A Case of Pseudohyperaldosteronism Induced by Yokukansan and Shakuyakukanzoto That Resulted in Severe Hypokalemia.

Pseudohyperaldosteronism can be induced by the excessive use of Chinese herbal medicines (Kampo medicines), resulting in serious disorders. We report a case of pseudohyperaldosteronism induced by two Kampo medicines which resulted in severe hypokalemia. A 70-year-old woman was hospitalized for a left calcaneal fracture. She had no subjective symptoms other than trauma. On her admission, blood test results revealed a low serum potassium level of 2.4 mmol/L by chance, as well as low levels of both renin and aldosterone. The patient had been taking 5 g of Yokukansan per day for the past three months. In addition, she was on 5 g Shakuyakukanzoto per day for three months until a month prior to hospitalization. The daily licorice content from the aforementioned herbs was 1.0 g and 4.0 g, respectively. After hospitalization, the administration of the Kampo medicines was discontinued, and 610 mmol of potassium was administered over a period of 13 days, which resulted in the normalization of serum potassium levels. Pre-existing hypertension slowly improved as well. Patients consuming licorice at doses of 2.5 g per day or more, as in our case, are at a high risk of developing pseudohyperaldosteronism. Furthermore, the risk is particularly high with long-term licorice consumption as well as for women and elderly patients. To this end, high-dose potassium supplementation may be necessary for normalizing serum potassium levels. Therefore, awareness regarding the adverse effects of licorice is crucial, even in cases of low dosages of licorice.

Inclusion body myositis in an older patient following a fall.

After experiencing a fall, an 82-year-old woman developed progressive loss of lower limb strength and was diagnosed with inclusion body myositis. Although falls and muscle weakness are often regarded as consequences of aging, inclusion body myositis should be considered in a patient with a history of multiple falls.

Cytomegalovirus colitis with a new diagnosis of ulcerative colitis in an elderly woman.

Objectives: Cytomegalovirus (CMV) colitis is generally diagnosed in immunocompromised patients. It is rare for patients who are not immunocompromised to develop CMV colitis. Cases of CMV colitis in patients with inflammatory bowel disease have also been reported. We encountered a case of CMV colitis with a new diagnosis of severe ulcerative colitis and demonstrated the importance of suspecting ulcerative colitis in immunocompetent patients with CMV colitis. Patient: A 78-year-old woman was hospitalized with fever and diarrhea that had lasted for a month. Colonoscopy revealed continuous diffuse edema, mucosal redness, and multiple punched-out ulcers with bleeding, suggesting cytomegalovirus (CMV) colitis, although she was not immunocompromised. Immunohistochemical staining revealed CMV-positive cells, and CMV colitis was diagnosed. One month later, a colonoscopy was conducted owing to persistent symptoms despite initiating the prescribed antiviral drug. A complete loss of vascular pattern, easy bleeding of the crude mucosa, and exacerbation of multiple punched-out ulcers were observed. She was diagnosed with severe ulcerative colitis. The symptoms of ulcerative colitis disappeared with prednisolone and 5-amino salicylic acid treatment. Conclusion: Ulcerative colitis should be suspected in immunocompetent patients with CMV colitis.

A case of diabetic ketoacidosis with hemorrhagic gastric ulcer.

This is a case of diabetic ketoacidosis with hemorrhagic gastric ulcer. Mortality rates increase when DKA is complicated with upper gastrointestinal bleeding, so it is important to consider this possibility.

A Case of Pyometra Caused by Achromobacter xylosoxidans and γ-Streptococcus in an Elderly Frail Woman.

Pyometra is an easily overlooked disease with nonspecific symptoms; however, a delayed diagnosis can lead to severe complications. An 80-year-old frail woman presented to our hospital with a chief complaint of persistent fever for 10 days. Her blood tests showed an elevated inflammatory response, and computed tomography showed a 10-cm cystic lesion in the pelvic floor compressing the bladder. A catheter was inserted from the vagina into the uterine cavity, resulting in pus drainage and pyometra diagnosis. A pus culture was subsequently performed, which detected Achromobacter xylosoxidans, a common cause of respiratory tract infections in cystic fibrosis and bloodstream infections, andγ-streptococcus. To the best of our knowledge, this is the first report of pyometra caused by Achromobacter xylosoxidans. The patient was treated with drainage and piperacillin-tazobactam administration. Pyometra is especially prevalent in older women with impaired activities of daily living and dementia. Although fever, lower abdominal pain, and increased discharge may occur, symptoms are often nonspecific, and half of such cases are asymptomatic. Furthermore, delayed diagnosis can lead to perforation of the uterus and consequent pan-peritonitis. Thus, the diagnosis of pyometra should be considered in older women presenting with unknown fever, and imaging studies and gynecological consultation should be requested promptly.

Chondroitin sulfate E blocks enzymatic action of heparanase and heparanase-induced cellular responses.

We examined whether chondroitin sulfates (CSs) exert inhibitory effects on heparanase (Hpse), the sole endoglycosidase that cleaves heparan sulfate (HS) and heparin, which also stimulates chemokine production. Hpse-mediated degradation of HS was suppressed in the presence of glycosaminoglycans derived from a squid cartilage and mouse bone marrow-derived mast cells, including the E unit of CS. Pretreatment of the chondroitin sulfate E (CS-E) with chondroitinase ABC abolished the inhibitory effect. Recombinant proteins that mimic pro-form and mature-form Hpse bound to the immobilized CS-E. Cellular responses as a result of Hpse-mediated binding, namely, uptake of Hpse by mast cells and Hpse-induced release of chemokine CCL2 from colon carcinoma cells, were also blocked by the CS-E. CS-E may regulate endogenous Hpse-mediated cellular functions by inhibiting enzymatic activity and binding to the cell surface.

Bronchial damage and diffuse alveolar hemorrhage following chlorine gas inhalation: A case report.

Chlorine is a toxic inhalant and sources of exposure for individuals include accidental releases of chlorine vapor due to industrial or chemical transportation accidents. Inhalation of a large quantity of gas may cause circulatory and respiratory disorders or even mortality; however, the effects of a small amount of chlorine gas may be asymptomatic. The present case study presents a successfully treated 55-year-old male patient exposed to chlorine gas, resulting in bronchial damage and diffuse alveolar hemorrhage. Endobronchial and alveolar injuries were evaluated by direct observation using fiberoptic bronchoscopy (FB) and analyzing bronchoalveolar lavage fluid obtained by FB. Taking a precise medical history from the patient is crucial to correctly diagnose toxic gas inhalation. In addition, a timely and proper evaluation with chest imaging as well as FB may provide useful clinical information. Therefore, clinicians should consider performing FB if the circumstances permit.

Reversible splenial lesion syndrome with a hyperosmolar hyperglycemic state and neuroleptic malignant syndrome caused by olanzapine.

A 27-year-old woman with panic disorder taking 20 mg olanzapine daily for 4 months was admitted to Mito Kyodo General Hospital, Mito, Ibaraki, Japan, because of disturbed consciousness with fever, hyperglycemia, hyperosmolarity and elevated creatine phosphokinase. She was diagnosed with a hyperosmolar hyperglycemic state and neuroleptic malignant syndrome. Brain magnetic resonance imaging showed transiently restricted diffusion in the splenium of the corpus callosum, with a high signal intensity on diffusion-weighted imaging. The neurological abnormalities disappeared along with improvement of metabolic derangements, and the follow-up magnetic resonance imaging carried out on the 26th day of admission showed complete resolution of the lesions in the splenium of the corpus callosum. These clinical and radiological features are highly suggestive of clinically mild encephalitis/encephalopathy with a reversible splenial lesion. The first case of mild encephalitis/encephalopathy with a reversible splenial lesion caused by olanzapine-induced hyperosmolar hyperglycemic state and neuroleptic malignant syndrome is reported.

Tetanus in the Elderly: The Management of Intensive Care and Prolonged Hospitalization.

Tetanus is a potentially fatal infection. Approximately 100 cases are reported in Japan each year; however, little is known about its clinical course and outcomes in the current era of treatment. We herein report three cases of tetanus in elderly patients who survived after mechanical ventilation and intensive care. These patients, together with six other similar cases, had a median weaning period of 31 days and median length of stay of 77 days. In elderly patients, severe systemic forms of tetanus require prolonged mechanical ventilation and hospitalization. To improve prevention, tetanus vaccination should be promoted more aggressively among those who are susceptible to the disease.

Fulminant Type 1 Diabetes Mellitus Presenting 11 Days after Delivery in a Patient of Mixed Genetic Background.

The patient was a 25-year-old woman whose paternal family was Japanese, maternal grandfather was Filipino, and maternal grandmother was Chinese. Eleven days after delivery, she presented with excessive thirst and disturbed consciousness due to diabetic ketoacidosis. She was diagnosed as having fulminant type 1 diabetes associated with pregnancy (PF). The antibody concentration against glutamic acid decarboxylase was 1.2 (<1.5) U/mL, and human leukocyte antigen (HLA) class II haplotypes were DRB1*04:10-DQB1*03:02 and DRB1*15:02-DQB1*05:01. The present case had unique HLA class II haplotypes that have not been previously reported in association with PF.

Pioglitazone-induced Pulmonary Injury in a Very Elderly Patient.

An 85-year-old woman with diabetes mellitus was admitted to our hospital due to progressive dyspnea. Two months previously, pioglitazone had been newly prescribed for diabetes management. Bilateral ground-glass opacities and progressive respiratory deterioration suggested respiratory failure due to a drug-induced lung injury. With discontinuation of pioglitazone and the administration of a corticosteroid, an improvement in her respiratory condition was achieved, although sequelae remained in some areas of the lungs. Results of drug-induced lymphocyte stimulation tests were positive for pioglitazone. Resumption of other drugs did not reinduce the lung injury. Therefore, a diagnosis of pioglitazone-induced lung injury was made. Although pioglitazone-induced lung injury is very rare, clinicians should keep it in mind when pioglitazone is used.

Refractory to treat Helicobacter cinaedi bacteremia with bilateral lower extremities cellulitis in an immunocompetent patient.

Helicobacter cinaedi is known to cause bacteremia with multi-focal cellulitis, usually, among immunocompromised patients. We report here a 54-year-old Japanese man who was found to have bacteremia complicated with bilateral lower extremities cellulitis due to H. cinaedi. This patient did not have any immunocompromised conditions including Human Immunodeficiency Virus infection. In this patient, the cellulitis was multi-focal which is rare among immunocompetent patients. In addition, interestingly, the cellulitis was symmetrically on the both sides on the lower dorsal part of the extremities. The patient was treated with meropenem, which was considered as one of the best available agents, however, he required a prolonged antimicrobial treatment. During the admission, he underwent colonoscopy which was unremarkable, and his stool culture was also negative while on meropenem. Subsequently, he developed recurrent symptoms of the right lower extremity twice and each time he was treated with intravenous meropenem followed by oral minocycline. After the total of 12 weeks of antimicrobial treatment, his symptoms subsided. Clinicians should be aware of this organism when treating multi-focal, or symmetrical cellulitis even if the patients are immunocompetent.