This is the case of an 89 -year-old man with lower back pain who reported difficulty in mobility 10 days before presenting to the emergency department of our hospital. He had a large pressure ulcer from his sacrum to the buttocks that measured 11 cm on the major axis. Computed tomography revealed gas formation in the subcutaneous tissues of the sacrum up to the perineum and both buttocks. The patient was diagnosed with Fournier’s gangrene secondary to pressure ulcer infection and was immediately hospitalized. On day 2 of hospitalization, he underwent expeditious debridement at the emergency outpatient unit, a laparoscopic sigmoid colostomy procedure, and further gangrene debridement. On day 15, he underwent the shoelace technique and negative pressure wound therapy with instillation and dwelling. On day 59, he received a split-thickness skin graft. Sufficient epithelialization was observed subsequently, and the patient was transferred to another hospital for rehabilitation on day 106 of hospitalization. This case suggests that wound management with laparoscopic sigmoid colostomy is safe and effective for the pressure ulcers of patients at risk of fecal contamination of the perineum.

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We describe an 82-year-old woman who developed Zolpidem-induced sleep-related eating disorder. She had a complaint that she seemed to be eating all over the place during nighttime sleep for about 6 months. Based on the history of abnormal, unconscious eating during sleep, a diagnosis of sleep-related eating behavior disorder was made. The patient’s complaints went away after the suspected drug, Zolpidem 10 mg/day, was reduced. We should consider that even elderly patients with recurrent eating behavior abnormalities can have drug-induced sleep-related eating behavior disorders.

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[Background] Hypoglycemia is a symptom of late dumping syndrome (LDS). LDS is caused by the rapid jejunal influx of carbohydrates, a rapid rise in blood glucose level, excessive insulin secretion, and delayed suppression of excessive insulin secretion by altered physiological continuity of the upper gastrointestinal tract. It presumably manifests itself in the early period after gastrectomy. [Cases] We experienced four patients who each showed no physical signs of Addison’s disease, but who were referred to our hospital because of frequent hypoglycemia. Each patient had undergone gastrectomy several years previously. All patients experienced hypoglycemia with glucose levels less than 50 mg/dL within 60 minutes of a 75-gram modified glucose tolerance test. These findings were consistent with LDS. Low-dose adrenocorticotrophic releasing hormone stimulation tests revealed that cortisol peak levels were less than 20μg/dL in each case. We therefore diagnosed these patients with subclinical adrenal insufficiency. After administration of hydrocortisone, the hypoglycemia was resolved in each case. [Conclusions] LDS may manifest many years after gastrectomy because of the subclinical development of adrenal insufficiency.

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A 62-year old man was admitted because of cough and fever. Chest X-ray and CT scan showed ground- grass opacity in the bilateral lungs. Initially he was diagnosed as community-acquired pneumonia and his symptoms were improved by intravenous antibiotics. He developed fever and exercise-induced dyspnea at home on the day of discharged. The BALF findings were compatible with hypersensitivity pneumonitis. Although his symptoms and laboratory data were improved after admission, recurrence happened when the patient went home, even though his house had been cleaned. A serum antibody test against Trichosporon asahii was negative. It was revealed that second-hand humidifier had been used for half a year. A provocation test using the humidifier induced fever and increased peripheral WBC count and serum CRP. A diagnosis of humidifier lung was confirmed by these findings. The serum precipitation test was positive for Candida albicans. No recurrence occurred after he stopped using the humidifier.

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An association between diabetes mellitus and ulcerative colitis (UC) has been suggested in epidemiological studies. However, the etiology of the coexistence of these diseases is unknown. Here, we report a case of diabetes mellitus due to insufficient insulin secretion newly developed through exacerbation of UC. A 66-year-old woman without a history of diabetes or obesity who was diagnosed with UC and started taking mesalazine four years previously presented with abdominal pain and mucous stool that began a month previously. She was treated with an increased dose of mesalazine without steroid, but started presenting excessive thirst and weight loss. A blood test showed highly elevated glucose and HbA1c levels (639 mg/dl and 10.0 %, respectively), indicating newly onset diabetes. Although islet-specific autoantibodies were undetectable and serum ketones were not significantly increased, her fasting serum CPR level was as low as 0.48 ng/ml even after the glucose level improved, indicating that insulin therapy was continuously required. When the UC conditions were improved four months later, the fasting CPR level was increased to 1.45 ng/ml. She successfully discontinued insulin therapy seven months later. In this case, we found a relation between UC activity and the ability to secrete insulin. Hospitalists should be cognizant of diabetes in patients with uncontrolled UC.

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A 79-year-old man came with a complaint of newly developed right-handed paralysis that had continued for one month. He had a history of left putaminal hemorrhage and had a residual mild movement disorder in his right upper and lower limbs. A finding of right wrist drop was newly revealed, and recurrence of cerebrovascular disease was suspected. Diagnostic imaging test showed no abnormalities indicating new cerebrovascular events. An additional interview revealed that hematochezia had continued for three months. Colonoscopy led to a diagnosis of sigmoid colon cancer. Laparotomy sigmoid resection was performed for his cancer, and physical therapy for the right wrist drop was continued. Two months after the operation, the right wrist drop improved. As a result, the patient was clinically diagnosed with paraneoplastic neurological syndrome. In this case, there was a newly developed neurological deficient symptom. Clinical features that need to be differentiated from cerebrovascular disease are called stroke mimics. Imaging testing did not lead to a diagnosis, but the addition of a closed question contributed to the confirmation of the diagnosis. While cerebrovascular disease is common in the elderly, it is becoming more important to accurately distinguish stroke mimics in neurological acute care.

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A man in his 30s was brought to the emergency room because of recurrent limb weakness and myalgia. On arrival at the hospital, he was found to have severe hypokalemia, which was corrected by intravenous potassium supplementation. After admission, blood tests showed hyperthyroidism, and endocrinological examination revealed Graves’ disease, Hashimoto’s disease, and slowly progressive type 1 diabetes mellitus. Therefore, autoimmune polyglandular syndrome (APS) type 3A was diagnosed. APS is an autoimmune disease that causes dysfunction in multiple tissues, including endocrine glands. APS type 3A is an autoimmune thyroid disease complicated by type 1 diabetes mellitus without Addison’s disease. Although APS type 3A is sometimes diagnosed based on the presence of complications associated with type 1 diabetes mellitus, such as diabetic ketoacidosis, no reports have described the diagnosis of APS type 3A based on hypokalemia, as in this case. It is important to determine the causative disease in patients with repeated electrolyte abnormalities. In addition, if diabetes mellitus is found in patients with thyroid dysfunction, further investigation should be performed to check for APS.

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We encountered a case of acute onset gait disorder in a patient who had lived in a car for more than 10 years. Dehydration, cerebral infarction, and lower limb venous thrombosis were suspected. However, blood and imaging tests did not identify a specific cause. After excluding various diseases, we diagnosed nutritional neuropathy based on findings of axonopathy from a peripheral nerve conduction test of the lower limbs, in addition to a long-term history of an extremely unbalanced diet (only favorite foods). Our experience with this patient emphasizes the continued existence of malnutrition-related diseases caused by inappropriate diet, even in the rich nutritional environment of present-day Japan.

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[in Japanese]

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