Medical Transport for 769 COVID-19 Patients on a Cruise Ship by Japan Disaster Medical Assistance Team.

The Diamond Princess cruise ship, carrying 3711 passengers and crew members, docked at Yokohama Port in Japan on February 3, 2020. A quarantine was immediately instituted because 1 passenger who had disembarked in Hong Kong was confirmed to have tested positive for coronavirus disease 2019 (COVID-19). After the quarantine began, all passengers and crew were tested using the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction assay on the ship, 696 of whom tested positive. In total, 769 patients, including 696 with COVID-19, required transport to a hospital. The Japan Disaster Medical Assistance Team (DMAT) successfully picked up and safely transported the COVID-19 patients using a novel classification system to prioritize patients. The Japan DMAT transported 203 patients to hospitals in Kanagawa and another 566 patients to hospitals in 15 different prefectures.

Persistence of positive severe acute respiratory syndrome coronavirus-2 reverse transcription-polymerase chain reaction test result for 24 days in a hospitalized asymptomatic carrier.

BACKGROUND: Several countries have imposed a mandatory 14-day period of quarantine on individuals arriving from countries considered high-risk for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. However, it is not clear how long asymptomatic patients infected with SARS-CoV-2 can be an asymptomatic carrier. CASE PRESENTATION: We experienced a case of an asymptomatic female patient infected with SARS-CoV-2 with abnormal chest computed tomography findings. She did not develop a fever during hospitalized isolation. She remained reverse transcription-polymerase chain reaction-positive for 24 days. CONCLUSION: An asymptomatic patient diagnosed with SARS-CoV-2 infection remained reverse transcription-polymerase chain reaction-positive for 24 days, although she was quarantined in an isolation hospital. This finding suggests that an asymptomatic patient diagnosed with SARS-CoV-2 infection with abnormal chest computed tomography findings can be an asymptomatic carrier for more than 3 weeks.

[31-year-old gravid woman of reversible posterior leukoencephalopathy syndrome associated with HELLP syndrome after labor].

We report on a 31-year-old gravid woman with reversible posterior leukoencephalopathy syndrome (RPLS) associated with HELLP syndrome. The patient was hospitalized and underwent an emergency cesarean section at the 34th week of pregnancy due to severe toxemia. After labor her blood pressure acutely increased to 180/100 mmHg and a generalized convulsion occurred. Laboratory data revealed hemolysis, elevated liver enzymes, and low platelets, consistent with HELLP syndrome. FLAIR and Apparent Diffusion Coefficient images on MRI showed hyperintense lesions bilaterally in the posterior white matter, however Diffusion-Weighted images revealed slightly hyperintense changes in the same locations. With the use of diltiazem for blood pressure control, and anticonvulsants, convulsions disappeared and consciousness level improved. Moreover the MRI abnormalities also improved after therapy. This case was diagnosed as RPLS associated with HELLP syndrome and is the first case of an investigation utilizing Diffusion-Weighted and Apparent Diffusion Coefficient images to establish this diagnosis. Based on these results, possible mechanisms of RPLS may be vasogenic edema mediated by a cerebrovascular endothelial disturbance of cerebral vessels and a rapid blood-pressure increase due to HELLP syndrome.

[A 26-year-old woman of interval form of acute carbon monoxide intoxication with cerebrospinal fluid abnormalities].

A 26-year-old woman was admitted to our hospital for the treatment of hyperbaric oxygen therapy to acute carbon monoxide intoxication. The consciousness disturbance improved and she was discharged after 23 times of the hyperbaric oxygen therapy. However, she was readmitted because of dementia and urinary incontinence after 22 days. Diffusion-weighted images showed bright high signal intensities in the periventicular white matter and corpus callosum. The condition was considered to be an interval form of carbon monoxide intoxication. She was treated by 38 times of the hyperbaric oxygen therapy with cytochrome C and fully recovered. MRI images and cerebrospinal fluid abnormality (high protein content and IgG index) became normalized somewhat later than the improvement of the symptoms. By an investigation utilizing diffusion-weighted images, we thought that not only the demyelination which mentioned formerly, but the vasogenic edema was involving in the mechanism of these high signal intensities in the periventicular white matter of the interval form. And in the range which we searched, this is the first report which mentioned the abnormal findings of cerebrospinal fluid in an interval form of carbon monoxide intoxication. So we believe this case is very important for telling us suspected the mechanism and some indications about the treatment of an interval form.

[Overlap syndrome of systemic lupus erythematosus and dermatomyositis presented a large demyelinating subcortical lesion mimicking brain tumor and high level of CSF antineuronal and serum anti-ribosomal P antibodies].

We reported a 50-year-old man with an overlap syndrome of dermatomyositis and SLE, whose magnetic resonance image of the brain showed a rapidly increasing large tumor-like focal lesion unequally enhanced by Gd-DTPA in the left frontal lobe. Its pathological finding by the brain biopsy was fibrinoid necrosis, inflammatory cell aggregation around blood vessels and many myelin-laden macrophages with central necrosis. Although many cases of blood vessel injury are reported in CNS lupus, in this case the brain lesion partly took reversible course and neural symptoms such as paresis were slight and the lesion well responded to steroid. Moreover we considered that the measurement of serum anti-ribosomal P and CSF antineuronal antibodies are useful to diagnose cases as CNS lupus.

Incidence and characteristics of biphasic and protracted anaphylaxis: evaluation of 114 inpatients.

AIM: Anaphylaxis is a systemic allergic reaction that potentially causes death. Most anaphylactic reactions are uniphasic, but some cases may be biphasic or protracted. However, these clinical epidemiology concepts are unfamiliar in Japan. Therefore, we have investigated the incidences and characteristics of patients with biphasic and protracted anaphylaxis. METHODS: We retrospectively evaluated patients with anaphylaxis in a single emergency medical center located in Yokohama, Japan from April 2009 to March 2012. We analyzed the incidences and characteristics of patients with biphasic and protracted anaphylaxis who needed to be admitted. RESULTS: A total of 253 patients were diagnosed with anaphylaxis and 114 patients needed to be admitted. Of the 114 patients, 103 (90.4%) were uniphasic, 7 (6.1%) were biphasic and 4 (3.5%) were protracted anaphylaxis. The most common antigens were foods and drugs. The median onset of a biphasic reaction was 8 h and dermatologic symptoms were mostly observed. Regarding severity, mild symptoms were seen in four cases, similar symptoms to the initial reaction were seen in two cases, and only one case was severe. The duration of protracted anaphylaxis varied from 2 to 8 days. CONCLUSION: The incidence of biphasic and protracted anaphylaxis in inpatients was 6.1% and 3.5%, respectively. The median onset of biphasic reaction was 8 h, and most symptoms were mild or similar to the initial reaction. We suggest that patients with anaphylaxis need an 8-h and ideally a 24-h observation period in order to monitor possible biphasic reactions. The duration of protracted anaphylaxis was up to 8 days.

[What ER physicians expects from neurologist].

The management of the Department of Emergency (ER) depends on greatly the views over the area which a hospital locates, and the organization of each hospital. The North American style ER has to treat many patients who show the neurological symptoms and neurological diseases. However, neurological examination is the special skill of the neurologist, and it takes long time to teach others. In our hospital, the neurologist and ER physicians took into consideration cooperatively the corresponding method to treat the high frequent neurological symptoms which ER physicians were not good at. And this trial was concluded successfully. In this paper, we show our trial.

Diaphragmatic paralysis in a patient with spinal cord infarction.

This report describes the rare case of a 72-year-old woman with spinal cord infarction who presented with persistent diaphragmatic paralysis. Her neurological examination showed tetraplegia, sensory loss to pain and thermal stimulations, and paradoxical abdominal movement. Chest X-ray and diaphragmatic fluoroscopy revealed absent diaphragmatic movement. A cervical magnetic resonance image showed bilateral anterior spinal cord lesions from the level of the second to the fifth cervical vertebrae. Diaphragmatic paralysis should be recognized as a clinical sign of cervical spinal cord infarction. Particular attention must be given to paradoxical abdominal movement during respiration in this disorder.