[Objective]We aimed to examine the clinical course of patients with toxic shock syndrome (TSS) from onset to diagnosis and to evaluate the reasons for misdiagnosis or diagnostic delay in a single center in Japan. [Methods]We retrospectively evaluated the characteristics of TSS cases at two hospitals in Japan. We reviewed the medical records of patients diagnosed with TSS admitted to our hospital between April 2011 and January 2019. [Results] Eleven patients were evaluated. The triggers for TSS were tampon use during menstruation, burns, erysipelas, vaginal delivery, surgery for appendicitis, and respiratory tract infections. The most common initial symptoms were fever, vomiting, diarrhea, and erythema. Three patients fulfilled all five diagnostic criteria defined by the Centers for Disease Control and Prevention. Two patients only fulfilled four criteria and three six criteria. [Conclusions]TSS has no specific symptoms, and its diagnostic criteria are unsuitable for achieving an early diagnosis. Therefore, diagnostic errors are possible in early-stage TSS cases. Physicians should consider the possibility of TSS if patients present with a poor general appearance with fever, digestive symptoms, and/or erythema, despite not fulfilling the diagnostic criteria for TSS.

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Although cerebellar infarction can be confirmed by head computed tomography (CT), it could be easily misdiagnosed in the emergency department. In recent years, a head CT scan is often performed with thin slices, except for cases where stroke is suspected, which requires thin and thick slices to avoid misdiagnosis. A 54-year-old man with poorly controlled diabetes mellitus visited another emergency department 1 day after experiencing sudden nausea, vomiting, and unsteadiness. Upon examination, including head CT, the cause of the symptoms remained unclear. Although nausea was alleviated, unsteadiness remained and, therefore, he was admitted to his family clinic because of unsteady walking 4 days before visiting our hospital. Although he was still receiving treatment in the clinic, the unsteady walking remained and, therefore, he presented to our hospital. On presentation, the patient demonstrated ataxia while in a standing position. On head CT, left cerebellar peduncle infarction was detected and confirmed by images reconstructed from thick slices. Therefore, physicians should use both thin and thick slices of head CT images for patients suspected of cerebral infarction. In addition, CT scans should be re- examined when abnormal neurological findings, such as truncal ataxia, are observed.

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A 77-year-old woman experienced acute muscle pain and weakness in the bilateral legs. Muscle magnetic resonance imaging revealed myositis, and muscle biopsy showed noncaseating granuloma. Since there were no significant findings except for elevated CD4-to-CD8 ratio on bronchoalveolar lavage, the patient was diagnosed with isolated muscular sarcoidosis.

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