Serum hyaluronan measurement is an option for diagnosing cirrhosis and assessing liver fibrosis, but it is of little use in the diagnosis of chronic hepatitis and compensated liver cirrhosis. It is generally known that intake of food results in elevation of the serum hyaluronan concentration. This work was designed to determine whether a change in the serum hyaluronan concentration after eating might reflect the hepatic sinusoidal endothelial cell impairment in chronic liver diseases. The chronological measurement of serum hyaluronan concentration after eating was performed after an overnight fast in 31 patients with chronic hepatitis, 31 cirrhotic patients, and 8 healthy subjects. The hyaluronan concentration in the loading test increased with the severity of the liver disease in the patients with chronic hepatitis, being significantly higher in the patients with moderate or a higher grade of necroinflammation than in those with a minimal grade, and also significantly higher in patients with stage 3 fibrosis than in those with stage 2 or less. The elevation of the concentration after eating in patients with liver cirrhosis was marked and the range did not overlap with that in patients with chronic hepatitis. Even in 14 patients with compensated liver cirrhosis whose hyaluronan concentration pre-prandially was less than 200 ng/ml, the range of the post-prandial peak concentration did not overlap with that in the chronic hepatitis patients. These results suggest that the evaluation of post-prandial serum hyaluronan concentration is potentially useful for assessing the grading of necroinflammation and staging of fibrosis in patients with chronic hepatitis, as well as for diagnosing compensated liver cirrhosis.
(Internal Medicine 37: 568-575, 1998)

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We examined the relationship between left ventricular hypertrophy (LVH) and renal and retinal damage in 174 untreated patients with essential hypertension. As an index of renal and retinal damage, we examined proteinuria and retinal vascular change. LVH was diagnosed according to left ventricular mass obtained from echocardiography. Of the hypertensive patients, 111 patients (64%) had LVH. The incidences of proteinuria and advanced retinal vascular change were higher in patients with LVH than in those without LVH. In a multiple regression model, there was a significant positive correlation between left ventricular mass and proteinuria, as well as diastolic blood pressure, sex, age and body mass index. In conclusion, proteinuria is related to elevated left ventricular mass in patients with essential hypertension.
(Internal Medicine 37: 576-580, 1998)

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We investigated the serum paraoxonase (PON) activity and genotype distribution in 139 patients with non-insulin-dependent diabetes mellitus and in 240 control subjects in a Japanese population. There were no significant differences in PON genotype frequencies between the diabetic and control subjects, but the PON activity was significantly less in diabetic subjects (p<0.01). PON activity was significantly related to levels of total cholesterol and high density lipoprotein (HDL) cholesterol in the control subjects, but not in the diabetic subjects. In diabetic subjects with the genotype A A, the mean maximum intimal-medial thickness (IMT) of the carotid artery was significantly greater than in subjects with genotype AB or BB. PON may play an important role in the development of atherosclerosis associated with diabetes mellitus.
(Internal Medicine 37: 581-584, 1998)

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To clarify the effectiveness of methylprednisolone pulse therapy on crescentic glomerulonephritis (CresGN), data of 46 patients was retrospectively studied. According to the slope of reciprocals of serum creatinine (s-Cr) the patients were divided into acute and insidious types, and each type was further divided into pulse (P) and conventional (C) therapy groups. In group C, s-Cr improved more frequently in the acute type (8/10) than in the insidious type (1/9, p<0.05), and the renal survival rate was somewhat higher in the former (p=0.09). In the acute type there was no difference in the improvement rate of s-Cr between the two therapy groups, whereas in the insidious type, the improvement rate was higher in group P (9/15) than in group C (1/9, p<0.05) and the renal survival rate was higher in the former (p<0.01). These results suggest that methylprednisolone pulse therapy may be highly effective for the insidious type of CresGN.
(Internal Medicine 37: 585-591, 1998)

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We report a case of idiopathic retroperitoneal fibrosis presenting with duodenal obstruction. A 55-year-old man suddenly developed severe epigastric pain and was admitted to our hospital. On abdominal computed tomography (CT), a large retroperitoneal mass was found. Hypotonic duodenography showed obstruction of the third portion of the duodenum. He was diagnosed as idiopathic retroperitoneal fibrosis and was treated with prednisolone. The patient improved dramatically. He has been well for twelve months without any further treatment.
(Internal Medicine 37: 592-598, 1998)

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We evaluated 3 patients with acromegaly who developed heart failure. Heart failure appeared to be due to acromegalic cardiomyopathy in 2 patients who did not have hypertension or evidence of coronary artery disease, and it was possibly due to acromegalic cardiomyopathy combined with familiar hypertrophic cardiomyopathy in 1 patient. The common echocardiographic findings in the present three cases were: 1) enlargement of the left atrium, 2) markedly dilated left ventricular cavity with diffuse hypokinesis, 3) decrease of indices of the left ventricular systolic function, and 4) no evidence of left ventricular hypertrophy. Echocardiographic findings in acromegaly with congestive heart failure resemble those of idiopathic dilated cardiomyopathy.
(Internal Medicine 37: 599-603, 1998)

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A 61-year-old man developed thyrotoxicosis after excision of a thymoma. His laboratory examination showed an increased level of thyroid hormone and a low thyroidal iodine uptake. No thyroidal autoantibody was detected. With the diagnosis of silent thyroiditis, he was treated with propranolol. He became euthyroid after 2 months. Thymoma often accompanies an autoimmune disease as a paraneoplastic syndrome, and an immunological mechanism is thought to be involved in the onset of silent thyroiditis. This case suggests the involvement of an immunological mechanism in the pathogenesis of silent thyroiditis.
(Internal Medicine 37: 604-605, 1998)

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We report a nephrotic syndrome patient with eosinophilia who developed ileus, epigastralgia and malabsorption due to Strongyloidiasis which became symptomatic by steroid therapy. The patient was then treated with thiabendazole and recovered. A percutaneous renal biopsy revealed minimal change nephrotic syndrome. This renal injury may be brought on by severe infection of Strongyloides stercoralis. It is important to rule out Strongyloidiasis prior to corticosteroid therapy to patients from eosinophilia endemic areas.
(Internal Medicine 37: 606-610, 1998)

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A 73-year-old woman who had a history of primary biliary cirrhosis developed rapidly progressive glomerulonephritis and pulmonary-renal syndrome. She was found to have anti-mitochondrial antibody (AMA) and myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibody (ANCA). She also had weak anti-glomerular basement membrane (GBM) antibody. She was treated with methylprednisolone pulse therapy, but died of respiratory failure. On postmortem examination, both lungs showed diffuse hemorrhage and the immunofluorescence study of the kidney revealed linear immunoglobulin G (IgG) deposition along the glomerular basement membrane.
(Internal Medicine 37: 611-613, 1998)

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Malignant mesothelioma of the pleura often involves the heart but seldom invades the intracardiac cavity. We report a 78-year-old woman with right pleural mesothelioma who died of heart failure. An autopsy revealed that the tumor was present at the right pleura and invaded the right upper lobe of the lung and the mediastinum. The tumor also extended to the left atrium via the right pulmonary vein and filled the atrial cavity. Repeated transthoracic echocardiography failed to detect the tumor, but magnetic resonance imaging was useful for diagnosis.
(Internal Medicine 37: 614-617, 1998)

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We report a case of Pneumocystis carinii pneumonia in a patient with acquired immunodeficiency syndrome diagnosed and monitored with polymerase chain reaction (PCR) for Pneumocystis carinii on sputum and measurement of plasma (1→3)-β-D-glucan (G-test). Results of both studies paralleled the clinical and radiographic improvement. However, the plasma (1→3)-β-D-glucan level remained higher than normal when PCR for Pneumocystis carinii became negative in sputum. Both PCR for Pneumocystis carinii on sputum and measurement of plasma (1→3)-β-D-glucan are useful for noninvasive diagnosis and monitoring of Pneumocystis carinii, although further investigation is necessary to quantify their relationship.
(Internal Medicine 37: 618-621, 1998)

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A case of pulmonary Mycobacterium avium (M. avium) disease associated with idiopathic CD4+ T lymphocytopenia is reported. A rapidly growing pulmonary nodule was detected on a chest roentgenogram in a young man. Bronchoscopic examination revealed M. avium infection. Hematological studies showed a low CD4+ cell count in the absence of any identifiable immunodeficiency, including human immunodeficiency virus (HIV) infection. With the combination of chemotherapy and surgery, he had a good clinical outcome. Idiopathic CD4+ T lymphocytopenia should be considered in patients with unexplained opportunistic infection.
(Internal Medicine 37: 622-624, 1998)

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Complete obstruction of the right main bronchus occurred in a 76-year-old woman due to pulmonary metastasis from the extraskeletal myxoid chondrosarcoma (EMC) which had been detected 5 years earlier. Treatment with Nd-YAG laser and biopsy forceps opened up the lumen of the right main bronchus 90%, and then X-irradiation was given toward the remaining tumor. The tumor disappeared almost completely following radiotherapy and such a state had lasted for several years until she died of old age at the age of 81. We judged that radiotherapy had been effective for this tumor. To date, the information concerning the effect of radiotherapy on this disease is insufficient.
(Internal Medicine 37: 625-627, 1998)

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We present a case of primary prostatic lymphoma referring to a 57-year-old man, who was admitted with the symptom of bladder outlet obstruction, and had a history of urination difficulty for two years. The symptoms and signs were compatible with a diagnosis of benign prostatic hypertrophy (BPH). The pathology of the specimen obtained from transurethral prostatectomy showed B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type. The patient has been asymptomatic and under complete remission after completion of chemotherapy consisting of doxorubicin, cyclophosphamide, vincristine and prednisone for 6 cycles.
(Internal Medicine 37: 628-630, 1998)

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A 75-year-old woman was admitted because of pain and numbness in the extremities and trunk. She subsequently suffered from lymphadenopathy and spiky fever. The immunohistochemical analysis of the biopsied lymph nodes and sural nerve and electrophysiological examination supported a diagnosis of angioimmunoblastic lymphadenopathy-like T cell lymphoma with polyneuropathy. The infiltrating lymphoma cells of the sural nerve and lymph node shared the same phenotype (CD45RO, CD3, CD30 positive). An increased expression of HLA-DR antigen was observed in endothelial and Schwann cells. Chemotherapy with CHOP-Bleomycin markedly relieved her pain. These findings suggest that a direct lymphocytic infiltration in the nerve may be associated with neuropathy in this case.
(Internal Medicine 37: 631-634, 1998)

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Due to pyloric stenosis in a 59-year-old male with the diagnosis of unresectable pancreatic head cancer, gastro-jejunostomy and cholecysto-jejunostomy were performed. Following the operation, the patient underwent a combination chemotherapy with cisplatin 10 mg/day × 5/week and continuous infusion of 5-fluorouracil 500 mg/day for 4 weeks. After three courses, the tumor size decreased and the serum carcinoembryonic antigen (CEA) level decreased from 89.6 to 4.2 ng/ml without significant adverse effects. During the follow-up, the CEA increased and the patient is now receiving the same treatment, surviving for more than one year.
(Internal Medicine 37: 635-637, 1998)

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We report a 23-year-old woman who developed ascites 3 years after Ventriculoperitoneal shunting. Revision of the shunt to ventricular drainage followed by ventriculo-atrial shunting was required for resolution of ascites. In our patient the pathophysiology of this rare shunt complication most likely involved impaired absorption of fluid within the peritoneum associated with multiple shunt reconstructions and tube extensions resulting in chronic inflammation. Cerebrospinal ascites must be suspected irrespective of post-shunt intervals in similar patients.
(Internal Medicine 37: 638-641, 1998)

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A 46-year-old woman was admitted to our department complaining of dermal eruption and weakness of muscles. She was diagnosed as having dermatomyositis and was initially treated with prednisolone. Since her condition rapidly deteriorated, high-dose intravenous immunoglobulin (IVIG) therapy (0.4 g/kg/day i.v. for 5 days) was administered. Marked improvement in muscle strength was observed the following day after the first administration. She unfortunately died of pneumocystis carinii pneumonitis 2 weeks after the IVIG therapy. Autopsy revealed no inflammatory cells in the muscles, suggesting that IVIG therapy has an important clinical application for refractory dermatomyositis.
(Internal Medicine 37: 642-645, 1998)

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Churg-strauss syndrome (CSS) is a disorder characterized by hypereosinophilia and systematic vasculitis occurring in individuals with bronchial asthma. We present a case of 24-year-old woman with CSS diagnosed by and followed with gastrointestinal flberscopic examination and electroneuromyography. The duodenal biopsy showed granulomatous angiitis with eosinophilic infiltration, and the electroneuromyography showed peripheral nerve dysfunction. After steroid treatment, the duodenal erosion and ulcer were almost completely resolved. There was no improvement in electroneuromyography, but the patient was able to walk independently after intensive rehabilitative training.
(Internal Medicine 37: 646-650, 1998)

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