Sjogren syndrome (SS) is a chronic, systemic autoimmune disease that primarily affects the exocrine glands, causing dry eyes and mouth, but also presents with a variety of other symptoms. SS is a common connective tissue disease but it can be difficult to diagnose due to the non-specific symptoms and lack of diagnostic markers in many cases. This report describes a case of an elderly patient on dialysis with newly diagnosed SS. The patient had been unable to eat a normal diet for a year, but treatment had not been initiated, presumably because of his age and the fact that he was on dialysis. The patient\'s symptoms improved with the administration of glucocorticoids. This is a very educational case for physicians to recognize undiagnosed SS patients presenting with non-specific symptoms.

The patient was 82-year-old man with type 1 diabetes mellitus. He had been using insulin degludec (IDeg) and insulin glulisine (IGlu) for treatment. He was admitted to our hospital due to diabetic ketoacidosis. As he started eating after recovery, we restarted intensive insulin therapy for glycemic control. Although he had eaten almost whole meals, his fasting blood glucose was extremely low, and the existence of nocturnal hypoglycemia was apparent. We reduced the dose and changed the injection time (evening→morning) of IDeg. We also stopped the evening IGlu injection; however, his nocturnal hypoglycemia did not improve. We decided to switch IDeg to insulin glargine U300 and to attach an intermittently scanned continuous glucose monitor (isCGM). His nocturnal hypoglycemia improved three days later. Since he had chronic heart failure and premature ventricular contractions, we used a Holter electrocardiogram to investigate the difference in arrythmia during hypoglycemia and non-hypoglycemia. As a result, the number of premature ventricular contractions was apparently high during hypoglycemia. In the present case, which involved an elderly patient with type 1 diabetes mellitus, chronic heart failure and nocturnal hypoglycemia, switching IDeg to insulin glargine U300 improved nocturnal hypoglycemia. IDeg differs from insulin glargine U300 in that it has a fatty acid side chain, which leads IDeg to combine with serum albumin. We thought that the increased level of free fatty acid due to hypoglycemia was competing against albumin combined IDeg, which increased free IDeg, and as a result, encouraged hypoglycemia.

We present a case of accidental ingestion of a foreign body-blister pill pack (FB-BPP) causing small bowel perforation in a patient taking aspirin and clopidogrel due to past history of coronary artery disease. A 71-year-old male presented in the emergency department (ED) with a two-day history of abdominal discomfort and loss of consciousness. His relevant home medication included aspirin and clopidogrel secondary to a history of coronary artery stents. Initial workup with emergent CT scan of abdomen/pelvis with intravenous contrast showed a loop of the terminal ileum with thickened wall and perforation. Incidentally, he was also found to have type II myocardial infarction. Emergent laparoscopic ileocecectomy with primary anastomosis was done. The postoperative course was unremarkable. The pathology report of the small bowel was consistent with a FB-BPP associated perforation. FB-BPP ingestion with perforation is a rare occurrence. It occurs more often in the elderly with significant mortality. Our case of accidental ingestion of FB-BPP was confirmed retrospectively after histopathological evaluation, and complicated by type II myocardial infarction. Emergent laparoscopic bowel resection was done despite significant preoperative risks.

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Celiac disease (CD) is widely perceived as a childhood disorder. However, it has been demonstrated that 19-34% of new CD cases are diagnosed in patients over 60 years of age and lack the typical presentation. A 76-year-old female was admitted to the clinic due to a recurrent fever that had lasted over a year accompanied by progressive weakness, weight loss of about 10 kg, dehydration, and malnutrition. The patient had undergone resection of a fragment of the small intestine due to perforation and abscess 13 years previously (at which time no histopathological examinations were performed). During the current hospitalization, despite extensive laboratory, microbiological, and imaging tests, no specific diagnosis was made. Symptomatic treatment and empirical antibiotic therapy were conducted, but the patient died on the twenty-seventh day of hospitalization due to progressive respiratory failure. The autopsy revealed peripheral T-cell lymphoma in the mesentery of the small intestine, uterus, cecum, lung, and mediastinal lymph nodes. Based on the clinical picture, we believe that the lymphoma was induced by long-term, undiagnosed CD. Current knowledge allows us to see age-related differences in the manifestation of celiac disease and to be alert to the possible late-stage complications of the disease. The lack of awareness of how CD\'s symptoms vary with age may lead to misdiagnosis and serious consequences of delayed diagnosis, including death.

BACKGROUND: Gangrenous cholecystitis is a form of acute cholecystitis which involves gangrenous alterations in the gallbladder wall and it often follows an acute and serious course. We herein report on two cases of very elderly people diagnosed early with gangrenous cholecystitis, who safely underwent laparoscopic cholecystectomy (LC) and both demonstrated a good outcome.
METHODS: Case 1: An 89-year-old female. She underwent abdominal contrast-enhanced computed tomography (CECT) due to abdominal pain and diarrhea. Her gallbladder wall indicated the absence of contrast enhancement, thus leading to diagnosis of gangrenous cholecystitis and she therefore underwent LC. Although her gallbladder demonstrated diffuse necrosis and it was also partly perforated, she was able to be discharged without any serious complications. Case 2: A 91-year-old female. She made an emergency visit with a chief complaint of abdominal pain. Abdominal CECT revealed swelling of the gallbladder and an ambiguous continuity of the gallbladder wall. She was diagnosed with gangrenous cholecystitis and underwent LC. Her gallbladder had swelling and diffuse necrosis. Although her preoperative blood culture was positive, she showed a good outcome following surgery.
CONCLUSIONS: Although a definite diagnosis of gangrenous cholecystitis is difficult to make prior to surgery, if an early diagnosis can be made and appropriate treatment can be carried out, then even very elderly individuals may be discharged without major complications.

An 89-year-old man was admitted because of persistent fever and impaired consciousness. On admission, his consciousness level was E3V3M4 according to the Glasgow Coma Scale. MRI of the brain showed high intensity lesions in the bilateral cingulate gyri. In the cerebrospinal fluid, both cell counts and glucose level were in the normal ranges. He had received antibiotics and intravenous isotonic saline. On the fifth day of hospitalization, blood examination revealed elevation of anti-herpes simplex virus (HSV) immunoglobulin M antibody, and herpes simplex encephalitis (HSE) was diagnosed. Despite treatment with acyclovir, his respiratory function and consciousness level deteriorated rapidly. On the eighth day, he died of respiratory failure. At autopsy, the brain showed multiple softenings of the gray and white matter in the hippocampus, amygdala, and temporal, insular, and cingulate cortices. Some of these lesions were hemorrhagic. Microscopic examination revealed that the lesions were necrotic and associated with perivascular inflammatory cell infiltration in the limbic system, hypothalamus, brainstem tegmentum area, and medulla. Eosinophilic intranuclear inclusions were rarely found in the astrocytes in the medulla. Immunohistochemistry revealed anti-HSV-1 antibody positive neurons in the brainstem tegmentum including reticular formation and the raphe nuclei. HSV-DNA was also detected in the postmortem cerebrospinal fluid. This was a rare case of HSE in which inflammation in the brainstem proved to be the cause of lethal respiratory failure.

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The discovery of human corpses in urban domestic settings does not constitute an unusual case in criminal casework. These scenarios can be very challenging to investigate since the uninformative evidences encountered also demand a multidisciplinary effort among several specialties in the forensic sciences field. The occurrence of this incident is usually accompanied by social isolation, which is an emblematic aspect of urban modern society. The elderly population is especially susceptible to being socially isolated, which is associated with higher mortality. We present a case report of an elderly woman who had been living with her husband\'s dead body, contributing to the scarce literature on the \"Living with the Dead\" phenomenon. The use of a multidisciplinary approach and the challenges that social isolation presents to forensic sciences and the contemporary society are discussed.

The high mortality rate due to severe Herpes simplex viral (HSV) hepatitis is associated with the difficulty of its diagnosis. We describe the extremely rapid disease course of a patient who died of severe HSV hepatitis. A 73-year-old woman was admitted for a bronchial asthma attack. Her symptoms improved with steroid treatment, but she developed a sore throat and painful swallowing. On day 12 after admission, she suddenly went into shock. Blood test results showed a significant increase in the liver enzyme levels, with remarkable disseminated intravascular coagulation. She died the same day. The autopsy revealed extensive coagulative necrosis of the liver. Viral inclusion of type A Cowdry bodies was found in the residual hepatocytes in the hepatic lobule. Immunostaining revealed HSV type 1 positivity. We diagnosed the cause of death as severe HSV hepatitis. On examination of a stored serum sample, the patient tested positive for the HSV immunoglobulin (Ig)-M antibody, and the HSV RNA level was very high (1 × 109 copies/mL). Remarkably, the HSV IgG test result was negative, and we diagnosed her as having had an initial HSV infection. Hepatitis due to HSV is very rare in healthy adults; however, there are many reports of immune-deficient cases. The presence of HSV IgG is decreasing in the elderly population because of the change in living environments/lifestyles. The increasing use of immunosuppressive drugs, such as steroids, for treating diseases in elderly patients could be linked to the increased prevalence of initial HSV infections, resulting in liver injury.