Aspergillus tracheobronchitis (ATB) is a rare but severe infection in immunocompromised patients that is distinct from invasive pulmonary aspergillosis. A 50-year-old man undergoing dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide chemotherapy for NK/T-cell lymphoma developed febrile neutropenia and worsening respiratory failure. Computed tomography revealed airway epithelial detachment and bronchoscopy confirmed pseudomembrane formation. Due to his "Do Not Intubate" status, mechanical ventilation was not initiated, and he died of CO₂ narcosis. Autopsy histopathologically confirmed pseudomembranous ATB. This case underscores the need for early bronchoscopy in high-risk patients with type 2 respiratory failure that cannot be explained by imaging findings alone, highlighting the crucial need for timely intervention to improve outcomes.

FMS-like tyrosine kinase 3 (FLT3) mutations are observed in 30% of acute myeloid leukemia (AML) cases and indicate a poor prognosis. FLT3 inhibitors, such as gilteritinib, improve outcomes but may cause differentiation syndrome (DS) in approximately 3% of patients. We herein report a case of FLT3-tyrosine kinase domain-mutated AML treated with idarubicin and cytarabine, followed by a single dose of gilteritinib. The patient developed DS that required intubation. Initial steroid therapy was ineffective; however, steroid pulse therapy and additional idarubicin resolved the DS. This case shows that gilteritinib-induced DS can occur early and severely and requires prompt and aggressive management.

Objective Impaired awareness of hypoglycemia (IAH) contributes to severe hypoglycemia (SH) in adults with type 1 diabetes mellitus (T1DM). This study compared the validity of the Gold, Clarke, and Pedersen-Bjergaard methods for predicting SH in Japanese adults with T1DM.

Methods IAH was assessed at baseline using three methods, and a prospective cohort study was conducted in adults with T1DM. Multivariate Cox proportional hazards regression models adjusted for covariates were used to compare the three methods for predicting SH, and diagnostic validity was calculated.

Patients We enrolled 286 participants (mean age: 50.5±14.6 years, men: 36.7%, diabetes duration: 17.6±11.1 years, mean HbA1c level: 7.7%±0.9%).

Results The prevalence of IAH identified using the Gold, Clarke, and Pedersen-Bjergaard methods was 12.2%, 19.2%, and 30.1%, respectively. The Clarke method showed the strongest association with SH [adjusted hazard ratio (aHR), 8.27; 95% confidence interval (CI), 3.43-20.0, P<0.001], whereas the Gold and Pedersen-Bjergaard methods had associations of aHR 1.90 (95% CI: 0.67-5.36, P=0.227) and aHR 2.65 (95% CI: 1.16-6.03; P=0.020), respectively. The Clarke method demonstrated 65.2% sensitivity, 84.8% specificity, a 27.3% positive predictive value, a 96.5% negative predictive value, a positive likelihood ratio of 4.29, a negative likelihood ratio of 0.41, and an overall diagnostic validity of 83.2%.

Conclusion Among the three methods, the Clarke method demonstrated the highest validity for predicting SH development. This information may assist physicians in assessing IAH in clinical practice.

Clinical trial registry no. UMIN000039475.

A 78-year-old man presented to our hospital with left-sided pleural effusion. A diagnosis could not be established based on blood or pleural fluid analyses. A re-evaluation of his medical history revealed that he had begun taking hachimijiogan five months prior to presentation. Pleural effusion resolved after discontinuation of hachimijiogan, resulting in a diagnosis of drug-induced pleuritis. Subsequently, an accidental rechallenge was performed to confirm the diagnosis. Drug-induced pleuritis due to Kampo medicines is uncommon, with no prior reports of hachimijiogan being associated with this condition. Obtaining a detailed medication history is essential for diagnosing pleural effusions of unknown etiology.

A 53-year-old woman with an atrioventricular septal defect who had undergone 3 valvuloplasties by 7 years old underwent a kidney biopsy because of lower extremity edema and proteinuria. The glomeruli were intact; however, the proximal tubules showed marked hemosiderin deposition, which was assumed to be related to a fissure in the calcified cardiac patch. The fissure acts as a collateral blood channel from the left ventricle to the left atrium, and the resulting mitral regurgitation and backflow of blood cause turbulent flow phenomena and chronic hemolysis. After hospitalization and dietary guidance on salt reduction, the edema improved, and the proteinuria disappeared.

A 78-year-old woman with AQP4 antibody-positive neuromyelitis optica spectrum disorder (NMOSD) developed acute-type adult T-cell leukemia (ATL) 1 month after initiating satralizumab, without prior HTLV-1 screening. She presented with respiratory symptoms and hematochezia after receiving three doses. Laboratory tests revealed abnormal lymphocytosis and HTLV-1 positivity, with monoclonal proliferation. Despite CHOP chemotherapy, the patient died within two weeks of treatment initiation. IL-6 inhibition may impair the host defense against HTLV-1 oncogenesis. This case highlights the potential risk of ATL following treatment with satralizumab, especially in HTLV-1 endemic areas, and the importance of HTLV-1 screening and clonality assessment before treatment in patients with NMOSD.

Post-transplant lymphoproliferative disorder (PTLD) is a life-threatening condition for organ transplantations. There are no established treatments for PTLD, and it is associated with a poor prognosis. Patients with PTLD treated with pola-R-CHP have rarely been reported, and long-term remission results are unknown. This is the first report of previously untreated PTLD treated with a pola-R-CHP regimen that achieved long-term remission. Pola-R-CHP may be a promising treatment option for patients with PTLD, especially monomorphic diffuse large B-cell lymphoma, and those with an increased International Prognostic Index score.

A 68-year-old woman presented with a history of hemoptysis. She had been receiving hormone therapy and chemotherapy for recurrent breast cancer. She was diagnosed with diffuse alveolar hemorrhage caused by metastatic breast cancer, as evidenced by increasingly bloody bronchoalveolar lavage fluid and malignant cells in multiple lung lobes. This condition was associated with tumor emboli in the pulmonary vasculature and transformation into a hormone receptor-negative state. Serial changes in chest computed tomography findings, from diffuse patchy ground-glass opacities to multiple nodules, are notable. This rare mode of metastasis may be associated with a poor prognosis.

Background: Recent reports have shown that patients with immunoglobulin A nephropathy (IgAN) develop gross hematuria after COVID-19) vaccination. However, the two-year prognosis remains uncertain.

Methods: We conducted a retrospective review of 301 patients with IgAN at our institution to identify those who developed gross hematuria after COVID-19 vaccination. We evaluated the patients' baseline characteristics, clinical courses, and changes in the renal function, proteinuria, and hematuria for two years post-vaccination. In addition, we conducted a systematic literature review of 16 case studies, with 28 cases and 5 cohort studies.

Results: Gross hematuria was observed in eight patients after vaccination. Their mean age was 42.9 years, and 87.5% were women. All patients relapsed or did not achieve clinical remission prior to vaccination. The median time to gross hematuria onset was 1.6 days, resolving within 3 days. The mean baseline estimated glomerular filtration rate (eGFR) was 69.4 mL/min/1.73 m², the urine protein-to-creatinine ratio (UPCR) was 0.23 g/g Cr, and the median baseline hematuria was 10-19 red blood cells (RBCs)/high-power field (HPF). One month after vaccination, the eGFR decreased by 8.6 mL/min/1.73 m² (−12.3%), the UPCR increased by 0.64 g/g Cr, and hematuria increased to 50-99 RBCs/HPF. By 6 months, the eGFR and UPCR had recovered, with median hematuria decreasing to 5-9 RBCs/HPF and stabilizing by 24 months.

Conclusions: We revealed the extended prognosis of gross hematuria in patients with IgAN following COVID-19 vaccination. With appropriate follow-up, temporary renal deterioration improved within six months and remained stable for two years. These findings support the safety of the COVID-19 vaccination in this vulnerable population.

Immune checkpoint inhibitors (ICIs) are effective against many types of cancers. However, these drugs can trigger unintended immune attacks on normal tissues, leading to a range of side effects known as immune-related adverse events (irAEs). Involvement of the hematopoietic system in irAEs is rare, and a standard treatment has not yet been established. We herein report a 72-year-old man with non-small-cell lung cancer who developed aplastic anemia (AA) after ICI treatment. Eltrombopag improved the long-term blood count without causing severe infection. This case suggests that eltrombopag may be a viable treatment option for ICI-induced AA.

We herein report a 60-year-old man with transient lupus anticoagulant positivity in the acute phase of cerebral infarction due to left vertebral artery dissection who experienced repeated occlusion of the affected artery despite mechanical thrombectomy and stent placement. The addition of anticoagulants prevented further cerebral infarctions. In this case, it was believed that vascular injury caused by vertebral artery dissection, combined with the presence of antiphospholipid antibodies, accelerated repeated thrombosis. Interestingly, anti-cardiolipin antibodies were detected eight months later, although all antiphospholipid antibodies were negative at the time of the first follow-up.

A 48-year-old man presented with impaired consciousness and aphasia. Magnetic resonance imaging (MRI) of the head revealed acute cerebral infarction in the left temporal and parietal lobes. Carotid ultrasonography revealed a mobile structure at the origin of the left internal carotid artery. Cervical MRI using fat-saturation T1 imaging showed an isointense structure at the origin, with a high-signal structure extending toward the head. Digital subtraction angiography revealed contrast stagnation, suggesting the presence of a carotid web (CaW). The mobile structure was released, indicating thrombus resolution. Carotid artery stenting eliminated contrast stagnation and was well-tolerated. This case highlights the diagnostic challenges associated with a CaW-related stroke.

We herein report a patient with immunoglobulin (Ig)G4-related hypertrophic pachymeningitis (HP) with myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA) positivity without renal dysfunction at the time of the diagnosis who subsequently developed nephritis after an unplanned interruption of maintenance glucocorticoid therapy. A renal biopsy specimen obtained at the time of the development of renal dysfunction revealed the possibility of both ANCA-associated nephritis and IgG4-related tubulointerstitial nephritis, with no HP relapse. The present case highlights the need to monitor other organ complications, including renal damage, in patients with IgG4-related HP with MPO-ANCA positivity, even after achieving remission.

We herein report a case of disseminated strongyloidiasis in a 64-year-old man with human T-lymphotropic virus type 1 (HTLV-1) infection who developed the condition after undergoing chemoradiotherapy for lung cancer. Treatment included daily ivermectin, which eradicated Strongyloides stercoralis after 7 days but was interrupted after 14 days due to the development of skin rashes. After excluding ivermectin as the cause of the drug eruption, intermittent ivermectin was continued monthly for six months, with no recurrence of strongyloidiasis or bacteremia. This case highlights the importance of obtaining a comprehensive patient history and making an early diagnosis to improve the outcomes of disseminated strongyloidiasis.

Background Anti-NMDAR encephalitis is an autoimmune disorder typically associated with normal or intraparenchymal brain magnetic resonance imaging (MRI) findings. We herein report a patient who initially presented with extraparenchymal brain lesions and later developed primary leptomeningeal lymphoma (PLML), an uncommon sequence that may inform clinical vigilance and diagnostic refinement.

Case presentation A 49-year-old woman presented with a headache and dysarthria. MRI revealed hyperintensity along the right central sulcus and fluid accumulation in the right frontal epidural space. Anti-NMDAR antibodies were detected in the cerebrospinal fluid (CSF), confirming the diagnosis of anti-NMDAR encephalitis. She was treated with steroids, intravenous immunoglobulin, plasma exchange, and cyclophosphamide, which resulted in a full recovery. Two years later, she presented with cerebellar symptoms and was diagnosed with PLML via a brain biopsy.

Results Atypical extraparenchymal brain lesions were present at disease onset. Despite successful initial treatment, the patient later developed PLML, suggesting a potential paraneoplastic relationship or immunological continuum between the two diseases.

Conclusions This case illustrates the diagnostic challenges posed by atypical neuroimaging findings in anti-NMDAR encephalitis and the need for a longitudinal follow-up. Clinicians should consider neoplastic etiologies when imaging or the clinical course deviates from the norm, even if anti-NMDAR antibodies are positive.

Patisiran is a disease-modifying RNA interference agent for ATTRv amyloidosis caused by transthyretin gene mutations. We herein report a case of hypothyroidism in a 70-year-old man with ATTRv amyloidosis after treatment with patisiran. Although his neurological function score did not deteriorate, non-pitting edema and weight gain appeared approximately 13 months after treatment, and blood tests revealed hypothyroidism. The symptoms and thyroid function improved after treatment with levothyroxine. This is the only case of hypothyroidism among 317 patients reported in a nationwide post-marketing surveillance study of patisiran. In ATTRv amyloidosis, long-term changes in thyloid function should be monitored regardless of the response to patisiran.

Anti-synthetase syndrome is an autoimmune disorder associated with anti-aminoacyl-tRNA synthetase antibodies, including anti-Jo-1. However, antibody positivity alone is insufficient for the diagnosis because overlapping features with other diseases may lead to a misdiagnosis. We herein report a 69-year-old woman initially suspected of having anti-synthetase syndrome due to anti-Jo-1 antibody positivity and muscle weakness. Additional findings, including mononeuritis multiplex, purpura, crescentic glomerulonephritis, and strongly positive myeloperoxidase-antineutrophil cytoplasmic antibodies, led to a diagnosis of microscopic polyangiitis. Although anti-Jo-1 antibodies are highly specific, false-positive results can occur. This case highlights the need for a comprehensive evaluation beyond antibody testing to avoid diagnostic errors.

Hyperuricemia is a common comorbidity of chronic kidney disease (CKD) and contributes to kidney dysfunction through mechanisms involving glomerular, tubular, and vascular injuries. Although hyperuricemia has traditionally been classified into overproduction and underexcretion types, recent evidence highlights the importance of intrarenal urate handling, particularly tubular reabsorption, in the pathogenesis of CKD. In this review, we revisit the physiology of renal urate transport and summarize the clinical evidence that links hyperuricemia to CKD progression. We also summarize the current evidence regarding urate-lowering therapies, mainly focusing on novel selective urate reabsorption inhibitors (SURIs) and kidney outcomes. Based on emerging data, we propose a refined classification of hyperuricemia in CKD that stratifies patients into glomerular under-filtration and tubular over-reabsorption subtypes using a novel index that integrates both glomerular filtration and tubular reabsorption. This new classification may better guide individualized treatment strategies for CKD patients with hyperuricemia.

We herein report 2 autopsied cases of intrathoracic undifferentiated/rhabdoid neoplasms showing rapid progress in patients who received immunosuppressive therapies for hematological diseases (Case 1, a 72-year-old man who underwent hematological cell transplantation for aplastic anemia; Case 2, a 77-year-old man who received chemotherapy for multiple myeloma). Both patients experienced progressive pulmonary effusion and died after three months and two weeks of follow-up, respectively. Autopsy revealed rhabdoid neoplasms infiltrating the alveolar spaces in both cases. Nuclear immunoreactivity for SMARCB1/INI1 was lost in Case 2. Clinicians and pathologists should consider the possibility of rapidly progressive neoplasms, such as intrathoracic undifferentiated/rhabdoid neoplasm, as a differential diagnosis for pneumonia in possible immunosuppressive conditions.

Atherosclerotic cardiovascular diseases, including ischemic heart disease (IHD), remain the leading cause of morbidity and mortality worldwide and are typically induced by the detrimental effects of risk factors on the cardiovascular system. Although some risk factors, such as age and sex, are non-modifiable, the identification and therapeutic interventions against standard modifiable cardiovascular risk factors (SMuRFs), namely hypertension, dyslipidemia, diabetes, smoking, and obesity, contribute to improved cardiovascular outcomes. Beyond SMuRFs, non-traditional, potentially modifiable risk factors for IHD have been identified, such as inflammation, lipoprotein (a), and air pollution. This review article summarizes recent clinical evidence regarding SMuRFs and non-traditional risk factors for IHD and atherosclerotic cardiovascular diseases.

This case report describes an 80-year-old man with severe immunoglobulin G4-related tubulointerstitial nephritis (IgG4-TIN), characterized by storiform fibrosis with diffuse lymphocytic and plasma cell infiltration observed on a renal biopsy. Steroid pulse therapy administered immediately after confirming a remarkable increase in urinary β2-microglobulin (100,948 μg/L) along with no evidence of malignancy significantly improved the renal function and reduced the urinary β2-microglobulin levels. This study highlights the potential utility of urinary β2-microglobulin as a biomarker for early treatment selection in severe IgG4-TIN and emphasizes the need for timely intervention to prevent irreversible kidney damage.

An 84-year-old woman undergoing hemodialysis for autosomal dominant polycystic kidney disease (ADPKD) was admitted for refractory hepatic cyst infection. Magnetic resonance cholangiopancreatography and contrast-enhanced computed tomography revealed a concurrent complication of Caroli disease, diagnosed by cystic dilatation of the intrahepatic bile duct and a central dot sign in the vicinity of the infected liver cyst. However, there was no traffic between the infected liver cyst and dilated bile duct, and the cyst drainage procedure was curative. In cases where both diseases were combined, it was suggested that two infections, cyst and biliary tract infections, could occur.

A 52-year-old woman with myalgia, anti-aminoacyl tRNA synthetase, anti-SS-A/Ro52 antibody positivity, and elevated creatine kinase levels was admitted to our hospital. She was diagnosed with Sjögren's disease (SjD) complicated by polymyositis (PM). No chest symptoms were observed. Although her electrocardiogram and echocardiogram findings were normal, cardiac magnetic resonance imaging (CMRI) revealed myocardial edema and fibrosis with late gadolinium enhancement, elevated extracellular volume, and elevated T2 values. After treatment with prednisolone, the myalgia and CMRI abnormalities improved. This case suggests that CMRI may be useful for the detection and treatment of subclinical myocardial damage in patients with SjD complicated by PM.

Hepatic ectopic adrenal glands are rare and can mimic hepatocellular carcinoma (HCC). We herein report a 60-year-old woman with a history of chronic hepatitis C who achieved a sustained virological response. A 23-mm hepatic lesion was detected and initially diagnosed as HCC. However, laparoscopic resection and histopathology confirmed the presence of an ectopic adrenal gland. Given the location of the posterior liver, a biopsy is challenging. Adrenal scintigraphy may aid in the diagnosis and reduce the need for invasive procedures. As more cases are reported, improved imaging-based diagnoses may facilitate noninvasive identification of hepatic ectopic adrenal glands, avoiding unnecessary surgical intervention.

The optimal endoscopic treatment for foveolar-type gastric tumors with raspberry-like appearance remains unclear. A 51-year-old man underwent endoscopic treatment for a 4-mm foveolar-type gastric tumor with a raspberry-like appearance. Because the patient preferred outpatient treatment, resection was performed using cold forceps polypectomy with jumbo forceps. Both the gross and pathological margins were negative, and the tumor was successfully resected without complications. This case suggests that cold forceps polypectomy with jumbo forceps may be a suitable and minimally invasive treatment for small foveolar-type gastric tumors with a raspberry-like appearance.

Objective Acute pleural empyema, defined as empyema diagnosed within three months of the onset, frequently affects patients with poor general health and often poses challenges for invasive treatments requiring general anesthesia. In addition, the number of respiratory surgeons was insufficient and unevenly distributed across urban base and core hospitals in Japan. Therefore, safe and effective therapeutic procedures that physicians can perform are required.

Methods We retrospectively analyzed 28 patients with acute pleural empyema who underwent decortication using medical thoracoscopy under local anesthesia (DMT-LA) in our department. All procedures were performed by respiratory physicians at our institution. The "success" of DMT-LA was defined by meeting all of the following criteria: (i) absence of residual clinically significant pleural effusion, (ii) resolution of clinical signs of sepsis, (iii) normalization of serum C-reactive protein (CRP) levels and white blood cell counts, (iv) no requirement for additional interventions, and (v) maintenance of these conditions for at least one month following antibiotic treatment.

Results Of the 28 patients, 21 met the criteria for success, yielding a success rate of 75.0%. Patients in the failure group were more likely to have an Eastern Cooperative Oncology Group-performance status of >3, stage III empyema, and high median serum CRP levels than those in the success group. Adverse events were observed in only one patient (3.4%) and involved prolonged sedative effects.

Conclusions DMT-LA is a safe and effective therapeutic procedure that can be performed by respiratory physicians and provides a viable treatment option for acute pleural empyema, particularly in facilities without respiratory surgeons.

A 62-year-old woman presented with jaundice and fatigue. A blood examination revealed markedly elevated serum transaminase and bilirubin levels and negative hepatitis virus markers. A radiographic examination revealed no bile duct abnormalities. Serum transaminase levels decreased and normalized without immunosuppression after transcatheter arterial embolization and splenectomy for spontaneous splenic rupture, respectively. The pathological findings of the liver biopsy specimens were consistent with those of acute-onset autoimmune hepatitis (AIH), despite normal serum IgG levels. The clinical course of the present case suggests that pathogenic immune responses associated with acute-onset AIH may arise in the spleen, but not in the liver.

Spontaneous regression (SR) of pancreatic neuroendocrine tumors (pNETs) is extremely rare. We herein report a 64-year-old man with a nonfunctioning pNET that was incidentally detected during an evaluation for back pain. Imaging showed a 30-mm mass in the pancreatic tail, but surgery was delayed because of an old myocardial infarction. Four months later, follow-up imaging revealed tumor shrinkage of 20 mm without treatment. Laparoscopic distal pancreatectomy confirmed a grade 3 pNET. While ischemia was considered, factors such as mild immune response or metabolic stress may have contributed. This case suggests that ischemia and other factors may also play a role. Further research is needed to elucidate the mechanisms underlying SR in NETs.

A 58-year-old woman with schizophrenia was transported to our hospital by ambulance due to impaired consciousness. At the time of the examination, the patient had significant abdominal distension and diabetic ketoacidosis associated with urinary retention. Although the symptoms improved with the insertion of a urinary catheter and glycemic control, the involvement of the antipsychotic olanzapine was considered the background to the pathophysiology of this case. We herein report the relationship between antipsychotic drugs, diabetic ketoacidosis, and urinary retention along with a literature review.

Aortic dissection (AD) is a rare but serious complication of transcatheter aortic valve implantation (TAVI) and should be considered in the differential diagnosis of acute kidney injury (AKI). We herein report an older man who developed AKI secondary to Stanford type B AD after transfemoral TAVI. Non-contrast computed tomography (CT) revealed inward displacement of the calcified intima, which is a key early finding. Contrast-enhanced CT confirmed AD extending to the renal artery. As endovascular intervention was not feasible, conservative management was selected. Nephrologists should recognize AD as an important cause of AKI following TAVI and carefully assess CT images for early subtle signs.

Objective Patients with acute myeloid leukemia (AML) transformed from myelodysplastic syndrome (MDS) have a poor prognosis, including those treated with azacitidine during the MDS phase; there is no standard for the care of these patients. Recently, azacitidine plus venetoclax (AZA/VEN) was reported to prolong the survival in treatment-naïve AML patients compared with AZA monotherapy. However, the results of AZA/VEN for AML transformed from MDS, particularly after AZA monotherapy, remain unclear. The present study therefore compared the clinical results of AZA/VEN treatment in these patients.

Methods and Patients Data from MDS patients diagnosed at 10 institutions in Nagasaki Prefecture were collected. Thereafter, patients with transformed AML following AZA monotherapy during the MDS phase were selected, and their treatment response and survival were analyzed.

Results The overall response (OR) rate, overall survival (OS), and event-free survival (EFS) were compared among patients treated with AZA/VEN (n=13), chemotherapy (intensive and low-intensity, n=35), AZA monotherapy (mAZA, n=15), and best supportive care (BSC, n=43) after AML transformation. The corresponding OR rates were 38.5%, 20.0%, and 6.7% for the AZA/VEN, chemotherapy, and mAZA groups, respectively (p=0.235). The respective median OS and EFS were 10.7 and 8.9 months for AZA/VEN, 3.2 and 2.0 months for chemotherapy, and 3.8 and 2.7 months for mAZA, and 1.7 months for BSC (OS only) (p=0.000023 for the OS and p=0.026 for the EFS),

Conclusion Our findings suggest the superiority of AZA/VEN for AML patients with transformation from MDS following AZA monotherapy.

Introduction Immunoglobulin A nephropathy (IgAN) is a common glomerular renal disease presenting with mesangial cell proliferation and mesangial matrix hyperplasia and is typically treated with oral glucocorticoids. However, the clinical presentations and treatment strategies for certain cases of oral glucocorticoid-resistant IgA nephropathy have not been established.

Clinical Presentation We herein report a case of recurrent IgA nephropathy presenting with nephrotic syndrome and membranoproliferative glomerulonephritis-pattern lesions. A 42-year-old woman presented to our clinic 22 years ago after urinary occult blood was detected during a health examination, leading to a diagnosis of IgA nephropathy based on a renal biopsy. Although temporary remission was achieved with oral glucocorticoid therapy, the relapse occurred repeatedly. Eight years ago, she underwent a third renal biopsy, which revealed grade II (C) and Oxford classification M1E0S1T0 findings. Temporary remission was achieved following tonsillectomy and steroid pulse therapy. Subsequently, she presented with nephrotic syndrome and rapidly increasing urinary protein levels. A fourth renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) pattern lesions that were not previously observed. The administration of cyclosporine and corticosteroids after steroid pulse therapy led to complete remission.

Conclusion In cases of recurrent IgA nephropathy complicated by nephrotic syndrome, MPGN-pattern lesions may underlie this condition. In these cases, both corticosteroids and additional cyclosporine may be effective.

Established fibrosis in pulmonary sarcoidosis is typically not progressive. However, progressive fibrosis similar to interstitial pneumonia occasionally occurs. We herein report a 49-year-old woman who was histologically diagnosed with sarcoidosis. She also had honeycomb-like manifestations in the lower lobes that resembled idiopathic pulmonary fibrosis on computed tomography, whereas pathological findings of a surgical lung biopsy suggested interstitial lung disease associated with rheumatoid arthritis. However, the patient did not develop clinical rheumatoid arthritis even after 17 years of follow-up. Notably, she showed progressive fibrosis and was treated with anti-fibrotic therapy. It is thus important to recognize progressive fibrosis in pulmonary sarcoidosis, although it is rare.

Objective This retrospective study assessed the longitudinal prognostic accuracy of the MELD, MELD-Na, MELD 3.0, and Child-Pugh scores in predicting mortality and rebleeding risk in patients with liver cirrhosis (LC) following successful endoscopic hemostasis for acute variceal hemorrhaging (AVH).

Methods Time-dependent receiver operating characteristics and survival analyses were performed to predict mortality. The risk of rebleeding was analyzed using a competing risk model.

Patients or Materials A total of 168 patients with LC who underwent successful endoscopic treatment, including ligation and sclerotherapy for AVH of the esophagus or stomach, were included.

Results The MELD 3.0, which demonstrated the highest accuracy for predicting mortality, had an average area under the curve of 0.789, remaining above 0.8 for up to 18 months. The survival rate was significantly worse in the high-MELD group (3.0) than in the low-MELD group (3.0), with a hazard ratio (HR) of 3.23 and a shorter median survival time of 113 days versus 1,750 days. Advanced hepatocellular carcinoma and the need for red blood cell transfusion were also independent risk factors for mortality. A high MELD-Na level was the only factor associated with an increased risk of rebleeding (HR, 2.07), and the cumulative rebleeding rate was significantly higher in the high-MELD-Na group than in the low-MELD-Na group.

Conclusion MELD 3.0 and MELD-Na serve as reliable non-invasive tools for predicting the long-term mortality and rebleeding risk after AVH. These scores can aid in clinical decision making, enabling the early identification of high-risk patients for targeted interventions and closer monitoring.

Alemtuzumab-based conditioning for allogeneic hematopoietic stem cell transplantation (allo-HSCT) effectively reduces graft rejection but may predispose patients to autoimmune complications. We herein report a 30-year-old man with severe aplastic anemia who developed thyroid storm due to autoimmune thyroiditis 6 months after undergoing allo-HSCT with an alemtuzumab-based regimen. Despite prompt engraftment, mixed T-cell chimerism and insufficient immune regulation may have contributed to the early onset and severity of the thyroid storm. Careful monitoring of the thyroid function and immune chimerism might facilitate the early detection and management of post-transplant autoimmune complications, including thyroid storm, in patients receiving alemtuzumab-based conditioning.

Hashimoto's encephalopathy (HE) is a type of encephalopathy characterized by neuropsychiatric symptoms, high serum anti-thyroid antibody concentrations, and good responsiveness to immunotherapy. We herein report a rare case of HE with positive serum anti-NH2 terminal of α-enolase (NAE) antibodies and abnormal findings in the bilateral basal ganglia on brain magnetic resonance imaging (MRI). In cases presenting with isolated lesions in the basal ganglia, HE should not be excluded from the differential diagnosis, particularly when other causes are excluded and serum anti-thyroid antibodies are elevated. In such cases, testing for anti-NAE antibodies may aid in the diagnosis.

Afatinib is a second-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor approved for the treatment of non-small-cell lung cancer. We herein report a 61-year-old woman who developed dyspnea and ventricular tachycardia (VT) after afatinib treatment for lung adenocarcinoma. Following restoration of sinus rhythm with continuous amiodarone infusion, echocardiography and cardiac computed tomography revealed Takotsubo-like left ventricular wall motion abnormalities. Unfortunately, the patient's cardiac function did not improve, and she developed circulatory failure, which resolved on day 3 of hospitalization. Takotsubo-like cardiac dysfunction and VT should be recognized as potential side effects of afatinib.

Objective Sex differences in fasting glucose levels or the prevalence of impaired fasting glucose (IFG) have been observed in various populations and ethnic groups, suggesting potential variations in the pathophysiology of diabetes between men and women. However, limited research has focused on sex disparities in fasting glucose levels among non-diabetic Asian populations. This cross-sectional study investigated sex differences in fasting glucose levels among non-diabetic Japanese individuals who underwent the 75-g oral glucose tolerance test (OGTT).

Methods The population analyzed comprised 176 men and 185 women, all of whom were Japanese without diabetes. Individuals with diseases or medications that affect glucose metabolism were excluded from the study. Fasting glucose and insulin levels were measured after a 12-h fast and during a 75-g OGTT. Subcutaneous and intra-abdominal fat areas were assessed using computed tomography. A multiple linear regression analysis was used to evaluate the association between sex and fasting glucose levels after adjusting for potential confounders.

Results There were significantly more isolated IFG in men than in women, and men had significantly higher fasting glucose levels than women. The association between sex and fasting glucose remained significant, even after adjusting for the age, BMI, intra-abdominal fat area, subcutaneous fat area, intra-abdominal fat area/subcutaneous fat area ratio, insulinogenic index, homeostasis model assessment for insulin resistance (HOMA-IR), and 2-h glucose.

Conclusion Among non-diabetic Japanese, the fasting glucose level was statistically significantly higher in men than in women, suggesting potential sex-specific variations in glucose metabolism. This sex difference was independent of the fat distribution, insulin secretion, and insulin sensitivity.

Objective The present study investigated the various clinical effects of dapagliflozin in chronic kidney disease (CKD) and its efficacy in patients with advanced renal dysfunction.

Methods A total of 94 CKD cases (non-diabetic, 58; diabetic, 36) were treated with dapagliflozin (10 mg) in an outpatient setting for 12 months. The estimated glomerular filtration rate (eGFR) was measured during the 12 months before and after, with laboratory findings determined at the baseline and at 12 months after dapagliflozin administration. In addition, the annual decrease in the eGFR (eGFR slope) was compared before and one year after the baseline readings, and the eGFR slope values before and after dapagliflozin administration in 34 rapid decliner cases with an eGFR slope >5 mL/min/1.73 m²/year before dapagliflozin administration and 19 cases with an eGFR <25 mL/min/1.73 m² at baseline were compared.

Results The body mass index, blood pressure, uric acid, and urine protein-to-creatinine ratio significantly decreased, and hemoglobin levels significantly increased after dapagliflozin administration. There was a significant increase after administration in the mean eGFR slope of all cases, rapid decliners, and cases with an eGFR <25 mL/min/1.73 m² at baseline (all p<0.001). Furthermore, there was a higher ratio of improvement in the eGFR slope in 39 patients who underwent multidisciplinary care within 1 year of dapagliflozin administration.

Conclusion Dapagliflozin is effective in preventing renal function decline in patients with rapidly worsening or advanced CKD, with the effect further enhanced after combination with multidisciplinary care.

There are no established guidelines for managing patients with rare but fatal ruptured splenic abscesses. In this clinical scenario, open splenectomy seems to be a standard literature-based intervention. However, open splenectomy under general anesthesia is not a priority in high-risk surgical patients. We herein report an endoscopic ultrasound-guided transmural dual drainage combined with lavage and intermittent negative pressure drainage as an alternative to surgery for a critical patient with a ruptured splenic abscess and discuss the benefits and drawbacks of open splenectomy as a case report and literature review.

Background and objective Endobronchial ultrasound with a guide sheath (EBUS-GS) is used to accurately position a bronchoscope in lung lesions using a guide sheath. Previous studies have focused on diagnostic success as the endpoint. The achievement of 'within' defined as reaching the lesion, is considered crucial in EBUS-GS procedures. This study investigated cases wherein 'within' is likely to be achieved and cases that can be diagnosed after achieving 'within'.

Methods This retrospective study evaluated 258 bronchoscopic examinations using EBUS-GS. We analyzed the relationship between patient background, lesion size and characteristics, achieving 'within', definitive diagnosis after achieving 'within', and complications.

Results and Conclusion A multivariate analysis revealed that lesion size ≥20 mm (odds ratio 12, 95% confidence interval [CI]: 6.0-21, p<0.01) and lesions with solid components (odds ratio 13, 95% CI: 1.3-120, p=0.03) were associated with achieving 'within'. For cancer cases, lesion size ≥20 mm was associated with a higher diagnostic rate following achieving 'within' than smaller lesions (odds ratio 4.23, 95% CI: 1.38-12.9, p=0.01). The occurrence of complications was linked to lesion size ≥20 mm (odds ratio 2.7, 95% CI: 1.02-6.9, p=0.045). The factors associated with 'within'-achieving bronchoscopy via EBUS-GS included lesion size ≥20 mm and solid components. Larger lesions were associated with a definitive diagnosis. Lesion size was a determinant in improving diagnostic rates, both for achieving within and for successful diagnosis after achieving 'within'.

Despite antiviral administration, a small number of patients still suffer from prolonged and severe COVID-19 owing to excessive inflammation. Traditional Kampo medicines (TKMs) with a heat-clearing effect have anti-inflammatory effects, such as a reduced NF-κB activity, and rarely cause serious side effects when administered for a short period of time. After oral administration, TKMs interact with the gut microbiota, producing two types of metabolites: metabolites from the gut microbiota (of food and host origin) and TKM compounds transformed by the gut microbiota. Both metabolites decreased the levels of pro-inflammatory cytokines. TKM compounds transformed by the gut microbiota may exhibit superior bioavailability compared with their precursors. In this review, we assessed the mechanism by which bioactive substances with anti-inflammatory effects, such as berberine, baicalin, saikosaponin, kaempferol, and short-chain fatty acids, are effective in treating respiratory symptoms after COVID-19 infection.