Paraneoplastic neurologic syndromes are degenerative diseases of the central or peripheral nervous system that develop in association with a systemic neoplasm without a direct invasion by tumor. The pathogenesis of this disorder has been hypothesized in the past, and now there is increasing evidence that autoimmune processes triggered by the underlying neoplasm play a major role in the pathophysiology, as documented by many reports of identification of autoantibodies that react with both the target neural tissue and the underlying neoplasm, as evidenced by the extensive application of molecular biology techniques. The presence of antibodies in serum or CSF of some patients with this disorder now accurately identifies the subgroup of the disorders related to specific neoplasms. The trend of recent studies on the pathogenesis of this disease may in the future lead to a new era to clarify the pathogenesis.
(Internal Medicine 35: 925-929, 1996)

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We administered a mixture of uracil and tegafur (UFT)/cisplatin (CDDP) chemotherapy in 28 patients with scirrhous gastric cancer. In the regimen, UFT was orally administered at a dose of 200 mg/m² twice a day. The CDDP was administered at a dose of 90 mg/m² by 24-hour continuous infusion every 4 weeks. As a result, antitumor effects for primary gastric foci were achieved in 14 of the 28 patients (50%). Ascites from peritoneal dissemination disappeared completely in eight of 13 patients (62%). Total gastrectomy was performed in ten patients after 2 to 3 courses of chemotherapy. Histological response grades assessed on the resected specimen were Grade 2 in four, Grade Ib in three, Grade la in one and Grade 0 in two patients. Neoadjuvant chemotherapy is feasible against scirrhous gastric cancer and a subsequent prospective randomized trial should be prepared to clarify the survival benefit of the treatment.
(Internal Medicine 35: 930-936, 1996)

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Embolization from the carotid bifurcation has been proposed as the most common cause of central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO). The purpose of this stuy was to evaluate carotid artery diseases in patients with CRAO and BRAO. Using carotid ultrasonography, 17 patients (13 males, 4 females, mean age 68.7±7.1 years) with CRAO and BRAO were examined for stenotic findings and plaque morphology (homogeneous or heterogeneous) within 7 days after onset. The internal carotid artery (ICA) ipsilateral to the affected side showed a significantly higher incidence of severe carotid stenosis as compared to the non-affected side. The occurrence of heterogeneous plaques in the ICA did not differ between the affected and the nonaffected side. We suspect that severe carotid stenosis in addition to heterogeneous plaques plays an important role in retinal artery occlusion.
(Internal Medicine 35: 937-940, 1996)

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To investigate the clinical significance of interactions between cisapride and sustained-release nifedipine, we compared the plasma nifedipine concentration and blood pressure after administration of nifedipine alone (20 mg) with those obtained after administration of nifedipine with cisapride (2.5 mg) in 20 patients with hypertension. The plasma nifedipine level was not altered by cisapride at one hour after administration, but was significantly increased at two (p<0.01), three (p<0.01), and four (p<0.05) hours when compared with the level measured after nifedipine alone. Cisapride significantly decreased the mean blood pressure at three hours (p<0.05) after administration of nifedipine. The acetaminophen method was used to determine gastric emptying time. The plasma concentration of acetaminophen at 45 minutes after administration was significantly increased by cisapride, suggesting that enhanced gastrointestinal motility might be the basis for the increase in the plasma nifedipine concentration. These results suggest that enhancement of the antihypertensive effect of nifedipine can occur when the drug is prescribed with cisapride, and that caution is needed when using such a combination therapy.
(Internal Medicine 35: 941-945, 1996)

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The clinical features of pulmonary tuberculosis associated with acquired immunodeficiency syndrome (AIDS) in Japan were surveyed utilizing questionnaires completed by 48 institutes around the Tokyo metropolitan area. We found 11 Japanese artd six foreign patients. The average number of patients per institute was 0.37. The Japanese patients had advanced human immunodeficiency virus (HIV) infection. A middle aged man, with fever and cough, nonspecific chest X-ray infiltrates, decreased lymphocyte counts, and a negative tuberculin skin test was the typical presentation of the Japanese patients. The clinical diagnosis was often difficult. The smear positive rate was high among those from whom smears were obtained, suggesting high communicability. None of the isolates indicated multidrug-resistant tuberculosis at the time of diagnosis. In conclusion, sputum smear and culture remain the keys to diagnosing tuberculosis in patients with AIDS, although the clinical picture may be atypical for pulmonary tuberculosis.
(Internal Medicine 35: 946-952, 1996)

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A classical carcinoid tumor, measuring 11 × 17 mm, was found in a 41-year-old woman in the neck of the gall bladder. The lesion infiltrated the muscular layer of the gall bladder wall. Histologically, the tumor was positive for only Grimelius and chromogranin A stains. In a literature search, approximately half of the tumors reported as gall bladder carcinoid tumor appear to be actually endocrine cell carcinomas, which are completely different from classical carcinoid tumors with respect to size, metastasis and prognosis. These carcinomas should not be termed as carcinoid tumors from both the clinical and histological points of view, and should be clearly distinguished from benign lesions when reported.
(Internal Medicine 35: 953-956, 1996)

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An 18-year-old female patient with Crohn's disease presented with left lower lobe pneumonia and pleural effusion which were resistant to treatment with antibiotics. Colo-bronchial fistula had not been recognized until she coughed up yellow sputa with feculent odor and developed acute respiratory distress syndrome. This type of fistula is a rare complication of Crohn's disease, but the present case certainly alerts physicians to search for a fistula between the bronchus and gastrointestinal tract when encountering patients with Crohn's disease accompanied by antibiotic-resistant chronic pneumonia.
(Internal Medicine 35: 957-960, 1996)

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We report a case of Mediterranean lymphoma treated with antibiotics. A 74-year-old woman visited the hospital due to abdominal pain. Endoscopic examination showed erosions and ulcerations on duodenal mucosa. Biopsy specimens histologically revealed massive infiltration of small-sized lymphocytes and plasma cells in subepithelial mucosa. Immunoperoxidase staining showed that the infiltrating cells were positively stained with anti-alpha heavy chain. Serum IgA concentration was elevated and immunoelectrophoresis of the serum demonstrated monoclonal protein composed of alpha heavy chain. During the antibiotic treatment her symptoms disappeared and serum IgA concentration was normalized. Endoscopic examination also showed healing of the duodenal ulceration. The similarities between Mediterranean lymphoma and gastric mucosa-associated lymphoid tissue (MALT) type lymphoma, both of which may be related to bacterial infection and can be treated with antibiotics, are discussed in this report.
(Internal Medicine 35: 961-965, 1996)

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We report a case of sudden death due to variant angina during Holter electrocardiogram (ECG) monitoring. The patient, a 60-year-old man, had been aware of chest discomfort lasting less than one minute at midnight 2 days earlier. Because variant angina or arrhythmia was suspected, Holter ECG monitoring was performed. The patient spent a whole day without a recurrence of chest pain before going to bed, but at midnight he developed sudden chest pain, and died immediately after taking a sublingual tablet of isosorbide-dinitrite. Analysis of the Holter ECG revealed ventricular fibrillation after several ventricular premature beats following ST-segment elevation in both the CMS and NASA leads. This case shows that sudden death from variant angina may occur within a few days after the first onset, and also highlights whether priority should be given to making a definite diagnosis or giving treatment when variant angina is strongly suspected.
(Internal Medicine 35: 966-969, 1996)

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A 41-year-old woman developed primary aldosteronism due to bilateral multiple aldosterone-producing adenomas (APA). She was suspected to have idiopathic hyperaldosteronism (IHA) 7 years previously. Although preoperative data suggested APA and IHA was suspected in a postoperative microscopic specimen, a definite clinical diagnosis could not be made. Cytochrome P-450 and other enzymes involved in aldosterone synthesis were found in the tumor portions but not in the zona glomerulosa of attached adrenals, which histopathologically showed "paradoxical hyperplasia". This was a rare case of bilateral multiple APA, which could be differentiated from IHA by immunohistochemical analysis of adrenal steroidogenic enzymes.
(Internal Medicine 35: 970-975, 1996)

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A near-death asthmatic reaction was induced by disodium cromoglycate (DSCG) as evidenced by positive skin and inhalation provocation tests. The patient's history revealed an episode of exacerbation by inhalation of DSCG. In spite of such an experience, he inhaled DSCG for relief of asthmatic attack, resulting in near-death exacerbation. This patient emphasizes the need to rerecognize that DSCG is not a reliever and that DSCG could cause fatal asthma.
(Internal Medicine 35: 976-978, 1996)

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Two patients with severe bronchiectasis, one patient without other disease and the other with hyper IgE syndrome, were successfully treated with long-term therapy with low doses of trimethoprim and sulfamethoxazole (TMP-SMZ). Recurrent respiratory infections with productive cough and high fever were resistant to various antibiotics and often disturbed the patients' activities in daily life. However, they showed marked improvement following TMP-SMZ therapy, which was started for methicillin-resistant Staphylococcus aureus (MRSA) infection. MRSA disappeared some months later, but Pseudomonas aeruginosa appeared again in the sputum. Both patients, however, have remained free from symptoms for over one year.
(Internal Medicine 35: 979-983, 1996)

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In a 44-year-old female esophagomediastinal fistula was found secondary to tuberculous mediastinal lymphadenitis. Chest computed tomography revealed amorphous air collection in the subcarinal region of the mediastinum with mediastinal lymphadenopathy. Esophagography with gastrografin confirmed esophagomediastinal fistula. The patient was treated with antituberculous therapy with rifampicin, isoniazid, pyrazinamide and ethambutol, resulting in resolution of the esophagomediastinal fistula and mediastinal lymphadenopathy.
(Internal Medicine 35: 984-986, 1996)

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A 36-year-old woman who had had Graves' disease for 6 years was admitted with severe thrombocytopenia. Evans' syndrome was diagnosed. The patient's family history showed multiple cases of Graves' disease but no cases of Evans' syndrome. Both conditions in this patient improved with corticosteroid and thiamazole therapy. Several autoimmune antibodies were found, but a common autoimmune mechanism was not clearly shown. Although the combination of Graves' disease and Evans' syndrome had not occurred previously in her family, genetic factors may play an important role in the pathogenesis of both conditions.
(Internal Medicine 35: 987-990, 1996)

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A 52-year-old woman with a history of a hearing disturbance since age 20 experienced visual hallucinations and convulsions, followed by right hemiparesis and aphasia. On the basis of a muscle biopsy and mitochondrial DNA analysis, she was diagnosed as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). This case is unique in that the stroke-like episodes occurred 30 years after disease onset.
(Internal Medicine 35: 991-995, 1996)

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A 35-year-old man with Guillain-Barré syndrome and ethylene diamine tetraacetic acid (EDTA)-dependent pseudothrombocytopenia associated with serologically-confirmed mumps is presented. A polyneuropathy developed 18 days after the onset of mumps, that improved with plasmapheresis. A decreased platelet count was observed 25 days after the onset of mumps attributed to platelet agglutination in blood anticoagulated with EDTA, and the agglutination was prevented by other anticoagulants. Guillain-Barré syndrome associated with mumps is rare and EDTA-dependent pseudothrombocytopenia following mumps has never been documented. This represents the first report of Guillain-Barré syndrome and EDTA-dependent pseudothrombocytopenia following mumps. Furthermore, our findings suggest activation of the humoral immune response as a potential pathogenesis.
(Internal Medicine 35: 996-999, 1996)

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