Objective In Caucasian type 1 autoimmune hepatitis patients with a main susceptibility of human leukocyte antigen DR3 and DR4, elderly patients have a higher frequency of concurrent autoimmune disease and cirrhosis at presentation. However, in Japanese patients, the disease is dominantly associated with DR4, and their clinical features may be different from those of previous reports. In this study, we assessed the clinical features of Japanese elderly patients with type 1 autoimmune hepatitis.
Methods We investigated 160 consecutive patients with type 1 autoimmune hepatitis, consisting of 34 elderly patients (≥65 years) and 126 younger patients (<65 years).
Results There were no differences in form of clinical onset, frequencies of concurrent autoimmune disease, positive proportions of anti-nuclear antibody and/or anti-smooth muscle antibody, and human leukocyte antigen DR status between the two groups. However, the elderly patients had lower serum levels of albumin (p=0.0049), and higher frequencies of cirrhosis (F4) and pre-cirrhosis (F3) (p=0.014) compared with the younger patients. In contrast, in elderly patients, the cumulative incidental rate of the normalization of serum alanine aminotransferase levels within 6 months after the introduction of initial treatment was higher in those treated with prednisolone ≥20 mg/day than those treated only with ursodeoxycholic acid (p=0.001).
Conclusion We speculate that more years may pass between the occurrence of the disease and the presentation in Japanese elderly patients than in younger patients, and we considered that, even in elderly patients, those with advanced fibrosis should be treated with prednisolone in order to prevent progress of the disease into liver failure.

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Objective This study was aimed to evaluate the correlation between dysphagia, detected by nursing staff in a brief interview and endoscopic findings in reflux esophagitis.
Patients and Methods A total of 8,031 Japanese subjects without medication for gastrointestinal disease were briefly asked about the presence of heartburn, dysphagia, odynophagia, and acid regurgitation by nursing staff before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification.
Results The grade of endoscopic esophagitis was not equivalent to symptoms of dysphagia in 8,031 subjects. We evaluated the characteristics of subjects who complained of only dysphagia. Univariate analysis indicated that non-smoking, and non-drinking females were associated with a higher risk for dysphagia, and multivariate analysis indicated the gender was associated with dysphagia. There was no association of dysphagia with herniation and distribution of age.
Conclusion This study indicated that dysphagia was not equivalent to the endoscopic findings according to a brief interview by nursing staff and that dysphagia might be more common in females and those who do not smoke or drink.

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Objective To investigate clinical features and pathophysiology of a rare form of new-onset type 1 diabetes mellitus that was superimposed on established type 2 diabetes.
Patients and Methods We retrospectively analyzed 126 consecutive type 2 diabetic patients, who were admitted to the hospital 2 or more times from July 2000 to December 2005 and had been repeatedly examined for islet-associated autoantibodies and insulin secretory capacity over a period of years.
Results We experienced 2 patients in whom autoantibodies including ICA, GADAb, and IA-2Ab were initially all negative, but in whom at least 1 of these antibodies later became positive, whose endogenous insulin secretion decreased, and who eventually reached an insulin-dependent stage. At the time of seroconversion of antibodies, the patients had 15 to 23 years' history of diabetes, and had microvascular complications specific to diabetes mellitus, and before seroconversion insulin secretory capacities were preserved. The patients had HLA types associated with susceptibility to Japanese type 1 diabetes mellitus.
Conclusions Our findings suggest that autoimmune type 1 diabetes mellitus may be superimposed on well-established type 2 diabetes.

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Aim To investigate if obesity which is not accompanied by diabetes and/or hypertension is associated with microalbuminuria in female patients.
Materials and Methods A total of 77 obese female patients from the Outpatient Clinic of Endocrinology of Istanbul University Cerrahpasa Medical Faculty and 30 age-matched, lean, healthy women were enrolled in the study. Patients with accompanying diabetes mellitus, hypertension, obesity associated with any endocrine abnormality, hepatic or renal disease, fever, infectious disease, malignancy were excluded. Weight, height, body-mass index (BMI), waist circumference, waist/hip ratio (WHR) and systolic and diastolic blood pressures were recorded. Albumin excretion in 24-hour urine samples (UAE) were measured using SYNCHRON LX® System with MA Microalbumin kit in two separate 24-hour urine samples from every patient. Statistical analysis was performed using t-test and Pearson's correlation in SPSS 12.0 for Windows Program.
Results The median albumin excretion in 24-hour urine sample was similar in obese and control groups (12.01 ± 10.69 mg/day vs 9.35 ± 4.09 mg/day; p= 0.211). There were no correlations between the albumin excretion in 24 hour urine samples and BMI, waist circumference, WHR, systolic or diastolic blood pressure.
Conclusion Diabetes mellitus and hypertension are known to be associated with microalbuminuria. In our study, microalbuminuria was not detected in obese women without diabetes and/or hypertension and UAE was similar in obese and lean women.

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Object No consensus has been reached whether clinical use of statins has beneficial effects on bone health, partly due to lower statin concentrations because of first-pass metabolism by the liver. We thus evaluated the effects of pitavastatin, which does not undergo first-pass metabolism, on bone metabolism.
Methods According to the therapeutic regimen, the subjects were divided into two groups (group A, 66 with pitavastatin; group B, 35 without pitavastatin). Bone-specific alkaline phosphatase (BAP) and serum N-terminal telopeptide of type I collagen (NTx) as bone turnover markers (BTMs) were compared between the two groups and between at baseline and after 3 months of treatment in each group. Correlations between baseline characteristics and ΔBTMs, and between Δlipid profile and ΔBTMs were investigated using both Pearson's correlation analysis and multivariate analysis.
Patients The subjects were 101 patients with untreated hypercholesterolemia.
Results After 3 months of treatment, BAP in group A did not change significantly compared with either the baseline value or that in group B. However, NTx in group A significantly decreased compared with both the baseline value and that in group B. In addition, ΔNTx was negatively correlated with NTx at baseline, and the significance of this correlation persisted after multiple regression analysis.
Conclusion Our findings suggest that pitavastatin may have potentially beneficial effects on bone metabolism primarily by reducing bone resorption rather than by stimulating bone formation. Further studies with more patients and longer duration are warranted to evaluate its effects, if any, on prevention of osteoporosis and subsequent fractures.

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Background and Objectives The clinical features of parvovirus B19 infection in adult patients have not been well described. The aim of this prospective study was to clarify the clinical features of adult patients with parvovirus B19 infection in primary care settings.
Methods The study subjects were adults over age 18 years who had visited one primary care clinic over a period of one year. They were chosen if they had at least two of the following three symptoms: edema, joint pain, and rash, and if they had contact with children with erythema infectiosum. The diagnosis was confirmed if anti-parvovirus B19 antibodies were identified. The process of these symptoms was recorded until they resolved.
Results Twenty patients met the inclusion criteria, and 14 (70%) patients were diagnosed with parvovirus B19 infection. The 14 adult patients consisted of two men and twelve women ranging from 33 to 63 years (median, 38 years). The patients consisted of two groups. In the first group, they presented with the first phase of infection showing symptoms such as malaise, muscle pain, and fever, and in the second phase presented with edema, rash, and joint pain that developed within two days of the first phase. In the second group, the first and second phases were clearly separated.
Conclusions Parvovirus B19 infection in adults can be efficiently diagnosed in primary care settings by observing clinical symptoms such as edema, joint pain, and rash, and by asking patients about their contact with children who have erythema infectiosum.

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A 35-year-old man presented with the complaint of epigastric discomfort. Gastrointestinal endoscopy and endoscopic ultrasonography revealed a cystic lesion 20 mm in size at the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed that the cystic lesion communicated with both the common bile duct and pancreatic duct via the common channel. Choledochocele was ruled out by close examination of the ERCP findings. The cystic lesion was surgically resected. Since histological findings revealed that the mucosa inside the lesion was duodenum-like and contained a layer of smooth muscle, the lesion was diagnosed as a congenital duplication cyst of the duodenum.

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Recently, autoimmune pancreatitis (AIP) has been reported with a variety of extra-pancreatic manifestations and infiltration of IgG4-positive cells into the affected organs. We report herein two cases with prostatitis. One was seen in a patient with typical AIP, and the other was observed without any clinical manifestation of AIP. Serum IgG4 levels were elevated in both cases. Histological examination of the prostates showed that parenchymal cells were partially or totally replaced with fibrosis and abundant infiltration of IgG4-positive cells. Significant uptake of [¹⁸F] fluorodeoxyglucose by the prostate was seen in both cases. In the case with AIP, the uptake completely disappeared after steroid therapy. The findings observed in these cases suggest that the pathological mechanism for prostatitis is similar to the mechanism previously implicated in AIP, namely IgG4-related autoimmune prostatitis.

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Coronary slow flow phenomenon is not an infrequent finding and is often associated with chest pain, but the mechanism has not been fully elucidated. We report a case of coronary slow flow phenomenon induced after contrast injection which was resolved by nicorandil administration. Therefore, the microvascular spasm might be an important factor in coronary slow flow phenomenon and contrast medium can be a trigger.

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This report describes a Japanese family with vessel and craniofacial abnormalities. Although the clinical findings of the patient's father fulfilled the diagnostic criteria for Marfan syndrome, arterial tortuosity, aneurysms, hypertelorism and a bifid uvula were noted in both the patient and his father. These findings were compatible with the clinical manifestations that were previously reported in Loeys-Dietz syndrome. A molecular genetic analysis demonstrated a heterozygous missense mutation of the transforming growth factor-beta receptor II gene in both the patient and his father, which thus caused Loeys-Dietz syndrome. This is the first Japanese family case report of typical Loeys-Dietz syndrome.

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We report a 31-year-old man with tuberculous meningitis (TM) mimicking CNS sarcoidosis. Although Mycobacterium tuberculosis (MTB) was not detected in CSF, the level of adenosine deaminase (ADA) in CSF was significantly raised. Brain biopsy showed caseous granuloma and a diagnosis of TM was made. The diagnosis of TM is often difficult and brain biopsy should be considered if MTB is not detected in the CSF. Evaluation of CSF ADA level could also strongly contribute to distinguishing TM from other meningitis. In addition to antituberculosis drugs, corticosteroid therapy was effective in our patient but careful reduction of its dosage was required.

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Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), complications of P. falciparum malaria are associated with a very high mortality but are rarely seen in P. vivax malaria. Herein, we report a 28-year old woman who developed ARDS after infection with P. vivax. In a systematic review the literature for the use of noninvasive ventilation (NIV) in cases of ALI/ARDS related to P. vivax, from among 45 reports noninvasive positive pressure ventilation (NIPPV) was used in the management of three cases of ALI/ARDS related to P. vivax. The use of NIV in vivax malaria related ALI/ARDS is associated with a good outcome.

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We treated 3 patients complicated with colon cancer without liver metastasis, who were admitted to our hospital because of a high fever and diagnosed with liver abscesses. In a general screening after performing percutaneous transhepatic abscess drainage, colon cancer was detected in each, though hepatobiliary diseases were not found. Hepatobiliary diseases were the most common etiology of hepatic abscesses in our hospital in the past 41 cases from 1990 to 2005, 3 of which were due to colon cancer. If a cause is not determined, general screening, especially of the colon tract, should be performed in hepatic abscesses patients.

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To discriminate between sarcoidosis and sarcoid reaction in the lymphadenopathy of malignancy is sometimes clinically important. We describe a case of sarcoidosis associated with double cancers of the esophagus and stomach. A patient who six months previously was found to have early gastric cancer, was then found to have esophagus cancer. The chest radiography demonstrated bilateral hilar lymphadenopathy. Pathological analysis of the lymph nodes and lungs showed non-caseating epithelioid cell granuloma, revealing the existence of sarcoidosis. The findings suggest that the possibility of systemic sarcoidosis should be considered in cases with established malignancy and newly disclosed radiographic findings.

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A 78-year-old man who had been diagnosed with ulcerative colitis was admitted because of uncontrolled severe, frequent, bloody diarrhea. He was treated with immunosuppressive therapy that included corticosteroid and azathioprine. Colonoscopy was used to assess disease activity. This revealed that the mucosa of his digestive tract from the rectum to the ileum was damaged. He developed a high-grade fever soon after colonoscopy. Blood culture demonstrated Listeria monocytogenes. Treatment was changed to intravenous ampicillin for 20 days. His general body symptoms, including the bloody diarrhea, improved after treatment. We assume that the colonoscopy induced Listeria monocytogenes septicemia through bacterial translocation in this patient.

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