PMC4533850_01
The serial chest and abdominal X-ray findings during the observation period. No abnormal findings were detectable on admission (A). On hospital day 40 (B), streaky lucencies over the mediastinum (narrow arrows) that extended into the neck (arrowhead) and remarkable gaseous distention of the bowel (wide arrows) were demonstrated by a routine chest and abdominal X-ray, respectively. These radiological findings, with slight improvement, were noted on hospital day 44 (C), followed by further improvements on hospital day 50 (D) and 57 (E) despite the resumption of dietary intake on hospital day 49.
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No abnormal findings were detectable in either the chest or abdominal X-rays (Fig. 1A). A routine chest X-ray performed 5 weeks after he had started oral PSL suggested the presence of right cervical subcutaneous emphysema and pneumomediastinum, while an abdominal X-ray showed remarkable gas collections along the bowel wall (Fig. 1B). Thereafter, the radiological indications of the disease were gradually improved and were no longer present on the 57th hospital day, despite the resumption of normal dietary intake (Figs. 1C-E).
Photomicrographs of the renal biopsy specimen. A light micrograph showed cellular crescent formation in several glomeruli (A). Periodic acid-Schiff stain), some of which were associated with segmental fibrinoid necrosis (B). Periodic acid methenamine stain). Immunohistochemical staining demonstrated the lack of immunoglobulin and complement deposition, and electron microscopy failed to show the presence of deposits along the capillary walls (C). The scale bars are indicated in each panel.
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Although vasculitic changes were absent in the blood vessels, cellular crescent formation was seen in the rest of the glomeruli, some of which exhibited a break in the GBM associated with fibrin extravasation (Fig. 2).
The clinical course of the current patient. A prompt decrease in the serum C-reactive protein level was confirmed just after the initiation of oral prednisolone, while the sCr levels began to decrease approximately 7 weeks after the initiation of corticosteroids treatment. Ganciclovir treatment for the CMV infection was transiently switched to oral famciclovir, when overt herpes zoster (characterized by a vesicular rash with a dermatomal distribution) developed. The time points corresponding to each panel in Figure 1 are demonstrated at the top.. Abbreviations: GC, ganciclovir; FV, famciclovir.
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Ag) was 2/5 when the treatment had been terminated for 1 week, because we gave priority to treatment with oral famciclovir for a concurrent herpes zoster infection that developed on the 27th hospital day (Fig. 3). A laboratory analysis revealed that the patient had postprandial hyperglycemia (290 mg/dL) 12 days after the initiation of oral PSL, leading to a diagnosis of steroid-induced diabetes.
CT scans of the chest and abdomen. Abnormal air accumulations characterized by radiolucent areas (black or white arrows in each panel) were observed in the cervical regions (A), mediastinum (B), intramural parts of the ascending colon (C) and mesentery, along with the retroperitoneum (D). A coronal reconstructed image (E) failed to show free air.
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Although the patient did not have any respiratory or abdominal symptoms, subsequent chest and abdominal computed tomography (CT) scans demonstrated intramural air in the bowel, gas collection in the mes-entery, and an abnormal air density in the mediastinum, as well as in the cervical subcutaneous regions (Figs. 4A-E).