Objective The object of our study was to identify the most useful predictor of patient prognosis in acute myocardial infarction (AMI), from 7 acute-phase cardiovascular peptides which take part in neurohumoral activation [brain natriuretic peptide (BNP), atrial natriuretic peptide (ANP), renin, aldosterone, adrenomedullin, epinephrine and norepinephrine]. Methods In 141 consecutive AMI patients, 24 hours from onset, we evaluated plasma concentration levels of the 7 types of cardiovascular peptides and the relationships between the values of these peptides and short-term clinical prognosis, including mortality. Results Plasma levels of all cardiovascular peptides were significantly higher in patients who suffered mortality than in surviving patients (BNP: 1, 267±997 pg/ml vs. 293±327 pg/ml, p<0.0001; ANP: 164±186 pg/ml vs. 64±76 pg/ml, p<0.001; adrenomedullin: 13.61±3.29 Fmol/l vs. 3.45±1.52 Fmol/l, p<0.0001; renin: 8.79±7.15 ng/ml/h vs. 4.34±5.10 ng/ml/h, p<0.01; aldosterone: 249±210 pg/ml vs. 68±74 pg/ml, p<0.0001; epinephrine: 3, 191±8, 360 pg/ml vs. 68±74 pg/ml, p<0.0001; norepinephrine: 21.8±46.2 ng/ml vs. 0.9±0.8, ng/ml p<0.0001). Multivariate analysis identified only high levels of adrenomedullin as an independent related factor of cardiogenic shock (risk ratio: 5.84, 95% C.I.: 1.80-18.95, p=0.003), and as an independent predictor of short-term mortality (risk ratio: 16.16, 95% C.I.: 1.38-189.71, p=0.03). Conclusions Acute-phase neurohumoral activation, involving renin, aldosterone, epinephrine, norepinephrine, BNP, ANP, and adrenomedullin may be closely related to poor patient outcomes, including mortality. Our results suggest that acute-phase plasma adrenomedullin concentrations may be the most useful predictor of patient prognosis in the setting of AMI, out of the 7 types of cardiovascular peptides involved in neurohumoral activation.
Objective The serum IgA/C3 ratio might be considered to serve as a diagnostic marker for patients with IgA nephropathy (IgAN), but its value as a marker of the severity of histological lesions or prognosis is unknown. Methods We studied the serum IgA/C3 ratio, using standardized reference material, in 86 patients with IgAN and in 32 with non-IgAN. The patients with IgAN were divided according to the severity of histological lesions (mild IgAN, n=29 and severe IgAN, n=57) based on Japanese clinical guidelines. Results The serum IgA level was significantly higher, while its C3 level was lower in patients with severe IgAN compared to those with non-IgAN. However, these levels were not different between patients with mild IgAN and non-IgAN. In contrast, the serum IgA/C3 ratio obviously differed among the three groups (2.47±0.96 vs. 3.63±1.44 vs. 4.72±1.86; p<0.01, ANOVA). Kaplan-Meier analysis of the patients with IgAN classified according to the mean serum IgA/C3 ratio revealed that the group with high serum IgA/C3 (4.5 and above) had a significantly poorer renal outcome (p<0.05, log-rank test), since the cumulative renal survival rate at 5 years was 84.4% vs. 100%. The ratio (%) of patients with severe IgAN in whom hematuria disappeared, was significantly higher in the low, than in the high serum IgA/C3 group (41.9% vs. 15.4%; p<0.05, t-test). Conclusion The serum IgA/C3 ratio appears to reflect the histological severity of IgAN and could serve as a marker of the progression of IgAN.
BackgroundS. pneumoniae is the leading cause of morbidity and mortality worldwide. β-lactam antibiotics were very effective against S. pneumoniae, however resistance to this class of antibiotic has become an increasing problem. Objectives To assess the clinical differences between penicillin-sensitive and penicillin-resistant pneumococcal pneumonia. Methods The medical records of 306 patients with pneumococcal pneumonia who visited Nagasaki University Hospital or affiliated institutions between January 1997 and December 2001 were retrospectively reviewed. The Pneumonia Severity Index (PSI), sensitivity of S. pneumoniae, antibiotic choices and information on clinical outcome were evaluated. Results Penicillin sensitive and resistant organisms were responsible for 177 (57.7%) and 129 (42.0%) cases of pneumonia, respectively. The median age of patients was 65.5 years, and 72.3% (222) were males. There were no significant differences in the resistance rate between elderly (>65 years) and young patients. The median PSI score was 76. No significant association was observed between the severity of illness and sensitivities of S. pneumoniae. Previous use of beta-lactams in the last 3 months and chronic obstructive pulmonary disease were associated with penicillin resistance. The failure rate of first line antibiotics was significantly higher in the resistant group (22.5%) than in the sensitive group (9.0%). Four of 306 patients died (mortality, 1.3%). Conclusion There were no significant differences clinically between the penicillin-sensitive and penicillin-resistant groups. The failure rate of first line antibiotics was higher in the resistant than in the sensitive group. Thus, the selection of antimicrobial agents should be carefully considered in the context of the patient’s risk factors.
A 49-year-old man, who had a 30-year history of drinking the equivalent of 80 g of ethanol per day, underwent a detailed medical examination for cough and dyspnea. Chest-abdominal computed tomography and endoscopic retrograde pancreatography led to the diagnosis of a mediastinal pancreatic pseudocyst resulting from obstruction of the pancreatic duct by a protein plug. The pseudocyst rapidly improved with conservative treatment with camostat mesilate, H2-receptor antagonist and digestive enzymes. Although the patient abstained from alcohol for approximately 6 months, he resumed drinking, leading to recurrent attacks of pancreatitis. Bromhexine hydrochloride was then administered for 6 months, with the expectation that it would have a mucolytic effect on the pancreatic juice, resulting in improvement in the clinical symptoms, pancreatic enzymes and pancreatic exocrine function, as well as elimination of the protein plug. Bromhexine hydrochloride may be a new therapy for pathological states, such as alcoholic chronic pancreatitis, in which there is increased viscosity of the pancreatic juice because of elevated protein concentration, leading to protein plug formation and temporary blockage of the pancreatic duct.
An 84-year-old man was admitted to our hospital with a 1-month history of epigastralgia. Upper gastrointestinal endoscopy revealed gastric cancer and a gastric submucosal tumor (SMT) on the greater curvature of the gastric body. By endoscopic ultrasonography, SMT was demonstrated as a well-circumscribed, smooth-bordered and hypoechoic mass localized in the submucosal layer. Total gastrectomy was performed. The histology of the resected specimen revealed a gastric lipoma and an early gastric cancer widespread to the surface on the lipoma. Two lesions were present in the same lesion, but not linked. We report a rare case of gastric lipoma complicated with early gastric cancer.
A 23-year-old man was admitted to our department due to hemorrhage from gastric varices. He had been diagnosed as having Wilson’s disease at the age of 17. Abdominal ultrasonography and computed tomography (CT) showed portal thrombosis and a large mass occupying most of the right lobe in the liver. The tumor was diagnosed as hepatocellular carcinoma (HCC) by image views and tumor markers. He died 3 months after the diagnosis, and an autopsy was performed. Histologic examination of the tumor showed moderately to poorly differentiated HCC. The nontumorous lesion of the liver revealed cirrhosis. HBX-DNA sequence was not detected in the liver. Hepatic cirrhosis is a well-recognized complication of Wilson’s disease, but HCC is extremely rare. We describe the clinical findings of this patient and discuss the relationship of the development of HCC with a review of the relevant literature.
We report a case of ulcerative colitis (UC) that occurred during the course of rheumatoid arthritis (RA). A 29-year-old woman with a 25-year history of RA was hospitalized for high fever, abdominal pain and hematochezia. Colonoscopy revealed erosive and reddish mucosa from the distal transverse colon to rectum. Histology revealed cryptitis (mainly caused by neutrophils), mild crypt abscess and goblet cell depletion. She was diagnosed with left-sided UC and treated with mesalamine enema. The abdominal symptoms and colonoscopic findings were greatly ameliorated. We conclude that the mesalamine enema was effective in this case of UC occurring during the course of RA.
A 54-year-old man with severe left ventricular dysfunction due to dilated cardiomyopathy was referred to our hospital for symptomatic incessant sustained ventricular tachycardia (VT). After the administration of nifekalant hydrochloride, sustained VT was terminated. An alternate class III agent, sotalol, was also effective for the prevention of VT. However, one month after switching over nifekalant to sotalol, a short duration of ST elevation was documented in ECG monitoring at almost the same time for three consecutive days. ST elevation with chest discomfort disappeared since he began taking long-acting diltiazem. Coronary vasospasm may be induced by the non-selective β-blocking properties of sotalol.
We report a very rare case of acute pulmonary edema caused by hypoglycemia from insulin overdose during an attempted suicide. A 16-year-old woman with type 1 diabetes was brought to our hospital because of hypoglycemic coma. She exhibited severe hypoxia; upon intubation, bloody froth poured out of the tube. Chest X-ray revealed bilateral infiltrates. Endocrinological data revealed high concentrations of catecholamines. This case indicates that pulmonary edema remains a potential complication of insulin overdose. The possible mechanisms of pulmonary edema associated with hypoglycemia are discussed.
In the treatment of severe asthma attack, acute application of non-invasive positive pressure ventilation is shown to be beneficial in some selected patients, while endotracheal intubation and mechanical ventilation is required in the remaining cases. Management with invasive ventilation in status asthmaticus is often associated with complications such as excessive mucus production and atelectasis, which may lead to prolonged hypoxemia and may increase mortality. We present a case of status asthmaticus who developed refractory atelectasis during invasive mechanical ventilation but had a dramatic resolution as well as successful weaning when non-invasive positive pressure ventilation was instituted.
Unmanipulated hematopoietic stem cell transplantation from haploidentical family donors is frequently associated with graft failure and severe graft-versus-host disease (GVHD). We employed a myeloablative conditioning regimen consisting of 125 mg/m2 of fludarabine, 140 mg/m2 of melphalan and TBI of 10 to 12 Gy for three patients. The donor in each case was a haploidentical two-loci HLA mismatch mother or son. Engraftment failure was observed in one patient. In the other two patients, engraftment was confirmed within 15 days after transplantation. Acute and chronic GVHD was observed, but was controllable in both cases. HLA mismatched transplantation based on feto-maternal tolerance may provide an alternative option for patients who do not have HLA-matched donors.
Transfusion-related acute lung injury (TRALI) is a clinical syndrome characterized by bilateral pulmonary edema in association with transfusions. We encountered a 23-year-old woman with acute lymphoblastic leukemia, in whom TRALI without anti-human leukocyte antigen class I and anti-granulocyte antibodies developed following allogeneic bone marrow transplantation. TRALI improved mainly in association with treatment of saline and ventilation support after several days, but graft-versus-host disease and thrombotic microangiopathy developed, resulting in death due to multiple organ failure. This case indicates that TRALI can also occur following allogeneic bone marrow transplantation.
A 54-year-old woman with a 21-year history of systemic lupus erythematosus (SLE) was admitted to the Matsuyama Red Cross Hospital due to subcutaneous and gingival hemorrhaging. She was diagnosed with acquired factor VIII inhibitors based on a prolonged activated partial-thromboplastin time (APTT) and factor VIII inhibitors. Steroid pulse and factor VIII plasma concentrate were administered to her, not long after which she was transferred to Ehime University Hospital due to gallbladder hematoma. Although her APTT and factor VIII activity were improved after treatment with human factor VIII, she died of multiple organ failure. The autopsy demonstrated a ruptured gallbladder.
We present a case of neurosarcoidosis showing bilateral carpal tunnel syndrome which disappeared without any medication. This patient was also suffering from motor and sensory disturbance caused by peripheral neuropathy of the four extremities. Magnetic resonance image showed transient swelling of the median nerve, and subperineurial edema was unexpectedly observed in some fascicles in sural nerve biopsy. We hypothesize that the carpal tunnel syndrome in this case was induced by the intercanal high pressure due to edema inside the tunnel, which might be related to the high level of serum IL-2.
POEMS syndrome is a syndrome that presents with polyneuropathy, organomegaly, endocrinopathy, M-proteins and skin changes. Elevated vascular endothelial growth factor (VEGF) has recently been reported in POEMS syndrome. We report a case of POEMS syndrome with high VEGF titers. Steroid, plasmapheresis and intravenous gamma-globulin had little effect. Various immunosuppressive agents were discontinued due to side effects. Although administration of aspirin did not decrease VEGF, ticlopidine decreased VEGF significantly. This case suggests that ticlopidine is a candidate for supportive therapy in POEMS syndrome and we should measure VEGF before and after the administration of ticlopidine in other cases.
Skeletal infections with atypical mycobacteria are usually a manifestation of advanced HIV disease with most patients having CD4 counts of less than 100 cells/mm3. We report a case of Mycobacterium kansasii vertebral osteomyelitis on highly active antiretroviral therapy with a CD4 count of 320 cells/mm3 and viral load below the level of detection at the onset.
Anthracycline, a widely used anti-cancer agent, can elicit irreversible cardiomyopathy called anthracycline-induced cardiomyopathy (ACM). In this report, we describe 5 cases of severe chronic heart failure due to ACM effectively treated with the beta-blocker, carvedilol. Their left ventricular function as well as cardiac symptoms were persistently improved after treatment with carvedilol, suggesting that carvedilol may be an effective therapeutic strategy for ACM as demonstrated in other forms of chronic heart failure.