To investigate the relationship between dipyridamole-induced ST depression and the severity of coronary artery stenosis, the dipyridamole injection test (D) at 0.568 mg/kg/4 min, and the symptomlimited treadmill exercise test (T) were performed separately in 16 normal volunteers and 167 patients who underwent coronary arteriography [91 patients without myocardial infarction (non-MI group) and 76 patients with previous myocardial infarction (MI group)]. Standard 12-lead electrocardiogram and body surface mapping of 87 leads were recorded in both tests. None of the normal volunteers had significant ST depression (≥0.10 mV) in D or T. Regarding the non-MI group, D had as high an incidence of ST depression as T (83% vs 93%) in patients with maximal coronary stenosis ≥90%, while in those with maximum coronary stenosis <90%, D had a lower incidence of ST depression than T (16% vs 48%, p < 0.01). For the MI group, the incidence of ST depression was compared to the maximal coronary artery stenosis supplying the non-infarcted area. In patients with maximal coronary artery stenosis ≥90%, D had as high an incidence of ST depression as T (71% vs 64%). While, D had a lower incidence of ST depression than T (19% vs 35%, p<0.05) in those with Maximum coronary artery stenosis <90%. For the diagnosis of coronary artery stenosis of ≥90%, D had as high sensitivity (non-MI group, 82% vs 93% ; MI group, 71% vs 64%) and higher specificity (non-MI group, 84% vs 52%, p < 0.01 ; MI group, 81% vs 65%, p < 0.05) compared with T. This study demonstrated that dipyridamole ECG is a sensitive and specific test to detect severe coronary artery stenosis.
(Internal Medicine 31 : 147-153, 1992)

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Intrahepatic infiltrate from 18 patients who died of fulminant hepatitis, was analyzed by an immunohistochemical method using formalin-fixed, paraffin-embedded liver sections and monoclonal antibodies. Inflammatory cells were characteristically located in the portal and periportal areas adjoining resting hepatocytes, but were infrequently found in the perivenular areas where hemorrhagic hepatocyte necrosis predominated. In the inflammatory infiltrate, Tcells were the most predominant cell type, composing about two-thirds of the total hepatic infiltrate, followed by lysozyme-positive macrophages which composed about one-third of the total hepatic infiltrate, irrespective of the etiology of the fulminant hepatitis. On the other hand, B cells made up less than 2% in all cases, and plasma cells were also few, less than 2% in 12 of 18 cases. Furthermore, an enhanced display of β₂-microglobulin on hepatocyte membranes was demonstrated in all cases with remaining hepatocytes, indicating an increased expression of class I MHC antigens on these cells. These results suggest that T cells may play an important role in the pathogenesis of the portal and periportal lesions of fulminant hepatitis, probbly with a help of MHC class I antigens on hepatocytes, while hemorrhagic necrosis of hepatocytes around the central veins may be caused by a different mechanism, most likely a circulatory disturbance secondary to cell-mediated immune reactions in the periportal areas.
(Internal Medicine 31 : 154-159, 1992)

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The significance of ultrasonography in the evaluation of metastasized neck and supra-clavicular lymph nodes from lung cancer was analyzed. By ultrasonography, the lymph nodes could be visualized clearly as low-echogenic round areas, and the size could be precisely measured in three dimensions. It was also possible to diagnose whether or not the lymph node adhered to the surrounding tissues and to determine the relationship and the connection of supraclavicular lymph node and upper mediastinal lymph node. The therapeutic effect related to the size of the lymph node was evaluable by ultrasonography. Therefore, the ultrasonographic approach to the neck and supraclavicular lymph nodes metastasized from lung cancer is considered to be useful for clinical use.
(Internal Medicine 31 : 160-164, 1992)

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Enalapril and trichlormethiazide were compared with respect to effects on the quality of life in a crossover study of 36 patients with hypertension. Multiple-choice 34-item questionnaires with three possible answers (severe, mild and none) per question were used to assess symptoms and mood. Twenty patients were initially given enalapril and 16 were initially given trichlormethiazide. There was no significant difference in the antihypertensive efficacy of the 2 drugs. Treatment with enalapril resulted in significant improvement in 11 of the 34 items, and a tendency for another 4 items to improve. Treatment with trichlormethiazide resulted in significant improvement in only 5 items and a tendency to improve in 2. When enalapril and trichlormethiazide were compared, significantly greater improvement in 2 items and a tendency toward greater improvement in 4 items was seen with enalapril treatment. Thus, enalapril was found to be more efficacious than trichlormethiazide with respect to quality of life in patients with hypertension.
(Internal Medicine 31 : 165-173, 1992)

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Data from 129 cases of central nervous systemic fungal infections reported in Japan between January 1979 and June 1989 were analyzed. Of 129 cases, 116 were cryptococcal meningitis, 6 candidal meningitis (including meningitis due to Trichosporon cutaneum) and 7 Aspergillus meningoencephalitis. Fifty-six of the patients with cryptococcal meningitis had an underlying systemic disease or condition. The overall survival rate was 72.4%, which was a markedly improved rate compared to earlier reports. Cryptococcal meningitis was treated most often with the combination of intravenous amphotericin B and 5-fluorocytosine and was associated with a survival rate of 81.8%. All 7 patients treated with fluconazole alone survived. Candidal meningitis occurred secondary to a shunt infection ; some patients with candidemia did well when adequate therapy was instituted. Aspergillus meningoencephalitis is most often diagnosed at autopsy or in surgical specimens and the prognosis of Aspergillus meningoencephalitis is generally poor.
(Internal Medicine 31 : 174-179, 1992)

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Magnetic resonance imaging, computed tomograpy, and liver biopsy findings were compared in ten patients with serum ferritin levels over 500ng/ml. The liver was observed as a low-intensity area on magnetic resonance imaging in all four patients with serum ferritin levels above 2, 000ng/ml, while no abnormalities were detected in four of the six patients with a serum ferritin level below 2, 000ng/ml. Computed tomography revealed the liver to be a high density area in five of the seven patients tested. However, it demonstrated no abnormality in a patient with steatosis despite a high serum ferritin concentration. Liver biopsy demonstrated iron deposits in nine of the ten patients. These findings indicate that liver biopsy remains the most accurate mean of detection of liver iron overload. Both magnetic resonance imaging and computed tomography could be used to be monitor the progress of a patient with liver iron overload treated by phlebotomy.
(Internal Medicine 31: 180-184, 1992)

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The relationship between the clinical parameters and chest film appearance was studied in patients with activ pulmonary tuberculosis. Patients with extended disease were often malnourished and had weak tuberculin reaction accompanied by lymphopenia. They excreted a large amount of mycobacterial bacilli and a longer period was required for negative conversion of sputum culture. We confirmed that the criteria for chest roentgenogram classification established by the Japanese Society for Tuberculosis ("Gakkai Classification") is useful in the estimation of the risk of infection and the prognosis of tuberculosis patients.
(Internal Medicine 31 : 185-188, 1992)

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To examine the possible association between the vascular complications of diabetes and changes in pulmonary function, we performed pulmonary function tests including assessment of the diffusing capacity (%DLco) in 80 patients with non-insulin-dependent diabetes mellitu (45 males and 35 females) without overt lung or heart disease. The mean age of the subjects was 57.9 years and the mean duration of diabetes was 10.8 years. The %DLco decreased significantly as the duration of diabetes increased (r=-0.38, p<0.01), and the same relationship was also observed in non-smoking subjects (N=37). The reduction in %DLco was greater in patients with diabetic microangiopathy (especially nephropathy) and in those treated with insulin. Other pulmonary function tests (%VC, FEV_1.0, PaO₂ and PaCO₂) showed no relationship to the duration of diabetes, the degree of microangiopathy or the type of treatment. These results suggest that diabetic microangiopathy may play an important role in the decrease of %DLco.
(Internal Medicine 31 : 189-193, 1992)

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Samples from 349 patients with systemic lupus erythematosus (SLE) were tested simultaneously for lupus anticoagulant (LAC) and anticardiolipin antibodies (ACL). LAC was detected in 27.2% of 349 SLE patients by a modified mixing kaolin clotting time. ACL was detected in 34.7% by enzyme-linked immunosorbent assay. Only half of the patients who had LAC or ACL were positive for both of them. In addition, isotypes of ACL in these patients were studied. The IgG isotype was detected in 81.8% of 121 patients, and more than half had only the IgG isotype. When clinical features of patients with LAC or ACL were studied, the incidence of thrombosis, fetal loss, and thrombocytopenia were significantly higher in both groups compared with patients without LAC or ACL. In particular, the patients with both LAC and ACL showed the highest risk of fetal loss (89%) during pregnancy. These results indicate that LAC and ACL are detected in partly different groups of SLE patients, but both of these groups are clinically similar.
(Internal Medicine 31 : 194-199, 1992)

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A46-year-old woman with chronic thyroiditis who had been receiving thyroid hormone treatment for 10yr developed severe hypothyroidism (FT₄ 0.37ng/dl, FT₃ 1.38pg/ml, TSH 151.00μU/ml) following tumor necrosis factor-α (TNF) infusion for the treatment of a complicated cutaneous T-cell lymphoma. Indirect immunofluorescence staining of thyroid follicular cells showed aberrant expression of HLA class II antigens. The mechanisms underlying the exacerbation of the hypothyroidism may be an augmentation of immunological processes in the thyroid and a direct action of TNF on the synthesis and secretion of thyroid hormone.
(Internal Medicine 31 : 200-203, 1992)

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Patients with Minamata disease (methylmercury intoxication) usually suffer from the glove and stocking type hypesthesia in the extremities. Recently it is believed that the sensory disturbance of the disease may be a manifestation of the cerebral involvement. The aim of this study was to determine the pain threshold of their extremities and body by algesimeter. The results showed that a majority of the patients had elevated pain thresholds in the body and the extremities, and suggest that the pain impairment is not responsible for the peripheral nerve involvement.
(Internal Medicine 31 : 204-207, 1992)

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We report two hepatitis B virus (HBV) carriers who had liver failure after withdrawal of corticosteroids (steroids) administered for treatment of serious asthmatic attacks. Liver functions deteriorated 1 to 2 wk after withdrawal of the steroid therapy and liver failure occurred. Steroid readministration and intensive therapy for liver failure did not prevent death. An excessive immune response provoked by steroid withdrawal and decreased reserve capacity due to underlying chronic liver disease were thought to be factors in the liver failure. Caution must be exercised in the administration of steroids to patients with underlying chronic HBV infection to prevent exacerbation of hepatitis. Prompt readministration of steroids is indicated if evidence of liver failure develops.
(Internal Medicine 31 : 208-213, 1992)

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Two patients with acute myeloid leukemia (AML)developed a chronic myelomonocytic leukemia (CMMoL)-like state after chemotherapy. Both patients showed morphological evidence of myelodysplasia together with acute leukemia at presentation (Case 1 : M_5b with trilineage myelodysplasia and Case 2 : M₄ with dysmegakaryocytopoiesis). They also showed persistent monocytosis without prominent blast cell proliferation after induction therapy. The possibility was suggested that these two patients were in acute transformation from CMMoL at presentation and returned to a CMMoL-like state after induction therapy.
(Internal Medicine 31 : 214-217, 1992)

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Progressive multifocal leukoencephalopathy (PML) developed in a 64-year-old woman who had undergone hemodialysis treatment due to chronic renal failure (CRF) for 6 yr. Her initial symptom was ataxia, and computed tomographic (CT) scan and magnetic resonance imaging (MRI) suggested a demyelinating disease of the cerebellum. Her cell-mediated immunity was impaired. At autopsy, the cerebellar disease was confirmed as PML by ultrastructual and immunohistochemical studies. Moreover, the JC type of papova virus infection was verified by Southern blot analysis.
(Internal Medicine 31 : 218-223, 1992)

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Four hepatitis C patients with intrafamilial clustering of hepatitis C virus (HCV) infection are reported. Antibodies to C100-3 antigen, capsid protein of HCV and GOR epitope were tested to detect histories of HCV infection. Transmission of HCV from mother to children, from father to children, and from wife to husband was implicated. Of all family members studied, three were positive for all antibodies, one for only antibody to capsid protein, two for antibodies to capsid protein and GOR epitope but negative for antibody to C100-3 antigen and onevice versa.
(Internal Medicine 31 : 224-226, 1992)

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An electrophysiologic study was performed on a patient with ischemic sustained ventricular tachycardia (VT). During pacing at the right ventricular apex, ventricular double potential was recorded at the left ventricular apex. Sustained VT was induced by double extra stimuli from the right ventricular apex. Three types of VTs with different QRS morphologies were observed, and each VT was changeable to other types. The interval between one of the two potentials and the surface QRS was constant during all VTs, but the other potential showed dissociation from the surface QRS. During this dissociation, an intrinsic rhythm of the potential was sometimes shorter than the cycle length of the VT. The mechanism of a block between the VT and a bystander could hardly explain these electrophysiologic findings. Concealed double ventricular tachycardia was considered to be the likely mechanism.
(Internal Medicine 31 : 227-231, 1992)

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A63-year-old patient with Henoch-Schönlein purpura (HSP) nephritis showed progressive proteinuria. Purpura was observed in the extremities as well as in the trunk without any preceding upper respiratory tract infections or drugs, and it disappeared after corticosteroid therapy although mild proteinuria continued throughout the therapy. Renal biopsy specimens showed mesangial IgA deposits in the glomeruli, but no IgA deposits were observed in the dermal vessels or in the intrarenal extraglomerular capillaries. Progressive proteinuria was improved with 37.5mg/day of captopril. Severity of HSP nephritis in middle-aged to aged patients in the literature was reviewed. It was suggested that careful observation is required in aged patients with HSP nephritis.
(Internal Medicine 31 : 232-238, 1992)

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A case of Goodpasture's syndrome with anti-myeloperoxidase (MPO) antibodies is reported. Histological examination revealed crescentic glomerulonephritis and alveolar hemorrhage with linear deposition of IgG along the glomerular capillary walls and alveolar capillary walls by immunofluorescence microscopy. Not only anti-glomerular basement membrane (GBM) antibodies but also anti-MPO antibodies, an anti-neutrophil cytoplasmic antibody, were simultaneously detected in the serum. Although it is generally accepted that crescentic glomerulonephritis in Goodpasture's syndrome is mediated by anti-GBM antibodies, this case suggested that anti-MPO antibodies might also participate in the pathogenesis of crescentic glomerulonephritis and probably alveolar hemorrhage of Goodpasture's syndrome, especially with vasculitis.
(Internal Medicine 31 : 239-243, 1992)

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Immune thrombocytopenia is a rare complication of progressive systemic sclerosis (PSS). A 47-year-old female with PSS treated with D-penicillamine developed immune thrombocytopenia, which promptly responded to prednisolone and withdrawal of D-penicillamine. Platelet-associated IgG was elevated and the bone marrow megakaryocyte count was normal. There was an inverse relationship between the level of platelet-associated IgG and the platelet count. A lymphocyte stimulation test sensitized by D-penicillamine was positive. The present case suggests that immunethrombocytopenia may be regarded as one of the D-penicillamine-related immune abnormalities. To our knowledge, its association with PSS has never been reported.
(Internal Medicine 31 : 244-245, 1992)

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A 66-year-old Japanese man presented with persistent hyponatremia without polydipsia and polyuria. Laboratory examination showed serum sodium of 117mEq/l, plasma osmolality 239mosm/kg, urine sodium 108mEq/l, urine osmolality 577mosm/kg, and normal levels (<2.0 pg/ml) of serum antidiuretic hormone (ADH). ADH release was regulated normally with changes in plasma osmolality. No obvious cause for the syndrome of inappropriate secretion of ADH (SIADH) could be detected. However, 20 months later, the patient had bouts of hematuria and was found to have cancer of the urinary bladder. Increased renal sensitivity to ADH was suspected as the underlying mechanism of SIADH.
(Internal Medicine 31 : 246-250, 1992)

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The progressive renal failure of a 49-year-old female diabetic patient with renal insufficiency and hypothyroidism was successfully prevented by levothyroxine sodium treatment. Her renal function worsened in parallel with the exacerbation of hypothyroidism. Cessation of progressive renal failure was observed after administration of levothyroxine sodium (0.05mg daily) for more than 24 months. Mean slopes of reciprocal serum creatinine levels for 12 months before and after the administration of levothyroxine sodium were -1.67×10^-3 and +8.68×10^-4, respectively. It was suggested that levothyroxine sodium was effective in the prevention of progressive renal failure in this patient.
(Internal Medicine 31 : 251-255, 1992)

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We report herein a case with myxedema (primary hypothyroidism) associated with marked ascites that was found during the course of examination for a suspected decompensated state of liver cirrhosis or malignant disease. Aspirated ascitic fluid was found to have the characteristics of the exudate. Thyroid hormone replacement resulted in rapid clinical improvement with resolution of the ascites. This case is an unusual association of hypothyroidism as a cause of ascites. In all cases with ascites of unknown etiology, the differential diagnosis requires consideration of myxedema.
(Internal Medicine 31 : 256-259, 1992)

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A 45-year-old woman who underwent gastrectomy for gastric carcinoma which had metastasized to the liver and ovaries, showed high serum levels of hCG, AFP and CEA. To locate the source, an immunohistochemical technique was utilized. HCG-producing cells were detected in poorly differentiated adenocarcinoma of a primary tumor and an ovarian metastatic site, and AFP-producing cells in poorly differentiated adenocarcinoma forming a medullarypattern of primary site and metastatic foci. CEA-producing cells were found diffused in primary tumor and metastatic foci. From the viewpoint of oncodevelopmental gene expression (Cancer Res 36 : 3423, 1976), it is interesting that the serum levels of these three tumor markers (hCG, AFP, CEA) were elevated simultaneously.
(Internal Medicine 31 : 260-264, 1992)

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A 53-year-old male was hospitalized with complaints of cough, fever and backache. Two-dimensional echo-cardiography showed a pericardial echo-free space and a mass in the rightatrium. Based on the MRI findings showing a pericardial mass originating from the atrial tumor, the final diagnosis of leiomyosarcoma was made by a percutaneous pericardial biopsy. Despite various therapies, the patient died after 3 wk. Because of its rareness (to date only 25 case reports), a premortem diagnosis of primary cardiac leiomyosarcoma is generally difficult. However, we feel that MRI and a subsequent biopsy is quite useful for making an early diagnosis of this disease.
(Internal Medicine 31 : 265-268, 1992)

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A 26-year-old Chinese-Malaysian female patient with β-thalassemia is presented. The main hematological values found in this patient were as follows : 1) normocytic hypochromic anemia (RBC 444×10⁴/μl, Hb 11.8g/dl) with marked anisopoikilocytosis, 2) erythroidhyperplasia, and 3) increased HbF (HbA 41.4%, HbA2 2.9%, HbF 48.9%). DNA obtained from peripheral leukocytes was analyzed using dot blot hybridization of the polymerase chain reaction (PCR)- amplified DNA with allele-specific oligonucleotide probes. A C→T substitution at position 654 of the second intervening sequence (IVS-2) was detected in her β-globin clone.
(Internal Medicine 31 : 269-272, 1992)

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We carried out chromosomal analysis of a 33-year-old male who was diagnosed as having aplastic anemia. The patient showed severe pancytopenia, a normal NAP score, hypoplastic marrow and no myelodysplastic changes. 45, XO was found in all bone marrow cells examined, and in 10% of peripheral blood cells examined. To our knowledge, this is the first reported case of male aplastic anemia to show loss of the Y chromosome in all bone marrow cells examined, and this case may suggest a possible mechanism of juvenile onset of aplastic anemia.
(Internal Medicine 31 : 273-276, 1992)

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We report a case of granulocyte colony-stimulating factor (G-CSF) producing lung cancer. A 38-year-old Japanese woman had a large cell undifferentiated carcinoma of the left lung with severe granulocytosis without any evidence of infection. A specimen was taken from a metastatic cervical lymph node and a tumor cell line was established. The culture supernatant of the line as well as patient's serum exhibited a high level of G-CSF by sandwich enzyme immunoassay. Immunohistochemical analysis demonstrated that tumor cells from transplanted nude mice were stained granularly in the cytoplasma by anti-human G-CSF monoclonal antibody, 4A6.
(Internal Medicine 31 : 277-280, 1992)

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An elderly patient with asymptomatic bilateral Bochdalek hernias is reported. The chest roentogenogram showed dome-shaped supradiaphragmatic masses about 6cm in diameter in the posteromedial regions of both sides of the lungs. Computed tomography showed a discontinuity of the lines of diaphragmatic musculature in the left thorax, and a mass with a homogenous low density area indicative of fatty tissues in the right thorax. The magnetic resonance imaging, coronal and sagittal T1-weighted images revealed interruptions of the diaphragmatic musculature adjacent to the masses and protrusion of retroperitoneal fat into the thoracic cavity. The lesions were therefore diagnosed as bilateral Bochdalek hernias of the diaphragm.
(Internal Medicine 31 : 281-283, 1992)

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Primary malignant fibrous histiocytoma (MFH) of the liver is reported in a 79-year-old man. The tumor, measuring 8.0×8.0×6.0cm, was located in the left lobe of the liver and consisted of spindle cells in a storiform pattern intermingled with bizarre giant cells. Immunohistochemically, most of the tumor cells expressed vimentin. Cytoplasmic immunoreactivity for α₁-antichymotrypsin was documented in the giant cells. However, epithelial expression could not be demonstrated.
(Internal Medicine 31 : 284-288, 1992)

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Primary biliary cirrhosis (PBC) was diagnosed in two siblings, a 42-year-old male and his 49-year-old sister. Furthermore, they were complicated with three types of autoimmune diseases : polymyositis, Hashimoto's thyroiditis and vasculitis of the right axillary artery. Although PBC is often associated with other autoimmune diseases, reports of the association with polymyositis and vasculitis syndrome are rare. Familial clustering of PBC with autoimmune diseases is also rare.
(Internal Medicine 31 : 289-293, 1992)

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A 64-year-old man with renal artery thrombosis (RAT) associated with nephrotic syndrome (NS) is reported. Although this patient was diagnosed as NS due to membranous glomerulonephritis (MGN) and treated with prednisolone, RAT occurred as a result of unknown mechanisms and caused mild renal dysfunction. Creatinine clearance has been about 70 ml/min for 9 years since the onset of RAT. The renal scintigraphic image has not changed since the onset. NS responded to prednisolone therapy initially and at the time of the relapse. Recent data have shown proteinuria levels of less than 0.2 g/day.
(Internal Medicine 31: 294-297, 1992)

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