An 18-year-old man presented with fatigue and polyarthralgia refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). He had no history of sore throat or other upper respiratory symptoms. Reactive arthritis was initially suspected. However, persistent symptoms, fever, polyarthritis, a cardiac murmur, atrioventricular block, and an elevated antistreptolysin O titer (739 IU/mL) suggested acute rheumatic fever. He met the revised Jones criteria for acute rheumatic fever. Treatment with amoxicillin and corticosteroids rapidly resolved his symptoms and electrocardiographic abnormalities.
A 75-year-old woman presented with nausea, exertional dyspnea, and right-sided chest pain. Chest imaging showed a right hilar mass with right pleural effusion. Initial assessment favored primary lung cancer with carcinomatous pleuritis. However, laboratory tests at admission revealed markedly elevated levels of total protein with hypoalbuminemia, resulting from monoclonal IgG-kappa (κ) gammopathy (IgG: 7,700 mg/dL). Thoracentesis demonstrated an exudative effusion; pleural fluid cytology and transbronchial tumor biopsy confirmed small cell lung cancer (SCLC). Anemia, markedly increased serum free κ light chain levels, and atypical plasmacytosis in the bone marrow confirmed the presence of multiple myeloma. She was then diagnosed with extensive-stage SCLC and concomitant multiple myeloma. Dose-reduced carboplatin plus etoposide was initiated for SCLC with clinical improvement and no severe acute toxicity; treatment for myeloma was planned after stabilization of SCLC. This case highlights that extreme hypergammaglobulinemia in a patient with suspected lung cancer should trigger prompt evaluation for multiple myeloma. Dual malignancy can coexist and may be overlooked if clinicians focus on a single diagnosis.
Objective Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of poor neurological outcomes. Although systemic inflammation related to nosocomial infection has been suggested to contribute to DCI, the specific role of bacteremia remains unclear. This study aimed to evaluate the association between nosocomial infection, particularly bacteremia, and the development of DCI in patients with aSAH treated with coil embolization. Methods We retrospectively reviewed patients with aSAH treated at our institution between April 2016 and July 2019. After applying predefined exclusion criteria, including early death due to primary brain injury and insufficient postoperative evaluation, 59 patients who underwent coil embolization were included. Patients were divided into two groups according to the occurrence of DCI. Clinical characteristics, infection-related variables, and outcomes were compared. Univariate analyses were performed, followed by multivariate logistic regression analysis to identify factors associated with DCI. Results DCI developed in nine of 59 patients (15%). In univariate analysis, angiographic vasospasm and nosocomial infection were significantly associated with DCI. In multivariate logistic regression analysis, bacteremia was independently associated with the development of DCI (odds ratio, 39.22; 95% confidence interval, 2.25-684.45; P = 0.01). Conclusions Bacteremia was independently associated with the development of DCI in patients with aSAH treated with coil embolization. Although causality cannot be established due to the retrospective design and limited sample size, these findings suggest that systemic infection characterized by bacteremia may be clinically relevant to the pathophysiology of DCI. Further prospective studies are warranted to clarify this association.
