Nasogastric tube syndrome (NGTS) is a complication of NGT placement that can cause sore throat, bilateral vocal cord paralysis, and airway constriction. Although rare, this condition should be known by all physicians because it is sometimes fatal. We report a case of NGTS that was successfully diagnosed and debrided with a rigid curved laryngoscope. A 79-year-old man was referred to our department for evaluation of persistent pharyngeal pain and dysphagia after thoracic aortic aneurysm surgery. He had restricted bilateral vocal fold abduction, and the NGT had been placed for nearly 120 days. After induction of general anesthesia, the patient underwent laryngeal examination using a rigid curved laryngoscope, which revealed ossified cricoid cartilage in the postcricoid area, leading to confirmation of NGTS. The NGT was removed, and the protruding bony lesion was debrided. Subsequently, the patient underwent gastrostomy to improve his nutritional status. One month later, the postcricoid lesion improved, and the patient was able to tolerate an oral diet. The pathophysiology of NGTS is thought to involve ulceration of the postcricoid mucosa and injury of the posterior cricoarytenoid muscle by contact with the NGT. Although the treatment has not been established, early removal of the NGT is important. In the present case, the rigid curved laryngoscope was useful for resection of the bony lesion, which contributed to early epithelialization and symptom improvement.

A 76-year-old woman was referred to our hospital for evaluation of markedly high intraocular pressures (IOPs): ≥40 mmHg in both eyes. No intraocular inflammation, pseudoexfoliation, or glaucomatous optic neuropathy was observed on ophthalmological examination. The 24-hour IOP fluctuations, measured with a Goldmann tonometer in the sitting position at 8, 12, 16, 20, and 24 o' clock, were 22/17, 33/28, 41/33, 30/22, and 30/24 mmHg, respectively, and showed a peak in the afternoon. The patient was diagnosed with ocular hypertension, and microhook trabeculotomy (μLOT) (right eye with lens reconstruction, left eye initially pseudophakic) was performed. After μLOT surgery in both eyes (4 days postoperatively in the right eye and 1 day postoperatively in the left eye), IOP decreased in both eyes to 12/15, 11/14, 12/15, 10/11, and 10/10 mmHg, and the fluctuation range was suppressed. At 3 months postoperatively (measured at 8, 12, 16, 20, 24, and 4 o' clock), the effect was maintained at 14/15, 15/19, 14/19, 11/12, 13/14, and 13/13 mmHg, respectively, but was slightly attenuated. In a patient with marked 24-hour IOP fluctuation, μLOT was effective in reducing IOP values and fluctuation.

A 38-day-old infant was referred to our hospital for evaluation of apnea, fever, and pyuria. Invasive bacterial infection, including meningitis, was suspected because of the presence of apnea. A contrast-enhanced CT scan revealed acute localized bacterial nephritis, and meningitis was ruled out. Gram-positive cocci and Gram-negative rods, ie, Enterococcus raffinosus and Escherichia coli, were isolated from a urine culture at the referring hospital. This case report describes the youngest case of E. raffinosus infection. Apnea was the main complaint, but the origin of fever was infant acute focal bacterial nephritis (AFBN) with mixed infection. In infants, bacterial infections, especially invasive bacterial infections, can result in poor outcomes and require careful evaluation and treatment. Furthermore, the possibility of AFBN should not be overlooked, because bacteriuria or leukocyturia may be absent and can flare up if antimicrobials are not administered for an adequate duration. Although ampicillin-susceptible E. raffinosus infection in our patient responded well to treatment, there have been reports of vancomycin-resistant enterococci, which highlights the importance of proper use of antimicrobial agents to avoid producing drug-resistant bacteria.

A rectovaginal fistula (RVF) is an abnormal tract between the rectum and vagina, which requires surgical intervention in many cases. Although there are many different therapeutic approaches for RVF depending on the patient's' condition, there are no established guidelines for the care of RVF. This study aimed to evaluate the results of laparoscopic colostomy in advanced cancer patients with RVF, and the safety and efficacy of this surgery. In this study, seven female advanced cancer patients with RVF were hospitalized and successfully treated with laparoscopic colostomy from 2015 to 2018 at our university hospital. Their data were retrospectively evaluated from their medical records. The early use of diverting stomas facilitated timely resumption of cancer treatment and enabled early treatment with chemotherapy or radiotherapy. Although vaginal stool leakage affected three patients, all patients recovered, experiencing neither pain nor infection during their cancer treatment. While colostomy was physically and mentally taxing for the patients, it improved the infection and pain caused by the RVF. We conclude that the early use of diverting stomas had two effects: a significant improvement in infection management and facilitation of the rapid resumption of cancer treatment.

Simple radiography is the most frequently and widely available technology to examine bone pathologies. Computed tomography (CT) can evaluate pathologies more accurately in multiple planes and three dimensions; however, radiation exposure is much higher than with simple radiography. In addition, diagnostic ability is decreased for both technologies when metal devices are present. Tomosynthesis is a radiographic technology used to evaluate tissues quasi−three-dimensionally with less radiation exposure. Tomosynthesis technology was recently upgraded to reduce the effects of metal artifacts. This case report compares examination time, medical expense, image resolution, and radiation exposure for upgraded tomosynthesis, simple radiography, CT, and standard tomosynthesis in three patients with metal devices in the affected knees. Examination times were similar for the imaging technologies. Diagnostic performance was better for upgraded tomosynthesis than for simple radiography and standard tomosynthesis, and similar to that for CT. Moreover, radiation exposure and expense were higher for tomosynthesis than for simple radiography but lower than for CT. These findings suggest that upgraded tomosynthesis is the best method for evaluating bone pathology when metal devices are present and radiation exposure must be limited.

Sellar reconstruction is important for preventing cerebrospinal fluid (CSF) leakage after transsphenoidal pituitary surgery. This report describes how, despite standard sellar reconstruction, CSF exudation resulted from dural thinning at the anterior skull base, outside the intrasellar area manipulated during pituitary tumor resection. A 76-year-old man underwent endoscopic transsphenoidal surgery for a pituitary tumor extending toward the anterior skull base. After opening the sellar floor, intractable bleeding from the anterior intercavernous sinus occurred during bone removal at the anterior skull base. Pseudocapsule-based extracapsular resection was completed after stopping the bleeding. On the 10th postoperative day, the patient developed CSF rhinorrhea complicated by marked pneumocephalus, and emergency endoscopic repair of the CSF leak was performed. CSF leakage originated from the thinned dura at the anterior skull base located outside the intrasellar area manipulated during tumor resection. The thinned dural area at the anterior skull base coincided with the site of intractable bleeding of the anterior intercavernous sinus during bone removal in tumor resection. The thinned anterior skull base dura was covered with fascia, overlaid with fat, and closed with the nasoseptal flap. Endoscopic CSF leak repair was successful. Severe damage to the anterior intercavernous sinus can cause extensive exposure of the single-layered inner meningeal dura, where thinning might result in CSF exudation. Therefore, use of autologous tissues to cover and reinforce the severely damaged area of the anterior intercavernous sinus might help prevent postoperative CSF exudation.

A 56-year-old right-handed man was referred to our hospital for evaluation of sudden-onset transient quadrantanopia, which was followed by throbbing headache consistent with migraine with aura (MA). Magnetic resonance imaging (MRI) of the right parieto-occipital cortex on admission showed a hyperintense region on diffusion-weighted imaging, which disappeared 7 days later. A small cortical infarct in the parieto-occipital cortex can cause MA-like headache, and the present infarct lesion was only detectable on MRI during the acute phase. Performing MRI for patients with suspected acute MA might help identify the cause of MA-like headache and ensure appropriate management of patients.

Prosopagnosia is a cognitive disorder in which facial recognition is severely impaired despite normal vision and intelligence. Prosopagnosia was first reported in the 1800s, but its cause remains unclear. Although other neurological symptoms are often present, some patients have pure prosopagnosia. The bilateral occipital lobes are believed to be associated with symptoms. Recent brain imaging techniques have identified the right fusiform gyrus (rFG), located at the junction of the right occipital temporal lobe, as the affected region. In this report, we present a case of associative prosopagnosia with no concomitant symptoms in a 76-year-old man. Brain magnetic resonance imaging detected a subcortical hemorrhage in the right temporal lobe. Using tractography based on diffusion tensor imaging, we visualized atrophy of the right inferior longitudinal fasciculus (ILF). This is the first time tractography has been used to show a clear association between associative prosopagnosia and ILF damage projecting from the rFG.

Schizophrenia develops during adolescence. Maternal infections during the fetal period increase the incidence of schizophrenia in children, which suggests that the pathogenesis involves neuroinflammation. Here, we report a case of new-onset schizophrenia in a 16-year-old boy after COVID-19. After developing COVID-19, he entered a catatonic state 4 days later and was hospitalized. Benzodiazepines alleviated his catatonia, but hallucinations and delusions persisted. Encephalitis and epilepsy were excluded by magnetic resonance imaging (MRI), encephalography, and cerebrospinal fluid examination. Psychosis persisted after the virus titer declined and the inflammatory response subsided. Moreover, the patient exhibited delusions of control—a Schneider's first-rank symptom. Schizophrenia was diagnosed, and olanzapine improved his symptoms. He had a brief history of insomnia before COVID-19 but his symptoms did not satisfy the ultra-high-risk criteria. However, COVID-19 may have facilitated development of schizophrenia through neuroinflammation and volume reduction in the gray matter of the right medial temporal lobe. This case demonstrates that infectious diseases in adolescents should be carefully managed, to prevent schizophrenia.

Painless thyroiditis, which is rare in children, exhibits the characteristic sequence of hyperthyroidism, including aggressive and disruptive behaviors. Unlike subacute thyroiditis or Graves' disease, painless thyroiditis is challenging to diagnose because of its mild symptoms and minimal or absent physical findings. Moreover, aggressive and disruptive behaviors in children with psychiatric disorders may be misconstrued as exacerbation of underlying symptoms. The present patient was a 16-year-old male with adjustment disorder who presented to a pediatric psychiatric clinic for assessment of irritability. After 4 months, he developed aggressive and disruptive behaviors that prompted initiation of risperidone but without improvement. After 1 month, he reported palpitations and dyspnea. His neck was supple and non-tender without thyroid enlargement. Thyroid studies revealed elevated free T4 and T3 levels and suppressed thyroid-stimulating hormone level, suggesting hyperthyroidism. A radioactive iodine uptake test revealed a barely visible thyroid gland, consistent with thyroiditis. Painless thyroiditis, without thyroid tenderness, was diagnosed. We describe a case of painless thyroiditis in an adolescent patient with aggressive and disruptive behaviors that were initially attributed to worsening of an underlying adjustment disorder. Even when minimal or no signs of hyperthyroidism are present, painless thyroiditis should be considered in the differential diagnosis of children with aggressive and disruptive behaviors. Awareness of potential anchoring bias is also recommended to prevent its delayed diagnosis of such behaviors.

Mixed connective tissue disease (MCTD) is characterized by mixed features of systemic lupus erythematosus, systemic sclerosis, and polymyositis/dermatomyositis and is rare in children. Here, we report a case of MCTD in a 10-year-old girl who presented at our hospital with arthralgia, Raynaud's phenomenon, and fatigue. Blood tests were positive for anti-U1-ribonucleoprotein (RNP) antibodies and for rheumatoid factors (RFs) IgG-RF and anti-galactose-deficient IgG. Levels of myogenic enzymes and hypergammaglobulinemia were elevated. Macrophages were prominent in bone marrow, with scattered phagocytic macrophages. MCTD was diagnosed based on the patient's symptoms and laboratory findings. Methylprednisolone pulse therapy combined with oral tacrolimus was administered, which led to resolution of symptoms. Three months after pulse therapy, arthralgia worsened and methotrexate was administered. Arthralgia improved but did not resolve. Magnetic resonance imaging performed to investigate the hip pain revealed a mature ovarian teratoma, which was surgically removed. Because the pain persisted and interfered with her daily life, she was treated with tocilizumab for joint pain relief, which decreased the pain level. Tocilizumab is a candidate for additional treatment of juvenile idiopathic arthritis-like arthritis associated with childhood-onset MCTD.

Anisakiasis is a parasitic infection affecting the human gastrointestinal tract. It is caused by the consumption of contaminated, raw or inadequately cooked fish or squid, which is typically used for making sushi and sashimi. Most cases involve gastric anisakiasis, whereas intestinal anisakiasis is rare. This report describes the case of a 63-year-old Japanese woman with a history of raw fish consumption who presented with acute-onset abdominal pain and vomiting. Abdominal computed tomography (CT) demonstrated thickened small bowel loops and ascites on the liver surface. The patient was admitted for supportive care. On the second day of hospitalization, contrast-enhanced abdominal CT revealed that the ascites had moved from the liver surface to the pouch of Douglas. On the fifth day of hospitalization, the patient was discharged with a substantial improvement in abdominal pain. Five days after the discharge, her eosinophil count was elevated, and parasitic disease was therefore suspected. Anti-Anisakis IgG/A and IgE (RAST) antibody levels were elevated, confirming the diagnosis of intestinal anisakiasis. A review of 51 reported cases of intestinal anisakiasis suggests that the presence of ascites and measurement of anti-Anisakis antibody titers are helpful for diagnosis in cases presenting with nonspecific abdominal symptoms after consumption of raw or undercooked fish.

Renal abscesses require prompt diagnosis and appropriate intervention, as they can be life-threatening. However, diagnosis based solely on clinical findings is often challenging. We present the case of a 69-year-old woman with left renal masses on follow-up computed tomography (CT) after surgery for pT2aN0M0 lung carcinosarcoma. The masses were localized only in the left kidney without suspected metastatic lesions at other sites. The patient was referred to our department for further evaluation and treatment under a diagnosis of suspected metastatic lung carcinosarcoma of the left kidney. On enhanced CT, the left renal masses, the largest of which had a diameter of 40×36 mm had thick irregular walls gradually enhanced by the contrast media and an internal low-attenuation area. The masses showed heterogeneous signal intensity with a pseudocapsule on T2-weighted magnetic resonance imaging. Clinical symptoms such as fever or costovertebral angle tenderness were absent, and blood and urine tests were not sufficiently inflammatory to suggest a renal abscess. Histopathological findings on CT-guided renal biopsy revealed only inflammatory tissue and no tumor cells. However, because lung carcinosarcoma metastatic nodules could not be ruled out, laparoscopic left nephrectomy was performed for a definitive diagnosis and curative intent. The pathological diagnosis was renal abscess without malignant lesions. Here, we present a case of renal abscess mimicking metastatic lesions in a patient with lung carcinosarcoma. Accurately differentiating renal abscesses from metastatic renal tumors before treatment is often difficult. Renal abscess diagnosis should be considered through a comprehensive evaluation of the clinical findings of individual cases.

Ischemic colitis is a common disease with a good prognosis; however, complications can occur in the presence of a serious underlying disease. Herein, we present a case report in which characteristic findings on lower gastrointestinal endoscopy led to a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). An 82-year-old woman visited our hospital for chronic heart and renal failure. She had a history of breast cancer, myocardial infarction, and hemorrhoidal fistula and was initially hospitalized for ischemic colitis. Subsequent lower gastrointestinal endoscopy revealed extensive ulcerative lesions in the ascending, transverse, and descending colon. Histopathologically, small vessels exhibited multiple fibrin thrombus formations. Based on histopathological and endoscopic results, the presence of an underlying disease was suspected. Flow cytometric analysis showed that erythrocytes and granulocytes had 5.5 and 86.4% CD55- and CD59-negative cells, respectively. The patient was ultimately diagnosed with PNH and considered severely ill, given the ischemic colitis-induced abdominal pain and the need for red blood cell transfusions (4–6 units per month). Accordingly, the patient was administered ravulizumab. Ischemic enteritis did not relapse following ravulizumab administration, and transfusion dependence improved. If a patient with ischemic colitis presents atypical lower gastrointestinal endoscopic findings, it is important to explore the presence of an underlying disease.

Extrahepatic portal vein obstruction (EHPVO) is a very rare disease-causing portal hypertension. Myeloproliferative neoplasm (MPN) including essential thrombocythemia (ET) is reported as a risk factor for EHPVO due to underlying persistent thrombophilia.

A Japanese woman in her 40s was referred to our hospital with a one-month history of gastric variceal bleeding due to EHPVO. Laboratory investigation demonstrated thrombocytosis despite portal hypertension. She had a mutation of clonal marker JAK2V617F with EHPVO, which prompted us to consult a hematologist. Bone marrow biopsy revealed megakaryocyte lineage proliferation, leading to a diagnosis of ET.

Esophagogastroduodenoscopy indicated esophagogastric varices (LsF2CbRC2, Lg-cF1RC1). Abdominal Computed Tomography and angiography revealed splenomegaly and portal vein thrombosis with cavernous transformation. These radiologic findings suggested EHPVO.

The patient had a history of ruptured esophagogastric varices and required prophylaxis against further variceal bleeding prior to anti-thrombotic therapy for EHPVO with ET. We performed laparoscopic Hassab's operation followed by endoscopic variceal ligation (EVL) and hematological cytoreduction therapy.

Laparoscopic Hassab's operation and three bi-monthly EVL improved the esophagogastric varix (LmF0RC0, Lg-f F0RC0) at 6 months after surgery. Platelet count decreased to 60.1 x10⁴ /uL by cytoreduction therapy. She was very healthy at 7 months after surgery.

Patients with EHPVO are traditionally referred to the gastroenterologist for abdominal pain, intestinal bleeding, or refractory ascites; however, hypercoagulative disease may be occult in such patients and require the attention of a hematologist. When encountering the patients with splanchnic thrombosis caused by EHPVO, the gastroenterologists should screen for hematological disease, including MPN.

Invasive neonatal infection with Group B Streptococcus (GBS) is a disease of concern that can lead to neurological sequelae. Guidelines for preventing mother-to-child transmission have been introduced to reduce the incidence of early-onset infection, but guidelines for controlling the late-onset form are lacking. Recently, the trans-breastfeeding route of transmission has been highlighted as an example of late-onset infection, but no consensus on how to manage such infections has been reached. In this report, we describe a case of late-onset bacteremia/meningitis in a neonate suspected to have been infected with GBS via breastfeeding. A vaginal culture test of the mother at 35 weeks' gestation was negative for GBS. Since she had symptoms of mastitis, breast milk and nipple cultures were also tested and found to be positive for the strain of GBS identified in the neonate on genetic analysis. Diagnosis of trans-mammary GBS infection is challenging because breastfeeding-related events are difficult to identify. In our case, the diagnosis was based on the mother's history of mastitis, and the patient was treated without escalation to sequelae. When a neonate develops a fever, physicians should consider GBS infection and examine the mother's medical history to facilitate accurate diagnosis, especially if the history includes mastitis. A breast milk culture should be performed if the mother has mastitis, especially in cases of infection in preterm infants and in recurrent cases.