山下 武志

Pyogenic spondylodiscitis is a rare infection, with cervical spine involvement occurring in only 3%–10% of the cases. Streptococcus gallolyticus subsp. pasteurianus , a normal gut flora component, is a rare causative agent of spinal infections. Here, we report the case of an 88‐year‐old man with cervical pyogenic spondylodiscitis caused by this organism, complicated by a clinical relapse following a standard antibiotic course. The patient presented with fever and neck pain. Blood cultures revealed Streptococcus gallolyticus subsp. pasteurianus , and cervical magnetic resonance imaging (MRI) revealed spondylodiscitis at the C4–C6 levels. The patient was treated with a 90‐day course of antibiotics (46 days intravenous and 44 days oral), leading to initial clinical and biochemical resolution. However, clinical relapse occurred on day 174, characterized by recurrent neck pain and elevated C‐reactive protein levels despite no clear signs of active inflammation on repeat MRI. Extended oral antibiotic therapy was resumed and continued for 9 months, resulting in sustained remission without surgical intervention. To our knowledge, only isolated case reports of spinal infections caused by this subspecies have been published, and no prior case has described clinical recurrence. This case suggests that standard antibiotic durations may be insufficient in selected complex or relapsing spinal infections caused by Streptococcus gallolyticus subsp. pasteurianus and highlights the importance of individualized treatment duration and long‐term surveillance.

Background and aim Cytotoxic lesions of the corpus callosum (CLOCCs) are transient lesions characterized by restricted diffusion on MRI and are associated with various infectious and noninfectious conditions. However, the clinical spectrum of infection-related CLOCCs, particularly those associated with bacterial infections, remains incompletely defined. This study aimed to describe the clinical, etiological, and neuroimaging characteristics of CLOCCs diagnosed at a single center, encompassing both infectious and noninfectious etiologies, with particular attention to infection-related cases. Methods We retrospectively reviewed patients diagnosed with CLOCCs at Jichi Medical University Saitama Medical Center between January 2016 and May 2025. Patients were identified by searching institutional radiology reports and electronic medical records for callosal lesions, followed by review of the corresponding records. Clinical characteristics, underlying etiologies, laboratory findings, MRI features, treatment, follow-up imaging, and clinical outcomes were extracted from medical records. Results Eight patients were identified (median age, 47.5 years; range, 12-70; five male and three female). Five patients had infection-related CLOCCs, including bacteremia, meningoencephalitis, and COVID-19-associated myocarditis. One patient had Fusobacterium nucleatum bacteremia, which, to the best of our knowledge, has not been well documented in association with CLOCCs. In all eight patients, the lesion was confined to the splenium of the corpus callosum. All patients showed hyperintensity on diffusion-weighted imaging, and six showed corresponding hypointensity on apparent diffusion coefficient maps. Follow-up MRI was available in seven patients (performed at a median of 17 days; range, 14-50 days); six showed complete resolution, whereas one showed near-complete resolution with faint residual fluid-attenuated inversion recovery hyperintensity. Seven patients improved clinically; one patient died during hospitalization from infection-related complications unrelated to the corpus callosum lesion, which had already resolved on follow-up MRI. Conclusions In this single-center case series, infection-related etiologies accounted for most of the cases. The association with F. nucleatum bacteremia, based on a single case, represents a possible rather than established addition to the bacterial infections reported in CLOCCs and should be regarded as hypothesis-generating. Early recognition of the characteristic MRI findings, evaluation for underlying infectious causes, and treatment directed at the underlying condition may support favorable clinical and radiological outcomes.

ABSTRACT Invasive Aspergillus tracheobronchitis (IATB) is a rare but potentially fatal manifestation of invasive aspergillosis. Because of its high mortality, prompt recognition and initiation of antifungal therapy are crucial. We report the case of a 71‐year‐old woman with a history of diffuse large B‐cell lymphoma (DLBCL) who presented with progressive dyspnea. Computed tomography revealed subglottic airway stenosis, necessitating an emergency tracheostomy to secure the airway. Histopathological and microbiological examination of bronchoscopic biopsy specimens demonstrated infiltration of Aspergillus fumigatus , establishing the diagnosis of IATB. Antifungal therapy with voriconazole was promptly initiated, resulting in gradual clinical and endoscopic improvement. The tracheostomy tube was successfully removed, and the airway lesion showed complete resolution. This case underscores the importance of early diagnosis and timely antifungal therapy to achieve a favourable outcome. When severe airway obstruction is present, airway interventions such as tracheostomy may be lifesaving.

We report a rare case of a right-to-left shunt through a patent foramen ovale (PFO) triggered by constrictive pericarditis secondary to an organized pericardial hematoma. A 72-year-old woman presented with thoracic back pain and subsequently developed persistent hypoxemia following idiopathic pericarditis. Despite appropriate anti-inflammatory and antimicrobial therapy, she experienced a cerebral embolism involving the right middle cerebral artery territory on hospital day 50. Imaging studies revealed a pericardial effusion compressing the right heart. Intraoperative transesophageal echocardiography confirmed a right-to-left shunt through a PFO. Surgical evacuation of the organized pericardial hematoma relieved right heart compression, normalized intracardiac pressures, and resolved the shunt. The pericardium was markedly thickened and adherent to the right ventricle with a fibrotic hematoma, and histopathology revealed fibrotic thickening with inflammatory infiltration and hemosiderin deposition. The patient's respiratory status gradually improved, and she was discharged home without the recurrence of paradoxical cerebral embolism. This case highlights a rare pathophysiological mechanism in which constrictive pericarditis elevates right atrial pressure, unmasking a previously silent PFO and resulting in paradoxical embolism and refractory hypoxemia. Constrictive pericarditis should be considered a potential trigger for right-to-left shunting in patients with unexplained hypoxemia or cryptogenic stroke.

We herein report a 47-year-old man who presented with progressive paraparesis. Imaging revealed a right upper pulmonary nodule, massive bilateral adrenal metastases, thoracolumbar vertebral osteolysis, and subcutaneous nodules. A biopsy of the right buttock nodule revealed a poorly differentiated metastatic carcinoma with high programmed cell death-ligand 1 expression and extensive chromosomal rearrangements. The patient died 10 days after the initiation of pembrolizumab treatment. Autopsy findings confirmed pulmonary pleomorphic carcinoma with extensive metastases. Quantification of chromosomal rearrangements revealed a jump-up mutation from the normal karyotype, followed by a further incremental increase in the degree of deviation.

Anorexia nervosa (AN) is often accompanied by numerous medical complications and mental disorders. There are few specialized AN facilities in Japan, resulting in the unmet medical needs of patients with AN. A 37-year-old Japanese woman was admitted to the hospital after experiencing a disturbance of consciousness. Her body mass index was 10.2 kg/m2. She developed the following serious medical concomitants associated with extremely severe AN: hypothermia, shock liver, refractory hypoglycemia, acute gastric mucosal bleeding, gelatinous marrow transformation, catheter-related bloodstream infection and infective endocarditis due to β-lactamase-negative Staphylococcus aureus, aspiration pneumonia, intracranial hemorrhage, candidemia, and osmotic demyelination syndrome in the pons, which led to a fatal condition that quickly worsened after we started treatment. The patient was able to overcome several serious concomitants and be discharged from the hospital after multidisciplinary treatment team care. AN is associated with increased rates of all-cause mortality. It is important to take an interdisciplinary approach with emergency physicians, intensivists, hematologists, gastroenterologists, psychiatrists, clinical psychologists, a nutrition support team with a nationally registered nutritionist and hospitalists, and hospitalization as required based on appropriate medical evaluation with good patient and family rapport. Furthermore, social and educational efforts aimed at preventing the development of AN are necessary.

A 37year old Japanese man experienced severe sore throat. He was infected by the Omicron variant of SARSCoV2. The posterior pharyngeal wall in the left showed closely aggregated multiple milletsized white spots with surrounding redness.

Aggregatibacter actinomycetemcomitans, an etiological agent associated with periodontitis, endocarditis, and other infections, has rarely been implicated in spondylitis. A 70-year-old man with aortic valve replacement presented with a 4-month history of lower back pain and was diagnosed with spondylitis. Prolonged incubation of blood cultures and a biopsy yielded A. actinomycetemcomitans. Concurrent infective endocarditis (IE) was probable considering the infectious organism and the patients' prosthetic valve. The patient was treated with ceftriaxone and recovered well. Pyogenic spondylitis with possible concurrent IE may be caused by A. actinomycetemcomitans. Extended incubation and repeated cultures should be considered if Haemophilus spp., Aggregatibacter spp, Cardiobacterium spp, Eikenella spp, and Kingella spp. (HACEK) infection is suspected.

Our case patient was a 38-year-old pregnant Japanese woman who underwent emergency Caesarean section because of massive vaginal bleeding due to a low-lying placenta. Immediately after delivery, she presented with rapidly progressive dyspnea. Contrast-enhanced computed tomography revealed bilateral pleural effusion, lung nodules, multiple liver tumors, and multiple osteolytic lesions. Accordingly, epidermal growth factor receptor-mutant advanced lung adenocarcinoma was diagnosed. This report highlights the occurrence of rapid progression of lung cancer following delivery that led to postpartum acute respiratory failure, rather than due to pulmonary thromboembolism associated with the existing deep venous thrombosis of the inferior vena cava.

We herein report a case of a 31-year-old Japanese man who simultaneously had a positive influenza A virus antigen test result and Vogt-Koyanagi-Harada disease (VKHD), demonstrated by both diffuse multiple early hyperfluorescent points on fluorescein fundus photography and serous retinal detachments on optical coherence tomography. He had meningitis. It was difficult to determine whether the main cause of meningitis was influenza A or VKHD. After initial treatment with peramivir for influenza A and then methylprednisolone pulse with subsequent corticosteroid therapy for VKHD, his symptoms improved gradually. These findings suggest that influenza A virus infection contributes to the onset or exacerbation of VKHD.

Talaromyces marneffei is a dimorphic fungus endemic mainly in southeast and south Asia. It causes severe mycosis, usually in immunocompromised individuals, such as those with human immunodeficiency virus (HIV) infection. Concomitant infection with T. marneffei and other opportunistic pathogens is plausible because the majority of T. marneffei infections occur in patients with advanced HIV infection. Nonetheless, coinfection in the same site has rarely been reported, and poses a considerable diagnostic and therapeutic challenge. We report the case of an HIV-infected Japanese patient who had lived in Thailand for 6 years. The patient developed T. marneffei and Mycobacterium tuberculosis coinfection, and both pathogens were isolated from the same sites: a blood specimen and a lymph node aspirate. Clinicians should be aware of concomitant infection with T. marneffei and other pathogens in patients with advanced HIV disease who are living in or who have visited endemic areas.

We report the case of a 71-year-old Japanese woman with adult-onset Still's disease (AOSD) in whom macrophage activation syndrome (MAS) developed despite therapy with oral high-dose prednisolone and intravenous methylprednisolone pulse therapy twice. She was successfully treated with tocilizumab (TCZ). Soon afterward, her fever ceased and high levels of both ferritin and C-reactive protein levels decreased. Her course was complicated by disseminated intravascular coagulation, cytomegalovirus infection, and Pneumocystis jirovecii pneumonia. After these were resolved, AOSD-associated MAS was well controlled. She was discharged on hospital day 87. Although biologics such as TCZ are becoming established for the treatment of AOSD, there is no recommended therapy for AOSD-associated MAS. Several biologics have been tried for this complication, but their efficacy and safety remain controversial. We reviewed reported cases of AOSD-associated MAS successfully treated with various biologics. TCZ initiation after adequate nonselective immunosuppressive therapy, such as methylprednisolone pulse therapy or a prednisolone-based combination of immunosuppressants, can be an effective treatment for AOSD-associated MAS. On the other hand, biologics given after insufficient immunosuppressive therapy may cause MAS. A strategy combining adequate immunosuppression and a biologic could be safe if special attention is given to adverse events such as opportunistic infections or biologic-associated MAS.

PURPOSE: Cerebral hyperperfusion following carotid endarterectomy (CEA) occurs in patients with preoperative impairments in cerebral hemodynamics. The aim of the present study was to determine whether late images/early images on preoperative brain (123)I-iomazenil (IMZ) single-photon emission computed tomography (SPECT), which correlate with oxygen extraction fraction images on positron emission tomography, could identify patients at risk for cerebral hyperperfusion following endarterectomy for unilateral cervical internal carotid artery (ICA) stenosis. METHODS: In 80 patients, preoperative brain SPECT scans were initiated immediately after (early images) and 180 min after (late images) administration of (123)I-IMZ. A region of interest (ROI) was automatically placed in the middle cerebral artery territory in both the cerebral hemispheres using a three-dimensional stereotaxic ROI template. Transcranial regional cerebral oxygen saturation (rSO(2)) was monitored using near-infrared spectroscope throughout carotid endarterectomy, and a patient was defined as having cerebral hyperperfusion when a ratio of rSO(2) at the end of the surgery to rSO(2) before ICA clamping was ≥ 1.1. RESULTS: Cerebral hyperperfusion was observed on intraoperative rSO(2) monitoring in eight patients (10%). Preoperative increase in affected side-to-contralateral side asymmetry on late/early (123)I-IMZ value was the only significant independent predictor of cerebral hyperperfusion (95% confidence interval [CI], 1.606 to 8.710; P = 0.0010). The preoperative late/early (123)I-IMZ asymmetry corresponded to an 88% sensitivity and 89% specificity, with 47% positive- and 98% negative-predictive values for the development of cerebral hyperperfusion. CONCLUSIONS: Preoperative late/early (123)I-IMZ images can identify patients at risk for cerebral hyperperfusion following endarterectomy for unilateral cervical ICA stenosis.