Ruminococcus gnavus (R. gnavus), which constitutes a part of the human intestinal flora, has been isolated in cases of septic arthritis and bacteremia with intestinal lesions. We report a case of bacteremia with R. gnavus in a very elderly man who presented with prolonged fever, but in whom the bacteremia was not associated with septic arthritis or intestinal lesion.

A 90-year-old man exhibited fever of approximately 38°C for 2 months. Two sets of blood culture samples were obtained. R. gnavus was detected in one of the anaerobic culture samples. Contrast computed tomography, positron emission tomography, and lower gastrointestinal-tract endoscopy did not demonstrate septic arthritis or intestinal lesions. He was treated for 16 days with ampicillin (4,000 mg) and 7 days with metronidazole (1,500 mg) intravenously, which resulted in improvement of his symptoms and negative blood culture. This is the first case of R. gnavus bacteremia without septic arthritis or intestinal lesions in a very elderly patient. With the global increase in the aging population, such cases are likely to become more frequent.

Our experience suggests that it is important to perform blood cultures in order to clarify the cause of fever in the elderly. As there are only a few case reports of R. gnavus infection, this report presents a novel clinical feature of R. gnavus infection.

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As adenomyomectomy can generate defects in the uterine muscular layer, pregnancy after adenomyomectomy is at significant risk of uterine rupture. We report a 40-year-old nulliparous woman who underwent uterine adenomyomectomy two years earlier. She underwent in vitro fertilization at an infertility clinic, resulting in pregnancy. However, at 7 weeks, the muscular layer covering the gestational sac was found to be precariously thin, and she was referred to our department. Transvaginal ultrasonography revealed that the gestational sac was localized within the muscular layer of the anterior uterine wall and a fetus was growing with heartbeat. The muscular layer over the sac was as thin as 2.4 mm and associated with marked development of blood vessels. The position of villi suggested that implantation occurred at the site of the adenomyomectomy scar. After thorough counseling, we injected methotrexate (MTX) into the sac, followed by systemic administration of the drug. However, due to the liver toxicity of MTX and re-elevation of the human chorionic gonadotropin level, we performed surgical evacuation. As it was difficult to excise the intramuscular gestational tissue by the conventional resectoscopic approach, we applied the “Transcervical Trocar Technique”, which was developed in our department. We first inserted a 12-mm camera port sheath through the uterine cervix, and then simultaneously inserted a thin diameter scope, suction/irrigation devices, and laparoscopic surgery forceps through the sheath. Through this approach, we successfully removed the residual gestation tissue within the muscular layer and spared the uterus. Our technique allows us to effectively perform transcervial surgery for lesions in the muscular layer using multiple forceps.

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A woman in her fifties was diagnosed with hypoplastic acute myeloid leukemia (AML). Soon after induction treatment, she developed pulmonary infiltrates in the lower lobe of the right lung, which shortly evolved into disseminated disease involving the left thorax, spleen, and liver. Although she had this life-threatening complication, complete hematological response was achieved after salvage and consolidation treatments. Positron emission tomography combined with computed tomography demonstrated formation of multiple abscesses, and biopsy of the liver revealed fungal hyphae, the morphology of which suggested mucormycetes; however, culture yielded no growth. As involved lesions remained unchanged or even deteriorated after >4 months of liposomal amphotericin B treatment, and because the underlying AML was in remission with normal hematopoietic recovery, the patient underwent carefully organized two-stage surgery to debride infected organs and tissues. The surgical specimens were composed of necrotic debris, but some areas contained hyphae with similar morphological features as those of the liver biopsy. The causative fungal pathogens were identified as Rhizomucor pusillus by a polymerase chain reaction-based molecular method. Currently, she regularly visits the out-patient clinic and is free from leukemia. This report suggests that extensive surgical debridement should be considered for disseminated mucormycosis when clinically possible.

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The uterus is formed by paramesonephric duct fusion during embryonic development. Rare mesonephric remnants lead to hyperplasia and mesonephric adenocarcinoma. We report a case of adenocarcinoma with mesonephric hyperplasia that was difficult to diagnose. We report a case of a 53-year-old, para 2, woman who was referred to our hospital because of irregular vaginal bleeding. She was diagnosed with endometrial cancer by biopsy because of endometrial thickening. Furthermore, a 5-cm localized adenomyosis lesion was observed in the uterine cervix on contrast MRI, and stage IA endometrial cancer was suspected. We performed cervical conization. Histopathology revealed uterine cervical cancer, possibly diffuse mesonephric hyperplasia adenocarcinoma, and cervical-endometrial curettage revealed endometrioid adenocarcinoma Grade 1. Suspecting cervical mesonephric adenocarcinoma, we performed radical hysterectomy with bilateral salpingo-oophorectomy. We visually confirmed several yellow pea-sized polyps protruding from the uterine isthmus; however, the myometrium and uterine cervix were normal. HE staining confirmed the 5-cm cervical lesion. Aggregates of cysts containing hyaline were present, but were not atypical. The adenocarcinoma was localized in the polyps protruding from the lumen, and the final diagnosis was endometrial cancer (endometrioid adenocarcinoma, Grade 1, pT1aN0M0 + diffuse mesonephric hyperplasia). According to the Treatment Guidelines for Endometrial Cancer, it is in the low-risk group, and additional treatments are not recommended. In cases of cervical mesonephric adenocarcinoma, additional treatment is required according to the Treatment Guidelines for Cervical Cancer. Therefore, we evaluated this case at the Meeting of the Japan Society of Gynecological Oncology. Immunohistochemically, the polyps were positive for CK, partially positive for CEA, and negative for p53, calretinin, CD10, and ER. Mesonephric hyperplasia lesions were negative for all markers. The 12 pathologists did not reach a consensus, but the final diagnosis was adenocarcinoma of the uterine isthmus with mesonephric hyperplasia, which was difficult to classify. We administered additional chemotherapy, and the patient has not developed recurrence for three years postoperatively.

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