We studied three siblings with Bartter's syndrome associated with hypomagnesemia; two of them showing marked hypomagnesemia and the other mild hypomagnesemia. Urinary potassium, sodium and chloride excretions were determined and distal fractional chloride reabsorption and free water clearance on water loading test were compared before and after magnesium supplementation. Baseline urinary potassium and magnesium excretions were elevated in spite of the decreased plasma levels, whereas distal fractional chloride reabsorption and free water clearance were depressed in all patients. Magnesium repletion resulted in significant decrease in urinary potassium, sodium and chloride and subsequent increase in plasma potassium in all patients. However, neither distal fractional chloride reabsorption nor free water clearance was affected. Hypomagnesemia may contribute to urinary potassium wasting and aggravate urinary sodium and chloride wasting in familial Bartter's syndrome by a mechanism independent of the defect in free-water formation by the active reabsorption of chloride in Henle's loop.
(Internal Medicine 33: 1-5, 1994)

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Multiple bullae have often been observed in the lungs of patients with idiopathic interstitial pneumonia (IIP). The etiology of bullae has been considered to be distinct from that of interstitial pneumonia and honeycomb lesions seen in IIP. The incidence of bullae was evaluated in 27 IIP patients (male; 23 cases, female; 4 cases) and clinical factors which are related to the development of bulla were analyzed. Of the 27 patients, 16 (59%) had bullae. All 16 were male smokers, and had higher smoking indices (p<0.01) than patients without bullae. Eleven of the 16 IIP patients with bullae had clubbed fingers (69%, p<0.05). Roentgenologically, cysts (75%, p<0.05), low attenuation area (56%, p=0.06), and honeycomb appearance (94%, p=0.07) were observed more often in IIP patients with bullae. These results suggest that smoking habits may have a close relationship to the development of bullae seen in patients with IIP.
(Internal Medicine 33: 6-9, 1994)

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The patient, a 48-year-old woman with cardiac fibroma, is the second oldest patient with this disease in Japan. Her electrocardiogram showed findings compatible with old high lateral, posterior and possibly lateral myocardial infarction, regions which corresponded to the tumor site. In patients whose electrocardiogram suggests a previous myocardial infarction (pseudo myocardial infarction), the possibility of intramyocardial tumor should be taken into consideration.
(Internal Medicine 33:10-12, 1994)

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A 63-year-old male patient with multiple myeloma developed congestive heart failure due to streptococcus endocarditis prior to the initiation of chemotherapy. Doppler echocardiographical examination revealed the presence of a large vegetation on the anterior mitral leaflet as well as the association of severe mitral regurgitation. Surgical repair (mitral valve replacement) was urgently undertaken and the postoperative course resulted in uneventful recovery. In immunodencient patients with such a streptococcus sepsis, the possibility of infectious endocarditis should be taken into consideration and proper management is mandatory in these circumstances.
(Internal Medicine 33:13-17, 1994)

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A 42-year-old woman with biopsy-proven chronic hepatitis B, who had been treated with human leukocyte-derived interferon-alpha (huLe-IFNα) therapy for two months was found to have liver tumors on routine abdominal ultrasonography examination. She underwent laparotomy, and partial hepatectomy was performed under the clinical diagnosis of hepatocellular carcinoma. The lesions were diagnosed histologically as pseudolymphoma based on the massive infiltration of small mature lymphocytes and the presence of hyperplastic lymph follicles with germinal centers. Immunohistochemistry revealed polyclonal origin of the involved lymphocytes. The possible association between IFNα treatment and chronic hepatitis B with the development of pseudolymphoma is discussed.
(Internal Medicine 33: 18-22, 1994)

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A 37-year-old man developed encephalopathy with prominent eosinophilia. Magnetic resonance imaging (MRI) revealed multiple T2-weighted high signal intensity lesions with dimeglumine gadopentetate (Gd-DTPA) enhancement on T1-weighted images, which were distributed in the cerebral cortex, thalamus, deep white matter and cerebellum. He was diagnosed as having systemic mastocytosis on the basis of proliferating mast cells in the bone marrow and peripheral eosinophilia. Following steroid administration, there was a rapid improvement of his symptoms and laboratory data. To our knowledge, this was the first reported case of systemic mastocytosis provoking encephalopathy with serial MRI findings.
(Internal Medicine 33: 23-26, 1994)

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We report a 27-year-old man with insulin-dependent diabetes mellitus and transient-pituitary-isolated gonadotropin deficiency. He had typical diabetic symptoms, and a loss of libido of a 6-month duration. Although antibodies to islet cells or islet cell surface were not detected in his sera, daily urinary excretion of c-peptide immunoreactivity was extremely low, and antibodies to the pituitary AtT-20 cell were detected. The plasma responses of gonadotropin to a single and a repetitive lute-nizing hormone-releasing hormone were extremely low, whereas testosterone concentrations in the serum and urine were low normal. After 6 months, the gonadotropin deficiency and loss of libido were not detected and antibodies to the AtT-20 cell was negative. We suspected that both insulin-dependent diabetes mellitus and transient-gonadotropin-deficiency might be an autoimmune mechanism.
(Internal Medicine 33: 27-30, 1994)

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A male case of synchronous double cancers of the breast and prostate is reported. An 84-yearold male was admitted to the hospital complaining of general malaise, anorexia and weight loss. A tumor 3 cm in diameter was noted in his left breast, which was removed by mastectomy, and was diagnosed as papillotubular carcinoma. An induration of his prostate and elevated prostate specific antigen, γ-seminoprotein and prostatic acid phosphatase levels were also noted. Needle biopsy of his prostate revealed adenocarcinoma. Among the previous 18 reported cases of this combination of cancers, those with no prior estrogen therapy were very rare, the present case being the third ever reported.
(Internal Medicine 33: 31-35, 1994)

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We present a 53-year-old man with rapidly progressive glomerulonephritis and Henoch-SchÖnlein purpura which developed during the course of treatment for polycythemia vera. An initial renal biopsy specimen showed mesangial proliferative glomerulonephritis. The patient was admitted to the hospital with cutaneous purpura and progressive renal failure after having received 700 mg of ranimustine over a 29 month period as therapy for the polycythemia vera. A second renal biopsy specimen revealed crescentic glomerulonephritis with deposition of immunofluorescent IgA. These data suggest that Henoch-SchÖnlein purpura nephritis may occur in response to ranimustine therapy.
(Internal Medicine 33: 36-40, 1994)

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This is a case report of a 64-year-old woman with poly myalgia rheumatica (PMR) and thyroid papillary carcinoma. Peripheral blood lymphocyte response to pokeweed mitogen, concanavalin A and phytohemagglutinin was increased compared to controls during aggravation of PMR. These responses were normalized to control values after low-dose corticosteroid therapy (prednisolone 10 mg; 7 days and 7.5 mg; 3 days) and PMR symptoms disappeared. The patient had undergone total neck thyroidectomy and metastatic neck lymph node dissection three and six years after the onset of PMR, respectively. Nine months after the removal of metastatic lymph nodes, she was free of symptoms of PMR and peripheral blood lymphocyte response to mitogens was within the control range. PMR appeared to be a component of the long-standing paraneoplastic syndrome, induced by the tumor which had impaired cell-mediated immunity.
(Internal Medicine 33: 41-44, 1994)

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We present a 61-year-old man who was hospitalized because of dyspnea, abdominal pain and liver dysfunction accompanied by ascites due to hepatic metastasis of a thymic carcinoid 20 years after the primary tumor was excised. His symptoms and liver function were well controlled by prednisolone, 30 to 60 mg daily, for the next 2 years, with a reduction in the size of the hepatic tumors and in the accumulation of ascites. He subsequently contracted pneumonia due to methicillin-resistant staphylococci, developed disseminated intravascular coagulation (DIC) and died. Thus, prednisolone should be considered for treating patients with metastasis of a thymic carcinoid.
(Internal Medicine 33: 45-47, 1994)

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We report localized polyarteritis nodosa in a 31-year-old man who had painful nodules in the left forearm and scrotum. Histopathological findings of both tissues revealed distinct arteritis. However, he had no clinical evidence of any systemic disease. We finally diagnosed this case as a localized polyarteritis nodosa occurring in both the left forearm and epididymis. This form of polyarteritis nodosa has not been reported in the literature.
(Internal Medicine 33: 48-52, 1994)

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A 38-year-old man had severe loin pain and computed tomography performed 48 hours later, after drip infusion pyelography (DIP), revealed wedge-shaped contrast enhancement. He showed mild impairment of renal function with no evidence of rhabdomyolysis. The loin pain lasted for 5 days and the wedge-shaped contrast enhancement on CT persisted for 14 days and improved. The case was compatible with the new syndrome, loin pain and persistent wedge-shaped contrast enhancement on CT, proposed by Ishikawa et al (Nephron 27: 31, 1981).
(Internal Medicine 33: 53-55, 1994)

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We report an autopsy case of pyruvate kinase deficiency anemia with severe hemochromatosis. This anemia is rarely associated with hemochromatosis. In this case, the autopsy findings showed hemochromatosis of the heart, pancreas, liver, kidneys, thyroid gland, adrenal glands, testes and skin. Microscopic examination showed iron depositions in these organs, but not in the bone marrow. A family study showed negative data for iron overload and no known HL A type suggestive of idiopathic hemochromatosis. To explain this rare association, we suggest that this patient's iron overload was an acquired type, which might have mainly been caused by increased iron absorption due to the severe hemolytic anemia.
(Internal Medicine 33: 56-59, 1994)

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A 40-year-old man developed slowly progressive muscle atrophy in his calf muscle. The patient became aware of asymmetry of his right big toe during in his teens; muscle atrophy was revealed at the age of 25 years. Multi-image examinations revealed "tethered cord syndrome" with spina bifida occulta. Spinal magnetic resonance image revealed a pathogenetic mechanism of asymmetry of muscle atrophy in the calf muscle. This suggested that spinal MRI imaging is one of the most useful diagnostic methods for this disease.
(Internal Medicine 33: 60-63, 1994)

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