This prospective randomized study investigated the possibility that duodenal ulcer relapse associated with Helicobacter Pylori infection is mediated by oxygen-derived free radicals. To this end, the radical scavengers allopurinol (50 mg 4 times daily) and dimethyl sulphoxide (DMSO, 500 mg4 times daily) were administered orally. One hundred and forty-six consecutive patients with previous symptomatic endoscopy proven duodenal ulceration, which had been shown endoscopically to have healed in the presence of gastric mucosal infection with Helicobacter Pylori, were randomized to receive for the period of one year either placebo, or cimetidine 400 mg at bedtime, or allopurinol, or DMSO. In one hundred and twenty-six patients evaluable for efficacy, the cumulative relapse at one year was: placebo 47%, cimetidine 24%, allopurinol 6%and DMSO6%. Cimetidine was significantly effective in preventing the relapse (p<0.01), however allopurinol and DMSO were superior to cimetidine in this respect (p<0.05). In the patients who relapsed, ulcer recurrence tended to occur early in those on placebo and cimetidine and to be evenly distributed over the year in those on free radical scavenging therapy. In all groups, ulcer recurrence throughout the maintenance year was more frequently symptomatic than silent. The incidence of infection with Helicobacter Pylori was not influenced by any of the regimens employed and the bacterium was detected with every relapse noted in this study and during the follow-up endoscopy which was carried out at 6 months and at 12 months during the maintenance year. The results suggest that oxygen-derived free radicals are involved in the relapse of duodenal ulceration in patients infected with Helicobacter Pylori.
(Internal Medicine 32: 359-364, 1993)

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Lung function was assessed in 52 patients with collagen vascular diseases (CVD) who had neither a smoking history nor an abnormality in their chest x-ray films. Values of the maximum mid-expiratory flow and the maximum expiratory flow after 50% or 75% of the forced vital capacity had been exhaled were decreased and the ratio of closing capacity to total lung capacity was increased in 36-100% (varied among categories of CVD) of patients with CVD, and the carbon monoxide diffusing capacity was decreased in 27-56% of the patients. These findings indicate that small airway diseases and a decrease in diffusing capacity are not rare in CVD patients, even if they had neither a smoking history nor abnormal findings in their chest x-ray films. Regular and routine tests on lung functions are thought to be effective to detect early pulmonary involvement in patients with CVD.
(Internal Medicine 32: 365-369, 1993)

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This study investigated the efficacy of applying the polymerase chain reaction (PCR) technique to the monitoring of therapy to P. carinii pneumonia (PCP). The PCR method was sensitive enough to determine P. carinii shedding in sputum samples which was not detectable by Diff-Quik (International Reagent Corp., Kobe, Japan) stain. By PCR, P. carinii disappeared in sputa on days 8 to 15 after treatment. Clinical improvements correlated with the loss of detectable P. carinii. This study represents a potential usefulness of PCR to monitor P. carinii shedding in sputum during treatment.
(Internal Medicine 32: 370-373, 1993)

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With two-dimensional (2D) color Doppler echocardiography, the cardiac and valvular function of 24 consecutive patients with a history of Graves' disease (17 were hyperthyroid and 7 were euthyroid at the time of the examination) were evaluated. The incidences of mitral regurgitation (MR), tricuspid regurgitation (TR) and MR plus TR were significantly higher in the patients with Graves' disease than in the age-matched control group of patients without this disease. In the patients who had signs of congestive heart failure (CHF) while they were hyperthyroid, a significantly higher incidence of severe TR was observed. This is the first report of a 2D color Doppler echocardiography study on the incidences of TR and/or MR in patients with Graves' disease. Our data indicate that in Graves' disease valvular dysfunction can be caused by systemic disorders and that severe TR is a possible risk factor for CHF.
(Internal Medicine 32: 374-376, 1993)

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We describe the clinicopathological features of 247 patients over the age of 60 with renal disorders. We acceded the histological classification of WHO recommendation, except for IgA nephropathy as primary glomerulonephritis. All nephrotic patients other than those with diabetic glomerulosclerosis (DGS) or amyloidosis were treated with steroids and/or immunosuppressants. Clinical data showed 88 patients with nephrotic syndrome. The histological study revealed that 142 patients had primary renal diseases and 105 patients had secondary renal diseases. Of 88 nephrotic patients, 35 were membranous nephropathy (MN) and 9 were minimal change nephrotic syndrome (MCNS). In secondary nephrosis, amyloidosis and DGS were diagnosed in 9 and 7 patients, respectively. A good response to therapy was obtained in MN(89%) and MCNS(78%). However, nephrotic patients with mesangial proliferative glomerulonephritis, amyloidosis, or DGS had unfavorable outcomes. Histological observations are useful aids in estimating the prognosis and therapy selection for renal disorders even in elderly patients.
(Internal Medicine 32: 377-381, 1993)

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Lipoprotein(a) has been strongly suggested to be a risk factor for atherosclerosis. However, its metabolism and/or regulation by drug treatment still remain unknown.Wetherefore studied the effects of glucocorticoid therapy on serum lipoprotein(a) in rheumatic diseases. Although the glucocorticoid treatment increased the total serum cholesterol, high-density lipoprotein cholesterol and apolipoprotein B concentrations, it reduced the serum lipoprotein(a) concentration (mean, 40%) in a dose-dependent manner in 9 patients with rheumatic diseases without nephrotic syndrome. Similar results were observed in 2 patients who did have nephrotic syndrome. It is assumed that the increase of total cholesterol and apolipoprotein B in serum levels are atherogenic, whereas the increase of high-density lipoprotein cholesterol and the decrease of lipoprotein(a) are protective for atherosclerosis. The clinical outcome of the concomitant results in lipid metabolism in the development of atherosclerosis remains to be studied.
(Internal Medicine 32: 382-386, 1993)

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A 70-year-old male developed rapidly progressive glomerulonephritis syndrome with serum perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCA). A renal biopsy showed diffuse crescentic glomerulonephritis. Immunofluorescence microscopy revealed 2+ granular staining of IgG over the mesangial area and along glomerular capillary walls. Electron microscopy showed scattered deposits in the paramesangial area. These morphologic findings were consistent with those of immune complex type crescentic glomerulonephritis (IC-CGN). Serum C3, C4, and CH50 were within normal limits, and circulating immunecomplexes were not detected by Clq-binding assay, but both P-ANCA and anti-myeloperoxidase antibodies were positive. A possible relation of P-ANCA to IC-CGN is discussed.
(Internal Medicine 32: 387-390, 1993)

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Secondary amyloidosis associated with systemic lupus erythematosus has rarely been reported. A 57-year-old female had been diagnosed as having possible systemic lupus erythematosus, although her clinical course was not typical. About one year after the diagnosis, treatment was begun with prednisolone because of progressive renal dysfunction, thrombocytopenia and low serum levels of complements. Recurrent diarrhea and gastrointestinal bleeding soon developed, then amyloidosis was revealed in the stomach and duodenum. Postmortem examination confirmed systemic amyloidosis. We discuss the significance of this rare association of systemic lupus erythematosus and secondary amyloidosis.
(Internal Medicine 32: 391-394, 1993)

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A 24-year-old woman was infected with falciparum malaria during travel to Kenya, complicated by intravascular coagulation and pulmonary edema. She was successfully treated with antimalarial drugs including chloroquine, quinine sulfate and pyrimethamine, with a combined regimen of heparin, antithrombin III and nafamostat mesilate for disseminated intravascular coagulation, and with methylprednisolone pulse therapy for pulmonary edema. The present case emphasizes the importance of early diagnosis and appropriate treatment in terms of falciparum malaria. This case, in particular, is believed to be worth reporting as overseas travel is increasing and yet anti-malarial drugs are not readily available to most physicians in Japan.
(Internal Medicine 32: 395-398, 1993)

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The patient, a Japanese male born to a highly consanguineous family, was diagnosed as Bloom's syndrome at the age of 33 when he presented with diabetes mellitus and refractory anemia with excess blasts. Chromosome abnormalities of bone marrow cells included 5q-, -7/7q-, and unusual translocations. During the ensuing years, he developed squamous cell carcinoma of the external auditory meatus, adenocarcinoma of the colon, and squamous cell carcinoma of the tonsil. The patient died of pneumonia at the age of 38. Autopsy revealed intestinal polyposis and hemochromatosis secondary to massive blood transfusions.
(Internal Medicine 32: 399-402, 1993)

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We report a case of primary T-cell non-Hodgkin's lymphoma of the lung. A definite diagnosis was made histologically at open lung biopsy. Atypical cells in the biopsy specimen reacted with monoclonal T-cell markers. Transbronchial lung biopsy and bronchoalveolar lavage fluid were useful in the diagnosis. Primary T-cell lymphoma of the lung is rare and is reviewed in this report.
(Internal Medicine 32: 403-407, 1993)

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We encountered a case of dystrophin-verified Becker muscular dystrophy which exhibited left heart failure as an initial symptom but no subjective muscle weakness. Severe cardiac involvement has been thought to rarely occur in the early stage of this disease, however accurate diagnosis was limited until the dystrophin diagnosis became available. This case suggests that some cases of dilated cardiomyopathy might be Becker muscular dystrophy, and that dystrophin tests should be added to the conventional investigation of patients with dilated cardiomyopathy.
(Internal Medicine 32: 408-411, 1993)

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A case of extramedullary plasmacytoma presenting with biclonal gammopathy is reported. The patient was an 82-year-old man in whom monoclonal-protein (M-protein) was not noted during his first hospitalization. On his second hospitalization generalized lymph node swelling and biclonal gammopathy (IgG-k, IgA-k) were observed. Histological findings were compatible with those of extramedullary plasmacytoma. In the terminal stages, the patient became cachexic. The autopsy disclosed dissemination of the plasmacytoma. Only two other cases have been reported in the literature, and a review of these previous reports is included.
(Internal Medicine 32: 412-415, 1993)

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Two cases of lung carcinoma with osteoplastic bone metastasis are reported. The bone roentgenogram of a 66-year-old woman with pleuritis carcinomotosa revealed multiple sclerotic changes in the right forearm, lumbar spine, and pelvis. Biopsy at internal fixation of the left humerus revealed metastatic adenocarcinoma with osteoplastic change. In a 77-year-old man with small cell carcinoma of the lung, after chemotherapy, osteoplastic bone changes were detected in roentgenograms. An ivory vertebra formation was seen in L1, L2 and L4, and bone scintigram showed, additionally, uptake in the ilium.
(Internal Medicine 32: 416-420, 1993)

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A 46-year-old woman with hypothyroid Graves' disease (EMO syndrome) is reported. The patient had bilateral exophthalmos, conjunctival chemosis, periorbital edema and limitation of lateral gaze. Laboratory examination revealed the presence of primary hypothyroidism with positive thyroid-stimulating hormone (TSH) binding inhibitory immunoglobulin and thyroid stimulation antibody. These fiindings indicated a diagnosis of hypothyroid Graves' disease or EMO syndrome. She received levothyroxine replacement and steroid pulse therapy followed by radiotherapy. Her visual symptoms showed marked improvement and pretibial myxedema disappeared. Although several studies indicate that hypothyroid Graves' disease is a different entity from hyperthyroid Graves' disease, this report suggests that steroid pulse therapy combined with radiotherapy may be effective to treat ophthalmopathy in both diseases.
(Internal Medicine 32: 421-423, 1993)

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Angioedema associated with angiotensin converting enzyme inhibitors is a rare adverse reaction. It commonly involves the face, oropharyngeal and laryngeal tissues. To our knowledge, angioedema of the abdominal viscera related to angiotensin converting enzyme inhibitors has not been reported previously. We present a rare case of a patient who had episodes of angioedema and abdominal pain with ascites probably related to the ACE inhibitor captopril.
(Internal Medicine 32: 424-426, 1993)

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A 54-year-old woman who underwent a hysterectomy and radiation therapy for carcinoma of the uterine cervix developed mucosal de novo cancer of the rectum 12 years later. The rectal lesion was elevated, measuring 0.8×0.7×0.3cm, and its surface was relatively smooth. Microscopically, this tumor consisted of a well-differentiated tubular adenocarcinoma which had invaded the depth of the mucosa. Late radiation injuries were observed around the tumor. We diagnosed this lesion as a radiation-induced mucosal de novo adenocarcinoma of the rectum on the basis of the criteria of Black and Ackerman (Clin Radiol 16: 278, 1965). This case underscores the need for careful longterm follow-up studies of the large intestines of patients who underwent therapeutic irradiation for uterine cancer.
(Internal Medicine 32: 427-429, 1993)

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Delayed post-anoxic encephalopathy (DPE) not related to carbon monoxide has rarely been reported and usually carries a poor prognosis. We describe two surviving patients with such DPE and its neuro-otological characteristics. The DPE was caused by shock due to hemorrhage in a 21-year-old student, and by severe hypoxia and hypotension in a 60-year-old man. Our findings suggest that this type of DPEmight not be rare, if the patients who suffered from severe anoxia, marked hypotension or both are carefully observed. Recognition of this DPE is important for appropriate management of such patients.
(Internal Medicine 32: 430-433, 1993)

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Hypocalcemi ccrisis developed in a patient with monophasic synovial sarcoma after amputation of the right leg, followed by long-term treatment with cisplatin and doxorubicin. Laboratory data revealed severe hypomagnesemia and hypocalcemia. High normal intact parathyroid hormone (PTH), elevated mid-region PTH and undetectable osteocalcin levels had already been found before the appearance of obvious symptomsconcomitantly associated with moderate hypomagnesemia and hypocalcemia. Further, both PTH levels measured by two different methods gradually decreased until the initiation of magnesium supplementation. The magnesium supplement immediately relieved the tetany, and induced striking increases in both intact and mid-region PTH levels transiently and continuous elevations of osteocalcin levels. These results suggest that magnesiumdepletion has dual effects on PTHsecretion, from stimulation to inhibition, as hypomagnesemia progresses. Both relative hypoparathyroidism and refractoriness of bone to PTH were thought to be responsible for hypocalcemia due to hypomagnesemia.
(Internal Medicine 32: 434-437, 1993)

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A patient with a history of adrenocortical carcinoma presented with massive pericardial effusion and a giant pericardial mass. Death resulted from cardiac tamponade. At autopsy a large necrotic mass was histologically similar to the original adrenocortical carcinoma. We present this case and review the literature on metastatic pericardial disease.
(Internal Medicine: 32: 438-440, 1993)

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