Acute Exacerbation of Idiopathic Pulmonary Fibrosis With Concurrent Cardiac Amyloidosis: A Technetium Pyrophosphate Study.

Amyloidosis presents a diagnostic challenge, particularly when concomitant with severe conditions like acute exacerbations of idiopathic pulmonary fibrosis (IPF). In this report, we detail the case of a 73-year-old patient with acute exacerbation of IPF and simultaneous emergence of cardiac amyloidosis. The patient's clinical journey began with persistent exertional dyspnea, progressing to hypoxemia on admission. Chest CT scans showed extensive ground-glass opacities, consolidations, and pre-existing honeycombing-like cysts and reticular shadows, accompanied by a right-sided pleural effusion. The therapeutic strategy for acute exacerbation of IPF encompassed methylprednisolone pulse therapy, tacrolimus, and nintedanib, augmented with intravenous immunoglobulin and recombinant thrombomodulin. Concurrently, heart failure with preserved ejection fraction was managed with a pharmacological trio: empagliflozin, diuretics, and eplerenone. A hypertrophied heart and low limb voltage prompted an investigation for cardiac amyloidosis, which 99mTechnetium pyrophosphate (99mTc-PYP) scintigraphy confirmed, yielding a probable diagnosis. Following steroid tapering, the patient was discharged home. This case prompted an investigation into the potential role of amyloidosis in pulmonary pathology. Our retrospective review of 10 patients, including four with cardiac amyloidosis, who underwent 99mTc-PYP scintigraphy, revealed a nonsignificant yet notable trend of increased pulmonary accumulation in cardiac amyloidosis cases (median (interquartile range): 5.4×104 (5.3-13.1×104) vs. 3.6×104 (2.4-5.1×104), p=0.0667). Notably, the pulmonary counts in this patient exceeded the negative cohort's mean values, hinting at a possible contribution of amyloid deposition to pulmonary pathology. This study, pioneering in evaluating lung field accumulation of 99mTc-PYP in cardiac amyloidosis, may provide novel insights into the influence of amyloidosis on pulmonary conditions.

Amikacin Liposome Inhalation Suspension in the Real-World Management of Refractory Mycobacterium avium Complex Pulmonary Disease.

The increasing prevalence of Mycobacterium avium complex (MAC) pulmonary disease poses a significant therapeutic challenge, particularly due to the limited efficacy and systemic toxicity associated with conventional guideline-based therapy. Amikacin liposome inhalation suspension (ALIS) has been developed, yet its real-world application remains underreported. This retrospective analysis, conducted from March 2021 to February 2024, examined ALIS's clinical use in patients aged 20 years or older with refractory MAC pulmonary disease at our institution. The primary objective of this study is to describe the patient characteristics and clinical trajectories associated with the initiation of ALIS therapy in real-world settings for individuals diagnosed with MAC pulmonary disease. Of 11 patients initiated on ALIS, one was excluded due to financial constraints impacting continuation. The analysis proceeded with the remaining 10 subjects. The mean age of participants was 70.2 years, with a predominance of female patients (n = 7, 70%) and a higher incidence of M. avium infections (n = 6, 60%). Forty percent of the cohort (n = 4) had a history of ethambutol-induced optic neuritis leading to the cessation of the drug. The average interval from the initiation of guideline-based therapy to the start of ALIS was 8.5 ± 6.9 years (mean ± standard deviation). The majority (80%) presented with positive Gaffky scores at ALIS initiation, and a significant proportion exhibited resistance to clarithromycin and ethambutol. Comorbid conditions, including diabetes and previous cancer, were noted. The study also observed elevated anti-MAC antibody levels. Treatment duration varied, with fatigue leading to discontinuation in two cases. Treatment-emergent adverse events were documented in individual patients, each presenting with grade 1 severity: hemoptysis (n = 1, 10%), elevated creatinine levels (n = 1, 10%), and dysphonia (n = 2, 20%) were observed, respectively. Correlation analysis revealed a significant inverse relationship between body mass index (BMI) and ALIS discontinuation due to fatigue, and a positive correlation between Gaffky scores and C-reactive protein (CRP) levels. These results underscore the potential benefits and limitations of ALIS, suggesting that timely intervention and comprehensive healthcare support are crucial for optimal outcomes in the treatment of advanced MAC pulmonary disease.

Relapsing eosinophilic pneumonia in a patient with recurrent breast cancer receiving abemaciclib plus endocrine therapy.

This report presents the case of a 42-year-old Japanese woman with recurrent hormone receptor-positive breast cancer who developed eosinophilic pneumonia (EP) during treatment with abemaciclib combined with endocrine therapy. Seven years after a radical surgery and definite diagnosis of Stage I breast cancer, her cancer recurred with metastases to multiple organs. Initially treated with abemaciclib plus letrozole and goserelin for 3 months, she developed EP, which improved after the discontinuation of anti-cancer treatment and the administration of prednisolone. However, EP occurred again upon the reintroduction of endocrine therapy (i.e., letrozole and goserelin). It improved gradually with the suspension of endocrine therapy and the re-administration of prednisolone. This case underscores the need for further research into the prevention and management of EP in patients receiving abemaciclib with endocrine therapy for advanced breast cancer.

A Case of Pneumocystis Pneumonia Developed During Rheumatoid Arthritis Treatment With Methotrexate and Golimumab.

Here, we report a case of an 87-year-old female patient with rheumatoid arthritis (RA) treated with methotrexate (MTX) and golimumab who developed severe pneumocystis pneumonia (PCP), also known as Pneumocystis jirovecii pneumonia. The patient presented with chief complaints of dyspnea on exertion, dry cough, and fatigue. A high-resolution chest CT scan revealed diffuse, unevenly distributed ground-glass opacities throughout both lungs. The patient was clinically diagnosed with PCP based on the clinical settings, imaging, and a high level of serum ß-D-glucan. While the patient required high-flow oxygen therapy, low-dose trimethoprim/sulfamethoxazole and corticosteroid therapy improved her condition, and the patient was discharged on day 25. Although to our knowledge no case report has been published regarding PCP in patients with RA treated with golimumab, this case emphasizes the importance of attention to opportunistic infections in elderly patients receiving immunosuppressive therapy. MTX use alongside tumor necrosis factor inhibitors like golimumab may increase the risk of serious infections such as PCP. The case underscores the necessity of prophylactic measures and early intervention for PCP, highlighting the delicate balance between immunosuppression benefits and infection risks in RA management.

Effective treatment of inhaled corticosteroid and bronchodilator for "lymphocytic interstitial pneumonia" in primary Sjögren's syndrome.

We present a case of an 86-year-old woman who visited our hospital with a one-year history of exertional dyspnea (modified medical research council dyspnea scale; mMRC grade 2). Despite the absence of any smoking or dust exposure history, multiple cystic lesions were apparent in both lungs on her CT scan. We suspected Sjögren's syndrome-associated lymphocytic interstitial pneumonia (LIP) due to her additional symptoms of dry mouth and eyes. Her respiratory function test showed a restrictive disorder with a forced vital capacity (FVC) of 1.23 L (70.3 % predicted), forced expiratory volume in 1 s (FEV1) of 0.88 L, and FEV1/FVC of 71.5 %. The flow-volume curve showed a downward convex, suggesting peripheral airway obstruction. We initiated a daily inhalation treatment regimen comprising vilanterol 25 µg and fluticasone furoate 200 µg. One month later, at the follow-up visit, the clinical diagnosis of Sjögren's syndrome with LIP was made by positive SS-A and SS-B antibodies in the initial blood work, a Saxon test that confirmed decreased salivary secretion, and a confirmed diagnosis of dry eyes by her ophthalmologist. We noted improvement in FVC of 1.45 L (+17.8 %) and FEV1 to 0.99 L (+12.5 %) in the subsequent respiratory function test, along with alleviation of her symptoms. The present case represents the first report of LIP treated exclusively with inhaled corticosteroids and bronchodilators, highlighting a potential therapeutic approach, particularly for elderly patients vulnerable to immunosuppressive therapies.

A case of inguinal lymphaticovenular anastomosis for refractory lymphatic ascites after uterine cancer surgery.

We herein report a case of refractory lymphatic ascites after uterine cancer surgery treated with bilateral inguinal lymphaticovenular anastomosis (LVA). LVA was performed four months after the uterine cancer surgery in a patient with refractory ascites that had developed one month after the gynecologic surgery. One year and eight months after LVA, there was no recurrence of ascites accumulation.

A Teaching Case: Persistent COVID-19 Pneumonia Resembling Cryptogenic Organizing Pneumonia in a Patient With Remitted Lymphoma.

We report a case of a female patient in her 50s, previously diagnosed with follicular lymphoma (now in complete remission), who was admitted to our hospital due to antibiotic-resistant pneumonia lasting a month. The patient had contracted coronavirus disease 2019 (COVID-19) pneumonia a year earlier and exhibited persistent hypogammaglobulinemia. Chest CT scans revealed wondering ground-glass opacities and consolidations initially suggestive of cryptogenic organizing pneumonia (COP). Despite repeatedly negative nasopharyngeal SARS-CoV-2 tests, the virus was detected in the bronchoalveolar lavage fluid (BALF) using the BioFire FilmArray Respiratory Panel 2.1. She was subsequently diagnosed with COVID-19 pneumonia and responded well to treatment with remdesivir (RDV) and intravenous immunoglobulin. The SARS-CoV-2 variant in the BALF was suspected as the Omicron variant (XBB.1.16), prevalent in the area at the admission, indicating a re-infection rather than a recurrence. This case underscores the protracted nature of COVID-19 pneumonia in immunocompromised patients and the risks of false negatives in nasopharyngeal SARS-CoV-2 tests. Direct SARS-CoV-2 measurement from BALF can be crucial in such cases. A COP diagnosis based solely on imaging and administering corticosteroids without antiviral treatment might exacerbate the situation by reactivating SARS-CoV-2. Given the current pandemic, clinicians should be aware of the potential for persistent or recurrent COVID-19, particularly in immunocompromised patients.

Acute Pneumonitis Associated With the Inhalation of Pyrethroid-Based Domestic Insecticides.

We report a 72-year-old female who presented to our hospital with a worsening cough and dyspnea that had emerged a week earlier following the accidental inhalation of a significant quantity of spray-type imiprothrin (a synthetic pyrethroid)-based insecticide in her bathroom. She exhibited acute respiratory failure necessitating 4 L/minute of nasal oxygen at maximum. Chest CT images showed diffuse centrilobular ground-glass opacities with mosaic attenuation and consolidation areas in the lower lobes of both lungs. The patient was diagnosed with acute pneumonitis due to insecticide inhalation, and her symptoms improved following methylprednisolone pulse and alpha-tocopherol therapy. Generally, the accidental inhalation of aerosolized pyrethroids does not induce significant respiratory symptoms, and case reports on pulmonary toxicity related to pyrethroid inhalation are scarce. This case report underscores the need to include inhaled pyrethroid insecticides in the differential diagnosis of patients with acute pneumonitis and suggests that methylprednisolone and alpha-tocopherol therapy can be beneficial for treating this condition.

An Unusual Case of Bilateral Lower Extremity Edema in the Elderly: Immunoglobulin A (IgA) Vasculitis.

We report a case of a 74-year-old male who exhibited bilateral lower extremity edema over three days. Examination revealed no signs of heart, renal, or hepatic failure, and hypothyroidism was also ruled out. An outpatient regimen of 40 mg furosemide was initiated. At a 12-day follow-up, although the edema had improved, the patient had developed pain in both lower limbs, especially ankles, accompanied by numerous petechiae and erythemas, some of which had formed papules. Skin biopsy of the rash displayed leukocytoclastic vasculitis with immunoglobulin A (IgA) deposition within the vascular walls, leading to a diagnosis of IgA vasculitis. Given the rarity of IgA vasculitis in elderly patients and the broad spectrum of potential diagnoses related to bilateral lower extremity edema in this population, IgA vasculitis can be easily overlooked. While this case did not present with glomerulonephritis, regular renal function monitoring is recommended due to the prognostic implications of renal involvement in adult-onset IgA vasculitis.

Intraoperative obturator nerve injury reconstructed using a PGA-collagen tube: Three case reports.

We herein report three cases of obturator nerve injury, which is rare in gynecological surgery. In all cases, it was difficult to suture both nerve ends without tension. Therefore, we used a PGA-collagen tube to interpose the nerve defect. After follow-ups of at least seven months, all three patients were able to adduct the hip joint and medial thigh sensations also improved. These results suggest the potential of a PGA-collagen tube in the treatment of obturator nerve injury.

Combination immunotherapy of nivolumab plus ipilimumab in a lung cancer patient with Werner syndrome; a case report.

Werner syndrome (WS) is a rare progressive disorder that is characterized by premature aging of all organs. Malignancy is a frequent complication of WS, however, lung cancer patients with WS are much rare. In patients with WS, the treatment for malignancy is often limited due to other complications of severe skin ulcer, diabetes mellitus and cardiovascular disease. Currently, immune-checkpoint inhibitors (ICIs) are standard therapy for several cancer patients and the combination of nivolumab plus ipilimumab has also been approved for the treatment of non-small cell lung cancer (NSCLC). Recent studies have also reported that serious immune-related adverse events (irAEs) induced by ICIs may correlate with elderly or more vulnerable patients. However, the efficacy and safety of ICIs in NSCLC patients with WS remain unclear. To the best of our knowledge, this is the first case describing a NSCLC patient with WS receiving the combination immunotherapy of nivolumab and ipilimumab. Our case showed objective response to ICIs, however, several immune-related adverse events (irAEs) including hypothyroidism, adrenal insufficiency, hard rash and interstitial lung disease occurred, thus resulted in early treatment discontinuation. Our case suggests that immunotherapy for NSCLC patients with WS could be effective, but physicians may be aware of the possibility of multiple irAEs undergoing immunotherapy for NSCLC patients with WS.

Reconstruction of a Scrotum by Combining Two Skin Flaps in a Ball Shape.

Background: The scrotum functions to maintain spermatogenesis and hormonal production of Leydig cells by preventing the testicles from rising in temperature and protecting them from the outside world. The scrotum, along with the penis, is also an organ that symbolizes masculinity. Therefore, deformity or loss of the scrotum can be a major psychological problem. Various scrotal reconstruction techniques have been reported. In these papers, there is some discussion about the type of skin flap, but little discussion about the method of suturing the skin flap. We devised a way to reconstruct a scrotum to a natural size by suturing two skin flaps together to form a ball shape. Case Presentation. Case 1 was a patient with a missing scrotum due to Fournier's gangrene. Total resection of the scrotum, including the bilateral testes, was performed to save his life. Reconstructive surgery was performed 11 days after the initial surgery. Reconstruction was performed using bilateral gluteal fold flaps. Case 2 was a patient with a congenital defect of the scrotum. The testis on the right side exhibited cryptorchidism, and the scrotum was missing, and the testis on the left side was encased in a hypoplastic scrotum. Reconstruction was performed using an internal pudendal artery perforator flap. Conclusion: There are two types of scrotal defects: those with testes present and those with testes missing. This method can be used for both types of scrotal defects, and we were able to create a scrotum that satisfied each patient.

Pleural empyema with gas formation caused by mixed infection of Edwardsiella tarda with Streptococcus constellatus.

Edwardsiella tarda is an anaerobic, gram-negative rod bacterium associated with freshwater and marine life. Human E. tarda infections are rare, and most infections in humans cause gastroenteritis. Extraintestinal infections of E. tarda such as pleural empyema are particularly rare. A 72-year-old man was admitted with cough and purulent sputum. His medical history included periodontal disease and gastric cancer for which he had undergone total gastrectomy. Chest computed tomography showed left pleural effusion with foci of gas, and both E. tarda and Streptococcus constellatus were cultured from the pleural effusion. Thus, he was diagnosed with gas-forming empyema. He was successfully treated with therapeutic thoracentesis and antibiotics. Our case suggests that a dietary habit of raw fish, undernutrition, gastrectomy and oral infection may be predisposing factors for empyema caused by E. tarda.

Distal nail embedding treatment using autogenous nails.

A regrowing nail tip after nail avulsion may excessively curve and invaginate into the nail bed. This is treated as a type of ingrown toenail, and is known as distal nail embedding. In most cases, further growth restores the original shape evenly over the nail bed. However, it is often painful and such cases may require treatment. We report a surgical approach that we applied to six cases of distal nail embedding involving pain or deformity of nails caused by a nail tip invaginating into the nail bed and/or cessation of forward nail growth. As our method involves removing a portion of the embedded tip edge nail and inserting the removed nail into the remaining depressed portion, the nail can grow over the bulge. In all six patients in whom we applied this method, the pain and nail deformity resolved and there was no recurrence. We used autogenous nails, which can reduce the pressure imbalance on a nail bed, and this contributed to improving the morphology of nails and nail beds. In addition, the risk of a hypertrophied nail is reduced because half of the nail adheres to the nail bed. Special materials are unnecessary and this method can be conducted with simple outpatient department procedures. There were no cases of a fixed nail section detaching due to a bulge at the nail tip. The inserted nail was maintained in all cases for several months until the nail grew over the bulge.

Utility of Preoperative Multidetector-Row Computed Tomographic Angiography after Sublingual Nitroglycerin with Three-Dimensional Reconstruction in Planning of the Anterolateral Thigh Flap.

The utility of nitroglycerin is well established in coronary angiography but less so in other surgical fields. In this study, the authors investigated the utility of preoperative computed tomographic angiography after sublingual nitroglycerin followed by three-dimensional visualization for selecting suitable perforators in planning the free anterolateral thigh flap. The authors performed preoperative computed tomographic angiography following sublingual nitroglycerin (after screening for contraindications) in patients for whom reconstructive surgery with the free anterolateral thigh flap was planned. Data were reconstructed three-dimensionally, mapping location and course of source arteries and perforators. Suitable perforators were selected, and flap design was planned. The characteristics of perforators were analyzed statistically. Of 14 patients for whom surgery was planned, two had contraindications to nitroglycerin and underwent computed tomographic angiography alone. Nitroglycerin allowed for the visualization of more peripheral branches. The Hounsfield units at the deep fascia of perforators selected for surgery were significantly higher than for those not selected (p = 0.003). The distance from the intermuscular septum to the selected perforators was significantly shorter than the distance to nonselected perforators (p = 0.017). There were no adverse events, and all flaps survived. Sublingual nitroglycerin before computed tomographic angiography was safe and increased the visibility of perforators, enabling preoperative planning of flap design based on the three-dimensionally-reconstructed image. The authors highly recommend this procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.