Multiple Ulcers in the Ileum and Lymphadenopathy Following the Usage of Methotrexate in a Patient With Rheumatoid Arthritis: A Case Report.

This case report aims to highlight a rare occurrence of severe anemia and lymphadenopathy secondary to methotrexate (MTX)-induced ileal mucosa damage in a patient with elderly onset rheumatoid arthritis (EORA). We present the case of a 72-year-old female with a history of EORA, treated with MTX, who exhibited hematochezia without accompanying pain, diarrhea, or known infectious contacts. Diagnostic investigations included imaging and endoscopic procedures. The patient's presentation of severe anemia was atypical, given the absence of significant pain or discomfort associated with EORA. The lack of active bleeding observed during endoscopy, coupled with multiple ileal ulcers, suggested a chronic progression of mucosal damage. Laboratory findings, including normal lactate dehydrogenase, soluble interleukin-2 receptor levels, and the absence of malignancy in mucosal biopsies, ruled out MTX-induced lymphoma. The patient's condition improved with the cessation of MTX and the introduction of symptomatic treatment and anemia management. This case underscores the need for vigilant monitoring and comprehensive evaluation in patients with RA, especially the elderly, treated with MTX. It also highlights the importance of considering drug-induced complications in the differential diagnosis of anemia. The case demonstrates the necessity of a personalized approach to treatment, emphasizing regular follow-ups and adjustments based on the patient's response to therapy. This report contributes to the growing body of evidence on the complexities of managing RA in the elderly, particularly regarding the side effects of common medications like MTX.

A Case of Insulin Autoimmune Syndrome Accompanied With Systemic Joint Pain: A Case Report.

Insulin autoimmune syndrome (IAS) is a rare disorder characterised by autoantibodies against endogenous insulin that cause spontaneous hypoglycemic episodes. Here, we present the case of a 66-year-old male with polyarticular pain and dizziness that was initially suspected to be an insulinoma. However, further testing confirmed the presence of IAS. The patient's joint pain fluctuated but improved with the control of blood glucose levels. Although the direct relationship between IAS and joint pain is not well established, individuals with a single autoimmune disorder may develop concurrent autoimmune conditions. Joint pain is prevalent in patients with autoimmune diseases. Although hypoglycemia may cause muscle cramps due to stress responses, direct musculoskeletal damage is uncommon. This case underscores the importance of differential diagnosis, particularly in differentiating between pancreatic cancer and the benign proliferation of pancreatic B cells. Elevated levels of insulin autoantibodies confirm IAS, whereas pancreatic cancer may manifest various symptoms and elevated cancer antigens (CA) 19-9. General physicians should comprehensively investigate hypoglycemia cases, particularly those associated with pancreatic enlargement, and continually monitor for potential malignancies.

Deciding a Treatment Plan for an Older Patient With Severe Idiopathic Pulmonary Fibrosis: A Case Report.

Idiopathic pulmonary fibrosis (IPF) is a group of diseases in which the main loci of lesions, mainly inflammatory and fibrotic, are within the interstitium of the alveolar and bronchiolar regions. Steroid therapy is the standard treatment for acute exacerbation of IPF, whereas antifibrotic agents are the standard treatment for chronic IPF. However, the vulnerability of older patients indicates that these treatments may be discontinued. Here, we report the case of an 86-year-old woman who had a dry cough for over a year and was subsequently diagnosed with IPF based on imaging studies. After using steroid pulses to treat acute exacerbations, the patient was transitioned to the chronic management phase, and time was allowed to plan the patient's advanced care with her family. The use of high-dose steroids in older patients with frailty is contraindicated. This case emphasizes the importance of considering initial intensive treatment for IPF in older patients for better palliative care.

Meningitis With Staphylococcus aureus Bacteremia in an Older Patient With Nonspecific Symptoms: A Case Report.

Staphylococcus aureus bacteremia has been associated with various symptoms that can spread to diverse organs, including the meninges, which can be challenging to diagnose given the nonspecific symptoms. Early examination, including assessment of the cerebrospinal fluid, is necessary when a patient is diagnosed with S. aureus bacteremia accompanied by unconsciousness. A 73-year-old male presented to our hospital complaining of general malaise without fever. The patient developed impaired consciousness immediately after hospitalization. Following the investigations, the patient was diagnosed with S. aureus bacteremia and meningitis. If a patient presents with symptoms of unknown cause and acute progressive disease, meningitis and bacteremia should always be considered. Blood cultures should be performed promptly, affording an early diagnosis, bacteremia treatment, and the establishment of meningitis.

Subacute Bacterial Cellulitis With a Subacute Clinical Course With Difficulty in Distinguishing From Sjögren's Syndrome: A Case Report.

Differentiating between infectious and autoimmune diseases regarding inflammatory changes in the soft tissues around the joints that develop in a subacute course is often difficult. Herein, we present the case of a 65-year-old woman who presented with a chief complaint of the tarsal metatarsal joint (Lisfranc joint) pain in the second, third, and fourth toes of her right foot that had persisted for several days. The patient was initially treated with non-steroidal anti-inflammatory drugs, colchicine, and prednisolone 10 mg for pseudogout and Sjogren's syndrome arthritis; however, there was little improvement. A few weeks later, the skin of the fingers and toes peeled, and the patient was diagnosed with subacute burn-like skin syndrome and treated with antibiotics. After the treatment, the inflammatory findings steadily improved. Arthritis associated with an infection is considered to have an acute course. However, subacute-to-chronic arthritis associated with Staphylococcus aureus infection may also be possible, as in this case. Therefore, the possibility of infection should be evaluated in patients with subacute-to-chronic refractory arthritis.

A Case of Pseudoappendicitis Caused by Campylobacter Enteritis Diagnosed by Gram Staining and Direct Microscopic Investigation of Stool Specimen.

Campylobacter infection may progress to a systemic infection through the intestinal tract. In many cases, symptoms are within the self-limiting range and do not require multidisciplinary treatment. In contrast, systemic infections in younger patients may be more severe and require hospitalization. Many differential diagnoses are considered when Campylobacter infection presents with severe abdominal pain, and the initial diagnosis may be difficult. We encountered a patient with Campylobacter infection who presented with acute-onset fever and general malaise. We diagnosed the case in a resource-poor setting by performing Gram staining of stool samples and fecal microscopy. This case suggests that a diagnosis of Campylobacter pseudoappendicitis can be made efficiently by combining various stool tests rather than waiting for culture results.

A Case of Capillary Leak Syndrome and Intestinal Ischemia Caused by Rheumatoid Vasculitis.

Rheumatoid vasculitis (RV) is a rare disease associated with rheumatoid arthritis (RA). The incidence of RV has decreased with the development of treatment for RA. However, some patients still develop RV in rural areas, where medical care for autoimmune diseases is inadequate. In this report, we describe a case of RV complicated by an acute exacerbation of generalized ulcerative lesions and capillary leak syndrome in an 86-year-old woman with a severe joint deformity due to RA. RV is a systemic vasculitis characterized by various symptoms. When a patient with RA is diagnosed with poorly controlled joint deformities, general physicians should consider the possibility of RV. Urgent investigation and intensive treatment should be initiated for vasculitis to support the lives of older patients with advanced RA.

Infection Route of Parvimonas micra: A Case Report and Systematic Review.

Parvimonas micra (P. micra), a bacterium that colonizes the gastrointestinal tract, is often isolated from periodontitis and abscesses as part of a complex bacterial infection. However, reports of monobacterium infections due to P. micra are limited. Here, we report a case of monobacterial bacteremia caused by P. micra with the aim of identifying the source of the invasion and clarifying the clinical features. A 54-year-old patient presented with bacteremia due to P. micra and with an oral invasion that we suspected resulted from prior dental treatment. Using PubMed and Google Scholar databases, we undertook a systematic review of monobacteremia caused by P. micra. We identified 26 patients (mean age, 70.15 years) in our systematic review. P. micra bacteremia and its associated phenotypes were most frequently identified in spinal discitis, followed by epidural and lumbar abscesses, and infective endocarditis. The major risk factors were malignancy, diabetes mellitus, and post-arthroplasty. When P. micra is detected in blood cultures, evaluation and intervention for oral contamination may be indicated.

Surgical Interventions in Cases of Esophageal Hiatal Hernias among Older Japanese Adults: A Systematic Review.

Background and Objectives: Given Japan's superaging population, an increasing number of older adults in the country need surgical treatment for esophageal hiatal hernias. Accordingly, this systematic review examines surgical interventions for symptomatic esophageal hiatal hernias in older Japanese patients and explores treatment outcomes. Materials and Methods: Articles on single operations for hiatal hernias published after 1991 were found on Google Scholar and Ichushi using specific keywords. Subsequently, articles fulfilling the predetermined inclusion criteria were considered in the study. Results: The mean patient age was 81.4 years, and the male-to-female ratio was 1:11.5. The main reasons for surgery were vomiting, dyspnea, and chest tightness. In terms of hernia classification, type IV was the most common (48%). Surgical modalities were laparoscopy in 15 cases, and laparotomy in 10 cases. Mean postoperative course was 26.47 days until hospital discharge, and there were no cases of perioperative death. Conclusions: Findings showed that multiple factors were involved in older adults' prognoses, and age was not the only biological factor. Therefore, aggressive surgical intervention should be considered for symptomatic older patients, even in the absence of surgery indicators.

Seronegative Rheumatoid Arthritis in an Elderly Patient With Anemia: A Case Report.

Anemia due to chronic inflammation reduces the quality of life in the elderly population. Various causes of chronic inflammation exist, and the elderly experience varying symptoms, making it challenging to investigate the cause. The risk of chronic inflammatory diseases, including autoimmune diseases, and the risk of rheumatoid arthritis (RA) increase with age. Here, we report a case of seronegative RA in an 88-year-old woman who was referred for a detailed examination of chronic inflammation and anemia. Although she had no chief complaint, a physical examination revealed bilateral symmetric polyarthritis. After ruling out other diseases based on blood culture findings, the patient was diagnosed with seronegative RA. She was successfully treated with prednisolone and methotrexate, and her anemia improved. She also attributed the anemia to a chronic inflammatory pattern of seronegative RA. Appropriate physical examination is important for older adults with various complaints, and anemia may precede arthritis during the clinical course of RA. Additionally, inflammation may progress rapidly in these individuals.

Interplay of flagellar motility and mucin degradation stimulates the association of Pseudomonas aeruginosa with human epithelial colorectal adenocarcinoma (Caco-2) cells.

Pseudomonas aeruginosa can penetrate the extracellular mucin barrier formed by the intestinal epithelial cell layer and establish gut-derived sepsis in immunocompromised patients. We found that two efficient mechanisms, flagellar motility and mucin degradation, are needed for penetration of P. aeruginosa through the mucin barrier. Deletion of the flagellar motility-related gene, the filament protein gene fliC, the cap protein gene fliD, and the motor complex protein genes motABCD from P. aeruginosa PAO1 decreased association of P. aeruginosa with the apical surface of human epithelial colorectal adenocarcinoma (Caco-2) cells. A penetration experiment using an artificial mucin layer suggested that the decreased penetration is caused by attenuation of mucin penetration ability. Additionally, the presence of P. aeruginosa decreased the total mucin, including the secreted mucin protein MUC2, on the surface of the Caco-2 cell monolayer, regardless of flagellar motility. Construction of the PAO1 mutant series knocked out 12 putative serine protease genes and identified the mucD gene, which participated in degradation of total mucin, including MUC2. Furthermore, decreased association with the surface of the Caco-2 cell monolayer was observed in the mucD mutant, and the decrease was synergistically amplified by double knockout with fliC. We conclude that P. aeruginosa can penetrate the mucin layer using flagellar motility and mucin degradation, which is dependent on the MucD protease or the mucD gene-related protease.