To determine the relationship between hypercholesterolemia and the endothelial function of coronary resistance vessels, we studied the changes in coronary blood flow (CBF) in response to acetylcholine, an endothelium-dependent vasodilator, and adenosine, an endothelium-independent vasodilator, in patients with hypercholesterolemia (n=17) and in control patients (n=17). All patients had normal epicardial coronary arteries. Serial 2-min infusions of acetylcholine, at 3 μg/min and 30 μg/min, caused a dose-dependent increase in CBF in each group. The acetylchol-ineinduced maximal increases in CBF were inversely correlated with the serum cholesterol level (r=-0.55, p<0.01), and were significantly smaller in the hypercholesterolemic patients than in control patients. However, the adenosine-induced increases in CBF were similar in the two groups. These results suggest that the endothelium-dependent vasodilation of resistance vessels is lessened in patients with hypercholesterolemia even before the formation of atherosclerotic stenotic lesions in epicardial coronary arteries, and that hypercholesterolemia impairs endothelium-dependent vasodilation of coronary resistance vessels.
(Internal Medicine 35: 89-93, 1996)

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The association between the lack of adrenergic symptoms during hypoglycemia and myocardial ¹²³I-metaiodobenzylguanidine (MIBG) accumulation was investigated in 12 insulin-treated non-insulin-dependent diabetes mellitus (NIDDM) patients who had no evidence of heart disease. These patients were divided into 2 groups according to the presence (group A) or absence (group B) of adrenergic symptoms during hypoglycemia. Autonomic function tests revealed significantly severe autonomic dysfunction in group B compared to that in group A. Insulin infusion test indicated no significant difference in the catecholamine response between the two groups. ¹²³I-MIBG scintigraphy showed that the heart/mediastinum ratio of MIBG uptake was significantly lower, and scintigraphic defect was greater in group B than in group A. There were no significant differences in the washout rate between the two groups. These results suggested that the lack of adrenergic symptoms during hypoglycemia may be associated with cardiac sympathetic nervous dysfunction in insulin-treated NIDDM patients, and this dysfunction is mainly due to cardiac sympathetic denervation.
(Internal Medicine 35: 94-99, 1996)

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Acid fog is a complex mixture of atomospheric pollutants containing multiple stimuli that may be capable of inducing bronchoconstriction. To investigate the effect of ambient acid fog on bronchoconstriction, we examined the relation between the hospital visit for asthma symptoms of 102 patients and various meteorological conditions for over the two-year period from January 1992 to December 1993. Dense fog occurs frequently every summer in Kushiro, a city located in Hokkaido, northernmost island in Japan. The acidity of the fog ranged from pH 3.32 to 6.91 (mean pH=5.05) during this period. A significant increase (p<0.05) of hospital visits on a foggy day was found in 9 cases, and a tendency (p<0.10) was found in 10 cases. The odds ratio for a hospital visit on a high water vapor pressure day (>12 hPa) was significantly high (p<0.01) in 5 cases among the above 19 cases. To exclude the effect of high water vapor pressure, the data was restricted to the condition of a foggy day with low water vapor pressure (<12 hPa); 9 patients had a significant increase (p<0.05) in hospital visits on such a day. These results indicated that hospital visits for asthma symptoms was increased on acid fog days in 8.8% of adult asthma patients. Inhalation of naturally occurring acid fog may have adverse effects on the respiratory tract of the asthmatic patient.
(Internal Medicine 35: 100-104, 1996)

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A portion of anticardiolipin antibodies is defined as phospholipid-dependent anti-β₂-glycoprotein I (β₂-GPI) antibodies and recognizes the conformationally altered (β₂-GPI which interacts with anionic phospholipids. We studied the clinical significance of IgG phospholipid-dependent anti-β₂-GPI antibodies in patients with antiphospholipid syndrome (APS). The subjects consisted of 60 APS patients. IgG phospholipid-dependent anti-β₂-GPI antibodies were detected by ELISA in 32 of the 60 patients (53%). Significantly higher incidences of prolonged APTT and lupus anticoagulants were found in patients with these anti-β₂-GPI antibodies. Moreover, significantly lower incidences of malar rash, serositis, LE cell preparation and anti-Sm antibodies were found in patients with these anti-β₂-GPI antibodies. It was found that 88% of the patients with these anti-β₂-GPI antibodies satisfied less than five of the revised criteria items for the classification of SLE. These findings indicate the clinical characteristics of APS patients with IgG phospholipid-dependent anti-β₂-GPI antibodies.
(Internal Medicine 35: 105-110, 1996)

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Malaria patients who were admitted to the Department of Infectious Diseases of the Tokyo Metropolitan Bokutoh General Hospital during the past 8 years are reviewed. Cases included 17 patients infected with Plasmodium falciparum (14 Japanese), 13 patients infected with P. vivax (9 Japanese), 3 patients infected with P. ovale (2 Japanese) and 1 Chinese patient with a mixed infection of P. falciparum and P. vivax. About 70% of Japanese patients infected with P. falciparum contracted the disease in Africa, about 90% P. vivax-infected Japanese patients contracted the disease in Asia and all P. ovate-infected patients contracted the disease in Africa. Only 13% of all (17% of Japanese) patients infected with P. falciparum who initially contacted doctors of other Japanese hospitals were correctly diagnosed, but 78% of all (67% of Japanese) patients infected with P. vivax who initially contacted doctors of other Japanese hospitals were correctly diagnosed. At present, malaria is not a rare disease in Tokyo among travelers to or from Africa or Asia.
(Internal Medicine 35: 111-114, 1996)

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A 59-year-old woman developed edema of the face and eyelids during interferon (IFN)-alpha-2b therapy for chronic hepatitis C with a cumulative dose of 6 million × 47 units. Despite cessation of the therapy, the edema progressed and was followed by exophthalmos, pyrexia, liver dysfunction, pancytopenia, and disseminated intravascular coagulation. Two months after initial presentation, she died of hemorrhagic shock and was diagnosed with histiocytic cytophagic panniculitis at autopsy. This may be a hitherto unrecognized adverse effect of therapeutic IFNα.
(Internal Medicine 35: 115-118, 1996)

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Nephrogenic diabetes insipidus (NDI) occurred in a 43-year-old woman who had received lobenzarit disodium for the treatment of rheumatoid arthritis (RA). Her urine output was initially 3 ι/day and urine osmolarity was 203 mOsm/ι. Based on a sodium chloride loading test and a vasopressin loading test, she was diagnosed as having lobenzarit-induced NDI. Seven days after the cessation of the use of lobenzarit disodium, polydipsia and polyuria disappeared, and the vasopressin test showed a normal response. These findings suggest that lobenzarit induces a reversible form of NDI as a side effect. The reports of lobenzarit-induced NDI in Japan during the past seven years are also reviewed.
(Internal Medicine 35: 119-122, 1996)

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A case of adrenal tumor producing 11-deoxycorticosterone, 18-hydroxy-11-deoxycorticosterone and aldosterone is reported. A 55-year-old woman had hypertension, hypokalemia, low plasma renin activity and an adrenal tumor. The plasma level of aldosterone was normal, and the levels of 11-deoxycorticosterone and 18-hydroxy-11-deoxycorticosterone were extremely high. After the tumor removal, the plasma level of aldosterone decreased and plasma levels of 11-deoxycorticosterone and 18-hydroxy-11-deoxycorticosterone were normalized. The tumor was benign adenoma and the production of steroid hormones was under control of adrenocorticotropic hormone. The enzyme activity of 21-hydroxylation in the tumor was elevated and that of 11β-hydroxylation was decreased compared with the adjacent tissue.
(Internal Medicine 35: 123-128, 1996)

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A 47-year-old man was admitted for evaluation of unsteady gait, postural instability, and dysarthria. On admission, neurological examinations revealed cerebellar ataxia, extrapyramidal signs including parkinsonism and positive Trousseau's sign. Laboratory findings revealed severe hypocalcemia and hyperphosphatemia, and serum intact parathyroid hormone was not detectable. Brain computed tomography revealed severe calcification of basal ganglia and dentate nuclei. He was diagnosed as idiopathic hypoparathyroidism; treatment with 1α (OH) vitamin D₃ brought marked improvement of neurological manifestations. We report a rare case of idiopathic hypoparathyroidism presenting with extrapyramidal and cerebellar dysfunction with a review of literature.
(Internal Medicine 35: 129-134, 1996)

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A 16-year-old male complained of a headache and a high fever followed by polyuria. The endocrinological studies showed he had hypopituitarism and central diabetes insipidus, and magnetic resonance imaging (MRI) revealed a pituitary mass. Diabetes insipidus gradually improved and hydrocortisone treatment was begun at three months after onset, but a month later painless thyroiditis developed. An MRI demonstrated a spontaneous shrinkage of the pituitary mass nine months after onset. Lymphocytic hypophysitis followed by painless thyroiditis was the most probable diagnosis, although it is very uncommon especially among men.
(Internal Medicine 35: 135-141, 1996)

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In this study, we investigated the association between the drug-induced pulmonary infiltration with eosinophilia (PIE) syndrome in a patient with hypertension and the angiotensin-converting enzyme inhibitor (ACE-I) captopril. Although the patient developed diffuse lung field infiltrates accompanied by productive cough and striking peripheral eosinophilia, these symptoms disappeared after termination of the administration of captopril, pronase and cephalexine. Furthermore, the results of the peripheral lymphocyte stimulation test, skin patch test and provocation test under informed consent showed a positive reaction only for captopril. Therefore, this patient was diagnosed as captopril-induced PIE syndrome.
(Internal Medicine 35: 142-145, 1996)

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We present a case of adenoid cystic carcinoma of the trachea. The tumor could not be resected due to extensive progression but it was effectively treated endoscopically with a Nd-YAG Laser followed by 70 Gy of conventional radiotherapy. Histologically-confirmed complete remission was achieved, and the patient has lived for nearly 9 years without recurrence of disease.
(Internal Medicine 35:146-149, 1996)

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A 90-year-old woman was admitted with progressive dyspnea. Chest roentgenogram and computed tomography revealed a massive pericardial effusion and bilateral pleural effusion, but no lymphomatous lesion was seen. A diagnosis of malignant lymphoma was made by cytological and immunological studies of the cells obtained from the pericardial effusion. Chromosome analysis showed a clonal abnormality and T-lineage clonality was determined by the rearrangement of the T-cell receptor γ gene. The patient achieved remission with chemotherapy, but she later relapsed, with right pleural effusion, and died. She exhibited no lymphomatous features throughout the clinical course, indicating the possibility of malignant lymphoma originating from the pericardium and/or pleura.
(Internal Medicine 35:150-154, 1996)

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A middle-aged woman with lupus cystitis showed no other symptoms of lupus vasculitis. Cystoscopic findings revealed mucosal hemorrhage and hyperemia. Histological studies of the bladder showed mucosal edema, inflammatory cellular infiltration and the deposition of immune complexes along the vessels. She was treated with a combination of intravenous methylprednisolone pulse therapy and oral prednisolone. Cystoscopy and histological findings showed appreciable improvement. Elevated urinary levels of chemokines such as interleukin-8 (IL-8) and monocyte chemotactic and activating factor (MCAF) decreased during convalescence. These results suggest that the early diagnosis and treatment with steroid pulse therapy achieves improvement of an unusual vasculitis symptom, lupus cystitis.
(Internal Medicine 35: 155-158, 1996)

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Temporal arteritis (TA) is an adult-onset, focal granulomatous inflammatory disorder of the small and medium sized arteries. Intestinal perforation is a rare complication of TA. Regarding its etiology, steroid-induced or arteritis-induced ulceration have been proposed. We describe a patient who developed T A in addition to preceding paroxysmal nocturnal hemoglobinuria. During steroid therapy for TA, intestinal perforation manifested, and it was proven to be arteritis induced perforation on histological examinations. The patient may be the 5th reported case of TA complicated with arteritis-induced intestinal perforation. The possibility of polyangitis overlap syndrome of TA and polyarteritis nodosa is discussed.
(Internal Medicine 35:159-161, 1996)

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A 74-year-old woman was noted to have a mass lesion near the right elbow joint during medication for pulmonary tuberculosis. After discontinuation of medication, the mass gradually became enlarged with swelling and tenderness of the joint. Radiological evaluation disclosed tenosynovitis with an encapsulated abscess. Microscopic examination and culture of an aspiration biopsy specimen from the abscess showed no microorganisms. However, DNA extracted from the specimen contained mycobacterium tuberculosis DNA, permitting a diagnosis of tuberculous tenosynovitis. Mycobacterium is not always detected in biopsy specimens of tuberculous arthritis and tenosynovitis. In such cases, genetic diagnosis may be of great use.
(Internal Medicine 35: 162-165, 1996)

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