[REITER'S SYNDROME FOLLOWING INTRAVASICAL BCG THERAPY FOR UROTHELIAL CARCINOMA. SUMMARY OF CASE REPORTS OVER THE PAST 13 YEARS IN JAPAN, INCLUDING OUR CURRENT 6 CASES].

Reiter's syndrome is one of the rare complications following intravesical bovis Bacillus Calmette-Guerin (BCG) treatment. In this study we have reviewed and discussed 101 cases including our own 6 cases over the past 13 years in Japan (2000-2013). The patients comprised 70 males and 25 females (6 cases were unknown), mean age of 63.1 (range 42 - 91). Arthritis occured 4-5 days after conjunctivitis. Thirty five (55%) of 68 patients needed corticosteroid treatment to control their arthritis. HLA-B27 is known as a risk factor of Reiter's syndrome, however, positive rate was only 2.4% (n = 41).

[Case of multiple vertebral osteomyelitis due to Streptococcus pneumoniae].

We report a rare case of multiple vertebral osteomyelitis due to Streptococcus pneumoniae. A 73-year-old man admitted for back pain and a low-grade fever was found in laboratory studies to have severe leukocytosis and increased C-reactive protein, but neither computed tomography (CT) nor vertebral magnetic resonance imaging (MRI) clarified the cause of infection in the painful hip lesion, and paralysis developed. in the left leg MRI eventually indicated a vertebral abscess involving multiple lesions at C4-7 and L4-5. We had started antibiotics before blood culture clarified Streptocccus pneumonaie, and antibiotics acted more effectively thereafter. The clinical course was good, little paralysis remained.

Infected Thoracic Aortic Aneurysm Caused by Helicobacter cinaedi.

The causative organism is not identified in some cases of infected aneurysms, a life-threatening condition. A 68-year-old man presented with chest/back pain and a 1-year history of intermittent fever and fatigue. Computed tomography revealed a thoracic aortic aneurysm. After several negative blood cultures, he was eventually diagnosed with an infected aneurysm caused by Helicobacter cinaedi via gene analysis of an aortic tissue specimen. As H. cinaedi is a low-virulence bacterium, infection with this pathogen should be suspected in cases of aortic aneurysms with unidentified causative organism and a long history of subjective symptoms. Detailed examinations, including polymerase chain reaction, should be conducted in such cases.

Renal Insufficiency in Concert with Renin-angiotensin-aldosterone Inhibition Is a Major Risk Factor for Hyperkalemia Associated with Low-dose Trimethoprim-sulfamethoxazole in Adults.

OBJECTIVE: Low-dose trimethoprim-sulfamethoxazole (TMP-SMX) is commonly used to prevent pneumocystis pneumonia in daily practice. Previous reports have shown a relationship between high- or standard-dose of TMP-SMX and hyperkalemia, however it remains unclear whether this is true for low-dose TMP-SMX. In this study we sought to determine the risk factors for hyperkalemia associated with low-dose TMP-SMX. METHODS: In this retrospective cohort study, 186 consecutive adult patients who received TMP-SMX as prophylaxis for pneumocystis pneumonia from January 2014 to January 2015 were evaluated. Data on the patients' age, gender, baseline estimated glomerular filtration rate (eGFR), baseline serum potassium, maximum serum potassium, duration reaching the maximal serum potassium level, dosage, and concomitant use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), ß-blockers, non-steroidal anti-inflammatory drugs and potassium-sparing diuretics were retrospectively collected. Hyperkalemia was defined as a serum potassium level ≥5 mEq/L. Univariate and multivariate analyses were performed. RESULTS: The median age of the patients was 66 years and 51.1% were men. Hyperkalemia associated with low-dose TMP-SMX was observed in 32 patients (17.2%). The median duration to reach the maximal serum potassium level was 12 days. The multivariate logistic regression analysis identified renal insufficiency to be a major risk factor for hyperkalemia associated with low-dose TMP-SMX (eGFR <60 mL/min/1.73 m(2), adjusted OR 4.62). Moreover, in the subpopulation of patients with renal insufficiency, ACEi/ARB use was considered to be a major risk factor for hyperkalemia (adjusted OR 3.96). CONCLUSION: Renal insufficiency in concert with ACEi/ARB use is a major risk factor for hyperkalemia induced by low-dose TMP-SMX.

[Spontaneous omental bleeding presenting as acute abdomen during treatment for polycythemia vera].

A 54-year-old woman with polycythemia vera (PV) presented as an emergency patient with acute abdomen. Her platelet count was 119 x 10(4)/microl. Computed tomography scan revealed fluid accumulation in the omentum and peritoneal space. An emergency laparotomy was undertaken because of severe abdominal pain and omental bleeding was diagnosed. Peritoneal hemorrhage and hematoma weighing in total 1040 g was drained. Although a part of the omentum and stomach was excised, we could not find any orifice from which bleeding could have occurred despite a thorough pathological examination. Massive hemorrhage should be considered in cases with PV presenting as acute abdomen, especially when the platelet count is extremely high (over 100 x 10(4)/microl).

Successful Treatment of Lupus Cerebrovascular Disease with Mycophenolate Mofetil.

We report a case of neuropsychiatric systemic lupus erythematosus successfully treated with mycophenolate mofetil (MMF). The patient was a 40-year-old female who maintained with 7 mg of prednisolone plus 100 mg of azathioprine (AZ) per day. According to transient ischemic attack that occurred repeatedly and an elevated level of interleukin-6 (IL-6) in spinal fluid, she was diagnosed as having neuropsychiatric systemic lupus erythematosus (NPSLE). Initial increase in doses of prednisolone and AZ to 20 mg and 150 mg per day, respectively, was ineffective. After switching from AZ to MMF, her symptoms of NPSLE completely resolved with marked improvement of the IL-6 level in her spinal fluid, suggesting that MMF was effective.

A Case of Immunoglobulin G4-Related Disease with Extensive Multiorgan Involvements.

We report a case of IgG4-related disease (IgG4-RD) with multiple ten-organ involvement. This case showed many clinical findings, such as bilateral swelling of salivary and lacrimal glands, autoimmune pancreatitis, interstitial nephritis, retroperitoneal fibrosis, periaortitis, systemic swelling of lymph nodes, pulmonary lesions, splenomegaly, and jejunal lesions. He was suspected as having SLE or malignant lymphoma but diagnosed as having IgG4-RD by the elevated serum IgG4 level and histological findings from kidney and lymph node. We report a case of IgG4-RD with multiple ten-organ involvement that was successfully treated with prednisolone therapy.

Rupture of the gallbladder in a patient with acquired factor VIII inhibitors and systemic lupus erythematosus.

A 54-year-old woman with a 21-year history of systemic lupus erythematosus (SLE) was admitted to the Matsuyama Red Cross Hospital due to subcutaneous and gingival hemorrhaging. She was diagnosed with acquired factor VIII inhibitors based on a prolonged activated partial-thromboplastin time (APTT) and factor VIII inhibitors. Steroid pulse and factor VIII plasma concentrate were administered to her, not long after which she was transferred to Ehime University Hospital due to gallbladder hematoma. Although her APTT and factor VIII activity were improved after treatment with human factor VIII, she died of multiple organ failure. The autopsy demonstrated a ruptured gallbladder.

[Community acquired sepsis by Serratia rubidaea].

A 48-year-old male who had a past history of alcoholic pancreatitis and diabetes mellitus was admitted to our hospital due to chills and vomiting, on August 13, 1998. His body temperature was 38.0 degrees C, and he had the disturbance of consciousness, tachypnea, tachycardia and hepatomegaly with tenderness. Laboratory findings showed highly inflammatory reactions, DIC and hepatorenal dysfunction. Abdominal CT and US revealed multiple liver abscess with portal vein thrombus. Serratia rubidaea was detected in the blood culture. SBT/CPZ and TOB were administered and he recovered. This is a rare case of Serratia rubidaea sepsis. It is also necessary to pay attention to Serratia infections as well as S. marcescens.

[Brugada syndrome occurring after autologous peripheral blood stem cell transplantation for acute myeloid leukemia].

A 74-year-old male was found to be suffering from the Brugada syndrome after undergoing high dose chemotherapy followed by autologous peripheral blood stem cell transplantation (ABSCT) for acute myeloid leukemia. A specific ECG pattern of right bundle-branch block and a coved-type ST-segment elevation in leads V1 through V3, which is compatible with the Brugada syndrome, was unmasked by febrile neutropenia on the 8th day after ABSCT. He experienced syncope on the 11th day due to ventricular tachycardia, which was immediately improved with the administration of intravenous lidocaine. The Brugada syndorome should be considered in febrile patients if they have a episode of syncope or ECG change.

Stone attenuation value and cross-sectional area on computed tomography predict the success of shock wave lithotripsy.

PURPOSE: To identify the parameters on noncontrast computed tomography (NCCT) that best predict the success of shock wave lithotripsy (SWL). MATERIALS AND METHODS: We reviewed the records of 75 patients who underwent SWL for urinary calculi measuring 5 to 20 mm. Using NCCT images, we estimated the largest stone cross-sectional area and contoured the inner edge of the stone. Clinical outcome was classified as successful (stone-free or <4 mm in diameter) or failed (stone fragments, ≥4 mm). The impact of preoperative parameters was evaluated by univariate and multivariate analysis. RESULTS: The overall success rate was 73.3%. Average stone attenuation value, stone length, and stone cross-sectional area in the success and failure groups were 627.4±166.5 HU (Hounsfield unit) vs. 788.1±233.9 HU (p=0.002), 11.7±3.8 mm vs. 14.2±3.6 mm (p=0.015), and 0.31±0.17 cm(2) vs. 0.57±0.41 cm(2) (p<0.001), respectively. In the multivariate analysis, stone attenuation value was the only independent predictor of SWL success (p=0.023), although stone cross-sectional area had a tendency to be associated with SWL success (p=0.053). Patients were then classified into four groups by using cutoff values of 780 HU for stone attenuation value and 0.4 cm(2) for cross-sectional area. By use of these cutoff values, the group with a low stone attenuation value and a low cross-sectional area was more than 11.6 times as likely to have a successful result on SWL as were all other groups (odds ratio, 11.6; 95% confidence interval, 3.9 to 54.7; p<0.001). CONCLUSIONS: Stone attenuation value and stone cross-sectional area are good predictors of extracorporeal SWL outcome.

Pandemic (H1N1) 2009-associated ARDS rescued by neuraminidase inhibitors with emergency use of extracorporeal membrane oxygenation.

A 36-year-old man with underlying systemic lupus erythematosus complicated by autoimmune hemolytic anemia underwent immunosuppressive treatment. After showing a low-grade fever for two days, his fever spiked. He was confirmed to have pandemic (H1N1) 2009 by real-time reverse transcription polymerase chain reaction (PCR). His condition deteriorated to acute respiratory distress syndrome (ARDS), and mechanical ventilation became necessary. The lowest PaO(2)/FIO(2) ratio was 77, and he was placed on extracorporeal membrane oxygenation (ECMO). Based on our observation, the emergency use of ECMO in addition to peramivir might be useful. A noteworthy point is that once ARDS deteriorates due to pandemic (H1N1) 2009, intensive supportive care should be started.

Recurrence of hepatitis-associated aplastic anemia after a 10-year interval.

Hepatitis-associated aplastic anemia (HAA) has been reported to show a successful outcome following immunosuppressive treatment. On the other hand, the long-term prognosis of HAA has not been sufficiently clarified. Herein we report a patient with HAA who had been treated with cyclosporine for one year, and maintained complete remission without treatment. Ten years later, acute non-A, non-B, and non-C hepatitis reccurred followed by bone marrow aplasia. A second immunosuppressive treatment with antithymocyte globulin and cyclosporine was effective. This case might provide useful information for the long-term follow-up of patients with HAA.