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Background Dialister pneumosintes ( D. pneumosintes ) is a slow-growing, obligate anaerobic Gram-negative bacillus commonly found in the oral cavity, nasopharynx, gastrointestinal tract, and vaginal microbiota. Although typically associated with periodontal disease, D. pneumosintes has rarely been implicated in bloodstream infections and, to date, has not been reported as a causative agent of meningitis. This case report describes D. pneumosintes bacteremia complicated by meningitis, highlighting the diagnostic challenges associated with fastidious anaerobes and the role of advanced microbiological techniques, including matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and 16S rRNA gene analysis, in accurate pathogen identification. Case presentation A 65-year-old woman presented with fever, dysarthria, and posterior neck pain. Clinical examination revealed altered consciousness, restricted neck mobility, bilateral eyelid edema, and nasal speech. Laboratory findings indicated hypokalemia and metabolic alkalosis. Imaging studies revealed marked mucosal thickening and fluid accumulation in the paranasal sinuses, suggesting sinusitis with possible extension to the middle ear. Lumbar puncture before initiation of antibiotic therapy revealed neutrophilic pleocytosis consistent with acute bacterial meningitis. Blood cultures grew Staphylococcus hominis and an unidentified anaerobic Gram-negative bacillus, which was later identified as D. pneumosintes using MALDI-TOF MS. Empirical antibiotic therapy with ceftriaxone, vancomycin, ampicillin, and corticosteroids was initiated. Persistent fever prompted endoscopic sinus surgery on hospital day 5, with intraoperative cultures yielding Staphylococcus aureus and revealing a benign nasal papilloma. Neurological symptoms improved postoperatively. The patient completed 14 days of intravenous antibiotic treatment and was ultimately discharged on day 45. Conclusion This is an exceptionally rare case of D. pneumosintes bacteremia complicated by meningitis. Given its propensity to originate from odontogenic or sinonasal infections and cause hematogenous dissemination with invasive complications such as abscesses or septic thrombosis, prompt identification is essential. When detected, clinicians should initiate a comprehensive systemic evaluation and consider surgical intervention as part of the treatment strategy. As advanced diagnostic tools such as MALDI-TOF MS and 16S rRNA gene sequencing become more widely available, increased clinical recognition of D. pneumosintes as a potential pathogen in severe anaerobic infections is warranted. Clinical trial number Not applicable.

Severe hyponatremia can cause life-threatening cerebral edema. Treatment comprises rapid elevation of serum sodium concentration; however, overcorrection can result in osmotic demyelination. This study investigated potential factors, including predictive correction based on the Edelman equation, associated with appropriate correction in 221 patients with a serum sodium concentration ≤ 120 mEq/L who were admitted to a hospital in Nagoya, Japan. Appropriate correction was defined as an elevation in serum sodium concentration in the range of 4–10 mEq/L in the first 24 h and within 18 mEq/L in the first 48 h after the start of the correction. Appropriate corrections were made in 132 (59.7%) of the 221 patients. Multivariate analysis revealed that predictive correction with an infusate and fluid loss formula derived from the Edelman equation was associated with appropriate correction of serum sodium concentration (adjusted odds ratio, 7.84; 95% confidence interval, 2.97–20.64). Relative without its use, the predictive equation results in a lower proportion of undercorrection (14.3% vs. 48.0%, respectively) and overcorrection (1.0% vs. 12.2%, respectively). These results suggest that predictive correction of serum sodium concentrations using the formula derived from the Edelman equation can play an essential role in the appropriate management of patients with severe hyponatremia.

Background Glucocorticoids (GC) comprise a cornerstone in the treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV); however, prolonged GC exposure leads to substantial toxicity and immune system-related complications. Hence, identifying treatment strategies that enable early GC withdrawal while maintaining disease control is of clinical importance. Objectives To investigate the proportion and characteristics of patients achieving GC-free clinical remission (GFCR) 48 weeks after treatment initiation in patients with newly diagnosed microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) and examine their long-term clinical outcomes (up to week 96). Methods We conducted a retrospective cohort study using clinical data from a multicenter, nationwide registry in Japan comprising patients with newly diagnosed MPA or GPA and at least 48 weeks of follow-up. GFCR was defined as a Birmingham Vasculitis Activity Score (BVAS) of 0 with complete GC withdrawal. Univariable and multivariable logistic regression analyses were used to identify independent predictors of GFCR at week 48, and a sensitivity analysis using a matched cohort was performed to validate robustness. Results A total of 728 patients were enrolled in the registry, of whom 544 were followed for ≥ 48 weeks; among them, 29 (5.3%) achieved GFCR at week 48. Use of rituximab (RTX) for induction therapy and avacopan within 48 weeks were independently associated with achieving GFCR (multivariable analysis, model 1: RTX: odds ratio [OR]: 3.9, 95% confidence interval [CI]: 1.5–10.0; avacopan: OR: 24.3, 95% CI: 5.8–101.9; both p  < 0.01). Conversely, methylprednisolone pulse therapy was associated with a lower likelihood of achieving GFCR (multivariable analysis, model 1: OR: 0.08, 95% CI: 0.02–0.44; p  < 0.01). Patient’s demographic and baseline disease characteristics were not predictive of GFCR. In the long-term (weeks 48 through 96), the rates of death, relapse, and serious infection were similar regardless of GFCR status at week 48. Conclusions The use of RTX for induction therapy and avacopan within 48 weeks is independently associated with achieving GFCR at week 48 in patients with MPA and GPA, supporting their potential as key components of GC-sparing strategies in AAV. Prospective studies are needed to confirm these results and optimize treatment algorithms to ensure disease control and minimize GC-related toxicity.

Background This study investigated the characteristics of hypertrophic pachymeningitis (HP) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), using information from a multicenter study in Japan. Methods We analyzed the clinical information of 663 Asian patients with AAV (total AAV), including 558 patients with newly diagnosed AAV and 105 with relapsed AAV. Clinical findings were compared between patients with and without HP. To elucidate the relevant manifestations for HP development, multivariable logistic regression analyses were additionally performed. Results Of the patients with AAV (mean age, 70.2 ± 13.5 years), HP was noted in 30 (4.52%), including 20 (3.58%) with newly diagnosed AAV and 10 (9.52%) with relapsed AAV. Granulomatosis with polyangiitis (GPA) was classified in 50% of patients with HP. A higher prevalence of GPA was significantly observed in patients with HP than in those without HP in total AAV and newly diagnosed AAV ( p < 0.001). In newly diagnosed AAV, serum proteinase 3 (PR3)-ANCA positivity was significantly higher in patients with HP than in those without HP ( p = 0.030). Patients with HP significantly had ear, nose, and throat (ENT) (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.03–2.14, p = 0.033) and mucous membrane/eye manifestations (OR 5.99, 95% CI 2.59–13.86, p < 0.0001) in total AAV. Moreover, they significantly had conductive hearing loss (OR 11.6, 95% CI 4.51–29.57, p < 0.0001) and sudden visual loss (OR 20.9, 95% CI 5.24–85.03, p < 0.0001). Conclusion GPA was predominantly observed in patients with HP. Furthermore, in newly diagnosed AAV, patients with HP showed significantly higher PR3-ANCA positivity than those without HP. The ear and eye manifestations may be implicated in HP development.

Background The characteristics of patients with advanced chronic kidney disease (CKD) who are recipients of public assistance in Japan, and the adequacy of their medical care have not been reported previously. Methods The records of patients with CKD stage G5 who visited nine facilities in Japan from April to June 2013 were retrospectively reviewed to compare the characteristics and care of recipients of public assistance with those of non-recipients. Receiving a presentation of kidney replacement therapy (KRT) options and polypharmacy were used as indicators of suboptimal medical care. Results Of the 592 patients included in this analysis (mean age, 69.6 years; male, 59.3%), 56 (9.5%) were recipients of public assistance and 536 (90.5%) were non-recipients of public assistance. The prevalence of diabetes mellitus, unmarried status, and living alone were higher in recipients of public assistance. In multivariable logistic regression analysis, compared with non-recipients of public assistance, recipients of public assistance were less likely to receive a presentation of KRT options (adjusted odds ratio [aOR], 0.31; 95% confidence interval [CI], 0.17–0.56), and were more likely to receive ≥ 10 (aOR, 1.92; 95% CI, 1.05–3.51), and ≥ 15 (aOR, 2.78; 95% CI, 1.23–6.26) types of medication. Conclusions Patients with advanced CKD receiving public assistance were less likely to receive a presentation of KRT options and more likely to receive ≥ 10 and ≥ 15 types of medication, suggesting that recipients of public assistance are more likely to receive suboptimal medical care.

We aimed to clarify the long-term safety and efficacy of rituximab (RTX) as a remission induction therapy following severe relapse in patients with antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV). We retrospectively collected the data of patients with severely relapsed AAV from a Japanese multicentre cohort. The primary exposure was RTX use; the primary outcome was complete remission (CR) proportions at week 24. Baseline characteristics were compared between the RTX and non-RTX groups. We performed multivariate logistic regression analysis and one-to-one propensity score matching analysis as a sensitivity analysis. Totally, 100 patients were enrolled: 52 in the RTX group and 48 in the non-RTX group. Baseline characteristics were comparable between the two groups, except for age, AAV subtype and ANCA serotype. The median age was 71 vs. 75 years, and the PR3-ANCA positivity rate was 44.2% vs. 18.8% in the RTX and non-RTX groups, respectively. No significant difference was observed in CR proportions at week 24 between the two groups (79.2% vs. 68.1%, p = 0.321), with an adjusted odds ratio of 1.27 (95% confidence interval [CI] 0.47–3.51). At week 48, CR proportions were significantly higher in the RTX group (91.7% vs. 64.9%, p = 0.005), with an adjusted odds ratio of 2.95 (95% CI 0.97–9.91). Serious infection rates were lower in the RTX group than in the non-RTX group, with no statistically significant difference. RTX was not superior to conventional immunosuppressive therapies at week 24 but showed significantly favourable results at week 48 for severely relapsed AAV.Key Points• RTX might be superior to traditional treatments as an induction therapy for severely relapsed AAV.• RTX has the potential to sustain long-term remission with fewer occurrences of infections in the treatment of severely relapsed AAV.

Some peritoneal dialysis catheter infections cannot be detected via a physical examination. Ultrasound of the PD catheter tunnel should be performed in cases of suspected infection or clinical abnormality at the catheter tunnel site. Some peritoneal dialysis catheter infections cannot be detected via a physical examination. In this case, we show importance of ultrasound examination in cases of suspected infection or clinical abnormality at the catheter tunnel site

Regardless of immunosuppressant use, physicians should be aware of pulmonary and extra‐pulmonary tuberculosis in patients with autoimmune disease including systemic sclerosis, especially if they follow unusual clinical courses. Regardless of immunosuppressant use, physicians should be aware of pulmonary and extra‐pulmonary tuberculosis in patients with autoimmune disease including systemic sclerosis, especially if they follow unusual clinical courses.

Rheumatoid arthritis (RA) is a global health concern with increasing prevalence. Despite recommendations for regular disease activity assessments, their implementation in routine clinical practice remains challenging. The Medical Support System for Rheumatoid Arthritis (MiRAi) is an offline, semi-automated system that calculates disease activity indices by integrating patient and clinician inputs from electronic health records (EHRs). This study evaluated the association between MiRAi implementation and the frequency of disease activity assessments in patients with RA. We conducted a retrospective cohort study of patients with RA treated at a tertiary hospital in Japan between April 2022 and March 2023. We included all adult outpatients (aged ≥18 years) with RA diagnosed according to the 2010 ACR/EULAR [American College of Rheumatology/European Alliance of Associations for Rheumatology] classification criteria. The hospital introduced MiRAi in June 2022 and achieved full deployment by October 2022. MiRAi calculated the clinical disease activity index (CDAI) and the modified health assessment questionnaire (mHAQ) through automated extraction of joint counts, patient global assessment, and functional status from structured EHR fields. Primary outcomes included the frequency of CDAI and mHAQ assessments. We administered a structured post-implementation survey to assess rheumatologists' perceptions of MiRAi. Physicians used MiRAi for 236/884 (26.7%) patients with RA. Patients with documented CDAI and mHAQ scores increased from 29 (5.9%) in June 2022 to 81 (19.0%) in November 2022, representing a 3.2-fold increase. Among surveyed rheumatologists (n=10), 5 (50%) reported the regular use of MiRAi. Physicians who regularly used MiRAi (n=5) cited improved accuracy in disease assessment and enhanced treatment decision-making. Non-users and occasional users (n=5) identified three primary barriers: limited familiarity with MiRAi, time constraints, and discrepancies between clinical judgment and MiRAi-generated outputs. Despite MiRAi's availability, only 168 (19%) patients underwent quantitative disease activity assessment by the study end. Among 15 patients with high disease activity (CDAI >22), physicians recorded 3 treatment modifications and 2 intra-articular steroid injections. MiRAi implementation increased disease activity assessment frequency by 3.2-fold over 6 months; however, physician adoption remained at 26.7%, below the 80% target for routine care. Future implementation strategies should address identified barriers through system integration, structured user training, and workflow optimization to achieve guideline-concordant care for patients with RA.