IntroductionExtranodal lymphoma (ENL) in the muscles is a rare manifestation of non-Hodgkin lymphoma (NHL). The aim of this case report is to describe and evaluate the clinical presentation and important radiologic features of ENL affecting the musculoskeletal system.Presentation of caseWe present a 52-year-old female with a 3-week history of left gluteal pain. Computed tomography (CT) showed a non-uniformly early enhancing mass in the left gluteal muscle, the tumor demonstrating central necrosis and adjacent bone involvement. Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET)/CT showed areas of increased 18F-FDG uptake in the left gluteal musculature, pelvic bones, para-aortic and mediastinal lymph nodes and both lungs. Histopathological examination showed a diffuse large B cell lymphoma (DLBCL). After 8 cycles of R-CHOP chemotherapy, the mass in the left gluteal muscle has completely disappearedDiscussionAlthough destructive tumor originating in the gluteal muscle with adjacent bone involvement is more common in soft tissue sarcoma, lymphoma should be regularly included in the differential diagnosis. While CT is a useful modality for assessing soft tissue masses, disruption and injury of the surrounding tissues, PET/CT fusion is superior for the detection of unexpected extranodal sites of disease, or for exclusion of disease in the presence of nonspecific extranodal CT findings.ConclusionA rapid growth pattern and destructive masses that invade adjacent structures on CT are key findings of DLBCL, and 18F-FDG PET/CT is a useful imaging modality to accurately determine the disease stage and disease aggressiveness of NHL.

Aim:Opportunistic infections (OIs) adversely affect outcomes in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV). This study aimed to identify the incidence proportion of risk factors for OIs in patients with AAV who were on remission-induction therapy, using a Japanese health insurance database.Method: This retrospective longitudinal population-based study was conducted using claims data provided by Medical Data Vision Co., Ltd. We defined individuals as AAV cases receiving remission-induction therapy if they met all of the following criteria: (a) having OIs with at least 1 specified International Statistical Classification of Diseases and Related Health Problems, 10th Revision code (M300, M301, M313, or M318); (b) receiving at least 1 prescription of oral corticosteroids (CS) with prednisolone (PSL)-equivalent dosage ≥30 mg/d, CS pulse therapy, immunosuppressive agents or rituximab during hospitalization between April 2008 and April 2017; and (c)at least 7 days of hospitalization while on the above-mentioned therapies. We calculated incidence and proportion of OIs during the year following remission-induction therapy and the adjusted odds ratio (OR) using a logistic regression model. Results:We included 2299 patients with AAV in this study. OIs occurred in 460 patients (20.0%), with the most frequently occurring OI being cytomegalovirus infection (n = 122, 6.5%). After adjusting for covariates, age by decade (OR 1.24, 95% CI: 1.12-1.36), daily PSL dose per 10 mg (OR 1.16, 95% CI: 1.08-1.25), and CS pulse therapy (OR 1.29, 95% CI: 1.04-1.60) were found to be significantly associated with occurrence of OIs. Conclusion:Older age and corticosteroid use were found to be significant risk factors for OIs in patients with AAV on remission-induction therapy, using a health insurance database. K E Y W O R D S antineutrophil cytoplasmic antibody-associated vasculitis, drug treatment opportunistic infection, epidemiology, risk S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section at the end of the article. How to cite this article: Sakai R, Tanaka E, Nishina H, Suzuki M, Yamanaka H, Harigai M. Risk of opportunistic infections in patients with antineutrophil cytoplasmic antibody-associated vasculitis, using a Japanese health insurance database. Int J

BackgroundIt has been reported that patients with antineutrophil cytoplasmic antibody associated vasculitis (AAV) had a high risk of infections1–3. Among infections, opportunistic infections (OIs) influence patients’ vital prognosis and complicate treatments. It is essential to investigate risk of OIs for appropriate management of patients with AAV. However, data about incidence of OIs and risk factors in patients with AAV is limited to date.ObjectivesTo identify incidence and risk factors of OIs under the remission-induction therapy in patients with AAV using Japanese health insurance database.MethodsThis retrospective longitudinal population-based study was conducted using claims data provided by Medical Data Vision Co., Ltd. We defined individuals as AAV cases receiving remission-induction therapy if they met all of the following: 1) had at least one ICD10 code (M300 or M301 or M313 or M318); 2) had at least one prescription of oral corticosteroids (CS) with prednisolone (PSL)-equivalent dosage ≥30 mg/day, methylprednisolone (mPSL) pulse therapy, immunosuppressive drugs (IS) (cyclophosphamide, methotrexate, mycophenolate mofetil), or rituximab during hospitalisation between April 2008 and ;April 2017 and 3) had at least 7 days of hospitalisation. If patients had multiple hospitalizations for AAV remission-induction therapy defined as above, the first hospitalisation between April 2008 and April 2017 was analysed in this study. OIs were defined as follows: at least one ICD10 code and one prescription of predefined drugs for each OI during hospitalisation. We calculated incidence proportion and adjusted odds ratio (OR) of risk factors for OIs using a logistic regression model.ResultsTwo thousands and two hundreds ninety nine patients were included in this study. The median age was 73 years and 55.2% were female. The number of patients with ICD10 code M300 for microscopic polyangitis, M301 for eosinophilic granulomatosis with polyangiitis, M313 for granulomatosis with polyangiitis, M318 for AAV, and two or more of these ICD10 codes was 1015 (44.1%), 385 (16.7%), 234 (10.2%), and 665 (28.9%), respectively. mPSL pulse therapy, oral PSL ≥30 mg/d, at least one IS, and rituximab was used in 37.5%, 83.3%, 26.2%, and 5.4%. OI occurred in 203 patients (8.8%) and the most frequent OI was cytomegalovirus infection (n=79, 3.4%). The numbers (%) of candida infection, aspergillus infection, and pneumocystis jirovecii pneumonia were 28 (1.2), 24 (1.0), and 22 (1.0). No case with tuberculosis was observed. After adjusting for comorbidities, age by decade (OR: 1.34 [95% CI, 1.16–1.57]), IS or rituximab use (OR 1.60 [1.17–2.18]), mPSL pulse therapy (OR 2.62 [1.93–3.56]), PSL dosage per 1 mg (OR 1.02 [1.01–1.03]) were associated with occurrence of OIs significantly.ConclusionsOlder age, immunosuppressive treatments were identified as significant risk factors of OIs under the remission-induction therapy in patients with AAV using health insurance database.References[1] Eur J Clin Invest2015;45:346–368.[2] Presse Med, 2015;44:e251-e2...

BackgroundIn 2006, the American College of Rheumatology (ACR) Ad Hoc Committee on Systemic Lupus Erythematosus (SLE) recommended the urinary protein level in a spot (untimed) urine specimen (determined as urinary protein-to-urinary creatinine ratio; spot P/C ratio) over a 24-hour urine protein excretion. In addition, the committee stated that renal function refers to the estimated glomerular filtration rate (GFR) and selected the MDRD study equation. However, several subsequent reports suggested that the spot P/C ratio may be inaccurate in the assessment of the degree of proteinuria in lupus nephritis (LN). In addition, there is no consensus as to which estimating equation is preferred for estimated GFR in LN.ObjectivesWe aimed to evaluate the validity of spot P/C ratio and estimated GFR by the modified MDRD study equation as measures of proteinuria and renal function in patients with LN.MethodsA total of 61 patients with active LN who were admitted to our hospital from 2010 through 2015 were included. LN was pathologically confirmed in 51 patients and renal biopsy was not performed in the other 10 patients. In addition, 22 SLE patients without active LN in whom spot P/C ratio, 24-hour urine protein excretion, estimated GFR, and 24-hour urine creatinine clearance were measured were also included. All the patients met the revised ACR classification criteria for SLE. Clinical and laboratory data were retrospectively collected from the electronic medical records and statistically analyzed.ResultsThe spot P/C ratio and the 24-hour urine protein excretion were moderately correlated (n=64, Pearson's r =0.62). However, the Bland-Altman plot demonstrated proportional bias (progressive deviation with values). Agreement of the spot P/C ratio ≥0.5 and the 24-hour urine protein excretion ≥0.5 g was moderate (Cohen's κ =0.56) whereas that of ≥0.2 was almost perfect (κ =0.83). Measured 24-hour urine creatinine excretion ranged from 220 mg to 2120 mg; the mean and median values were 860 mg and 840 mg, respectively. Among the 10 patients in whom serial data could be obtained in more than 3 times, the spot P/C ratio and the 24-hour urine protein excretion were highly correlated (r =0.87 to 0.99), except for 2 patients (r = -0.30 and 0.68, respectively). In these serial samples derived from the 8 patients, there was substantial agreement between the spot P/C ratio and the 24-hour urine protein excretion about whether increased or decreased compared to previous data (κ =0.65). The estimated GFR by the modified MDRD study equation and the body surface area (BSA) corrected 24-hour urine creatinine clearance were moderately correlated (n=81, r =0.62). However, the Bland-Altman plot demonstrated both fixed and proportional bias. Agreement of the estimated GFR and the BSA-corrected 24-hour urine creatinine clearance ≥60 (ml/min/1.73 m2) was moderate (κ =0.48).ConclusionsOur results supported the validity of spot P/C ratio and estimated GFR by the modified MDRD study equation as convenient screening and monitoring measures of proteinuria ...

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