We present a case of a 47-year-old man with Type 2 diabetes mellitus who attempted suicide with 2,100 U of insulin injected subcutaneously. Administration of dextrose intravenously was required to maintain the blood glucose concentration normally for 5 days. Moreover, hypokalemia, hypophosphatemia,and hypomagnesemia were also seen for 24 hours after insulin injection. The serum phosphorus and magnesiumconcentrations decreased to nadirs of 1.6 mg/dl and 1.6 mg/dl respectively 7 hours after insulin injection. Electrolyte disorders other than hypokalemia may be induced in hypoglycemic patients by massive insulin overdose. (Internal Medicine 39: 55-57, 2000)

Adult-onset Still's disease (AOSD) usually affects young adults. Some cases of elderly-onset Still's disease (EOSD) have been reported, but its clinical features are unclear. We herein report a 74-year-old woman who developed AOSD with macrophage activation syndrome (MAS). We also reviewed 24 previous EOSD cases in patients over 70 years old and compared the findings with overall AOSD. While the clinical features were similar between the two, including the presence of MAS, disseminated intravascular coagulation was more frequent in EOSD than in AOSD. Furthermore, despite a similar frequency of glucocorticoid use, immunosuppressants and biologics were less frequently administered in EOSD than in AOSD. This report highlights the fact that typical AOSD can develop in elderly patients with some characteristic features.

Castleman disease was initially described as a lymphoproliferative disorder causing mediastinal masses characterized by abnormal histopathology. 1 Castleman disease has since been subclassified clinically into unicentric (UCD) and multicentric Castleman disease (MCD), 2 and subclassified histopathologically into the hyaline-vascular type (HV), plasma-cell type (PC), mixed type, plasmablastic type, and hypervascular type. 3 MCD was recently subclassified into human herpes virus-8 (HHV-8)-associated, HHV-8unassociated (idiopathic MCD [iMCD]), POEMS syndromeassociated, and others. 3 A new clinical entity, TAFRO syndrome, characterized by thrombocytopenia, anasarca (edema, pleural effusion, and ascites), fever, reticulin myelofibrosis (or renal insufficiency), and organomegaly (hepatosplenomegaly and lymphadenopathy), was recently described. 4 Its diagnostic criteria and disease severity criteria, determined by the All Japan TAFRO Syndrome Research Group in the Research Program for Intractable Diseases of the Ministry of Health, Labour and Welfare (MHLW) of Japan, 5 were recently updated (https:// www.facebook.com/CastlemanTAFRO). As the lymph nodes of individuals with TAFRO syndrome were characterized histopathologically as Castleman disease, 6 TAFRO syndrome has been categorized as part of iMCD. Recently, clinical and basic studies on Castleman disease and TAFRO syndrome were started in Japan and the USA. We collected and analyzed data from more than 200 patients with iMCD, TAFRO syndrome, or conditions mimicking these disorders. Most patients with iMCD exhibit a chronic/ indolent clinical course, characterized by polyclonal hypergammopathy, multiple lymphadenopathy, and thrombocytosis. In contrast, most patients with TAFRO syndrome have an acute or sub-acute onset and progressive clinical course, characterized by normal to reduced gammaglobulin levels, thrombocytopenia, small or unnoticeable lymph nodes, and severe pleural effusion, ascites, and anasarca. Lymph node

We describe a 64-year-old woman with chronic sclerosing sialadenitis and dacryoadenitis, which developed during treatment for cervical lymph node tuberculosis. Anti-tuberculosis treatment did not improve the swelling in the lacrimal and submandibular glands, and a biopsy specimen of the lacrimal gland showed inflammation, with abundant lymphoid follicles with fibrosis and granuloma without caseous necrosis. Immunohistological examination of a repeat biopsy specimen showed abundant immunoglobulin (Ig) G4-positive plasma cell infiltration. Corticosteroid therapy improved the salivary gland swelling without reactivation of the tuberculosis. This case suggests that an abnormal immunological reaction to tuberculosis may be one of the etiological candidates for IgG4-related disease.