The Warburg effect is a rare but potentially fatal metabolic complication of hematological malignancies. We report a case of diffuse large B-cell lymphoma (DLBCL) presenting with severe hypoglycemia and lactic acidosis,...The Warburg effect is a rare but potentially fatal metabolic complication of hematological malignancies. We report a case of diffuse large B-cell lymphoma (DLBCL) presenting with severe hypoglycemia and lactic acidosis, consistent with tumor-associated aerobic glycolysis. The prompt initiation of R-CHOP rapidly corrected both hypoglycemia and lactic acidosis, and a complete metabolic response was achieved after six cycles. An immunohistochemical analysis showed the diffuse expression of pyruvate kinase M2 (PKM2) and focal positivity for hexokinase 2 (HK2), suggesting a cancer-specific glycolytic phenotype. Both the PKM2 and HK2 expression have been implicated in the Warburg effect, and early therapeutic intervention could be life-saving.
A persistent left superior vena cava (PLSVC) can contribute to atrial fibrillation (AF) and it often requires complex ablation because of multiple electrical connections with the left atrium. An 86-year-old woman underwe...A persistent left superior vena cava (PLSVC) can contribute to atrial fibrillation (AF) and it often requires complex ablation because of multiple electrical connections with the left atrium. An 86-year-old woman underwent pulsed field ablation (PFA) for pulmonary vein and PLSVC isolation. After successful isolation without causing either phrenic nerve injury or coronary spasm, postprocedural remapping revealed a newly formed low-voltage area with conduction delay in the adjacent mitral isthmus. No atrial tachyarrhythmia recurrence was observed during the one-year follow-up. This case suggests that careful remapping may be warranted after PLSVC ablation using PFA.
Type B insulin resistance syndrome (TBIRS) is an extremely rare autoimmune disorder characterized by severe insulin resistance and/or hypoglycemia caused by autoantibodies against the insulin receptor (IRAb). We report t...Type B insulin resistance syndrome (TBIRS) is an extremely rare autoimmune disorder characterized by severe insulin resistance and/or hypoglycemia caused by autoantibodies against the insulin receptor (IRAb). We report the case of a 52-year-old woman who presented with weight loss and severe hyperglycemia resistant to high-dose insulin therapy. Markedly elevated IRAb levels confirmed the diagnosis of TBIRS. Glucocorticoid-based immunosuppressive therapy with cyclosporine rapidly improved glycemic control, and clinical remission was achieved approximately 40 days after treatment initiation. Intermittently scanned continuous glucose monitoring enabled the visualization of the transition from extreme insulin resistance to near-normoglycemia and helped avoid severe hypoglycemia during the patient's antibody decline period.
The diagnosis of cancer-associated stroke is challenging because the presence of active cancer does not necessarily indicate a causal association with stroke. Recent advances in mechanical thrombectomy have enabled the h...The diagnosis of cancer-associated stroke is challenging because the presence of active cancer does not necessarily indicate a causal association with stroke. Recent advances in mechanical thrombectomy have enabled the histopathological analysis of retrieved thrombi. In contrast to thrombi associated with conventional stroke etiologies, those associated with cancer have been reported to have a white gross appearance and to be rich in fibrin and platelets. We report a case in which the histological features of a retrieved thrombus provided important clues for diagnosing cancer-associated stroke. A histopathological analysis of a retrieved thrombi may contribute to the diagnostic evaluation of cancer-associated stroke.
A 73-year-old man with severe asthma developed secondary adrenal insufficiency after long-term high-dose inhaled fluticasone therapy. Switching to inhaled ciclesonide worsened the symptoms (fatigue, muscle pain, diarrhea...A 73-year-old man with severe asthma developed secondary adrenal insufficiency after long-term high-dose inhaled fluticasone therapy. Switching to inhaled ciclesonide worsened the symptoms (fatigue, muscle pain, diarrhea, and eosinophilia), and oral hydrocortisone had little effect. Reintroducing fluticasone rapidly improved the symptoms and normalized eosinophilia, suggesting that fluticasone may exert a uniquely strong individualized effect on the hypothalamic-pituitary-adrenal axis. Tapering requires prolonged management, but treatment with Saireito, a Kampo medicine, may have facilitated adrenal recovery. This case highlights that inhaled corticosteroids can significantly affect the systemic corticosteroid physiology, suggesting the need for careful monitoring when changing the preparations.
A 59-year-old man presented with progressive fever, headache, and right hemiparesis. Brain magnetic resonance imaging revealed an elongated tubular rim-enhancing lesion extending along the corticospinal tract. The lesion...A 59-year-old man presented with progressive fever, headache, and right hemiparesis. Brain magnetic resonance imaging revealed an elongated tubular rim-enhancing lesion extending along the corticospinal tract. The lesion showed a selective radiological response to ampicillin and trimethoprim-sulfamethoxazole but relapsed after treatment discontinuation. Repeat blood cultures, cerebrospinal fluid cultures, polymerase chain reaction testing, and autopsy revealed no identifiable pathogens. Based on the characteristic tract-based imaging features and selective antimicrobial response, this case was clinically considered a probable Listeria monocytogenes brain abscess. Retrospective imaging revealed a small pulmonary arteriovenous malformation that may have contributed to the brain abscess formation.
Median arcuate ligament syndrome (MALS) involves compression of the celiac artery and it can cause a hemodynamic disturbance. We report a case of acute upper gastrointestinal bleeding from a Dieulafoy lesion arising from...Median arcuate ligament syndrome (MALS) involves compression of the celiac artery and it can cause a hemodynamic disturbance. We report a case of acute upper gastrointestinal bleeding from a Dieulafoy lesion arising from the collateral arterial circulation, considered secondary to MALS. Although initial hemostasis was achieved by endoscopic clipping, given the aneurysmal appearance and the presence of a developed collateral circulation on computed tomography, an interventional radiology evaluation and transcatheter arterial embolization were performed to prevent rebleeding. Surgery was performed two months later for median arcuate ligament division and aorto-celiac bypass. No recurrence or abnormal vascular findings were identified during the >5 years of follow-up.
Sugimoto H, Sawa N, Watanabe S
… +11 more, Mizuno H, Oba Y, Sekine A, Yamanouchi M, Hasegawa E, Suwabe T, Wada T, Kono K, Ohashi K, Yamaguchi Y, Ubara Y
We examined a kidney biopsy from an 83-year-old woman with rapidly progressive renal failure who tested positive for anti-GBM antibody, MPO-ANCA, and PR3-ANCA. Of the 50 obtained glomeruli, 40 showed acute-phase necrotiz...We examined a kidney biopsy from an 83-year-old woman with rapidly progressive renal failure who tested positive for anti-GBM antibody, MPO-ANCA, and PR3-ANCA. Of the 50 obtained glomeruli, 40 showed acute-phase necrotizing glomerulitis with fibrin deposition. Five glomeruli showed fibrocellular crescent formation, and the remaining five showed chronic changes with global sclerosis. Very small necrotizing vasculitis was observed in the small arteries. Widespread tubulointerstitial nephritis was observed. The high incidence of acute-phase lesions in this case can be explained by anti-GBM glomerulonephritis. However, the coexistence of the latter chronic lesions suggests the involvement of MPO- and PR3-ANCA-associated vasculitis. After steroid pulse therapy followed by the tapering oral prednisolone, hemodialysis was initiated, and the serologic remission of anti-GBM antibodies and ANCAs was achieved without additional immunosuppression. However, febrile relapse with a re-elevation of anti-GBM antibody and myeloperoxidase-ANCA levels occurred 18 months after steroid discontinuation and she promptly responded to reintroduction of low-dose prednisolone, with no further recurrence. Together with the biopsy findings of acute anti-GBM-type necrotizing glomerulitis superimposed on lesions suggestive of ANCA-associated vasculitis, this course supports overlapping pathogenic mechanisms in triple-seropositive disease and underscores the need for long-term clinical and serologic follow-up even after apparent remission.
Ulcerative colitis (UC) and human immunodeficiency virus (HIV) infection represent opposing immunological states, and their coexistence poses distinct clinical challenges. Although several cases of UC in HIV-infected pat...Ulcerative colitis (UC) and human immunodeficiency virus (HIV) infection represent opposing immunological states, and their coexistence poses distinct clinical challenges. Although several cases of UC in HIV-infected patients have been reported, remission induced by antiretroviral therapy is exceptionally rare in the literature. We describe a patient with UC complicated by HIV infection who achieved sustained remission following the initiation of antiretroviral therapy without any additional immunosuppressive therapy. Furthermore, we review the immunological interplay between UC and HIV infection and discuss their relevance to the pathophysiology and therapeutic strategies of the disease.
Upadacitinib (UPA), a selective Janus kinase 1 inhibitor, is approved for treating both Crohn's disease (CD) and atopic dermatitis (AD). However, clinical experience in patients with coexisting CD and AD is limited. We r...Upadacitinib (UPA), a selective Janus kinase 1 inhibitor, is approved for treating both Crohn's disease (CD) and atopic dermatitis (AD). However, clinical experience in patients with coexisting CD and AD is limited. We report two adult men with concurrent CD and AD who were treated with UPA. In both cases, the intestinal and cutaneous symptoms improved within one month of treatment, followed by the endoscopic remission of CD and continued control of AD. Disease control was maintained after the dose reduction. These cases suggest that UPA may be a useful therapeutic option for selected patients with coexisting CD and AD.
Aim Metabolic and alcohol-associated liver disease (MetALD) is a newly defined category of steatotic liver disease. It remains unclear whether the severity of fibrosis differs between MASLD-predominant and ALD-predominan...Aim Metabolic and alcohol-associated liver disease (MetALD) is a newly defined category of steatotic liver disease. It remains unclear whether the severity of fibrosis differs between MASLD-predominant and ALD-predominant MetALD. This study aimed to compare liver stiffness measurements (LSM) using shear wave elastography (SWE) and non-imaging non-invasive liver disease assessments (NILDAs) between these subtypes. Methods In this single-center cross-sectional study, participants with MetALD were stratified into MASLD-predominant (n=176) and ALD-predominant (n=72) groups. Significant fibrosis was defined as a ≥8 kPa. We also compared non-imaging NILDAs (FIB-4 index, NAFLD fibrosis score, Fibrotic NASH index, MAF-5 score, and LiverRisk score) between the two groups. Results No significant differences were observed in LSM (6.35 vs. 6.13 kPa, p=0.1209) or the prevalence of significant fibrosis (36.3% vs. 26.3%, p=0.1308) between the MASLD-predominant and ALD-predominant groups. Similarly, other non-imaging NILDAs, including the Fibrotic NASH index and MAF-5 score, showed no significant differences in the proportion of analyses using clinical cut-offs. In contrast, the proportion of patients with a high FIB-4 index was significantly higher in the ALD-predominant group than in the MASLD-predominant group (18% vs. 30.8%, p=0.0331). Multivariate and decision tree analyses identified the AST levels as the most impacted independent factor of a high FIB-4 index in the ALD-predominant group (OR 1.033, 95%CI 1.011-1.058, p=0.0028). Conclusion Fibrosis severity as assessed by SWE and most non-imaging NILDAs is comparable between MASLD-predominant and ALD-predominant MetALD, supporting their management as a unified clinical entity regarding liver fibrosis. However, the FIB-4 index may overestimate the fibrosis risk in ALD-predominant MetALD due to an alcohol-induced AST elevation.
Radiation-associated anastomotic stenosis is often rigid and poorly distensible, rendering conventional dilation hazardous. We report a case of a 67-year-old man who developed severe esophagogastric anastomotic stenosis...Radiation-associated anastomotic stenosis is often rigid and poorly distensible, rendering conventional dilation hazardous. We report a case of a 67-year-old man who developed severe esophagogastric anastomotic stenosis after chemoradiotherapy for local recurrence following subtotal esophagectomy for esophageal squamous cell carcinoma. Endoscopy revealed a pinhole-like lumen. Four superficial mucosal incisions were made with a needle knife, followed by graded balloon dilation and an intralesional triamcinolone injection. Repeat dilation, performed one week later, increased the lumen to 12 mm. No adverse events occurred, and luminal patency with an improved oral intake was maintained for one month. This approach may therefore be feasible in high-risk patients.
Objective Takotsubo syndrome is characterized by transient left ventricular dysfunction, and prophylactic heparin is recommended for high-risk patients to prevent thrombotic events. Although a recent Swedish registry stu...Objective Takotsubo syndrome is characterized by transient left ventricular dysfunction, and prophylactic heparin is recommended for high-risk patients to prevent thrombotic events. Although a recent Swedish registry study reported a reduced 30-day mortality with heparin use, the analysis did not consider treatment timing and potential confounders. This study aimed to examine the association between the early administration of unfractionated heparin and the short-term outcomes in patients with Takotsubo syndrome. Methods We conducted an observational study using the Diagnostic Procedure Combination database in Japan from April 2010 to March 2022. Patients Patients diagnosed with Takotsubo syndrome were categorized into two groups: those who received unfractionated heparin initiated within the first 2 days and continued until day 2, and those who did not. The primary outcome was 30-day in-hospital mortality. The secondary outcomes were ischemic events, bleeding events, and blood transfusions. A Cox regression model with inverse probability of treatment weighting (IPTW) adjustment was used to estimate the hazard ratios for the outcomes. Results Among 9,920 eligible patients, 4,127 received unfractionated heparin, and 5,793 who did not were considered as controls. After IPTW adjustment, heparin therapy was associated with a lower risk of 30-day mortality (3.3% vs. 4.3%; adjusted hazard ratio, 0.67; 95% confidence interval, 0.53-0.84; p<0.001). The proportions of ischemic and bleeding complications did not differ between the groups. Conclusion Unfractionated heparin use was associated with a reduced 30-day in-hospital mortality in Takotsubo syndrome without increasing the risk of ischemic or bleeding complications. Further investigation of heparin use in Takotsubo syndrome is therefore warranted.
A unicuspid aortic valve (UAV) is a rare congenital anomaly that can cause aortic stenosis in young patients. We present the case of a 44-year-old woman who demonstrated an asymptomatic progression of severe aortic steno...A unicuspid aortic valve (UAV) is a rare congenital anomaly that can cause aortic stenosis in young patients. We present the case of a 44-year-old woman who demonstrated an asymptomatic progression of severe aortic stenosis and ascending aortic dilatation originally detected during pregnancy, and who underwent valve and ascending aortic replacement to reduce the perioperative risk of breast cancer surgery. A gross examination revealed a unicommissural UAV with marked commissural thickening and intraleaflet hemorrhage. A histological examination confirmed micro-intraleaflet hemorrhage and macrophage-rich chronic inflammation. Repetitive commissural mechanical stress may contribute to remodeling and stenosis progression in the UAV.
Visceral disseminated varicella-zoster virus (VZV) infection is an uncommon, but potentially life-threatening complication in immunocompromised patients and it may initially present with severe abdominal pain before any...Visceral disseminated varicella-zoster virus (VZV) infection is an uncommon, but potentially life-threatening complication in immunocompromised patients and it may initially present with severe abdominal pain before any rash appears. This narrative review, supported by a structured PubMed search through March 2026, aimed to characterize such abdominal-pain-first presentations and identify practical clues for making earlier diagnosis. We integrated the findings from a previously published illustrative case meeting the review focus. Across the available literature, recurrent features included severe abdominal pain disproportionate to the abdominal findings, a delayed or absent rash at presentation, limited or non-diagnostic computed tomography findings, and periarterial fat stranding around the celiac artery or superior mesenteric artery in some reports. In immunocompromised patients with severe unexplained abdominal pain, a visceral disseminated VZV infection should be included in the differential diagnosis. Repeated skin examinations, early blood VZV-DNA testing, prompt intravenous aciclovir, and a reduction of immunosuppression when feasible may facilitate both earlier recognition and treatment.
We report a case of leptospiral meningitis in a 50-year-old man in Gunma, Japan, following contact with a rat carcass. Initially diagnosed with aseptic meningitis, cerebrospinal fluid (CSF) PCR identified Leptospira inte...We report a case of leptospiral meningitis in a 50-year-old man in Gunma, Japan, following contact with a rat carcass. Initially diagnosed with aseptic meningitis, cerebrospinal fluid (CSF) PCR identified Leptospira interrogans. The patient fully recovered after 7 days of intravenous ceftriaxone treatment. With 53 cases reported in Japan in 2024, continuing an upward trend since 2020, leptospirosis is an emerging etiology of acute febrile illness in Japan. Clinicians must maintain a high index of suspicion for leptospirosis in aseptic meningitis cases, reflecting the evolving epidemiology of this disease. Furthermore, clinicians should recognize the utility of CSF PCR testing in facilitating an early diagnosis.
We report a case of exogenous lipoid pneumonia, which was possibly caused by the chronic aspiration of olive oil during recurrent self-induced vomiting episodes. A 28-year-old woman with a history of depression, self-ind...We report a case of exogenous lipoid pneumonia, which was possibly caused by the chronic aspiration of olive oil during recurrent self-induced vomiting episodes. A 28-year-old woman with a history of depression, self-induced vomiting, and type 1 diabetes was referred because of abnormal chest radiography findings during screening. Chest CT revealed ground-glass opacities, predominantly in the right middle and lower lobes. A bronchoalveolar lavage fluid examination revealed a bi-layer separation of lipid-laden macrophages from the cell suspension. Diagnostic video-assisted thoracoscopy confirmed the diagnosis of exogenous lipoid pneumonia. Following the cessation of olive oil intake, her radiologic abnormalities improved without steroid therapy.
A 70-year-old woman consistently showed elevated serum potassium levels, whereas her whole blood potassium levels, as determined by a blood gas analysis, were within the normal range. This discrepancy was caused by handg...A 70-year-old woman consistently showed elevated serum potassium levels, whereas her whole blood potassium levels, as determined by a blood gas analysis, were within the normal range. This discrepancy was caused by handgrip-induced pseudohyperkalemia. This case highlights three important clinical aspects. First, pseudohyperkalemia should be considered in cases of asymptomatic hyperkalemia without any apparent cause. Second, handgrip or fist clenching may consistently elevate potassium levels. Finally, pseudohyperkalemia due to handgrip or fist clenching tends to elevate potassium levels, particularly in the first-drawn sample, which can result in a discrepancy between the serum and whole blood potassium levels.