The concept and clinical implication of left ventricular remodeling have been gradually extended. Cardiac remodeling plays important roles in the progression of cardiovascular diseases including myocardial infarction, valvular heart diseases, myocarditis, and dilated cardiomyopathy. In addition to cardiac myocytes, fibroblasts, extracellular matrix proteins and coronary vasculature are also involved in the remodeling process. Cardiac remodeling is associated with alterations of many mediators such as neurohumoral factors, cytokines, enzymes, ion channels, oxidative stress and mechanical stress. Although remodeling is initially an adaptive response to maintain normal cardiac function, it gradually becomes maladaptive and leads to progressive decompensation. Recent research has attempted to elucidate underlying molecular mechanisms of cardiac remodeling and to develop novel therapeutic strategies for heart failure. The modulation of remodeling process is effective for preventing the progression of heart failure.
(Internal Medicine 42: 465-469, 2003)

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Objective There are many reports on the diagnosis and management of acute pulmonary embolism (APE), but there have been no investigations concerning the actual conditions in which recent developments in diagnostic imaging techniques and therapies have been applied in clinical practice. The present study was designed to investigate the changes in diagnostic imaging techniques and therapies for APE.
Methods and Patients Three hundred and nine APE patients diagnosed during January 1994-October 1997 (Group 1) were compared with 257 APE patients diagnosed during November 1997-October 2000 (Group 2) in terms of the diagnostic imaging techniques and therapies for APE.
Results Compared with Group 1, pulmonary angiography and contrast-enhanced computed tomography were more frequently performed for diagnosis in Group 2 [45.3% vs 56.8% (p=0.0069) and 13.9% vs 57.6% (p<0.0001), respectively]. Heparin and vena cava filter were used more often in Group 2 [74.4% vs 82.1% (p=0.033) and 18.4% vs 33.9% (p<0.0001), respectively]. The frequency of thrombolytic therapy was unchanged between the two groups. Warfarin use in discharged patients increased from 71.9% to 83.8% (p=0.0022). However, the examination rates for deep vein thrombosis (DVT) were low (60.8% in Group 1 and 65.4% in Group 2, p=0.29) and unchanged using any imaging techniques.
Conclusion The diagnostic imaging techniques for APE increased in variety and the management has improved, while the diagnosis for DVT remains unchanged. (Internal Medicine 42: 470-476, 2003)

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Objective To evaluate mild Legionella pneumonia (LP) by chest CT, and clinical features.
Patients In June 2000, an outbreak of LP occurred in Japan. Eight patients with mild LP (seven men, one woman; mean age 55.9 years) had fevers of more than 38°C, but respiratory symptoms were observed only in four. Chest CT was performed before starting an appropriate treatment.
Measurement CT images were assessed by the distribution of ground-glass opacity (GGO), consolidation, and the existence of pleural effusion.
Results Chest CT findings: multiple segments were affected in all of the patients, (pleural effusion in three, peripheral lung consolidation in seven, and GGO in seven). GGO was located around the consolidation in six patients.
Conclusion Mild LP may present as fever without respiratory symptoms. Chest CT findings of mild LP are bilateral, multiple affected segments and peripheral lung consolidation with GGO.
(Internal Medicine 42: 477-482, 2003)

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Objectives The prevalence of idiopathic pulmonary fibrosis (IFF) tends to be greater in the elderly although the precise outcome is not known. The present study investigated the outcome of IFF in elderly patients whose pathological diagnosis corresponded to usual interstitial pneumonia (DIP) on autopsy findings.
Methods In a consecutive autopsy series, (n=4, 554 cases), complete information was obtained in 86 cases in which the clinical and pathological diagnosis was IFF and UIP, respectively.
Results Mean subject age was 80.5 years and there were 52 males and 34 females. Median survival time (MST) was 3.5 years overall. Dyspnea ranking by the MRC dyspnea scale (DR) on admission was closely related to the outcome. When MST was compared between DRO and DR1, or DR2 and DR3, the former patient group survived significantly longer than the latter (p<0.05). Twenty percent of patients died of severe respiratory failure. Other causes of death were disease progression of IFF (10.5%), bacterial pneumonia (23.3%) and lung cancer (17.4%). The patients in the young-elderly group (age <75) survived for a significantly longer period than those in the old-elderly group (age ?? 75) (MST; 5.5 vs 2.0 years; p<0.001). Both lung cancer and pneumonia were significantly more prevalent among IFF patients than among non-IPF patients; these IFF with lung cancer profoundly reflected the smoking history of IFF patients.
Conclusions The poor outcome in IFF in elderly patients was characterized by more severe dyspnea, advanced age and co-morbidity.
(Internal Medicine 42: 483-489, 2003)

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Objective Rapid detection of serum anti-ganglioside antibodies in Guillain-Barré syndrome (GBS) could facilitate early diagnosis and early initiation of treatment, which might shorten the term of illness and reduce sequelae. We examined serum anti-ganglioside antibodies in patients with GBS using the latex agglutination assay developed by Alaedini and Latov (J Immunoassay 21: 377-386, 2000) with some modifications.
Materials and Methods We used 75 sera from GBS patients, which exhibited IgG anti-GM1, GD1b, or GQ1b, or IgM anti-GM2 antibodies on previous enzyme-linked immunosorbent assay (ELISA). Blue latex beads (2.5% solution of 0.3 μm) were coated with 1 mg/ml of GM1, GD1b, GQ1b or GM2. Aliquots (4 μl) of serum and the ganglioside-coated particles were mixed and rocked on a glass slide for 30 to 40 seconds. The reaction was observed under a microscope and compared with the anti-ganglioside antibody titers determined with ELISA.
Results Agglutination was strong in sera of which the IgM or IgG titers of anti-GM1, GD1b, GQ1b or GM2 antibodies were found to be more than 1:6, 400 on ELISA except for 2 samples, but weak or absent in sera with titers of 1:3, 200. Agglutination was absent in sera of which the antibody titers were less than 1:3, 200 on ELISA.
Conclusion We could rapidly detect serum IgM and IgG anti-GM1, GD1b, GQ1b and GM2 antibodies in patients with GBS by means of the latex agglutination assay when sera exhibited high titers of the respective antibodies on ELISA. The sensitivity of our agglutination assay was much lower than that of ELISA.
(Internal Medicine 42: 490-495, 2003)

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We report a case of primary biliary cirrhosis (PBC) complicated by slowly progressive insulin-dependent diabetes mellitus (SPIDDM). A 67-year-old woman was diagnosed as having PBC based on clinical manifestations and a positive result of anti-mitochondrial antibody. Furthermore, SPIDDM was diagnosed by her clinical course and a positive result of anti-glutamic acid decarboxylase antibody. Both PBC and SPIDDM are considered to be autoimmune diseases. However, the coexistence of PBC and SPIDDM is extremely rare. Liver cirrhosis sometimes accompanies hyperglycemia. When the etiology of liver cirrhosis is an autoimmune disorder such as PBC, SPIDDM should be considered as a cause of hyperglycemia.
(Internal Medicine 42: 496-499, 2003)

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This report concerns a case of primary mesenteric malignant lymphoma detected with routine color Doppler ultrasonography. When a 44-year-old man underwent a first-time medical checkup, ultrasonographic imaging and computed tomography showed the presence of a large tumor measuring about 8 cm in transverse diameter. Color Doppler ultrasonography identified the characteristic vessel structure of a nodal lesion, namely, a hilar vessel, a curved section of the central vessel together with peripheral branches, and focal absence of perfusion in a hypoechoic imaging of the left periumbilical area. These findings contributed to the diagnosis of a malignant lymphoma and the surgical treatment of the tumor was successful.
(Internal Medicine 42: 500-502, 2003)

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A 73-year-old hypertensive, non-diabetic woman without obvious renal dysfunction had frequently been hyperkalemic over four years after receiving antihypertensive drugs including the calcium channel blocker (CCB) benidipine. One week after all medications were accidentally discontinued, the serum potassium level returned to normal. After we obtained the informed consent of the patient, benidipine alone was administered again for over two weeks and hyperkalemia developed once more. This previously uncommon side effect of hyperkalemia induced by benidipine is not very serious but it is apt to be overlooked. Since CCBs are now widely prescribed, the development of hyperkalemia should be considered.
(Internal Medicine 42: 503-506, 2003)

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A 46-year-old woman was presented with mineralocorticoid excess syndrome and a large mass originating from the right adrenal gland. Clinical examination before right adrenalectomy revealed elevated serum concentrations of 18-hydroxy-ll-deoxycorticosterone (18-OH-DOC) both systemically and in the adrenal veins bilaterally. Histopathological and immunohistochemical analyses of the surgical specimen demonstrated adrenal hyperplasia of outer fasciculata cells, and the presence of cystic mass. The adrenalectomy ameliorated her blood pressure (BP) from 156/96 mmHg to 148/87 mmHg with a concomitant increase of serum potassium concentration from 3.1 mEq/l to 3.5 mEq/l. These results suggest that uni-adrenalectomy is, at least in part, effective in ameliorating not only BP but also potassium concentration in a patient of adrenal hyperplasia with excessive bilateral 18-OH-DOC production.
(Internal Medicine 42: 507-512, 2003)

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A 38-year-old woman was admitted with severe thirst and polyuria at 31 weeks' gestation. The plasma concentration of vasopressin (AVP) was very low (0.73 pg/ml) under conditions of high plasma osmolality (316 mOsm/kg). T1-weighted magnetic resonance (MR) images revealed enlargement of the pituitary posterior lobe with absence of the hyperintense signal. After delivery, restoration of the hyperintense signal was demonstrated. This depletion-repletion process, which reflects the decrease and increase in amount of neurosecretory granules, is recognized in the case of transient central diabetes insipidus during pregnancy. We consider that an increase in cystine-aminopeptidase (CAP) activity is implicated in the pathogenesis.
(Internal Medicine 42: 513-516, 2003)

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A 52-year-old man was admitted to our hospital for diabetic ketoacidosis. On admission, Hb_A1c was 6.5%, anti-GAD antibody 10.3 U/ml, serum amylase 144 W/l, lipase 169 U/l and elastase-11, 000 ng/dl. There were no abdominal symptoms, and abdominal CT showed unremarkable findings. He was treated with intensive insulin therapy. After 1 month, urinary excretion of C-peptide was 3.8 μg/day. Serum pancreatic exocrine enzyme concentrations returned to normal after 3 months. After 10 months, anti-GAD antibody had become negative, but insulin therapy was still needed for glycemic control. This report concerns a case of autoimmune fulminating onset type 1 diabetes.
(Internal Medicine 42: 517-520, 2003)

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A rare case of 49-year-old woman having pulmonary bronchogenic cyst associated with bronchial atresia in the same lobe was presented. The diagnosis was confirmed by aortography and operation specimen. Three-dimensional reconstructed images of computed tomography clearly demonstrated the defference between mucoid impaction of bronchial trees in the left S⁹not communicating with hilar bronchus and the cyst in the left S¹⁰ oppressing surrounding vessels.
(Internal Medicine 42: 521-524, 2003)

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A 55-year-old woman presented with massive refractory ascites in the course of idiopathic myelofibrosis. The ascites was exudative, and a cytological examination revealed granulocytes of varying maturity, erythroblasts, and megakaryocytes with trisomy 8. The ascites was assumed to have developed from peritoneal extramedullary hematopoiesis. An abnormal karyotype in the cells in the ascitic fluid, which was the same abnormality as in peripheral blood, helped to prove extramedulary hematopoiesis in this case, which can be an aid in making a differential diagnosis in cases of ascites associated with myelofibrosis.
(Internal Medicine 42: 525-528, 2003)

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A 54-year-old woman had been administered propylthiouracil (PTU) for Graves' disease for 4 years. Recently, she complained of hemoptysis due to pulmonary alveolar hemorrhage causing anemia, and also had microhematuria. Antineutrophil cytoplasmic antibody against myeloperoxidase (MPO-ANCA) was positive, and she was diagnosed with PTU-induced vasculitis. Cessation of PTU and the administration of corticosteroids ameliorated these manifestations.
(Internal Medicine 42: 529-533, 2003)

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A 52-year-old woman was admitted because of high-grade remittent fever, erythema nodosum, and arthritis which had been lasting two months. Antibiotics did not improve her condition. A chest CT scan examination revealed bilateral hilar and mediastinal adenopathy and multiple nodular opacities in the bilateral lungs. The wedge biopsy of the right lower lobe using video-assisted thoracoscopy presented the histological findings of sarcoidosis. Finally, this case fulfilled the criteria of Löfgren's syndrome. Due to the uncovered cardiac involvement, the systemic glucocorticoid therapy had to be initiated. This case suggests that atypical forms of sarcoidosis should be kept in mind as well, when facing cases with unknown fever.
(Internal Medicine 42: 534-537, 2003)

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A 42-year-old woman with systemic lupus erythematosus (SLE) had an episode of fever, arthralgia and anemia. In order to treat the suspected activation of SLE, the daily dose of steroid was increased, however, the anemia progressed and pancytopenia developed. Both IgM anti-B19 antibodies to human parvovirus B19 (B19) and B19 DNA were positive, and bone marrow analysis revealed pure red cell aplasia with giant proerythroblasts. High dose γ globulin was administered and the daily dose of steroid was tapered, resulting in the improvement of her condition. B19 infection should be ruled out in cases with reactivation of autoimmune diseases.
(Internal Medicine 42: 538-540, 2003)

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