Nosocomial transmission of multidrug-resistant Streptococcus pneumoniae (MDRSP) is rare but possible. We report a case of an older woman who developed invasive MDRSP infection acquired via possible nosocomial transmission. We aim to highlight the challenges Japan faces regarding its increasing susceptible elderly population, the low rates of pneumococcal vaccination, suboptimal adherence to standard precautions, and the possible need for transmission-based precaution policies for MDRSP.

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A 31-year-old man with a 10-year history of migraine was referred to our hospital with a treatment-resistant chronic headache. He complained of a gradually worsening headache, with sharp pain appearing for several hours, as if having just eaten ice-cream. Five years previously, his headaches began to persist throughout the day, with no complete remission. With extremely severe headaches, he sometimes stayed in bed for a few days. He had been prescribed analgesic SG combination granules (an isopropylantipyrine, acetaminophen, allylisopropylacetylurea, and caffeine combination) 7 years previously, which he had taken 2 to 4 times daily for the past 5 years. Using International Classification of Headache Disorders diagnostic criteria (3rd Edition), he was diagnosed with a medication overuse headache (MOH) (8.2.5 Combination-analgesic- overuse headache). One month later, following complete discontinuation of his analgesic medication, his headaches had improved significantly (numeric rating scale, 1-2/10). MOHs can be overlooked as refractory headaches. Physicians should be aware that patients with MOHs may present with non-specific headache symptoms, including cold stimulus-like headaches, and an active headache and medication history should be taken to ensure accurate diagnosis and effective treatment, such as discontinuation of the causative agents.

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A 23-year-old Japanese woman with Crohn’s disease treated with mesalazine one year previously presented with a four-day history of fever, dry cough, and chest pain during swallowing. Chest computed tomography revealed wall thickening on the trachea, whereas magnetic resonance imaging (MRI) confirmed a high-signal intensity and wall thickening on the trachea. Laboratory data showed leukocytosis and increased inflammatory response. We initially considered a diagnosis of bacterial infection and relapsing polychondritis, but antibiotics and steroid administration were ineffective. We considered that respiratory disorders associated with inflammatory bowel disease was unlikely, because colonoscopy showed no active findings of Crohn’s disease. However, when we interrupted mesalazine on day 12, all of the symptoms disappeared, and white cell count and inflammatory response gradually improved. Although there have been reports of mesalazine causing respiratory complications, this is the first case of lesions confined to the trachea.

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