Nobuaki Mori

Portosystemic encephalopathy without liver cirrhosis masquerading as depression

A 69-year-old woman was hospitalized due to progressive lethargy with hyperammonemia. Five months before the current admission, she was diagnosed with depression based on her low level of daily physical activity and thus began taking antidepressants. Abdominal computed tomography revealed a portosystemic shunt running between the left renal vein and inferior mesenteric vein. Balloon-occluded retrograde transvenous obliteration of the shunt vessel was performed, and the patient showed a remarkable clinical improvement. The possibility of a portosystemic shunt should be considered in the presence or absence of underlying liver disease and the ammonia level should be measured before diagnosing depression, as portosystemic encephalopathy may be reversible with interventional radiology treatment.

Characteristics of mucoid Streptococcus pyogenes isolated from two patients with pneumonia in a local community

Streptococcus pyogenes (Group A Streptococcus, GAS) infections can develop into life-threatening disorders. However, the occurrence of some GAS pneumonia cases is relatively rare in a local community. We report here characteristics of mucoid GAS isolates obtained from the sputum of two patients with pneumonia in a local community. Although case-patients did not have contact with each other, case-patient 1′s child and case-patient 2′s grandchild attended the same kindergarten where a GAS pharyngitis epidemic had occurred. We conducted phenotypic and genotypic analyses with the GAS isolates from sputum of both patients, to examine (1) colony appearance between the isolates, (2) numerical profile based on API-20 Strep system, (3) similarity to the type strain using 16S rRNA sequencing, (4) emm type (subtype) and emm full-length sequence, (5) sequence type, (6) sic allele, (7) antimicrobial susceptibility result and the resistance determinant, (8) genome profile following a random amplified polymorphic DNA fragments, and (9) pattern of digested DNA fragments by pulse-field gel electrophoresis. These phenotypic and genotypic analyses revealed similar matching between the isolates from both cases. Our findings suggest that when clinicians examine adult patients having infection with the mucoid GAS, they should confirm whether anyone within the same household also developed the infection and need to investigate epidemic situations in local communities, including kindergartens and elementary schools.

Roving eye movements in a patient with hypoglycemic coma

Roving eye movements are the sign of cortical dysfunction not involving the brainstem. This finding is useful in the differential diagnosis of impaired consciousness and indicates cerebral damage in patients with hypoglycemic coma.

Characteristics and Immunological Roles of Surface Layer Proteins in Clostridium difficile

Clostridium difficile is a major causative agent of antibiotic-associated diarrhea and has become the most common pathogen of healthcare-associated infection worldwide. The pathogenesis of C. difficile infection (CDI) is mediated by many factors such as colonization involving attachment to host intestinal epithelial cells, sporulation, germination, and toxin production. Bacterial cell surface components are crucial for the interaction between the bacterium and host cells. C. difficile has two distinct surface layer proteins (SLPs): a conserved high-molecular-weight SLP and a highly variable low-molecular-weight SLP. Recent studies have shown that C. difficile SLPs play roles not only in growth and survival, but also in adhesion to host epithelial cells and induction of cytokine production. Sequence typing of the variable region of the slpA gene, which encodes SLPs, is one of the methods currently used for typing C. difficile. SLPs have received much attention in recent years as vaccine candidates and new therapeutic agents in the treatment of C. difficile-associated diseases. Gaining mechanistic insights into the molecular functions of C. difficile SLPs will help advance our understanding of CDI pathogenesis and the development of vaccines and new therapeutic approaches. In this review, we summarize the characteristics and immunological roles of SLPs in C. difficile.

Seesaw-like movement of the chest wall

Examination of apical impulse is an important component of nonauscultatory cardiac examination. Seesaw‐like movements of the chest wall during the systolic phase suggest severe tricuspid regurgitation.

Papillary atrophy of the tongue

Do not forget to give cobalamin supplementation after gastrectomy. Patients at risk of vitamin B12 deficiency should have their vitamin B12 level monitored routinely.

Epithelioid cell granuloma in the bone marrow secondary to Epstein-Barr virus infection

A previously healthy 19-year-old man presented to our outpatient department with a 10 day history of fever and fatigue and a 3 day history of sore throat and epigastralgia. He had reduced appetite and had had watery diarrhoea for 3 days, 10 days earlier. He was examined by a primary physician and despite being given cefditoren pivoxil (300 mg/day) and laninamivir (single inhaled dose of 40 mg), he was febrile. On physical examination, his temperature was 38°C. He had right tonsil exudates and tender left posterior cervical lymphadenopathy, but no skin rashes. Laboratory tests indicated leucocytosis (10·3 × 109 cells per L) with lympho cytosis (lymphocytes, 55·5%; atypical lymphocytes, 16·0%), and elevated aminotransferase con centrations (aspartate amino trans ferase 7·2 μkat/L, alanine amino trans ferase 7·2 μkat/L), lactate dehydrogenase (17·8 μkat/L), and alkaline phosphatase (6·2 μkat/L). Abdominal ultrasonography showed hepatomegaly, spleno megaly, and lymphadenopathy of the hepatic portal region. We suspected infectious mononucleosis and treated with paracetamol (400 mg per dose) and intravenous hydration. An HIV antibody test was negative. A test for cytomegalovirus IgM was equivocal and for cytomegalovirus IgG was positive. Tests for Epstein-Barr virus anti-viral capsid antigen IgM and IgG were positive. Epstein-Barr virus nuclear antigen was undetectable. Epstein-Barr virus DNA load was 4·4 × 103 copies per 106 cells. The fever persisted for about 3 weeks and he gradually developed pancytopenia a week after admission. We did bone marrow aspiration and took a biopsy followed by administration of 60 mg prednisolone. The patient immediately became afebrile. Prednisolone was tapered off after 6 weeks. The patient made a complete recovery and remained well after 3 months. The bone marrow specimens were normocellular, but several small non-caseating epithelioid cell granuloma were noted (figure, A). Ziehl–Neelsen staining of the tissue granuloma was negative. Periodic acid–Schiff and Grocott’s methenamine silver stainings did not show fungal elements. Several Epstein-Barr virus-encoded small RNA-1-positive lymphoid cells were identified by in-situ hybridisation (figure, B). Epstein-Barr virus infection is common and various manifestations have been observed. Causes of bone marrow granuloma include sarcoidosis, drugs, and infection, including Epstein-Barr virus.

Honeycomb liver abscess

A 65-year-old Japanese woman was presented with a 2-day history of fever. The patient had undergone a surgery for uterine myoma 20 years prior. Drug history was unremarkable except for acetaminophen use. On admission, her temperature was 39.9 C; she had tachycardia (117 beats/min) and no abdominal pain. A contrast-enhanced abdominal computed tomography revealed multiple multiloculated low-density areas in the liver (Figs. 1 and 2); pyogenic liver abscess was consequently suspected. Percutaneous drainage of the liver abscess was performed, although drainage was incomplete. Blood cultures on admission and liver abscess cultures grew Klebsiella pneumoniae. Subsequently, ceftriaxone and metronidazole were administered for the first week. However, since the fever persisted despite the susceptibility of K. pneumoniae to the antibacterials, meropenem was administered for the next 2 weeks. Following this, the fever subsided and

Streptococcus pneumoniae-induced purpura fulminans

A 60-year-old man presented to the emergency department owing to a 2-day history of frequent vomiting and diarrhea, and fever. He had not undergone abdominal surgery, did not have an immunocompromised status, and had not received vaccination against pneumococcus. Clinical examination revealed high-grade fever, tachycardia, low blood pressure and systemic purpura lesions on the skin (Figure 1A). Laboratory analysis results indicated leukocytosis (white cell count, 22 …