A 91-year-old male on treatment for type 2 diabetes mellitus was admitted to our hospital complained of general fatigue and high-grade fever since one day. He noticed hematuria for two days before admission. On physical examination, costovertebral angle tenderness pain was not observed. His body temperature was 39.1 °C, and heart rate was 110 beats per minute. Blood laboratory examination showed that white blood cell counts were 18,050/L, C-reactive protein 17.9 mg/dL, blood sugar was 254 mg/dL, and procalcitonin was 10.1 ng/mL. Urinalysis revealed moderate hematuria and proteinuria. On plain pelvic X-ray [computed tomography (CT) scan positioning image], unique linear circular-shaped gas was observed (arrow in Figure 1A). On plain abdominal CT demonstrated mildly thickened bladder wall and emphysematous region of bladder lumen (arrow in Figure 1B). We diagnosed this case as emphysematous cystitis. Urine culture revealed Staphylococcus aureus as the pathogen of this case. Intravenous administration of ampicillin sodium/ sulbactam sodium (3.0 g every 8 hour for seven days) was started and a balloon catheter was placed in the bladder. Then hematuria was improved. After seven days of treatment, administration of ampicillin sodium/ sulbactam sodium and placement of ballooned-bladder catheter were discontinued. Moreover, the patient was discharged ten days after admission.

Background Although drug-induced interstitial pneumonia is a well-known adverse side-effect of cancer chemotherapy, the disease is difficult to detect in the early phase. We report a case of oxaliplatin-induced interstitial pneumonia in which eosinophilia and high-grade fever with relative bradycardia were useful presenting signs for the early diagnosis. Case presentation A 76-year-old Japanese woman with postoperative recurrent rectal cancer (peritoneal dissemination and liver metastasis) was admitted to our hospital because of productive cough and consolidation on thoracic computed tomography (CT) images. Two months prior to the consultation, she had started chemotherapy (fluorouracil, oxaliplatin, and bevacizumab). After finishing three courses of chemotherapy, she developed fever and was noted to have relative bradycardia. After another two courses of chemotherapy, she developed productive cough, chest discomfort, and high-grade fever. At this time, thoracic CT revealed patchy areas of consolidation distributed predominantly in the periphery. Despite the administration of tazobacterium/piperacillin, the consolidation seen on CT scans gradually worsened. Fiberoptic bronchoscopy was performed, and bronchoalveolar lavage fluid analysis showed increased lymphocytes, eosinophils, and total cell count but a low CD4/ CD8 ratio. No specific pathogen was identified. With a diagnosis of interstitial pneumonia, prednisolone was started and chemotherapy was temporarily discontinued. Her productive cough gradually decreased, and the infiltrative shadows on the thoracic CT scans improved. Conclusion Although cases of oxaliplatin-related pneumonia with complicating relative bradycardia are not uncommon, drug-induced interstitial pneumonia should be taken into account in the differential diagnosis. In this case, an increased circulating eosinophil count and high-grade fever with relative bradycardia were the first signs of drug-induced interstitial pneumonia.

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An 81-year-old woman being treated for chronic urticaria consulted our outpatient clinic with a twoweek history of productive cough and fever. Six months prior to the consultation, she consulted a dermatologist and was treated with an antihistamine-1-receptor blocker against urticaria. Since her itching continued, diaminodiphenyl sulfone (DDS), 50 mg daily, was added. The chronic urticaria then gradually improved, and the DDS was continued. Two weeks prior to the consultation, she developed malaise and cough with whitish sputum. On thoracic computed tomography (CT), a bilateral upper lobe and subpleural lesion-dominant, multiple, nonsegmental, consolidative shadow was observed (Figure 1). The possibility of community-acquired pneumonia was highly suspected, and a combination of clarithromycin and ceftriaxone for one week was given at a family practice office. However, her symptoms and the infiltrative shadow on chest X-ray gradually worsened, and she consulted our outpatient clinic. On physical examination, auscultation of her chest showed early inspiratory crackles. Blood laboratory examination showed: white blood cell count 9150/µL, eosinophils 5.8% (531/µL), red blood cell count 2,800,000/µL, hemoglobin 8.8 g/dL, hematocrit 28.1%, platelet count 249,000/µL, total protein 6.8 g/dL, albumin 4.0 g/dL, AST 20 IU/mL, ALT 9 IU/mL, LDH 201 U/mL (normal range: 106-211 U/mL), Fe 76 µg/mL, ferritin 402 mg/ mL, total iron-binding capacity 110 µg/mL, Na 145

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