The Persistent Approach to Diagnose Infectious Hepatic Cysts in a Patient With Recurrent Fever: A Case Report

Diagnosing Infectious Hepatic Cysts in an Older Patient With Multiple Skin Masses: A Case Report

Among the most severe complications of hepatic cystic diseases is infectious hepatic cysts (IHCs). IHCs may appear mainly among immunocompromised hosts. However, older patients have a variety of immunological conditions. The detection of the factors suppressing immunity is essential for patients with IHCs. Herein, we present the case of an 86-year-old woman admitted to the emergency department with a fever. We suspected IHCs based on changes in abdominal ultrasound findings. After multiple follow-ups to determine the cause of the fever that was unresponsive to treatment, we discovered debris in the cyst that had not been present at the time of the initial presentation. The patient was subsequently treated with percutaneous transhepatic drainage and tazobactam/piperacillin. The investigation of the causes of immunosuppression clarified the multiple skin masses. The biopsy of the mass clarified diffuse large B cell lymphoma without lymph node swellings. Consecutive ultrasound can detect findings missed during the initial presentation and changes that occur within a short period. The detection of the causes of immunosuppression is essential even among older patients with IHCs for better care among older patients.

Subacute Bacterial Cellulitis With a Subacute Clinical Course With Difficulty in Distinguishing From Sjögren's Syndrome: A Case Report

Differentiating between infectious and autoimmune diseases regarding inflammatory changes in the soft tissues around the joints that develop in a subacute course is often difficult. Herein, we present the case of a 65-year-old woman who presented with a chief complaint of the tarsal metatarsal joint (Lisfranc joint) pain in the second, third, and fourth toes of her right foot that had persisted for several days. The patient was initially treated with non-steroidal anti-inflammatory drugs, colchicine, and prednisolone 10 mg for pseudogout and Sjogren's syndrome arthritis; however, there was little improvement. A few weeks later, the skin of the fingers and toes peeled, and the patient was diagnosed with subacute burn-like skin syndrome and treated with antibiotics. After the treatment, the inflammatory findings steadily improved. Arthritis associated with an infection is considered to have an acute course. However, subacute-to-chronic arthritis associated with Staphylococcus aureus infection may also be possible, as in this case. Therefore, the possibility of infection should be evaluated in patients with subacute-to-chronic refractory arthritis.

Meningitis With Staphylococcus aureus Bacteremia in an Older Patient With Nonspecific Symptoms: A Case Report

Staphylococcus aureus bacteremia has been associated with various symptoms that can spread to diverse organs, including the meninges, which can be challenging to diagnose given the nonspecific symptoms. Early examination, including assessment of the cerebrospinal fluid, is necessary when a patient is diagnosed with S. aureus bacteremia accompanied by unconsciousness. A 73-year-old male presented to our hospital complaining of general malaise without fever. The patient developed impaired consciousness immediately after hospitalization. Following the investigations, the patient was diagnosed with S. aureus bacteremia and meningitis. If a patient presents with symptoms of unknown cause and acute progressive disease, meningitis and bacteremia should always be considered. Blood cultures should be performed promptly, affording an early diagnosis, bacteremia treatment, and the establishment of meningitis.

Gallstone Hepatitis Caused by Transient Common Bile Duct Obstruction in a Middle-Aged Woman

The interpretation of hepatocholangial laboratory test results is challenging. Possible liver biochemical tests include the evaluation of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, 5'-nucleotidase, lactate dehydrogenase, bilirubin, and albumin levels, as well as prothrombin time and international normalized ratio. When liver enzyme levels are elevated, R-values are generally used for diagnosis. A 62-year-old woman presented to our hospital with the chief complaint of abdominal pain and was consequently diagnosed with gallstone hepatitis based on her blood test results. Generally, gallstone hepatitis manifests as elevated liver enzyme levels showing a hepatocellular pattern, while common bile duct obstructions show a cholestatic pattern. Since gallstone hepatitis is indistinguishable from viral and ischemic hepatitis in the early stages of onset, it is vital to monitor changes in symptoms, biochemical tests, and imaging results over time to diagnose this disease.

Refractory Immunoglobulin A (IgA) Vasculitis in an Elderly Patient: A Case Report

Immunoglobulin A (IgA) vasculitis is small-vessel arteritis triggered by autoimmunity and allergies. IgA vasculitis among elderly patients is rare, and there is a lack of evidence regarding the choice of medicine and treatment duration. The main treatment for IgA vasculitis is steroids which can be cured with a small dose of prednisolone without immunosuppressants. Here, we report a case of a 90-year-old patient with the chief complaint of appetite loss and purpura on the legs who was diagnosed with IgA vasculitis based on biopsy results. The patient was initially treated with prednisolone effectively but exacerbated with steroid tapering, eventually requiring the use of an immunosuppressant. This case highlights the importance of monitoring the symptoms of IgA vasculitis while tapering steroids and clarifying the timing of immunosuppressant initiation.

Seronegative Ocular Myasthenia Gravis in an Older Woman With Transient Dizziness and Diplopia

Myasthenia gravis (MG) is a neuromuscular junction disease caused by an autoimmune response against cholinergic receptors. The challenge in diagnosing MG in older patients is the variety of symptoms and clinical manifestations. Clinical reasoning, precise history, and physical examination leading to a logical diagnosis should be performed to diagnose seronegative MG. We report a case of seronegative MG with the chief complaint of dizziness in a 91-year-old female. Despite the complicated clinical course, continuous clinical reasoning and testing can lead to appropriate diagnosis and treatment. As the dizziness symptoms in this older patient could not be explained by chronic or peripheral symptoms alone, ocular MG was considered as a possible diagnosis based on her history and physical examination findings. Appropriate diagnosis of seronegative ocular MG reactivated older patients with a good quality of life. In community medicine, where the behavior of elderly patients varies, it is important to improve the accuracy of diagnosis and treatment through appropriate history and physical examination, which will lead to longer home life in older patients.

Serotonin Syndrome Triggered by Overuse of Caffeine and Complicated With Neuroleptic Malignant Syndrome: A Case Report

Serotonin syndrome is a rare complication occurring in patients with psychiatric disorders that are treated with selective serotonin reuptake inhibitors (SSRIs). There are various triggers for serotonin syndrome, including non-SSRI antidepressants. In rare cases, serotonin syndrome may be triggered by nonmedicinal foods, such as coffee. The patient described in this case report was a 65-year-old woman with a past medical history of major depression and a diagnosis of Parkinson’s disease who presented to our medical center with chief complaints of nausea, vomiting, and drowsiness. She had previously been prescribed paroxetine hydrochloride hydrate for depression, and she was prescribed levodopa and carbidopa for Parkinson’s disease. She also drank 20 cups of coffee in a short period of time two days prior to admission due to excessive sleepiness. She was diagnosed with serotonin syndrome based on her clinical symptomology, which included diaphoresis, mydriasis, fine tremor, myoclonus, hypertension, and tachycardia. She was treated with diazepam and cyproheptadine hydrochloride hydrate. Later, she experienced muscle pain with increased creatinine kinase levels after she failed to take levodopa and carbidopa. These findings were suggestive of neuroleptic malignant syndrome. The patient was treated with supportive care. Excessive coffee intake triggers serotonin syndrome by promoting 5-hydroxytryptamine (serotonin) secretion. Patients with psychiatric diseases that necessitate treatment with SSRIs should be educated regarding caffeine consumption. Moreover, patients presenting with agitation and drowsiness should be evaluated for serotonin syndrome within the differential diagnosis. Patients with depression and Parkinson’s syndrome should be evaluated for associated comorbidities, particularly serotonin syndrome and neuroleptic malignant syndrome.

Herpes Simplex Virus Pneumonia Mimicking Legionella Pneumonia in an Elderly Patient With Heart and Liver Failure

The diagnosis of viral pneumonia is often difficult because of its varied presentations. Regarding the serological diagnosis of viral infections, it is difficult to perform a viral DNA test in general medical facilities, especially in rural settings. Among viral pneumonia cases, herpes simplex virus (HSV) pneumonia can occur in immunocompromised hosts. However, when the clinical course of HSV pneumonia is acute, and the features of pneumonia are not distinct, the diagnosis can be challenging. We report the case of a 69-year-old man who visited the hospital with complaints of dyspnea and cough for two days. Although the patient had no fever and the urine was negative for Legionella antigen, we suspected Legionella pneumonia based on the clinical course, Gram stain of sputum, and CT findings. After undergoing treatment with antibiotics, his condition worsened, with dyspnea and an increase in the demand for oxygen at 5 L. The patient also had complications related to the heart and liver. The sputum culture was negative, and the HSV serum test revealed that HSV IgM level was elevated to 1.16 (reference value: ≤0.80) and IgG level at admission and at follow-up 21 days later was elevated to 28.1 and 60.0 respectively (reference value: ≤2.0); accordingly, the patient was diagnosed with HSV pneumonia. In cases of pneumonia with atypical courses, the coexistence of multiple diseases, and immunosuppression, HSV pneumonia should be included in the differential diagnosis. In rural settings, viral pneumonia should be investigated using antibodies against viruses due to the limited availability of other medical resources. When a patient is judged to be immunosuppressed in the treatment of pneumonia of unknown cause, it is important to consider the possibility of HSV infection and take prompt action. Furthermore, it is essential to consider the possibility of multi-organ failure secondary to HSV infection, which requires systemic management.

A Rare Case of Herpes Esophagitis in an Immunocompetent Elderly Patient

Herpes esophagitis is common among immunocompromised hosts but is relatively rare among immunocompetent patients. Its symptoms are vague because many different symptoms can be induced by esophageal lesions. Here, we report a case of herpes esophagitis in an elderly immunocompetent patient. A 91-year-old woman visited our community hospital with a complaint of appetite loss for several days. Although she did not have any symptoms of epigastric, oral, or retrosternal pain, multiple ulcers were detected in her esophagus. Biopsy of the edge of the ulcer showed giant cells, indicating a herpes virus infection. She was diagnosed with herpes esophagitis and treated with acyclovir for one week. Her symptoms completely resolved after treatment, and she was discharged. Herpes esophagitis can manifest as vague symptoms in immunocompetent elderly patients. Therefore, herpes esophagitis must be considered in the differential diagnosis of elderly patients presenting with vague symptoms.