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We encountered a 64-year-old Japanese woman who developed subarachnoid hemorrhaging (SAH) with multiple cerebral artery stenoses during remission induction therapy for eosinophilic granulomatosis and polyangiitis (EGPA). The treatment involved intensified steroid pulse therapy and continued intravenous cyclophosphamide pulse therapy, which led to beneficial effects. Given the rarity of multiple EGPA-associated cerebral artery stenoses and SAH, it is crucial to differentiate them from other diseases. The mortality rate of EGPA complicated by intracranial hemorrhagic lesions, including SAH, is high. When headache is present at the onset of EGPA, the possibility of SAH must be considered. more...

Streptococcal toxic shock syndrome (STSS) has a dramatic clinical course and high mortality rate. Here, we report a case of STSS complicated by primary peritonitis and bilateral empyema. A previously healthy young woman was diagnosed with STSS complicated by primary peritonitis and bilateral empyema. Blood culture results on admission were negative. Sever shock, respiratory failure, systemic inflammation, thrombocytopenia, renal failure, ascites, and pleural effusion occurred, mimicking thrombocytopenia, anasarca, fever, reticulin fibrosis/renal failure and organomegaly (TAFRO) syndrome. Retesting blood cultures identified Streptococcus pyogenes . Gram staining of ascites and pleural fluid indicated gram-positive cocci in chains. Antibiotics, immunoglobulins, and surgical intervention led to recovery without complications. Ex-post genotypic analyses showed uncommon emm103 .0 (cluster E3) of emm long sequence (784 base) and novel sequence type 1363. STSS diagnosis can be difficult as it mimics other systemic inflammatory diseases. Therefore, it is crucial for clinicians to perform microbiological examinations from infection foci, even if the initial culture is negative., Competing Interests: None., (© 2024 The Authors.) more...

Background: Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales have become a global concern owing to increased infections, high mortality, and limited antibiotic treatment options. Carbapenems (CPMs) are effective against ESBL-producing Enterobacterales, but their overuse leads to the emergence of multidrug-resistant bacteria. Cefmetazole (CMZ) is effective in vitro; however, its clinical efficacy remains unclear., Methods: We retrospectively reviewed patients who were treated with CMZ or CPMs for bacteremia caused by ESBL-producing Enterobacterales between 1 April 2014 and 31 September 2022 at Tenri Hospital. The primary outcome measure was 90-day mortality. We also evaluated resistance genes and sequence types of ESBL-producing Enterobacterales., Results: In total, 156 patients were enrolled in this study. Ninety patients (58%) received CMZ therapy. Patients in the CMZ group were significantly older than those in the CPM group (median [IQR], 79 years [71-86] vs 74 years [64-83]; P = .001). The severity of the Pitt bacteremia score of the CMZ group was lower than that in the CPM group (0 [0-2] vs 2 [0-2], P = .042). Six patients (7%) in the CMZ group and 10 (15%) in the CPM group died by day 90 ( P = .110). Charlson Comorbidity Index and prevalence of sequence 131 between the groups were statistically insignificant., Conclusions: Our findings suggest that CMZ is a well-tolerated alternative to CPM for treating bacteremia caused by ESBL-producing Enterobacterales., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.) more...

We encountered a case of refractory adult-onset Still's disease (AOSD) with two relapses. Prednisolone and methotrexate were begun as induction therapy, resulting in the patient's first relapse during tapering of prednisolone. After the introduction of tocilizumab, she achieved remission. However, she experienced a second relapse following prednisolone tapering. While lactate dehydrogenase (LDH) levels and white blood cell (WBC) counts increased in both relapses, interleukin-6 (IL-6) suppression resulted in stable C-reactive protein and ferritin levels in the second relapse. A comparison of the two relapses indicated that increases in both WBC counts and LDH levels can aid in the diagnosis of AOSD relapse. more...

We herein report a case of multisystem inflammatory syndrome in adults (MIS-A) complicated with Kikuchi-Fujimoto disease (KFD). A previously healthy 41-year-old man presented with painful swelling of the cervical lymph nodes, fever, diarrhea, conjunctivitis, edema, and hypotension one month after the onset of asymptomatic coronavirus disease 2019. Laboratory investigations revealed an elevation of CRP, and echocardiography indicated diastolic dysfunction. We diagnosed the patient to have MIS-A. Histopathology of the lymph nodes showed necrotizing lymphadenitis. After the initiation of hydrocortisone and diuretics, his symptoms resolved immediately. This case suggested that post-viral immune dysregulation in MIS-A could play a role in the etiology of KFD. more...

TAFRO syndrome is a rare disorder that manifests as thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. Although this disease often follows a severe clinical course, the cause remains unknown. The coronavirus disease 2019 (COVID-19) pandemic is a major global problem. Vaccination against COVID-19 has been successful; however, there are concerns about severe adverse events. Herein, we report a rare presentation of TAFRO syndrome triggered by the COVID-19 vaccine with a fatal clinical course. A 42-year-old Japanese man presented to our hospital complaining of fever lasting for 2 weeks that occurred a day after receiving the BNT162b2 mRNA (Pfizer-BioNTech) COVID-19 vaccine. The patient had a low platelet count, ascites, reticulin myelofibrosis, renal failure, and lymphadenopathy and was diagnosed with TAFRO syndrome. Despite administering several immunosuppressive drugs, the condition did not improve. The patient repetitively developed and eventually died of bacteremia caused by multidrug-resistant Klebsiella pneumoniae. We highlight the first reported case of TAFRO syndrome after COVID-19 vaccination., (Copyright © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.) more...

Mycobacterium farcinogenes is the causative agent of bovine farcy. M. farcinogenes shares common properties with rapidly growing mycobacteria, and distinguishing between M. farcinogenes and M. fortuitum is reportedly complex and challenging. Moreover, few studies have isolated M. farcinogenes from human clinical samples. A previously healthy 37-year-old male construction worker presented to the emergency department after a severe injury and was diagnosed with a Gustilo-Anderson type ⅢA fracture. After an uneventful postoperative period of two months, he experienced pain and serous discharge from the upper shin and lower calf region. Frequent debridement provided no relief, and the pathology cultures of the tissue were negative. However, M. farcinogenes was isolated from the fluid of the wound. The patient's symptoms gradually improved with anti-mycobacterial drug treatment. Nontuberculous mycobacterial infections, including those caused by M. farcinogenes , should be considered in patients developing soft tissue infections despite negative pyogenic bacterial cultures several months after sustaining an open fracture., Competing Interests: We have no conflict of interest to declare., (© 2022 The Authors.) more...

Background: The coronavirus disease 2019 (COVID-19) pandemic is associated with a heavy burden on patient's mental and physical health, regional healthcare resources, and global economic activity. An aging society such as Japan has many retirement homes and long-term stay hospitals for the elderly and their inhabitants. During the COVID-19 pandemic, disease clusters are often identified in retirement homes and long-term stay hospitals. Although we hypothesize that additional burdens of nursing care for elderly patients will reinforce the anxiety and exhaustion of medical staff and healthcare resources in the aging society, the actual situation is not well understood. In this study, we aimed to evaluate the current situation and countermeasures of the COVID-19 pandemic in the aging society. Methods: We reviewed COVID-19 patients who required hospitalization at the National Hospital Organization Kyoto Medical Center, a 600-bed capacity hospital located in Kyoto, Japan, between 1 April 2020 and 31 March 2021. We assessed the characteristics of the COVID-19 patients, disease severity, duration of hospitalization, outcome at discharge, degree of activities of daily living (ADLs), and complications unique to elderly patients. Results: We enrolled 118 patients who required hospitalization during the study period. Approximately 40% of the patients were aged ≥ 80 years. Dementia (27.1%) was the most prevalent underlying disease, followed by diabetes mellitus (23.7%) and chronic kidney disease (23.7%). Approximately 60% of hospitalized COVID-19 patients had impaired ADL at admission. The COVID-19 patients aged 80 years or older required significantly more longer-term hospitalization than the COVID-19 patients aged under 80 years (15.5 ± 8.2 vs. 13.1 ± 7.7, P = 0.032). In elderly patients aged 80 years or older, approximately 50% of patients had geriatric mental disorders, and approximately 70% had bedridden status and feeding difficulty. Poor ADL at admission was significantly associated with COVID-19 mortality (Odds ratio, 5.6; 95% confidence interval, 1.04-45.2; p -value = 0.044). Conclusions: The proportion of elderly patients aged 80 years or older was relatively high during the hospitalization for COVID-19. Poor ADL at admission in these elderly patients was significantly associated with poor prognosis of COVID-19. We should keep in mind that healthcare workers are forced to have an additional burden of nursing care in the aging society during the COVID-19 pandemic. Therefore, interventions to reduce the burden are urgently required., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Fujita, Kashihara, Kanai, Hata, Yasoda, Odagaki and Mio.) more...

Disseminated nontuberculous mycobacterial (NTM) infections usually occur in severely immunosuppressed patients. These infections may also occur in previously immunocompetent patients with acquired anti-interferon-gamma antibodies (anti-IFN-γ Abs). A previously healthy 33-year-old man presented with a 3-week history of cough and fever. Chest computed tomography showed air-space consolidation in the middle lobe of the right lung and enlargement of the supraclavicular, mediastinal, and hilar lymph nodes. Tissue samples obtained via mediastinoscopy showed granuloma formation with acid-fast bacteria; cultures from the tissue revealed Mycobacterium kansasii . Accordingly, a diagnosis of disseminated M. kansasii disease was made. The positive control tested negative in the QuantiFERON-TB Gold In-tube test, suggesting the presence of anti-IFN-γ Abs. The ELISA test for anti-IFN-γ Abs demonstrated an increased titer. Antimycobacterial drug treatments were initiated after diagnosis. His symptoms improved over 2 months, and he remains well on outpatient management. Disseminated M. kansasii disease is a very rare condition suggestive of immunosuppression. Testing for anti-IFN-γ antibodies might be important in all cases of disseminated M. kansasii disease. more...

Septic pulmonary embolism (SPE) is a rare condition, indicating bacteraemia. We report a rare case of Staphylococcus aureus bacteraemia causing SPE and multiple abscesses in a previously healthy patient. A previously healthy 33-year-old man presented to our hospital with fever and back pain for 3 weeks. Chest contrast-enhanced computed tomography image was suggestive of SPE, and the blood culture showed methicillin-susceptible S. aureus . Additional focus identification revealed pyogenic spondylitis and abscesses in the psoas muscles. After the 6-week antimicrobial treatment, his clinical condition and image findings improved, and he was discharged. SPE should be considered as a critical consequence of bacteraemia, and early focus identification is essential for appropriate treatment. more...

Cutaneous lymphangitis carcinomatosa (CLC) is a rare form of cutaneous metastasis that causes lymphoedema and various eruptions. We report a case of lung cancer with CLC that caused both superior vena cava (SVC) stenosis and cervicofacial oedema, suggestive of SVC syndrome. A 64-year-old woman with lung adenocarcinoma presented with cervicofacial oedema and erythema, followed by severe dyspnoea 2 months after four cycles of carboplatin, pemetrexed and bevacizumab triplet therapy. Although chest CT indicated SVC stenosis, cervicofacial oedema remained despite treating the SVC stenosis via balloon dilation. A skin biopsy of the erythematic sample confirmed CLC as the cause of the patient's symptoms. CLC should be considered as a differential diagnosis of cervicofacial oedema in addition to SVC syndrome, especially when it is observed in combination with skin erythema and induration. Moreover, a skin biopsy should be performed promptly for accurate diagnosis of CLC and to decide on appropriate treatment., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.) more...

Camptothecin is a monoterpenoid indole alkaloid that exhibits anti-tumor activity. In Ophiorrhiza pumila, production of camptothecin and its related alkaloids was high in the hairy roots, but not in the cell suspension culture derived from hairy roots. To identify the intermediates in camptothecin biosynthesis, expression of genes encoding tryptophan decarboxylase (TDC) and secologanin synthase (SLS), the two enzymes catalyzing the early steps in camptothecin biosynthesis, were suppressed in the hairy roots of O. pumila by RNA interference (RNAi), and metabolite changes were investigated. In most TDC- and SLS-suppressed lines, accumulation of camptothecin and related alkaloids, strictosidine, strictosamide, pumiloside, and deoxypumiloside was reduced. The accumulation levels of secologanin exhibited a strong negative correlation with the expression level of TDC, and that of loganin exhibited a negative correlation with the expression level of SLS. Some hairy root-specific chromatographic peaks detected by liquid chromatography Fourier transform ion cyclotron resonance mass spectrometry (LC-FTICR-MS) exhibited positive or negative correlation with TDC expression, suggesting their possible involvement in camptothecin biosynthesis., (Copyright © 2012 Elsevier Ltd. All rights reserved.) more...

A case of a superior lumbar hernia in a 50 year old woman is described herein. She presented with a 7 x 8 cm soft, nontender, smooth-surfaced mass in the left flank, and barium meal with follow through showed herniation of the descending colon. At operation, a 6 x 5 cm defect was found in the transversalis fascia, which was repaired with mattress sutures to the transversalis fascia together with suturing of the external oblique to the latissimus dorsi. This article presents the above case and reviews the published literature relating to this subject. more...

During a 21-year period, 3040 patients with malignant tumors were treated at the Division of Surgery, Fukuyama National Hospital. Of these 86 (2.8%) were diagnosed as having double cancers. The simultaneous double cancer rate was 27.3%. Statistical study showed that the etiology had a relation to family history and previous therapy, but not to immunology. The prognosis was good and diagnosis by RI was non-specific. more...

The relationships between mental abilities and lateralities were examined. On any items of a lateral preference questionnaire, significant differences between subjects with right and left preferences were not found on either verbal or non-verbal scores of intelligence scales. Some significant differences were found between tasks. On the geometric figure-combination task, subjects using scissors left handed had lower scores than right-handed ones. more...

The relationship between cognitive ability and laterality was examined in terms of the relation of intelligence test scores to lateral preference. The factor analysis was performed on the variables of 12 tasks of the intelligence scale and total lateral preference. A slight relation was found between lateral preference and figure combination task. To clarify the relationship, the mean scores of tasks were tested for subjects who preferred the right and left on each preference item. Some significant differences were found. On some items, the mean scores of subjects with left preferences were inferior to those of subjects with right preferences on the figure-combination task. The result confirmed Levy's finding (1969). But cross-validation on a large sample is required. more...

EEGs were recorded from 12 positions of the scalp (10-20 system) in 30 normal right-handed subjects. Powers of alpha component obtained from contralateral loci during their performance of verbal tasks (definition of nouns, tongue twisting) and non-verbal tasks (memorization of shapes, imagination of a face) were compared. At the frontal and occipital regions, the right hemisphere dominance of the alpha component was more distinctly demonstrated during the verbal tasks than the non-verbal tasks, while at the occipito-temporal region, the left hemisphere dominance was distinctly demonstrated during the non-verbal tasks than the verbal tasks. However, the alpha components were dominant at the left occipito-temporal region during the verbal tasks and at the right frontal and occipital regions during the non-verbal tasks. The latter result was discussed in relation to the findings of Moss, Davidson, & Saron (1985) and noise generated by apparatuses. Component analysis was carried out for a correlation matrix made by four task variables and 12 samples of electrode positions. Two factors were derived; the first factor was loaded on the verbal tasks whereas the second factor on non-verbal tasks. The factor scores of the first factor were high at the right temporal region and those of the second factor at the left temporal region. These results proved the utility of principal factor method onto general patterns of alpha component during the tasks. more...

The time course of the concentration of cefmetazole (CMZ) in the serum and in skin and intestinal tissues was determined after a single intravenous injection of 2 g of the drug. CMZ moved into them well. Furthermore, 41 patients with postoperative wound infection (superficial in 29 and deep in 12) were treated with CMZ 2-4 g daily. Bacteriological examination of the lesions with simultaneously carried out. As a result, 101 strains of bacteria were isolated and identified. Mixed infection was found in 27 cases (65.9%). Fifteen strains (14.9%) of E. coli, 15 (14.9%) of B. fragilis, 7 (6.9%) of Klebsiella sp. and 7 (6.9%) of Proteus sp., were the main bacteria isolated. Eight cases (19.5%) had mixed infection of E. coli and B. fragilis. The committee (3 members) evaluated CMZ to be effective in 75.6% (31 of 41 cases) and bacteria disappeared in 60.5% (23 of 38 cases). The side effects observed were pyrosis and feeling of gastric malaise in 1 case. The results suggest that CMZ is useful, which exerts an excellent effect on postoperative wound infections. more...