Kawasaki disease (KD) is an acute childhood febrile illness that is classified as a systemic vasculitis syndrome. Combination intravenous immunoglobulin (IVIG) and acetylsalicylic acid is the standard initial and second-line therapy for KD to resolve inflammation and reduce the occurrence of coronary artery lesions (CALs). The goal of treatment in the acute phase of KD is to decrease inflammation and arterial damage to prevent CALs. For IVIG-resistant KD, however, additional treatments should be administered promptly before CAL formation, such as steroids, infliximab, cyclosporin A (CsA), and plasma exchange (PE). Although the effectiveness of PE on refractory KD is well known, it is highly invasive, especially in infants. Therefore, safer treatments are needed to avoid or minimize the number of PE courses in severe infantile cases. We herein report the clinical outcomes of 2 infants with IVIG-resistant KD who were treated successfully with a combination therapy of CsA and PE as third-line treatment, thereby possibly reducing the number of PE sessions.

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In laparoscopic radical hysterectomy (LRH) for early-stage cervical cancer, uterine manipulation is essential to expand the surgical field by raising the uterus with appropriate force and direction. On the other hand, a phase III randomized controlled trial reported that minimally invasive surgery such as LRH has a poorer prognosis than laparotomy. The trial also pointed out that the use of a uterine manipulator might be one of the poor prognostic factors and a contraindication. We report a case who underwent LRH using a novel uterine manipulation method instead of a uterine manipulator. The patient was a 69-year-old woman diagnosed with stage IB1 cervical cancer, a usual-type endocervical adenocarcinoma, according to the cone biopsy. After being informed of the treatment options in detail, the patient requested LRH. Thus, we performed LRH with her written consent. The round ligament, fallopian tube, and ovarian ligament were sutured together by a thread at the uterine angle. We guided one end of the thread to the anterior wall of the lower abdomen and another to the contralateral umbilical level for traction. By adjusting the traction force of each traction thread, we could pull the uterus in an arbitrary direction to expand the surgical field. The anatomical structure around the uterine cervix was well confirmed by this method. The operation could be completed without intraoperative complications with a blood loss of 300g. The present case suggests that our approach may be helpful for uterine manipulation in LRH.

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A 32-year-old pregnant woman presented to our hospital at 32 weeks' gestation with progressive headache and visual disturbance. Head MRI revealed a homogeneously well Gd-enhanced parasellar lesion with optic chiasma compression. After delivery by cesarean section at 35 weeks' gestation, the lesion was biopsied by endoscopic endonasal approach and diagnosed as lymphocytic hypophysitis. External decompression with resection of the tuberculum sellar was also added for rapid decompression of the optic nerve to preserve visual function. The postoperative course was uneventful and visual function improved immediately after surgery.
Lymphocytic hypophysitis is rare and difficult to diagnose, especially during pregnancy. There is still no consensus on the treatment strategy. Although drug therapy is the most common treatment, surgical treatment may be considered in a case with drug resistance or worsening of neurological symptoms. In addition to biopsy, surgical treatment may include decompression of the optic nerve with removal of the lesion, although pituitary function cannot be preserved.
In the present case, the neurological symptoms improved immediately after endoscopic endonasal external decompression, which suggested that this novel procedure may be one of the treatment options for lymphocytic hypophysitis to preserve both visual and pituitary function, although careful consideration of the indications for this procedure is mandatory in each case.

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