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Background: Nontraumatic spontaneous renal hemorrhage is caused by tumor such as renal cell carcinoma or angiomyolipoma in most cases. Vasculitis including periarteritis nodosa or antineutrophil cytoplasmic antibody (ANCA)-mediated vasculitis may also be the next underlying background. Herein, we report the first case of nontraumatic spontaneous bilateral renal hemorrhage combined with chronic infection of Chlamydia pneumoniae.Case presentation: The patient serially suffered from left and right back pain within 78 days due to bilateral spontaneous renal hemorrhages. Transcatheter arterial embolization was successfully performed twice to treat serial spontaneous bilateral renal hemorrhages. The serological examination apparently revealed his chronic infection of Chlamydia pneumoniae and a slight elevation of anti-deoxy nucleotide antibodies. Furthermore, computed tomography (CT) angiogram and 67galium citrate scintigram also suggested underlining severe arteriosclerosis without severe inflammation in bilateral kidneys. Chronic infection of Chlamydia pneumoniae and underlying autoimmune vasculitis may pull a trigger of bilateral spontaneous renal hemorrhages although the real mechanisms remain unknown. Conclusions: In conclusion, we reported an extremely rare case of nontraumatic spontaneous bilateral renal hemorrhage of unknown etiology. Severe atherosclerosis caused by chronic infection due to Chlamydia pneumoniae may predispose to the vascular vulnerability of the bilateral renal arteries in close association with hypertension, oral intake of antiplatelets, and underlying autoimmune vasculitis.

BackgroundWith the implementation of mass vaccination campaigns against COVID-19, the safety of vaccine needs to be evaluated.ObjectiveWe aimed to assess the incidence and risk factors for immediate hypersensitivity reactions (IHSR) and immunisation stress-related responses (ISRR) with the Moderna COVID-19 vaccine.MethodsThis nested case-control study included recipients who received the Moderna vaccine at a mass vaccination centre, Japan. Recipients with IHSR and ISRR were designated as cases 1 and 2, respectively. Controls 1 and 2 were selected from recipients without IHSR or ISRR and matched (1:4) with cases 1 and cases 2, respectively. Conditional logistic regression analysis was used to identify risk factors associated with IHSR and ISRR.ResultsOf the 614,151 vaccine recipients who received 1,201,688 vaccine doses, 306 recipients (cases 1) and 2,478 recipients (cases 2) showed 318 events of IHSR and 2,558 events of ISRR, respectively. The incidence rates per million doses were estimated as – IHSR: 266 cases, ISRR: 2,129 cases, anaphylaxis: 2 cases, and vasovagal syncope: 72 cases. Risk factors associated with IHSR included female, asthma, atopic dermatitis, thyroid diseases, and history of allergy; for ISRR, they were younger age, female, asthma, thyroid diseases, mental disorders, and a history of allergy and vasovagal reflex.ConclusionIn the mass vaccination settings, the Moderna vaccine can be used safely owing to the low incidence rates of IHSR and anaphylaxis. However, providers should beware of the occurrence of ISRR. Risk factor identification may contribute to the stratification of high-risk recipients for IHSR and ISRR.

Case We describe a rare case of antibiotic-associated fulminant pseudomembranous enterocolitis caused by Klebsiella oxytoca. A 79-year-old man with a history of antibiotic therapy was admitted to our emergency department, complaining of consciousness disturbance. Initially, we suspected septic shock and diabetic ketoacidosis caused by intestinal infection. Although we administered sufficient extracellular fluid, his blood pressure was not elevated and his abdomen gradually swelled. Outcome The patient died of shock and abdominal compartment syndrome. Autopsy revealed widespread jejunal necrosis in conjunction with colitis, suggesting fulminant pseudomembranous enterocolitis caused by K. oxytoca infection. Conclusion As the clinical features of pseudomembranous enterocolitis caused by K. oxytoca resemble the features of colitis caused by Clostridium difficile, conservative therapy is applied first. However, fulminant pseudomembranous enterocolitis is a lethal disease, necessitating early operation for resection of the necrotic lesion. This report highlights the need for better surgical criteria at an early stage.

The incidence of traumatic brain injury (TBI) in elderly patients is increasing. We retrospectively investigated the poor prognostic factors at discharge in elderly patients aged 75 years or older admitted to hospital with mild TBI. We continuously enrolled 83 patients aged 75 years or older with mild TBI, in a private general Japanese hospital. The Glasgow Coma Scale scores on admission were within the range of 13-15. Patients with good recovery or moderate disability were included in the "good outcome" group, and those with severe disability, in a persistent vegetative state, or who died were included in the "poor outcome" group. We performed statistical analyses using 8 parameters. We conducted a univariate analysis on each item. Next, we conducted a logistic regression analysis on variables where the p 0.20 in the univariate analysis. Elderly patients had a poor prognosis when they had dementia (odds ratio [OR]: 20.357, 95% confidence interval [CI]: 2.075-199.683, p = 0.010), cancer (OR: 14.005, 95% CI: 1.262-154.444, p = 0.032), or a history of antithrombotic therapy before admission (OR: 6.673, 95% CI: 1.072-41.526, p = 0.042). When elderly patients aged 75 years or older with mild TBI have the 3 poor prognostic factors of dementia, cancer, or a history of antithrombotic therapy, their outcomes might be worse compared to other elderly patients. Elderly patients who have these factors should be carefully managed.

Background When symptoms of cerebral infarction are recognized in a patient, he or she should be transported to a hospital and should be started on the appropriate treatments. The effectiveness of delayed treatment of cerebral infarction with respect to the initial diagnosis or perception of the disease is still unclear. Methods We retrospectively investigated whether the functional outcomes would improve if patients with cerebral infarction were transported to the hospital with minimum delay. One-hundred twenty-two patients who were transported to Mishuku Hospital from January 2012 to August 2015 were included. We conducted multiple regression analyses. The criterion variable included the BI at discharge, and the explanatory variables were age, sex, days of hospital stay, the Barthel Index (BI) on admission, time from symptom onset to hospital arrival, time from emergency medical service perception to hospital arrival, recombinant tissue plasminogen activator (rt-PA) treatment, and the occluded artery type. Results In all 122 cases, the BI at the time of discharge was not related to onset time ( P = .453) but was significantly related to perception time ( P = .026). BI scores at discharge were high for young patients ( P = .002) and for patients with short hospital stays ( P .001). In the rt-PA group (52 cases), BI scores at discharge were also high when the perception time was short ( P = .036). Conclusions A short interval between perception and hospital arrival improves the functional outcomes for patients with cerebral infarction. Thus, patients with cerebral infarctions must be treated with minimal delay after diagnosis of the condition.

Blast-induced mild traumatic brain injury (mild bTBI) has been a frequent battlefield injury in soldiers during the conflicts in Iraq and Afghanistan. Understanding the pathophysiology and determining effective treatments for mild bTBI has become an international problem in the field of neurotrauma research. Contributing to this problem is a lack of an experimental model that accurately mimics the characteristics of mild bTBI. To date, the "mild'' versions of common experimental models of TBI have simply been less severe degrees of traumatic injury; these animals do not necessarily exhibit the clinical characteristics of mild bTBI seen in humans. Therefore, our first objective was to develop a highly controlled mouse model of bTBI using laser-induced shockwaves (LISWs). We established the parameters necessary to cause a reproducible injury of very mild severity, the most important feature seen in clinical practice. We defined very mild bTBI as having no traumatic change on the head visible to the naked eye after the insult was applied using very mild shockwaves to the heads of mice. Our very mild bTBI mouse model exhibited neurobehavioral changes in the chronic phase, such as cognitive impairment and depression-like behavior. We also observed an increase in 5-bromo-2'-deoxyuridine-positive, proliferating cells in the dentate gyrus during the acute phase and a subsequent decrease during the chronic phase. This model appears to be an accurate representation of the damage occurring in actual mild bTBI patients. We also found that an increase in cell proliferation in the dentate gyrus during the acute phase is the most prominent feature after a TBI.

Hypertrophic pachymeningitis is an uncommon disorder that causes a localized or diffuse thickening of the dura mater. Recently, the possibility that IgG4-related sclerosing disease may underlie some cases of intracranial hypertrophic pachymeningitis has been suggested. We herein report the tenth case of IgG4-related intracranial hypertrophic pachymeningitis and review the previous literature. A 45-year-old male presented with left-sided focal seizures with generalization. Magnetic resonance imaging (MRI) revealed a diffuse thickening and enhancement of the right convexity dura matter and falx with focal nodularity. The surgically resected specimens exhibited the proliferation of fibroblast-like spindle cells and an infiltration of mononuclear cells, including predominantly plasma cells. The ratio of IgG4-positive plasma cells to the overall IgG-positive cells was 45% in the area containing the highest infiltration of plasma cells. On the basis of the above findings, IgG4-related sclerosing disease arising from the dura mater was suspected. IgG4-related sclerosing disease should be added to the pachymeningitis spectrum.

True posterior communicating artery (PCoA) aneurysm is an aneurysm that originates from the PCoA, and large or giant true PCoA aneurysms are rare. We report a case of a large true PCoA aneurysm successfully clipped after anterior clinoidectomy and discuss the diagnostic pitfalls associated with this rare clinical entity.

A metastatic brain tumor originating from esophageal carcinoma is very rare, accounting for only about 2% of all intracranial metastatic tumors. We review three cases of metastatic brain tumor from esophageal carcinoma and present one interesting case. A 60-year-old man was referred to our hospital with aphasia, 3 years after surgery for esophageal carcinoma. Magnetic resonance imaging demonstrated a 7-cm mass lesion with a cystic component in the left temporal lobe. Tumor resection was performed and an Ommaya reservoir system was placed. Histological analysis indicated squamous cell carcinoma, and metastatic brain tumor from esophageal carcinoma was diagnosed. After surgery, the cystic component was collapsed by drainage through the Ommaya reservoir, and cyberknife therapy was performed as an adjunctive therapy. Regrowth of the cystic component and exacerbation of cognitive dysfunction were identified 2 months later, so aspiration of cyst fluid through the Ommaya reservoir was continued. However, the cystic component regrew 5 months after the operation, and the patient died 1 month later. Metastatic brain tumors from primary esophageal carcinoma often have a cystic component, which makes treatment difficult. Control of cyst growth by aspiration using the Ommaya reservoir is effective for improvement of functional prognosis in such patients.