Cross-sectional studies have revealed that bone mass is reduced in patients with chronic obstructive pulmonary disease (COPD). To elucidate the factors influencing bone mass in COPD, we measured whole body bone mineral content (BMC) by dual energy X-ray absorptiometry (DXA), pulmonary function, and twelve-minute walking distance (TMD) in men with COPD, who had been monitored for at least one year. We studied the body composition in 22 male patients with COPD and 19 age-matched male controls (age 72.6 ± 7.2 vs 67.5 ± 10.1 years, mean ± SD). COPD patients showed a significantly lower body weight (49.3 ± 5.7 vs 57.9 ± 3.5 kg, respectively), body mass index (18.9 ± 2.1 vs 22.1 ± 1.3 kg/m²) and BMC (1.9 ± 0.4 vs 2.2 ± 0.4 kg) than controls. The changes in BMC were significantly correlated with TMD (r=0.53, p<0.02). These results demonstrate that decreased exercise capacity, at least in part, accounts for acceleration of bone mass loss in COPD patients.
(Internal Medicine 36: 450-453, 1997)

View full abstract

To investigate the relationship between hypercapnia during sleep and its influence on the PaCO₂ during the morning after sleep in patients with obstructive sleep apnea syndrome (OSAS), the transcutaneous PCO₂ (PtcCO₂) was measured throughout the night, and the arterial blood gases (ABG) were also measured while awake before and after polysomnography in 30 OSAS patients with (n=13, hypercapnic group: HC) and without (n=17, normocapnic group: NC) hypercapnia. Significant differences were observed in the body mass index (p=0.03), the difference between the highest PtcCO₂ during sleep and the PtcCO₂ during awake before sleep (D-PtcCO₂), (HC: 11.1±1.7 mmHg; NC: 6.3±0.5 mmHg; p=0.0057) and the lowest SaO₂ during sleep (p=0.0007). In the HC, the PaCO₂ on the morning after sleep (50.0±0.14 mmHg) was significantly increased (p=0.0029) compared with the PaCO₂ on the night before sleep (47.4±1.1 mmHg). In the NC, this phenomenon was not observed. Severe hypercapnia (high D-PtcCO₂) during a single night's sleep has a significant effect on the waking PaCO₂ immediately following sleep in the HC.
(Internal Medicine 36: 454-460, 1997)

View full abstract

We encountered a case of cytomegalovirus (CMV) retinitis with spontaneous regression in association with an increased number of CD8⁺ but not CD4⁺ T lymphocytes in a patient with acquired immunodeficiency syndrome (AIDS). Thus, we examined the number of CD4 and CD8 counts at the diagnosis of CMV retinitis and compared with those of Pneumocystis carinii pneumonia (PCP). All 21 patients with a confirmed diagnosis of PCP (22 episodes) and 14 CMV retinitis patients were included in this study. Although PCP occurred after depletion of CD4 count to below 200/μl, CD8 count at that time varied widely and remained normal in some patients (median: 276.5/μl, range: 133-900/μl). In contrast, as CMV retinitis occurred after further depletion of CD4 count to below 50/μl, CD8 count decreased to below 500/μl (median: 238/μl, range: 43-448/μl) (p<0.05; PCP vs CMV retinitis). The values of the sensitivity and specificity for CMV retinitis obtained at the cutoff point of either 400/μl in CD8 count and 50/μl in CD4 count were similar. When these two cutoff points were combined, the positive predictive value was 46%. Monitoring of CD8 count may prove valuable as an additional predictor of CMV retinitis in patients with AIDS after CD4 depletion.
(Internal Medicine 36: 461-465, 1997)

View full abstract

Forty-six patients who were exposed to sarin consulted our hospital because of darkness of vision, and ocular pain, vomiting, dyspnea and headaches on June 27 and 28, 1994. Eighteen patients were admitted and 4 of them were in the critical state. There were 6 features: 1) depression of plasma cholinesterase activity (17 of 18 patients, 94%), 2) hypokalemia (4/18, 22%), 3) depression of triglyceride (12/18, 67%), 4) hypocapnia (5/17, 29%), 5) partial pressure of oxygen (PaO₂) <80 mmHg, or requirement of O₂ inhalation (15/18, 83%), 6) white blood cells (WBC) >9, 000 per mm³ (13/18, 72%). Seventeen patients were discharged from hospital, but one patient is still suffering from akinetic mutism after two years.
(Internal Medicine 36: 466-470, 1997)

View full abstract

We report 3 patients with chronic total occlusion of the left main coronary artery, which is considered to be very rare. In all three cases, coronary arteriograms showed a total occlusion of the left main coronary artery with good collaterals from the intact right coronary arteries. All of the patients underwent successful coronary artery bypass surgery; two of the cases were followed up for more than 10 years after the surgery. The Japanese literature is reviewed, and a comparison of foreign and Japanese cases is discussed.
(Internal Medicine 36: 471-478, 1997)

View full abstract

We present a diabetic patient with long-standing constipation complicated by paralytic ileus and septic shock. She successfully recovered from a critical condition, and her diabetes was well controlled. However, the constipation did not improve even after the administration of conventional medications. Epalrestat, an aldose reductase inhibitor (ARI), improved her bowel motility and autonomic cardiovascular dysfunction, as evident from her heart rate and blood pressure response. Gastroenteropathy is a major diabetic complication which may cause disturbed bowel motility leading to serious enterobacterial infections, thus, its amelioration is important. ARI may be beneficial in the treatment of diabetic gastroenteropathy refractory to conventional therapies.
(Internal Medicine 36: 479-483, 1997)

View full abstract

A 54-year-old female was admitted to our hospital for gingival bleeding and was diagnosed as acute promyelocytic leukemia (APL). She received induction therapy according to the AML92 protocol of the Japan Adult Leukemia Study Group (JALSG) with all-trans retinoic acid (ATRA) plus chemotherapeutic agents. She achieved complete remission, but one year later had a relapse in her external auditory canal without leukemic cell in the bone marrow. Extramedullary disease is rare in APL. This case suggests the importance of careful observation for extramedullary relapse in patients who are treated with ATRA.
(Internal Medicine 36: 484-486, 1997)

View full abstract

Two cases of leukemia were treated successfully with apheresis for delayed recovery of erythropoiesis due to antibody-mediated red cell aplasia after ABO-mismatched bone marrow transplantation (BMT). A 25-year-old female (ABO group O) underwent BMT from her brother (group A). Immunoadsorption using Biosynsorb A performed on day 146 after BMT followed by double filtration plasma pheresis (DFPP) reduced anti-A antibody titers from 1:32 to 1:2. Anemia improved dramatically within 2 weeks. A 49-year-old female (group O) underwent BMT from her mother (group A). She was treated with DFPP on day 131 after BMT. Anti-A antibody titers dropped from 1:16 to 1:1 and anemia improved gradually.
(Internal Medicine 36: 487-491, 1997)

View full abstract

A 54-year-old man presented with tremor and unusual behavior. He was admitted two months later because of dementia and myoclonus. Periodic synchronous discharges were observed on the electroencephalogram. Based on these findings, we diagnosed the case as Creutzfeldt-Jakob disease. About two weeks after admission, decubitus, bowel dysfunction and hypohidrosis occurred. We observed various autonomic nervous system dysfunctions such as abnormal pupillary response to autonomic drugs, reduced coefficient of variation of R-R interval, and abnormal diurnal blood pressure variation.
(Internal Medicine 36: 492-496, 1997)

View full abstract

The level of plasma brain natriuretic peptide (BNP) was elevated in 8 of 15 female gene carriers of Duchenne muscular dystrophy (DMD), and the level correlated with indices of cardiac function. In one of these carriers, whose clinical course was followed for one year, the plasma BNP level was elevated before the development of cardiac symptoms, further increased with the evolution of cardiac symptoms, and then decreased after treatment for cardiac failure. These results suggest that the plasma BNP level may be useful for the early detection of cardiac dysfunction and for evaluating the efficacy of cardiac treatment in female DMD carriers.
(Internal Medicine 36: 497-500, 1997)

View full abstract

We report siblings of late-onset Charcot-Marie-Tooth disease type 1A (CMT1A) of whom the elder brother presented with drop foot. DNA analysis confirmed the 17p11.2-p12 duplication. Estimation of the age of onset is difficult in CMT1A because of the subtle and slow progress of the symptoms. These cases are unique in that the initial clinical manifestation was a pressure palsy in the brother and both siblings were quite delayed in their clinical presentations. The peripheral myelin protein-22 gene duplication is uniformly found in CMT1A patients. However, other factors influencing the disease manifestations are yet to be determined.
(Internal Medicine 36: 501-503, 1997)

View full abstract

We describe a 66-year-old man with a 20-year history of ataxic gait who suddenly developed diplopia on rightward gaze. Neurologic examination revealed right hemi-ataxia and hemi-hypesthesia, and left internuclear ophthalmoplegia. MRI showed a cavernous angioma in the left tectum, mild right cerebellar atrophy, and left interior olivary hypertrophy. Single photon emission computed tomography (SPECT) imaging demonstrated contralateral cerebellar diaschisis. We discuss the findings and review the literature concerning contralateral cerebellar diaschisis.
(Internal Medicine 36: 504-507, 1997)

View full abstract

A 46-year-old female patient who was diagnosed with systemic sclerosis (SSc) developed rapidly progressive renal failure without elevation of blood pressure or plasma renin concentration. Renal biopsy revealed necrotizing crescentic glomerulonephritis (pauci-immune type) and the myeloperoxidase-speciflc anti-neutrophil cytoplasmic autoantibodies (MPO-ANCA) liter was found to be elevated to 669 EU/ml. Methylprednisolone (MP) pulse therapy followed by prednisolone (PSL) and mizoribine (MZR) did not suppress the progression of renal failure. Therefore, we started double-filtration plasmapheresis (DFPP) which effectively removed MPO-ANCA and prevented renal failure despite the relatively low dose of immunosuppressive agents.
(Internal Medicine 36: 508-513, 1997)

View full abstract

We treated a patient with an atypical presentation of Wegener's granulomatosis (WG) with dural involvement as the initial clinical manifestation. A 37-year-old man had a dural lesion without lower respiratory tract or renal manifestations in the initial clinical course. His only initial symptom was headache, and at disease onset computed tomography (CT) and magnetic resonance imaging (MRI) of the head revealed bilateral abnormal subdural masses. The diagnosis of WG was made based on the results of needle biopsy of the nasal polyps and the finding of positive circulating antineutrophil cytoplasmic antibodies (c-ANCA). He achieved remission on daily prednisone and cyclophosphamide with the later addition of sulfamethoxazole-trimethoprim.
(Internal Medicine 36: 514-518, 1997)

View full abstract

Interstitial lung disease, especially the rapidly progressive type, carries a grave prognosis when associated with polymyositis (PM)/dermatomyositis (DM). We describe a case of rapidly progressive interstitial lung disease associated with DM. Pathological findings included bronchiolitis obliterans organizing pneumonia (BOOP) pattern in the right upper lung lobe and interstitial fibrosis with microscopic honeycomb lesions in the right lower lung lobe. The patient's respiratory distress was severe and persistent, and oral intubation with mechanical ventilation was transitionally introduced. The respiratory distress condition responded to intravenous cyclophosphamide pulse therapy.
(Internal Medicine 36: 519-523, 1997)

View full abstract

A 33-year-old man was admitted to our hospital because of intermittent claudication and finger tip ulceration with a skin rash on the upper and lower extremities. He later developed a massive melena. Angiography revealed arterial occlusion in the hand and foot, skin biopsy showed vasculitis with eosinophilic infiltration, and biopsy of the colon showed mucosal vasculitis with thrombosis. A diagnosis of polyangiitis overlap syndrome was made, and all these symptoms improved after corticosteroid therapy.
(Internal Medicine 36: 524-527, 1997)

View full abstract

A 37-year-old woman underwent an emergency operation at our hospital because of severe abdominal pain and ileus. Most of her small intestine and ascending colon were observed to have become necrotic due to occlusion of her superior mesenteric artery (SMA). Pathological findings of the resected intestine revealed that her SMA was completely thrombosed 2 cm distal from its origin with smooth muscle proliferation. Post-surgical blood analysis of her pre-operative serum was positive for lupus anticoagulant and antinuclear antibodies. She noticed vaginal bleeding due to missed abortion on the 31st day after the operation. We diagnosed her acute abdominal pain to be that of antiphospholipid syndrome associated with her pregnancy.
(Internal Medicine 36: 528-531, 1997)

View full abstract