MARCH 2024 Volume 6-2

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

Editorial

Resilience in Hospitals in Japan during
the COVID-19 Pandemic ・・・・・・・・・・・・・・・・・・・ Yasuharu Tokuda

Original Article

Infection is the Most Frequent Disease Category
of Autopsy-detected Diagnostic Errors in Japan ・・・・・・・・・Kohta Katayama 　 17

Case Reports

Review

Clinical Reasoning Expertise in View of Diagnostic Excellence・・・・Taro Shimizu　　47

JHGM 2024：6(2)：17-24

Original Article

Infection is the Most Frequent Disease Category
of Autopsy-detected Diagnostic Errors in Japan

Kohta Katayama 1)2)※　　Tomoharu Suzuki 3)　　Kenji Numata 4)　　Maho Adachi-Katayama 5)
Takashi Watari 6)　　Yasuharu Tokuda 7)8)　　Payal K. Patel 9)　　Yoshiyuki Ohira 1)

1) Department of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.
2) Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan.
3) Department of Hospital Medicine, Urasoe General Hospital, Okinawa, Japan.
4) Department of Emergency Medicine, St. Marianna University School of Medicine Hospital, Kanagawa, Japan.
5) Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan.
6) General Medicine Center, Shimane University Hospital, Izumo, Shimane, Japan.
7) Muribushi Okinawa Center for Teaching Hospitals, Okinawa, Japan.
8) Tokyo Foundation for Policy Research, Tokyo, Japan.
9) Department of Infectious Diseases, Intermountain Health, Murray, UT, USA

Key Words：Autopsy diagnosis, Diagnostic error, Infectious Diseases

[Background] Autopsy plays an essential role in determining the cause of death of patients. This study aimed to illustrate details of such cases revealed during autopsies in Japan.
[Methods] This descriptive study used the case report abstract database of the Japanese Society of Internal Medicine chapter meetings. Autopsy cases from 2016 to 2020 were included. We defined diagnostic errors as discrepancies in the primary cause of death between autopsy and clinical diagnosis. This was categorized according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10).
[Results] Among 288 cases, diagnostic errors occurred in 113 cases (39. 2%). The most frequent category of autopsy-detected diagnostic error cases was infection (39, 34.5%), followed by neoplasm (35, 31.0%). Among 39 diagnostic error cases of infections, the most frequent causes were bacteremia (7, 17.9%), followed by tuberculosis (6, 15.4%) and abscess (6, 15.4%).
[Conclusions] The most frequent category of autopsy-detected diagnostic error was infection in Japan. Understanding how diagnostic errors for infectious diseases can be reduced is be a worthy topic for future work in Japan.

JHGM 2024：6(2)：25-29

Case Report

Primary pulmonary Cryptococcosis presenting
as a mass and organizing pneumonia

Saori Ikeda ※　　Makiko Yomota　　Yukio Hosomi

Department of Respirology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Japan

Key Words：mass, organizing pneumonia, pulmonary cryptococcosis

　　We herein report a case of primary pulmonary cryptococcosis manifesting as a mass and cooccurring with organizing pneumonia. We also discuss the radiological and pathological findings of the case along with a review of some past studies.
　　A 35-year-old male patient with no underlying disease, presented with the chief complaint of pain on deep inspiration. Computed tomography revealed a 52-mm mass near the pleura. A transbronchial lung biopsy found cryptococci and alveolar lymphocytic infiltration, which is generally seen in organizing pneumonia. A serum analysis returned positive for Cryptococcus neoformans antigen.

JHGM 2024：6(2)：30-34

Case Report

A case of disseminated carcinomatosis
of the bone marrow due to gastric cancer,
confirmed by autopsy

Kazuo Eguchi 1)※　　Susumu Maruta 2) 　　Yukiko Nakajima 3)　　Jiro Kamiyama 3)
Hiroki Sasaki 4)　　Chih-Ping Li 5)　　Akiko Adachi 5) 　　Youhei Koushima 2)

1) Department of General Internal Medicine, Saitama Red Cross Hospital, Saitama, Japan
2) Hepatobiliary Pancreatic Department, Saitama Red Cross Hospital, Saitama, Japan
3) Department of Emergency Medicine, Saitama Red Cross Hospital, Saitama, Japan
4) Department of Radiology, Saitama Red Cross Hospital, Saitama, Japan
5) Department of Pathology, Saitama Red Cross Hospital, Saitama, Japan

Key Words：fever of unknown origin, disseminated carcinomatosis of the bone marrow, gastric cancer

　　A 40-year-old man was transferred with high fever and back pain. MRI showed diffuse low intensity in the bone marrow. DIC, hepatic failure, and respiratory failure rapidly occurred, and he died on the 11th hospital day. Final diagnosis was disseminated carcinomatosis of the bone marrow (DCBM) due to advanced gastric cancer. DCBM should be considered when FUO with back pain is seen.

JHGM 2024：6(2)：35-38

Case Report

Unnecessary Tickborne Disease Prophylaxis
and Adverse Events

Hiroshi Ito ※　　Daiki Kobayashi

Division of General Internal Medicine, Department of Internal Medicine, Tokyo Medical University Ibaraki Medical Center

Key Words：tickborne disease, post-exposure prophylaxis, minocycline

Post-exposure prophylaxis, commonly employed in infectious diseases, involves using antibiotics to prevent tickborne diseases. However, weighing the benefits against the drawbacks, including drug adverse effects, is crucial. We present a case of fever and nausea resulting from prophylactic minocycline in a 44-year-old Japanese woman bitten by an Ixodes spp. tick. With no signs of a rickettsial disease or Lyme Disease and suspecting minocycline side effects, minocycline was halted, leading to symptom resolution. Our case emphasizes the risks of unnecessary prophylactic medication, particularly in regions like Ibaraki Prefecture where the prevalence of Lyme disease and Japanese spotted fever is low. Despite guidelines recommending prophylactic antibiotics within 72 hours of high-risk tick bites, the rarity of these infections in the region questions the proactive use of such measures. Considering local epidemiology is essential for informed decision-making, as seen in our case where the risk did not warrant prophylactic antibiotics. This report stresses the need for shared decision-making and incorporating regional infection risks to prevent adverse effects associated with unnecessary prophylactic antibiotics.

JHGM 2024：6(2)：39-42

Case Report

A case of dermatomyositis positive
for anti-melanoma differentiation-associated
gene 5 (MDA5) antibodies presenting with a facial
erysipelas-like rash: a challenging diagnosis

Masanori Tei ※　　Akifumi Miyake　　Muneyoshi Aomatsu

Saku Central Hospital

Key Words：Anti-MDA5 dermatomyositis, erysipelas-like rash

　　Prompt diagnosis is crucial for patients with anti-MDA5 antibody-positive dermatomyositis because of its association with rapidly progressive interstitial pneumonia and poor prognosis. Here, we report a case of anti-MDA5 antibody-positive dermatomyositis that had an atypical skin rash as its initial manifestation, thereby resulting in a 3-month diagnostic delay. A right-side erysipelas-like rash persisted despite 3 months of antibiotic treatment in a dermatology clinic. The patient, a male octogenarian, was then referred to our hospital for suspected metastatic cutaneous cancer. Gottron’s sign was detected during the investigation of the primary cancer site, which facilitated the diagnosis of anti-MDA5 antibody-positive dermatomyositis. When an antibiotic-resistant erysipelas-like rash is encountered in clinical practice, it is crucial to consider both neoplastic metastases and autoimmune diseases, such as dermatomyositis, as the underlying factors.

JHGM 2024：6(2)：43-46

Case Report

Usefulness of Fecal Calprotectin in Differentiating
Inflammatory Bowel Disease in a Young Patient
with Autism Spectrum Disorder

Shota Shimanaga 1)　　Kohta Oyama 3)※　　Yugo Takaki 2)　　Toshihiko Miyagi 1)

1) Department of Pediatrics, Kumamoto Kenhoku Hospital
2) Department of Pediatrics, Japanese Red Cross Kumamoto Hospital
3) Department of General Internal Medicine, Kumamoto Kenhoku Hospital

Key Words：autism spectrum disorder, Crohn disease, fecal calprotectin

　　Herein, we report the clinical course of a young patient with autism spectrum disorder (ASD) complicated by inflammatory bowel disease (IBD). A 14-year-old Japanese male patient with a medical history of ASD and short stature presented with a 1-month history of abdominal pain and fever. A fecal occult blood test revealed positive results suggestive of IBD. To differentiate IBD from irritable bowel syndrome (IBS), the fecal calprotectin (FC) level was measured and found to be high. Therefore, colonoscopy was performed for further assessment, which led to a diagnosis of Crohn disease (CD). This case suggests that physicians should consider measuring the FC level to enable early diagnosis of CD in children with developmental disabilities, for whom endoscopies can be expected to be difficult.

JHGM 2024：6(2)：47-53

Review

Clinical Reasoning Expertise in View
of Diagnostic Excellence

Taro Shimizu

Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Japan

Key Words：Diagnostic Error, Diagnostic Excellence, Diagnostic Quality, Hospital General Medicine

　　This article discusses the evolution from recognizing diagnostic error (DE) to aiming for diagnostic excellence (DEx) in healthcare. Highlighting the alarming number of deaths from medical errors reported by the National Academy of Medicine in 1999 it underscores the significance of DE as a major healthcare concern. DE is now acknowledged as a crucial aspect of healthcare quality. The concept of evolving from DEx to DE has gained momentum, focusing on integrating key healthcare elements like safety, efficiency, and patient-centeredness. It is a comprehensive approach to diagnosis that involves collaborative and patient-centered methods. In the U.S., discussions of DEx predate global awareness, with ongoing research and initiatives, including the Patient Safety Plan by the Agency for Healthcare Research and Quality (AHRQ). In Japan, strategies to promote DEx are rising, especially in research. A key to DEx is enhancing clinical reasoning with strategies for individual healthcare professionals, including continuous learning and recognizing biases. The article introduces the ECR formula “ECR= e × i-In” to frame DEx at an individual level from the view of clinical reasoning. In conclusion, the article emphasizes DEx as essential for future healthcare, advocating for increased involvement of healthcare professionals in improving diagnostic practices.