To address the problems of pharmacological evaluation in paroxysmal atrial fibrillation (PAf), we interviewed 108 consecutive patients with documented PAf regarding symptoms, frequency and trigger factors of PAf and analyzed the 24-hour ambulatory electrocardiographic monitoring (Holter monitoring) records in relation to symptoms. Twenty-nine patients were totally asymptomatic, while 79 patients were symptomatic of which 49 patients had obvious trigger factors. PAf was documented by Holter monitoring in 22 of 79 symptomatic patients. On analysis of PAf-documented 25 Holter monitoring records, the patients checked event marks as PAf in only 20 of 155 PAf episodes. Six episodes of 26 event marks that patients thought to be PAf proved to be premature atrial or ventricular contractions. Nine patients in whom PAf persisted for more than 24 hours became asymptomatic. Patients suitable for pharmacological evaluation constituted about one-fifth of the PAf patients in our consecutive study. Even with the selection of these patients, pharmacological evaluation based on symptoms is difficult because disappearance of PAf may be associated with persistent atrial fibrillation.
(Internal Medicine 37: 1005-1008, 1998)

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To assess the acute effects of nasal continuous positive airway pressure (CPAP) on the 24-hour blood pressure and the secretion of catecholamines in urine and plasma, we investigated the changes in the 24-hour blood pressure and urinary and plasma concentrations of epinephrine (E) and norepinephrine (NE) in 26 men with obstructive sleep apnea (OSA) with and without nasal CPAP. Nasal CPAP resulted in significant decreases in the daytime diastolic pressure (from 86 ± 16 mmHg to 83 ± 12 mmHg), the nighttime diastolic pressure (from 81 ± 12 mmHg to 77 ± 9 mmHg) and the nighttime systolic pressures (from 125 ± 15 mmHg to 120 ± 10 mmHg). There was no significant difference between patients with and without CPAP in the daytime or nighttime urinary E level, but patients who received CPAP showed a significant decrease in daytime urinary NE level (from 156 ± 112 μg/14h to 119 ± 101 μg/14h) and nighttime urinary NE level (from 143 ± 91 μg/10h to 112 ± 65 μg/10h). The morning plasma level of NE also decreased (from 371 ± 181 pg/ml to 273 ± 148 pg/ml) in patients who received nasal CPAP (p<0.02), but the plasma level of E remained unchanged. There were no correlations between PSG parameters and the reductions in blood pressure and the catecholamine levels induced by nasal CPAP. These findings suggest that OSA contributes, at least in part, to the development of systemic hypertension by increasing sympathetic nervous activity.
(Internal Medicine 37: 1009-1013, 1998)

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During the 25-year period from 1972-1996, 360 episodes of bacteremia occurred in 248 (45%) of a total of 548 patients with acute leukemia on our hematology ward, with the rate of occurrence remaining almost unchanged. Patients with acute nonlymphocytic leukemia, however, had a significant decrease in the incidence of bacteremia during the last 5-year period. Gram-negative bacilli decreased in relative frequency from 64% for the first 15-year period to 40% for the last 5-year period, whereas gram-positive cocci increased from 24% to 51%. Escherichia coli and Enterobacter cloacae somewhat decreased in frequency, whereas coagulase-negative staphylococci and streptococci had considerable increases. In contrast, Pseudomonas aeruginosa was isolated at a relatively constant frequency, forming one of the top two pathogens throughout the study period. Despite the shift toward gram-positive cocci, therefore, P. aeruginosa remains a key organism in considering the initial empiric antibiotic regimen and infection prevention during neutropenia.
(Internal Medicine 37: 1014-1018, 1998)

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A 54-year-old woman came to our office because of pretibial edema. She had no gastrointestinal symptoms. Laboratory tests revealed severe hypoproteinemia. Upper gastrointestinal endoscopy demonstrated enlarged gastric folds and multiple aphthoid nodules on the body and the fornix of the stomach. The biopsy specimen revealed a large number of CDS positive intraepithelial T-lymphocytes infiltrating the gastric mucosa. Both serum total protein and the gastric lesions improved eight months after her first visit without any therapy for peptic ulcer or eradication of Helicobacter pylori. The data suggest that spontaneous remission may occur in lymphocytic gastritis without any gastrointestinal symptoms.
(Internal Medicine 37: 1019-1022, 1998)

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A 50-year-old man was admitted with acute pericarditis. Echocardiography demonstrated a large mass on the right atrial free wall along with a pericardial effusion. We performed transvenous biopsy of this mass under transesophageal echocardiographic guidance. Though the biotome obtained the mass, the pathological findings were of organized thrombus. Two weeks later, a new precordial mass appeared around the left third rib and was suspected to be a metastasis. Incisional biopsy of this mass gave the diagnosis of angiosarcoma.
(Internal Medicine 37: 1023-1026, 1998)

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We report a 65-year-old woman with thyrotropin (TSH) secreting pituitary adenoma, who was diagnosed based on the lack of inhibition of serum TSH despite an increased serum free thyroxine (T₄), a low response of serum TSH to thyrotropin releasing hormone, and a pituitary tumor as revealed by magnetic resonance imaging. The pituitary adenoma was, however, inoperable due to chronic respiratory failure. The treatment with octreotide in a dose of 100 μg b.i.d. resulted in inhibition of serum TSH and free T₄ to euthyroid levels and considerable shrinkage of the pituitary tumor. These effects were continued over 8 months after the start of octreotide therapy without any adverse effects. These findings add further evidence that octreotide is useful for treating inoperable TSH secreting pituitary adenoma.
(Internal Medicine 37: 1027-1030, 1998)

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A 79-year-old man had been treated with recombinant human insulin since the age of 77. He developed subcutaneous fat atrophy around the injection site 16 months after induction of insulin therapy. Skin biopsy of the atrophic site revealed inflammatory changes and adipocyte atrophy. Changing the type of insulin and injection site relieved the fat atrophy. Although insulin-induced lipoatrophy was a common complication before the development of human insulin, it is now rare. The immunological reaction to the insulin product, as in conventional impure insulin-induced lipoatrophy, seemed to be involved in the etiology of lipoatrophy in this case.
(Internal Medicine 37: 1031-1033, 1998)

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A 48-year-old woman developed hepatic metastases from malignant pheochromocytoma resected 8 years previously. Angiography revealed multiple tumor stains in the liver. Transcatheter oily Chemoembolization using styrenomaleic acid neocarzinostatin and iodized oil was performed. The patient complained of severe right upper quadrant pain immediately following the transcatheter oily Chemoembolization. Necrotizing cholecystitis developed on the 4th day post-transcatheter oily Chemoembolization, hepatic infarction on the 12th day, and a biloma on the 19th day. Despite the administration of antibiotics and percutaneous transhepatic drainage, neither the volume of drainage nor the size of the biloma decreased. Biliary reconstruction was performed using a metallic stent, which decreased the size of the biloma.
(Internal Medicine 37:1034-1038, 1998)

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A 21-year-old man with Prader-Willi syndrome (PWS) was hospitalized due to hyperglycemia. After diet therapy and transient insulin administration, his blood glucose levels improved. Based on the fact that his urinary C-peptide levels increased, the diabetes mellitus may have been due to insulin resistance with obesity. In addition, his testes had become atrophied. Testosterone levels remained low even after human chorionic gonadotropin (HCG) administration. Luteinizing hormone (LH) levels were also low after LH releasing hormone (LHRH) administration. The LH response increased slightly after daily LHRH administration, indicating hypothalamic hypogonadism. Follicle stimulating hormone (FSH) levels were, however, high and increased after LHRH administration. The selective FSH elevation may have been due to the accompanying idiopathic oligospermia.
(Internal Medicine 37:1039-1041, 1998)

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This report describes an extremely rare combination of mediastinal germ cell tumor and visceral hemangiomatosis in a 17-year-old boy who initially presented with chest pain and dyspnea. He was treated with chemotherapy consisting of cisplatin, cyclophosphamide, bleomycin, vinblastine, and dactinomycin followed by surgery. Multiple low-density nodules developed in the spleen three weeks later, suggesting metastases from the primary tumor, but the resected specimen showed cavernous hemangiomas within the splenic parenchyma. The patient died of recurrence of germ cell tumor 19 months after the initial treatment. Postmortem examination disclosed multiple hemangiomas in the lung and liver similar to those in the spleen.
(Internal Medicine 37: 1042-1045, 1998)

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We report a case of fungus ball due to Pseudallescheria boydii (pseudallescherioma) associated with systemic lupus erythematosus. Direct microscopical examination revealed a fungus with broad septate hyphae resembling Aspergillus and the fungus was identified as P. boydii on culture. Surgical resection was required to control episodes of hemoptysis. Cases of pulmonary pseudallescheriasis are rare, especially in Japan. However, some cases previously diagnosed as pulmonary aspergillosis may have been found to be caused by P. boydii, if adequate culture studies had been conducted. Unlike Aspergillus, P. boydii is resistant to amphotericin B. Therefore, we emphasize the importance of a correct diagnosis based on culture examination.
(Internal Medicine 37:1046-1049, 1998)

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A 38-year-old male with follicular lymphoma at clinical stage IV failed to achieve complete remission (CR), and developed leukemic change. After the patient was further treated with intensive chemotherapy for acute lymphoblastic leukemia, lymphoma cells in the peripheral blood and bone marrow disappeared, but the bulky mass persisted. Then, the patient received allogeneic peripheral blood stem cell transplantation (allo-PBSCT) from his human lymphocyte antigen (HLA)-identical brother following high-dose cyclophosphamide and 12Gy total body irradiation, and the patient achieved CR with the disappearance of Bcl-2 rearrangement. The patient is now alive in continuous CR for more than 19 months after allo-PBSCT.
(Internal Medicine 37: 1050-1054, 1998)

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A 45-year-old woman with type IIIa glycogen storage disease (GSD IIIa) died of variceal hemorrhage secondary to liver cirrhosis. The postmortem examination disclosed increased intracellular glycogen in the liver as well as in the heart and skeletal muscle. Although most liver injuries in GSD IIIa have been considered to be non-progressive in adulthood, liver cirrhosis can be a cause of death in some patients.
(Intenal Medicine 37: 1055-1057, 1998)

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Two patients with polymyositis (PM) or dermatomyositis (DM) complicated with massive pleural effusion are reported here. Both patients presented a high-grade fever, pleural effusion prominent on the right, and good response to steroid therapy. In a 50-year-old woman with PM, combined process of pleural inflammation, cardiomyopathy and coexisting hypothyroidism were considered to be responsible for the accumulation of the massive pleural effusion. However, in a 34-year-old man with DM, pleural inflammation associated with interstitial pneumonia or pleural microvasculopathy in DM was considered to be responsible for the accumulation of the massive pleural effusion.
(Internal Medicine 37: 1058-1063, 1998)

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A 29-year-old man developed atopic bronchial asthma in association with eosinophilia and hyperimmunoglobulinemia E (hyper-IgE). A biopsy specimen from an inguinal lymph node showed changes consistent with Kimura's disease. IPD-1151T (suplatast tosilate), an anti-allergy drug, attenuated eosinophilia and hyper-IgE as well as the serum level of eosinophil cationic protein (ECP). The drug, however, did not affect the positivity for specific IgE antibodies against common allergens or the bronchial hyperresponsiveness to acetylcholine. Interleukin (IL)-2, IL-4, IL-5, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α were measured to be undetectable in serum before or during therapy. However, the expressions of mRNAs for IL-2, IL-4, IL-5, IFN-γ, and TNF-α in peripheral blood T-lymphocytes and the expression of IL-5 mRNA in peripheral blood eosinophils were detected before and during therapy, which were unchanged by therapy with IPD1151T. The present results suggest that different mechanisms other than the predominance of type 2 helper (T_H2)-like T-lymphocytes may underlie Kimura's disease and atopic bronchial asthma regarding the findings of eosinophilia and hyper-IgE, which could be modulated by IPD-1151T.
(Internal Medicine 37:1064-1067, 1998)

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Pontiac fever has rarely been found in sporadic cases. Here, we report the first sporadic cases of non-pneumonic legionellosis, Pontiac fever in Japan. Case 1. A 53-year-old man with spinocerebellar degeneration was presented to our hospital. He had an acute onset of high fever and consciousness disturbance. A chest X-ray film on admission was normal, but transient bilateral pleural effusions were revealed on hospital day 14. Case 2. A 77-year-old woman with gastric ulcer was presented to our hospital. She had an acute onset of high fever. A chest X-ray film on admission was normal, but transient bilateral pleural effusions were revealed on hospital day 7. High fever, resistant to β-lactam antibiotics, continued in both cases. Both had serologic confirmation of legionellosis by indirect fluorescent antibody assay for Legionella pneumophila without seroconversion for Mycoplasma pneumoniae, and Chlamydia pneumoniae, and had a good prognosis. Both were thought to be sporadic community-acquired cases rather than epidemics.
(Internal Medicine 37: 1068-1071, 1998)

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