A 30-year-old man presented with various manifestations including general malaise, headache, palpitation, and diaphoresis, which occurred ten days after an acute respiratory infection. The patient showed high blood pressure, and an investigation for secondary hypertension demonstrated marked catecholamine elevations, supporting a diagnosis of pheochromocytoma;however, computed tomography and 123I-meta-iodobenzylguanidine scin- tigraphy denied any adrenal tumours or paragangliomas. The catecholamine overproduction spontaneously normalized over time without surgical intervention or chemotherapy. The patient’ s clinical course suggested transient catecholamine overproduction, possibly triggered by the preceding infective event. General practitioners need to be aware of the possibility of a post- infectious condition of pseudo-pheochromocytoma.

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An 18-year-old woman was admitted to our hospital with fever and malaise. Her body temperature was 39.4 °C, but no abdominal pain was present and the intestinal peristaltic rhythm was normal. She complained of tiredness and bilateral thigh muscle pain at the time of the examination. The blood biochemical test values were as follows:leukocytes, 11, 600/μL; aspartate aminotransferase, 72 U/L;lactate dehydrogenase, 524 U/L;creatine phosphokinase (CPK), 7,263 U/L;creatinine, 0.72 mg/dL;serum myoglobin, 266.0 ng/mL;and C-reactive protein, 0.64 mg/dL. Slightly increased inflammation and increased muscle-derived enzyme levels were observed. The patient was then diagnosed with rhabdomyolysis (RM) with infectious diseases and hospitalized for medical treatment. Immediately after hospitalization, watery diarrhea and vomiting were frequently observed. Campylobacter jejuni was detected in a stool culture. At the time of the admission, the abdominal symptoms were poor and the diagnosis was difficult. Although the serum CPK value was unusually high, acute renal failure was avoided. We concluded that the C. jejuni infection may have been a cause of the RM.

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Peripartum cardiomyopathy (peripartum cardiomyopathy:PPCM) is a secondary cardiomyopathy presenting with heart failure due to left ventricular systolic dysfunction within 1 month before delivery and 5 months after delivery with an estimated incidence of 1 in 20,000 live births in Japan. We report a case of PPCM in a 41-year-old Japanese woman with a history of hypertensive disorder of pregnancy who presented with dyspnea and hypoxia 4 days after cesarean section. Her respiratory rate was 30 breaths/minute with an SpO2 of 80 % (with 10 L/minute of oxygen), and the brain natriuretic peptide level was markedly elevated at 2,282 pg/mL. Chest radiography showed marked pulmonary edema, and echocardiography revealed severely reduced left ventricular function with ejection fraction of 30 %. She was intubated and managed in the intensive care unit. Her left ventricular ejection fraction improved to 49 % on day 16, and the patient was discharged 20 days after admission. This case underlines the importance of careful monitoring of cardiopulmonary symptoms in peripartum women, particularly those with risk factors for PPCM such as hypertensive disorders of pregnancy. Clinicians should also prepare for intensive care including mechanical ventilation and circulatory support.

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A 60-year-old woman with diarrhea was referred to our hospital due to low values for serum total protein, liver dysfunction with elevated biliary enzymes, and abnormal shadows on chest X- ray from a health examination. Computed tomography of the chest showed a mass in the anterior mediastinum, and the specimen from thymectomy revealed type-AB thymoma. We diagnosed Good’ s syndrome, a rare form of acquired immunodeficiency, because of the thymoma concomitant with agammaglobulinemia. Further examinations revealed multiple tumors in the liver indicating metastatic thymoma. Diarrhea disappeared after total thymectomy, but hypogammaglobulinemia persisted. The patient is now receiving immunoglobulin-replacement therapy and has remained well for the two and a half years since the first visit.

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An 85-year-old Japanese woman with hypertension and diabetes was receiving several medications, including hydrochlorothiazide, and presented with a 3-week history of bilateral leg edema. Laboratory test results indicated renal dysfunction and proteinuria. Further evaluation revealed bicytopenia, and tests for antinuclear antibody and anti-double-stranded DNA were positive. Drug-induced lupus was initially considered, but her condition did not improve following hydrochlorothiazide discontinuation. Thus, late-onset lupus was diagnosed. Late-onset lupus is characterized by an insidious onset with nonspecific manifestations, and it is difficult to diagnose. Unexplained cytopenia in the elderly may be an essential characteristic to consider in late-onset lupus diagnosis.

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Objective:The aim of the current study was to investigate possible associations be- tween the site of abdominal pain and the organ involved. Methods:Patients with abdominal pain visiting the outpatient clinic of the Department of General Medicine of Saga University Hospital, Japan from April 2014 to July 2015 were retrospectively analyzed. The sites of pain and the organs involved were both classified into 11 categories, and the relation between them was statistically analyzed. Results:The study included 472 patients. The mean patient age was 50 years. There was a statistically significant association between right-subcostal pain and the hepatobiliary system. The highest likelihood ratio was 7.5 for the relation between right-subcostal pain and the musculoskeleton, followed by right-flank pain and the skin, left-subcostal pain and the musculoskeleton, entire abdominal pain and the intestine, and left-flank pain and the urinary tract. Conclusion:Identifying the site of abdomi- nal pain may facilitate correct diagnosis, because there is a statistically significant association between the site of abdominal pain and the organ involved.

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A 28-year-old Japanese man had complained of prolonged fever of unknown origin for 7 months. Because his pancytopenia was mild and serum C-reactive protein (CRP) level was negative, hematologic malignancy had not been suspected. After admission to our hospital, his serum lactate dehydrogenase (LDH) level gradually increased and bone marrow aspiration was performed. B lymphoblasts were detected by flow cytometric analysis, leading to a diagnosis of acute lymphoblastic leukemia/lymphoblastic lymphoma (ALL/LBL). Although no increase in serum CRP and slow progression of pancytopenia are rare in ALL/LBL, hematologic malignancy should be suspected in febrile patients with prolonged fever of unknown origin.

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