Aspiration pneumonia is associated with decreases in both swallowing and cough reflexes and is the most common cause of death in the elderly. Basal ganglia strokes might predispose these patients to develop pneumonia owing to reductions of both reflexes, resulting in frequent aspiration during sleep. An impairment of dopamine metabolism in the basal ganglia is observed in these patients and levodopa administration improves the impaired swallowing reflex. Both swallowing and cough reflexes are mediated by endogenous substance P (SP) released from vagal sensory nerves in the pharynx and upper airways. The addition of a low dose of capsaicin to liquid or food, which stimulates the release of SP, may help prevent aspiration pneumonia. Angiotensin-converting enzyme inhibitor decreases SP catabolism resulting in improvements in both reflexes. Oral care and the sitting position after meals may decrease aspiration pneumonia in the elderly.
(Internal Medicine 36: 851-855, 1997)

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We measured the levels of interleukin-8 (IL-8) and monocyte chemoattractant protein-1 (MCP-1) in the bronchoalveolar lavage (BAL) fluids from 27 patients with active pulmonary sarcoidosis and examined the relationship between chemokine levels and some clinical manifestations. The levels of two chemokines were assessed by enzyme-linked immunosorbent assay. There were significant positive correlations between the absolute number of lymphocytes and MCP-1 levels. The level of MCP-1 was significantly higher in the group with age at onset of over 50 year than that in the group with age at onset under 30 year. There were no significant differences between the non-smokers and smokers, or among the groups of patients classed according to stages. We conclude that MCP-1 can play an important role in the pathogenesis and clinical course of pulmonary sarcoidosis, although further analysis is needed to delineate the exact role of IL-8.
(Internal Medicine 36: 856-860, 1997)

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To examine the clinical efficacy of a newly developed pressure swing adsorption (PSA) type oxygen concentrator with a membrane humidifier without added water for humidification, the new machine was compared with the conventional PSA type oxygen concentrator with bubble water humidifier in 10 patients with chronic pulmonary disease. Relative humidity, partial pressure of oxygen (PaO₂) and partial pressure of carbon dioxide (PaCO₂) in arterial blood were measured when the patient breathed air and oxygen from the oxygen concentrators. No significant difference between PaO₂ while breathing oxygen flow from the new machine and that while breathing oxygen from the conventional oxygen concentrator was observed. All patients answered that there was no difference on subjective impression between breathing oxygen from the new machine and from the conventional oxygen concentrator. Sufficient relative humidity (above 50%) of oxygen flow was obtained by using membrane humidifier. Since this machine saves the troublesome procedures of cleaning the container and changing the water, it will be beneficial to the patients who use a PSA-type oxygen concentrator in their home.
(Internal Medicine 36: 861-864, 1997)

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To assess the use of bronchofiberscopy for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA), we retrospectively analyzed bronchofiberscopic and pathologic findings of specimens obtained by bronchofiberscopy in 8 patients who met the British criteria for ABPA. Two of the 8 patients completely met Rosenberg's primary criteria for ABPA, while the remaining 6 lacked only 1 or 2 immunologic and radiographic conditions of the criteria. Bronchofiberscopic inspection revealed the presence of mucus plugs in all patients. Pathologic examination of plug specimens obtained by suction from 6 of 7 of these patients showed that the plugs consisted of allergic mucin containing fungal hyphae, diagnostic of ABPA. Bronchofiberscopy appears to be a useful tool in the diagnosis of ABPA, if immunologic and radiographic findings are not typical of ABPA. This bronchofiberscopic method is easily applicable for diagnosing allergic bronchopulmonary fungal disease (ABPFD) in addition to ABPA.
(Internal Medicine 36: 865-869, 1997)

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Activities of daily living (ADL) were evaluated in 421 elderly people, aged 60-95, who resided in 27 randomly selected communities in the town of Mifune, Japan. The disability of ADL increased with age, and was particularly rapid after age 80. Most of the elderly were independent; the prevalence of dependent elderly ranged from 0.7% (in feeding) to 9.5% (in working). The prevalence of dependent elderly increased markedly after age 80 in all ADL items, especially those related to behavior such as ambulation, stair climbing, transfers, and working (i.e., employment, housekeeping, etc.). These results emphasize the importance of community health care of the elderly for preventing and treating neurological disorders which comprised the main cause of disabilities of behavioral ADL.
(Internal Medicine 36: 870-875, 1997)

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In order to study the pathological mechanisms of neuromuscular sarcoidosis, we carried out an immunohistochemical investigation in five cases (five muscle specimens and two sural nerve specimens). We evaluated the distribution of inflammatory mononuclear cells and major histocompatibility complex (MHC) antigen expressions. Our data showed a dominant infiltration of helper/inducer T cells (CD4-T cells), suggesting the importance of cell-mediated immune responses in neuromuscular sarcoidosis. However, we could not identify the distinct distributional patterns of T cells as reported in sarcoid lymphadenitis. This result may be attributed to the difference of the affected organs. Moreover, failure to detect class II antigens in the muscle fibers may imply the difference in pathogenic mechanism between neuromuscular sarcoidosis and other inflammatory myopathies.
(Internal Medicine 36: 876-881, 1997)

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It has been reported that anti-phospholipid antibodies are detected in some patients with idiopathic thrombocytopenic purpura (ITP). To study the significance of determination of antiphospholipid antibodies in patients with ITP, clinical and laboratory findings were compared between patients whose sera were positive for these antibodies (Group A) and non-positive patients (Group B). Anti-cardiolipin antibody (aCL) was determined by enzyme-linked immunosorbent assay and lupus anticoagulant (LA) was determined by activated partial thromboplastin time (aPTT) and thromboplastin time inhibition test. Seven out of 27 cases of ITP belonged to Group A and 3 of the 7 were confirmed to have anti-phospholipid antibody syndrome (APS). There was a tendency for habitual abortion, and thrombosis, megakaryocytes in the bone marrow and plateletassociated IgG (PAIgG)-positive cells were more frequent in Group A than in Group B. However, it was difficult to discriminate APS from ITP alone, when there were no symptoms or signs of APS. Therefore, measurement of anti-phospholipid antibodies in ITP was thought to be useful for the differential diagnosis of APS and subsequently for the prevention of thrombosis.
(Internal Medicine 36: 882-885, 1997)

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A 72-year-old woman was admitted for recurrent episodes of encephalopathy. Laboratory data showed mild liver dysfunction and hyperammonemia, while she had neither anemia nor splenomegaly. The dilated inferior mesenteric vein (IMV) was opacified retrogradely from the superior mesenteric vein by superior mesenteric arteriography, and IMV was found to connect with the inferior vena cava (IVC) through a torturous shunt. No obstruction of the extrahepatic portal vein or hepatic vein was observed by arteriography. Histological evaluation of the liver biopsy indicated remarkable fatty change without cirrhosis. Finally, we diagnosed this case as extrahepatic portosystemic venous shunt without portal hypertension.
(Internal Medicine 36: 886-889, 1997)

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A case with esophageal anisakiasis accompanied by reflux esophagitis is described. A 38-year-old man visited our hospital with complaints of heartburn and disturbance of food passage about seven hours after eating raw cuttlefish. The first esophagogastroscopy revealed an anisakis larva invading the squamocolumnar junction. Near the anisakis larva, a whitish exudate was demonstrated in the distal esophagus just proximal to the squamocolumnar junction. An anisakis larva was easily extracted from the esophagus by forceps. Reflux esophagitis with whitish exudative mucosal lesions and an area of linear erythema more than 5mm long were noted endoscopically 8 weeks after treatment with lansoprazole and cisapride. After six months the third endoscopic examination clarified that there was neither exudate nor erythema in the distal esophagus. Judging from the clinical course that he complained of newly experienced heartburn about seven hours after eating law cuttlefish, and that whitish exudative mucosal lesions and an area of linear erythema did not disappear at three months after extraction of the anisakis larva. It was concluded that an anisakis larva enters the stomach first and then returns to the esophagus by gastroesophageal reflux.
(Internal Medicine 36: 890-893, 1997)

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Acute necrotizing eosinophilic myocarditis is characterized by acute onset, fulminant congestive heart failure, and extensive necrosis of myocytes with striking eosinophilic infiltration. However, multinucleated giant cells sometimes appear in the fulminant phase of severe myocarditis. This is the first case of a patient with a 1 year previous history of idiopathic thrombocytopenic purpura, who presented with acute necrotizing eosinophilic myocarditis with giant cell infiltration.
(Internal Medicine 36: 894-897, 1997)

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A 68-year-old man with a 28-year history of non-insulin dependent diabetes mellitus (NIDDM) was admitted to our hospital because of foot gangrene. He had previously suffered from cerebral infarction resulting in right hemiplegia and his right foot was amputated because of right femoral lesion presenting diabetic foot gangrene 5 years previously. The diabetic foot gangrene gradually became worse, although he had received various medications. Then, we attempted to treat the patient with low density lipoprotein (LDL)-apheresis ten times a month. The foot gangrene itself and the local circulation around the gangrene lesion were remarkably improved after treatment with LDL-apheresis. We present here the first case of diabetic foot gangrene improved by LDL-apheresis. LDL-apheresis therapy is anticipated to be a new therapeutic approach for treatment of fatal foot gangrene associated with diabetes mellitus.
(Internal Medicine 36: 898-902, 1997)

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We describe a 26-year-old male hemodialysis patient with erythropoietin (EPO) resistant anemia associated with primary hyperthyroidism. Use of the anti-hyperthyroid drug, methimazole, led to improvement of his hyperthyroidism and anemia. Before the anti-hyperthyroid therapy, he had received transfusions to maintain an adequate hematocrit during recombinant human EPO therapy. After the therapy, his hyperthyroidism improved and his hematocrit gradually increased without any transfusion. These findings suggest that the patient's EPO resistant anemia was the result of primary hyperthyroidism, and that this complication is reversible if accurate treatment is given.
(Internal Medicine 36: 903-905, 1997)

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We describe a rare case of a rapidly progressive glomerulonephritis (RPGN) superimposed on diabetic nephropathy. A 68-year-old woman with non-insulin-dependent diabetes mellitus (NIDDM) complicated with diabetic triopathy demonstrated a rapid deterioration of renal function. Her urinary sediment contained many red blood cell (RBC) cells and casts, suggesting an additional renal disease accompanying diabetic nephropathy. Renal biopsy revealed crescent formation in many glomeruli characteristic of the pauci-immune type of RPGN. Steroid pulse therapy transiently halted the deterioration in renal function, but the patient died of pneumonia complicated with methicillin-resistant staphylococcus aureus (MRSA) infection. The unusual findings in diabetic nephropathy indicated the coexistence of primary glomerulonephritis and diabetic glomerulosclerosis in this case.
(Internal Medicine 36: 906-911, 1997)

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A 41-year-old man visited our hospital with the complaint of palpitation by atrial flutter. He was finally diagnosed as total anomalous pulmonary vein drainage by helical computed tomography (CT). This case is very unusual due to the lack of symptoms until the age of 41. The absence of pulmonary artery stenosis, and the presence of atrial septal defect providing sufficient right to left shunt flow to maintain the output of left ventricle are some of the reasons to explain the lack of symptoms and very slight impact on daily life. Helical CT, in particular 3-dimensional imaging, is very useful in diagnosing complicated cardiovascular deformation as in this case.
(Internal Medicine 36: 912-916, 1997)

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A 54-year-old nonsmoker female developed atelectasis of the anterior basal segment of the right lower lobe. A non-pulsating endobronchial tumor was observed bronchoscopically obstructing the right basal bronchus. The tumor was confirmed on arteriography to be a saccular aneurysm of the right bronchial artery. The aneurysm was treated with bronchial artery embolization. Bronchial artery aneurysm, without a predisposing disease, is quite rare, but should be considered as an etiological factor of atelectasis.
(Internal Medicine 36: 917-919, 1997)

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The mechanism of severe hyperlipidemia in a 54-year-old woman with multiple myeloma and monoclonal immunoglobulin A (IgA) gammopathy was investigated. Her plasma total cholesterol and triglyceride concentrations were 29.7 mmol/l (1, 150 mg/dl) and 11.9 mmol/l (1, 060 mg/dl), respectively. Western blot analysis demonstrated that her low density lipoproteins (LDL) contained IgA. This IgA also was shown to bind to control LDL and inhibited ¹²⁵I-LDL binding to flbroblasts, suggesting that by binding to the LDL, IgA interfered with LDL binding to LDL receptors. These findings indicate that an inhibitory monoclonal IgA against LDL binding may explain, at least in part, the severe hyperlipidemia observed in this case.
(Internal Medicine 36: 920-925, 1997)

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A breast cancer patient with bone metastases showed a marked response to treatment with a bisphosphonate, an inhibitor of osteoclastic bone resorption. The patient was admitted to our hospital with hypercalcemia, widespread bone metastases and severe disseminated intravascular coagulation (DIC). We treated her conservatively with pamidronate and gabexate mesilate, because the patient had refused any anti-cancer chemotherapy. She showed marked improvement in performance status, hypercalcemia, DIC and tumor markers, whereas splenomegaly due to metastasis progressed. These results suggest that pamidronate has the potential to suppress metastatic tumor growth selectively in bone.
(Internal Medicine 36: 926-930, 1997)

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A case of isolated angiitis of the central nervous system (IACNS) in puerperium with a clinical presentation of bilateral frontal lobe hemorrhage is described. Her symptoms and arteriographic abnormalities were resolved by institution of corticosteroid. After cessation of steroid treatment she showed no evidence of relapse. This case indicates that there appears to be a benign form of IACNS, although the etiology of postpartum IACNS is not known. The postpartum cerebral angiopathy described in the literature may be an identical disorder, since there are no clinical points of specific distinction between them.
(Internal Medicine 36: 931-934, 1997)

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A 30-year-old Japanese female developed insulin-dependent diabetes mellitus (IDDM). She later complained of muscle pains at the age of 37. Erythrocyte sedimentation rate and C-reactive protein were abnormal, with negative antinuclear antibody and rheumatoid factor tests. The diagnosis of polymyalgia rheumatica (PMR) was made. She had HLA phenotypes including A2 and without DR4, consistent with common types of Japanese PMR. Her DNA typing included DQB1^*0303 which is positively associated with Japanese IDDM. It seems likely that she suffered from these diseases at a young age on the basis of having the HLA-susceptibility to both PMR and IDDM.
(Internal Medicine 36: 935-937, 1997)

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