大杉 泰弘

Hepatic encephalopathy (HE) is a neurological impairment that typically occurs in patients with liver dysfunction or portosystemic shunting. Diagnosing HE can be challenging since it requires a process of exclusion. Ammonia is considered a major contributor to HE, though ruling out HE solely based on ammonia levels has the potential for misdiagnosis.  Malignancy infiltration is uncommon as an etiology of HE, although there are reported cases of HE patients with pancreatic neuroendocrine tumors (PNETs) diagnosed by the presence of hyperammonemia. We report a case of a disoriented patient with a PNET and diffuse metastases to the liver who presented without hyperammonemia. After excluding possible etiologies of altered mental status, we diagnosed the patient with HE and started on lactulose, which improved his condition. PNET patients can experience HE without hyperammonemia, and a thorough evaluation to rule out other etiologies is necessary for the diagnosis.

OBJECTIVES: Multidrug-resistant (MDR) bacterial infections are highly prevalent among long-term care facility (LTCF) residents, and are thus important targets for antimicrobial stewardship. Diagnoses of urinary tract infections (UTIs), which are associated with antimicrobial use in these facilities, are not always made by physicians. Past epidemiologic studies have included asymptomatic bacteriuria together with UTIs. The National Healthcare Safety Network has initiated a surveillance program to identify the causative organisms of UTIs in LTCF residents. In Japan, medical care for these residents is provided through in-person physician visits; however, limited related data are available. Therefore, we investigated the organisms causing UTIs and their drug susceptibility among LTCF residents in central Japan, and examined the prevalence of multidrug resistance, its risk factors, and correlations with clinical outcomes. METHODS: We retrospectively evaluated clinical and urine culture data of LTCF residents with physician-diagnosed UTIs between April 1, 2019, and April 30, 2022. RESULTS: The detection rate of multidrug-resistant organisms was high, with Escherichia coli being the most prevalent. Ceftriaxone was frequently used for initial therapy. The initial antimicrobial agents were significantly less active against MDR pathogens than non-MDR pathogens. Most residents continued to receive the initial agents regardless of culture results. Nonetheless, differences in the therapy duration, relapse and hospitalization rates, and death rate within 28 days between the multidrug-resistant and non-multidrug-resistant groups were not significant. CONCLUSIONS: Antimicrobial stewardship is essential for reducing antimicrobial use and selective pressure in LTCFs in Japan; however, more specific data are needed for its effective implementation.

Pneumocystis jirovecii is a common opportunistic fungal pathogen that commonly affects immunocompromised individuals and can cause P. jirovecii pneumonia. Extrapulmonary P. jirovecii infections are extremely rare. Herein, we present a case of an HIV-positive, antiretroviral therapy-naïve patient who had extrapulmonary pneumocystosis (EPC). He presented with complaints of decreased appetite, abdominal fullness, and weight loss. Computed tomography (CT) revealed multiple low-attenuation masses in the spleen, liver, and both adrenal glands but no pulmonary involvement. A core-needle biopsy of a splenic lesion confirmed the diagnosis of EPC. The patient was initiated on intravenous trimethoprim-sulfamethoxazole (TMP-SMX) and CT-guided percutaneous catheter drainage of the splenic lesion was performed. Intravenous TMP-SMX therapy was completed in 3 weeks and intravenous pentamidine (250 mg daily) therapy was commenced. Pentamidine was completed after 3 weeks, and antiretroviral treatment (ART) was initiated with dolutegravir 50 mg and Descovy HT (emtricitabine [200 mg] and tenofovir alafenamide fumarate [25 mg]). After starting ART, the patient's clinical condition improved, and the abscesses gradually reduced. TMP-SMX is commonly used to treat EPC; however, there is no standard method of treatment. ART may become the key to EPC treatment in individuals with HIV infection.

AIM: This study aimed to report clinical courses of patients who had mild coronavirus disease 2019 (COVID-19), defined as SpO2 of 96 or higher, and treated with/without casirivimab/imdevimab in Japan, where mortality and number of severe patients were very limited compared to other resource-rich countries. METHODS: We conducted a retrospective cohort study in Toyota Regional Medical Center, Toyota, Japan, from August 31, 2021, to September 27, 2021. We included all patients with COVID-19 who were diagnosed at the hospital's family medicine department. Our primary outcome was admission to the hospital due to COVID-19 and secondary outcome was mortality due to COVID-19. We compared those who received casirivimab/imdevimab and those who did not. RESULTS: A total of 104 patients were included, of whom 30 received casirivimab/imdevimab and 74 did not receive casirivimab/imdevimab. The mean age of the patients was 47.8 ± 15.6 (standard deviation {SD}) years, 57 (54.8%) patients were male. During a median follow-up period of 12 days (interquartile range: 10-16 days), 19 (18.3%) patients were admitted to the hospital and none died. Patients who received casirivimab/imdevimab had similar rate to admission (p = 0.87). The hazard ratio (HR) of admission tended to be lower for those who received casirivimab/imdevimab (HR: 0.76, 95% confidence interval {CI}: 0.23-2.49, p-value = 0.65), but not statistically significant compared to those who did not, after adjusting for age, gender, risk factors, including obesity. CONCLUSIONS:  Our study demonstrated that patients with COVID-19 had similar disease progression rates regardless of casirivimab/imdevimab administration.