Negative myoclonus as a manifestation of cefepime neurotoxicity.

Negative myoclonus may present in the early stages of cefepime neurotoxicity. Cefepime neurotoxicity typically presents as reduced consciousness, myoclonus, and seizures; however, negative myoclonus is uncommon. This video shows an older woman with cefepime neurotoxicity that presented as a negative myoclonus of the upper limbs.

Empyema caused by Streptococcus dysgalactiae subsp. equisimilis subsequently to bacteraemia.

Streptococcus dysgalactiae subsp. equisimilis (SDSE) commonly causes a variety of infections in older individuals. However, respiratory infections are uncommon. We present the case of an older man with empyema due to SDSE subsequently to bacteraemia. He presented with a 1-day history of fever and laboratory findings revealed an increased white blood cell count and C- reactive protein (CRP) level. Chest CT revealed no infiltration and no pleural effusion. SDSE was detected in the blood cultures. Primary bacteraemia was suspected and antibiotic administration was initiated; however, 2 days later, his right breath sound diminished, and chest radiography revealed right pleural effusion. Thoracentesis yielded cloudy fluid with frank pus; thus, he was diagnosed with empyema due to SDSE, and a drainage tube was placed. Thereafter, his fever improved, and his CRP level decreased. Thus, SDSE can cause empyema probably by haemotological spread of SDSE to the pleura.

Infective endocarditis and septic arthritis caused by Corynebacteriumstriatum.

Corynebacterium striatum occasionally causes nosocomial infections, such as catheter-related bloodstream infection and pneumonia; however, C. striatum-related infective endocarditis or septic arthritis is uncommon. We present the case of an 85-year-old woman with infective endocarditis at the native valve and septic arthritis at the native shoulder joint caused by C. striatum. The patient was admitted for a 10-day history of fever and right shoulder pain. She had no history of artificial device implantation, injury, arthrocentesis, or hospitalization. A physical examination revealed conjunctival petechiae, a systolic heart murmur, and right shoulder joint swelling. C. striatum was observed in two blood culture sets. Transesophageal echocardiography revealed vegetation in the right aortic coronary cusp. Arthrocentesis at the right shoulder aspirated pyogenic fluid and C. striatum was detected in the culture. The patient was diagnosed with infective endocarditis and septic arthritis caused by C. striatum, and ampicillin was administered based on antimicrobial susceptibility test results. The patient's condition was initially stable; however, she developed pulmonary congestion on day 56 and eventually died. An autopsy demonstrated perforation of the aortic left coronary cusp with vegetation. C. striatum may cause native valve endocarditis and native joint septic arthritis.

Immune-mediated Necrotizing Myopathy in a Patient with Microscopic Polyangiitis: A Case Report.

We herein report a case of immune-mediated necrotizing myopathy (IMNM) in a patient with microscopic polyangiitis (MPA). A 77-year-old Japanese woman presented with a 2-day history of proximal muscle weakness and myalgia, with elevated serum creatinine kinase (CK) levels. Findings of a muscle biopsy were compatible with IMNM; however, anti-SRP and anti-HMGCR antibodies were negative. She also had peripheral neuropathy with elevated serum MPO-ANCA titers, leading to a diagnosis of MPA. IMNM can be a pathological result of MPA muscle involvement.

Four cases of dermatomyositis with abnormally high anti-MDA-5 antibody titres and not high levels of serum ferritin.

Anti-melanoma differentiation-associated gene 5 (MDA-5) antibody-positive dermatomyositis is a fatal disease presenting with rapidly progressive interstitial lung disease. High ferritin levels are a well-known poor prognostic factor. A high anti-MDA-5 antibody titre was also recently identified as a poor prognostic factor. We encountered four cases that had extremely high anti-MDA-5 antibody titres without high levels of ferritin in the initial examination. All cases were female with ages ranging between 29 and 54 years (mean age, 44 years). In the initial examination, anti-MDA-5 antibody titres were 2060-3040 (normal range, <32 index), ferritin levels were 87-480 ng/ml (normal range, 2.6-129.4 ng/ml), KL-6 level was 186-1806 U/ml (normal range, <500 U/ml), and creatine kinase level was normal in all patients. One patient had respiratory distress on exertion. Computed Tomography (CT) images showed mild ground-glass attenuation/reticular shadows near the pleura in all patients. Three patients were treated with a combination of high-dose glucocorticoids, intermittent intravenous cyclophosphamide, and calcineurin inhibitors, and two required plasma exchange due to the worsening of lung lesion. In these patients, ferritin and KL-6 levels tended to elevate after the beginning of treatment. Very mild pulmonary lesions disappeared in one patient treated with moderate doses of a glucocorticoid and calcineurin inhibitor. All patients survived, and one required oxygen on exertion at discharge. The condition of patients with abnormally high anti-MDA-5 antibody titres may deteriorate even though ferritin levels were not high and lung shadows are minimal at presentation. Therefore, intensive treatment needs to be considered early in the course of the disease regardless of the serum ferritin level.

A Flare of Hepatitis C Virus-Associated Cryoglobulinemic Vasculitis After COVID-19.

While undergoing treatment for hepatitis C virus (HCV)-associated cryoglobulinemic vasculitis (CV), a 53-year-old male contracted coronavirus disease 2019 (COVID-19), resulting in a disease flare. Although HCV became negative due to the use of glecaprevir/pibrentasvir, CV remained uncontrolled, and the patient was treated with prednisolone, azathioprine, colchicine, and rituximab. He had not been vaccinated against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was infected with SARS-CoV-2, likely the omicron variant, and developed a severe illness. However, mechanical ventilation and the administration of remdesivir, dexamethasone, unfractionated heparin, and tocilizumab improved his respiratory failure. Despite improvement in respiratory failure, the patient's skin lesions and peripheral neuropathy rapidly worsened, followed by the development of intestinal ischemia, which led to death. To the best of our knowledge, this is the first case of acute exacerbation immediately after SARS-CoV-2 infection of HCV-associated CV on immunosuppressive therapy.

[Tetanus: the clinical features of 11 cases].

Tetanus is an infectious disease induced by wound invasion of Clostridium tetani, which is ubiquitous among soil. Many more cases are reported in Japan than in other developed countries. In this study, we report 11 cases of tetanus experienced at our hospital and discuss the preceding trauma and treatment course. The mean age at onset was 68 years old (35-86 years) and 7 cases required intensive care. Some preceded injuries were clearly contaminated, and others were small and minor. Even minor injuries developed serious tetanus. Trauma was not identified in 2 cases yet both used their family garden every day and had a high risk of exposure to C tetani, suggesting that micro-wounds may have been a gateway to entry. The average length of stay in the intensive care unit was 28 days (4-73 days) and average total hospitalization was 55 days (13-114 days). Only 4 out of 11 cases were diagnosed correctly by the initial physician and others, especially when the trauma was minor or absent, were misdiagnosed even when presenting with characteristic symptoms like lockjaw and posterior neck stiffness. Tetanus should be diagnosed based on medical history and physical examination due to lack of high specific testing. Therefore, a detailed history taking is required, including hobbies in addition to the appropriate neurological examination, thereby facilitating a quick diagnosis and commencement of treatment as soon as possible.