This study was designed to characterize the nocturnal fall of blood pressure (NFBP) of elderly hypertensive patients (EH), with or without cerebrovascular disease or diabetes mellitus, as measured by automated blood pressure (BP) monitoring. Systolic and diastolic BP and heart rate was measured every 15 minutes in 133 hospitalized patients with nearly similar schedules and diets. The patients were divided into five groups : I, normotensive elderly patients over age 65 : II, EH without cardiovascular diseases, controlled without medication : III, EH with cerebral infarction, chronic stage : IV, EH with noninsulin-dependent diabetes mellitus : and V, hypertensives under age 65, without cardiovascular diseases. A significant NFBP was observed in the patients of groups I and V, a significant but smaller NFBP in the hypertensives of groups II and IV, and no NFBP in the patients of group III. Administration of the antihypertensive drugs, enalapril and nifedipine, tended to augment the NFBP. These preliminary observations showed that NFBP did occur in elderly hypertensives but the fall was smaller than that observed in younger hypertensives or elderly normotensives. Although the ambulatory BP measurements were useful in the overall clinical evaluation of elderly patients, NFBP in elderly patients was affected by hypertensive drugs and therefore NFBP should be interpreted with caution.
(Internal Medicine 31:441-446, 1992)

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The number of atopic patients presenting only chronic non-productive cough appears to be increasing. This study was conducted to confirm the existence of non-asthmatic cough associated with atopy. We prospectively examined atopic findings, therapeutic effects of inhaled procaterol, azelastin, and/or glucocorticoids, improvement of FEV₁i by bronchodilator therapy and bronchial responsiveness to methacholine in 20 patients. The cough was relieved by inhaled procaterol in 10 patients (Group 2) but not in the other 10 patients (Group 1). The increase in FEV₁ by inhaled salbutamol following aminophylline injection was significantly less in Group 1 than in Group 2. Bronchial responsiveness to methacholine was normal in Group 1 while that in Group 2 was hyperreactive. These findings indicate that there is atopic non-asthmatic bronchodilator-resistive cough (Group 1) which is a different entity from bronchodilator-responsive cough (Group 2), or the so-called "cough variant asthma".
(Internal Medicine 31:447-452, 1992)

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We assessed the hourly coefficient of variance of RR intervals (CVRR) in 29 subjects with non-insulin-dependent diabetes mellitus and 19 age-matched healthy subjects using an ambulatory 24-hour ECG monitoring system. We also evaluated CVRR during 100 beats in both groups in the supine posture at 07:00 and 10:00 in the morning. Hourly CVRR showed an overt diurnal variation in both groups especially in the daytime and at midnight, but was significantly lower (p<0.05) in diabetic patients. CVRR during resting 100 beats at 07:00 was significantly higher (p<0.05) than that at 10:00 in both groups. These findings indicate that HRV shows an obvious diurnal variation in both groups. As a steep and marked change occurs in the morning, careful consideration is necessary to assess the test performed for a short time span at random times throughout the day, particularly in the morning.
(Internal Medicine 31:453-456, 1992)

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A 60-year-old male with acute promyelocytic leukemia demonstrated bilateral diffuse airspace consolidation on chest X-ray. An autopsy on the next day revealed pure pulmonary alveolar hemorrhage without leukemic infiltration or inflammation. Disseminated intravascular coagulation was confirmed microscopically. In severe hemorrhagic diathesis and leukopenia, it is impossible to distinguish pulmonary hemorrhage from pneumonia by X-ray alone. Broncoalveolar lavage may be the only possible diagnostic approach.
(Internal Medicine 31:457-458, 1992)

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A rare occurrence of the association of parathyroid adenoma in a case of thyroid papillary carcinoma is described. The patient was incidentally found to have parathyroid adenoma which was preoperatively diagnosed to be a metastatic lymph node. Analysis of her serum obtained before operation showed an elevation of serum parathyroid hormone (PTH) concentration without hypercalcemia. Since the association of hyperparathyroidism is high in patients with thyroid diseases, examination of not only serum levels of calcium and PTH but also careful interpretation of computed tomography (CT) and/or nuclear magnetic imaging (MRI) is necessary in the diagnosis of co-existing asymptomatic hyperparathyroidism.
(Internal Medicine 31:459-462, 1992)

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A 63-year-old man who developed episodes of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) twice in the course of multiple sclerosis (MS) is reported. SIADH in this patient occurred only during the administration of antibiotics (sulbactam/cefoperazone, SBT/CPZ). At autopsy, demyelinating lesions in the optic nerves, cervical and thoracic spinal cord, and areas adjacent to the lateral ventricles were observed. Destruction and loss of neuronal cells were found in the supraoptic nuclei. Lymphocytic infiltration was observed in the area adjacent to the supraoptic nuclei. Destruction and swelling of axons and reactive astrocytic gliosis were observed in the hypothalamus. SIADH associated with MS is rare and the histological findings in such a case have not yet been reported. It is suggested that the development of SIADH in MS may be related to the damage in the supraoptic nuclei of the hypothalamus.
(Internal Medicine 31:463-466, 1992)

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A 65-year-old Japanese man who suffered from secondary hypopituitarism due to Rathke's cleft cyst is reported. Although computed tomography failed to detect any pituitary abnormality, magnetic resonance imaging demonstrated the presence of a cystic intrasellar mass, initially suggesting craniopharyngioma or abscess. Operative findings revealed Rathke's cleft cysts within the pituitary fossa which resulted in secondary hypopituitarism. Among cases of secondary hypopituitarism with abnormal findings in the pituitary, symptomatic Rathke's cleft cysts should be included in the differential diagnosis of adrenal insufficiency.
(Internal medicine 31 : 467-469, 1992)

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Here we describe four young Japanese women aged 25-33 years, whose clinical findings are characterized by episodic angioedema, marked leukocytosis with eosinophilia, benign course with spontaneous remission or low-dose prednisolone treatment. The recognized causes of eosinophilia, such as allergy, parasite, and collagen diseases, and the causes of edema, such as heart, kidney, and liver diseases, were ruled out. The findings in these patients are very similar to those reported as episodic angioedema with eosinophilia, which is clearly distinct from the socalled hypereosinophilic syndrome. We suggest that this syndrome is not rare, and should be widely recognized as a new clinical entity for accurate and prompt diagnosis.
(Internal Medicine 31 : 470-473, 1992)

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A 67-year-old woman with Sjögren's syndrome was found to have left hydronephrosis and stenosis of the left ureter. Exploratory laparotomy disclosed a nodule at the ureteropelvic junction of the left ureter. Histopathological examinations of the biopsied specimen of this nodule showed lymphoid hyperplasia within the ureteral wall. Low dose prednisolone improved hydronephrosis and pseudolymphoma within several months. Hydronephrosis secondary to pseudo-lymphomatous infiltration of the ureter is a rare but, if properly treated, reversible complication of Sjögren's syndrome.
(Internal Medicine 31 : 474-477, 1992)

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A 16-year-old girl with anorexia nervosa first presented with malnutrition, liver dysfunction, and rhabdomyolysis. Administration of fluid and nutrition saved her from the initial critical state, but acute renal failure followed. Laboratory examination revealed intrinsic renal failure induced by rhabdomyolysis. Latent phosphate depletion and refeeding-induced hypophosphatemia was implicated as the cause of rhabdomyolysis ; however coexisting hypotension, dehydration, and liver dysfunction may have contributed to the renal failure. The patient recovered from azotemia by hemodialysis. This is the first reported case of anorexia nervosa with acute renal failure resulting from rhabdomyolysis induced by hypophosphatemia or phosphate depletion.
(Internal Medicine 31 : 478-482, 1992)

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A 67-year-old female was admitted to our hospital because of pancytopenia. Forty-six percent of erythroblasts in the bone marrow were ringed sideroblasts. Laboratory findings showed an IgG-κ monoclonal gammopathy. She was diagnosed as having sideroblastic anemia associated with multiple myeloma in mosaic (45, X/46, XX/47, XXX) Turner's syndrome. There was no response to therapy. The chromosomal pattern of the patient was varied, and was accompanied by the development of refractory anemia with an excess of blasts from refractory anemia with ringed sideroblast 4 months after presentation. Cytogenetic studies suggested that the abnormal clone was restricted to the monosomic cell line.
(Internal Medicine 31 : 483-485, 1992)

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A patient with myelocytic leukemia who showed electrical alternans of the T-U wave with no change in the QRS complex following chemotherapy is described. Electrocardiogram taken 4 days later showed ventricular quadrigeminy in which the T-U wave of the first sinus beat after the ventricular premature contraction was markedly less prominent compared to the successive two sinus beats which showed marked prolongation and inverted T-U waves. The causative factors for alternans of T-U waves may include hypochloremic alkalosis with hypopotassemia and myocardial damage by anticancer drugs such as daunomycin and aclarubicin chloride used for the underlying disease.
(Internal Medicine 31 : 486-488, 1992)

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A 31-year-old man with multiple osteomyelitis due to Mycobacterium avium is reported. The patient had been on prednisolone for systemic lymphadenopathy which was thought to be caused by sarcoidosis. In June 1990, he noticed high fever and general bone pain. He was found to have multiple lytic lesions in the bones which were biopsied showing acid-fast bacilli. This organism was revealed to be M. avium. The chest radiograph film revealed no abnormal pulmonary findings. Multiple bone lesions in the absence of pulmonary disease is reported to be rare for atypical mycobacterial infection.
(Internal Medicine 31 : 489-492, 1992)

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We describe a patient with rheumatoid arthritis (RA) who had preceding evidence of post-transfusion non-A, non-B hepatitis. The patient showed positive serological tests for anti-hepatitis C virus (HCV) antibody. The manifestations of RA, including progressive polyarthritis and positive serum rheumatoid factors, emerged after the ameriolation of hepatitis and persisted for more than 3 years, indicating that the polyarthritis in this patient was not the prodrome of the hepatitis. This patient had HLA-DR4 and HLA-Bw54 which are found to be strongly associated with RA in Japan. It is therefore suggested that HCV may trigger the development of RA especially in genetically susceptible individuals.
(Internal Medicine 31 : 493-495, 1992)

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A 66-year-old Japanese male with diffuse non-Hodgkin's lymphoma, of the pleomorphic type, complicated with Klinefelter's syndrome is reported. His phisique was characterized by a long arm span, disproportionately longer lower body dimensions and a small sized penis. He had no children. Chromosomal study revealed 47, XXY and hormonal quantification showed hypergonadtropic hypogonadism. Although chemotherapy was administered, his disease took a progressive course and he died. A discussion of chromosomal alteration and oncogenesis and review of the literature are included.
(Internal Medicine 31 : 496-499, 1992)

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A patient with polyarteritis nodosa (PN) presenting with exophthalmos and facial swelling, which are rarely found in PN, is reported. The patient, a 27-year-old male, complained of painful facial swelling and diplopia. Physical examinations showed facial swelling around the right orbit and exophthalmos. After admission, he experienced myalgia in both calves. Laboratory studies disclosed leukocytosis and liver dysfunction. Celiac and renal angiograms showed aneurysms. A biopsy specimen of his left calf showed an arterial inflammatory process. The patient was diagnosed as having PN. He had an excellent response to corticosteroids, with prompt improvement.
(Internal Medicine 31 : 500-503, 1992)

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A 36-year-old woman was admitted for idiopathic plasmacytic lymphadenopathy with polyclonal hyperimmunoglobulinemia (IPL) associated with nephrotic syndrome. She was expected to lapse into renal failure because renal biopsy showed focal glomerulosclerosis. VEMP chemotherapy and bolus methyl prednisolone were not effective against excessive urine protein of over 10g/day. We thus began administration of ticlopidine (6mg/kg/day), prednisolone (0.4mg/kg/day) and cyclophosphamide (1mg/kg/day). After 3 months of this regimen, the urine protein level decreased to less than 0.5g/day, and renal function was maintained for more than 3 years. It is suggested that ticlopidine is effective for nephropathy complications associated with IPL.
(Internal Medicine 31 : 504-507, 1992)

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An outbreak of Legionnaires' pneumonia occurred at a nursing home in December1990. A 79-year-old female and a 73-year-old male clerk who were staying at the nursing home developed pneumonia with only a 5-day interval. Legionella pneumophila serogroup I was isolated from transtracheal aspirate of the former and sputum of the latter. After treatment with a combination of erythromycin and rifampicin both patients improved. Serological surveillance of inpatients and staff of the nursing home was performed in February 1991. Seven out of 51 samples (14.0%) showed a titer higher than 1:128 of anti-Legionella pneumophila serogroup I antibody determined by indirect immunofluorecence ; two of these seven complained of respiratory symptoms. Molecular epidemiology analyzed by restriction endonuclease digestion of isolated L. pneumophila showed an identical pattern which suggested a common origin.
(Internal Medicine 31 : 508-512, 1992)

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A 70-year-old man was admitted to our hospital because of paraplegia. A spinal epidural tumor (Th VII-XI) was diagnosed by magnetic resonance imaging and resected. Histological examination of the tumor showed non-Hodgkin's lymphoma of the diffuse large cell type (Lymphoma Study Group classification), with a B cell phenotype. The clinical stage was I_EA by the Ann Arbor classification. Radiation therapy of the involved field was performed (total dose : 40Gy), followed by six courses of modified cyclophosphamide, adriamycine, vincristine, prednisolone (CHOP) therapy. He was discharged walking unaided 10 months later and has shown no evidence of relapse in the 26 months since discharge.
(Internal Medicine 31 : 513-515, 1992)

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A 63-year-old male complainined of right upper abdominal pain and jaundice. Laboratory data on admission showed hyperbilirubinemia, elevation of biliary enzymes and an extraordinarily high value of serum CA19-9 (60, 000 U/ml). Diagnostic imaging modalities including abdominal ultrasonogram, abdominal CT and PTC suggested a stone impaction of the common bile duct. Jaundice subsided after PTC-drainage in association with decreasing serum CA19-9 value, which returned to the normal level six weeks later. Spontaneous delivery of the stone via the fistula was confirmed by cholangiography through the drainage tube. Though there are few reports of such a high serum CA19-9 level, the possibility of benign biliary tract disease should be considered in patients showing an extraordinarily high serum CA19-9 value.
(Internal Medicine 31 : 516-520, 1992)

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A 46-year-old woman previously diagnosed as having systemic lupus erythematosus presented with severe hypoalbuminemia and anasarca. She was demonstrated to have protein-losing enteropathy without any other active symptoms of SLE. Her bowel habit was normal and endoscopic examination revealed non-specific colitis and a small ulcer in the duodenum. Serum biochemistry showed an abnormal profile of the serum protein, including severe hyperlipoproteinemia and hyperfibrinogenemia. The process of protein-losing was not selective in terms of the molecular size. All of these symptoms and the abnormalities in laboratory data were improved by corticosteroid therapy.
(Internal Medicine 31 : 521-524, 1992)

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A case of lung cancer associated with eosinophilia in the peripheral blood and pleural fluid is reported. A 55-year-old man With a tumor in the right lower lung lobe and right pleural effusion was admitted to Ehime University Hospital. Histology of specimens biopsied under a bronchoscope revealed that he had poorly differentiated squamous cell carcinoma. On admission, his peripheral blood leukocyte count was 11, 500/μl with 7.8% eosinophils and the pleural fluid showed a high eosinophil count (60.5%). After chemotherapy, blood eosinophilia disappeared and the pleural effusion was decreased with the reduction of the tumor. The patient's serum had the activity to stimulate eosinophil proliferation in human bone marrow cell culture, suggesting that the tumor may have produced an eosinophil proliferating factor.
(Internal Medicine 31 : 525-529, 1992)

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We report a 29-year-old Japanese female with severe hypertension and unilateral renal dysplasia, which is rarely found in adults. The involved kidney was surgically removed and then the blood pressure fell to borderline levels without any changes in plasma renin activity or plasma aldosterone concentration. Histological examinations revealed typical renal dysplasia without hyperplasia of the juxtaglomerular apparatus. Unilateral renal dysplasia may be a cause of secondary hypertension in adults, though the mechanisms are still unknown.
(Internal Medicine 31 : 530-533, 1992)

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A 38-year-old man with a history of bronchial asthma developed marked eosinophilia, mononeuritis multiplex and transient pulmonary infiltration. Pathological findings from the lung and nerve biopsy were helpful in determining the diagnosis as allergic granulomatosis and angiitis (AGA). Echocardiogram indicated dilation of the left ventricle with impaired systolic contraction. Coronary arteriography demonstrated significant stenosis only in the peripheral segment of the circumflex artery. After 1 year of corticosteroid therapy, echocardiogram revealed improvement of left ventricular contractility evaluated by ejection fraction (from 28% to 67%). To our knowledge, no previous reports have described amelioration of severe cardiac lesions during long-term steroid treatment in patients with AGA.
(Internal Medicine 31 : 534-539, 1992)

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A 63-year-old woman with chronic necrotizing pulmonary aspergillosis complicated by active pulmonary tuberculosis is reported. A small infiltrative shadow appeared, but no definite diagnosis was made. Six years later the shadow was found to have increased in size ; chest CT revealed a fungus ball, while a transbronchial lung biopsy revealed aspergillus hyphae. The intrabronchial inoculation of amphotericin B proved ineffective, and a lobectomy was performed. Histopathologic findings showed necrotic granulomas containing aspergillus and some acid-fast bacilli. While the superinfection of healed tuberculous lesions by Mycobacteria or Aspergillus species is well documented, their coexistence is rare.
(Internal Medicine 31 : 540-543, 1992)

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A 42-year-old Japanese male was admitted to our hospital because of congestive heart failure (CHF). A diagnosis of primary amyloidosis was made on the basis of a heavy deposition of amyloid in the gastric submucosal tissue in addition to the hematological and immunological findings. Intermittent chemotherapy in combination with daily oral dimethylsulfoxide (DMSO) resulted in a dramatic decrease of plasma cells in the marrow as well as a gradual improvement of CHF. With this therapy, the cardiac ejection fraction was markedly improved. This case indicates that the long-standing administration of DMSO combined with cytoreductive chemotherapy is therefore effective in treating some cases with primary amyloidosis.
(Internal Medicine 31 : 544-548, 1992)

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A 51-year-old male was admitted because of eyelid edema and anosmia, which developed in 1985. He showed bilateral cervical lymphadenopathy, with nodes larger than 2×2cm, and remarkable eyelid edema. Anemia, hyperimmunoglobulinemia with hypo-albuminemia (no M-protein) and liver dysfunction were found. Bone marrow, renal function, urine analysis and LDH level were normal. Cervical lymph node biopsy showed interfollicular proliferation of plasma cells without any malignant appearance. On day 3 of oral prednisolone (PD), anosmia abruptly improved and from day 7, eyelid swelling, cervical lymphadenopathy and gammopathy subsided gradually. Since PD was tapered off, no relapse has been observed thus far.
(Internal Medicine 31 : 549-552, 1992)

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A 56-year-old male was admitted to our hospital with lymphocytosis (16.4×10⁹/1 ; 79% lymphocytes including 50% small lymphocytes), generalized lymphadenopathy, massive splenomegaly, and heavily infiltrated bone marrow. Immunophenotype analysis of the neoplastic cells in the bone marrow revealed that they were B cells (CD20+CD19+Ia1+sIgM+) positive for CD10. By contrast, the cells in the lymph node were CD20+CD19+Ia1+sIgM+ but negative for CD10. The patient was tentatively diagnosed as having lymphosarcoma cell lymphoma, however, the final diagnosis was leukemic phase of intermediate lymphocytic lymphoma. We concluded that CD10+ neoplastic cells in the bone marrow and peripheral blood had differentiated to CD10- cells.
(Internal Medicine 31 : 553-556, 1992)

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A 50-year-old female patient was admitted because of an enormously enlarged spleen and thrombocytopenia. Ultrasonography and magnetic resonance imaging revealed multiple space-occupying lesions in the spleen. She was diagnosed as having Gaucher's disease based on the low level of beta-glucosidase activity in leukocytes and Gaucher's cells present in bone marrow aspirate. Severe hypersplenism necessitated splenectomy. Pathological studies of the excised spleen, including ultrastructural examinations, demonstrated that multiple space-occupying lesions in the spleen were composed of typical Gaucher cells.
(Internal Medicine 31 : 557-560, 1992)

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An idiopathic hypoparathyroidism-induced cardiomyopathy patient had severe long-lasting hypocalcemia. The dramatic improvement of cardiac function with correction of only the serum calcium concentration could be quantitatively demonstrated on both echocardiogram and ventriculogram. The concentration of the extracellular calcium ion was considered to have a direct effect on the strength of the myocardial contraction through excitation-contraction coupling. Furthermore, elevated serum creatine phosphokinase and lactate dehydrogenase levels which were thought to be delivered from skeletal muscle returned to the normal range concomitant with the correction of hypocalcemia. The serum calcium concentration and these enzyme levels showed significant inverse correlations.
(Internal Medicine 31 : 561-568, 1992)

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A 77-year-old woman with primary esophageal non-Hodgkin's lymphoma in clinical stage I_EA (Ann Arbor Classification) developed pain and difficulty in swallowing. An upper gastrointestinal examination revealed a submucosal tumor from the upper to the middle portion of the esophagus. Histopathological examination at endoscopic biopsy with endoscopic partial incision showed non-Hodgkin's lymphoma(diffuse type-large cell). Immunohistological examination of tumor cells disclosed LCA (+), CD3 (DAKO) (+), MT1 (+), UCHL1(+), MB1 (+), MxPanB (-) and EMA (-) reactivity and showed T cell lymphoma. The clinical stage was determined to be I_EA after further work-up. Improvement of swallowing difficulty and esophageal findings on upper gastrointestinal series were noted after modified CHOP therapy and radiotherapy (total 50Gy).
(Internal Medicine 31 : 569-572, 1992)

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