The number of valve surgeries is increasing with a change in the disease structure from rheumatic valvular heart disease （VHD） to arteriosclerotic or degenerative VHD. The treatment strategies for VHD have also been changing over the last two decades. Repair techniques for valve regurgitation have been established with excellent long-term clinical results. As valve repair has advantages over prosthetic valve replacement in terms of avoidance of anticoagulation and reduced risk of valve infection, it has become the first choice for treatment of degenerative VHD even for infective endocarditis, which is closely related to dental caries, periodontal disease, and related dental procedures. With the development of technologies, minimally invasive cardiac surgery is evolving, including the introduction of video-assisted or robotically-assisted valve surgeries via minithoracotomy, or percutaneous transcatheter therapies. Notably, recently introduced transcatheter aortic valve replacement has shown excellent clinical results compared to surgical aortic valve replacement and has become a standard therapy for aortic stenosis in the elderly. Reoperative aortic valve replacement for a degenerated bioprosthetic valve can also be performed using the transcatheter “valve in valve” technique. These minimally invasive approaches are likely to become more widely adopted and may determine the scope of therapeutic strategies for VHD into the future.
Paraneoplastic pemphigus is a subtype of pemphigus that accompanies benign or malignant neoplasms. It is primarily accompanied by lymphoproliferative disorders, and manifests as painful oral mucositis along with a variety of skin lesions. Herein, we report the case of a 74-year-old woman with peripheral T-cell lymphoma who developed paraneoplastic pemphigus while on chemotherapy. During chemotherapy, the patient developed severe oral mucositis and was referred to our department because of the absence of improvement despite discontinuing chemotherapy 1 month earlier. Suspecting chemotherapy as the causative factor, we administered the patient with oral care; however, the oral mucositis worsened and bullous lesions developed on her extremities. We next suspected the cause to be paraneoplastic pemphigus and performed biopsies from an ulcer on the vermilion of the lip and from a bullous lesion on her skin. We treated her with oral prednisolone. Histopathological examination of the skin lesions revealed acanthosis, and an indirect immunofluorescence study revealed the intercellular deposition of immunoglobulin G in the transitional epithelium of the rat urinary bladder. Immunoblot analysis detected both envoplakin and periplakin proteins. Based on the results of our pathological analysis, paraneoplastic pemphigus was diagnosed. Her skin lesions improved noticeably; the oral lesions, while also showing some improvement, partially remained. Hence, the chemotherapy was restarted. However, the peripheral T-cell lymphoma worsened and she died of an underlying malignancy 6 months after her initial visit to our department.
Giant cell arteritis （GCA） is a chronic, idiopathic, granulomatous vasculitis, especially involving the extracranial branches of the carotid arteries, in particular, the temporal artery. GCA affects the elderly population and has a variable clinical presentation and devastating complications including vision loss. Physicians should be aware of its different clinical phenotypes so that they can recognize it early and promptly administer steroids, the main choice of therapy.
We report a case of GCA diagnosed by an initial manifestation of buccal tumorous nodule. A man in his seventies visited our department with a chief complaint of a left buccal nodule. On palpation of the left buccal mucosa, a hard nodule was felt. A biopsy of the buccal nodule was performed, and the histopathological diagnosis was GCA. The biopsy specimen was considered to be a part of the facial artery. He fulfilled the GCA diagnostic criteria established by the American Association of Rheumatology. Pulse steroid therapy was administered in the Department of General Internal Medicine, and his symptoms markedly improved. After initial treatment, there was no recurrence of symptoms.