MAY 2024 Volume 6-3

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

Editorial

Prevention and Management of Prescription Cascade・・・・・・・・ Yasuharu Tokuda

JHGM 2024：6(3)：54-61

Case Report

A case of clozapine-induced myocarditis leading
to ventricular fibrillation and hypoxic encephalopathy
despite slow titration

Yuji Otsuka 1)※　　Yuki Kikuchi 2)3)

1) Department of Psychiatry, Asahi General Hospital
2) Department of Psychiatry, Graduate School of Medicine, Tohoku University
3) Department of Psychiatry, Kodama Hospital

Key Words：clozapine, myocarditis, slow titration

We report a case of clozapine-induced myocarditis in a Japanese man that occurred despite a slow increase in the dose of clozapine. The patient developed myocarditis on day 24 of treatment with clozapine, and his clinical course was complicated by ventricular fibrillation (VF) and permanent brain damage. Clozapine is the only effective antipsychotic against treatmentrefractory schizophrenia (TRS). Nevertheless, the administration of this agent is associated with a risk of myocarditis. This risk is higher for East Asians versus other populations; therefore, it is important to titrate clozapine slowly in these populations of patients. The Japanese package insert for clozapine recommends a faster rate of titration than that stated in international guidelines, which may increase the risk of myocarditis. This case suggests that myocarditis can occur even if the dose of clozapine is increased at a markedly slower rate than that recommended in the package insert. Thus, we recommend revision of the Japanese package insert for clozapine to align with the international guidelines. This case also highlights the importance of close monitoring for adverse events in patients receiving treatment with clozapine, even under slow titration.

JHGM 2024：6(3)：62-67

Case Report

A case of anti-MDA5-positive clinically amyopathic
dermatomyositis presenting acrodermal
erythromelalgia complicated with Basedow’s disease

Akihito Kimura 1)　　Norio Horiguchi 1)※ 　　Kuniko Yoshida 1)　　Mayu Ishizaki 2)
Yukie Endo 2)　　Sei-ichiro Motegi 2)　　Hiroko Sato 1) 　　Sakura Kanazashi 1)
Yukako Hirayama 1)　　Yoshio Ohyama 3)　　Keiko Kawai-Kowase 1)

1) Department of General Medicine, Gunma University Graduate School of Medicine
2) Department of Dermatology, Gunma University Graduate School of Medicine
3) Gunma University Graduate School of Health Sciences

Key Words：amyopathic dermatitis, anti-MDA5 antibody, acrodermal erythroderma, Beasedw’s disease,rapidly progressive intestinal lung disease

　　A 48-year-old Japanese woman was referred to our hospital due to swelling and pain in both fingers. Tachycardia with a pulse rate of 120/min and redness, swelling, and spontaneous pain in the terminal phalanges of both fingers were observed. Based on physical examinations and blood tests, the patient was diagnosed as having acrodermal erythromelalgia complicated with Basedow’ s disease. Therefore, administration of thiamazole was started. Fever persisted for several days, and dry cough appeared. Fine crackles in the bilateral lower lung fields were heard on auscultation, and bilateral interstitial pneumonia was observed on chest computed tomography. Blood tests were positive for anti-MDA5 antibody, and the patient was diagnosed as having clinically amyopathic dermatomyositis and rapidly progressive interstitial lung disease. We report this case because, in addition to acrodermal erythromelalgia, amyopathic dermatomyositis complicated with Basedow’s disease is extremely rare

JHGM 2024：6(3)：68-75

Case Report

A Case of Miliary Tuberculosis Confirmed via
Repeated Chest Computed Tomography
and Interferon-γ Release Assay

Hikaru Uechi 1)　　Kenichiro Yaita 2)※ 　　Mamiko Koga 3)　　Daichi Mine 1)
Yoshio Sawada 4)　　Shiori Kakudo 4)　　Yasuharu Arima 1)
Mariko Kawakami 5)　　 Yoshifumi Matsushita 6)　　Kazumi Yamamoto 1)

1) Department of General Internal Medicine, Chidoribashi General Hospital, Fukuoka, Japan
2) Division of Infectious Diseases, Chidoribashi General Hospital, Fukuoka, Japan
3) Department of Clinical Laboratory, Chidoribashi General Hospital, Fukuoka, Japan
4) Department of Respirology, Chidoribashi General Hospital, Fukuoka, Japan
5) Department of Radiology, Chidoribashi General Hospital, Fukuoka, Japan
6) Department of Pathology, Chidoribashi General Hospital, Fukuoka, Japan

Key Words：Miliary Tuberculosis; Foreign Patients; Interferon-γ release assay

A febrile 27-year-old male patient with lymphadenopathies was admitted to our hospital. Tuberculosis was considered as one of the differential diagnoses. Lung lesions were not apparent by the first chest computed tomography, and the result of T-SPOT®.TB was negative. A secondary chest computed tomography, however, showed a miliary pattern shadow in images of the bilateral lungs, and a QuantiFERON®-TB Gold Plus test was positive. In addition, an acid-fast bacillus was detected in the patient’s gastric lavage, and a collection of epithelioid cells was revealed in a trans-bronchial lung biopsied specimen. We finally confirmed the patient’ s diagnosis as miliary tuberculosis. Clinicians should be aware that tuberculosis cases often require difficult diagnostic processes with vigorous support from many specialists.

JHGM 2024：6(3)：76-78

Short Case Report

A case of emphysematous urinary tract infection
with a rapid course

Nobuyasu Kanai ※　　 Ryota Sekine　　Yujin Nozaki
Chisato Kainaga　　 Yuuki Taneda　　Toshihiro Yamamoto

Tokyo Kita Medical Center

Key Words：emphysematous urinary tract infection, septic shock, urological emergency, untreated diabetes,
conservative treatment

JHGM 2024：6(3)：79-80

Key Image

Peripheral blood smears are useful for clinical decision-making in the early stages of febrile illness with lymphadenitis

Masahiko Saito 1)※　　Kazunori Murai 2)　　Ryuji Imagawa 1)
Kazutaka Sakamoto 1)　　Akiko Sumiyoshi 1)

1) Department of General Medicine, Iwate Prefectural Central Hospital, Morioka, Iwate
2) Department of Hematology, Iwate Prefectural Central Hospital, Morioka, Iwate

Key Words：Epstein-Barr virus, VCA-IgM antibody, atypical lymphocyte

JHGM 2024：6(3)：81-82

Key Image

Thymoma extending into the superior vena cava
through a small blood vessel

Yoshihiko Sato 1)※　　Koichi Nishino 1)2)　　Kengo Koike 1)　　Hitomi Shiozaki 1)
Koshin Kastu 1)　　Ryoko Murashima 1)　　Shun Nakazawa 1)
Yoshihiro Masui 1)　　Takehito Shukuya 1)　　 Mitsuaki Sekiya1)2)
Takuo Hayashi 3)　　Kenji Suzuki 4)　　Kazuhisa Takahashi 1)

1) Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
2) Department of Respiratory Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
3) Department of Human Pathology, Juntendo University School of Medicine, Tokyo, Japan
4) Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan

Key Words：thymoma, anterior mediastinal tumor, superior vena cava

MAY 2024 Volume 6-3

JOURNAL OF HOSPITAL GENERAL MEDICINE