SEPTEMBER 2022 Volume 4-5

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2022：4(5)：204-213

Original article

Baloxavir marboxil for uncomplicated influenza
in children：a multicenter, randomized,
non-inferiority trial

Takeshi Goda 1)＊　　Masaya Suematsu 1)2)＊　　Hisato Ito 1)　　Go Horiguchi 3)
Ryo Ikushima 1)　　Utsuki Matsumura 1)　　Kohei Mitsuno 1)　　Takashi Morita 1)
Seiji Tanaka 1)　　Toshihiro Tomii 1)　　Kitaro Kosaka 4)　　Yoshiki Katsumi 4)
Sachiko Goto 4)　　Fumihiro Matsui 5)　　Akemi Sato 6)　　 Tomoko Iehara 2)※

＊ contributed equally as co-first authors

1) Department of Pediatrics, Kyoto Chubu Medical Center
2) Department of Pediatrics, Kyoto Prefectural University of Medicine
3) Department of Biostatistics, Kyoto Prefectural University of Medicine
4) Department of Pediatrics, Saiseikai Kyoto Hospital
5) Matsui Pediatric Clinic
6) Sato Clinic

Key Words：adverse drug reactions, baloxavir marboxil, influenza, neuraminidase inhibitors

　　Baloxavir marboxil (BM), a newly approved drug for influenza treatment, is prescribed for pediatric patients less frequently than for adults. The purpose of this study was to evaluate the non-inferiority of the clinical effects of BM to oseltamivir for children aged ＜ 6 years and that of BM to laninamivir for children aged ≥ 6 years. We enrolled 201 influenza patients aged 1 to 15 years from December 2018 through October 2019. The participants were divided according to age (age ＜ 6 years or age ≥ 6 years), and then randomly assigned to the BM or neuraminidase inhibitors (NAIs) group. The primary outcome was the time to fever resolution after treatment. In the age group ＜ 6 years, the median time for the BM and oseltamivir groups was 24.0 h vs. 32.0 h. In the age group ≥ 6 years, the median time of the BM and laninamivir groups was 29.8 h vs. 32.5 h. These results met criteria for non-inferiority. The type and frequency of side effects were almost the same between the BM and NAIs groups. In conclusion, BM would be an effective therapeutic option for children as well as adults.

JHGM 2022：4(5)：214-220

Original article

Clinical differentiation of bacterial and viral enterocolitis：
a Japanese, single center, post hoc analysis

Yosuke Sasaki ※　　Hitoshi Nakajima　　Tadashi Maeda　　Urita Yoshihis

Department of General Medicine and Emergency Care, Toho University School of Medicine

Key Words：colitis, diarrhea, dysentery, infectious diarrhea, ischemic colitis

[Introduction] Clinical manifestations of infectious enterocolitis vary depending on the causative microorganism, providing clues in the search for the cause. However, studies on the simple clinical differentiation between bacterial enterocolitis (BE) and viral enterocolitis (VE)
are scarce. we performed a post hoc analysis to examine the clinical differentiation between BE and VE.
[Methods] We performed a post hoc analysis using a previously performed study on hospitalized patients with infectious diarrhea. BE was defined as cases in which a specific causative organism was definitely detected from stool culture, and VE was defined as cases with a positive rapid stool antigen testing for virus. We compared the clinical characteristics of BE and VE.
[Results] The data of 44 BE patients and 26 VE patients showed that the BE patients were younger and had a higher prevalence of fever, longer onset-visit interval, and higher serum CRP level. Unexpectedly, hematochezia was prevalent in VE. Higher serum CRP level for BE (odds ratio：1.30) and older age for VE (odds ratio：0.96) were significant in the logistic regression analysis.
[Conclusions] Our study suggests that serum CRP is useful for diagnosing BE in adults and that VE cases with hematochezia may include cases with “viral diarrhea-induced ischemic colitis”.

JHGM 2022：4(5)：221-227

Original article

Factors related to prednisolone-free remission
in patients with polymyalgia rheumatica

Harutaka Yamaguchi1)　　Yoshihiro Okura2)　　Ryo Tabata1)
Yoshinori Nakanishi 2) 　　Keisuke Kawahito 1) 　　Kenji Tani 2)※

1) Department of General Medicine, Institute of Biomedical Sciences, The University of Tokushima Graduate School
2) General Medicine and Primary Care, Tokushima University Hospital

Key Words：polymyalgia rheumatica, prednisolone, remission, CRP

　　Polymyalgia rheumatica (PMR), a common inflammatory rheumatic disease, typically affects elderly individuals and has been known to respond well to low dosages of corticosteroids. The aim of this study is to evaluate predictive factors that correspond to subsequent remission of PMR. Twenty-four patients with PMR were treated with prednisolone. After 2 years, patients were divided into prednisolone-free remission and no remission groups for comparison of clinical factors. Ten patients (41.7%) had achieved prednisolone-free remission at 2 years. The level of initial CRP was not significantly different between the groups. Significantly short duration from the treatment start to negative CRP was observed in patients with prednisolone-free remission when compared in those with no remission. The percentage of patients who showed negative CRP after 8 weeks was significantly higher in the prednisolone-free remission group than in the no remission group. The prednisolone dosage at 1 year was significantly less in prednisolone- free remission group than in the no remission group. This study suggests that, even if the initial CRP levels are high, negative CRP early in the treatment results in a subsequent prednisolone- free remission.

JHGM 2022：4(5)：228-233

Case report

A case of severe myositis after COVID-19 vaccination

Kazuo Eguchi1)※　　Tomotaka Nishizawa2)　　Kanto Toriumi3)
Masanobu Horikoshi 3) 　　Youhei Koushima 4)

1) Department of General Internal Medicine, Saitama Red Cross Hospital
2) Department of Respiratory Medicine, Saitama Red Cross Hospital
3) Department of Rheumatology, Saitama Red Cross Hospital
4) Hepatobiliary Pancreatic Department, Saitama Red Cross Hospital

Key Words：COVID-19 vaccination, fever of unknown origin, myositis.

　　A 68-year-old man presented with fever and swelling of the thigh and calf after a COVID-19 vaccination. The lower leg MRI showed inflammation of the calf, and the patient was diagnosed with post-vaccination myositis. After introducing prednisolone 60 mg/day, the inflammation improved. COVID-19 vaccine can cause inflammatory myositis as a presentation of systemic immune-mediated reactogenicity.

JHGM 2022：4(5)：234-237

Case report

Delayed Diagnosis of a Complication in a Patient
with a Positive COVID-19 Test

Hidehiro Someko ※　　Toshiaki Shiojiri

Department of general internal medicine, Asahi general hospital

Key Words：diagnostic error, covid-19, lateral medullary infarction

[Introduction] During the coronavirus disease (COVID-19) pandemic, some patients erroneously suspected of having COVID-19 were later diagnosed with other diseases. This type of diagnostic error, known as COVID blindness, can be corrected by COVID-19 test negativity. However, diagnostic errors related to COVID-19 test positivity have rarely been discussed.
[Case Description]An 82-year-old man presented to our emergency department with suddenonset nausea, vomiting, and gait disturbance. Based on the results of a COVID-19 test and chest computed tomography, he was diagnosed with COVID-19 pneumonia. After treatment for pneumonia, brain magnetic resonance imaging revealed left lateral medullary infarction.
[Discussion] When a screening test for COVID-19 is positive and patients are diagnosed with
COVID-19, the possibility of other diseases may be ignored, leading to delayed diagnosis, as
illustrated in this case. Complications of atherosclerotic disease, which are common, especially in
patients with COVID-19, should be cautiously ruled out.
[Conclusions] COVID-19 test positivity may not always be a definitive diagnosis.

JHGM 2022：4(5)：238-242

Case report

Prolonged steroid therapy effectively treats
long COVID-19 pneumonia

Megumi Shimada1)※　　Eriko Goto1) 　　Hideki Ozawa2)

1) Department of General Internal Medicine, Tokai University Oiso Hospital
2) Department of General Internal Medicine, Tokai University

Key Words：COVID-19, steroid, oxygen therapy

　　A 72-year-old man was admitted to our hospital on an emergency basis on the seventh day after the onset of fever and cough. A PCR test for COVID-19 was positive. Computed tomography (CT) scan of his chest showed bilateral pneumonia；hence, favipiravir and ciclesonide were administered. However, the patient continued to have fever with worsening respiratory condition；hence, oxygen therapy was started. Because the second CT revealed worsening of the pneumonia, the treatment was switched to remdesivir and dexamethasone. The initial oxygen therapy that required a maximum of 4 L/min was eventually reduced to 1 L/min. However, his blood oxygen saturation (SpO2) was less than 90% during exertion, and the respiratory status did not improve in the first month after COVID-19 onset. Combination therapy with additional steroids and respiratory rehabilitation was suggested, and the patient was started on 30 mg/day prednisolone. His respiratory status improved drastically on the seventh day of this treatment, and he was weaned completely off oxygen therapy. We report that additional steroid therapy is an important new treatment strategy that is effective for residual pulmonary lesions in patients with COVID-19 pneumonia.

JHGM 2022：4(5)：243-250

Case report

A case of IgG4-related disease with periaortitis/
periarteritis that progressed to unstable angina
pectoris during multidisciplinary treatment

Toru Suzuki 1)2)※　　 Kazuyoshi Kaneko 3)　　 Wataru Katawaki3)
Kenji Takahashi 1)　　Masato Hoshikawa 4) 　　Ohtake Hiroya 5)

1) Department of Diabetes and Endocrinology, Yamagata City Hospital SAISEIKAN
2) Suzuki Yu Clinic
3) Department of Cardiology, Yamagata City Hospital SAISEIKAN
4) Department of Nephrology, Yamagata City Hospital SAISEIKAN
5) Department of Pathological Diagnosis, Yamagata City Hospital SAISEIKAN

Key Words：IgG4-related disease, periaortitis, periarteritis

　　IgG4-related disease (IgG4-RD) is an autoimmune disorder in which lymphocytes and IgG4- positive plasma cells infiltrate organs and tissues throughout the body that may occur asynchronously, presenting various clinical symptoms. Steroid therapy is known to be effective. Vascular lesions in IgG4-RD include periaortitis/arteritis and aneurysms. We encountered a case of IgG4-RD-related autoimmune pancreatitis (AIP) and interstitial nephritis complicated by periaortitis in the abdominal aorta and periarteritis in the coronary artery. Steroid therapy improved the AIP and interstitial nephritis, and IgG4 levels showed gradual improvement to normal. But, abdominal periaortitis was only slightly improved on periodic ultrasound examinations (US). Furthermore, when it came to the coronary arteries, the patient eventually developed unstable angina despite multidisciplinary treatment. Therefore, steroid therapy may be limited in the treatment of IgG4-RD-related periaortitis/periarteritis, and it is important that extensive, careful follow-up be done with periodic evaluation of periaortitis/periarteritis, even if amelioration is seen in other organs.

JHGM 2022：4(5)：251-252

Brief report

Low excess mortality rate during
the COVID-19 pandemic waves in Japan

Hirotake Mori 1) 　　Akira Komori 1)2)　　Toshio Naito 1)※

1) Department of General Medicine, Juntendo University Faculty of Medicine
2) Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital

Key Words：COVID-19, excess mortality rate, Japan, Asia

JHGM 2022：4(5)：253-256

Brief report

Pancreatitis secondary to ceftriaxone-associated
pseudolithiasis

Shota Nakayama1)※　　Takashi Sugioka 2)　　 Akihiko Ogushi 3)

1) Department of Support of Rural Medicine, Yamaguchi Prefectural Grand Medical Center
2) Department of General Medicine, Saga Municipal Fuji Yamato Onsen Hospital
3) Sakai Clinic

Key Words：ceftriaxone, pseudolithiasis, pancreatitis

JHGM 2022：4(5)：257-261

Brief report

Immunogenicity and Safety of a Two-Dose Regimen
of the BNT162b2 Vaccine in Dialysis Patients

Kenji Ina 1)※　　Yoshiteru Tanaka 2)　　Asuka Ito 3)　　Yukie Kato 4)
Munetaka Fujiwara 4)　　Kengo Nanya 4)　　Satoshi Kayukawa 4)　　Shinji Hasegawa 4)
Megumi Kabeya 4)　　Yuka Okada 2)　　Toshimitsu Koga 5)　　Yoshihiro Ota 5)

1) Department of Geriatric Medicine, Shinseikai Daiichi Hospital
2) Department of Pharmacy, Shinseikai Daiichi Hospital
3) Department of Laboratory Medicine, Shinseikai Daiichi Hospital
4) Nagoya Memorial Hospital
5) Department of Internal Medicine, Shinseikai Daiichi Hospital

Key Words：SARS-CoV-2, hemodialysis, BNT162b2 vaccine

JHGM 2022：4(5)：262-263

Brief report

A case of rectus sheath hematoma
of a left-handed high school volleyball club member
during spike practice

Shimon Takada 1)※　　Kiyoshi Takemoto 2)　　Yasuharu Tokuda 3)

1) Division of General Internal Medicine, Hikosaka Hospital
2) Division of Critical Care Medicine, Nara Prefecture General Medical Center
3) Muribushi Okinawa Center for Teaching Hospitals and Tokyo Foundation for Policy Research

Key Words：rectus sheath hematoma, RSH, Carnett’s sign

JHGM 2022：4(5)：264-265

LETTERS TO THE EDITOR

Common foundations of hospital general medicine
and family medicine in Japan：
harmonizing and merging

Masaki Tago 1)※　　Risa Hirata 1)　　 Kiyoshi Shikino 2)　　 Takashi Watari 3)
Yosuke Sasaki 4)　　Hiromizu Takahashi 5)　　Takuya Nakamura 6)　　Miho Kiyota 7)
Taku Yabuki 8)　　Kenya Ie 9)　　Taro Shimizu 10)

1) Department of General Medicine, Saga University Hospital
2) Department of General Medicine, Chiba University Hospital
3) General Medicine Center, Shimane 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) Shiga Center for Family Medicine, Yuge Medical clinic
7) Centre for Family Medicine Development / Asao clinic
8) Department of Internal Medicine, National Hospital Organization Tochigi Medical Center
9) Department of General Internal Medicine, St. Marianna University School of Medicine
10) Department of Diagnostic and Generalist Medicine, Dokkyo Medical University