Hepatitis E virus (HEV) is a major cause of acute hepatitis in many developing countries. HEV is transmitted principally by the fecal-oral route, and water-borne epidemics are characteristic of hepatitis E. Recently, there is growing consensus that HEV-associated hepatitis also occurs among individuals in industrialized nations who had no history of travel to endemic areas. Zoonotic spread of HEV has been suggested as human and swine HEV strains are closely related genetically and experimental cross-species infection of swine HEV to a chimpanzee and that of human HEV to swine have been demonstrated. This review describes the clinical, epidemiological and virological characteristics of domestic HEV infection in Japan, the genetic relatedness of Japanese human and swine HEV strains, and possible modes of HEV transmission, emphasizing that HEV should be considered in the diagnosis of acute or fulminant hepatitis of non-A, non-B, non-C etiology, even in patients who have not traveled abroad.
(Internal Medicine 42: 1065-1071, 2003)

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Objective This study was conducted to determine the association between gastrointestinal (GI) colonization and the development of invasive Pseudomonas aeruginosa infections and risk factors for acquisition of P. aeruginosa colonization in gut.
Methods All stool specimens sent for microbiological examination were cultured for P. aeruginosa search for three years.
Patients and Materials P. aeruginosa had been isolated from stool of 207 patients for three years. Of the 207 patients, 87 patients were identified P. aeruginosa-colonized patients.
Results Forty-five (52%) were exposed to previous invasive procedures and eighty-three (95%) were prescribed antibiotics before the isolation of P. aeruginosa. Fourteen distinctive P. aeruginosa infections were developed in 13 patients (15%). Infections associated with GI colonization included 4 pneumonia, 4 urinary tract infection, 3 skin infection, and 3 bacteremia. The age, gender, underlying diseases, previous invasive procedures, and the duration of hospitalization were not significant. Twelve (34%) patients were diagnosed with ileus and three (9%) were undergoing gastrostomy during the acquisition of P. aeruginosa colonization in gut.
Conclusion Gastrointestinal disorders, especially obstruction and surgical interventions, are also important for the acquisition of by P. aeruginosa, in the GI tract.
(Internal Medicine 42: 1072-1076, 2003)

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Objective The goal of this study was to investigate transesophageal echocardiographic (TEE) findings after the termination of atrial fibrillation to clarify the direct evidence for occurrence of acute cardiogenic brain embolism (CBE) in patients with paroxysmal atrial fibrillation (PAF).
Patients and Methods Among 98 consecutive patients with CBE, we investigated TEE in 16 patients with PAF (Group CBE, 72±10 years) within 7 days of the onset and 2 weeks after the first study, in comparison with 15 age-matched PAF patients without CBE (Group N). The duration from reversal to normal sinus rhythm to first TEE was 6±1 days in both groups.
Results There were no significant differences in left atrial dimension and emptying flow velocity of the left atrial appendage (LAA-eV) between groups. Group CBE had significantly larger LAA area (4.3±1.3 cm²vs.3.1±1.0 cm², p<0.05), smaller LAA fractional area change (LAA-FAC) (43±25% vs. 80±22%, p<0.001), and a higher incidence of left atrial spontaneous echo contrast (LAA-SEC) (25% vs. 7%, p<0.05) than group N, and those abnormalities in group CBE were significantly improved at the second TEE (LAA area: to 3.2±0.9 cm², p<0.05; LAA-FAC: to 84±26%, p<0.001; LAA-SEC: to 0%, p<0.05), respectively.
Conclusion LAA-FAC is a more sensitive marker for LAA dysfunction than the widely used index, LAA-eV, and a sustained deterioration of LAA-FAC may be direct evidence for thrombus formation and occurrence of acute CBE in patients with PAF.
(Internal Medicine 42: 1077-1083, 2003)

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Objective Stenting of small coronary arteries has always been limited by high rates of restenosis, and restenosis has mainly been attributed to inflammatory reactions resulting in cell proliferation and intimal hyperplasia. Based on our experience for several years, we retrospectively investigated the effect of hydrocortisone on reducing in-stent restenosis.
Patients and Methods Study population consisted of consecutive 166 patients, 221 lesions, who electively underwent stent implantations stent diameter less than 3 mm into coronary arteries between February 1999 and October 2002. We intravenously administered hydrocortisone before the procedure to 40 patients for preventing allergic reactions due to contrast material, and the effect of hydrocortisone on reducing restenosis was retrospectively compared with 126 patients who did not receive this treatment.
Results There was no significant difference in the prevalence of diabetes mellitus, hyperlipidemia, or hypertension between the two groups. There was no significant difference in the type of lesion, length of stent, balloon/artery ratio, or initial success rate between the two groups, but stent diameter was significantly smaller in the hydrocortisone group compared with the control group. On six-month angiographic follow-up, the restenosis rate was significantly lower in the hydrocortisone group compared with the control group (16.2% vs 34.0%, respectively), and the target lesion revascularization rate was also significantly lower in the hydrocortisone group compared with the control group (13.2% vs 27.5%, respectively).
Conclusion These results suggest that intravenous administration of hydrocortisone reduces in-stent restenosis of small coronary arteries. Prospectively controlled trials will be necessary to confirm this preventive effect of hydrocortisone.
(Internal Medicine 42: 1084-1089, 2003)

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Objective The incidence of pulmonary thromboembolism (PTE) is much lower in Japan than in the United States. The number of deaths from PTE, however, has gradually increased. The present study was designed to investigate the incidence and characteristics of PTE in Japan.
Methods and Materials We sent 5, 582 questionnaires to inquire about the number of new cases of PTE between August 1, 2000 and September 30, 2000.
Results We received 1, 702 replies and 205 new cases were registered. The number of new cases per year was 4, 022 (95% confidence interval: 3, 704-4, 305) and the incidence was 32 (95% confidence interval: 29.2-33.9) patients per 1, 000, 000 people per year. Main risk factors were immobilization, surgery, trauma, and malignancy. The mortality within a month and 6 months was 16% and 20%, respectively. Half of the deaths within a month occurred on the diagnosis day.
Conclusion The results showed that the incidence of PTE in Japan 2000 tended to increase compared with that in 1996, but it was still much lower than that in the United States.
(Internal Medicine 42: 1090-1094, 2003)

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Objective High-resolution B-mode ultrasonography has been widely used for the noninvasive assessment of atherosclerosis in hemodialysis patients. But, there are two major methods of carotid ultrasonography: one including plaque and the other excluding plaque.
Methods The subjects were 112 hemodialysis patients (58 men and 54 women) with a mean age of 55.8±13.0 years. The maximum intima-media thickness (IMT) of the carotid artery (including plaque) was measured as an index of arterial wall thickening and atheroma formation, while the mean IMT (without plaque) was measured as an index of arterial wall thickening. In addition the value of (maximum-mean) IMT was calculated as an index of atheroma formation. Therefore, the independent risk factors associated with the maximum IMT, mean IMT, and (maximum-mean) IMT were investigated by stepwise multiple regression analysis.
Results The independent risk factors associated with the maximum IMT were age, diabetes mellitus, smoking, and intact parathyroid hormone (PTH) (R=0.569, p<0.0001), while factors associated with the mean IMT were age, hypertension, dyslipidemia, intact PTH, and lipoprotein (a) (R=0.602, p<0.0001). The independent risk factors associated with the (maximum-mean) IMT were age, diabetes mellitus, smoking, and intact PTH (R=0.515, p<0.0001).
Conclusion These findings suggest that risk factors for the maximum IMT and mean IMT are somewhat different in hemodialysis patients.
(Internal Medicine 42: 1095-1099, 2003)

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Objective Pain-related differential expressions of nerve growth factor (NGF), glial cell line-derived neurotrophic factor (GDNF) and interleukin-6 (IL-6), and their receptors were investigated in human vasculitic neuropathies.
Materials and Methods The mRNA levels of painrelated neurotrophic factors, NGF, GDNF and IL-6, were examined in the sural nerves of 22 painful and non-painful patients with acute necrotizing vasculitic neuropathies, together with their concomitant soluble receptors (p75, GFRα-1 and IL-6Rα).
Results The mRNAs for these factors and receptors in the lesioned nerves were up-regulated to a variable extent in both groups. NGF mRNA expression was more closely correlated with that of p75 in painful neuropathy with relatively preserved large fiber density, compared with non-painful neuropathy, though the NGF mRNA level in painful neuropathy was lower than that in non-painful neuropathy. GDNF was closely associated with GFRα-1 in mRNA levels regardless of the pain state, but IL-6 was not associated with IL-6Rα.
Conclusion The differential expression of neurotrophic factors and their cognate soluble receptors in human vasculitic neuropathy suggests that NGF, which was effectively transferred to sensory axons with p75, may induce pain.
(Internal Medicine 42: 1100-1103, 2003)

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A 27-year-old Japanese man with no past history of liver disease was admitted to our hospital due to liver abnormalities. The patient was diagnosed with drug-induced hepatitis, as the three episodes of hepatitis occurred just after repeated use of hair dye. After cessation of the hair dye use, abnormal liver function tests improved to within the normal range. Although hair dyes contain various hepatotoxic compounds, hair dye is not known to cause drug-induced hepatitis. Thus, in cases of liver abnormality of unknown origin, the history of hair dye use should be investigated.
(Internal Medicine 42: 1104-1106, 2003)

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We report a 75-year-old man with ischemic cardiomyopathy who had mitral regurgitation which was increased markedly by intermittent left bundle branch block (LBBB). He complained of angina-like chest pain that was preceded by episodes of LBBB. During LBBB, a marked elevation of the V wave in the pulmonary capillary wedge pressure was shown, and an increase in mitral and tricuspid regurgitation was observed with color Doppler echocardiography. Biventricular pacing (BVP) therapy was selected so as to protect the patient from episodes of LBBB. After BVP, the patient did not experience chest pain or dyspnea. This case sheds valuable light on the ongoing investigation of the hemodynamic benefit of BVP.
(Internal Medicine 42: 1107-1111, 2003)

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We report a multiple endocrine neoplasia type 1 (MEN1) patient associated with carcinoid syndrome. A 50-year-old woman had parathyroid hyperplasia with primary hyperparathyroidism, a pancreatic tumor and carcinoid tumors in the liver and duodenum. The primary lesion of the carcinoid was probably the bronchus. Direct sequencing analysis revealed a novel missense mutation at codon 342 in exon 7 causing an amino acid change from alanine to proline (A342P) of the MEN1 gene. Loss of heterozygosity (LOH) was also detected in the resected parathyroid tissue. This mutation appeared to play an important role in the tumorigenesis of the endocrine tissues in the present case.
(Internal Medicine 42: 1112-1116, 2003)

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A 49-year-old man with syringomyelia and a Type I Arnold-Chiari malformation (Chiari-I) was diagnosed with growth hormone insensitivity syndrome (GHIS). He was short in stature, had high circulating levels of GH, and low circulating levels of insulin-like growth factor-I (IGF-I) and IGF binding protein-3 (IGFBP-3). His GH responses to the administration of growth hormone-releasing hormone (GHRH) and L-DOPA were normal, but his levels of IGF-I and IGFBP-3 did not increase after the administration of exogenous GH. Direct genomic DNA sequencing revealed neither a mutation nor deletion in this patient's GH receptor (GHR) gene, though one polymorphism was detected, indicating that his GHR gene was normal. This is the first reported case of an association of GHIS with syringomyelia and Chiari-I malformation.
(Internal Medicine 42: 1117-1121, 2003)

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A 27-year-old Japanese man visited our hospital for further evaluation of multiple shadows on his chest X-ray. A 6 cm hard mass was palpable in the left lower abdominal region. Histological examination revealed that the lung tumor resected by the video-assisted thoracoscopic surgery was an embryonal carcinoma (EC). He was diagnosed as retroperitoneal EC with multiple lung metastases. He underwent chemotherapy with cisplatin, etoposide, and bleomycin, followed by 3 courses. A curative surgical operation revealed that there were no malignant cells in the lung lesions and primary lesion. This patient responded well to chemotherapy and achieved complete remission by chemotherapy.
(Internal Medicine 42: 1122-1126, 2003)

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We report influenza-induced rhabodmyolysis and congestive heart failure after high-dose therapy and hematopoietic stem cell transplantation for malignant lymphoma. Four months after autologous peripheral blood stem cell transplantation for the treatment of malignant lymphoma, a 65-year-old Japanese man developed acute congestive heart failure requiring artificial ventilation and rahbdomyolysis. Since influenza A virus was documented from his nasal cavity, he was diagnosed as rhabdomyolysis and congestive heart failure induced by influenza A infection. Neuraminidase inhibitor (oseltamivir 150 mg/day for 5 days) was administrated, and heart failure and respiratory status were improved. Our experience suggests that early treatment with neuraminidase inhibitor may improve the clinical outcome of influenza-induced rhabdomyolysis and congestive heart failure.
(Internal Medicine 42: 1127-1130, 2003)

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A 45-year-old man developed severe arterial hypertension associated with unusual hyperintensity in the brainstem, around the right internal capsule and in the deep white matter around the bilateral anterior horn of the lateral ventricle on T2-weighted and fluid-attenuated inversion-recovery images. The characteristic clinical findings were mild left hepiparesis and altered mental status which corresponded to the lesions of MR imagings. The lesions improved gradually with improvements in hypertension, which suggested that edema could be the principal cause of the unusual hyperintensity on MR images.
(Internal Medicine 42: 1131-1134, 2003)

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An 80-year-old man was admitted to our hospital because of bradykinesia, muscle rigidity and respiratory dysfunction during sleep. Concerning bradykinesia and muscle rigidity, we diagnosed him as the early/moderate stage of Parkinson's disease without autonomic dysfunction. Polysomnography (PSG) showed a series of obstructive hypopneas and apneas. After administration of antiparkinsonian drugs, rigidity of the neck and trunk was diminished along with a drastic decrease in hypopnea on PSG. We consider that sleep hypopnea in this patient is caused by involvement of the striated musculature surrounding the upper-airway and/or rigidity in the trunk. These conditions are treatable with antiparkinsonian drugs.
(Internal Medicine 42: 1135-1138, 2003)

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We report a patient who developed reversible posterior leukoencephalopathy syndrome (RPLS) in puerperium without preeclampsia-eclampsia or chronic hypertension. The woman suddenly complained of visual loss and headache 10 days after delivery caused by edematous lesions mainly distributed in the bilateral occipital lobe. Apparent diffusion coefficient map was useful for distinction of this vasogenic edema from cytotoxic edema due to brain infarction. Under the diagnosis of RPLS, we successfully treated her disease using a trinitroglycerin as an antihypertensive, a hyperosmolar agent, methylprednisolone, and a free radical scavenger. Postpartum women may have the risk of development of RPLS even without preeclampsia-eclampsia. Vascular endothelial dysfunction may trigger RPLS, in addition to acute and modest increase in systemic pressure.
(Internal Medicine 42: 1139-1143, 2003)

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A 28-year-old woman had chief complaints of headache and a 40°C fever. At this time, findings indicative of inflammation including elevated CRP and increased WBC were observed, and E. coli was detected on blood and urine culture. As a result, the patient was diagnosed with pyelonephritis and sepsis. Furthermore, markedly increased hepatobiliary enzymes and elevated anti-mitochondrial antibody were confirmed. The administration of antimicrobial agents resulted in improvement of the pyelonephritis and sepsis and normalization of hepatobiliary enzyme and anti-mitochondrial antibody levels. It has been documented that the incidence of urinary tract infection is high among patients with primary biliary cirrhosis (PBC). The findings obtained from the present patient are of considerable interest in elucidating the mechanism of onset in PBC.
(Internal Medicine 42: 1144-1148, 2003)

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