Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative disorder with diverse clinical manifestations, including encephalitis-like, stroke-like, and seizure episodes. We report a female patient who exp...Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative disorder with diverse clinical manifestations, including encephalitis-like, stroke-like, and seizure episodes. We report a female patient who experienced recurrent stroke-like attacks with cerebrovascular changes resembling an embolism. At the ages of 65 and 71, she exhibited transient stenosis and hypoperfusion of the left middle cerebral artery, followed by hyperperfusion. Initial imaging lacked characteristic diffusion-weighted imaging (DWI) abnormalities, resulting in a misdiagnosis of infarction. The diagnosis of NIID was later confirmed by the appearance of characteristic corticomedullary junction (CMJ) hyperintensity on DWI and the identification of a GGC repeat expansion in NOTCH2NLC. A retrospective review of serial brain MRIs revealed that FLAIR hyperintensity in the paravermal region was present significantly earlier than CMJ hyperintensity on DWI. NIID should therefore be considered in cases of recurrent stroke-like episodes with reversible perfusion changes. Even in the absence of CMJ hyperintensity on DWI, paravermal hyperintensity on FLAIR imaging may serve as an important early diagnostic clue for NIID.
A 77-year-old man was admitted with respiratory failure. Chest computed tomography revealed right pleural thickening and pleural effusion. A cytological examination of the pleural fluid showed a predominance of neutrophi...A 77-year-old man was admitted with respiratory failure. Chest computed tomography revealed right pleural thickening and pleural effusion. A cytological examination of the pleural fluid showed a predominance of neutrophils without any malignant findings. The peripheral white blood cell count increased to a maximum of 74,070/μL. Laboratory tests revealed that the serum level of granulocyte colony-stimulating factor (G-CSF) was 268 pg/mL. The autopsy findings indicated malignant pleural mesothelioma. The clinical course was consistent with that of G-CSF-producing malignant pleural mesothelioma. This is a rare case of desmoplastic malignant pleural mesothelioma that clinically mimicked a G-CSF-producing tumor and empyema.
Objectives The number of internal medicine inpatients is increasing, and elderly individuals account for most hospitalizations. Vertebral fractures should be considered in patients hospitalized for internal medicine. Thi...Objectives The number of internal medicine inpatients is increasing, and elderly individuals account for most hospitalizations. Vertebral fractures should be considered in patients hospitalized for internal medicine. This study aimed to investigate thoracic vertebral fractures in patients hospitalized for internal medicine diseases. Methods This study included 2,977 patients who underwent chest computed tomography (CT). Chest CT images were reconstructed to visualize the thoracic spine. The anterior, middle, and posterior vertebral heights were measured using artificial intelligence (AI). A vertebral fracture was defined as a height loss of ≥20% at a vertebra. Results The prevalence rates of thoracic vertebral fractures in all patients, males, and females were 31.6%, 25.2%, and 38.7%, respectively, and the prevalence rates of severe thoracic vertebral fractures were 12.4%, 9.2%, and 15.9%, respectively. The prevalence rates of multiple thoracic vertebral fractures in all patients, males, and females were 9.6%, 5.0%, and 14.6%, respectively. Conclusion The high prevalence of thoracic vertebral fractures among older internal medicine inpatients underscores the need for routine vertebral assessment. Incorporating AI-assisted CT evaluation may enhance the early detection and management of osteoporosis-related fractures in this vulnerable population.
Ohtaka M, Tomomatsu K, Yamazaki K
… +13 more, Endo K, Hirasawa H, Katagiri M, Katayama M, Komatsu R, Tsukimoto K, Uotani H, Urata M, Tanaka J, Hayama N, Ito Y, Oguma T, Asano K
An 84-year-old woman with epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma developed sequential cardiotoxicity during treatment with two EGFR tyrosine kinase inhibitors. Osimertinib induced QT prolonga...An 84-year-old woman with epidermal growth factor receptor (EGFR)-mutated lung adenocarcinoma developed sequential cardiotoxicity during treatment with two EGFR tyrosine kinase inhibitors. Osimertinib induced QT prolongation without systolic dysfunction, thus necessitating discontinuation. After switching to gefitinib, the patient developed heart failure with a reduced ejection fraction, which resolved after drug withdrawal, but recurred upon rechallenge. This case represents a rare instance of severe gefitinib-induced heart failure following electrical instability associated with osimertinib and highlights the need for careful cardiac monitoring and the awareness of cumulative cardiotoxicity when switching EGFR tyrosine kinase inhibitors, even to first-generation agents which are considered to be safe.
Objective The exaggerated activation of xanthine oxidase (XO) provokes oxidative stress, a feature of type 2 diabetes mellitus (T2DM) and obesity. Because measuring the plasma XO activity is complicated, we tested whethe...Objective The exaggerated activation of xanthine oxidase (XO) provokes oxidative stress, a feature of type 2 diabetes mellitus (T2DM) and obesity. Because measuring the plasma XO activity is complicated, we tested whether urinary isoxanthopterin (IXP), the end product of pterin metabolism catalyzed by XO, could serve as an alternative marker. Methods We enrolled 51 patients with mild T2DM and obesity (BMI ≥25 kg/m; median HbA1c 6.7%) and 9 healthy individuals. Urinary IXP level was determined by HPLC-FL. Correlations between 24-hour and spot urinary IXP were examined in healthy individuals to validate spot urine, followed by analyses in patients stratified by the median IXP/Pterin ratio. Results In healthy individuals, spot urinary IXP correlated with 24-h measurements (r=0.795, p=0.010); however, both urinary IXP levels and the IXP/Pterin ratio were not correlated with the XO activity. In patients with mild T2DM and obesity, the urinary IXP/pterin ratio was significantly associated with fasting plasma glucose (p=0.030). Among patients with higher urinary IXP/Pterin ratios, this association was tightly independent of other clinical parameters (p=0.028). Conclusion The level of spot urinary IXP was correlated with that of 24-h excretion, but not with circulating XO activity. The ratio of IXP/Pterin was associated with fasting hyperglycemia and provides a novel avenue to evaluate glucose dysmetabolism in obese patients with mild T2DM.
Ectopic pancreas is usually asymptomatic but it may rarely cause gastric outlet obstruction when complicated by pancreatitis. We report two cases of ectopic pancreatitis in the gastric antrum, presenting with recurrent e...Ectopic pancreas is usually asymptomatic but it may rarely cause gastric outlet obstruction when complicated by pancreatitis. We report two cases of ectopic pancreatitis in the gastric antrum, presenting with recurrent epigastric pain and vomiting. In the first case, imaging and Endoscopic ultrasound (EUS)-guided biopsy confirmed ectopic pancreas with chronic pancreatitis, and laparoscopic wedge resection resolved the symptoms. In the second case, ectopic pancreatitis with a pseudocyst was successfully managed with EUS-guided drainage, with no recurrence during the 3-year follow-up. Ectopic pancreatitis should be considered in the differential diagnosis of gastric outlet obstruction in young patients. Furthermore, the therapeutic strategy should be tailored to the characteristics of the lesion.
Kanemoto S, Nishihara M, Fujiwara E
… +11 more, Sonoda M, Hirakawa R, Miyoshi A, Ro S, Okafuji K, Kitamura A, Tomishima Y, Miura Y, Kitamoto T, Ouchi S, Jinta T
We present the case of a 74-year-old man with Stage IVB lung adenocarcinoma who developed changes in his psychiatric symptoms following three cycles of treatment with cisplatin, pemetrexed, and pembrolizumab. A thorough...We present the case of a 74-year-old man with Stage IVB lung adenocarcinoma who developed changes in his psychiatric symptoms following three cycles of treatment with cisplatin, pemetrexed, and pembrolizumab. A thorough examination revealed the presence of anti-titin antibodies in the serum, leading to a diagnosis of autoimmune encephalitis. This is the first documented case of anti-titin antibody-positive encephalitis in a patient with non-small cell lung cancer (NSCLC). This case highlights the importance of considering immune-mediated neurological complications during Immune Checkpoint Inhibitor (ICI) treatment and the value of early antibody detection and prompt immunosuppressive therapy.
Remnant cholecystitis caused by cystic duct stones is a rare cause of post-cholecystectomy syndrome and it is often difficult to diagnose. We report the case of a man in his seventies with recurrent epigastric pain one y...Remnant cholecystitis caused by cystic duct stones is a rare cause of post-cholecystectomy syndrome and it is often difficult to diagnose. We report the case of a man in his seventies with recurrent epigastric pain one year after laparoscopic cholecystectomy. Computed tomography revealed a 10-mm cystic duct stone. Endoscopic retrograde cholangiography (ERC) demonstrated macroscopic purulent bile from the remnant cystic duct, whereas bile from the common bile duct was grossly normal. This confirmed the diagnosis of localized remnant cholecystitis, without the need for cholangioscopy. ERC-guided drainage and subsequent stone removal resulted in a complete recovery. To the best of our knowledge, this is the first report demonstrating macroscopic bile differentiation and successful treatment with ERC-alone.
Objective We evaluated the prognostic significance of small-bowel vascular lesions (SBVLs) by comparing the overall survival and cardiovascular disease (CVD) incidence in patients with and without SBVLs following small-b...Objective We evaluated the prognostic significance of small-bowel vascular lesions (SBVLs) by comparing the overall survival and cardiovascular disease (CVD) incidence in patients with and without SBVLs following small-bowel bleeding. Methods We retrospectively analyzed consecutive patients who underwent capsule endoscopy or double-balloon enteroscopy for suspected small bowel bleeding between January 2015 and September 2023. Patients with liver cirrhosis, Osler-Weber syndrome, or a follow-up period of <1 month were excluded. The patients were categorized into the SBVL-present and SBVL-absent groups. The baseline characteristics were compared, and cumulative survival and CVD incidence were assessed using the Kaplan-Meier method and Cox proportional hazards models. Results The cohort comprised 327 patients (188 men and 139 women; mean age, 71.5 years), of whom 95 (29%) had SBVLs. The SBVL-present group had a higher prevalence of smoking, hypertension, preexisting CVD, chronic kidney disease, and antiplatelet and proton pump inhibitor use. Over a median follow-up of 33 months, cumulative survival did not differ significantly between the groups (5-year survival: 73% vs. 83%, p=0.17), and no deaths were attributable to gastrointestinal bleeding. In contrast, the cumulative CVD incidence was significantly higher in the SBVL-present group (5-year incidence: 43% vs. 9%, p<0.01). The presence of SBVL was independently associated with an increased risk of CVD events (adjusted hazard ratio, 3.81; 95% confidence interval, 1.86-7.78). Conclusion SBVLs do not adversely affect overall survival, but are independently associated with a substantially increased risk of subsequent CVD events. Therefore, the detection of SBVLs may serve as a marker of systemic vascular vulnerability, warranting careful long-term cardiovascular surveillance.
A 45-year-old male was admitted to our hospital with complaints of nausea, vomiting, and abdominal pain for the past two days. He had been receiving treatment for diabetes for 6 years. Two weeks before hospitalization, d...A 45-year-old male was admitted to our hospital with complaints of nausea, vomiting, and abdominal pain for the past two days. He had been receiving treatment for diabetes for 6 years. Two weeks before hospitalization, despite experiencing a loss of appetite and difficulty in eating, he continued drinking alcohol. Canagliflozin and metformin were discontinued concurrently. Laboratory findings revealed high anion gap metabolic acidosis due to elevated serum ketone bodies and mild hyperglycemia. Alcohol ketoacidosis was diagnosed on the basis of a history of excessive alcohol intake and an increased osmolarity gap. Abdominal computed tomography (CT) revealed distension of the stomach with no obstructing mass.
Solitary pulmonary capillary hemangioma (SPCH) is a rare vascular disease of the lung that is characterized by the pathological proliferation of capillary vessels and thickened alveolar septa. SPCH often shows localized...Solitary pulmonary capillary hemangioma (SPCH) is a rare vascular disease of the lung that is characterized by the pathological proliferation of capillary vessels and thickened alveolar septa. SPCH often shows localized ground-glass attenuation (GGA) on computed tomography (CT), which is difficult to distinguish from early stage lung cancer, such as adenocarcinoma in situ. We herein present two cases of SPCH that demonstrated GGA on CT images. The patient underwent surgical resection for diagnostic therapeutics and was pathologically diagnosed with SPCH. Although it could be difficult to identify SPCH radiologically, it should be considered in the differential diagnosis.