Lymphoproliferative disorders and Epstein-Barr virus reactivation (EBV-LPDs) have various forms of onset, ranging from infectious mononucleosis-like syndrome (IM-like) to lymphoma, although whether or not IM-like progresses to lymphoma remains unclear. A 61-year-old man was diagnosed with aplastic anemia (AA). Polyclonal atypical B-lymphocytes were observed in the peripheral blood, and IM-like was diagnosed. Atypical lymphocytes disappeared, but a gastrointestinal examination revealed diffuse large B-cell lymphoma (DLBCL). Rituximab was initiated but later discontinued because of severe acute respiratory syndrome coronavirus 2 infection. Pancytopenia due to AA exacerbation recurred. The patient ultimately died of multiple organ failure due to bacterial infection.

Objective This study retrospectively compared the outcomes of emergently admitted patients with aortic stenosis (AS) with or without urgent transcatheter aortic valve replacement (TAVR).

Methods Patients hospitalized between February 2015 and December 2019 for symptomatic AS were retrospectively analyzed by comparing the received conservative management (continued medical therapy with or without elective surgical transcatheter replacement [SAVR] or TAVR scheduled after the index hospitalization) and urgent TAVR (TAVR during the index hospitalization).

Results The cohort comprised 114 patients with symptomatic AS who required emergency admission. Urgent TAVR was performed for 37 patients, while conservative management was provided for 77 patients, including 1 who received urgent SAVR. Urgent TAVR was more likely to be performed in patients with a history of hospitalization for heart failure, high New York Heart Association class scores, a lower clinical frailty scale at admission, and a high aortic valve peak velocity (P = 0.01, P <0.001, P <0.01, and P = 0.02, respectively). Kaplan-Meier analyses with log-rank test revealed favorable outcomes of urgent TAVR in all-cause mortality and cardiovascular events within 60 days of admission (p <0.01, p <0.01, respectively).

Conclusions Urgent TAVR had better short-term outcomes in patients with symptomatic AS who required emergency hospital admission than conservative management. When considering urgent TAVR, patients with typical heart failure symptoms due to AS with a history of heart failure hospitalization and relatively little frailty can be selected.

The development of allergic diseases is common in the young but rare in the elderly. We encountered an elderly patient with food-dependent exercise-induced anaphylaxis (FDEIA). An 82-year-old man was rushed to the hospital for symptoms of anaphylaxis. Because the symptoms occurred after ingestion of wheat products and exercise, we made a diagnosis of FDEIA based on a high ω5-gliadin IgE level and a positive exercise test. Based on our review of the existing literature, this was the oldest patient to ever be diagnosed with FDEIA in Japan. This case suggests that physicians should keep in mind that older adults can develop FDEIA.

We experienced a 36-year-old man with lupus nephritis and antiphospholipid syndrome (APS) who received a donor kidney from his father. Twenty-two months after transplantation, at a time of poor adherence to immunosuppressants and warfarin, the patient developed sudden graft loss due to hemolytic uremic syndrome with rapid deterioration of renal function, thrombocytopenia, and hemolytic anemia. A kidney biopsy showed thrombotic microangiopathy (TMA) related to platelet thrombus formation; however, there was no recurrence of lupus and no findings suggestive of post-transplant rejection, so acute TMA associated with APS was thought to be the cause of the graft loss. This case highlights the importance of instructing patients with lupus nephritis to adhere to treatment with warfarin, a therapeutic drug for APS.

Objective The treatment background, as well as the frequency and type of complications, in autologous (auto-) and allogeneic (allo-) hematopoietic stem cell transplantation (HSCT) survivors influence the appearance of moderate to vigorous physical activity (MVPA) or sedentary behavior. We therefore assessed differences in the MVPA and sedentary behavior between auto- and allo-HSCT survivors.

Methods This prospective observational study included 13 auto- and 36 allo-HSCT survivors (approximately 4 years after HSCT). The MVPA and sedentary behavior were assessed using a triaxial accelerometer.

Results There were no significant between-group differences in the MVPA or sedentary behavior (p =0.768 and 0.739, respectively). In allo-HSCT survivors, the MVPA was negatively correlated with the Hospital Anxiety and Depression Scale score (r =-0.358, p =0.032). A stepwise multiple regression analysis showed that age was a significant predictor of sedentary behavior in allo-HSCT survivors (β =0.400, p =0.016).

Conclusion We observed no significant between-group differences in the MVPA or sedentary behavior. Our results suggest that it may be unnecessary to change the rehabilitation program according to the donor type in interventions for promoting MVPA and reducing sedentary behavior in long-term HSCT survivors.

A 91-year-old woman was brought to our hospital with altered consciousness. Blood tests showed an increased ammonia level of 468 μg/dL and a normal liver function. Chest computed tomography showed massive right pleural effusion with loculation. We immediately performed chest drainage using two drainage tubes. The pleural effusate pH was 8.5. We diagnosed her with right empyema leading to hyperammonemia and initiated ampicillin/sulbactam therapy. However, she developed progressive renal failure and died on the third day. Empyema caused by urease-producing bacteria can lead to hyperammonemia. This is the first report of hyperammonemia due to empyema in the English literature.

A 72-year-old woman was admitted to our hospital with numbness in her lower extremities and hypereosinophilia. She was diagnosed with eosinophilic granulomatosis with polyangiitis (EGPA). On admission, she was suspected of being complicated with pneumonia and sepsis; therefore, treatment with mepolizumab monotherapy was begun, resulting in partial improvement. After the possibility of a complicating infection was ruled out, corticosteroids were initiated, followed by intravenous gamma globulin therapy. Although the induction of remission of EGPA with mepolizumab monotherapy is not usually recommended, induction with mepolizumab monotherapy may be an option in terms of safety and clinical efficacy in some cases.

A 46-year-old woman was referred for hypertension and a right adrenal tumor. Primary aldosteronism (PA) was suspected because of the high plasma aldosterone concentration-to-plasma renin activity ratio. However, a subsequent evaluation revealed coexistent PA and pheochromocytoma. We performed laparoscopic right adrenalectomy. Histology of the resected adrenal gland confirmed pheochromocytoma and multiple aldosterone-producing adrenocortical micronodules. Following adrenalectomy, the urinary catecholamine levels normalized, and hyperaldosteronism improved but persisted. Hypertension also improved but persisted and was normalized with spironolactone. The clinical course indicated that the PA lesions were likely bilateral. This was a histologically proven case of coexistent pheochromocytoma and PA due to multiple aldosterone-producing micronodules.

As coronavirus disease 2019 (COVID-19) vaccine booster campaigns progress worldwide, new reports of complications following COVID-19 vaccination have emerged. We herein report a case of new-onset anti-glomerular basement membrane (GBM) disease concomitant with myeloperoxidase-antineutrophil cytoplasmic antibody positivity concurrent with high levels of interleukin (IL)-26 following the second dose of the Pfizer-BioNTech COVID-19 vaccine. The temporal association with vaccination in this case suggests that an enhanced neutrophilic immune response through IL-26 may have triggered necrotizing glomerulonephritis and a T-cell-mediated immune response to GBMs, leading to the development of anti-GBM antibodies, with an enhanced B-cell response after the vaccination triggering anti-GBM IgG and the onset of anti-GBM disease.

Malignant hypertension triggers incremental renin activity, whereas primary aldosteronism suppresses such activity. We encountered a patient with malignant hypertension refractory to multiple anti-hypertensive agents. Repeated neurohormonal assessments, instead of a single one, eventually uncovered trends in an incremental aldosterone concentration, ranging from 221 up to 468 pg/mL, with a decline in the renin activity from 2.3 to <0.2 ng/mL/h. Adrenal venous sampling confirmed bilateral aldosterone secretion. Following the diagnosis of bilateral primary aldosteronism, we initiated a mineralocorticoid receptor antagonist, which improved his blood pressure. Repeated neurohormonal assessments are encouraged to correctly diagnose underlying primary aldosteronism with malignant hypertension.

A 36-year-old man was diagnosed with multiple gastric polyps by esophagogastroduodenoscopy. Subsequent colonoscopy identified two tubular adenomas, and computed tomography revealed subcutaneous tumors. Based on these findings, we suspected that gastric polyposis was associated with the APC gene, either attenuated familial adenomatous polyposis (AFAP) or gastric adenocarcinoma and proximal polyposis of the stomach (GAPPS). A genetic analysis demonstrated that he had a frameshift variant at codon 1928 of APC, suggesting AFAP. In this era of less Helicobacter pylori infection and frequent use of proton pump inhibitors, diagnoses of AFAP and GAPPS should be considered in patients with prominent gastric fundic gland polyposis.

A 76-year-old man undergoing hemodialysis complained of pain and discoloration of his right finger. The hemodialysis arteriovenous fistula was in the right upper extremity. Ultrasonography showed right subclavian artery occlusion. The lesion could not be approached from the lower extremity and olecranon artery. Thus, we performed the procedure after exposing the proximal brachial artery. We were able to recanalize the subclavian artery and restore blood flow to the right upper extremity. When the lesion is on the side of the arteriovenous fistula and approaching from the lower extremity is difficult, exposure of the proximal brachial artery can be considered.

We performed 3 kidney biopsies in a 71-year-old man. At the first biopsy, we made the diagnosis of immunoglobulin G4 (IgG4)-related interstitial nephritis characterized by the simultaneous presence of IgG4-positive plasma cells and characteristic fibrosis with a bird's-eye pattern. At the second biopsy, rather than finding fibrosis as a post-inflammatory scar, we noted that steroid treatment had caused the simultaneous disappearance of IgG4-positive plasma cells and fibrosis and had restored the normal tubular structure. The third biopsy showed the recurrence of the disease with inflammatory cells accompanied by fibrosis. These findings suggest that IgG4-positive plasma cells and fibrosis occur simultaneously.

Background Direct-acting antiviral agents (DAAs) can eliminate hepatitis C virus at a high rate, although the long-term incidence of portal hypertension and hepatocellular carcinoma (HCC) has not yet been elucidated. In this observational study, we clarified the predictors associated with the incidence of esophageal varices (EVs) and HCC after DAAs treatment based on ultrasound findings and blood examinations.

Methods A total of 78 patients treated with DAAs were enrolled in this study. The primary endpoint was to identify the predictors associated with EVs and HCC occurrence using univariate and multivariate analyses. Secondary endpoints were to extract the cutoff values for EVs and HCC occurrence and clarify the changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), portal vein flow volume (PVF), and blood examination at 12 weeks after the end of DAAs treatment.

Results The mean observation period was 1,402±546 days. SI change (SI after DAAs - SI before DAAs) was a predictor of EVs occurrence in multivariate analysis (p = 0.045). The treatment history of HCC, albumin value before DAAs, and SI change were predictors of HCC occurrence in multivariate analysis (p = 0.002, p = 0.032, and p = 0.009, respectively). LS, SS, PVF, SI, and liver function significantly improved after DAAs treatment.

Conclusion Portal hypertension seems to improve after DAAs treatment over a long period. Patients with splenomegaly deterioration after DAAs treatment need to be carefully monitored for the occurrence of EVs and HCC.

Omalizumab can cause hypersensitivity reactions. We herein report the first case of an 18-year-old woman with refractory cough-predominant asthma that correlated with allergic reactions caused by omalizumab and the coronavirus disease 2019 (COVID-19) vaccine. The patient developed angioedema after taking omalizumab. She had previously experienced intense coughing immediately after receiving a COVID-19 vaccine. A skin prick test was positive for polysorbate 20, which was probably the cause of the allergic reactions to omalizumab and the COVID-19 vaccine. Clinicians should check for an allergic reaction, irrespective of its intensity, triggered by polysorbate and be careful when prescribing biologics to patients in order to avoid allergic reactions.

Finding the ideal balance between efficacy and safety of immunosuppression is challenging, particularly in cases of severe TAFRO syndrome. We herein report a 60-year-old man diagnosed with grade 5 TAFRO syndrome mimicking hepatorenal syndrome that was successfully treated by glucocorticoid, tocilizumab, and cyclosporin despite virus infection. Furthermore, by examining 14 peer-reviewed remission cases, we revealed that the recovery periods among inflammation, renal dysfunction, and thrombocytopenia were quite different, with recovery from thrombocytopenia notably slow. All patients requiring dialysis were successfully withdrawn from dialysis, and the reversibility from kidney injury was good. This clinical information will help clinicians plan treatments and tailor the intensity of immunosuppression.

We herein report a case of intracranial myeloid sarcoma mimicking hypertensive intracerebral hemorrhage. A 71-year-old man with a history of acute myeloid leukemia was admitted with acute-onset dysarthria. A hematoma-like lesion was found on computed tomography in the left putamen. Magnetic resonance imaging (MRI) and cerebrospinal fluid cytology confirmed the diagnosis of intracranial myeloid sarcoma. The patient showed a favorable response to chemotherapy, and follow-up MRI revealed shrinkage of the tumor. Since the computed tomography findings resemble those of intracerebral hemorrhage, it is important to suspect intracranial neoplasm, particularly in cases with a history of hematologic diseases.

Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.

Mutations in the surfactant protein C gene (SFTPC) are responsible for hereditary interstitial lung disease (ILD), which is a rare disease. We herein report a patient with a clinical history of endogenous lipoid pneumonia in infancy who developed diffuse progressive pulmonary fibrosis in adulthood associated with SFTPC mutations. A surgical lung biopsy and genetic sequencing revealed fibrotic interstitial pneumonia and two SFTPC mutations (c.215 G>A and c.578C>A). Based on these findings, we diagnosed the series of lung diseases as sporadic ILD caused by SFTPC mutations. Physicians should suggest genetic sequencing in patients with early-onset ILD.

Adenoid cystic carcinoma (ACC) is a rare type of malignant tracheal tumor originating from the secretory glands. Complete surgical resection is the current standard of care for tracheal ACC. However, there have been few case reports of chemoradiotherapy for unresectable tracheal ACC. We herein report a 28-year-old man with unresectable tracheal ACC who received concurrent chemoradiotherapy (CCRT) followed by maintenance therapy with durvalumab. CCRT was completed with a good response and safety, and the patient is currently receiving durvalumab as maintenance therapy. Durvalumab after CCRT can be a treatment option for patients with unresectable tracheal ACC.

Ponatinib is a novel multi-tyrosine kinase inhibitor (TKI) with potent inhibitory activity against refractory chronic myeloid leukemia (CML). Despite its high clinical efficacy, ponatinib induces various adverse events due to its multi-target characteristic. However, renal complications associated with ponatinib are rare. A 76-year-old woman had a history of chronic myeloid leukemia (CML) resistant to imatinib and nilotinib. Our patient developed proteinuria and renal function deterioration during treatment with ponatinib but not with imatinib or nilotinib. We herein report the first case of a patient with secondary focal segmental glomerulosclerosis (FSGS) with partial glomerular collapse induced by ponatinib treatment.

Uromodulin, also known as the Tamm-Horsfall protein, is predominantly expressed in epithelial cells of the kidney. It is secreted mainly in the urine, although small amounts are also found in serum. Uromodulin plays an important role in maintaining renal homeostasis, particularly in salt/water transport mechanisms and is associated with salt-sensitive hypertension. It also regulates urinary tract infections, kidney stones, and the immune response in the kidneys or extrarenal organs. Uromodulin has been shown to be associated with the renal function, age, nephron volume, and metabolic abnormalities and has been proposed as a novel biomarker for the tubular function or injury. These findings suggest that uromodulin is a key molecule underlying the mechanisms or therapeutic approaches of chronic kidney disease, particularly nephrosclerosis and diabetic nephropathy, which are causes of end-stage renal disease. This review focuses on the current understanding of the role of uromodulin from a biological, physiological, and pathological standpoint.

Objective The early diagnosis of rheumatoid arthritis (RA) improves disease outcomes. Using bilateral magnetic resonance imaging (MRI), we investigated whether or not tenosynovitis at the level of the metacarpophalangeal (MCP) and wrist joints, as well as non-symmetrical versus symmetrical involvement, predicts RA development in undifferentiated arthritis (UA) patients.

Methods We collected the clinical and serological findings as well as bilateral gadolinium-enhanced 1.5-T MRI data of UA patients after 1 year. A multivariate logistic regression analysis was used to determine the association of tenosynovitis in UA with RA development.

Patients and Materials Ninety-one UA patients from the Nagasaki Early Arthritis Clinic who did not meet the 2010 European League Against Rheumatism/American College of Rheumatology classification criteria for RA were selected. Tenosynovitis at the MCP and wrist joints was scored according to the RA MRI scoring system.

Results Of these 91 UA patients, 29 (31.9%) progressed to RA, with a median disease duration of 3 months, despite only 10.9% being positive for anti-cyclic citrullinated peptide antibody (ACPA). A univariate analysis showed higher MCP tenosynovitis scores, MCP flexor tenosynovitis, and symmetrical MCP tenosynovitis in the RA development group than in the non-development group (p <0.05). A multivariate analysis showed that symmetrical MCP tenosynovitis was independently associated with RA development after adjusting for age, gender, swollen joint count, C-reactive protein level, and ACPA positivity (odds ratio: 4.96). The presence of symmetrical MCP tenosynovitis had low sensitivity (35%) but high specificity (87%) for RA development.

Conclusion MRI-detected tenosynovitis, especially symmetrical findings at the MCP joint, is predictive of RA development in a UA population with low ACPA positivity.

Protein S deficiency causes spinal cord infarction in rare cases. We herein report the first case of severe cervicothoracic cord infarction in an adolescent with protein S deficiency. A 16-year-old boy presented with neck pain, four-limb paralysis, and numbness. Magnetic resonance imaging revealed spinal artery infarction in the C4 to Th4 area. Protein S antigen and activity were decreased. The patient was diagnosed with protein S deficiency-associated cervicothoracic cord infarction, which was treated with anticoagulation. Protein S deficiency should be considered as a potential cause of spinal cord infarction in young healthy patients and should be appropriately treated with anticoagulation.

Myasthenia gravis (MG) development is female-dominant in younger patients and male-dominant in older patients. The reason for the sex-ratio inversion in elderly MG patients remains unclear. One possible explanation is the decrease in androgen secretion that occurs with aging, as androgen has an immunosuppressive function. We experienced two elderly men who developed MG after initiating androgen deprivation therapy (ADT) for treatment of prostate cancer and whose symptoms were ameliorated after ADT cessation. Our cases indicate that MG in older male patients can be caused by an androgen effect.

Objective This study investigated self-monitoring of blood glucose (SMBG) adherence and flash glucose monitoring patterns using a cluster analysis in Japanese type 1 diabetes (T1D) patients with intermittently scanned continuous glucose monitoring (isCGM).

Methods We measured SMBG adherence and performed a data-driven cluster analysis using a hierarchical clustering in T1D patients from Japan using the FreeStyle Libre system. Clusters were based on three variables (testing glucose frequency and referred Libre data for hyperglycemia or hypoglycemia).

Patients We enrolled 209 participants. Inclusion criteria were patients with T1D, duration of isCGM use ≥3 months, age ≥20 years old, and regular attendance at the collaborating center.

Results The rate of good adherence to SMBG recommended by a doctor was 85.0%. We identified three clusters: cluster 1 (low SMBG test frequency but high reference to Libre data, 17.7%), cluster 2 (high SMBG test frequency but low reference to Libre data, 34.0%), and cluster 3 (high SMBG test frequency and high reference to Libra data, 48.3%). Compared with other clusters, individuals in cluster 1 were younger, those in cluster 2 had a shorter Libre duration, and individuals in cluster 3 had lower time-in-range, higher severe diabetic distress, and high intake of snacks and sweetened beverages. There were no marked differences in the incidence of diabetic complications and rate of wearing the Libre sensor among the clusters.

Conclusions We stratified the patients into three subgroups with varied clinical characteristics and CGM metrics. This new substratification might help tailor diabetes management of patients with T1D using isCGM.

Objective Vonoprazan (VPZ), clarithromycin (CAM), metronidazole (MNZ) and VPZ, MNZ, and sitafloxacin (STFX) regimen are all established Helicobacter pylori eradication therapies for patients with penicillin allergy in Japan. However, no study has assessed the efficacy of a VPZ, CAM, and MNZ (VCM) regimen in patients with clarithromycin resistance (CAM-R). We therefore assessed the efficacy of a VCM regimen for treating H. pylori infection in patients with CAM-R and penicillin allergy.

Methods Fifty-three patients with penicillin allergy who received H. pylori eradication therapy were retrospectively analyzed. Eight patients received a 7-day proton-pump inhibitor, CAM, and MNZ (PCM) regimen; 35 patients [11 CAM-R, and 10 with clarithromycin sensitivity (CAM-S)] received 7-day VCM regimens; and 10 patients received 7-day VPZ, MNZ, and STFX (VMS) regimens. A ¹³C-urea breath test was used to determine eradication. The efficacy of eradication was evaluated via both intention-to-treat (ITT) and per-protocol (PP) analyses.

Results According to ITT and PP analyses, eradication rates (ERs) with PCM, VCM, and VMS therapies were 50.0% and 50.0%, 94.3% and 100%, and 90% and 90%, respectively. Treatment was successful in all patients with CAM-S. For patients with CAM-R, treatment was successful in 10 patients, and 1 patient discontinued treatment owing to an adverse event. According to ITT and PP analyses, ERs were 90.9% and 100% in CAM-R, and were 100% and 100% in CAM-S, respectively.

Conclusion The VCM regimen for H. pylori eradication may be a viable candidate therapy for patients with penicillin allergy, regardless of CAM-R.

Objective To evaluate the effects of one-year aerobic interval training on endothelial dysfunction in patients with atrial fibrillation.

Patients and methods Seventy-four patients with atrial fibrillation (53 men, 21 women; mean age 63±6 years old) were randomized into a 1-year continuous aerobic interval training (CT), 6-month detraining after 6 months of aerobic interval training (DT), or medical treatment only (MT) group. Aerobic interval training was performed 3 times a week for 1 year or 6 months, with an exercise intensity of 85%-95% of the peak heart rate. The primary outcome was a change in biomarkers of endothelial dysfunction from baseline at six months or at the one-year follow-up.

Results Six-month aerobic interval training reduced von Willebrand factor (CT: 103.7±30.7 IU/dL and DT: 106±31.2 IU/dL vs. MT: 145±47.7 IU/dL, p=0.044). Improvements were maintained with continuous aerobic interval training; however, the values increased again to the baseline levels upon detraining (CT: 84.3±39.1 IU/dL vs. DT: 122.2±27.5 IU/dL and MT: 135.9±50.4 IU/dL, p=0.002). Interleukin 1 beta levels decreased after 6 months of aerobic interval training (CT: 0.59±0.1 pg/mL and DT: 0.63±0.09 pg/mL vs. MT: 0.82±0.28 pg/mL, p=0.031), and the improvement was maintained with continuous aerobic interval training and even after detraining (CT: 0.58±0.08 pg/mL and DT: 0.62±0.09 pg/mL vs. MT: 0.86±0.28 pg/mL, p=0.015).

Conclusions One-year aerobic interval training improves endothelial dysfunction in patients with atrial fibrillation and is primarily associated with the reduction in circulating thrombogenic and pro-inflammatory factors. A definitive way to sustain these improvements is the long-term continuation of aerobic training.

Trial registration Clinical Research Information Service (registration no. KCT0007264, registered on May 11, 2022). Retrospectively registered.

Objective In general, surface ulceration in gastric gastrointestinal stromal tumor (GIST) is considered a malignant feature; however, the mechanism underlying its formation has not been evaluated in detail. In this study, we analyzed the factors involved in ulceration using resected specimens of gastric GIST.

Methods A total of 48 samples were retrospectively analyzed. We examined the association of surface ulceration of gastric GIST with the MIB-1 labeling index, mitotic number, tumor size, endoscopic ultrasound (EUS) findings and growth pattern on computed tomography (CT).

Results The proportion of men was significantly higher in the ulceration group than in the non-ulceration group (p=0.04146), whereas age was not significantly different between the groups. Tumor was significantly larger in the ulceration group than in the non-ulceration group (p=0.0048). There was no correlation between tumor size and ulcer number. The MIB-1 index was not related to ulceration, nor were EUS findings. The number of mitotic cells tended to be higher in the ulceration group than in the non-ulceration group (p=0.05988). Intraluminal growth pattern was strongly associated with ulceration (p=0.00019). After a multivariate analysis, the growth pattern was the only factor associated with ulceration of gastric GIST.

Conclusion Although formation of surface ulceration in gastric GIST was partially associated with the degree of malignancy, the growth pattern was the most important factor associated with ulceration in gastric GIST.

Objective Although blood cultures to identify the presence of bacteremia are recommended for nursing- and healthcare-associated pneumonia (NHCAP), the incidence of true bacteremia and the relationship between true bacteremia and the outcome remain unclear. Physicians can therefore sometimes be confused regarding whether or not blood cultures should be obtained for NHCAP patients. This study assessed the incidence of true bacteremia and the relationship between true bacteremia and the outcome of NHCAP in a Japanese hospital setting.

Methods We retrospectively analyzed NHCAP patients hospitalized between April 2016 and March 2021. The primary outcome was the incidence of true bacteremia in blood cultures. The incidence of true bacteremia was also examined according to quick Sequential Organ Failure Assessment (qSOFA) and A-DROP scores. In addition, we compared the incidence of true bacteremia between survivors and non-survivors.

Results In total, 205 patients were included in this study. Blood cultures were obtained from 150 of the 205 patients (73.2%). Positive blood cultures were detected in 26 patients (17.3%), of which only 8 cases (5.3%; 95% confidence interval, 2.3%-10.2%) were considered true bacteremia. Trend analyses for the incidence of true bacteremia according to qSOFA scores and A-DROP did not show any statistically significant results (p =0.49 for qSOFA; p =0.14 for A-DROP). The proportion of true bacteremia cases did not differ significantly between survivors and non-survivors.

Conclusions The incidence of true bacteremia among NHCAP patients was very low. A strategy for determining indications for obtaining blood cultures from NHCAP patients needs to be established.

Objective The coronavirus disease 2019 (COVID-19) pandemic has led to a global restriction of public behavior due to lockdowns in various major cities. Lifestyle changes and reduced rates of outpatient lifestyle guidance/consulting may have had some impact on glycemic control in patients with type 2 diabetes. This study analyzed the impact of changes in the frequency of nutritional guidance/consulting (NGC) during the COVID-19 pandemic on outpatient care for type 2 diabetes.

Methods Among 785 patients, 67 who received regular NGC during the COVID-19 pandemic were assigned to the continuation group (CG), 143 whose NGC was discontinued after the pandemic were assigned to the discontinuation group (DG), and 575 who did not receive regular NGC regardless of the COVID-19 pandemic status were assigned to the irregular NGC group (IGG). The three groups were followed up for two years. Analyses among the three categories were performed using the chi-square test or an analysis of covariance.

Results The number of diabetes medications after the declaration of the COVID-19 emergency did not markedly increase in the CG (2.0±1.4 to 2.1±1.5, p>0.05) but significantly increased from 2.2±1.4 to 2.6±1.4 in the DG (p<0.005) and from 2.2±1.4 to 2.4±1.4 in the IGG (p<0.005). The increase in HbA1c adjusted for confounders was unchanged at 0.12%±1.06% for the CG and -0.07%±1.29% for the IGG but was significantly increased at 0.19%±1.49% for the DG (p<0.05).

Conclusion In patients with type 2 diabetes mellitus, regular nutritional guidance may be important for maintaining good glycemic control, even during the COVID-19 pandemic.

Anti-myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating disorder that mainly occurs post-infection or post-vaccination. MOGAD after inoculation with coronavirus disease 2019 (COVID-19) vaccines is rare, and we herein report a rare case of a patient with MOGAD after vaccination using the Pfizer-BioNTech COVID-19 vaccine (BNT162b2; Pfizer Japan Inc.; Tokyo). Our report highlights the fact that MOGAD following inoculation with COVID-19 vaccine may show clinical relapse during reduction of the oral steroid dose, and continuous treatments with immunological agents is needed to prevent disease recurrence.

A 61-year-old man presented with a 7-day history of watery diarrhea and loss of appetite after receiving the second dose of the Pfizer-BioNTech Covid-19 vaccine. Laboratory studies showed significant eosinophilia and an elevated IgE level (white cell count, 18.4×10⁹/L; eosinophil count, 9.5×10⁹/L; and IgE level, 540 IU/L). Symptoms resolved 10 days after vaccination without any steroids or antiallergic medications, and the eosinophil count had also returned to within normal limits 2 months later. Several cases of eosinophilic disorders following receipt of any type of injectable COVID-19 vaccine have been reported, so the etiology should be examined.

A 69-year-old woman with a history of otitis media with anti-neutrophil cytoplasmic antibody-associated vasculitis who had been receiving corticosteroid monotherapy presented with shortness of breath. The otitis media had been alleviated, but she had saddle nose. Chest enhanced computed tomography (CT) showed stenoses of the bronchi and large vessels surrounded by mass-like lesions in the mediastinum. These manifestations indicated an active state of granulomatosis with polyangiitis (GPA). After she was started on high-dose corticosteroids and intravenous cyclophosphamide, the mass-like lesions disappeared with improvements of the stenoses. Ameliorating mass-like lesions resulting from GPA requires therapeutic intervention using corticosteroids and immunosuppressants.

Pregnancy is a known risk factor for amebic enteritis, which develops into potentially fatal fulminant amebic enteritis in some cases. We describe a case of a 27-year-old non-immunosuppressed pregnant woman with fulminant amebic enteritis complicated with cytomegalovirus enteritis. She improved with intensive care and intravenous metronidazole and ganciclovir but eventually required subtotal colectomy for intestinal stenosis. It is difficult to diagnose amebic enteritis, especially in a non-endemic area. Amebic enteritis must be considered as a differential diagnosis for refractory diarrhea with bloody stools in women in the perinatal period, even those without immunosuppression.

Cryptococcal meningitis is a critical disease that occasionally involves immunosuppressed patients. We herein report a 79-year-old Japanese man who received low-dose prednisolone therapy for neurosarcoidosis and panhypopituitarism. He presented a 10-day history of a fever and altered mental status. The FilmArray^® Meningitis/Encephalitis Panel and serum cryptococcal antigen tests were both negative, but the cerebrospinal fluid sample became positive for Cryptococcus neoformans after seven-day incubation. After the diagnosis of cryptococcal meningitis, we successfully treated the patient with a recommended treatment regimen. When an immunocompromised patient presents with a subacute fever accompanying any central nervous symptoms, cryptococcal meningitis should be screened for.

Speech-induced atrial tachycardia (AT) with presyncope is extremely rare. A 52-year-old woman employed at a supermarket reported recurrent presyncope while speaking out loud at her job. Holter electrocardiography revealed AT while swallowing without presyncope. The patient's blood pressure decreased during AT, and she experienced presyncope while saying "IRASSHAIMASE" loudly during a tilt table test. Accordingly, bisoprolol 1.25 mg was prescribed, and the patient did not experience episodes of presyncope with recurrence of AT for 2 years. This case suggests that provocation of arrhythmia in the tilting position may be useful for demonstrating a relationship between arrhythmia and presyncope and/or syncope.