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Neurotoxicity is a rare and intolerable adverse effect associated with levofloxacin therapy, whose diagnosis has mostly been reported based on medical history rather than quantitative measures in the blood. We report a 68-year-old man with levofloxacin-associated encephalopathy and myoclonus with high levels of levofloxacin in the blood and cerebrospinal fluid. After hemodialysis, these decreased, and his symptoms rapidly improved. An electroencephalogram was also normal. This case showed the concentration of levofloxacin to be clearly related to levofloxacin-associated neurotoxicity. Therefore, an estimation of its concentration may contribute to accurate diagnosis.

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A 30-year-old healthy woman presented with a 2-day history of fever and severe throat pain. She reported dysphagia and odynophagia but denied dyspnea, trismus, or sialorrhea. Amoxicillin and clarithromycin had been prescribed by her primary physician but did not relieve her symptoms. Her school-age children had complained of similar symptoms, which resolved spontaneously several days before her presentation. Her past medical history included palatine tonsillectomy 9 years previously.Physical examination revealed vital signs within normal ranges except for a body temperature of 39.6˚C. Her voice was muffled, but the airway was patent without stridor. Her oropharynx appeared normal but the anterior cervical lymph nodes were tender to palpation. The Figure shows the irregular mass at the base of the tongue on a soft tissue lateral neck radiograph. These findings are consistent with acute lingual tonsillitis. Laryngoscopy was performed following consultation with an otolaryngologist. Lingual tonsils were edematous with white exudates in the crypts. We diagnosed acute viral lingual tonsillitis based on adenovirus antigen detected in the swab. The patient recovered uneventfully on analgesics and has not experienced a recurrence.The lingual tonsils constitute Waldeyer ring, along with the palatine, tubal, and pharyngeal (adenoid) tonsils. The tonsils consist of lymphoid tissues covering the posterior surface of the tongue behind the vallate papillae, which lie in front of the epiglottis. The tissues are likely affected by the same etiology as the palatine tonsils and can become hypertrophic or hyperplastic in response to infection, foreign bodies, and palatine tonsillectomy. 1,2 Further, enlargement may be seen in patients with varices, congenital abnormalities (dermoid cysts, thyroglossal duct cysts, lingual thyroid gland), and benign or malignant growths of any tissues at the tongue base. 1,3,4 Lingual tonsil swelling can cause a wide variety of signs and symptoms due to its anatomical position, including altered phonation, airway stenosis (obstructive sleep apnea, stridor, airway Funding: None.

An 86-year-old man who underwent endovascular aortic repair (EVAR) for impending rupture of an abdominal aortic aneurysm a year ago presented to our hospital because of fatigue and black stools. Multiple bacterial specimens were detected in blood cultures, and computed tomography following oral administration of gastrografin demonstrated gastrografin in the abdominal aorta. The diagnosis of aortic duodenal fistula was confirmed and emergency abdominal aortic replacement was performed. The pathological findings of the aorta included a large number of IgG4-positive plasma cells infiltrating all layers of the aortic wall, with particularly marked thickening of the adventitia. The serum IgG4 level was 241 mg/dL and IgG4-related periaortitis was diagnosed. Aortoduodenal fistula is a rare but fatal complication of IgG4-related periaortitis. Patients should be followed carefully after EVAR for inflammatory abdominal aortic aneurysms.