Objective This study investigated the frequency and risk factors of acute liver injury (ALI) and the association between ALI and treatment in hospitalized patients with coronavirus disease 2019 (COVID-19).

Methods This was a single-center retrospective study of 631 hospitalized patients ≥18 years old who were diagnosed with COVID-19 and received treatment between July 1, 2020, and January 31, 2024. Demographic and clinical data were extracted from the electronic medical records. ALI was defined according to the consensus guidelines of the Asia Pacific Association of the Study of Liver. Patients were divided into two groups according to the presence of ALI to assess the risk factors for the occurrence of ALI.

Results Seventy-six patients (12.0%) developed ALI. Seven patients discontinued remdesivir owing to hepatic impairment, and only 1 patient (0.2%) had an increase in alanine aminotransferase (ALT) ≥10 times the upper limit of normal. ALI was associated with men (odds ratio [OR]=3.052, 95% confidence interval [CI]=1.456-6.398), a higher WHO ordinal scale score at admission (OR=1.408, 95% CI=1.036-1.912), higher ALT level at admission (OR=1.017, 95% CI=1.009-1.024), tocilizumab administration (OR=2.788, 95% CI=1.372-5.666), the absence of diabetes (OR=0.456, 95% CI=0.226-0.922) and the absence of dyslipidemia (OR=0.244, 95% CI=0.083-0.723). In the comparison of the propensity score-matched groups, neither remdesivir nor tocilizumab administration was associated with ALI.

Conclusion Men, severe COVID-19, and elevated ALT levels at admission were significantly associated with an increased risk of ALI in patients treated for COVID-19. ALI may have been associated with tocilizumab administration but not with remdesivir administration.

Hyponatremic hypertensive syndrome (HHS) is a rare disorder, particularly in adults. A 76-year-old woman presented with vomiting and severe hyponatremia. The patient had been hospitalized four times over the past four years due to hyponatremia and recurrent vomiting. On admission, magnetic resonance angiography revealed left renal artery stenosis, which led to a diagnosis of HHS. Treatment with enalapril followed by tolvaptan improved the patient's condition, without the need for renal artery angioplasty. HHS should therefore be considered in patients with hyponatremia, hypertension, or recurrent vomiting. In addition to angiotensin-converting enzyme inhibitors and renal artery angioplasty, tolvaptan may also be a new effective treatment option for HHS.

Objective Lusutrombopag is recommended for severe thrombocytopenia (<5.0×10⁴/μL) in patients with chronic liver disease who are scheduled to undergo invasive procedures. However, reports on the efficacy of repeated lusutrombopag dosing are scarce. It is also not known whether lusutrombopag causes the platelet count to exceed 5.0×10⁴/μL. We evaluated the efficacy of repeated lusutrombopag dosing and the efficacy of the platelet prediction simulation software program.

Methods We evaluated the number of platelet elevations according to the number of lusutrombopag administrations. We also evaluated the correlation between the highest software-predicted platelet count and the platelet count measured in actual clinical practice.

Patients This retrospective study included 236 patients treated with lusutrombopag at 11 medical institutions in Japan.

Results The platelet count increased with the number of lusutrombopag administrations (1, 2, 3, 4, >4) in all groups, and no significant difference was found among the groups (p = 0.169). In all groups, the platelet counts reached their highest levels at 8-14 days after treatment with lusutrombopag (p = 0.243). There was a correlation between the highest software-predicted platelet count and the platelet count measured in actual clinical practice in all dose frequency groups; however, the correlation was the strongest in the one-dose group (r = 0.74, p <0.0001).

Conclusion Frequent lusutrombopag administration is therefore both effective and safe, and a platelet prediction simulation software program is thus considered to be useful in practice.

Objective Anemia frequently complicates cardiovascular disease (CVD) and is associated with high mortality rates. A bioelectrical impedance analysis (BIA) is a noninvasive method for measuring human body composition. A direct association between serum hemoglobin (Hb) levels and the extracellular water-to-total body water (ECW/TBW) ratio, as measured by a BIA in patients with diabetes, has been reported. However, the predictive value of the ECW/TBW ratio for detecting anemia in patients with CVD has not been fully elucidated.

Methods We conducted a study involving consecutive patients admitted to our cardiology department from January 1, 2021, to December 31, 2022. A BIA was performed once during hospitalization for all patients, whenever possible. The correlation between the Hb level and ECW/TBW ratio was assessed. The predictive accuracy for anemia was evaluated using a receiver operating characteristic (ROC) curve analysis.

Results The ECW/TBW ratio was significantly higher in the anemia group than in the non-anemia group (0.41 [0.40, 0.41] vs. 0.39 [0.38, 0.40], p<0.001). The ECW/TBW ratio exhibited a significant negative correlation with Hb, with an R value of 0.57 and a p-value of <0.01. However, this correlation coefficient decreased to 0.45 among subjects with BNP levels ≥200 pg/mL. The area under the ROC curve (AUC) for the ECW/TBW ratio for detecting anemia was 0.83. However, its predictive performance decreased in patients with BNP levels exceeding 200 pg/mL, with an AUC of 0.71.

Conclusion The BIA-derived ECW/TBW ratio is a valuable predictor of anemia in patients with CVD, provided BNP levels are not elevated.

Kabuki syndrome is a rare genetic disorder that causes multiple congenital anomalies, including characteristic facial features reminiscent of Kabuki syndrome. It is often associated with congenital anomalies of the kidneys and urinary tract as well as immune abnormalities. While various autoimmune diseases have been reported in patients with this syndrome, only one case of membranoproliferative glomerulonephritis has been documented. We herein report a case of Kabuki syndrome in which immunoglobulin A nephropathy developed in a renal allograft, which subsequently improved with the administration of pulse steroids and an angiotensin II receptor blocker.

A 60-year-old man who developed rhabdomyolysis and severe acute kidney injury (AKI) after the fourth COVID-19 mRNA vaccination, necessitating renal replacement therapy (RRT). The patient presented to the hospital two days post-vaccination with muscle pain in both lower extremities and anuria. Diagnostic tests revealed elevated creatinine kinase (CK) levels of 160,000 IU/L and serum creatinine levels of 6.59 mg/dL, confirming AKI due to rhabdomyolysis. Intravenous therapy was ineffective, leading to the utilization of online hemodiafiltration. Following treatment, CK levels normalized, and the renal function fully recovered.

Evans syndrome (ES) is characterized by the development of autoimmune hemolytic anemia and immune thrombocytopenic purpura and is often linked to autoimmune diseases, such as systemic lupus erythematosus (SLE). Standard treatment includes prednisolone and intravenous immunoglobulin; however, relapse commonly occurs when prednisolone is tapered or stopped. Rituximab is increasingly used for refractory ES with SLE, although its efficacy in new-onset cases remains unclear. We herein report a 67-year-old woman with new-onset ES and SLE with lupus nephritis class IV-G whose condition improved with rituximab after prednisolone, hydroxychloroquine, and mycophenolate mofetil. The patient remained relapse-free for one year, suggesting that rituximab is a potentially viable first-line therapy.

Recently, several Japanese patients have developed interstitial nephritis or acute tubular injury/necrosis, both accompanied by Fanconi syndrome, after consuming a specific red yeast rice supplement. In most cases, the renal function did not fully recover even after discontinuation of supplements and glucocorticoid treatment. A 52-year-old woman developed interstitial nephritis and Fanconi syndrome after receiving supplements. A renal biopsy revealed mild lymphocytic infiltration. Her renal function recovered after discontinuing the supplement without glucocorticoids. The supplement was contaminated with puberulic acid, a known cause of tubular necrosis; however, the cause of interstitial nephritis remains uncertain. Biopsy findings guided the decision to avoid glucocorticoids.

Birt-Hogg-Dubé syndrome (BHDS) is an autosomal dominant disease caused by germline folliculin (FLCN) mutations and it is characterized by skin folliculomas, pulmonary cysts, and renal cell carcinomas (RCC). We herein report the first case of a female patient with BHDS who was diagnosed with multiple myeloma. Daratumumab-based treatment was effective, and the patient remained responsive for over three years. Whole-exome sequencing confirmed an FLCN germline mutation and nine somatic mutations, including an MPDZ mutation, which is a component of the tumor-suppressive Hippo-YAP pathway. Considering the reported association between the Hippo-YAP pathway and RCC with BHDS, an MPDZ mutation may contribute to carcinogenesis in patients with BHDS.

Objective High-dose methotrexate (HD-MTX) is widely used as central nervous system (CNS) prophylaxis in patients with diffuse large B-cell lymphoma (DLBCL) who are at a high risk of CNS relapse. Ensuring safe prophylactic administration with minimal adverse events is a key concern; however, few studies have detailed the safety profile of HD-MTX prophylaxis in patients with high-risk DLBCL. We analyzed the adverse events associated with HD-MTX in this population, focusing on delayed MTX elimination.

Methods This multicenter retrospective study included 98 patients with DLBCL at high risk of CNS relapse who received HD-MTX as part of frontline therapy between 2014 and 2020. CNS prophylaxis involved 2 cycles of HD-MTX (3.0 g/m²) at 2-week intervals.

Results The median age at the diagnosis was 63 (34-84) years old, and 34 patients received a reduced methotrexate (MTX) dose. The overall incidence of delayed MTX elimination was 18.4%. No cases of delayed MTX elimination were observed in the group that received a 3-h MTX infusion (n=50). Toxicities were more frequent in patients with delayed MTX elimination than in those without (77.8% vs. 26.2%, p≤0.05), including higher incidences of grade ≥3 adverse events and grade ≤2 renal dysfunction.

Conclusion Delayed MTX elimination is associated with increased complications. Shorter MTX infusion rates, particularly at 3 h, may reduce the risk of delayed MTX elimination.

Biologics against interleukin-5 were administered to five patients with eosinophilic gastroenteritis (EGE) and bronchial asthma (BA). BA and abdominal symptoms as well as changes in steroid dose and the blood eosinophil count were examined. The man-to-woman ratio was 1:4. The average age of onset was 63 years old. The duration of the disease was three to nine years. Four patients showed improved BA symptoms with mepolizumab or benralizumab, and three successfully discontinued steroids. Regarding abdominal symptoms, mepolizumab was effective in one of three cases, while benralizumab improved symptoms in three of four cases. Biologics targeting interleukin-5 are effective in some patients with EGE accompanied by BA.

Cutaneous arteritis (CA) is a rare cutaneous manifestation of Crohn's disease. A 50-year-old woman with a 15-year history of CA was admitted to our hospital with a fever, abdominal pain, and hematochezia. Based on these symptoms and increased C-reactive protein levels, systemic vasculitis was considered. However, emergency colonoscopy revealed multiple longitudinal ulcers throughout the colon, thus suggesting Crohn's disease. Prednisolone (60 mg/day) was administered intravenously. A histopathological examination of the biopsied colonic mucosa revealed epithelioid granulomas, which confirmed the diagnosis of Crohn's disease. Because the systemic evolution of CA is rare, other comorbidities should be considered when patients with CA experience systemic manifestations.

Endoscopic ultrasound-guided pelvic abscess drainage (EUS-PAD) has emerged as a viable alternative to percutaneous drainage (PCD). However, reports of this method are limited to procedures associated with transrectal access. We herein present the first case of successful transvaginal EUS-PAD in a 22-year-old female who developed a pelvic abscess after undergoing a cesarean section. An ultrasound endoscope was inserted transvaginally to visualize the abscess. Puncture and dilation were performed and a 7 Fr endoscopic nasobiliary drainage (ENBD) tube was put in place. The patient showed a rapid improvement after the procedure and was discharged without any complications. This case report highlights the efficacy and safety of transvaginal EUS-PAD as a viable option for performing pelvic abscess drainage.

We report the case of a 62-year-old man who presented with bilateral adrenal enlargement and systemic lymphadenopathy. Imaging and clinical findings led to the diagnosis of bilateral adrenal hemorrhage. Bone marrow aspiration and lymph node biopsy confirmed TAFRO syndrome, which met the established diagnostic criteria. Although adrenal hemorrhage in TAFRO syndrome is exceedingly rare, this case is unique, as it represents the first reported instance of massive bilateral adrenal hemorrhage with confirmed progression. This case underscores the need for awareness regarding this potential complication of TAFRO syndrome.

A 48-year-old man with Fisher syndrome was admitted to our hospital for amino acid-containing peripheral parenteral nutrition. On day 19 of his hospital stay, he became febrile and Bacillus cereus was isolated from blood cultures. Vancomycin was administered, and the entire infusion set was replaced. The cultures were prepared from the infusion set. B. cereus was detected in several connectors and hubs, although catheter tip culture was negative. Echocardiography revealed cephalic venous thrombophlebitis. In cases with no improvement despite effective antibiotic use, clinicians should consider the possibility that the infusion set might have become contaminated.

Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome that results from tumors that secrete fibroblast growth factor 23 (FGF23). This leads to chronic hypophosphatemia. Burosumab, an anti-FGF23 antibody, is an effective treatment when surgery is not possible; however, it complicates FGF23 measurements and postoperative monitoring. We describe the first case report of TIO in which the responsible tumors were discovered during burosumab therapy and successfully resected. Despite tumor removal, the serum FGF23 levels remained elevated. In the postoperative monitoring of patients treated with burosumab, physicians should focus on the serum and urine levels of phosphate rather than FGF23.

Although there have been several reports of drug-induced pneumonitis caused by herbal medicines in recent years, herbal medicine-induced diffuse alveolar hemorrhage (DAH) is rare. We herein report two cases of DAH associated with herbal medicines. Patient 1 developed dyspnea and hemoptysis after receiving jidabokuippo. Patient 2 developed a fever and dyspnea after taking otsuji-to. Both patients exhibited severe respiratory failure, and bronchoalveolar lavage revealed bloody fluid that confirmed the diagnosis of DAH. In both patients, discontinuation of herbal medicines and corticosteroid therapy resulted in significant improvement. These cases highlight the potential risks of DAH associated with herbal medicines.

Diagnosing sarcoid neuropathy (SN) can be difficult because of its nonspecific symptoms and requirement for histological confirmation. We herein report a 71-year-old woman who presented with distal muscle weakness and paresthesia. Nerve conduction studies support the existence of polyneuropathy. Nerve ultrasonography revealed enlargement of the sural nerve and loss of the normal "honeycomb" appearance. In addition, increased intraneural blood flow within the nerve and small saphenous vein wall thickening were observed. These ultrasound findings led to a successful nerve biopsy confirming SN. Steroid therapy has resulted in clinical and ultrasonographic improvements. These results suggest the potential utility of ultrasound for diagnosing and monitoring SN.

Objective The respiratory rate (RR) can be monitored continuously using a HiSanso^®i, a stationary oxygen concentrator with a built-in respiratory sensor. To examine the efficacy of this device, we compared its performance with that of polysomnography in inpatient settings and the home sleep apnea test (HSAT) in residential settings for patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD).

Methods The oxygen flow rate was set at 1, 3, and 5 L/min in inpatient settings and 1-3 L/min (conditions similar to the home surroundings) in residential settings. Intraclass correlation coefficients (ICCs) (2,1) were calculated to determine the agreement between the RR measured with the HiSanso^®i and that measured with polysomnography or the HSAT. The minimum acceptable reliability level is 0.7.

Results In total, 14 (10 with ILD and 4 with COPD) and 5 (all with ILD) patients were assessed in inpatient and residential settings, respectively. In inpatient settings, the detection rate of patients' respiration measured with the HiSanso^®i was 77.0% and 73.3% in patients with ILD and COPD, respectively. At oxygen flow rates of 1, 3, and 5 L/min, the ICCs (2,1) were 0.91, 0.85, and 0.91, respectively, for patients with ILD and 0.96, 0.90, and 0.74, respectively, for patients with COPD. In residential settings, the detection rate of patients' respiration measured with the HiSanso^®i was 86.6%, and the ICC (2,1) was 0.97.

Conclusion The HiSanso^® accurately monitored the RR without any additional devices, independent of oxygen flow rates or disease status.

Myasthenia gravis (MG) is an autoimmune disease characterized by muscle weakness caused by antibodies targeting acetylcholine receptors (AChRs) or muscle-specific kinases (MuSK). Double-seropositive MG (DSP-MG) caused by both antibodies is rare. We herein report a 78-year-old woman who developed DSP-MG after COVID-19 infection. She presented with neck muscle fatigue and upper-limb weakness. Elevated levels of anti-AChR and anti-MuSK antibodies were detected. The patient responded well to the immunosuppressive therapy. This case highlights the potential for various autoimmune neurological conditions post-viral infection and the significance of prompt recognition and treatment.

Advancements in immunotherapy, the phenomenon of hyperprogression in cancer patients, have garnered increasing attention. We herein report a case of acute adult T-cell leukemia/lymphoma (ATL) that developed after administration of the PD-L1 inhibitor durvalumab in a patient with lung cancer. Although the patient was a carrier of human T-cell leukemia virus type 1 (HTLV-1), this was unknown prior to durvalumab treatment. HTLV-1 bZIP factor was detected in formalin-fixed lymph node tissue, confirming the diagnosis of ATL. Our findings suggest a potential association between immune checkpoint inhibition and ATL development in HTLV-1 carriers.

A 47-year-old man with a family history of juvenile dementia in his mother presented with memory loss and cognitive decline. Neuropsychological tests revealed impaired orientation, working memory, and apraxia. Magnetic resonance imaging revealed diffuse brain atrophy, and fluorodeoxyglucose positron emission tomography (PET) showed hypometabolism in the bilateral parietal lobes, posterior cingulate gyri, and precuneus, suggestive of Alzheimer's disease. However, amyloid-beta and tau PET scans were negative. Genetic testing revealed an abnormal repeat insertion in the prion protein gene, confirming inherited prion disease. This case highlights the need to consider inherited prion disease in the differential diagnosis of early-onset familial dementia.

The efficacy of the anti-influenza drugs was examined before and after the 2009 H1N1 pandemic. Anti-influenza drugs reduce the viral load, which leads to improvement of symptoms, a reduced illness period, suppression of complications, and protection from transmission. It is desirable to administer antiviral drugs within 48 hours of the onset of symptoms. The use of antiviral drugs is limited mainly to individuals who are hospitalized, those who have severe, complicated, or progressive illness, or those who are at high risk for influenza complications in Western countries. On the other hand, the rapid diagnosis of influenza and treatment with antiviral drugs have been effective in Japan, leading to the suppression of worsening symptoms. Baloxavir, the newest anti-influenza drug, and neuraminidase inhibitors are recommended for use in adult patients.

Variable vessel vasculitis is a rare presentation of systemic vasculitis. We herein report a Japanese woman with large- and small-vessel vasculitis accompanied by basal cell carcinoma. The clinical course of our patient suggested paraneoplastic variable vessel vasculitis. Our case suggests that there are two aspects that need to be considered. First, clinicians should consider cancer-related complications when treating variable-vessel vasculitis. Second, the evaluation of variable vessels is needed when treating paraneoplastic vasculitis.

With its increasing incidence, lung cancer has become one of the leading causes of cancer-related deaths worldwide, posing a great threat to the health and lives of patients. Due to varying economic and cultural backgrounds, there are significant differences in clinical treatment practices and related basic research on lung cancer between China and Japan. These differences are mainly reflected in many aspects, such as cancer prevention, cancer treatment, provision of medical insurance, patient compliance, medical education system, and sources of research funding. By understanding these differences, China and Japan can learn from each other, make progress together, and strengthen further exchanges and cooperation, which will help improve the long-term efficacy of lung cancer treatment and improve patients' clinical outcomes.

Anti-synthetase syndrome (ASyS) is a subset of idiopathic inflammatory myopathies characterized by a triad of myositis, interstitial lung disease, and arthritis. Patients with ASyS are generally treated with glucocorticoids, immunosuppressants, or both. We encountered a 53-year-old woman who developed anti-OJ autoantibodies-positive anti-synthetase syndrome following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and Cov-2 messenger RNA (mRNA) vaccination. Her dyspnea and rash resolved within 4 weeks of the initial examination, achieving spontaneous remission without treatment 52 weeks after the diagnosis. This case suggests a potential association between SARS-CoV-2 infection, mRNA vaccination, and the transient development of anti-OJ antibodies-positive ASyS.

An 80-year-old woman presented with the sudden onset of vertigo and vomiting and was diagnosed with acute cerebellar infarction. Twelve days after the onset, she experienced positional vomiting, predominantly in the lying-down position, triggered by postural changes with immediate or delayed onset. Over 1 month, 23 episodes of vomiting occurred. Brain computed tomography revealed edema in the infarcted area, fourth ventricular outlet compression, and lateral ventricular enlargement. These findings suggest that fluctuations in intracranial pressure are associated with intermittent obstructive hydrocephalus exacerbated by the patient's posture. This case highlights the importance of considering postural triggers in patients with recurrent vomiting associated with cerebellar infarctions.

We herein report a case of acute kidney injury and Fanconi syndrome associated with a red yeast rice supplement. A 72-year-old woman's serum creatinine rose from 0.7 to 3.97 mg/dL after starting the supplement, accompanied by metabolic acidosis, proteinuria, hematuria, and glucosuria. A kidney biopsy showed proximal tubular injury without abundant tubulitis. Immunostaining showed dilated tubules that were positive for CD10, confirming proximal tubule localization. Discontinuation of the supplement and steroid pulse therapy improved the patient's condition. This case highlights the health risks associated with unregulated dietary supplementation.

Approximately 20% of patients with Takotsubo syndrome (TTS) develop complications such as left ventricular outflow tract obstruction (LVOTO). The published data suggest that a significant proportion of these patients have predisposing septal hypertrophy or sigmoid septum. However, the pathophysiology regarding this connection has not yet been fully elucidated. We herein present the case of a 75-year-old female patient with TTS complicated by LVOTO, which was successfully managed. During the follow-up, mild basal septal hypertrophy was observed. Subsequent exercise and dobutamine stress echocardiography were performed to reveal the mechanism of LVOTO in TTS.

Objective We conducted a prospective, randomized controlled, open-label study to investigate the efficacy of a combination of cyclosporine and low-dose prednisolone in patients with idiopathic membranous nephropathy (IMN).

Methods We recruited biopsy-proven IMN patients with nephrotic syndrome who had never been treated with immunosuppressants. The patients were randomized into 2 groups treated after randomization with cyclosporine (3 mg/kg/day) alone or with an oral low-dose corticosteroid (prednisolone 15 mg/day) for 24 months.

Results We recruited 30 patients with IMN and nephrotic-range proteinuria, 28 of whom were included in this study. Fourteen patients were randomized for treatment with only cyclosporine (Group A), and 14 were randomized for treatment with cyclosporine plus low-dose corticosteroids (Group B). Cyclosporine monotherapy induced remission in 12 of the 14 patients in Group A, including partial remission in 7 patients (50.0%) and complete remission in 5 patients (36.7%). In Group B, 12 of 14 patients achieved proteinuria remission, including 11 (78.6%) with complete remission and 1 (7.1%) with partial remission. Although there was no marked difference in the overall remission rate, the complete remission rate was significantly higher in Group B than in Group A (p=0.02). Furthermore, there was a statistically significant difference between the groups in the time from the start of the study to complete remission (10.2±7.8 months in Group A; 9.5±6.1 months in Group B, p=0.03).

Conclusion The combination of cyclosporine and low-dose corticosteroid treatment is an effective and important option in the management of patients with IMN with nephrotic-range proteinuria, either as an initial therapy or as a long-term treatment.

Objective Short-acting β₂ agonists (SABAs) are key drugs for the treatment of asthma and chronic obstructive pulmonary disease (COPD). A high-flow nasal cannula (HFNC) is widely used for respiratory failure. Recently, a consensus statement on inhalation therapy with HFNC has been published. However, information regarding the real-world state of inhalation therapy practices in Japan is lacking.

Methods An anonymous online questionnaire survey endorsed by three Japanese associations (the Japanese Respiratory Society, Japanese Society of Intensive Care Medicine, and Japanese Society of Respiratory Care Medicine) was administered from October to November 2023. Responses were stratified into three questions: Question A, "Do you routinely treat patients with asthma and COPD?" Question B "Do you routinely perform high-flow therapy?"; and Question C "How do you provide inhaled SABAs during high-flow therapy in patients with asthma or COPD?"

Participants This questionnaire was distributed to all members of the three societies.

Results Of the 567 participants who completed the questionnaire, 387 responded to all 3 questions. When a nebulizer was included in high-flow devices, the frequencies of using an ultrasonic nebulizer, jet, vibrating mesh, other, or not performing nebulization were 49.1%, 30.8%, 5.4%, 0.5%, and 14.2%, respectively; when a nebulizer was included in high-flow devices, these frequencies were 24.0%, 11.1%, 16.0%, 0%, and 48.9%, respectively.

Conclusion Various techniques for inhalation therapy are being employed, revealing a discrepancy between current practices in Japan and the recommendations outlined in the consensus statement.

Aortic angiosarcoma is an extremely rare malignancy that is often diagnosed postoperatively or during autopsy. We present a case that was diagnosed through random skin biopsy. A 75-year-old woman with Alzheimer's disease and chronic kidney disease presented with persistent fever and elevated C-reactive protein levels. Contrast-enhanced computed tomography showed irregular thickening of the aortic wall, which was initially suspected to be atherosclerosis. A random skin biopsy revealed tumor cells that were positive for vascular endothelial markers. The patient died 69 days later, with an autopsy confirming aortic angiosarcoma. Random skin biopsies may aid in the diagnosis of aortic angiosarcoma by detecting metastatic lesions when invasive procedures are not feasible.

Anamorelin is a selective ghrelin receptor agonist that is used to treat cancer-related cachexia. Ghrelin stimulates growth hormone (GH) secretion. However, the association between anamorelin and hyperglycemia remains unclear. We herein report a case of anamorelin-induced hyperglycemia in a patient with type 1 diabetes mellitus. A 67-year-old woman with a history of type 1 diabetes was hospitalized because of a pleural effusion. After hospitalization, the patient was administered anamorelin. Four days after starting anamorelin treatment, her blood glucose and GH levels increased. These results suggest that anamorelin stimulates GH secretion and induces hyperglycemia. Our findings suggest the need to take special care of hyperglycemia when anamorelin is prescribed to patients with type 1 diabetes.

Systemic lupus erythematosus (SLE) is a systemic disease that affects several organs. The diagnosis was performed using the international classification criteria updated in 2019. The significance of antinuclear antibodies (ANAs) with a centromere pattern has not been clearly documented in these criteria. We herein report a patient with ANAs with a centromere pattern and anti-centromere antibodies, without anti-Sm antibodies or anti-dsDNA antibodies, who developed severe lupus nephritis, neuropsychiatric SLE, and lupus pleuritis. The patient was successfully treated with prednisolone, hydroxychloroquine, mycophenolate mofetil, cyclophosphamide, and belimumab, despite several relapses. Anti-centromere antibodies are not regarded as characteristics of SLE but can be detected in SLE patients with severe organ involvement.

A 65-year-old woman was admitted to our hospital with heart failure secondary to aortic regurgitation and paroxysmal atrial fibrillation. During surgery for valve-sparing aortic root replacement, a biopsy was obtained from the right atrium because of paroxysmal AF and mild LV hypokinesis. A histopathological examination revealed atrial natriuretic peptide amyloidosis, and the patient was clinically diagnosed with isolated atrial amyloidosis (IAA). Although IAA is rarely diagnosed clinically, it should be considered in patients with AF and heart failure.

The causes of hypercalcemia vary. There are high-calcium-containing preparations in Chinese herbal medicine, which may contribute to drug-induced hypercalcemia. We encountered a case of hypercalcemia following the simultaneous administration of an active vitamin D3 preparation and several Chinese herbal medicines. The patient had been treated at several medical institutions, with one institution administering eldecalcitol and another institution administering Keishikaryukotsuboreito, Borei powder, and Goreisan. The patient presented with drug-induced hypercalcemia due to an unexpected synergistic effect. Confirmation of prescriptions for patients with multiple medical visits and recognition of the components and side effects of Chinese herbal medicines is thus considered to be extremely important.

Although the liver is often involved in sarcoidosis, the majority of patients are asymptomatic and have a normal liver function; therefore, hepatic sarcoidosis may sometimes not be recognized in clinical practice. Radiologically, most hepatic nodules show hypoenhancement on contrast-enhanced computed tomography or magnetic resonance imaging (MRI) and they are hypointense across all sequences of MRI. In this case, hepatic nodules were slightly hyperintense on T2-weighted images and contrasted from the early phases on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid. We faced difficulties in distinguishing hepatic sarcoidosis from metastatic liver tumors with concurrent duodenal adenocarcinomas. Consequently, this case was diagnosed based on the pathological findings from a laparoscopic lateral segment hepatectomy.

A 45-year-old woman with Basedow's disease, who was later diagnosed with slowly progressive type 1 diabetes mellitus (SPIDDM), developed iron deficiency anemia. Despite normal vitamin B12 levels, the endoscopic findings of the residual fundic glands and severe atrophy predominantly in the body of the stomach and fundus, along with serological tests, confirmed a diagnosis of autoimmune gastritis (AIG). This case highlights the significance of an early AIG diagnosis in non-elderly patients with type 1 diabetes mellitus (T1DM) and autoimmune thyroid disease (AITD) because of the risk of developing pernicious anemia and gastric neoplasms.

Key words:slowly progressive type 1 diabetes mellitus (SPIDDM); latent autoimmune diabetes in adults (LADA); Basedow's (Graves) disease; autoimmune gastritis (AIG); thyrogastric disease; autoimmune polyglandular syndrome (APS) type 3.

We present the case of a patient with lung cancer who developed brachial plexitis following treatment with immunochemotherapy, which included atezolizumab and palliative radiotherapy for a metastatic cervical spine tumor. This case highlights the importance of considering immune-related adverse events (irAEs) when initiating immune checkpoint inhibitor therapy, in addition to other recognized causes such as radiation, tumor compression and invasion, and paraneoplastic syndromes. While brachial plexitis has been reported as an irAE associated with programmed cell death 1 (PD-1) antibodies, this is the first report associated with the administration of programmed cell death ligand 1 (PD-L1) antibodies.