eosinophilia, and myeloperoxidase-ANCA positivity, and had a history of asthma. Consequently, the patient was diagnosed as having EGPA. We report the first case of EGPA caused by durvalumab, an anti-programmed death-ligand 1 (PD-L1) antibody.

We report a case of tsutsugamushi disease in a 41-year-old woman diagnosed during a non-endemic season in a previously low-incidence region without any history of outdoor exposure. The patient owned five cats with close contact that moved freely between the indoor and outdoor environments, suggesting the possibility that infected chiggers were carried indoors by the cats and transmitted Orientia tsutsugamushi to the patient. This case suggests that tsutsugamushi disease may be under-recognized and under-reported in such regions. Even in the absence of typical histories such as outdoor exposure, a detailed examination of pet ownership may help raise clinical suspicion.