MAY 2020 Volume 2-3

ISSN 2185-8136

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2020：2(3)：56-61

Original article

Trend and cause of death of HIV-infected patients
in Japan:A descriptive study using hospital
admission records

Mai Suzuki　　Yukiko Fukui　　Mizue Saita

Mika Tanei　　Akihiro Inui　　Toshio Naito ※
Department of General Medicine, Juntendo University Faculty of Medicine

　　The life-expectancy of people living with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) (PLWHA) has substantially increased over the past decade owing to improved antiretroviral therapies. The cause and trend of mortality in PLWHA is expected to differ from the previous prognostic models. In this descriptive study, we extracted the records of HIV-infected patients from the admissions database of an academic medical center in Japan, and evaluated the trend and cause of death in this cohort. A total of 115 admission records from 75 hospitalized HIV-infected individuals were available from the years 2014-2018. The mean age at last hospital admission was significantly higher in the mortality group than the non-mortality group (67.9 ± 16.6 years v.s. 44.8 ± 12.4 years, p = 0.008). The mean age at first HIV diagnosis and the mean length of hospital stay were also significantly greater in the mortality group than the non-mortality group (age at first HIV diagnosis:58.3 ± 18.3 v.s. 39.3 ± 10.7 years, p = 0.032;length of hospital stay:40.0 ± 26.0 v.s. 13.9 ± 16.2 days, p = 0.014). The causes of death in the 4 patients were not directly AIDS-defining (i.e. idiopathic cytopenia purpura, brain tumor, tongue cancer, and anal cancer). In conclusion, the present preliminary analysis indicates that the life expectancy of PLWHA may also have extended in Japan, and the implementation of appropriately designed healthcare policies is required to accommodate the aging PLWHA population. Larger confirmatory studies are needed to control for inherent confoundings.

JHGM 2020：2(3)：62-70

Original article

Clinical characteristics of Aeromonas bacteremia at
Hiroshima University Hospital:Literature review and
therapeutic proposal

Kazuki Kimura ※　　Yuichiro Otani　　Akihiro Kawahara

Keishi Kanno　　Susumu Tazuma
Department of General Internal Medicine, Hiroshima University Hospital

[Introduction]The genus Aeromonas is native to mesophilic freshwater environments. Aeromonas infections are rare in non-tropical areas with well-equipped water supply facilities. However, some cases of severe Aeromonas septicemia and Necrotizing Soft Tissue Infection (NSTI) caused by bacterial translocation have been reported in Japan.
[Methods]We examined all culture tests submitted to our Hospital over a 14 years period (2004 – 2017). We identified 21 cases in which Aeromonas was isolated from blood culture. Information relating to medical history and clinical course were collected for each of these cases. In addition, we analyzed various factors against Aeromonas bacteremia.
[Methods]The total number of culture samples inspected was 248,790, comprising 58,739 (19.7%) blood culture samples. The total number of blood culture from which Aeromonas was isolated was 21cases. 11 cases (52.4%) fulfilled the criteria of septic shock. Of these, 3 died, of which 2 had advanced to NSTI. 15 cases (71.4%) had underlying hepatobiliary disease and 7 cases had undergone hepatobiliary invasion examinations. There was a significant difference between the time to start of antibiotic treatment and the mortality rate.
[Conclusions]Gastroenterological invasive examinations can increase Aeromonas bacteremia due to bacterial translocation. When Aeromonas septicemia is suspected, immediate empiric therapy is crucial.

JHGM 2020：2(3)：71-77

Case report

A case of successfully treated invasive pulmonary
aspergillosis following influenza B infection:
A case report and literature review

Hiroaki Ikezaki, MD, PhD 1)2) 　Atsuko Fujita, MD 3)

Aika Aoto, BPharm 4) 　Maiko Itoh, BPharm 4)
Mariko Nakamichi, BPharm 4) 　Fujiko Kaseida, MD, PhD 1)2)
Kahori Miyoshi, MD, PhD 3) 　Atsuhiko Sakamoto, MD 1)
Masayuki Murata, MD, PhD 2)　 Jun Hayashi, MD, PhD 1)2)

1）Department of General Internal Medicine, Haradoi Hospital
2）Department of General Internal Medicine, Kyushu University Hospital
3）Department of Internal Medicine, Haradoi Hospital
4）Department of Pharmacy, Haradoi Hospital

Abstract
　　Invasive pulmonary aspergillosis (IPA) typically occurs in immunocompromised patients, however, some IPA cases have been reported in immunocompetent hosts following influenza virus infection. A 90-year-old woman hospitalized for aspiration pneumonia suffered from non- severe influenza B virus infection. Ten days later, Aspergillus fumigatus was positive in her sputum culture and cavity formations were seen in both lungs on computed tomography. She was diagnosed with IPA and successfully treated with 13 weeks of voriconazole. Because IPA could be fatal even in immunocompetent hosts, IPA should be given due consideration as a possible cause of secondary pneumoniae after influenza virus infection.

Key Words：Invasive pulmonary aspergillosis, influenza infection,
immunocompetent patient

JHGM 2020：2(3)：78-84

Case report

PET/CT, a useful approach to improving the diagnosis
of large vessel vasculitis when conventional
imaging fails

Taiju Miyagami 1)※ 　Hiromizu Takahashi 1)
Kenji Murai 1) 　Gautam A. Deshpande 1)2)　 Toshio Naito 1)

1）Department of General Medicine, Juntendo University Faculty of Medicine
2）Department of Internal Medicine, University of Hawaii

Abstract
　　Large vessel vasculitis often manifests as a diverse set of symptoms, making it challenging to diagnose. Diagnostic criteria focus on physical examination and imaging findings. However, for elderly patients with arteriosclerosis, it may be difficult to distinguish vascular thickening from arteriosclerotic burden, further complicating diagnosis. 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET/CT) examination is a potentially important modality for the diagnosis of large vessel vasculitis. We report on the utility of PET/CT for diagnosis of large vessel vasculitis for three patients with fever and markedly elevated inflammatory markers of unknown cause who were hospitalized at our department.

Key Words： large vessel vasculitis, PET/CT, FUO, inflammation

JHGM 2020：2(3)：85-89

Case report

Clinically Amyopathic Dermatomyositis Complicated
by Rapidly Progressive Interstitial Lung Disease

Yoshio Hisata, MD 1)2)※ 　Eisuke Sasaki, MD, PhD 3)
Yosuke Harada, MD, PhD 4)　 Hirofumi Nakano, MD, PhD 5)
Shinji Naito, MD, PhD 6)　 Takashi Sugioka, MD, PhD 1)

1）Community Medical Support Institute, Faculty of Medicine, Saga University
2）Department of General Medicine, Saga University Hospital
3） Division of Respiratory Medicine, National Hospital Organization Ureshino Medical Center
4）Division of Respiratory Medicine, Nagasaki Harbor Medical Center
5）Division of Respiratory Medicine, Fukuoka Seisyukai Hospital
6） Division of Pathology, National Hospital Organization Ureshino Medical Center

Abstract
　　Clinically amyopathic dermatomyositis (CADM) may be complicated by rapidly progres- sive interstitial lung disease (RP-ILD) and consequently has a poor prognosis. Anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody is reportedly associated with RP-ILD in patients with CADM and is useful for early diagnosis. The characteristic skin rash of CADM can be a clue to early diagnosis. In patients with such a rash, we should consider measuring the anti- MDA5 antibody level and perform magnetic resonance imaging of the skeletal muscle, even without clinical or laboratory findings of myopathy.

Key Words：clinically amyopathic dermatomyositis, anti-melanoma differentiation-associated gene 5 antibody, rapidly progressive interstitial lung disease

JHGM 2020：2(3)：90-92

Case report

Vertebral compression fracture with upper　lumbar
radiculopathy without spinous process tenderness

Takashi Akimoto, MD 1)2)※ 　Tadashi Kobayashi, MD, PhD 1)
Hiroki Maita, MD 2)3)　 Hiroshi Osawa, MD, PhD 1)
Hiroyuki Kato, MD, PhD 1)2)3)

1）Department of General Medicine, Hirosaki University School of Medicine and Hospital
2）General Medicine, Hirosaki University Graduate School of Medicine
3）Development of Community Healthcare, Hirosaki University Graduate School of Medicine

Abstract
　　A 71-year-old man complained of pain in the right leg that gradually increased over a 2-week period. Pain was not related to any traumatic event. One year before this event, the patient underwent endovascular aortic repair for a ruptured abdominal aortic aneurysm. In addition, he had been administered oral prednisolone 10 mg/day to treat interstitial pneumonia in the last 2 years. Although the patient had no spinous process tenderness or abnormal neurological symptoms in the lower legs, moderately weakened muscle and sensory disturbance of the right thigh were observed. Lumbar X-ray images and magnetic resonance imaging revealed a fracture of the second lumbar vertebra. The patient underwent conservative therapy using a thoracolumbar corset. The symptoms improved after 3 months. We recommend that primary care physicians should not rule out vertebral fractures despite a lack of evidence of spinous process tenderness or abnormal neurological symptoms of the lower legs on physical examination. Neurological examination of the thigh should be performed in such cases.

Key Words：closed-fist percussion sign, prolonged corticosteroid use, red flags

JHGM 2020：2(3)：93-98

Case report

Non-perforated hemorrhagic gastric ulcer presenting
with left shoulder pain and orthostatic dizziness,
but without abdominal pain

YNaoyasu Kashima　Yosuke Sasaki ※　Tadashi Maeda

Hiroaki Za　Yoshihisa Urita
Department of General Medicine and Emergency Care, Toho University School of Medicine

Abstract
　　Not only as a referred pain due to acute myocardial infarction, but also shoulder pain has been reported as a rare symptom of perforated peptic ulcer. However, shoulder pain due to non- perforated gastric ulcer has not been reported previously. We describe the case of an 86-year-old anticoagulant user with non-perforated hemorrhagic gastric ulcer manifesting with left shoulder pain and orthostatic dizziness. The shoulder pain responded to proton pump inhibitor administration without specific shoulder pain treatment. Although such shoulder pain is a referred pain due to perforated peptic ulcer in association with phrenic irritation, it has not been reported as a symptom for patients with non-perforated peptic ulcer. Orthostatic dizziness is an important sign of gastrointestinal bleeding by elderly patients, as tachycardia and abdominal pain are less incident for them. Our experience with this case suggests the importance of the combination of orthostatic dizziness and referred shoulder pain as a diagnostic clue to hemorrhagic gastric ulcer.

Key Words：peptic ulcer, referred pain, orthostatic hypotension

JHGM 2020：2(3)99-103

Special contribution

To which journal should generalists submit
a clinical case report?

Masaki Tago MD, PhD 1)※　Takashi Watari MD, DTMH, MS, MCTM 2)

Kiyoshi Shikino MD, PhD 3) 　Yosuke Sasaki MD, PhD 4)

Hiromizu Takahashi MD, PhD 5)　 Taro Shimizu MD, PhD, MPH, MBA 6)

1）Department of General Medicine, Saga University Hospital
2）Postgraduate Clinical Training Center, Shimane University Hospital
3）Department of General Medicine, Chiba University Hospital
4）Department of General Medicine and Emergency Care, Toho University School of Medicine
5）Department of General Medicine, Faculty of Medicine, Juntendo University
6）Department of Diagnostic and Generalist Medicine, Dokkyo Medical University

Abstract
　　Case reports with detailed examinations of diagnoses and pathophysiologies are the foundation of clinical research. Moreover, the accumulation of individual cases will lead to the construction of high-quality research and evidence in the future, hence contributing to improvement in academic research.
　　Generalists often struggle with choosing which journal to submit clinical case reports because they cover a wide range of diseases and clinical settings. Moreover, case reports written by generalists primarily focus on meaningful clinical lessons or intriguing clinical findings that sometimes lack novel topics. There has been no list of journals suitable for topics and case reports in the general practice area. Information from those who have already published or been accepted is valuable for creating a list of the potential target journals. Hereby, the authors of this article provide information on case reports. We hope this list will help generalists who wish to submit their first case report in the near future.

Key Words：clinical case report, generalist, journal list, scientific journal