Objective To determine whether collateral recruitment is involved in the preconditioning effect on the electrocardiogram, chest symptoms, and lactate metabolism during coronary angioplasty in patients with stable angina pectoris.
Methods and Patients Sixteen patients with stable angina pectoris underwent three consecutive 2-min balloon inflations 5-min apart. The greatest ST elevation (ΔTmax), the sum of ST elevations in all leads (ΣST), and QT dispersion (QTd) were measured at the end of each balloon inflation. Chest pain score was evaluated on a scale ranging from no pain (0) to the most severe pain (10). Lactate extraction ratio (LER) was determined by simultaneous blood sampling from the aorta and the coronary sinus. Collateral flow index (CFI) was derived from simultaneous measurements of mean aortic pressure and coronary wedge pressure obtained from a pressure guidewire during balloon inflation.
Results Significant decreases were noted in ΔSTmax (3.3±2.1 vs. 3.0±1.9 vs. 2.6±1.8 mm, p<0.01), ΣST (9.7±7.2 vs. 8.5±6.1 vs. 6.9±5.3 mm, p<0.01), QTd (55.3±13.8 vs. 46.9±9.0 vs. 42.5±10.0 ms, p<0.01), and chest pain score (4.3±3.1 vs. 2.8±2.6 vs. 1.4±1.5, p<0.01) during the three sequential balloon inflations. LER significantly increased (-55.5±47.8 vs. -36.7±34.3 vs. -19.6±26.2%, p<0.01), indicating decreased lactate production. No significant difference was observed in CFI (0.16±0.10 vs. 0.15±0.10 vs. 0.15±0.10).
Conclusion Repeated balloon inflations during coronary angioplasty elicited a preconditioning effect on ST-segment shift, QT dispersion, chest pain, and lactate production that does not involve collateral recruitment.
(Internal Medicine 41: 509-515, 2002)

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Objective Hypertriglyceridemia is often associated with impaired fasting glucose (IFG) and diabetes mellitus. But the contribution of hypertriglyceridemia to the development of IFG and diabetes mellitus remains unclear. We evaluated whether or not hypertriglyceridemia is a risk factor for the development of IFG and diabetes mellitus.
Methods From 1990 through 1999, 7, 222 Japanese with normoglycemia at baseline were followed. Fasting plasma glucose levels were measured. IFG and diabetes mellitus were defined by ADA criteria.
Result The multivariate-adjusted relative risks for the development of IFG were 1.38 for hypertriglyceridemia (p=0.001), 1.30 for obesity (p=0.003), 1.29 for hypertension (p=0.007), 1.26 for family history of diabetes (p=0.027), and 1.02 for age (p=0.035). The multivariate-adjusted relative risks for the development of diabetes mellitus were 1.003 for triglyceride level (p=0.013), 1.30 for level of body mass index (p=0.003), and 2.38 for family history of diabetes (p=0.001).
Conclusion Hypertriglyceridemia is an independent risk factor for the development of IFG and diabetes mellitus in Japanese patients.
(Internal Medicine 41: 516-521, 2002)

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Objective The effects of endothelin-1 (ET-1) on pulmonary vascular tone depend on the complex interplay of ET-1-induced vasoconstriction and vasodilation due to the secondary generation of endothelium-derived vasorelaxants. Therefore, it is likely that the response to ET-1 varies, depending on whether it is applied to the luminal or adventitial side of pulmonary vessels. Therefore, this study was designed to determine the change in luminal ET-1 levels during exercise in patients with chronic obstructive pulmonary disease (COPD).
Methods All subjects performed a constant-load exercise test for 5 minutes on the ergometer with right heart catheterization while breathing room air or oxygen. ET-1 levels at rest, just after exercise, and 1 hour after exercise were measured in the pulmonary capillary wedge region.
Patients Thirty-six patients with COPD.
Results While breathing room air, ET-1 levels did not significantly differ between at rest, just after exercise and 1 hour after exercise [at rest; 4.15 (0.43) pg/ml, just after exercise; 4.15 (0.44) pg/ml, 1 hour after exercise; 4.13 (0.42) pg/ml]. In contrast, while breathing oxygen, ET-1 levels were significantly higher just after exercise [4.41 (0.43) pg/ml] than at rest [3.90 (0.37) pg/ml, p=0.0116] and 1 hour after exercise [3.93 (0.38) pg/ml, p=0.0246]. The change in ET-1 levels between before and just after exercise (ΔET-1) was negatively correlated with change in mPAP (ΔmPAP) (r=-0.638, p=0.0001). However, ΔET-1 was not significantly correlated with any FEV1 (% predicted), DLCO, PaO₂, or baseline pulmonary hemoch namics.
Conclusion The impairment of ET-1 release into the luminal side was observed in patients with COPD during exercise while breathing room air. However, oxygen supplementation reversed the capacity of ET-1 release, and ΔET-1 with exercise was negatively correlated with ΔmPAP.
(Internal Medicine 41: 522-525, 2002)

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Objective To elucidate the prognosis of the elderly with neurologically asymptomatic atheromatous plaques of the carotid arteries.
Methods A total of 228 subjects aged 60 years or older, examined by carotid ultrasonography and platelet aggregation test, were studied. They were divided into 3 groups based on plaque morphology: the no lesion group (n-110), the nodular plaque group (n=47), and the mural plaque group (n=71). Platelet aggregability was assessed as suppressed, normal, or accelerated.
Results During the 4.0 years of mean follow-up period, 31 subjects died, and 16 of the deaths were due to vascular events such as cerebral infarction or ischemic heart disease. The annual mortality rate due to vascular events was 0.5% in the no lesion group, 1.4% in the nodular plaque group, and 4.1% in the mural plaque group, and Kaplan-Meier survival curve showed poor prognosis of the mural plaque group (logrank statistics: 12.8, Df=2, p=0.0017). According to the Cox proportional hazard model, a high hazard ratio (HR) was seen in the mural plaque group (5.3) and also the accelerated platelet aggregability group (4.0).
Conclusion These findings suggested that subjects with mural plaques and accelerated platelet aggregability, even when asymptomatic, have a poor prognosis due to vascular events. Antiplatelet therapy and exercise stress test for detecting coronary artery disease should be considered in these subjects.
(Internal Medicine 41: 526-531, 2002)

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Objective To clarify the clinical heterogeneity and genotype-phenotype correlation in dysferlinopathy.
Methods We evaluated clinical parameters of 74 dysferlinopathy patients with known dysferlin gene mutations who were previously reported in the literature.
Results The age at onset varied from 12 to 59 years (mean 21.7 years). Based on the initial distribution of muscle involvement, clinical phenotypes were divided into four subtypes: limb-girdle type, Miyoshi's type, distal anterior compartment type, or scapuloperoneal type. These phenotypic differences were prominent at the early stages, but were difficult to recognize later in the progression of the disease. Patients with missense mutations had significantly more severe functional status at examination and higher creatine kinase levels than those with frameshift or nonsense mutations.
Conclusion Dysferlinopathy exhibited marked heterogeneity in the age at onset, initial distribution of muscle involvement, and rate of disease progression. As this heterogeneity was observed even within the same family, some additional factors distinct from dysferlin might be involved.
(Internal Medicine 41: 532-536, 2002)

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We report a case of groove pancreatitis in which a hypoechoic mass between the duodenum and pancreas head was clearly imaged, and narrowing of the supra-ampullary area of the duodenum and bile duct stenosis were also found. The diagnosis was confirmed by surgery. Microscopic examination showed extensive scarring between the duodenum and pancreas head. Protein plugs were found in Santorini's duct. We consider that the disturbance of the pancreatic juice outflow in Santorini's duct is one of the important pathogenic factors in the development of groove pancreatitis. Therefore, we emphasize the finding of Santorini's duct in the differential diagnosis of groove pancreatitis.
(Internal Medicine 41: 537-542, 2002)

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We report a 69-year-old woman with liver cirrhosis due to chronic hepatitis C virus (HCV) infection in whom iatrogenic arteriovenous fistula (AVF) developed after sigmoidectomy. A soft mass with bruit led to the diagnosis of inferior mesenteric AVF. Most mesenteric AVF cases have portal hypertension, but this patients showed none of the usual symptoms of portal hypertension; however, she had a splenomegaly that became worse after sigmoidectomy. Clinicians should be aware of the possibility of AVF in patients with a history of abdominal surgery.
(Internal Medicine 41: 543-548, 2002)

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A 57-year-old man showed high serum cortisol, plasma adrenocorticotropin (ACTH) and corticotropin-releasing hormone (CRH) levels with a large pituitary tumor and a prostatic cancer. High dose dexamethasone did not suppress cortisol secretion and CRH administration did not stimulate cortisol secretion. After surgical removal of the pituitary tumor, plasma CRH, ACTH and serum cortisol levels were normalized. Histological examinations showed pituitary adenoma and prostatic adenocarcinoma, and pituitary adenoma was stained with both anti-CRH and anti-ACTH antibodies, but prostatic cancer was not stained. A CRH-producing pituitary adenoma is a new type of Cushing's syndrome.
(Internal Medicine 41: 549-554, 2002)

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A 21-year-old woman was admitted with altered consciousness and hyperammonemia. She was diagnosed as having adult-onset type II citrullinemia (CTLN2) by DNA analysis. The patient had mutations of the SLC25A13 gene, which were compound heterozygotes of 851 del 4 and IVS11+1G>A. CTLN2 has a poor prognosis, in spite of various intensive medications, and we performed a living related partial liver transplantation (LRLT). Over a 2-year follow-up, the patient has been well. CTLN2 can be diagnosed by the DNA analysis and can be treated by LRLT.
(Internal Medicine 41: 555-560, 2002)

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We report here a 47-year-old woman with isolated adrenocorticotropin (ACTH) deficiency (IAD). She presented impaired renin-angiotensin-aldosterone (R-A-A) system and suppressed parathyroid hormone (PTH)-vitamin D system. She showed severe hyponatremia due to secondary adrenocortical insufficiency, which was deteriorated by hypoaldosteronism. She also showed hyperphosphatemia and relative hypercalcemia with suppressed PTH-vitamin D axis. Moreover, she showed hypothyroidism, which was thought to be important to maintain normal Ca levels under secondary hypoadrenalism via decrease in bone resorption by T3. Replacement with glucocorticoid completely normalized PTH-vitamin D axis and R-A-A system. Thus, the present case implicates that severe adrenocortical deficiency due to IAD might affect both R-A-A system and PTH-vitamin D axis. These findings suggest that the ACTH-cortisol axis has an important role in mineral metabolism in vivo.
(Internal Medicine 41: 561-565, 2002)

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A 53-year-old woman was admitted because of hypertension and diabetes mellitus. Elevated diastolic blood pressure, hypertensive retinopathy and renal dysfunction indicated malignant hypertension. Adrenocorticotropic hormone (ACTH) and cortisol levels were high although there were no Cushingoid features.One mg dexamethasone administration decreased neither ACTH nor cortisol levels. Brain magnetic resonance imaging revealed a left pituitary tumor (7 mm × 6 mm). Upon removal, the tumor showed positive ACTH staining by immnohistochemistry, and was diagnosed as pituitary ACTH-secreting adenoma (Cushing's disease). Her blood pressure, renal function, blood glucose and hormone levels subsequently improved. Malignant hypertension and deteriorated diabetes mellitus may have been due to subclinical Cushing's disease.
(Intrenal Medicine 41: 566-570, 2002)

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We reported the first case of hypersensitivity pneumonitis (HP) by an edible mushroom, Pleurotus Eryngii (Eringi). A 54-year-old woman had worked in a Bunashimeji mushroom factory for 42 months, and she moved to a new factory producing Eringi. Two months after, she was found to have HP by the spore of Eringi. Although no radiological finding was detected 6 months before the onset of HP, serum surfactant protein D (SP-D) had been elevated. We speculated that type II pneumocyte activation might prepare the ground for HP during the former exposure to Bunashimeji, and serum SP-D levels might reflect their conditions.
(Internal Medicine 41: 571-573, 2002)

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A 32-year-old man presented with the chief complaint of severe cough. Examination of peripheral blood showed a marked increase in eosinophils. Chest CT demonstrated multiple ground glass opacities in both lungs. Bronchoalveolar lavage showed abundant eosinophils. Abdominal CT demonstrated multiple low attenuation areas in the liver. Liver biopsy with ultrasonography revealed severe eosinophil infiltrations around the portal veins. Serologically, a multi-dot enzyme linked immunosorbent assay (DOT-ELISA) and ELISA inhibition test using microtiter plates were positive for Ascaris suum. Thus, visceral larva migrans due to Ascaris suum was diagnosed. Outbreaks of this disease in Japan have previously been confined to the Kyushu area. The present case which occurred outside that area, illustrates the importance of constant attention to the epidemiology of this disease.
(Internal Medicine 41: 574-579, 2002)

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A 29-year-old woman with primary myelofibrosis developed severe pneumonia, and 20 days later her 31-year-old sister also contracted pneumonia. The first patient had been in contact with parakeets but the second patient had not been in contact with any birds. Psittacosis was diagnosed in both cases by microplate immunofluorescence antibody technique. Person-to-person transmission between the sisters was suspected to have taken place.
(Intrenal Medicine 41: 580-583, 2002)

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It has been reported that there is a subgroup of dermatomyositis (DM) patients with rapidly progressive interstitial lung disease (ILD) who have mild muscle symptoms, slightly increased levels of muscle enzymes, and absence of anti- Jo1 antibody. A 51-year-old woman with DM was intubated requiring mechanical ventilation because of a rapidly progressing ILD in spite of the absence of the typical poor prognostic factors. A high dose or pulse therapy of corticosteroids was not effective, but additional treatment of cyclosporine gradually improved her respiratory condition. It is not clear why a rapidly progressive ILD occurred in this case lacking poor prognostic factors. However, if corticosteroid treatment is not effective, additional administration of cyclosporine in the early period of rapidly progressive ILD may rescue deteriorating cases.
(Intrenal Medicine 41: 584-588, 2002)

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A 66-year-old Japanese man developed severe anemia and erythroid hypoplasia in bone marrow without any significant underlying disease. The results of an antiglobulin test were strongly positive, and serum erythropoietin (Epo) was high. The patient was diagnosed as having acquired pure red cell aplasia (PRCA) and was treated with steroids. Anemia was subsided by reticulocyte production in parallel with a decrease in the titer of antiglobulin test and the level of Epo. We studied the immunological mechanism directed against erythroid cells in vitro by using the patient's serum. In vitro analysis indicated the presence of an inhibitor of erythroid precursors at onset, and its disappearance at remission, suggesting the presence of inhibitor against erythroid precursors.
(Internal Medicine 41: 589-592, 2002)

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The patient, who was a non-obese woman with no predisposing conditions of lipomatosis, slowly developed cauda equina syndrome. Spinal magnetic resonance imaging (MRI) presented mass lesion of high intensity on T1-weighted image (WI) and an intermediate signal intensity in T2 WI in the epidural space of SI to coccyges. It has been reported that most idiopathic epidural lipomatosis (IEDL) is observed in obese men, and all cases have involved the thoracic or lumbar region. This is the first report of a patient with cauda equina syndrome caused by idiopathic sacral epidural lipomatosis (EDL).
(Internal Medicine 41: 593-594, 2002)

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