Obstructive shock due to a spontaneous haemothorax caused by primary lung cancer.

We describe the case of a 67-year-old man with shock and hypoxemia. Chest X-ray showed bilateral lung mass shadows and left pleural effusion with a mediastinal shift, suggesting malignancy. Physical examination and point-of-care ultrasound findings did not suggest obstructive or cardiac shock, but the patient had prolonged shock refractory to fluid and blood transfusion therapy. We inserted a drain into the left thoracic cavity, which enabled the patient to recover from shock. We diagnosed the patient with obstructive and hypovolemic shock due to spontaneous haemothorax caused by primary lung cancer. Tension haemothorax due to malignancy is rare, and when obstructive shock is combined with haemorrhagic shock, it can be very difficult to determine the cause of shock.

Aseptic meningitis after amenamevir treatment for herpes zoster ophthalmicus with oculomotor nerve palsy in a patient taking immunosuppressant.

A 79-year-old woman presented with vomiting after being prescribed amenamevir by her primary care physician. She had a medical history of rheumatoid arthritis and was administered prednisolone and methotrexate. She was finally diagnosed with herpes zoster ophthalmicus and aseptic meningitis, and intravenous antiviral therapy was initiated. However, the patient developed oculomotor nerve palsy on the 11th day of hospitalization. In this case, there was a time lag between the administration of antiviral drugs and clinical improvement. Our case suggests the necessity of selecting antivirals, especially in high-risk cases of CNS complications, to avoid the low intracerebral transferability of antiviral drugs, including amenamevir.

Treatment of Listeria monocytogenes bacteremia with oral levofloxacin in an immunocompromised patient.

A 72-year-old woman presented with fever, malaise, and diarrhea. The patient was conscious, and was negative for meningeal signs on physical exam. Blood tests revealed elevated C-reactive protein (CRP) and white blood cell count with neutrophil dominance. Suspecting a bacterial infection, empirical antimicrobial treatment with oral levofloxacin was initiated after collecting two sets of blood culture. On the 3rd day, the patient's fever resolved. On the 7th day, Listeria monocytogenes bacteremia was diagnosed with both blood cultures turning positive. On the 15th day, the patient's symptoms had improved. We ceased treatment when the CRP level decreased. Listeria monocytogenes is a gram-positive bacterium that causes serious infections in elderly and immunocompromised hosts. Penicillin, ampicillin, amoxicillin, and gentamicin are recommended for the treatment of Listeria infections. It has been reported that new fluoroquinolones may be effective in vitro and in animal models. Although further evidence is required, new fluoroquinolones, especially levofloxacin, may provide an option for the treatment of Listeria infection.

Key diagnostic characteristics of fever of unknown origin in Japanese patients: a prospective multicentre study.

OBJECTIVE: To identify the key diagnostic features and causes of fever of unknown origin (FUO) in Japanese patients. DESIGN: Multicentre prospective study. SETTING: Sixteen hospitals affiliated with the Japanese Society of Hospital General Medicine, covering the East and West regions of Japan. PARTICIPANTS: Patient aged ≥20 years diagnosed with classic FUO (axillary temperature≥38.0°C at least twice within a 3-week period, cause unknown after three outpatient visits or 3 days of hospitalisation). A total of 141 cases met the criteria and were recruited from January 2016 to December 2017. INTERVENTION: Japanese standard diagnostic examinations. OUTCOME MEASURES: Data collected include usual biochemical blood tests, inflammatory markers (erythrocyte sedimentation rate (ESR), C reactive (CRP) protein level, procalcitonin level), imaging results, autopsy findings (if performed) and final diagnosis. RESULTS: The most frequent age group was 65-79 years old (mean: 58.6±9.1 years). The most frequent cause of FUO was non-infectious inflammatory disease. After a 6-month follow-up period, 21.3% of cases remained undiagnosed. The types of diseases causing FUO were significantly correlated with age and prognosis. Between patients with and without a final diagnosis, there was no difference in CRP level between patients with and without a final diagnosis (p=0.121). A significant difference in diagnosis of a causative disease was found between patients who did or did not receive an ESR test (p=0.041). Of the 35 patients with an abnormal ESR value, 28 (80%) had causative disease identified. CONCLUSIONS: Age may be a key factor in the differential diagnosis of FUO; the ESR test may be of value in the FUO evaluation process. These results may provide clinicians with insight into the management of FUO to allow adequate treatment according to the cause of the disease.

Risk factors of catheter-related bloodstream infection caused by Bacillus cereus: Case-control study in 8 teaching hospitals in Japan.

In this multicenter, matched case-control study, patients diagnosed with catheter-related bloodstream infection (CRBSI) caused by Bacillus cereus (n = 108) were matched to controls (n = 269). In the multivariable analysis, administration of an amino acid preparation and an indwelling peripheral catheter were significant variables for B cereus-related CRBSI.

Impact of holding position during inhalation on drug release from a reservoir-, blister- and capsule-type dry powder inhaler.

OBJECTIVE: To determine whether drug release may be impaired by tilting some dry powder inhalers (DPIs). METHODS: Using an inhalation simulator, we measured drug release from Turbuhaler® (TBH), Diskus® (DKS) and Breezhaler® (BZH) at several peak inhaled flow rates (PIFs) while the DPIs were held at level and tilted (80°). Drug release was then measured from all three DPIs at 0, 30, 60 and 90° of tilt, and capsule rotation was also recorded. RESULTS: Drug release from TBH was flow-dependent while that from DKS and BZH was flow-independent. With TBH, the plot of drug release vs. PIF either at level or at tilted position scattered along approximately the same regression lines. With DKS and BZH, drug release at tilted position was significantly lower than that while at level. With DKS the decrease was almost 20%, while with BZH, drug release frequently failed. With BZH, significant reductions in drug release were observed while the device was tilted by 30-90°. CONCLUSION: The position in which the DPI is held may affect drug delivery, especially when using BZH.

Relationships between Causes of Fever of Unknown Origin and Inflammatory Markers: A Multicenter Collaborative Retrospective Study.

OBJECTIVE: Although inflammatory markers, such as the white blood cell (WBC) count, erythrocyte sedimentation rate (ESR) and levels of C-reactive protein (CRP) and procalcitonin, are widely used to differentiate causes of fever of unknown origin (FUO), little is known about the usefulness of this approach. We evaluated relationships between the causes of classical FUO and the levels of inflammatory markers. METHODS: A nationwide retrospective study including 17 hospitals affiliated with the Japanese Society of Hospital General Medicine was conducted. PATIENTS: This study included 121 patients ≥18 years old diagnosed with "classical FUO" (axillary temperature ≥38.0°C at least twice over a ≥3-week period without elucidation of the cause on three outpatient visits or during three days of hospitalization) between January and December 2011. RESULTS: The causative disease was infectious diseases in 28 patients (23.1%), non-infectious inflammatory disease (NIID) in 37 patients (30.6%), malignancy in 13 patients (10.7%), other in 15 patients (12.4%) and unknown in 28 patients (23.1%). The rate of malignancy was significantly higher for a WBC count of <4,000/µL than for a WBC count of 4,000-8,000/µL (p=0.015). Among the patients with a higher WBC count, the rate of FUO due to NIID tended to be higher and the number of unknown cases tended to be lower. All FUO patients with malignancy showed an ESR of >40 mm/h. A normal ESR appeared to constitute powerful evidence for excluding a diagnosis of malignancy. In contrast, the concentrations of both serum CRP and procalcitonin appeared to be unrelated to the causative disease. CONCLUSION: The present study identified inflammatory markers that should be considered in the differential diagnosis of classical FUO, providing useful information for future diagnosis.

Diagnostic workup for fever of unknown origin: a multicenter collaborative retrospective study.

OBJECTIVE: Fever of unknown origin (FUO) can be caused by many diseases, and varies depending on region and time period. Research on FUO in Japan has been limited to single medical institution or region, and no nationwide study has been conducted. We identified diseases that should be considered and useful diagnostic testing in patients with FUO. DESIGN: A nationwide retrospective study. SETTING: 17 hospitals affiliated with the Japanese Society of Hospital General Medicine. PARTICIPANTS: This study included patients ≥18 years diagnosed with 'classical fever of unknown origin' (axillary temperature ≥38°C at least twice over a ≥3-week period without elucidation of a cause at three outpatient visits or during 3 days of hospitalisation) between January and December 2011. RESULTS: A total of 121 patients with FUO were enrolled. The median age was 59 years (range 19-94 years). Causative diseases were infectious disease in 28 patients (23.1%), non-infectious inflammatory disease in 37 (30.6%), malignancy in 13 (10.7%), other in 15 (12.4%) and unknown in 28 (23.1%). The median interval from fever onset to evaluation at each hospital was 28 days. The longest time required for diagnosis involved a case of familial Mediterranean fever. Tests performed included blood cultures in 86.8%, serum procalcitonin in 43.8% and positron emission tomography in 29.8% of patients. CONCLUSIONS: With the widespread use of CT, FUO due to deep-seated abscess or solid tumour is decreasing markedly. Owing to the influence of the ageing population, polymyalgia rheumatica was the most frequent cause (9 patients). Four patients had FUO associated with HIV/AIDS, an important cause of FUO in Japan. In a relatively small number of cases, cause remained unclear. This may have been due to bias inherent in a retrospective study. This study identified diseases that should be considered in the differential diagnosis of FUO.

Pulmonary tumor embolism secondary to uterine corpus carcinosarcoma mimicking pulmonary thromboembolism.

We herein report a case of pulmonary tumor embolism caused by hematogenous metastasis that mimicked pulmonary thromboembolism in a 62-year-old Japanese woman with a history of uterine corpus carcinosarcoma. The case suggests that tumor embolism must be included in the differential diagnoses of respiratory symptoms in patients with a history of malignancy. It also illustrates the usefulness of such findings as beaded, dilated pulmonary arteries by computed tomography (CT) and high (18)F-fluorodeoxyglucose (FDG) uptake by fusion FDG positron emission tomography/CT imaging for differentiating a pulmonary tumor embolism from pulmonary thromboembolism.

[A case of Legionnaires' pneumonia accompanied by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) with transient altered mental status and cerebellar symptoms, which responded to treatment by antibiotics and corticosteroid].

A 60-year-old man was admitted because of fever, headache, and difficulty in walking. Respiratory symptoms included only mild cough, but crackles were present on auscultation at the right lung base, the chest roentgenogram and computed tomography scans showed consolidation in the right lower lobe. Laboratory findings revealed hyponatremia, elevated liver function test values and creatine phosphokinase, and Legionella pneumophila antigen in urine. Neurological examination revealed mild mental status change, dysmetria, dysarthria, and ataxic gait. Diffusion-weighted magnetic resonance imaging (MRI) of the brain, performed at the time of admission, revealed regions of high intensity in the splenium corpus callosum. We diagnosed Legionnaires' pneumonia accompanied by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS), and started treatment with ciprofloxacin and methylprednisolone at 1 mg/kg/day. Neurological symptoms gradually improved. On day 6 after admission, mild dysarthria and ataxic gait remained, a 123-IMP single photon emission computed tomography revealed no abnormality. On day 15 after admission, the only neurological symptom was mild ataxic gait; the MRI scans showed no abnormalities. On day 29 after admission, neurological symptoms were completely resolved. This is the first reported case of Legionnaires' pneumonia accompanied by clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) was treated with not only antibiotics but also corticosteroid.

[A case of acute respiratory distress syndrome associated with pandemic influenza A (H1N1) pneumonia which was aggravated by the cessation of corticosteroid therapy].

A 72-year-old man was admitted to the intensive care unit of our hospital with acute respiratory distress syndrome (ARDS). A chest CT scan showed diffuse consolidations and ground-glass opacities in both lungs. We diagnosed ARDS secondary to community-acquired pneumonia. We then started mechanical ventilation with airway pressure release ventilation and treated him with antibiotics, peramivir, and corticosteroids, despite negative results for a rapid antigen test for influenza. Bronchial lavage on day 10 showed blood-tinged fluid and hemosiderin-laden macrophages, but no bacteria or fungi. Real-time reverse-transcriptase polymerase chain reaction testing yielded a positive result for pandemic influenza A (H1N1). The mechanical ventilator was removed on day 15, corticosteroid administration was discontinued on day 22 and antibiotics were discontinued on day 23. However, he had a fever on day 28, pleural pain and dyspnea on day 29, and exacerbation of the infiltration as demonstrated on chest CT on day 30. On day 31, repeat bronchoalveolar lavage showed an increase in the number of total cells which were lymphocyte-predominant, but there were no pathogens. We believed that this clinical exacerbation might have occurred due to the re-exacerbation of pandemic influenza A (H1N1) pneumonia due to the cessation of corticosteroids. The re-administration of corticosteroids was effective, and were eventually tapered. Currently, the use of corticosteroid therapy for severe pandemic influenza A (H1N1) pneumonia is controversial, but even the late administration of corticosteroid therapy may be effective. However, this case also suggests that the early administration of corticosteroid therapy as immunomodulation might be effective in selected cases, and that cessation of such therapy during the early phase of ARDS may cause exacerbation of clinical symptoms.

Two cases of type 1 diabetic women with diabetic ketoacidosis presenting as alkalaemia.

We report two type 1 diabetic patients with diabetic ketoacidosis accompanied by alkalaemia. Twenty-three cases have been reported to date, and the main causes for alkalaemia were vomiting, alkali ingestion, and diuretics use. Our report indicated that poorly controlled diabetic patients who already had autonomic neuropathy are at risk.

Systematic literature review of role of noroviruses in sporadic gastroenteritis.

We conducted a systematic review of studies that used reverse transcription-PCR to diagnose norovirus (NoV) infections in patients with mild or moderate (outpatient) and severe (hospitalized) diarrhea. NoVs accounted for 12%(95% confidence interval [CI] 10%-15%) of severe gastroenteritis cases among children <5 years of age and 12% (95% CI 9%-15%) of mild and moderate diarrhea cases among persons of all ages. Of 19 studies among children <5 years of age, 7 were in developing countries where pooled prevalence of severe NoV disease (12%) was comparable to that for industrialized countries (12%). We estimate that each year NoVs cause 64,000 episodes of diarrhea requiring hospitalization and 900,000 clinic visits among children in industrialized countries, and up to 200,000 deaths of children <5 years of age in developing countries. Future efforts should focus on developing targeted strategies, possibly even vaccines, for preventing NoV disease and better documenting their impact among children living in developing countries, where >95% of the deaths from diarrhea occur.