We report four cases of post coronavirus disease 2019 (COVID-19) condition in which the patients suffered from a severe sense of fatigue that was successfully treated with warming-tonifying therapy using bukuryoshigyakuto, allowing them to return to normal social life. All four patients were unable to engage in social or school activities and had difficulty performing daily living tasks. Initially, they were treated with Kampo formulas corresponding to the yang pattern, which proved ineffective. However, their sense of fatigue was relieved after starting bukuryosigyakuto. Case 1 (36-year-old man) was a latent yin-deficiency pattern, in which an electro-acupuncture test revealed his interior cold. In Case 2 (53-year-old man), Case 3 (17-year-old woman) and Case 4 (11-year-old boy), the administration of bukuryoshigyakuto was based on the presence of severe sense of fatigue, characterized by the need to lie down almost all day and worsening symptoms after walking several dozen meters or taking a bath. There have been some case reports of tonifying therapies being effective in treating post COVID-19 conditions which are considered examples of qi deficiency or qi and blood deficiency following acute infectious disease. Kampo therapy with warming-tonifying formulas may be useful for post COVID-19 conditions that correspond to a late yin stage pattern in the six stage classification, particularly those presenting with severe sense of fatigue.

Deep neck abscess can cause upper airway stenosis and obstruction, and sometimes emergency airway management is required. Here we present a case of deep neck abscess in which awake intubation with a video laryngoscope (McGRATH™ MAC) was more useful than with flexible bronchoscope. A man in his 80s was transported to our hospital with throat and chest pain. Contrast-enhanced computed tomography revealed a deep neck abscess (right peritonsillar abscess). The otolaryngologist attempted drainage by puncture, but this was ineffective. There was a risk of upper airway obstruction, and emergency airway management was required. First, we attempted endotracheal intubation with a flexible bronchoscope but could not secure the field of view because of the upper airway edema and stenosis. Next, we attempted tracheal intubation using a video laryngoscope, which ultimately was successful. The blade of the video laryngoscope compressed and lifted the soft tissue and then it secured the space of the upper airway.

We encountered a case in which decreased cardiac afterload due to intra-aortic balloon pumping (IABP) caused left ventricular outflow tract obstruction (LVOTO), resulting in cardiogenic shock in a patient with hypertrophic obstructive cardiomyopathy (HOCM). The patient was a woman in her 60 with HOCM and angina, which were had been diagnosed before endometrial cancer surgery. An intra-aortic balloon pump was placed before surgery to maintain coronary artery blood flow, and increases in diastolic blood pressure were observed. However, she went into shock upon induction of anesthesia and required a large dose of vasopressor. The patient remained in shock after surgery and was admitted to the ICU while unresponsive and intubated. Transthoracic echocardiography showed LVOTO and mitral regurgitation, indicating the possibility that lowered cardiac afterload by IABP caused LVOTO. Discontinuation of IABP resulted in striking recovery from shock such that no vasopressor was required, and echocardiography findings improved. Although IABP offers a variety of benefits such as maintenance of coronary artery blood flow, we should keep in mind that decreased cardiac afterload due to IABP may cause LVOTO in patients with HOCM.

Mushroom poisoning with Russula subnigricans can lead to severe rhabdomyolysis. Here we describe a case of severe mushroom poisoning that resulted in severe rhabdomyolysis with acute kidney injury, hypotension, and shock 12 h after oral ingestion of R. subnigricans. The patient's serum myoglobin was 6,475 ng/mL and his creatine phosphokinase (CK) level was 38,100 IU/L on admission. Although aggressive fluid resuscitation and on-line hemodiafiltration (OHDF) were initiated, vascular permeability and shock failed to improve. Continuous hemodiafiltration (CHDF) and OHDF was repeated, but their effects were limited. He later developed generalized edema, and his weight increased from 55 kg to 72.5 kg within 4 days. On day 5, his CK level reached 203,800 IU/L. He died 160 h after oral ingestion of R. subnigricans. CHDF and OHDF filter out circulating myoglobin, potassium, and some toxic substances released due to muscle cell disruption. Although OHDF was performed nearly 24 h a day in our patient, it failed to remove toxic intracellular components from muscle cells due to the severe R. subnigricans mushroom poisoning in this case.