To clarify the bronchoscopic findings in metastatic spread to the bronchi, we analyzed the records of 65 cases of metastatic pulmonary disease in which fiberoptic bronchoscopy had been done. Forty-five patients (69.2 % ) had abnormal bronchoscopic findings. These patients could be divided into three groups, according to bronchoscopic findings and route of metastatic spread to the bronchi: endobronchial metastasis (n=15), bronchial involvement (that is, direct extension to the bronchi from adjacent metastatic foci, n=15), and lymphangitis carcinomatosa (n=15). Breast cancer and colon cancer were common in cases of endobronchial metastasis, and the bronchial tumor often presented as a polypoid or nodular lesion covered with necrotic material. Submucosal swelling with an irregular margin and narrowing of the bronchial lumen were seen in cases of bronchial involvement. In conclusion, each type of primary extrapulmonary tumor is associated with characteristic endobronchial findings of pulmonary metastases such as endobronchial metastasis and bronchial involvement, which should be discriminated if possible, because of their different metastatic process.
(Internal Medicine 37: 349-353, 1998)

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We prospectively examined the survival rate of 67 chronic obstructive pulmonary disease (COPD) and 74 late sequelae of pulmonary tuberculosis (TB seq) patients to clarify whether nocturnal oxyhemoglobin desaturation (NOD)could be one of the independent factors determining their mortality. The sleep monitoring of arterial oxygen saturation (SpO₂) and pulmonary function tests were assessed in all patients at the time of registration. Forty %of COPD and 24%of TB seq died as the direct result of deterioration of chronic respiratory failure during the 7-year observation period. Cox's proportional hazards analysis showed that NOD was an independent prognostic factor in both groups, and this was especially prominent when evaluated in terms of sleep lowest SpO₂ in COPD and 85% desaturation time in TB seq. No significant prognostic factor was observed among age, vital capacity percent predicted (%VC), forced expiratory volume in one second (FEV_1.0%)and partial pressure of carbon dioxide (PaCO₂). We conclude that the degree of NOD can affect mortality in COPD and TB seq.
(Internal Medicine 37: 354-359, 1998)

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We compared characteristic features in ischemic stroke lesions from the hyperacute to the chronic stage on diffusion-weighted (DW)and magnetization transfer (MT) images with those on T2-weighted (T2W) images, and assessed changes in apparent diffusion coefficient (ADC), MT effect (MTe), and T2 ratios (infarct/normal) over time. DW images were particularly useful for detecting hyperacute infarcts within 6 hours of onset and in distinguishing acute lesions from chronic lesions. ADC ratios were lower within 7 days after onset and rose toward 1.0 in the subacute phase, becoming relatively isotense on ADC maps, but elevated thereafter. Although MTe ratios were unchanged or only subtly changed in the acute stage, they became significantly lower in the subacute and chronic stages. These combined magnetic resonance (MR)techniques were useful in the assessment of ischemic stroke and facilitated the determination of the age of cerebral infarct.
(Internal Medicine 37: 360-365, 1998)

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A huge coronary aneurysm resulting from a coronary artery-to-left ventricle fistula is a rare condition. A 57-year-old male had severe recurrent angina attacks. The cause of angina pectoris was a right coronary artery-to-left ventricle fistula with a huge coronary aneurysm. The histological examination of surgically excised specimens revealed that two vertical smooth muscle layers of media of the aneurysm might be associated with dysplasia. Mucoid degeneration was also shown in the intima and around the vasa-vasorum. Abnormal hemodynamics related to the fistula might have induced these vessel wall changes resulting in the huge coronary aneurysm.
(Internal Medicine 37: 366-369, 1998)

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Leiomyosarcomasare extremely rare primary cardiac tumors. We report a rapidly growing primary leiomyosarcoma of the right ventricle, which obstructed the right ventricular outflow tract within one month after symptom onset in a 68-year-old man. Two-dimensional echocardiography was useful in diagnosing the extent and progression of the tumor. The tumor was surgically resected on an emergency basis, and the right ventricle and pulmonary artery were successfully reconstructed. Recurrence of the tumor on the right ventricle was observed, and the patient was overcomeby sudden dyspnea and died three months after surgery.
(Internal Medicine 37: 370-375, 1998)

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A 68-year-old manvisited our hospital because of heartburn. A firm mass was palpated in the left upper abdominal quadrant. Ultrasonography and computed tomography revealed a large left sided retroperitoneal tumor. A barium enema examination showed shallow irregularly depressed or elevated lesions. Colonoscopy revealed an irregularly shaped ulcer and multiple submucosal masses suggesting invasion by an extrinsic malignant tumor. Although colonoscopic biopsy was negative, a resected tumor was histologically diagnosed as a malignant fibrous histiocytoma (MFH). When such varigated lesions are detected in the colon, MFH should be considered, and an attempt to sample the submucosallayer maybe necessary.
(Internal Medicine 37: 376-380, 1998)

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There are numerous reported cases of lingual thyroid with an obvious prevalence in pediatric age. Such ectopic thyroid glands are probably quantitatively deficient and thyroid function may be low or at a low normal level. Apparently, most cases of ectopic thyroid tissue develop congenital hypothyroidism, the so-called cretinism. In this report, we describe a very rare adult male case of lingual thyroid who developed hypothyroidism in adulthood; the anomaly remained undiscovered, being without local common symptoms, and permitted a normal life.
(Internal Medicine 37: 381-384, 1998)

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A 49-year-old woman with Cushing's syndrome due to unilateral adrenal hyperplasia is presented. She had developed obesity and menopause for 2 years, but no hypertension or hypertrichosis was observed. Although plasma adrenocorticotropin and serum cortisol levels were within normal ranges, the circadian rhythm has completely disappeared. Free thyroxine and triiodothyronine levels were decreased. Adrenocorticotropin did not respond to corticotropin-releasing hormone, and urinary excretion of 17-hydroxycorticosteroids was not suppressed by dexamethasone. Abdominal computed tomography and ¹³¹I-Adosterol scintigraphy demonstrated a unilateral functioning mass in the left adrenal gland. The resected left adrenal mass was pathologically diagnosed as the rare condition of adrenocortical nodular hyperplasia.
(Internal Medicine 37: 385-390, 1998)

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A 78-year-old woman with hypertension was hospitalized with acute bronchitis. However, she was also found to have hypernatremia, hypokalemia, and metabolic alkalosis. Detailed examination showed a low plasma renin activity and plasma aldosterone concentration. A provisional diagnosis of Liddle's syndrome was established and the patient was successfully treated with triamterene. Although Liddle's syndrome is generally considered an inherited hypertensive disease found in young people, a review of the literature indicated that muscle weakness is an important clinical finding in elderly patients with this disease. Liddle's syndrome should be considered in the differential diagnosis of hypertension even in elderly individuals.
(Internal Medicine 37: 391-395, 1998)

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Pamidronate is an effective drug used not only in patients with tumor-associated hypercalcemia, but also in normocalcemic patients with metastatic bone disease to relieve pains. We describe a 39-year-old normocalcemic patient with subclinical hypoparathyroidism and bone metastasis due to breast carcinoma. Following parenteral administration of 60 mg pamidronate, the corrected serum level of calcium decreased from 2.12 mmol/l (=8.9 mg/dl) to 1.42 mmol/l (5.7 mg/dl), accompanied with carpal pedal spasm. The present case indicates that the hypocalcemia due to latent hypoparathyroidism was compensated by extensive osteolysis due to bone metastasis, and that overt hypocalcemia may develop after intravenous administration of pamidronate in such a patient.
(Internal Medicine 37: 396-397, 1998)

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We report a 62-year-old male patient who had variant angina and isolated adrenocorticotropic hormone(ACTH) deficiency. His serum sodium concentration was low and vasopressin was inappropriately high for the low plasma osmolality. Serum free thyroxine (FT₄) was low and thyroid stimulating hormone (TSH) was high with positive anti-thyroperoxidase antibodies, compatible with Hashimoto's thyroiditis. Treatment with Amrodipine and hydrocortisone relieved chest symptoms and hyponatremia, and hypothyroidism was also normalized. It is suggested that coronary artery spasm may be related to cortisol deficiency and/or inappropriately high vasopressin secretion and that hypothyroidism was ameliorated because the reduced responsiveness to TSH returned to normal due to hydrocortisone supplement.
(Internal Medicine 37: 398-402, 1998)

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A 41-year-old female had pheochromocytoma which secreted adrenocorticotropic hormone (ACTH). She was admitted to our hospital because of weight loss and excessive sweating. Not only urinary metanephrine but also plasma ACTH was extremely high. An abdominal echogram showed a cystic tumor in the left adrenal gland. An abdominal magnetic resonance imaging scan showed a hyperintense T2-weighted abnormality inside the tumor. Left adrenalectomy was done. The tumor consisted of benign pheochromocytoma cells diffusely stained with anti-ACTH antibody. The present case did not show any typical Cushingoid symptoms which are common in ACTH-secreting pheochromocytomas.
(Internal Medicine 37: 403-406, 1998)

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We report two cases of diffuse malignant pleural mesothelioma occurring almost simultaneously in one family. Patient 1 was a 42-year-old Japanese man who had worked as an electrical engineer for 25 years. Patient 2, his mother, was 69 years old. She lived for 10 years with patient 1 after he started his work, and also worked at a shipyard herself for 6 years. The concentrations of cytokeratin subunit 19 fragment (CYFRA 21-1) in pleural fluid of the two patients were 1, 500 ng/ml, and 1, 200 ng/ml, respectively. Measurement of CYFRA 21-1 concentration in the pleural fluid maybe a useful tool for a diagnosis of malignant mesothelioma.
(Internal Medicine 37: 407-410, 1998)

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Adult T-cell leukemia-lymphoma (ATL) is resistant to currently available chemotherapy and has a poor prognosis. We describe here a patient with ATL successfully treated with 2- chlorodeoxyadenosine (2-CdA). A 75-year-old Japanese male with an acute type of ATL, who had become resistant to the initial cytotoxic chemotherapy, was treated with 2-CdA administered by continuous drip infusion of 0.09 mg/kg/d for seven consecutive days in one month (one cycle). After three cycles of treatment, partial remission (PR) was achieved. Surprisingly, 249 days after the administration of 2-CdA, ATL cells completely disappeared from the peripheral blood. PR was maintained during 10 weeks until evidence of a new lymphadenopathy. No remarkable toxicity of 2-CdA occurred.
(Internal Medicine 37: 411-413, 1998)

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A case of thymic squamous cell carcinoma producing interleukin-6 (IL-6) is reported. C-reactive protein (CRP), white blood cell (WBC)count, and serum IL-6 had been elevated, and normalized immediately after tumorectomy. IL-6 in the culture supernatant from the tumor was significantly elevated and the expression of IL-6 mRNA was demonstrated in the tumor by a reverse transcriptase polymerase chain reaction method. Immunohistochemical study demonstrated that tumor cells were stained positive with an anti-IL-6 antibody. IL-6 derived from the tumor cells reflected the increase CRP and WBC counts. This case suggested that asymptomatic elevation of acute-phase reactants might be clues for the diagnosis of an IL-6 producing tumor.
(Internal Medicine 37: 414-416, 1998)

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Peripheral polyneuropathy and the complication of eosinophilic fasciitis (EF) is rare; only 2 such cases have been described previously. A 40-year-old woman suffered from swelling of the extremities after strenuous exercise and complained of bilateral paresthesia on the soles of her feet. The diagnosis was EF according to clinical symptoms, peripheral eosinophilia, and histological examination of the fascia. Nerve conduction tests also revealed sensory disturbance as mononeuritis multiplex. After administration of prednisolone, the swelling and tenderness of the extremities improved immediately but the neuropathy lasted for 6 months.
(Internal Medicine 37: 417-420, 1998)

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The results of the autopsy ofa 38-year-old female with mixed connective tissue disease who had suffered from painful subcutaneous calcification in her buttocks and extremities for 14 years and died from rapidly progressive pulmonary hypertension are reported. On autopsy, her heart and lungs revealed changes of severe pulmonary hypertension with intimal thickening and plexiform lesions in the small pulmonary arteries which had resulted in the collapse of both lungs and caused marked dilatation and hypertrophy of the right ventricle of the heart. Microscopic examinations of the subcutaneous calcified tissues indicated that the calcification may have been caused by repeated panniculitis.
(Internal Medicine 37: 421-425, 1998)

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