Tsuneaki Kenzaka

Physicians' opinions regarding the criteria for resuming oral intake after aspiration pneumonia: A questionnaire survey and cluster analysis of hospitals across Japan.

To investigate the items that are considered by physicians when making decisions regarding the resumption of oral intake among patients with aspiration pneumonia who have undergone short‐term fasting.

Factors involved in the discontinuation of oral intake in elderly patients with recurrent aspiration pneumonia: a multicenter study

Purpose To assess the factors involved in oral intake discontinuation in elderly patients with recurrent aspiration pneumonia. Patients and methods This study included patients with pneumonia who were treated at Jichi Medical University Hospital between 2007 and 2013, at Toyooka Public Hospital between 2011 and 2013 and at Yuzawa Community Medical Center between 2010 and 2012. We consecutively enrolled patients with aspiration pneumonia. The primary study point was oral intake discontinuation after the initiation of oral intake during hospitalization in cases of recurrent aspiration. Various parameters were recorded at admission, at the initiation of intake, and during hospitalization; these parameters were statistically evaluated. Results A total of 390 patients were assigned to either a “no reaspiration of intake” group (n=310) or a “reaspiration of intake” group (n=80), depending on whether intake was discontinued owing to aspiration during hospitalization. At admission, the following items significantly differed between the groups: level of consciousness, respiratory rate, oxygen saturation, CURB-65 score, extent of infiltration/opacity on chest radiography, albumin levels, blood urea nitrogen levels, and application of swallowing function assessment. At the initiation of intake, level of consciousness, pulse rate, and albumin levels significantly differed between the groups. The following items did not significantly differ between groups: systolic blood pressure, pulse rate, C-reactive protein, bacteremia, use of ventilator at admission, oxygen administration, respiratory rate, and systolic blood pressure at initiation of intake. Multivariate analysis revealed that application of swallowing function assessment, level of consciousness at the initiation of intake, and extent of infiltration/opacity on chest radiography were significant predictive variables for discontinuation of intake. Conclusion A low level of consciousness at the initiation of intake and a greater extent of infiltration/opacity on chest radiography and the application of a swallowing function are important factors. These factors may be helpful to determine a suitable timing for resumption of oral intake.

Right upper lobe pulmonary edema

A 90-year-old male patient who had been treated at our institution for chronic heart failure associated with mitral regurgitation and chronic atrial fibrillation presented at the outpatient clinic with aggravated wheezing, dyspnea upon exertion, and facial/lower leg edema that had started 3 days earlier. The vital signs upon presentation were as follows: blood pressure, …

Influenza follicles in the posterior pharyngeal wall.

Influenza develops rapidly with a high fever accompanying chills and malaise. Respiratory symptoms such as nasal discharge, cough and sore throat, gastrointestinal symptoms such as vomiting and diarrhoea, headache, joint pain, muscle pain, etc., frequently accompany it, but they are non-specific symptoms. On the other hand, influenza follicles in the posterior pharyngeal wall are very characteristic physical findings for the seasonal influenza diagnosis.1 Sakuma’s well-known paediatric pharynx findings textbook in Japan2 notes influenza follicles in the posterior pharyngeal wall. However, the textbook is written only in Japanese and is not indexed in the search systems of …

Adult-onset Kawasaki disease (mucocutaneous lymph node syndrome) and concurrent Coxsackievirus A4 infection: a case report.

Introduction Kawasaki disease (KD) most commonly develops in infants, although its specific cause is still unclear. We report here a rare case of adult-onset KD which revealed to be concurrently infected by Coxsackievirus A4. Case presentation The patient was a 37-year-old Japanese man who presented with fever, exanthema, changes in the peripheral extremities, bilateral non-exudative conjunctival injection, and changes in the oropharynx, signs that meet the diagnostic criteria for KD defined by the Centers for Disease Control and Prevention. In this case, the patient had a significantly high antibody titer for Coxsackievirus A4, which led us to presume that the occurrence of KD was concurrent Coxsackievirus A4 infection. Conclusion We reported a very rare case of KD which suggests that the disease can be concurrent Coxsackievirus A4 infection. Although KD is an acute childhood disease, with fever as one of the principal features, KD should also be considered in the differential diagnosis when adult patients present with a fever of unknown cause associated with a rash.

Spontaneous Isolated Common Hepatic Artery Dissection

A 66-year-old man presented with sudden lower back pain on both sides when in a sitting position. He had a medical history of appendicitis at 18 years of age and stomach cancer surgery at 56 years of age. He presented to our emergency department as the pain persisted. On abdominal examination, he presented with periumbilical tenderness with hypercavity bowel sounds, without tapping pain or muscle rigidity. Abdominal enhanced computed tomography revealed dissection of the common hepatic artery from the proximal portion to the proper hepatic artery bifurcation, but no abnormal findings were noted in the other arteries (Picture). He was therefore transferred to the cardiovascular department of another hospital. We believe that, in cases with a sudden onset of persistent back pain, particularly among patients with risk factors for arteriosclerosis, the use of diagnostic imaging is essential to detect the presence of common hepatic artery dissection.

Hyperammonemia in Urinary Tract Infections

Objectives The present study investigated the incidence of hyperammonemia in urinary tract infections and explored the utility of urinary obstruction relief and antimicrobial administration to improve hyperammonemia. Methods This was an observational study. Subjects were patients who were diagnosed with urinary tract infection and hospitalized between June 2008 and June 2009. We measured plasma ammonia levels on admission in patients who were clinically diagnosed with urinary tract infection and hospitalized. We assessed each patients level of consciousness on admission using the Glasgow Coma Scale (GCS) and performed urine and blood cultures. We also assessed hearing prior to hospitalization using the Eastern Cooperative Oncology Group performance status (ECOG-PS). In cases with high ammonia levels on admission, plasma ammonia and GCS were measured 24 hours and 5–7 days later. Results Sixty-seven candidates were enrolled; of these, 60 cases (89.6%) with bacterial cell counts ≥104 CFU/mL were studied. Five cases (8.3%) presented with high plasma ammonia levels. Cases with hyperammonemia were significantly more likely to present with low GCS scores and urinary retention rate. All five cases received antimicrobial therapy with an indwelling bladder catheter to relieve urinary retention. The case 5 patient died shortly after admission due to complicated aspiration pneumonia; in the remaining cases, plasma ammonia levels were rapidly normalized and the level of consciousness improved. Conclusions The occurrence of hyperammonemia in urinary tract infections is not rare. The cause of hyperammonemia is urinary retention obstruction. Therefore, along with antimicrobial administration, relief of obstruction is important for the treatment of hyperammonemia caused by this mechanism.

A case of thyroid storm with cardiac arrest

A 23-year-old man became unconscious while jogging. He immediately received basic life support from a bystander and was transported to our hospital. On arrival, his spontaneous circulation had returned from a state of ventricular fibrillation and pulseless electrical activity. Following admission, hyperthyroidism led to a suspicion of thyroid storm, which was then diagnosed as a possible cause of the cardiac arrest. Although hyperthyroidism-induced cardiac arrest including ventricular fibrillation is rare, it should be considered when diagnosing the cause of treatable cardiac arrest.

Mandibular Herpes Zoster

A 65-year-old Japanese woman with no history of immunosuppressive disease presented at our hospital with tongue and lip pain that had persisted for three days. Vesicles on the lower left lip (Picture 1a) and left buccal mucosa (Picture 1b), and a white plaque on the left side of the ventral tongue (Picture 1c) were found, all of which were reported to be painful. We suspected herpes zoster based on the characteristic distribution of the vesicles and white plaque, which were on the area of the mandibular nerve (third branch of the trigeminal nerve). Trigeminal herpes zoster accounts for 18.5% to 22.0% of all herpes zoster cases (1). Mandibular herpes zoster is, however, very rare. We prescribed famciclovir, acetaminophen and pregabalin. The vesicles and protruding tongue lesion completely disappeared after one week (Picture 2). After one month’s remission, the postherpetic neuralgia continued, and acetaminophen and pregabalin were discontinued. At first, the patient’s anti-Varicella zoster virus immunoglobulin M, and -G levels were 3.54 and 124, respectively. After three weeks, her anti-Varicella zoster virus immunoglobulin M, and -G levels were 1.85 and >128, respectively. We therefore diagnosed mandibular herpes zoster.

Serum matrix metalloproteinase 3 in detecting remitting seronegative symmetrical synovitis with pitting edema syndrome: A case report

We report a case of remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome in a 71-year-old woman. She referred to our hospital with finger stiffness, edema of both hands and feet, pain of bilateral shoulder, wrist, metacarpophalangeal, proximal interphalangeal, and ankle joints. Rheumatoid factor was negative, human leukocyte antigen -B7 antigen was positive. Moreover, matrix metalloproteinase 3 (MMP-3) was high. She was diagnosed with RS3PE syndrome, and treatment with prednisolone (15 mg/d) was started. One week after prednisolone treatment initiation, CRP decreased to negative, and joint pain was almost completely resolved. However, hand stiffness persisted, and MMP-3 level was still high. Thus, prednisolone dose was increased to 20 mg/d, and the stiffness resolved. Twenty days after treatment initiation, MMP-3 was normalized. MMP-3 was more indicative of RS3PE syndrome symptoms than CRP. Thus, MMP-3 seems to be more sensitive to RS3PE syndrome symptoms.