Obstructive nephropathy is a relatively common entity that is treatable and often reversible. It occurs at all ages from infancy to elderly subjects. Obstructive uropathy is classified according to the degree, duration and site of the obstruction. It is the result of functional or anatomic lesions located in the urinary tract. The causes of obstructive uropathy are many. Obstruction of the urinary tract may decrease renal blood flow and the glomerular filtration rate. Several abnormalities in tubular function may occur in obstructive nephropathy. These include decreased reabsorption of solutes and water, inability to concentrate the urine and impaired excretion of hydrogen and potassium. Renal interstitial fibrosis is a common finding in patients with long-term obstructive uropathy. Several factors: macrophages, growth factors, hypoxia, cytokines are involved in the pathogenesis of interstitial fibrosis. It has been shown that ACE inhibitors ameliorate the interstitial fibrosis in animals with obstructive uropathy.
(Internal Medicine 39: 355-361, 2000)

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Objective Hyperinsulinemia has been associated with the risk of coronary heart disease, stroke, and renal disease in nondiabetic subjects. However, direct evidence that hyperinsulinemia per se is directly associated with atherosclerosis has been conflicting. The present study was designed to investigate the cross-sectional association of carotid artery atherosclerosis with insulin, independent of well-known cardiovascular risk factors, in nondiabetic subjects.
Methods and Subjects Between 1996 and 1997, 1, 335 subjects (620 men and 715 women) were recruited from one Japanese community, interviewed, and examined. Clinical measurements in the study included intimal-medial thickness (IMT) of the carotid artery, fasting plasma insulin, serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting plasma glucose (FPG), hemoglobin type HbA_1c, systolic blood pressure (SBP), diastolic blood pressure (DBF), and body mass index (BMI). We divided the subjects of both genders into three subgroups according to age (40-49 years of age; 50-59; and 60-69).
Results Using simple regression analysis, we found that IMT was significantly correlated with at least one of TC, LDL-C, HbA_1c, SBP, DBF, and BMI in each subgroup. The results of multivariate analysis showed that IMT was independently correlated with TC, HDL-C, LDL-C, SBP and BMI in males and with TC, TG, HDL-C, LDL-C, HbA_1c, SBP, DBF, and BMI in females. Insulin levels showed no correlation with IMT in either males or females.
Conclusion Fasting hyperinsulinemia does not appear to be correlated with carotid artery atherosclerosis based on the present cross-sectional results.
(Internal Medicine 39: 362-368, 2000)

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Objective and Methods We examined the prognostic significance of electrocardiographic change during anginal attack, C-reactive protein and fibrinogen in 169 patients with unstable angina.
Results During the 90-day follow-up period, 26 patients (15%) exhibited new cardiac events (death, myocardial infarction or urgent revascularization). Using multivariate analysis, ST depression (relative risk 7.507 [95% confidence intervals 1.842-30.592], p<0.01) during anginal attack was found to be an independent risk factor to predict cardiac events as well as diabetes mellitus, an increased total cholesterol level and the use of a thrombolytic agent. C-reactive protein and fibrinogen did not have prognostic significance.
Conclusion ST depression during anginal attack is an independent risk predictor for new cardiac events in patients with unstable angina.
(Internal Medicine 39: 369-374, 2000)

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Objective The purpose of the present study was to determine whether electroencephalographic (EEC) and cardiac arousal, i.e. heart rate elevation at the termination of apnea/hypopnea are related to aging.
Methods The subjects were 13 middle-aged (40-60 years of age, 47.8±5.35 years) and 10 elderly (>60 years of age, 69.8±5.31 years) male patients with obstructive sleep apnea syndrome. We evaluated the number of apneas per an hour of sleep (apnea index: AI), the number of hypopneas per an hour of sleep (hypopnea index: HI), the summation of HI and AI (apnea/hypopnea index: AHI), sleep stage, the amount of time during which nocturnal oxygen saturation was decreased below 90% (oxygen desaturation time: ODT), and EEG and cardiac arousal at the termination of apnea/hypopnea using polysomnography with pulse oximetry.
Results There was no significant difference in AHI, duration of apnea/hypopnea, and sleep stage distribution between the two groups. However, the ratio of apnea/hypopnea with EEG and cardiac arousal was significantly higher in middle-aged than in elderly patients. The ratio of HI to AHI was significantly lower in middle-aged than in elderly patients. In middle-aged patients, EEG and cardiac arousal were significantly correlated with AI, AHI, and ODT, whereas, in elderly patients, these parameters were not similarly correlated.
Conclusion Our findings suggest that the differences in EEG and cardiac arousal, and the pattern of sleep-disordered breathing (SDB) between middle-aged and elderly patients with SDB might be a physiological phenomenon of aging.
(Internal Medicine 39: 375-380, 2000)

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Object The fold plication method is a new operative procedure for lung volume reduction surgery whereby the target area is obliterated by plicating the folded tissue using a knifeless stapler, without the use of bovine pericardium. The effectiveness of this new method was evaluated in patients with advanced pulmonary emphysema.
Patients and Methods Two weeks before and 6 months after surgery, pulmonary function, static lung compliance, maximal esophageal pressure, maximal inspiratory and expiratory mouth pressures, 6-min walking distance and the Borg scale were determined in twenty consecutive patients who underwent video-assisted thoracoscopic unilateral surgery.
Results There was an increase in forced expiratory volume in one second (31%), forced vital capacity, peak expiratory flow rate and maximal voluntary ventilation, and a decrease in functional residual capacity (-16%) measured by plethysmograph. Static lung compliance decreased, and maximal esophageal pressure, and maximal inspiratory and expiratory mouth pressures increased. The 6-min walking distance increased (20%) and the Borg scale decreased (5.9 to 3.5).
Conclusion The results compare favorably with those obtained with other methods. Thus, the fold plication method could be considered an alternative procedure for lung volume reduction surgery.
(Internal Medicine 39: 381-384, 2000)

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A 64-year-old woman with a known history of hypertrophic obstructive cardiomyopathy presented with severe anemia of unknown origin. She had also suffered from repeated episodes of upper gastrointestinal bleeding for the previous 3 years. Despite bone marrow examination and panendoscopic and angiographic studies, the origin of anemia remained undefined until a small bleeding site was found during a duodenoscopic examination. The lesion proved to be angiodysplasia. This case report is interesting in that angiodysplasia elicited gastrointestinal bleeding and was the cause of anemia. In the international literature, there are very few reported cases of bleeding from gastrointestinal angiodysplasia in association with subvalvular aortic obstruction.
(Internal Medicine 39: 385-388, 2000)

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We treated a case of ventricular septal perforation (VSP) who survived for 14 years after myocardial infarction. Nine years after the onset of myocardial infarction, an apparent cardiac murmur was discovered by chance, and following further examination, the patient was diagnosed as having VSP. The patient is still in the NYHA functional class I, and requiring no surgical treatment. In general, the prognosis of myocardial infarction complicated with VSP is so poor that there have only been 14 reported cases of long survival without surgical treatment. Among these patients, only 2 survived for more than 10 years. The present case is extremely rare, and evidently is the longest living survivor with this condition yet reported.
(Internal Medicine 39: 389-393, 2000)

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A 66-year-old man who underwent a total gastrectomy 13 years ago was admitted to our hospital complaining of severe low back pain and muscle weakness. Biochemical examinations revealed hypocalcemia, hypophosphathemia, low serum 25 (OH) vitamin D and hyperparathyroidism. A chest CT scan revealed pseudofractured ribs, whereas plain X-photography did not show any significant findings. We diagnosed the illness as osteomalacia due to malabsorption. The patient has been receiving oral active vitamin D and calcium, and the pain and serum calcium and phosphate values have improved to the point that he can receive outpatient treatment.
(Internal Medicine 39: 394-396, 2000)

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Type II cryoglobulinemia is sometimes observed in patients with HCV infection. It is also well known that some cases with membranoproliferative glomerulonephritis (MPGN) possess cryoglobulinemia, which can induce neuropathy. We treated a 73-year-old woman with hepatitis C virus (HCV) who was admitted to our department because of proteinuria. She was diagnosed as MPGN according to renal biopsy. Her ankle jerk was absent with reduced touch sensation and vibration below the knees; sural nerve biopsy revealed demyelinating neuropathy. Administration of prednisolone resulted in improved proteinuria. Cryoglobulinemia associated with HCV infection seemed to induce MPGN and demyelinating neuropathy.
(Internal Medicine 39: 397-400, 2000)

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We report a case of acute eosinophilic pneumonia (AEP). Although the patient had been a habitual cigarette smoker for over 4 months, he had had not any respiratory distress. After he inhaled smoke from fireworks for 3 consecutive nights, the patient began to complain of cough, fever and dyspnea. He showed leukocytosis of 16, 200/μl and hypoxemia of 58.1 torn Chest radiograph showed bilateral infiltrates with Kerley A and B lines. The bronchoalveolar lavage fluid revealed 38.5% eosinophils. He was diagnosed as AEP. In this patient, inhaling of smoke from fireworks was clinically suspected to be associated with the induction of AEP.
(Internal Medicine 39: 401-403, 2000)

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The prognosis of diffuse panbronchiolitis (DPB) has been remarkably improved after the development of low-dose erythromycin therapy, possibly due to anti-inflammatory rather than anti-infective mechanisms. Interestingly, DPB associated with lung cancer is quite rare. Here, we report an autopsy case of DPB who developed lung cancer after a long successful therapy with low-dose erythromycin.
(Internal Mrdicine 39: 404-106, 2000)

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We describe the clinical courses of the 3 fatal patients (2 females and 1 male) with idiopathic non-specific interstitial pneumonia (NSIP) among 24 patients with NSIP. Lung biopsies were diagnosed to be NSIP group II in all patients. The clinical courses from onset to death of these 3 patients were 41 months, 46 months, and 91 months. A follow-up chest CT demonstrated no apparent honey-comb formation. We found that i) about 20% of patients with NSIP died of respiratory failure, ii) in the chest CT findings, apparent honey-comb formation was rare even just before death, iii) prediction of the prognosis based on the histological findings was difficult. This is the first report to describe the clinical features of deceased patients with idiopathic NSIP; the incidence of fatal cases was considered to range from 10 to 20%.
(Internal Medicine 39: 407-411, 2000)

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We report a 50-year-old man who developed therapyrelated myelodysplastic syndrome after treatment with etoposide-including chemotherapy for extratesticular germ cell tumor. Chromosomal analysis showed inversion 11 (p15q22) translocation. Reverse transcriptase-polymerase chain reaction amplification of patient RNA showed a fusion transcript of nucleoporin gene NUP98, and putative DEAD-box RNA helicase gene DDX10. NUP98 is implicated in the transformation through aberrant nucleocytoplasmic transport. DDX10 is suggested to be involved in ribosome assembly. The NUP98-DDX10 fusion transcript may promote the development of secondary hematological malignancies caused by DNA-topoisomerase II inhibitors through aberrant nucleocytoplasmic transport and/or alteration in ribosome assembly.
(Internal Medicine 39: 412-415, 2000)

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A 61-year-old woman, who was diagnosed in 1982 as having polycythemia vera, was admitted to our hospital in July 1998 because of a splenic tumor in an enlarged spleen due to myelofibrosis. As it was difficult to identify the etiology of the splenic tumor, partial splenectomy was carried out. The resected tumor proved to be an extremely proliferative lesion as the result of extramedullary hematopoiesis. Since it is difficult to diagnose the etiology of splenic tumor, the collection and analysis of reports of relevant cases may well facilitate diagnosis.
(Internal Medicine 39: 416-118, 2000)

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We report a case with portal systemic encephalopathy who presented with dressing and constructional apraxia and subtle weakness of the left hand. We initially suspected a cerebrovascular attack in the right cerebral hemisphere, but brain T₁-weighted magnetic resonance (MR) imaging revealed high intensity in the basal ganglia and hyperammonemia was detected. We performed abdominal MR angiography, which visualized an intrahepatic portal systemic shunt. Cerebral blood flow, measured by xenon-enhanced computed tomography, was decreased in the bilateral, but more dominantly right-sided, parietal watershed regions. We speculate that these boundary territories might be susceptible to damage by toxic metabolites of hepatic encephalopathy.
(Internal Medicine 39: 419-423, 2000)

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A 51-year-old man with osteomyelitis developed acute renal failure and superior mesenteric venous (SMV) thrombosis after piperacillin (PIPC) treatment. Coagulation profile disclosed disseminated intravascular coagulation (DIG). The serum levels of IgE and eosinophil cationic protein showed significant increases, while a lymphocyte stimulation test with PIPC also demonstrated an extremely high index. These observations suggest that hypersensitivity to PIPC might play a role in the pathogenesis of acute renal failure and SMV thrombosis due to hypercoagulopathy. Withdrawal of PIPC and anticoagulation therapy resulted in clinical improvement and normalization of the affected laboratory data. This is the first report to describe PIPC-induced hypercoagulopathy.
(Internal Medicine 39: 424-427, 2000)

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Interstitial pneumonia of polymyositis and dermatomyositis (PM/DM), especially the rapid progressive type, is a serious complication. We report a case of acute exacerbated interstitial pneumonia associated with DM. The respiratory distress condition was refractory to steroid pulse therapy and cyclosporine, however, there was a good response to additional intravenous Cyclophosphamide pulse therapy (IVCY). We propose the possibility that the combination of these immunosuppressants might be useful for interstitial pneumonia with DM which is resistant to conventional steroid therapies.
(Internal Medicine 39: 428-430, 2000)

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We describe six elderly cases of acute myositis with type A influenza virus infection (Sydney) during the 1998-1999 outbreak. AH six cases suffered from myalgia or muscle weakness especially in the lower extremities and the serum creatine kinase (CK) values were elevated above 1, 000 IU/l without MB isoenzymes or electrocardiogram abnormalities. There have been a few case reports of acute myositis associated with influenza virus infection in the elderly. However, we noticed a high incidence of acute myositis among elderly patients with type A influenza virus infection. This complication may occur more commonly in elderly patients than has previously been thought.
(Internal Medicine 39: 431-432, 2000)

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We report a case of Paragonimus westermani infection with a reticulonodular lesion in the right lung, left pleural effusion, and a mobile subcutaneous mass. Analyses of pleural effusion and bronchoalveolar lavage fluid (BALF) showed marked eosinophilia and high levels of eosinophil cationic protein and interleukin (IL)-5. Transbronchial lung biopsy revealed the presence of pneumonia with mild eosinophilic infiltration but remarkable lymphocytic infiltration. In this patient, high IL-5 levels in both BALF and pleural effusion could explain the remarkable eosinophilia.
(Internal Medicine 39: 433-136, 2000)

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