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

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

A 53-year-old man with Eisenmenger syndrome (ES), caused by a large secundum atrial septal defect (ASD) and severe pulmonary arterial hypertension (PAH), showed a marked hemodynamic improvement following an escalation of PAH-specific therapy. Surgical ASD closure using a fenestrated patch was successfully performed after a significant reduction in both the patient's pulmonary pressure and vascular resistance. This case highlights the potential utility of the "treat-and-repair" strategy in patients with ES and severe PAH, who exhibit a favorable response to medical therapy, resulting in both a symptomatic and hemodynamic improvement.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The acute immune-mediated disorder, Bickerstaff brainstem encephalitis (BBE), is characterized by consciousness disturbance, external ophthalmoplegia, and ataxia. BBE is usually readily diagnosed and patients recover well, but rare features may sometimes obscure the diagnosis, and some patients develop prolonged weakness. We herein describe a Japanese patient with BBE who presented with uncharacteristic features of a decorticate-like posture, involuntary movements, and impaired visual acuity, entered a coma requiring intubation, and later required orthosis-assisted ambulation for 10 months. Despite these uncharacteristic features, the typical triad and other BBE characteristic features can be valuable for making an early diagnosis. BBE with a coma or intubation may therefore occasionally lead to prolonged weakness.

A 67-year-old man with type 1 autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis experienced a relapse, while presenting with pancreatic head swelling and distal bile duct stenosis. Despite an increase in the prednisolone dosage (from 7.5 20 mg/day), the disease worsened. A significant dilatation of the main pancreatic duct (8 mm) and new stenosis of the pancreatic tail duct were observed. Malignancy was ruled out by repeated endoscopic ultrasound-guided fine-needle aspiration biopsies. A further escalation of the prednisolone dose to 40 mg/day led to clinical and radiological improvements. This case underscores the difficulty in distinguishing a steroid-resistant AIP relapse from pancreatic cancer, and the importance of ruling out malignancy before intensifying immunosuppressive therapy.

Cardiorenal syndrome (CRS) is a complex, multiorgan condition that encompasses a spectrum of disorders arising from the close interaction between cardiovascular and renal diseases. The serum creatinine (SCr) levels and estimated glomerular filtration rate (eGFR) have traditionally been used in the diagnosis and prognosis of CRS; however, these biomarkers are not always effective in detecting early acute renal damage. CRS type 1 is characterized by an acute cardiac event that leads to acute kidney injury (AKI). The Kidney Disease: Improving Global Outcomes definition has several limitations in diagnosing AKI owing to the limited specificity, sensitivity, and timeliness of the SCr levels. The use of tubular injury biomarkers to detect the early stages of kidney disease has led to the development of subclinical AKI. This review summarizes the currently available renal biomarkers and their potential clinical applications in CRS type 1.

Pneumatosis cystoides intestinalis (PCI) is characterized by the presence of gas in the gastrointestinal wall. It is rarely observed in patients with pulmonary Mycobacterium avium complex (MAC) infection, although the exact mechanisms are unclear. We, herein, present a case of PCI potentially associated with long-term antibiotic therapy for pulmonary MAC infection. An 83-year-old woman developed PCI after 3 years of antibiotic therapy for a pulmonary MAC infection, with subsequent improvement following the discontinuation of antibiotics. Based on the clinical course, we suggest that clinicians consider the development of PCI, especially in patients receiving long-term antibiotic therapy for pulmonary MAC infection.

Sodium zirconium cyclosilicate hydrate (SZC) is a novel potassium binder that can be administered either orally or via nasogastric tubes. We report the case of a 77-year-old woman who developed a 37-mm gastric bezoar after nasogastric SZC administration during intensive care for acute adrenal insufficiency. Endoscopic removal was performed, and the analysis confirmed that the SZC was the primary constituent. Impaired gastric motility, acidic gastric environment, and limited hydration are likely contributors. This case highlights the potential for SZC-induced gastric bezoar formation in critically ill patients, and underscores the importance of imaging monitoring, careful gastrointestinal management, and the awareness of this potential complication during SZC therapy.

Deep cerebral venous thrombosis (DCVT) is an uncommon cerebrovascular disease with diverse neurological deficits and a poor prognosis. Therefore, the early diagnosis and treatment of DCVT are needed. We herein present a case of DCVT with edematous lesions in the bilateral thalami with Korsakoff syndrome (KS) as the initial symptom. Although KS mainly occurs in patients with thiamine deficiency, it can also result from cerebrovascular disease. Because thalamic dysfunction may be associated with KS, DCVT with thalamic lesions should be considered a cause of KS to facilitate its early diagnosis and treatment.

A 58-year-old man was diagnosed with acute myeloid leukemia with myelodysplasia-related changes. Induction therapy with CPX-351 achieved complete remission, and a second course of consolidation therapy was administered. Shortly after the second course, he developed aphthous ulcers on the tongue that progressively worsened. Although a tongue biopsy showed no specific findings, serum anti-BP180 antibodies were positive. Mucous membrane pemphigoid (MMP) was diagnosed, and corticosteroid therapy led to a rapid improvement. Given the temporal relationship between CPX-351 administration and the MMP onset, CPX-351 was considered to be the likely causative agent.

A 65-year-old woman with a history of silicone breast implantation was admitted to our hospital with abnormal chest shadows. Although the implants had already been removed, chest CT revealed diffuse ground-glass opacities in both lungs. Thoracoscopic lung biopsy revealed non-necrotizing epithelioid granulomas and silica-phagocytic macrophages, leading to a diagnosis of silicone-implant-associated autoimmune/inflammatory syndrome induced by adjuvants (ASIA). Over a follow-up period of more than 15 years without treatment, the ground-glass opacities improved only slightly. We herein present the longest follow-up chest CT findings of silicone implant-associated ASIA.

We herein report four patients who were unable to receive idecabtagene vicleucel (ide-cel) due to disease progression, despite undergoing leukapheresis within specification. The median age of the patients was 70 (range, 68-77) years old. Two patients had nonsecretory subtypes at the diagnosis. The median number of prior therapy lines was 4.5 (range, 4-6), and 3 patients were penta-refractory. All patients were refractory to the latest treatment. The median time from apheresis to ide-cel cancellation was 44.5 (range: 24-71) days. Our findings suggest that the nonsecretory subtype and penta-refractoriness may increase the risk of treatment discontinuation. Early ide-cel application and improved bridging therapy are warranted to enhance treatment completion after leukapheresis.

Objective Acquired hemophilia A (AHA) is a rare and often severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Both the prompt diagnosis and treatment of patients with AHA are essential. Data on Japanese AHA diagnostic delay are lacking; therefore, this study aimed to determine the time to AHA diagnosis in Japan, as well as to identify factors influencing the time from presentation to diagnosis.

Methods This web-based, prospective, observational study surveyed physicians in Japan who had diagnosed or treated patients with AHA. The time from bleeding onset to diagnosis was the primary endpoint, with diagnostic testing barriers as the secondary endpoints.

Results Of the 322 physicians who accessed the survey, 112 were included in the study. The time from bleeding onset to referral and from referral to diagnosis was ≥8 days in 31.3% (n=35) and 23.2% (n=26) of cases, respectively. The tests most commonly conducted in-hospital were activated partial thromboplastin time (aPTT) and aPTT cross-mixing tests (85.7% and 73.2%, respectively), for which results typically took <1 day to obtain. FVIII activity and FVIII inhibitor tests were more often outsourced, and when performed in-hospital, the results took ≥2 days in over 25% of cases. Across the tests surveyed, 41.7-76.2% of physicians noted difficulty in interpreting test results as a reason for AHA diagnosis delay.

Conclusion More efficient diagnostic procedures and enhanced physician education and awareness are needed to shorten AHA diagnosis times in Japan.

Olanzapine, a widely prescribed atypical antipsychotic, is associated with significant metabolic side effects including hyperglycemia and new-onset diabetes mellitus. While it often contributes to or mimic conventional type 2 diabetes through weight gain and insulin resistance, olanzapine can also induce a distinct, acute, ketosis-prone form of diabetes characterized by acute, severe hyperglycemia, and a high risk of diabetic ketoacidosis (DKA). This review summarizes the current understanding of olanzapine's multifaceted diabetogenic mechanisms, distinguishing its contributions to both type 2 diabetes and this severe drug-induced presentation, and emphasizes the critical implications for patient management, particularly concerning the acute manifestations of DKA. We also discuss its unique position within the broader classification of other types of diabetes and drug-induced etiologies.

Objective: The pathophysiology of right ventricular failure in patients with pulmonary hypertension has not been completely examined and monitoring strategies are lacking. The 14-3-3 protein family plays a regulatory role in cardiac fibroblasts. This study investigated whether 14-3-3 epsilon, a member of the 14-3-3 protein family, was associated with right ventricular failure.

Methods: A monocrotaline-induced pulmonary hypertension rat model was used to investigate the role of 14-3-3 epsilon in right ventricular failure. Plasma samples from patients with pulmonary hypertension were analyzed using an enzyme-linked immunosorbent assay for 14-3-3 epsilon.

Patients and Materials: Right ventricular samples from a monocrotaline-induced pulmonary hypertension rat model and plasma samples (n = 83) from patients with pulmonary hypertension were used.

Results: The right ventricular 14-3-3 epsilon expression was higher in the monocrotaline group than in the control group. In patients with pulmonary hypertension, the median plasma 14-3-3 epsilon level was 95 ng/mL. Plasma 14-3-3 epsilon levels were significantly associated with tricuspid lateral annular peak systolic velocity and right ventricular fractional area changes in patients with pulmonary hypertension.

Conclusion: This is the first study to demonstrate an association between 14-3-3 epsilon and right ventricular failure. Plasma 14-3-3 epsilon level may be a useful circulating marker for evaluating right ventricular dysfunction in patients with pulmonary hypertension.

A 63-year-old woman underwent endoscopic submucosal dissection for early gastric cancer. The lesion initially met the former eCura B criteria but was reclassified as eCura A under the updated Japanese guidelines, which do not recommend routine imaging follow-up. Nineteen months after curative resection, a solitary swollen lymph node was detected on computed tomography and metastasis was histopathologically confirmed. After chemotherapy, the patient underwent a total gastrectomy without residual carcinoma. While such recurrence is rare, this case suggests that clinicians should remain aware of the possibility of lymph node metastasis, even in lesions considered curative under the current criteria.

Objective To determine the clinical significance of sputum Pasteurella multocida in adults with structural lung disease by operationally distinguishing infection from colonization and describing outcomes of pathogen-directed therapy.

Methods We performed a single-center, retrospective case study. Infection was defined a priori by new or worsening lower -respiratory symptoms at the time of culture, supported by inflammatory or radiologic changes; isolation without symptoms was classified as colonization. Two pulmonologists blinded to the clinical data reviewed the chest CTs scans. Antibiotic selection and clinical responses within 2-4 weeks were extracted from the charts.

Results Seven adults (five women; mean age, 67.1 years) with structural airway disease were included. Middle lobe syndrome and diffuse panbronchiolitis were predominant, while bronchiectasis was present in two patients. Five of the seven patients (71.4%) reported regular dog/cat exposure. Sputum cultures were obtained for acute symptom exacerbations in four patients and for incidental imaging abnormalities in three. Three symptomatic patients received penicillin-class therapy and all improved. One symptomatic patient improved without antibiotics. No recent animal bites or scratches were reported. No severe treatment-related adverse events were observed.

Conclusion In elderly patients with structural airway disease, sputum P. multocida during symptomatic episodes likely represents true infection and responds to targeted narrow-spectrum therapy, whereas asymptomatic isolates may reflect colonization. These observations provide a pragmatic framework to distinguish infection from colonization, support susceptibility-aligned narrow-spectrum management, and offer small-series evidence to inform antimicrobial stewardship in structural lung diseases.

Fibrin interference can cause spurious immunoassay results, particularly in patients with coagulopathy or those receiving anticoagulant therapy. We report the case of an asymptomatic 79-year-old woman treated with apixaban, who presented spuriously elevated free thyroxine and free triiodothyronine levels, mimicking a syndrome of inappropriate secretion of thyroid-stimulating hormone. Plasma measurements revealed values within the reference range, which confirmed fibrin interference. To our knowledge, this is the first case to demonstrate fibrin interference in thyroid function testing during direct oral anticoagulant therapy. The relevant literature suggests a greater susceptibility to specific free thyroxine assay platforms. Clinicians should recognize this phenomenon to avoid unnecessary investigation of apparent thyroid dysfunction.

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

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

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

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

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

Endoscopic ultrasonography (EUS) has become an indispensable tool for the diagnosis and treatment of biliary and pancreatic diseases. Originally introduced for high-resolution imaging and tissue acquisition through fine-needle aspiration (EUS-FNA), the clinical role of EUS-FNA has expanded remarkably with the evolution of interventional EUS (iEUS). EUS-guided drainage procedures targeting the bile duct, gallbladder, pancreatic duct, and peripancreatic fluid collection have emerged as minimally invasive alternatives to traditional surgical or percutaneous approaches. The advent of the lumen-apposing metal stent (LAMS) has further enhanced procedural safety and efficacy, enabling direct endoscopic necrosectomy and EUS-guided gastrojejunostomy. Beyond drainage, EUS facilitates tumor ablation, targeted injection therapy, and vascular interventions, significantly broadening its therapeutic spectrum. This review summarizes the current advances and future perspectives in EUS for the management of biliary and pancreatic disorders, with particular emphasis on diagnostic and interventional innovations. Continued technological refinement and procedural standardization are expected to further expand the clinical potential of EUS as a diagnostic and therapeutic platform in pancreatobiliary medicine

We report a rare case of intraductal papillary mucinous carcinoma (IPMC) in a young male who initially presented with imaging findings suggestive of autoimmune pancreatitis (AIP) and was later diagnosed with tumor-associated pancreatitis. Despite symptom resolution with conservative treatment, follow-up imaging revealed a pancreatic tumor. Surgical resection confirmed the presence of IPMC with adenocarcinoma components. This case highlights the importance of excluding malignancy even in young patients with AIP-like features. Given the limited sensitivity of FDG-PET for early stage tumors, adjunctive modalities such as endoscopic ultrasound (EUS) and serial pancreatic juice aspiration cytological examination (SPACE) should be actively considered.

An 81-year-old Japanese man with IgG4-related disease (IgG4-RD) presented with marked edema in the right lower leg. He was diagnosed with IgG4-RD with retroperitoneal fibrosis, hilar and mediastinal lymphadenopathy, elevated serum IgG4 levels, and IgG4-positive plasma cell infiltration in a mediastinal lymph node. Lymphatic scintigraphy revealed an obstruction corresponding to edema due to retroperitoneal fibrosis. Glucocorticoid therapy resulted in rapid improvement. Lymphedema due to IgG4-RD with retroperitoneal fibrosis is rare and no standard treatment exists. This case underscores the importance of considering IgG4-RD which is a potentially reversible cause of lymphedema.

2-Hydroxyglutaric aciduria is a rare genetic metabolic disorder, especially in Japan. Although magnetic resonance images show characteristic abnormalities in the subcortical white matter, some cases have been diagnosed in adulthood, namely many decades after onset. We herein report the case of a bedridden 37-year-old 2-hydroxyglutaric aciduria male patient who was diagnosed three decades after onset. Despite this, combination treatment with riboflavin and levocarnitine improved his condition, thus allowing him to walk by himself. Considering our case and the previous literature, we emphasize the importance of correctly diagnosing and treating patients with 2-hydroxyglutaric aciduria.

Few studies have longitudinally evaluated Hashimoto's encephalopathy with anti-NH₂-terminal α-enolase (anti-NAE) antibodies using detailed imaging and neuropsychological assessments. We present the case of a man in his 50s who presented with acute hallucinations, catatonia, seizures, and cognitive decline. Initial MRI revealed diffuse white matter hyperintensities, and SPECT revealed widespread hypoperfusion. These symptoms improved with immunotherapy, but progressive frontal and temporal atrophy and residual hypoperfusion appeared over 33 months. His cognitive function improved, but he remained impaired, with persistent disinhibition and perseveration. This case suggests that Hashimoto's encephalopathy with anti-NAE antibodies can cause lasting structural and functional brain abnormalities and cognitive impairments, requiring long-term neuroimaging and neuropsychological follow-up.

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

This report presents a rare case of 5-aminosalicylic acid (5-ASA)-induced colitis in a 76-year-old man with no history of inflammatory bowel disease (IBD). The patient, who was undergoing treatment for rheumatoid arthritis, developed persistent diarrhea and fever following sulfasalazine (SASP) administration and later experienced a high fever shortly after taking mesalazine. The drug-induced lymphocyte stimulation test result was positive for mesalazine and weakly positive for SASP, thereby supporting the diagnosis of 5-ASA intolerance. This case emphasizes that 5-ASA-induced colitis may occur in patients without IBD. Clinicians should consider this possibility when unexplained gastrointestinal symptoms appear after starting 5-ASA therapy even in patients without any prior IBD.

Human metapneumovirus (hMPV), which can cause severe lower respiratory tract disease and, rarely, extrapulmonary complications, was identified in a 64-year-old immunocompetent man who presented with acute hypoxemia, bronchoscopic evidence of diffuse alveolar hemorrhage (DAH), and clinically diagnosed acute myocarditis. Notably, hMPV was detected by multiplex PCR on a bronchoalveolar lavage (BAL) sample despite an initial negative upper airway evaluation. The patient's condition was severe and required invasive mechanical ventilation and inotropic support. After the viral etiology was identified, empiric steroids were discontinued, the patient recovered, and his left ventricular ejection fraction improved from ~9% to 40% at discharge. This case underscores the fact that during the hMPV season, acute hypoxemia with diffuse opacities should prompt consideration of infectious DAH and that lower-respiratory multiplex PCR (from BAL or deep tracheal aspirate) can identify pathogens when upper airway tests are negative. It also highlights that, in unexplained DAH, empirical immunosuppression should be used cautiously to perform a full infectious evaluation. Furthermore, when myocarditis is suspected, timely hemodynamic assessment and consideration of mechanical circulatory support may influence the outcomes.