MARCH 2022 Volume 4-2

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

Original article

Case report

Brief report

Reappraisal of Chest Radiograph-Derived Cardiothoracic Ratio
for the Detection of Heart Failure in Older Adults ・・・・・・・・・・・ Takahiro Ohara　 108
Multiple myeloma causing osteolytic changes
in a single lumbar vertebra・・・・・・・・・・・・・・・・・・・・・ Tsunenori Tanabe　 114
A Case of Thyroid Storm Following Herpes Zoster Infection ・・・・・・・・ Ippei Jinno　 117

Key Image of General Medicine

Iatrogenic pneumomediastinum presenting with facial swelling due
to a dental procedure ・・・・・・・・・・・・・・・・・・・・・・・・・Yosuke Sasaki　 119
Peritoneal mesothelioma in an elderly patient ・・・・・・・・・・・・・ Sho Nishiguchi 　121
Primary herpetic gingivostomatitis of adult onset ・・・・・・・・・・・・ Takuto Inoue 　123

JHGM 2022：4(2)：40-45

Original article

Relationship between Treatment Strategy and Clinical
Outcome of Hip Fracture in the Long-Term Care
Insurance System (LTCIS) Users

Masaru Nakayama 1)※　　Fumie Nakayama 2)　　Shinnosuke Fujii 3)
Taku Nagai 3)　　Izumi Owada 3)　　Manabu Fujihara 3)
Satoko Watanabe 3)　　Astushi Ishii 3)　　Umashi Suzuki 4)

Youjyoukai Kashima Hospital
1) Division of Cardiology
2) Division of Radiology
3) Division of General Practice
4) Division of Orthopedics

Key Words：hip fracture, long-term care insurance system, prognosis

The optimal treatment of hip fracture in patients requiring long-term care is unclear. In this study, we evaluated the background, treatment strategy, and outcomes in 241 long-term care insurance system users with hip fractures. The mean age of the patients was 84 years, and surgery was performed in 162 patients. The pre-injury long-term care level and dementia complication rate were significantly higher in the conservative treatment group. The mean length of hospitalization was significantly longer in the surgical group, and the discharge rate to their own home was significantly higher in the surgical group. In-hospital death was significantly higher in the conservative treatment group. In patients with hip fractures who required nursing care prior to injury, conservative treatment was more likely to be chosen when dementia was present and pre-injury nursing care needs were high, resulting in lower physical activity and higher patient mortality. Surgical treatment was associated with better functional outcome and return to home rate, not on shortening hospitalization. It will be necessary to evaluate the effect of surgical treatment on patients requiring long-term care who have cognitive dysfunction.

JHGM 2022：4(2)：46-56

Original article

Evaluation of the antibody response and adverse
reactions to the BNT162b2 vaccine of participants
with prior COVID-19 infection in Japan

Toshiya Mitsunaga 1)2)※　　　Yuhei Ohtaki 2)　　　Yutaka Seki1)3)4)
Masakata Yoshioka 4)　　Hiroshi Mori 5) 　Midori Suzuka 6)
Syunsuke Mashiko 2) 　Satoshi Takeda 2) 　　Kunihiro Mashiko1)

1) Department of Emergency Medicine, Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital
2) Department of Emergency Medicine, Jikei University School of Medicine
3) Department of Cardiology, Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital
4)Department of Internal Medicine, Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital
5) Department of Medical Engineering, Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital
6) Department of Pharmacy, Association of EISEIKAI Medical and Healthcare Corporation Minamitama Hospital

Key Words：COVID-19, vaccine, antibody, adverse reaction, prior infection

[Objective] The aim of this study is to evaluate the antibody titer and adverse reactions to the BNT162b2 vaccine among participants with prior COVID-19 infection in Japan.
[Methods] The data for this study was collected between April 15, 2021, and June 9, 2021. All of the hospital staff who received the BNT162b2 vaccine were included in this study and were sorted into either a prior infection group or a control group. We collected the data of adverse reactions through self-reporting and calculated the anti-SARS-CoV-2 spike-specific antibody titer for all participants.
[Results] The antibody titer of the prior-infection group in first antibody test was significantly higher than that of the control group in the second antibody test. There was no significant difference in adverse reactions between the prior infection group receiving its first vaccination and the control group receiving its second vaccination.
[Conclusions] Our study shows that the antibody response following the first vaccination in the prior COVID-19 infection group was comparable to that of the second vaccination in the control group；however, the evaluation of adverse reactions was inadequate and further, large-scale studies are needed.

JHGM 2022：4(2)：57-65

Original article

Epidemiology and clinical characteristics
of outpatients with suspected COVID-19：
A prospective observational study from
the COVID-19 outpatient center at a university hospital

Yuki Goto 1)2)　　Toru Yamada 1)※ 　　Yuiko Nagamine 1)3)　　Suguru Mabuchi1)
Yu Akaishi 1) 　Shoko Yoshida 1) 　Risa Suzuki 1)　　Yamawaki Masanaga1)4)

1) Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
2) Department of Global Health Promotion, Tokyo Medical and Dental University
3) Department of Tokyo Metropolitan Health Policy advisement, Tokyo Medical and Dental University
4) Department of Medical Education, Graduate School of Medicine and Dentistry, Tokyo Medical and Dental University

Key Words：COVID-19, outpatient, university hospital, epidemiology, chest CT findings

　　The purpose of this study was to investigate the epidemiological and clinical characteristics of patients who visited the COVID-19 outpatient center at a university hospital and to evaluate the usefulness of chest CT for diagnosis. This prospective observational study was conducted from May to August 2020 and compared the characteristics of two groups：1) new patients referred to the university hospital because of suspected COVID-19 from other medical institutions, and 2) patients originally followed by the university hospital and sent to our COVID-19 outpatient center with suspected COVID-19. We also evaluated the sensitivity and specificity of chest CT versus PCR results. The total number of patients was 250 (56% male；mean age 52 years)：66 new patients (7 PCR-positive) and 184 follow-up patients (3 PCR-positive). Fever and malaise were common in both groups, and cough was significant in new patients. Ageusia/anosmia was a specific symptom in the PCR-positive group. The sensitivity of chest CT was less than 70%, and the specificity was 87% in new patients and 66% in follow-up patients. For new patients, chest CT findings may aid in diagnosis, but are less useful for follow-up patients. University hospitals should undertake careful screening for COVID-19 and not rely solely on CT findings.

JHGM 2022：4(2)：66-74

Original article

Outcomes of Veno-venous Extracorporeal
Membrane Oxygenation in the Elderly

Jun Maruyama 1)3)　　Keiko Kawai-Kowase 1)※　　Yuki Ideno 2)
Kenji Fujizuka 3)　　Mitsunobu Nakamura 3)　　Jun’ichi Tamura 1)

1) Department of General Medicine, Gunma University Graduate School of Medicine
2) Gunma University Center for Mathematics and Data Science
3) Advanced Medical Emergency and Critical Care Center,
Intensive Care Unit and Department of Emergency & Critical Care Medicine, Japanese Red Cross Maebashi Hospital

Key Words：venovenous ECMO, pneumonia, ARDS, hypoxia, elderly people

[Objective] This study aimed to examine the effects of age on the survival of patients with severe respiratory failure treated with veno-venous extracorporeal membrane oxygenation (V-V ECMO).
[Methods] We retrospectively analyzed adult patients treated with V-V ECMO at the Maebashi Red Cross Hospital between January 2013 and July 2020. The patients were divided into three groups：patients aged ＜ 65 years (group Y), those aged 65–74 years (group E), and those aged 75 years and older (group L). We compared the 6-month survival rates in each group and calculated their survival rates for each 5-year age group.
[Results] A total of 89 patients underwent V-V ECMO during the specified period, but 19 were excluded. 30, 23, and 17 cases were assigned in groups Y, E, and L, respectively. The 6-month survival rates were 76.7%, 60.9%, and 52.9% in groups Y, E, and L, respectively. The survival rate peaked in the 50s and tended to decrease with increasing age.
[Conclusions] The older groups had a worse prognosis, but the difference was not significant. With appropriate patient selection, V-V ECMO may be useful in the elderly. A large-scale study to evaluate the pros and cons of V-V ECMO in the elderly is warranted.

JHGM 2022：4(2)：75-79

Case report

A case of primary chylopericardium presenting
as cardiac tamponade

Tetsuya Kurimoto※　　Hidenori Adachi　　Madoka Ihara
Yuhei Nojima　　Shinsuke Nanto

Department of Cardiology, Nishinomiya Municipal Central Hospital

Key Words：primary chylopericardium, cardiac tamponade, thoracic duct

　　A 15-year-old male high school student visited our hospital for scrutiny of the findings of cardiac enlargement. Echocardiography revealed marked pericardial effusion with evidence of cardiac tamponade. Urgent pericardiocentesis brought out bloody to chylous fluid；however, the cause could not be determined. Primary chylopericardium is a condition wherein chyle accumulates in the pericardial sac without an apparent etiology. Primary chylopericardium rarely leads to cardiac tamponade. We feared that it would lead to a cardiac accident because he went about his daily activities without realizing that cardiac tamponade was the cause.

JHGM 2022：4(2)：80-86

Case report

Cutaneous Vasculitis Suggestive of IgA Vasculitis
and Acute Exacerbation of Ulcerative Colitis
after COVID-19 Vaccination in a Patient
with Ulcerative Colitis in Remission

Haruhiko Egawa 1)※　　Yu Tomita 2)

1) Internal Medicine, Sakai Wakabakai Hospital
2) Clinical Laboratory, Sakai Wakabakai Hospital

Key Words：IgA vasculitis, Ulcerative colitis, COVID-19 vaccine

　　A 30-year-old man with ulcerative colitis that had been in remission for 15 years developed intermittent abdominal pain and multiple episodes of diarrhea per day 1 day after receiving the second dose of the coronavirus disease 2019 (COVID-19) vaccine. Thirteen days after initial symptom onset, he was admitted to our hospital with the aforementioned symptoms along with slight fever, abnormal gait due to bilateral calf pain, and purpura in the bilateral lower legs, which had appeared 1 day previously. The results of clinical tests, including skin biopsy, suggested that the patient’s symptoms were due to immunoglobulin (Ig)A vasculitis. The purpura and calf pain resolved with rest and symptomatic treatment；however, intermittent fever (nocturnal body temperature ＞ 39 ℃) and firm bloodstained stools appeared 17 days after initial symptom onset. He was transferred to the gastroenterology department of another hospital 19 days after initial symptom onset and diagnosed with acute exacerbation of ulcerative colitis. Cases of IgA vasculitis and ulcerative colitis in patients with no history of recent tumor necrosis factor-α inhibitor use are rare. Although cases of IgA vasculitis after COVID-19 vaccination have been reported, this is the first case in which histological examination was performed.

JHGM 2022：4(2)：87-92

Case report

Cold agglutinin disease initially regarded
as mechanical hemolysis and alcoholism

Daisuke Nagase 1)　　Yosuke Sasaki2)※　　Ai Hirota1)　　Hirofumi Irita1)
Naoki Onda1)　　Kazuhiko Natori1)　　Yoshihisa Urita2)

1) Division of Hematology and Oncology, Department of Medicine, Toho University Omori Medical Center
2) Department of General Medicine and Emergency Care, Toho University School of Medicine

Key Words：availability bias, hyperkalemia, Raynaud’s phenomenon

　　Cold agglutinin disease (CAD) is a rare condition that typically presents with a combination of extravascular hemolysis, which is caused by immunoglobulin M binding to the RBC membrane, and cold-induced symptoms such as Raynaud’s phenomenon due to agglutination of red blood cells (RBC) under temperatures of around 3 to 4 ℃. We report a case of CAD that was initially diagnosed as mechanical hemolysis and alcoholic liver disease. It took 25 days to diagnose CAD despite the patient presenting with the typical combination of hemolytic anemia and Raynaud’s phenomenon. We believe that our experience offers the following three lessons for primary care physicians：1 ) Physicians must recognize CAD as a rare but important cause of the combination of Raynaud’s phenomenon and hemolysis. 2 ) Physicians must differentiate hemolytic disorders from mechanical hemolysis through the evaluation of reticulocytes, haptoglobin, and Coombs’ test, even when mechanical hemolysis is highly suspected. 3 ) When encountering new or unexpected combinations of symptoms, physicians must be open to a broad range of possible diagnoses and avoid a tendency toward availability bias.

JHGM 2022：4(2)：93-96

Case report

Lung adenocarcinoma with nivolumab-associated
pleuritis showing decreased pleural
complement titres

Yasuyuki Taooka ※　　Junya Inata　　Hiroyuki Ito

Department of Respiratory Medicine, Medical Corporation JR Hiroshima Hospital

Key Words：nivolumab, immune-related adverse events, pleural effusion

　　Although drug-induced interstitial pneumonia is a well-known adverse effect of nivolumab, pleuritis is rare. A case of nivolumab-related pleuritis showing decreased pleural complement titres is presented. A 74-year-old woman with lung adenocarcinoma (T4N2M1a) was admitted to our hospital because of dry cough and dyspnoea. Three months prior to admission, she started receiving nivolumab as second-line chemotherapy. After finishing 6-courses of chemotherapy, she developed dyspnoea on exertion. Thoracic computed tomography showed a pleural effusion. Although pleural cytology was performed three times, the results showed no evidence of malignancy. Increased pleural LDH and total protein, with a decreased 50% haemolytic unit of complement (CH50) titre, were found. Because nivolumab-associated pleuritis was suspected, prednisolone was started, and chemotherapy was discontinued. Her dry cough and dyspnoea decreased gradually. When a pleural effusion is seen during treatment with nivolumab, measuring the CH50 titre might be useful to make the diagnosis of an immune-related adverse event.

JHGM 2022：4(2)：97-101

Case report

Secondary hypereosinophilic syndrome triggered
by sublingual immunotherapy

Daisuke Nagase1)　　Yosuke Sasaki2)※　　Takahiro Saito2)
Atsushi Yamada2)　　Ai Hirota1)　　Hirofumi Irita1)
Naoki Onda1)　　Kazuhiko Natori1)　　Yoshihisa Urita2)

1) Division of Hematology and Oncology, Department of Medicine, Toho University Omori Medical Center
2) Department of General Medicine and Emergency Care, Toho University School of Medicine

Key Words：eosinophilia, esophagitis, pericarditis

　　Hypereosinophilic syndrome (HES) is a hypereosinophilia (blood eosinophils ＞ 1500/mm3) with organ damage and/or dysfunction due to eosinophil invasion. It can be caused by hematologic neoplasms (primary HES) or stimulated by parasitic infections, etc. (secondary HES). Sublingual immunotherapy (SLIT) is an established treatment option for pollenosis (hay fever). In addition to anaphylaxis, eosinophilic esophagitis (EE) has been reported as a complication of SLIT. However, this complication is not well known. We report the case of a 67- year-old woman with SLIT-induced HES who presented with fever and anasarca following laryngeal edema. She was clinically diagnosed with eosinophilic pericarditis and eosinophilic esophagitis. Although pathological evidence of eosinophilic esophagitis and pericarditis was lacking, we successfully treated the patient with 1 mg/kg of prednisolone after excluding primary HES. To the best of our knowledge, there have been no previous reports of eosinophilic pericarditis associated with SLIT, but we thought the patient had eosinophilic pericarditis because the pericardial effusion decreased after glucocorticoid administration. Given that generalists will be in charge of acute management of eosinophilic complications of SLIT, such as EE and anaphylaxis, our report will remind general physicians to be aware of the eosinophilic complications of SLIT.

JHGM 2022：4(2)：102-107

Case report

Tricuspid valve infective endocarditis associated
with pyogenic spondylitis

Yoshinobu Abe1)　　Tomoya Oizumi1)　　Chiho Sanada1)
Keiko Nakagawa2)　　Syuhei Tada1)　　Hideya Itagaki1)
Tomoki Furuya1)　　Takahiro Ohara3)　　Tomoyuki Endo1)

1) Division of Emergency and Disaster Medicine, Tohoku Medical and Pharmaceutical University
2) Emergency Department, Tohoku Medical and Pharmaceutical University Hospital
3) Division of Community Medicine, Tohoku Medical and Pharmaceutical University

Key Words：tricuspid valve infective endocarditis, pyogenic spondylitis, pacemaker

　　A man in his 70s presented with complaints of back pain. He had a pacemaker implanted previously for bradycardic atrial fibrillation and tricuspid valve regurgitation. Although he had a fever, computed tomography showed no cause of fever, including septic pulmonary embolism； however, we made a diagnosis of pyogenic spondylitis using findings of a magnetic resonance imaging of the lumber spine. Streptococcus gordonii was identified on blood culture, and echocardiography revealed tricuspid valve vegetation. In patients with tricuspid valve regurgitation and an indwelling cardiac pacemaker, complications of tricuspid valve IE should be considered when treating pyogenic spondylitis.

JHGM 2022：4(2)：108-113

Brief report

Reappraisal of Chest Radiograph-Derived
Cardiothoracic Ratio for the Detection
of Heart Failure in Older Adults

Takahiro Ohara1)3)※　　Kazuhisa Sato2)　　　　Hiroyuki Nakajima3)　　Shigeto Mashiko1)
Aiko Ishiki1)　　Chika Oyama1)　　Atsuhiro Kanno1)
Juri Ueda1)　　Yuko Fujikawa1)　　Isabelle Miyazawa1)
Kazuhiro Sumitomo1)　　Nobuo Koinuma1)　　Katsutoshi Furukawa1)

1) Division of Community Medicine, Tohoku Medical and Pharmaceutical University
2) Faculty of Medicine, Tohoku Medical and Pharmaceutical University
3) Clinical Laboratory Department, Tohoku Medical and Pharmaceutical University Hospital

Key Words：cardiothoracic ratio, heart failure, B-type natriuretic peptide, elderly, diagnosis

JHGM 2022：4(2)：114-116

Brief report

Multiple myeloma causing osteolytic changes
in a single lumbar vertebra

Tsunenori Tanabe1)　　Hiroki Isono1)※　　　Masaki Nakasuka2)

1) Department of General Medicine, HITO Medical Center
2) Department of orthopedic surgery, HITO Medical Center

Key Words：Multiple myeloma, osteolytic changes

JHGM 2022：4(2)：117-118

Brief report

A Case of Thyroid Storm Following
Herpes Zoster Infection

Ippei Jinno1)　　Momoko Isono2)　　Hiroki Isono2)※
Kousuke Ihra2)　　Keisuke Kondo2)

1) Ehime University School of Medicine
2) Department of General Medicine, HITO Medical Center

Key Words：thyroid storm, thyroid crisis, hyperthyroidism

JHGM 2022：4(2)：119-120

Key Image of General Medicine

Iatrogenic pneumomediastinum presenting
with facial swelling due to a dental procedure

Yosuke Sasaki1)※　　Masashi Koumura2)　　　Kousuke Kaneko2)　　Tadashi Maeda1)
Tomoyuki Shigeta1)　　Fumiya Komatsu1)　　Atsushi Yamada1)

Takahiro Saito1)　　Hideki Sekiya2)　　Yoshihisa Urita1)

1) Department of General Medicine and Emergency Care, Toho University School of Medicine
2) Department of Oral Surgery, Toho University School of Medicine

Key Words：anaphylaxis, cardiac tamponade, emphysema

JHGM 2022：4(2)：121-122

Key Image of General Medicine

Peritoneal mesothelioma in an elderly patient

Sho Nishiguchi1)※　　Manayo Matsumoto2)

1) Department of General Internal Medicine, Shonan Kamakura General Hospital
2) Department of Obstetrics and Gynecology, Shonan Kamakura General Hospital

Key Words：Peritoneal mesothelioma, laparoscopic biopsy, ascites

JHGM 2022：4(2)：123-124

Key Image of General Medicine

Primary herpetic gingivostomatitis of adult onset

Takuto Inoue　　Momoko Isono　　Hiroki Isono※　　Kousuke Ihara

Department of General Medicine, HITO Medical Center

Key Words：herpes simplex virus, pharyngitis, gingivostomatitis