MAY 2021 Volume 3-4

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2021：3(4)：111-117

Original article

Clinical features and outcomes of a nosocomial
outbreak of COVID-19 pneumonia associated
with survival in hospitalized patients

Nobuhiro Ikeda 1)　　Hayate Masubuchi 1)　　Haruki Sato 1)　　Shiori Nakashima 1)
　　Takayuki Fujii 1)　　Senhime Akashi 1)　　Toshio Naito 2)※

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

Key Words：Coronavirus, Covid-19, Nosocomial, Older adults, Prognosis, Viral pneumonia

Limited data are available on nosocomial infected COVID-19 patients with existing comorbidities. This study aimed to describe the clinical features, laboratory measures, and outcomes of patients with hospital-acquired COVID-19 infection in Eiju General Hospital, one of the largest nosocomial outbreaks of in Japan. Consecutive patients diagnosed with hospitalacquired, laboratory-confirmed COVID-19 infection who were receiving treatment in the Department of General Internal Medicine between March 1, 2020 and May 31, 2020 were enrolled. Data of 11 patients (81. 3 years ± 8. 7 years), including 6 survivors and 5 nonsurvivors, were analyzed. Admission diagnoses included fracture ( n = 3 ), neurological disorders ( n = 3 ), cardiovascular diseases ( n = 2 ), cold agglutinin disease ( n = 1 ), gastrointestinal disorder ( n = 1 ), and infection ( n = 1 ). Fever and diarrhea were the most frequent symptoms. There were no significant differences in baseline characteristics, nor comorbidities between survivors and non-survivors. Peak CRP and peak LDH during the critical treatment period were significantly higher in non-survivors than in survivors (both p = 0. 036). Between-group differences in glucose and peak D-Dimer values were of borderline significance (glucose, p = 0.083；D-Dimer, p = 0.054). In conclusion, peak CRP, LDH, and D-Dimer values are potential prognostic factors associated with greater risk of progression to critical condition or death. Further investigation is needed to determine whether these laboratory parameters may predict favorable response to different treatment strategies for COVID-19 infection.

JHGM 2021：3(4)：118-123

Original article

Online-Learning Program for Japanese General
Physicians to Promote an Appropriate Screening Test
for Human Immunodeficiency Virus Infection

Hiroki Iriyama 1)　　Mizue Saita 1)　　Yoshiyuki Yokomaku 2)
Kunihisa Tsukada 3)　　Toshio Naito 1)※

1）Department of General Medicine, Juntendo University Faculty of Medicine
2）Department of Infectious Diseases and Immunology, Clinical Research Center, National Hospital Organization Nagoya Medical Center
3）AIDS Clinical Center, National Center for Global Health and Medicine

Key Words：human immunodeficiency virus, acquired immunodeficiency syndrome

[Objectives] To provide an online-learning program for general physicians in Japan about the screening of human immunodeficiency virus (HIV) infection
[Methods] We conducted an online-learning program and questionnaire survey about HIV infection on the Japanese Society of the Hospital General Medicine official web page between July 2019 and March 2020. The learning program was about HIV epidemiology in Japan, indicator conditions for screening of HIV infection, management of antiretroviral therapy, and long-term complications. The questionnaire survey, which was conducted before and after the online-learning program, included physicians’ knowledge about HIV infection and their attitude toward diagnosing and treating it.
[Results] We included 126 physicians. The number of physicians who correctly recognized herpes zoster and acute type B hepatitis as indicators for screening of HIV infection increased during the learning program (from 74 [59%] to 125 [99%] and 84 (67%) to 124 (98%),
respectively).
The number of physicians with confidence in diagnosing and treating HIV infection and who would like to diagnose and treat patients with HIV infection increased during the learning program (from 9 [7%] to 19 [15%] and 52 [41%] to 70 [56%], respectively).
[Conclusions] The online-learning program could be used to train general physicians to perform appropriate screening of HIV infection.

JHGM 2021：3(4)：124-128

Original article

ESBL Growth Screening Indicator (E-GSI) tube
for the rapid detection of extended-spectrum
β-lactamase (ESBL)-producing strains in patients
with Escherichia coli bacteremia

Kentaro Kikuchi 1)　　Keisuke Kurita 2)　　Sayuri Osaki 2)　　Chiyoko Motegi 2)
Tomohiro Kikuyama 3)　　Sho Ohyatsu 1)　　Tomoyuki Nariyama 1)　　Kotaro Matsumoto 3)
Hiromichi Tsunashima 3)　　Hikari Fujioka 1)　　Masumi Hara 1)

1）Fourth Department of Internal Medicine, Teikyo University Mizonokuchi Hospital
2）Central Laboratory, Teikyo University Mizonokuchi Hospital
3）Department of Gastroenterology, Teikyo University Mizonokuchi Hospital

Key Words：Extended-spectrum β-lactamase, Escherichia coli, bacteremia

When Gram-negative rods are detected in a blood culture, it takes about 3 days to determine whether they are ESBL-producing Enterobacterales. However, using the ESBL Growth Screening Indicator tube (E-GSI tube), E. coli grown in blood culture bottles can be screened for ESBL production in 6 hours. In this study, we evaluated the diagnostic accuracy of the E-GSI tube during screening for ESBL production in Escherichia coli in patients with bacteremia. Samples were collected from blood cultures from 177 cases in which Gram-negative rods were detected and later identified as E. coli. After each sample was centrifuged, the supernatant was inoculated into an E-GSI tube, and the resultant color change was observed for 6 hours. As a result, 42 of 44 samples of ESBL-producing E. coli were positive. The sensitivity and specificity of the E-GSI tube for detecting ESBL-producing E. coli were 95.5% and 98.5%, respectively. We conclude that the EGSI tube is useful for screening for ESBL-producing E. coli. The E-GSI tube is inexpensive and effective for detecting 3rd-generation cephalosporin-resistant Enterobacterales.

JHGM 2021：3(4)：129-135

Case report

Intravascular large B-cell lymphoma with endocrine
disorder of the hypothalamus-pituitary axis required
repeat random skin biopsy for diagnosis

Risa Hirata 1)2)　　Motoshi Fujiwara 1)　　Hidetoshi Aihara 1)　　Satsuki Oie 1)
Shun Yamashita 1)　　Yoshinori Tokushima 1)　　Yuka Hirakawa 1)　　Shu Soejima 3)
Rika Yamaguchi 4)　　Yoshimasa Oda 2)　　Naoko E Katsuki 1)　　Masaki Tago 1)※

1）Department of General Medicine, Saga University Hospital
2）Department of General Medicine, Yuai-Kai Foundation and Oda Hospital
3）Department of Internal Medicine, Hiramatsu Hospital
4）Department of General Medicine, Keiaikai Saga Memorial Hospital

Key Words：intravascular large B-cell lymphoma, random skin biopsy, endocrine abnormalities

A 71-year-old man with hypertension presented with normal blood pressure without the use of antihypertensive medication in the past 6 months, low-grade fever and nocturnal sweating for 2 weeks, and anorexia for a week. The patient visited a different hospital and although the findings of blood examination suggested malignant lymphoma, computed tomography showed only splenomegaly and random skin biopsy showed no abnormality. Two weeks later the patient was referred to our hospital. Upon admission, physical examination revealed hypotension, tachycardia, and enlarged thyroid gland. Blood examination revealed elevated CRP, LDH, and soluble IL-2 receptor, hypothyroidism, low LH, high prolactin, and low early morning cortisol. CRH/TRH/LHRH loading test and GH releasing protein-2 loading test showed abnormal endocrine disorder of the hypothalamic-pituitary axis. After bone marrow biopsy failed to inform a diagnosis, a second random skin biopsy revealed the presence of CD3-negative and CD20- positive atypical lymphocytes in the blood vessels, which supported a diagnosis of intravascular large B-cell lymphoma (IVLBCL). IVLBCL can present with endocrine disorders of the hypothalamus-pituitary axis and can be diagnosed by repeated random skin biopsy. When a patient presents with unexplained endocrine disorders and IVLBCL is strongly suspected, random skin biopsy should be repeated even if the first biopsy is negative.

JHGM 2021：3(4)：136-140

Case report

Non-episodic angioedema with eosinophilia
undetected by an automated hematology analyzer

Hiroki Maita 1)※　　Tadashi Kobayashi 2)　　Takashi Akimoto 2)
Hiroshi Osawa 2)　　Hiroyuki Kato 1)2)

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

Key Words：automated hematology analyzer, eosinophil, granulocyte

A 37-year-old woman with a history of bipolar disorder and insomnia presented to our hospital with edema of the extremities, pruritus, and weight gain that had persisted for 1 month. Blood tests conducted at a community hospital showed mildly elevated white blood cell (WBC) and normal WBC differential counts. However, tests conducted at our hospital revealed an extremely high eosinophil count. Based on the patient’ s history and test results, she was diagnosed with non-episodic angioedema with eosinophilia (NEAE), a rare hypereosinophilic disease that occurs predominantly in young females and often poses diagnostic challenges to physicians. Prednisolone was administered and her symptoms and laboratory results improved within 1 week. Automated hematology analyzers are commonly used in medical institutions in Japan and classify the WBC differential into three categories, which leads to difficulty in identifying NEAE based on abnormalities in the eosinophil count. It is crucial to understand the specifications of automated hematology analyzers before using them, and if necessary, manual counts should be performed to correctly diagnose patients. Although NEAE is considered to resolve spontaneously within a few months even without steroid treatment, physicians should consider the administration of steroids as a treatment option depending on the patient’ s symptoms and comorbidities.

JHGM 2021：3(4)：141-146

Case report

A case of diabetic muscle infarction recurring
in a short period of time

Toshitaka Sawamura 1)2)3)※　　Misato Maeno 2)　　Takuya Higashitani 2)3)
Mitsuhiro Kometani 3)4)　　Shigehiro Karashima 4)　　Yuko Katsuda 2)3)
Yoshiyu Takeda 1)　　Takashi Yoneda 3)4)

1）Department of Internal Medicine, Asanogawa General Hospital
2）Department of Diabetes and Endocrinology, Fukui Prefectural Hospital
3）Division of Endocrine and Diabetes, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
4）Department of Laboratory Sciences, Faculty of Health Sciences

Key Words：Diabetic muscle infarction, diabetes, strict glucose control

Diabetic muscle infarction (DMI) is a rare diabetic complication characterized by an acute onset muscular pain and swelling. Physicians often have difficulty in diagnosing DMI, as differential diagnoses are multiple. A 38-year old man presented at our hospital with complaints of right femoral myalgia. His femur was swollen and a thumb-tip-sized nodule was palpated. T2- weighted magnetic resonance imaging (MRI) demonstrated hyperintensity in the affected muscle, and heterogenous low-contrast focus in the muscle was shown using contrast-enhanced T1-weighted image. This MRI finding is typical and has high specificity to DMI. He was diagnosed with DMI and his symptoms improved by an administration of loxoprofen and rest of the lower limbs. However, recurrence in other muscles was observed and muscle biopsy was made.However, specific pathological findings of DMI were not obtained. This was thought to be caused by the biopsy to surrounding muscle that had no ischemic and necrotic change. His symptoms improved with same treatments. However, the muscle to which biopsy was made needed longer recovery time compared with other muscles. For the diagnosis of DMI, physicians must have a physical finding of palpitated nodule and low-contrasted focus in contrast-enhanced MRI, which indicate the infarction and necrosis in the affected muscle.

JHGM 2021：3(4)：147-152

Case report

Two sporadic cases of Legionnaires’
disease developed after heavy rainfall in Japan

Hiroki Wakabayashi ※　　Yasuo Matsuzawa 　　Kotaro Iwasaki
Sho Hayakawa 　　Hagino Rikitake　　Kotaro Kumano

Department of Internal Medicine, Toho University Medical Center Sakura Hospital

Key Words：Legionnaires’ disease, heavy rainfall, disaster

Legionnaires’ disease is an infection that develops by inhalation of bacteria contained in
aerosols and that can cause localized outbreaks. Herein, we report two cases of Legionnaires’
disease associated with a heavy rainfall disaster in Sakura City, Chiba, Japan. Case 1 developed
Legionnaires’ disease after walking in a flooded road. There was no obvious cause for Case 2 . For
Case 1 , the period from heavy rainfall to the onset of symptoms and the result of sequencebased
typing indicated that Legionnaires’ disease was associated with the heavy rainfall. Case 2
was diagnosed by means of elevated serum antigen titer, although both the urinary antigen test
and PCR of sputum were negative. We considered Legionnaires’ disease in Case 2 because both
cases were hospitalized at the same time. Legionnaires’ disease can occur sporadically due to
heavy rainfall. In addition, it can develop in patients without a clear history of exposure to more
common aerosol infection routes. Legionnaires’ disease should be considered in the diagnosis of
pneumonia after heavy rainfall.

JHGM 2021：3(4)：153-157

Case report

Five cases of choking on a foreign body alleviated
successfully with a vacuum-attached nozzle

Yuji Otsuka
Department of Psychiatry, Asahi General Hospital

Key Words：choking, foreign body, IMG sucking nozzle

Foreign body airway obstruction (FBAO) can cause severe symptoms. Following the recommended methods of basic life support (BLS) established by the American Heart Association has not always been practical. Some psychiatric patients show problematic eating habits, such as fast eating, and their prognosis for choking is poor. In May 2005, we began utilizing a vacuum-attached nozzle, the IMG sucking nozzle (IMGsn), to remove foreign bodies (FBs) at psychiatric wards. We started to use it because of the terrible prognosis of patients with FBAO. The power for removal of FBs by IMGsn is approximately ten times stronger than for abdominal thrusts or chest compressions. Here, we report five cases of FBAO who were treated with IMGsn. The patients in all five cases had risk factors. The FBs were removed successfully in all cases, and the patients recovered entirely despite a temporary severe status. Sucking FBs would be a helpful method for cases in which BLS methods are not effective.

JHGM 2021：3(4)：158-159

Key Image of General Medicine

Tetanus preceded by difficulty in expectorating
and dysphagia

Kazuhiro Okada1)※　　Youshi Fujita 2)

1）Kaga medical center
2）Fujita Neurology Hospital

Key Words：tetanus, difficulty in expectorating, dysphagia

JHGM 2021：3(4)：160-161

Key Image of General Medicine

A case of acute type 1 diabetes
with Hamman’s syndrome

Tetsuo Yamaji ※　　Ayumi Tsuzuki 　　Makoto Takaoka
Department of Emergency Medicine, Steel Memorial Hirohata Hospital

Key Words：Hamman’s syndrome, mediastinal emphysema, diabetic ketoacidosis

JHGM 2021：3(4)：162-163

Key Image of General Medicine

Segmental herpes zoster abdominal paralysis：
Unilateral abdominal bulge that enlarged in size
with abdominal pressure

Masaki Tago 1)※　　Tomoko Nishi 2)

1）Department of General Medicine, Saga University Hospital
2）Saga City Mitsuse Clinic

Key Words：abdominal paralysis, abdominal pseudohernia, herpes zoster