Bilateral bartholin's gland abscesses in a 4-year-old girl with vitamin a deficiency: a case report.

BACKGROUND: A Bartholin's gland abscess is one of the most common infections in women of reproductive age. Although Bartholin's gland abscesses have been reported in prepubertal children, they are rarer in prepubertal children than in adults. Herein, we report a case of bilateral Bartholin's gland abscesses in a 4-year-old girl with vitamin A deficiency. CASE PRESENTATION: A 4-year-old girl diagnosed with autism spectrum disorder was admitted to the hospital for close examination and treatment because of persistent fever and malaise. The child was a marked fussy eater and was diagnosed with corneal ulceration and night blindness secondary to vitamin A deficiency. Both of the patient's labia were swollen, and a diagnosis of a bilateral Bartholin's gland abscess was made using computed tomography. Incisional drainage was performed under general anesthesia. The patient's postoperative course was uneventful, and she was discharged from the hospital on day 8 after the surgery. During hospitalization, attempts were made to correct the vitamin deficiency by adding nutritional supplements to the diet. Three months after the surgery, no recurrence of abscesses was noted. CONCLUSIONS: Decreased immunocompetence and mucosal barrier function due to vitamin A deficiency is thought to be the underlying cause of Bartholin's gland abscesses. Although prepubertal Bartholin's gland abscesses have been reported, they are rare. To the best of our knowledge, no reports of bilateral Bartholin's gland abscesses potentially caused by vitamin A deficiency have been reported. When prepubertal girls present with Bartholin's gland abscesses, the presence of immunodeficiency due to vitamin or trace element deficiency should also be considered.

Pyogenic Spondylitis Caused by Parvimonas micra: A Case Report.

Parvimonas micra (P. micra) is a gram-positive anaerobic coccus endemic to the oral cavity and intestinal tract. We report a case of pyogenic spondylitis caused by P. micra and summarize the clinical features of previous case reports. An 81-year-old man with a history of lumbar vertebral compression fracture two years previously presented to the emergency department with low back pain. He was clinically diagnosed with pyogenic spondylitis due to difficulty in moving his body, spinal tapping pain, and signs of inflammation. He was hospitalized, and aerobic and anaerobic blood culture samples were collected, but the results were negative. Computed tomography and magnetic resonance imaging revealed inflammation in the second and third lumbar vertebrae and L2/3 and L3/4 intervertebral discs, and culture of the infected disc biopsy showed P. micra growth. After six weeks of treatment with ampicillin-sulbactam and ampicillin, the patient's symptoms improved, and he was discharged. During hospitalization, he was diagnosed with periodontitis and type 2 diabetes; his dentures were adjusted, and he was started on an oral hypoglycemic agent. Pyogenic spondylitis caused by P. micra tends to be associated with oral infections. This case illustrates the importance of appropriate detection and treatment of the source of infection to prevent recurrence.

Hyponatremia due to adrenal insufficiency after a Mamushi bite: a case report.

BACKGROUND: Mamushi bites are the most common venomous snake bites in Japan, with known complications including rhabdomyolysis and acute kidney injury; however, adrenal insufficiency as a result of snake bites has not been previously reported. We report a case of empty sella with transient adrenal insufficiency during hospitalization for a Mamushi bite. CASE PRESENTATION: An 84-year-old man was admitted to our hospital with a Mamushi bite on the right fifth finger. Serum sodium (Na) level remained in the normal range. On the ninth day of admission, he developed hyponatremia, with a serum Na level of 114 mEq/L and serum cortisol level of 4.0 µg/dL (reference value 4.5-21.1 µg/dL). His serum Na level was restored within the normal range after administration of corticosteroids with 3% NaCl solution. Both rapid adrenocorticotrophin and corticotropin-releasing hormone loading tests showed low cortisol response. Based on the results of the hormone loading tests, a diagnosis of pituitary adrenal insufficiency was made. Contrast-enhanced pituitary magnetic resonance imaging (MRI) showed primary empty sella. After discontinuation of corticosteroids, the hyponatremia did not recur, and the patient was discharged on the 24th day of hospitalization. After discharge, the patient visited an outpatient clinic, but hyponatremia recurrence was not observed. CONCLUSIONS: This is the first report of hyponatremia due to pituitary adrenal insufficiency during hospitalization for a Mamushi bite in a patient with empty sella. When hyponatremia occurs during hospitalization for a Mamushi bite, cortisol measurement, hormone loading test, and head MRI should be performed to search for pituitary lesions because of the possibility of adrenal insufficiency caused by snake venom.

A Case of Milk-Alkali Syndrome Caused by Diuretic-Induced Alkalosis and Polypharmacy.

Milk-alkali syndrome, which is characterized by hypercalcemia, metabolic alkalosis, and renal dysfunction, typically results from the ingestion of large amounts of calcium and absorbable alkaline products. However, these symptoms can also manifest when alkalosis and calcium loading occur simultaneously, owing to other factors. We report a case of milk-alkali syndrome caused by loop-diuretic-induced alkaline load and polypharmacy in an 85-year-old Japanese woman with multiple comorbidities, including osteoporosis, hypertension, type 2 diabetes, dyslipidemia, and Parkinson's disease. The patient regularly took 14 drugs, including calcium L-aspartate, eldecalcitol, celecoxib, and a fixed-dose combination of losartan and hydrochlorothiazide. Immediately before admission, furosemide was administered for the treatment of edema. The patient presented with chest discomfort, general malaise, and clinical signs of dehydration, hypercalcemia, hypophosphatemia, hypokalemia, and hypomagnesemia, accompanied by electrocardiogram abnormalities, renal dysfunction, and chloride-resistant metabolic alkalosis. The hypercalcemia was specifically induced by calcium L-aspartate and eldecalcitol. The hypomagnesaemia and hypophosphatemia were caused by diuretics and hypercalcemia. Thus, all the oral medications were discontinued, and rehydration and electrolyte correction therapy were administered. The final diagnosis was milk-alkali syndrome caused by the concomitant use of loop diuretics and other medications, without absorbable alkaline preparation use. This case underscores the importance of considering drug-related factors, checking concomitant medications, and being aware of the benefits, harmful effects, and side effects of polypharmacy in older adults with multimorbidity.

Diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression was useful in a patient with isolated myocardial abscess confined to the right atrial wall: a case report.

BACKGROUND: Myocardial abscess is often associated with infective endocarditis (IE), and isolated myocardial abscess without IE is rare. Echocardiography and computed tomography (CT) are often used to diagnose myocardial abscess; however, to the best of our knowledge, diffusion-weighted whole-body magnetic resonance imaging with background body signal suppression (DWIBS) has not been used. Here, we present a case of myocardial abscess without IE that was diagnosed using DWIBS. CASE PRESENTATION: A 72-year-old Japanese man with a history of hypertension, dyslipidemia, and retinitis pigmentosa presented to our hospital with malaise and a fever lasting 10 days. Blood test results showed elevated inflammatory marker levels (white blood cell count 18,700/µL and C-reactive protein level 23.0 mg/dL). Infection was suspected; however, the source of the infection could not be identified. DWIBS, which was performed on day 7 of admission to determine the source of infection, showed a high signal surrounding the right wall, suggesting inflammation. Contrast-enhanced CT performed on day 1 of hospitalization revealed a low-density area in the same region; however, the pathological implications of this finding could not be determined. Based on DWIBS findings, we concluded that the condition presented as a myocardial abscess that was confined specifically to the right atrial wall. Three sets of blood cultures revealed negative findings, and echocardiography showed no vegetation or valve regurgitation. Therefore, the patient was diagnosed with an isolated myocardial abscess uncomplicated with IE. An electrocardiogram on admission showed no P waves, and the patient had a junctional rhythm. However, on day 20 of hospitalization, he developed a complete atrioventricular block. After complete myocardial abscess healing following antibiotic treatment was confirmed, the patient underwent pacemaker implantation. Ten months after surgery, the patient had no signs of infection recurrence. CONCLUSIONS: Based on history and physical examination alone, diagnosis of an isolated myocardial abscess can be challenging. In addition to CT and echocardiography, DWIBS might be helpful for the diagnosis of myocardial abscesses.

Asymptomatic Idiopathic Renal Infarction Detected Incidentally on Contrast-Enhanced Computed Tomography: A Case Report.

Background: Renal infarction is an extremely rare disease. Although more than 95% of cases are symptomatic, there have been no previously reported asymptomatic cases, without any abnormal blood and urine test findings. Furthermore, the efficacy of long-term treatment of idiopathic renal infarction remains unknown. Case Presentation: A 63-year-old Japanese male underwent laparoscopy; a very low anterior resection of the rectum for lower rectal cancer (stage II) four years and five months prior to diagnosis with renal infarction. During the follow-up imaging studies, asymptomatic idiopathic renal infarction was found incidentally. The blood and urine test findings were normal. Contrast-enhanced computed tomography revealed a linearly bordered area of poor contrast in the dorsal region of the right kidney; however, no renal artery lesions, thromboembolic disease, or coagulation abnormalities were observed. Initial treatment with rivaroxaban 15 mg/day resulted in the remission of the infarcted lesion. The anticoagulation therapy was terminated after about 18 months without any incidences of re-infarction or bleeding events. Conclusions: We reported a very rare case of asymptomatic idiopathic renal infarction where blood and urine tests revealed no abnormal findings, and it was diagnosed incidentally during a post-treatment follow-up examination for lower rectal cancer. Long-term anticoagulant therapy for idiopathic renal infarction should be terminated at an appropriate time, taking the risk of bleeding into account.

Pulmonary syphilis with a cicatricial variant of organizing pneumonia: a case report.

BACKGROUND: Syphilis is a chronic disease that progresses in the primary, secondary, latent, and tertiary stages. Pulmonary manifestations of syphilis are rare, and their histological features have not been well-described. CASE PRESENTATION: A 78-year-old man was referred to our hospital because of a solitary nodular shadow in the right middle lung field on a chest radiograph. Five years prior, a rash appeared on both legs. He was tested for syphilis at a public health center, and the non-treponemal test result was negative. When he was approximately 35 years old, he had unspecified sexual intercourse. Chest computed tomography showed a 13-mm nodule with a cavity in S6 of the right lower lobe of the lung. Robot-assisted resection of the right lower lobe was performed because of suspected localized right lower lobe lung cancer. A cicatricial variant of organizing pneumonia (CiOP) was observed, and immunohistochemistry identified Treponema pallidum inside the macrophages in the nodule cavity. The rapid plasma regain (RPR) value was negative, and the Treponema pallidum hemagglutination assay was positive. The patient was diagnosed as having secondary syphilis with pulmonary involvement. Insidious progression of secondary syphilis may result in CiOP and a negative RPR test result. CONCLUSIONS: We report the first case of pulmonary syphilis with a histological pattern of CiOP. It may be asymptomatic and difficult to diagnose because the RPR test may be negative for a long period of time. When either non-treponemal or treponemal test results are positive, the possibility of pulmonary syphilis should be considered along with appropriate medical treatment.

Computed tomography values of pericardial effusion may predict chylopericardium: a case report.

BACKGROUND: Idiopathic chylopericardium is a rare disease characterized by filling of the pericardial cavity with chylous fluid and has no evident cause. Secondary chylopericardium usually results from injury or damage to the thoracic duct. The most common causes of secondary chylopericardium are trauma, thoracic or cardiac surgery, and congenital lymphangiomatosis. Conservative or surgical treatment can be pursued; however, surgical treatment is required if conservative treatment is unsuccessful. Pericardiocentesis plays a crucial role in the definitive diagnosis of chylopericardium. However, although a serious complication, its occurrence is infrequent. Non-invasive methods, such as computed tomography (CT), could be useful in predicting the color or characteristics of pericardial effusion. CASE PRESENTATION: A 37-year-old Japanese woman presented to our hospital with a cough that persisted for 1 week. Echocardiography revealed pericardial effusion, which was diagnosed as acute pericarditis and treated with loxoprofen. However, pericardial effusion increased, and the patient presented to the emergency room with cardiac tamponade 1 month later. Pericardiocentesis was performed, which confirmed that the pericardial effusion was chylopericardium. Lymphatic scintigraphy did not show any connection between the thoracic duct and pericardial cavity, and the patient was diagnosed with idiopathic chylopericardium. The patient underwent continuous drainage for 11 days. After completion of cardiac drainage, the patient was discharged from the hospital without any exacerbation. The CT attenuation value of the pericardial fluid was 11.00 Hounsfield units (HU). Compared with the other causes of pericardial effusions encountered at our hospital, the HU on CT scan of pericardial effusion was low in our study and similar to the values on CT scan of chylous ascites reported in previous studies. CONCLUSIONS: Although idiopathic chylopericardium is rare, it should be considered an important cause of pericardial effusion. Pericardiocentesis is necessary for definitive diagnosis; however, the CT findings of pericardial effusion may help predict the presence of chylous fluid.

Treatment of portosystemic shunt-borne hepatic encephalopathy in a 97-year-old woman using balloon-occluded retrograde transvenous obliteration: A case report.

BACKGROUND: Hyperammonemia and hepatic encephalopathy are common in patients with portosystemic shunts. Surgical shunt occlusion has been standard treatment, although recently the less invasive balloon-occluded retrograde transvenous obliteration (B-RTO) has gained increasing attention. Thus far, there have been no reports on the treatment of portosystemic shunts with B-RTO in patients aged over 90 years. In this study, we present a case of hepatic encephalopathy caused by shunting of the left common iliac and inferior mesenteric veins, successfully treated with B-RTO. CASE SUMMARY: A 97-year-old woman with no history of liver disease was admitted to our hospital because of disturbance of consciousness. She had no jaundice, spider angioma, palmar erythema, hepatosplenomegaly, or asterixis. Her blood tests showed hyperammonemia, and abdominal contrast-enhanced computed tomography revealed a portosystemic shunt running between the left common iliac vein and the inferior mesenteric vein. She was diagnosed with hepatic encephalopathy secondary to a portosystemic shunt. The patient did not improve with conservative treatment: Lactulose, rifaximin, and a low-protein diet. B-RTO was performed, which resulted in shunt closure and improvement in hyperammonemia and disturbance of consciousness. Moreover, there was no abdominal pain or elevated levels of liver enzymes due to complications. The patient was discharged without further consciousness disturbance. CONCLUSION: Portosystemic shunt-borne hepatic encephalopathy must be considered in the differential diagnosis for consciousness disturbance, including abnormal behavior and speech.

A Ruptured Left Gastric Artery Aneurysm That Neoplasticized during the Course of Coronavirus Disease 2019: A Case Report.

Coronavirus disease 2019 (COVID-19) is an acute respiratory syndrome caused by SARS-CoV-2 and is known to cause respiratory and systemic symptoms. A SARS-CoV-2 infection is involved in aneurysm formation, enlargement, and rupture in medium-sized vessels, such as the cerebral and coronary arteries and the aorta. In contrast, its involvement in forming aneurysms in medium-sized vessels other than the cerebral and coronary arteries has not been reported. An 84-year-old Japanese man with COVID-19 was admitted to our hospital. The treatment course was favorable, and the COVID-19 treatment was completed by the 10th day. On day 14, pancreatic enzymes increased mildly. An abdominal computed tomography revealed a ruptured left gastric aneurysm after spontaneous hemostasis. Arterial embolization was performed. In this patient, a new left gastric aneurysm was suspected of having formed and ruptured during the course of the COVID-19 treatment. To the best of our knowledge, this is the first report of abdominal visceral aneurysm formation caused by COVID-19 in a medium-sized vessel, and it is necessary to remember that aneurysms can be formed at any site when treating this syndrome.

Giant infected hepatic cyst causing exclusion pancreatitis: A case report.

BACKGROUND: An infected hepatic cyst causes clinical symptoms, such as fever and abdominal pain. A cyst with a diameter > 10 cm increases the likelihood of exclusion symptoms in adjacent organs. Herein, we report a case of pancreatitis caused by an infected hepatic cyst. CASE SUMMARY: The patient was an 88-year-old woman with a history of polycystic liver disease and a cyst > 10 cm in diameter. She was referred to our hospital for upper abdominal pain that persisted for four days before consultation. She had a fever of 37.4ºC, and a blood test showed a C-reactive protein level of 23 mg/dL. An infected hepatic cyst was diagnosed by abdominal ultrasonography, computed tomography, and magnetic resonance imaging. Antibacterial therapy and percutaneous cyst puncture did not elicit sufficient therapeutic effects. As the cyst growth continued, laparoscopic hepatic cyst fenestration was performed on hospitalization day 20. Thereafter, symptoms improved, and she was discharged on hospital day 31. CONCLUSION: To our knowledge, this is the second case report of pancreatitis associated with hepatic cyst growth. Percutaneous cyst puncture and drainage or surgical therapy can be considered if a slight improvement with antibiotic therapy alone or exclusion of surrounding organs is observed. Further, attention is needed to avoid potential recurrence.

Epstein-Barr virus-associated infectious mononucleosis with acute epididymitis: a case report.

BACKGROUND: Infectious mononucleosis due to the Epstein-Barr virus is an infectious disease that causes the appearance of atypical lymphocytes in the peripheral blood; it mainly presents with fever, tonsillar pharyngitis, and lymphadenopathy. In addition to hepatitis, splenomegaly, and rashes, it can involve different organs. Here, a case of epididymitis as a rare complication in a patient with Epstein-Barr virus-associated infectious mononucleosis was reported. CASE PRESENTATION: A healthy 23-year-old man visited an outpatient clinic with fever and pharyngitis. Tonsillar pharyngitis, lymphadenopathy, atypical lymphocytes in the peripheral blood, liver dysfunction, and splenomegaly were observed. The patient was diagnosed with infectious mononucleosis based on clinical signs. The next day, the patient developed left testicular pain and was immediately transferred to the emergency outpatient ward. Pain, redness, and swelling were observed in the left scrotum. Ultrasonography revealed swelling of the epididymis and increased blood flow, and the patient was hospitalized with a diagnosis of left epididymitis. The patient's symptoms improved with symptomatic treatment and was discharged on day 16 after admission. Changes in antibody titers established a definitive diagnosis of infectious mononucleosis caused by the Epstein-Barr virus. Based on the disease course, the patient was also diagnosed with infectious mononucleosis associated with unilateral epididymitis. CONCLUSIONS: This is the first case report of Epstein-Barr virus-associated infectious mononucleosis complicated with acute epididymitis. Infectious mononucleosis can cause numerous organ-related complications; thus, physicians and healthcare workers should remain cognizant of Epstein-Barr virus-associated complications throughout the body and not just in the primary organs affected by infectious mononucleosis.

Varicella-zoster virus-associated meningitis, encephalitis, and myelitis with sporadic skin blisters: A case report.

BACKGROUND: Varicella-zoster virus (VZV) generally causes chickenpox at first infection in childhood and then establishes latent infection in the dorsal root ganglia of the spinal cord or other nerves. Virus reactivation owing to an impaired immune system causes inflammation along spinal nerves from the affected spinal segment, leading to skin manifestations (herpes zoster). Viremia and subsequent hematogenous transmission and nerve axonal transport of the virus may lead to meningitis, encephalitis, and myelitis. One such case is described in this study. CASE SUMMARY: A 64-year-old man presented with dysuria, pyrexia, and progressive disturbance in consciousness. He had signs of meningeal irritation, and cerebrospinal fluid (CSF) analysis revealed marked pleocytosis with mononuclear predominance and a CSF/serum glucose ratio of 0.64. Head magnetic resonance imaging revealed hyperintense areas in the frontal lobes. He had four isolated blisters with papules and halos on his right chest, right lumbar region, and left scapular region. Infected giant cells were detected using the Tzanck test. Degenerated epidermal cells with intranuclear inclusion bodies and ballooning degeneration were present on skin biopsy. Serum VZV antibody titers suggested previous infection, and the CSF tested positive for VZV-DNA. He developed paraplegia, decreased temperature perception in the legs, urinary retention, and fecal incontinence. The patient was diagnosed with meningitis, encephalitis, and myelitis and was treated with acyclovir for 23 days and prednisolone for 14 days. Despite gradual improvement, the urinary retention and gait disturbances persisted as sequelae. CONCLUSION: VZV reactivation should be considered in differential diagnoses of patients with sporadic blisters and unexplained central nervous system symptoms.

Effects of Vaccination Day Routine Activities on Influenza Vaccine Efficacy and Vaccination-Induced Adverse Reaction Incidence: A Cohort Study.

We aimed to investigate the effect of vaccination day routine activities on the influenza vaccine efficacy and vaccination-induced adverse reaction incidence. Study participants were workers at three hospitals in the Hyogo Prefecture, Japan, who received the influenza vaccine between October and November, 2018 and 2019. Their data were collected using a questionnaire. The main factors, which were examined for vaccination day routine activities, were personal hygiene (bathing), smoking, alcohol consumption, caffeine intake, and exercise. The main outcome markers included influenza incidence during the winter season and vaccination-induced local or systemic adverse reaction incidence. The risk ratio for the main factors of vaccination day routine activities was calculated against the main outcome markers using the modified Poisson regression. Overall, 3780 people received the influenza vaccination, and 2731 submitted the questionnaire. We found that vaccination day routine activities did not affect the influenza vaccine efficacy, and engaging in strenuous exercise on the vaccination day tended to cause systemic adverse reactions. Moreover, lifestyle-related activities had no impact on the incidence of systemic or local adverse reactions. Therefore, it is advisable to only avoid strenuous physical exercise, and no other lifestyle-related restrictions are necessary on the day of influenza vaccination.

Multiple thrombosis associated with Cytomegalovirus enterocolitis in an immunocompetent patient: a case report.

BACKGROUND: Cytomegalovirus (CMV) is reported to have thrombogenic characteristics that activate factor X in vitro and stimulate the production of factor VIII and von Willebrand factor (vWF). Thrombosis associated with CMV infection is prevalent among immunocompromised patients and predominantly presents as a solitary large thrombus in the deep vein, pulmonary artery, splanchnic arteriovenous ducts, or other similar sites. Multiple thrombi, however, are rarely observed in such cases. Here, we report about an immunocompetent man with multiple microthrombi associated with CMV infection. CASE PRESENTATION: A 72-year-old Japanese man who complained of abdominal pain was hospitalized with multiple colonic stenosis. He was later diagnosed with CMV enterocolitis and treated with ganciclover from Day 27 post-admission. During hospitalization, the patient developed thrombi in his fingers. He was initially treated with anticoagulant therapy (rivaroxaban); however, the therapy was discontinued owing to a prolonged activated thromboplastin time and an elevated international normalized ratio of prothrombin time. Instead, vitamin K and fresh-frozen plasma were administered. Nevertheless, his coagulation profile remained abnormal. Eventually, he developed colonic perforation and had to undergo emergency surgery. An intraoperative specimen showed several microthrombi in the middle and small arteriovenous ducts of his small and large intestines. The patient's coagulopathy improved preoperatively, and his overall condition improved postoperatively. Since the activation of ADAMTS13 was reduced remarkably, the thrombotic tendency was determined to be a thrombotic microangiopathy-like condition owing to increased vWF. We could not attribute the coagulopathy to any other cause except CMV infection; therefore, we concluded that this was a case of multiple thrombosis associated with CMV. CONCLUSIONS: We present an extremely rare case of a patient with multiple thrombotic microangiopathy-like microthrombosis caused by CMV infection. Our findings suggest that CMV infection may be considered as a differential diagnosis for immunocompetent individuals who present with thrombosis of unspecified cause.

Methotrexate-associated lymphoproliferative disorder with an osteolytic vertebral lesion in an elderly patient with rheumatoid arthritis: A case report.

WHAT IS KNOWN AND OBJECTIVE: Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a rare complication that develops in patients treated with methotrexate (MTX). CASE SUMMARY: A 76-year-old male patient had been taking MTX for his rheumatoid arthritis. Computed tomography (CT) revealed masses in the liver, right adrenal gland and T6-T7 vertebra, including an osteolytic lesion. FDG-PET scan showed increased uptake in each lesion. MTX was discontinued, and CT showed complete remission of the tumours after three months. The disease course confirmed MTX-LPD diagnosis. WHAT IS NEW AND CONCLUSION: Bone lesions in LPDs mimic those of metastatic cancer. MTX-LPD should be considered in patients on MTX presenting with mass lesions.

Encephalopathy Induced by Preventive Administration of Acyclovir in a Man with Symptomatic Multiple Myeloma and Renal Dysfunction.

BACKGROUND: Acyclovir (ACV) neurotoxicity is a neuropsychiatric condition induced by the anti-herpetic drugs ACV and valacyclovir (VACV). It is presumed that elevated blood levels of ACV and its metabolite 9-carboxymethoxymethylguanine are involved in the development of ACV-induced encephalopathy; age and renal dysfunction are risk factors. Here, we report a case of encephalopathy caused by the administration of VACV for herpes zoster prophylaxis in a patient with renal dysfunction owing to multiple myeloma. CASE PRESENTATION: Renal dysfunction was diagnosed in a 70-year-old man visiting our hospital for a medical checkup. His creatinine clearance rate was 8 mL/min. He was diagnosed with symptomatic multiple myeloma, and bortezomib/dexamethasone (BD) therapy for multiple myeloma and VACV for herpes zoster prophylaxis were initiated. We administered 500 mg/day of VACV three times a week, a lower dosage than recommended, after adjusting for his renal impairment. His renal function was monitored twice per week during therapy. During the second course of BD therapy, 6 weeks after starting treatment, he was hospitalized owing to impaired consciousness (Glasgow Coma Scale score: E2, V4, M4), and his BD and VACV therapy were suspended. Brain magnetic resonance imaging and cerebrospinal fluid analysis showed no abnormalities. Three days after discontinuing BD and VACV therapy, his consciousness recovered completely, and impaired consciousness did not recur after resuming BD therapy. His clinical diagnosis was thus ACV-induced encephalopathy. CONCLUSION: VACV is often prescribed to patients with multiple myeloma receiving BD therapy to prevent herpes zoster. ACV-induced encephalopathy is commonly observed in patients with renal dysfunction; especially among patients with multiple myeloma with Bence-Jones proteinuria, renal tubules are easily damaged and plasma ACV concentrations are likely to increase and induce ACV-induced encephalopathy. Careful monitoring of the level of consciousness is necessary during preventive ACV therapy in patients with renal dysfunction.

End-of-life home care of an interstitial pneumonia patient supported by high-flow nasal cannula therapy: A case report.

BACKGROUND: High-flow nasal cannula (HFNC) therapy and morphine continuous subcutaneous infusion (CSI) have been used to ameliorate dyspnea in non-cancer patients with end-stage respiratory diseases, including chronic obstructive pulmonary disease and interstitial pneumonia, primarily in hospital settings. However, it is rare to perform home-based medical treatment using these. We observe a case to assess the feasibility of this treatment strategy. CASE SUMMARY: Here, we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization, by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device. CONCLUSION: Active utilization of HFNC and morphine CSI with patient-controlled analgesia device would substantiate successful end-of-life palliative home care of idiopathic interstitial pneumonia patients.

[Curd Formation Resulting from a Reaction between Cranberry Juice and Enteral Formula].

White solids were observed in the esophagus of a patient with multiple system atrophy. The patient was receiving enteral nutrition with a polymeric formula and cranberry juice via nasogastric feeding. To test the assumption that the precipitates were formed from a reaction between the juice and the formula, a verification experiment was conducted usingformulae of differinging redients, pH and protein content. The results indicated that a precipitate was formed when formulae with lower pH values and higher protein content were used. Mixing a pH neutral enteral formula with cranberry juice, vinegar or their 2- fold diluted solutions may result in the formation of precipitates in the stomach and esophagus.