In the new Japanese control law for infectious diseases, most varieties of acute viral encephalitis belong to Category IV requiring report of all cases at sentinel hospitals. Herpes simplex virus type 1 (HSV-1) encephalitis comprises the majority of cases. With the increased prevalence of diagnostic procedures such as polymerase chain reaction (PCR), several forms of HSV-1, and -2 central nervous system (CNS) infections, including acute disseminated encephalomyelitis, brainstem encephalitis, and myelitis, have been clarified. Since 1990 we have conducted a survey of HSV CNS infections in the Kyushu and Okinawa regions, and the data are reviewed here. Trends include an increase in a new subtype of non-herpetic acute limbic encephalitis. In contrast, the incidence of Japanese encephalitis (JE) in Japan has dramatically decreased to a few patients per year; however, JE remains a threat for those with decreased or absent immunity to the JE virus. Imported emerging and reemerging CNS infections such as Murray Valley and West Nile encephalitis can occur in Japan. Influenza-associated encephalitis/encephalopathy is also described as a threat for adults as well as young children.
(Inte

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Objective Inhaled nitric oxide (NO) has been used for pulmonary vasodilation therapy in patients with pulmonary hypertension. Inhaled NO for awake and ambulatory patients, however, is unusual because it requires intubation or a tightly fitting facemask, and a large-scale delivery system for the safe management of toxic nitrogen oxides. We undertook this study to investigate the possibility of using inhaled NO therapy for awake and ambulatory patients with pulmonary hypertension.
Methods Patients with pulmonary hypertension underwent cardiac catheterization and hemodynamic variables were measured at the baseline, after inhaled NO using our pulse delivery system, which involved a nasal cannula and a pulse device, and after inhaled NO using a continuous delivery system.
Patients or materials We studied seventeen patients with precapillary pulmonary hypertension (4 men and 13 women; age, 41±3, ranging from 19 to 61).
Results Cardiac output was increased significantly by each system. Pulmonary vascular resistance was decreased significantly by each system. There was no significant change in mean pulmonary artery pressure, mean systemic artery pressure, or systemic vascular resistance. The concentrations of NO and nitrogen dioxide (NO₂) in the expiratory gas using the pulse delivery system were 0.0 ppm as long as the pulse device was synchronized with the patient's respiratory cycle.
Conclusion Inhaled NO using our pulse delivery system changed the hemodynamic variables similarly to those when using the continuous delivery system. The concentrations of NO and NO₂ in the expiratory gas using the pulse delivery system were within safe limits.
(Internal Medicine 41: 429-434, 2002)

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Objective Nitric oxide (NO) production is enhanced in patients with liver cirrhosis (LC). Although most patients with mild LC have neither dyspnea nor platypnea, they might have mild oxygenation abnormalities due to intrapulmonary vasodilatation caused by increased NO. We investigated whether oxygenation abnormalities, such as hypoxemia and orthodeoxia, are present in patients with mild LC.
Methods We investigated 148 consecutive patients with biopsy-proven chronic liver diseases such as CH (noncirrhotic chronic hepatitis) (n=46), LC(A), LC(B), and LC(C) (LC Child's A, B, and C) (n=18, 51, 33, respectively). The oxygen saturation by pulse oxinietry (SpO₂) in the supine and upright positions was determined in patients and controls (normal subjects, n=29). The change in SpO₂ on standing was defined as ΔSpO₂. NO output in exhaled air was measured in 16 patients.
Results Four patients [two LC(B) and two LC(C)] had hypoxemia (supine SpO₂≤94% and/or upright SpO₂≤94%). Although there was no intergroup difference in the supine SpO₂ or the upright SpO₂, the ΔSpO₂ decreased [control, +0.2±0.6%; CH, +0.1±0.9%; LC(A), -0.3±0.8%; LC(B), -0.2±0.9%; LC(C), -0.5±1.1%; mean±SD; p=0.005] with worsening liver disease, and the prevalence of desaturation on standing (ΔSpO₂≤-1%) increased [control, 7%; CH, 20%; LC(A), 33%; LC(B), 35%; LC(C), 42%; p=0.01]. The NO output was inversely correlated with ΔSpO₂ (r=-0.66, p=0.006).
Conclusions Desaturation on standing is present in one-third of normoxemic patients with mild LC of Child's A, and is associated with the severity of liver disease. This postural desaturation is correlated with the exhaled NO, which suggests that intrapulmonary vasodilatation may play some role in this phenomenon.
(Internal Medicine 41: 435-140, 2002)

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A 42-year-old woman with autosomal dominant polycystic kidney disease (ADPKD) was admitted to our hospital on April 29, 1999, with complaints of abdominal pain. A diagnosis of intestinal obstruction was reached on the basis of clinical findings and X-ray evidence. A computed tomography scan of the abdomen showed massively enlarged kidneys, especially the right kidney, which seemed to compress the small intestine. The patient underwent percutaneous aspiration of the largest cysts on the surface of the right kidney. The symptoms, in this rare case of intestinal obstruction by an enlarged kidney in ADPKD, were alleviated the day after the aspiration procedure.
(Internal Medicine 41: 441-44, 2002)

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Verapamil is widely used for the termination of paroxysmal Supraventricular tachycardia (PSVT) with little proarrhythmic effect. We describe two cases of PSVT that changed to non-sustained polymorphic ventricular tachycardia after administration of verapamil. Electrophysiological study revealed atrioventricular nodal reentrant tachycardia in the first case, and atrioventricular reentrant tachycardia due to a concealed left lateral accessory pathway in the second case. Catecholamine-induced automaticity was one of the possible mechanisms of VT in the first case, but the mechanism is unknown in the second case.
(Internal Medicine 41: 445-448, 2002)

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A 53-year-old man was admitted to Osaka City University Hospital on July 21, 1998, for investigation of symptomatic hypercalcemia. Laboratory data on admission revealed that serum Ca had increased to around 12.6 nig/dl and there was a significant increase in urinary Ca excretion. The serum phosphate level remained normal. Although the serum PTH level was below the detection limit, serum 1, 25-dihydroxyvitamin D (1, 25(OH)₂D) was increased. Diagnosis of sarcoidosis was supported by a negative tuberculin test and by the elevated levels of serum angiotensin-converting enzyme (ACE), lysozyme activity, and CD4/CD8 ratio in bronchoalveolar lavage specimen; there was however no imaging evidence of sarcoidosis such as bilateral hilar lymphnode enlargement on chest X-ray, high resolution CT or ⁶⁷Ga citrate scintigraphy. Biopsy specimens from the cervical lymphnode revealed no epitheloid cell granulomas or giant cells. Administration of prednisolone achieved a decrease in serum ACE and 1, 25(OH)₂D levels, followed by restoration of serum Ca and urinary Ca excretion to the normal range, and finally by an increase of serum PTH to the normal level. These observations suggested that the hypercalcemia could be explained by extrarenal production of 1, 25(OH)₂D. We report here on this rare case of sarcoidosis with initial symptoms of symptomatic hypercalcemia resulting from extrarenal production of 1, 25(OH)₂D.
(Internal Medicine 41: 449-452, 2002)

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A 34-year-old man with neurofibromatosis type 1, who had received radiation therapy after the excision of a brain tumor 5 years earlier, was admitted to our hospital with vomiting and weight loss. Cortisol and adrenocorticotropin (ACTH) were undetectable before and after administration of 100 μg corticotropin releasing hormone. The level of growth hormone without stimulation was 24.7 ng/ml. We diagnosed him to have complete ACTH deficiency attributable to radiation therapy. This is the first known case of a patient with complete ACTH deficiency after radiation therapy and a growth hormone reserve that remained normal.
(Internal Medicine 41: 453-457, 2002)

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A 37-year-old woman had been found to have proteinuria in October 1996. About 8 months later, the first renal biopsy was performed, revealing focal segmental necrotizing and crescentic glomerulonephritis. At that time, serum creatinine was 1.0 mg/dl and urinary protein 3+. In October 1999, laboratory tests revealed positivity for MPO-ANCA and a serum creatinine level of 1.42 mg/dl, anemia and proteinuria of 2+. A second renal biopsy showed almost the same histological findings. Accordingly, a diagnosis of MPO-ANCA positive glomerulonephritis was made. This patient was thought to be a rare case of MPO-ANCA-positive slowly progressive glomerulonephritis presenting focal segmental tuft necrosis and crescents.
(Internal Medicine 41: 458-462, 2002)

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A 49-year-old man was admitted for the evaluation of a bilateral mass shadow in his chest X-ray film. No definitive diagnosis was established either by brushing cytology or biopsy through bronchoscopy. No malignancies were suggested by general work-up. Both masses were surgically removed, and were diagnosed as pulmonary hyalinizing granuloma (PHG). Fifteen months later, low grade fever continued and the renal function decreased. Laboratory examinations revealed bilateral hydronephrosis with polyclonal hypergammaglobulinemia. The findings of abdominal CT and urography were compatible with retroperitoneal fibrosis. Steroid treatment completely reversed the initial abnormality in laboratory data and the symptoms disappeared.
(Internal Medicine 41: 463-466, 2002)

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The applicability of monitoring concentrations of serum KL-6 and serum surfactant protein-D (SP-D) in the detection of methotrexate-associated lung injury (MTX pneumonitis) in patients with rheumatoid arthritis (RA) was investigated. The concentrations of these markers, sequentially measured in two patients with RA complicated with MTX pneumonitis, were increased in accordance with the severity of MTX pneumonitis. Conversely, the concentrations of these markers were decreased with the improvement of MTX pneumonitis, suggesting that the monitoring of these markers could be applicable not only for detecting the onset of MTX pneumonitis, but also for detecting the therapeutic response of MTX pneumonitis.
(Internal Medicine 41: 467-473, 2002)

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We report a case of multiple atypical adenomatous hyperplasia (AAH) associated with synchronous multiple primary bronchioloalveolar carcinomas (BACs). A 58-year-old man was visited for bronchial asthma. A chest computed tomography (CT) scan revealed small, multiple nodules with ground glass attenuation (GGA) throughout both lungs, predominantly in the upper lobes. A high resolution CT (HRCT) scan disclosed well-defined nodules with uniform GGA. Thoracoscopic wedge lung biopsy confirmed the diagnosis. The patient was treated with chemotherapy and had stable disease for two years. It is important to recognize that multiple AAH associated with multiple BACs can present as diffuse, well-defined nodules with uniform GGA on HRCT.
(Internal Medicine 41: 474-477, 2002)

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A 38-year-old woman presented with worsening cough, blood eosinophilia, and pulmonary infiltrates. Bronchoalveolar lavage showed 96.4% eosinophils. The diagnosis of visceral larva migrans (VLM) was made based on the positive results in enzyme-linked immunosorbent assay for Toxocara canis together with clinical symptoms and laboratory data. Pulmonary infiltrates due to VLM generally manifest as a transient form of Löffler's syndrome or simple eosinophilic pneumonia mainly in children. Here we report an adult case of VLM, with pulmonary infiltrates pathologically proven to be eosinophilic pneumonia, which persisted for 7 weeks before anthelmintic treatment with albendazole and manifested as chronic eosinophilic pneumonia.
(Internal Medicine 41: 478-482, 2002)

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An asymptomatic patient with exogenous lipoid pneumonia (ELP) due to silent aspiration of liquid paraffin ingested as a lubricant was diagnosed by bronchoalveolar lavage (BAL). BAL fluid separated into oily upper phase and lower aqueous phase spontaneously. Microscopic analysis of BAL cells revealed the presence of lipid-laden alveolar macrophages. Classic histochemical staining and electron microscope examination indicated that neutral lipid was dominant but phospholipid was also present in the lipid-laden macrophages. Together with the history of ingestion of liquid paraffin, we identified that the ingested liquid paraffin was the origin of the neutral lipid in the lipid-laden macrophages observed in the BAL fluid.
(Internal Medicine 41: 483-486, 2002)

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A 78-year-old woman was found to have a small bronchioloalveolar carcinoma with ground-glass attenuation in the gravity-dependent gradient in the left lower lobe during a preoperative chest computed tomography (CT) evaluation, which was performed for previously-diagnosed adenocarcinoma of the right upper lobe. To remove the gravitational effect of the CT, the patient underwent a thin section CT in the prone position. Then, a ground-glass attenuation was revealed clearly in the left lower lobe. Postoperative pathological diagnosis was synchronous multiple bronchioloalveolar carcinomas, stage IA. This case suggests that focal areas of ground-glass attenuations on a thin-section CT in patients with BAC would be considered to be multicentric development of BAC. CT with the patient in the prone position helps to exclude the gravitational effect and narrow the differential diagnosis of ground-glass opacity, including localized forms of BAC.
(Internal Medicine 41:487-490, 2002)

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We report two cases of long-standing iron-deficiency anemia in premenopausal women that improved after eradication of H. pylori infection. There were no ulcerations or hemorrhagic lesions in the gastrointestinal tract and no bleeding focus in gynecological organs. Both cases showed H. pylori infection in the stomach and gastric atrophy. After successful eradication of H. pylori infection, the iron-deficiency anemia in both patients dramatically improved, and neither patient suffered from anemia for about 2 years. The cure of H. pylori infection is an optional treatment for iron-deficiency anemia in one fraction of the patients.
(Internal Medicine 41: 491-494, 2002)

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We describe a patient with multifocal relapsing-remitting myelitis. This case had abnormal high intensity lesions in the spinal cord at the cervical and thoracic levels on magnetic resonance imaging (MRI). She had complicated atopic dermatitis and high serum IgE levels, which showed strong sensitivity to mite antigen. These features closely resemble those of atopic myelitis, suggesting that atopic myelitis may develop a relapse with multifocal involvement of the spinal cord, which can mimic multiple sclerosis.
(Internal Medicine 41: 495-497, 2002)

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An 84-year-old woman was referred to our hospital because of aches and pain in her left hand and foot. Three months before her symptoms occurred, a pacemaker had been implanted for the treatment of a 2:1 atrioventricular block with bradycardia. In an X-ray examination, prominently decreased bone density was noted in her left fingers and toes. She was diagnosed to have CRPS-I, which was considered to have been induced by the pacemaker implantation. After treatment with methylprednisolone and Neurotropin^®, her symptoms dramatically improved.
(Internal Medicine 41: 498-501, 200

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