Objective Several cohort studies have shown a link between serum uric acid (SUA) and subsequent cardiovascular disease. However, such an association did not remain significant after adjusting for concomitant risk factors for atherosclerosis in some studies. Thus, the role of SUA as an independent risk factor remains controversial. We therefore investigated the association between SUA and sclerotic lesions of common carotid atherosclerosis. Patients and Methods We evaluated sclerotic lesions of the common carotid arterial intima-media thickness (IMT) by ultrasonography in 398 men aged 74±8 (range, 60-97) years and 521 women aged 75±8 (range, 60-104) years. To investigate the relation between SUA and various factors, all subjects were divided into three groups based on the tertile of SUA. Results Stepwise multiple linear regression analysis using IMT as an objective variable, adjusted by various risk factors as explanatory variables showed that SUA [B, 0.0099; 95% confidence interval (CI), 0.0022-0.0175] was a significant independent contributing factor along with known risk factors such as age, sex, smoking status, systolic blood pressure, diastolic blood pressure, antihypertensive drug use, HDL-cholesterol, and LDL-cholesterol. Multiple logistic regression analysis for carotid IMT as a tertile of SUA and dependent variables showed that the adjusted odds ratio was 1.25 (95% CI, 0.87-1.78) for those in the middle tertile (4.2-5.5 mg/dl), and 1.66 (95% CI, 1.16-2.39) for those in the highest tertile (5.6-14.1 mg/dl) compared to that for subjects in the lowest tertile of SUA levels (0.51-4.1 mg/dl). Conclusion We suggest that SUA is a risk factor or marker for ultrasonographically determined IMT.
Objective This study aims to create a method of calculating intra-abdominal visceral fat volume by using ultrasound (US). The visceral fat volume measured by US was evaluated by comparison with the volume measured by computed tomography (CT). Methods Eighty-seven patients (52 males and 35 females) were enrolled in this study. Both US and CT were performed, and the visceral fat volume was measured. Both the distance and thickness of the parameters in US were measured as follows: 1) the distance between the internal surface of the abdominal muscle and the splenic vein, 2) the distance between the internal surface of the abdominal muscle and the posterior wall of aorta on the umbilicus, and 3) the thickness of the fat layer of the posterior right renal wall. Results The equation was calculated as follows: [visceral fat volume]=-9.008+1.191×[distance between the internal surface of the abdominal muscle and the splenic vein (mm)]+0.987×[distance between the internal surface of the abdominal muscle and the posterior wall of the aorta on the umbilicus (mm)]+3.644×[thickness of the fat layer of the posterior right renal wall (mm)]. There was a good correlation between the visceral fat volume calculated by the above equation and the volume by CT described (r=0.860, p<0.0001). Conclusion The measurement of the visceral fat volume using US provided results as effectively as CT, and it was proven to be a useful method.
Objectives Anemia is observed in various malignancies including lung cancer and is recently considered to be a poor prognostic indicator. We investigated whether there is a correlation between anemia, other clinicopathologic factors, and survival. Methods We retrospectively examined the clinical records of 611 patients with lung cancer. Results Of those, 298 (48.8%) patients had anemia at the time of their first visit to our hospital. There was a significant correlation between anemia and age (p=0.0006) or ECOG performance status (p=0.0002), however, there was no correlation of anemia with gender, histological type, clinical stage, or serum level of lactate dehydrogenase. Survival was significantly shorter in 298 patients with anemia (median survival time (MST): 7.5 months) compared with 313 patients without anemia (MST: 11.8 months, p<0.0001). Multivariate analysis of prognostic factors using the Cox proportional hazards model revealed that anemia appeared to be an independent prognostic indicator. Conclusion Anemia observed at the first presentation is an independent poor prognostic indicator in patients with lung cancer.
Objective Many Japanese patients with obstructive sleep apnea (OSA) are less obese than Caucasian OSA patients despite their similar severity of OSA, suggesting that their etiology of OSA may differ. The purpose of this study was to identify bony factors associated with OSA in the Japanese population. Methods The clinical records of study subjects were retrospectively reviewed, and cephalometric measurements based on Sella-Nasion references and the Ricketts method were statistically compared. Patients Two hundred and six consecutive Japanese men complaining of habitual snoring and daytime sleepiness were enrolled in the study. All subsequently underwent an overnight polysomnographic examination. Results Multiple regression analysis showed that the body mass index (p<0.0001) and facial axis angle (p=0.007) were the dominant overall determinants for the apnea hypopnea index. The sella to nasion to subspinale angle (SNA) and sella to nasion to supramentale angle (SNB) were lower in the non-obese, severe group than for non-obese, mild and moderate patients with OSA (p=0.0047 and 0.0016, respectively). Conclusion The risk factors for OSA in Japanese men may be obesity and the dolico facial pattern seen by the Ricketts method. In addition, a smaller SNA and SNB seem to be associated with the severity of OSA in non-obese patients.
Object The serum levels of KL-6, surfactant protein A (SP-A), and SP-D are useful biomarkers and prognostic factors for the activity of interstitial pneumonias. The aim of this study was to determine the clinical roles of the levels of KL-6, SP-A, and SP-D in the serum and bronchoalveolar lavage fluid (BALF) of patients with acute eosinophilic pneumonia (AEP). Materials and Methods We researched 5 cases of AEP. The levels of KL-6, SP-A, and SP-D in the sera and BALF of those patients were measured by enzyme-linked immunosorbent assay. Results KL-6 levels in BALF did not differ between AEP patients and the healthy control group, while SP-A and SP-D levels in BALF were significantly higher in the AEP patients than in the healthy control group. In sera, AEP patients had significantly higher than normal levels of SP-A and SP-D, but not of KL-6. Only in sera there was a positive correlation between SP-A and SP-D, but no apparent correlations in BALF and also between KL-6 and the others. Furthermore, the BALF levels of SP-D, but not of SP-A or KL-6, statistically correlated with the concentration of albumin in BALF. After clinical improvement, the elevated levels of serum SP-A or SP-D in AEP patients decreased until normal levels were reached within 2 months. Conclusion These results suggest that the serum or BALF levels of SP-D appear to be more sensitive than those of SP-A or KL-6 at reflecting the inflammatory response in AEP lungs.
Objective To examine laboratory data including total blood cell count, leukocyte morphology and coagulation parameters during treatment for acute promyelocytic leukemia (APL) at a single institute, and compare the precise differences between all-trans retinoic acid (ATRA) and arsenic trioxide (As2O3) treatment. Patients and Methods Sixteen patients with APL who were treated with ATRA or As2O3 alone and achieved complete remission (CR) were analyzed. ATRA 45 mg/m2/day was given orally until CR. As2O3 0.15 mg/kg/day was given intravenously until leukemic blasts and promyelocytes were eliminated from the bone marrow. Results All 7 patients in the ATRA-treated group were primary cases and all 9 patients in the As2O3-treated group were relapsed cases after the achievement of CR with the ATRA. There was no difference in the data before treatment between these two groups. The duration of leukocytopenia and neutropenia during As2O3 treatment was significantly longer than those of ATRA treatment. The nadir of leukocyte and neutrophil counts was observed later in the As2O3-treated group. Terminal neutrophil differentiation was observed more obviously in the ATRA-treated group. The red blood cell count and hemoglobin concentration decreased significantly at the end of As2O3 treatment and were lower than those of ATRA treatment. Platelets recovered earlier in the ATRA-treated group. Coagulation parameters were not significantly changed between the two groups. Conclusion In comparison with ATRA treatment, the recovery of several components in the peripheral blood cells was delayed in As2O3 treatment. Therefore we should pay more and longer attention in As2O3 treatment.
Although several diagnostic imaging modalities have been significantly improved in the recent years, the definitive diagnosis of intrahepatic cholangiocarcinoma (IHC) is still sometimes difficult because of the versatile features of IHC with each imaging. A 68-year-old Japanese man with alcoholic liver cirrhosis developed an intrahepatic tumor. Several imaging modalities demonstrated various features, such as central calcification and arterio-portal (A-P) shunt. Since we could not reach a final diagnosis and the tumor size gradually increased, partial hepatectomy was done after obtaining written informed consent from the patient. The postoperative histopathological examination revealed a cholangiocarcinoma. Herein, we report this case of IHC that was very difficult to diagnose due to the simultaneous association with central calcification and A-P shunt.
A 14-year-old boy was admitted for the evaluation of recurrent syncope. His ECG on admission revealed a sinus rhythm with an undetermined QRS axis, T wave inversion at leads V3, V4 and abnormal q at leads I, aVL, V5 and V6. However, no underlying disease could be detected by any morphological examination. Programmed ventricular stimulation also induced no ventricular tachycardia or fibrillation (VF). Only signal-averaged ECG showed ventricular late potential and the cause of syncope was not clarified. As his brother with a similar ECG had died suddenly, he was prophylactically treated with an ICD. However, 14 months later he died suddenly after playing a video game. The ICD recorded VF, which was not converted despite 6 cardioversion attempts by the ICD. Progression of myocardial damages and/or elevation of defibrillation threshold may have been the cause of unsuccessful cardioversion.
A patient with type 2 diabetes and hypothalamic damage due to a suprasellar tumor developed impaired glycemic control and central obesity. The patient showed exaggerated adrenocorticotropic hormone responsiveness as determined by a corticotrophin releasing hormone test and elevated serum leptin concentrations associated with ravenous appetite and insulin resistance mediated in part through disturbances in leptin signaling. Combination treatment with metformin and pioglitazone was markedly effective in improving glycemic control. Additionally, metformin treatment showed marked anorectic effects on the hyperphagia. This case has important implications for the pathogenesis and management of diabetes in patients with hypothalamic-pituitary-adrenal axis deficiencies.
We report a 59-year-old woman with type 2 diabetes mellitus (DM) complicated with smoldering myeloma and non-alcoholic steatohepatitis. A diagnosis of smoldering myeloma was made on the basis of elevation of IgA, M-protein (type:IgA-λ) and histological findings of bone marrow without bone lesion. As to liver dysfunction, anti-HBV, anti-HCV and a series of auto-immune antibody were negative. She had no alcohol drinking habit and histological findings showed pericellular fibrosis without fatty degeneration, suggesting liver cirrhosis due to non-alcoholic steatohepatitis (NASH). To date, there are no reports of cases with DM, NASH and myeloma. Particular attention may be necessary for these complications.
The most common cause of hyperinsulinemic hypoglycemia in adults is insulinoma. Nesidioblastosis is a rare, but well-recognized disorder of persistent hyperinsulinemic hypoglycemia in infancy, but adult-onset nesidioblastosis associated with hyperinsulinemic hypoglycemia, termed noninsulinoma pancreatogenous hypoglycemic syndrome (NIPHS), has been reported. Here, we describe an extremely rare case of NIPHS in an elderly man. A 78-year-old man was admitted to our hospital due to hypoglycemic coma. During the previous 3 months, he noticed excessive sweating at midafternoon. His low fasting plasma glucose level (27 mg/dl) and high immunoreactive insulin level (11.1 μU/ml) were consistent with the possible presence of insulinoma. Localizing studies including computed tomography of the abdomen and celiac arteriography were negative, but selective arterial calcium infusion (SACI) test suggested the presence of insulinoma in the body and tail of the pancreas. Surgical exploration by palpation and intraoperative ultrasonography failed to detect any mass in the pancreas, and 60% distal pancreatectomy was performed. Postoperatively, his hypoglycemic episodes completely disappeared. Histological examination of the resected pancreas revealed diffuse islet cell hyperplasia consistent with a pathological diagnosis of nesidioblastosis. Thus, our case is a very rare case of NIPHS, or adult-onset nesidioblastosis, in which SACI test was proven to be a useful diagnostic tool for localization of the pancreatic lesion.
A 76-year-old woman with a history of total thyroidectomy for a thyroid carcinoma at the age of 63 was admitted to our hospital for the treatment of a renal rupture induced by a tumor of about 3 cm in diameter. High levels of blood thyroglobulin (Tg >1,000 ng/ml) led us to suspect a recurrence of thyroid carcinoma. Strong accumulation in whole-body 123I and 201Tl scintigraphy scans after the nephrectomy revealed tumors in the right lung and left thigh muscle measuring 5 cm and 9 cm in diameter, respectively. The tumors of the kidney and thigh muscle were pathologically diagnosed as poorly differentiated follicular thyroid carcinoma, and the lung tumor was also suggested to be a metastasis of the thyroid carcinoma based on the scintigraphy findings. We report this rare case of follicular thyroid carcinoma associated with metastases to the thigh muscle and kidney leading to a rupture 13 years after a total thyroidectomy. Care should be taken to determine whether unknown tumors are thyroid carcinoma metastases.
A 68-year-old woman was referred for evaluation of nephrotic-range proteinuria and a course suggesting rapidly progressive glomerulonephritis. Serum anti-neutrophil cytoplasmic antibody against myeloperoxidase (MPO) was 204 U/ml. A renal biopsy specimen revealed necrotizing glomerulonephritis with crescent formation. However, immunofluorescence showed staining with IgG and C3 along capillary walls. IgG positivity included both IgG1 and IgG4. Electron microscopic examination disclosed both paramesangial and subepithelial deposits. This case suggests that rarely, MPO-ANCA-related crescentic glomerulonephritis may present nephrotic-range proteinuria and show immune deposits along capillary walls.
Purple urine bag syndrome (PUBS) is an uncommon disorder, in which the plastic disposable urinary catheter bag turns purple or blue following hours or days of urinary catheterization. The purple discoloration results from indirubin dissolved in the plastic mixing with indigo in the urine. Bacteria possessing indoxyl sulfatase degrade indoxyl sulfate into indirubin and indigo. Indoxyl sulfate is derived from the metabolism of tryptophan. PUBS usually occurs in chronic catheterized elderly women who are constipated and poorly ambulant. The clinical course is benign and rarely causes sepsis. This investigation reports a 61-year-old female diabetic patient with end-stage renal disease on maintenance hemodialysis, who had two episodes of blue or purple urine bag discoloration. The urine culture of the first episode yielded Klebsiella pneumoniae, whereas that of the second episode yielded Escherichia coli, Enterococcus faecalis, and Proteus vulgaris. Both episodes resolved following oral antibiotics treatment and placement of new foley catheters. To our knowledge, this is the first recorded case of PUBS in a dialysis patient.
A 41-year-old man with productive cough was admitted to our hospital. His chest roentgenogram showed multiple small nodules in the bilateral lung fields. The nodules were revealed as intrapulmonary metastases of the adenocarcinoma of the lung. Systemic chemotherapy with paclitaxel and carboplatin was not effective, and continuous oral gefitinib therapy was initiated. Twenty-one days later, spontaneous pneumothorax was found in the left lung, and four days after that, in the right lung as well. The extent of the pneumothorax was slight; therefore, he recovered without drainage within several days. Spontaneous pneumothorax, especially bilateral pneumothorax, is a rare complication of chemotherapy for lung cancer.
Radiological and histological correlation was evaluated in patients with malignant tumors of the lung that underwent radiofrequency ablation (RFA). One of the patients had a primary lung tumor and another patient had three metastatic lung tumors. RFA was performed under computed tomography (CT) fluoroscopic guidance. CT showed ground glass shadows around the tumoral lesions immediately after RFA, but one week later homogenous opacification without tumoral enhancement was noted. Two months after RFA, most lesions showed cystic changes without activity on FDG-PET. Histological evaluation showed massive coagulation necrosis throughout the tumor and some viable cells at the peripheral areas in all lesions. Although RFA is a promising therapeutic approach for malignant lung tumors, some viable cells may persist in peripheral areas of the tumor.
A case of self-limiting pneumonia due to Chlamydia pneumoniae is described. A 39-year-old male visited our hospital complaining of a persistent cough. No antibiotics were administered to this patient because of the absence of fever and a mild positive inflammatory response, but an infiltrate on a chest radiograph improved. Finally, a diagnosis of C. pneumoniae pneumonia was made by seroconversion of the C. pneumoniae-specific antibody and detection of the C. pneumoniae gene in bronchoalveolar lavage fluid. Self-limiting C. pneumoniae pneumonia is rarely encountered, although self-limiting upper respiratory tract infections due to C. pneumoniae are common. Thus, most self-limiting C. pneumoniae pneumonia may be missed when symptoms are minimal.
A previously healthy 19-year-old girl was admitted to our hospital because of hyperkalemia. Pseudohyperkalemia was diagnosed because there was a marked difference between levels of serum and plasma potassium. Her plasma potassium level was markedly increased after 6-hour in vitro incubation of blood at room temperature, suggesting excessive potassium release from red blood cells without coagulation. The plasma potassium levels of the patient and her father were markedly elevated in blood specimens incubated in vitro at 4°C, but not at 37°C. These data indicated pseudohyperkalemia syndrome caused by abnormal leakage of potassium from red blood cells at the lower temperatures.
Disseminated fungal infection is an important cause of morbidity and mortality among patients with hematological malignancies. Ochroconis gallopavum is a dematiaceous and thermotolerant fungus that causes opportunistic infections in immunocompromised hosts. About only 30 cases of this organism infection have been reported worldwide. We report a disseminated Ochroconis gallopavum infection in a B-cell chronic lymphocytic leukemia patient. In spite of intensive anti-fungal treatment, no improvement in the clinical condition was observed and the patient died 4 months after diagnosis of the infection. Ochroconis gallopavum infection is a potentially fatal disease in hematological malignancies.
A 42-year-old woman presented gradual development of hypersomnia and memory disturbance. T2-weighted and FLAIR MRI scans revealed a high intensity abnormality in the hypothalamus. Stereotactic brain biopsy specimen revealed prominent infiltration of the lymphocytes in the vessel walls. Since there was no evidence of systemic angiitis, the diagnosis of isolated angiitis of the CNS (IAC) was made. Polysomnographic study showed decreased REM sleep and increased stage I sleep. Orexin A in the CSF was decreased. Hypersomnia and a decrease of the CNS orexin A improved after corticosteroid therapy. Hypersomnia can be an initial symptom of IAC if it involves the hypothalamus.
We report a case of an adolescent girl with atypical manifestations of pancreatitis with autoimmune phenomenon presenting with epigastralgia and back pain. While no abnormalities were detected on computed tomography and magnetic resonance imaging, apart from the absence of peripancreatic spread, laboratory and serological findings, such as hypergammaglobulinemia, a high titer of immunoglobulin G, a high titer of immunoglobulin G4, slight positivity for antinuclear antibodies, and positivity for autoantibodies to lactoferrin, were suggestive of autoimmune pancreatitis (AIP). Magnetic resonance cholangiopancreatography imaging (MRCP) visualized only the main pancreatic duct (MPD) in the pancreas head region. Proteoclastic enzyme inhibitor treatment was ineffective but the patient responded well to oral prednisolone. The patient and her family did not consent to endoscopic retrograde pancreatography or biopsy/histopathological examination. The case could not be diagnosed as AIP due to lack of typical diagnostic criteria, and thus the final diagnosis was considered pancreatitis with autoimmune phenomenon. We considered that the MRCP finding of partly visible MPD was due to diffuse irregular narrowing of the MPD. This case suggests that while MRCP imaging of the MPD may be helpful in the diagnosis of pancreatitis with autoimmune phenomenon, a negative result does not preclude such diagnosis.
After influenza vaccination an 83-year-old woman was referred to us because of fever and sore throat with no response to antibiotics. Chest computed tomography showed thickened bronchovascular bundles, multiple nodules with feeding vessels, and consolidation. Laboratory tests showed a high level of serum myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) and soluble interleukin-2 receptor (sIL-2R), as well as abnormal renal function and urinary sediment. Transbronchial lung biopsy revealed organizing pneumonia. We made a diagnosis of microscopic polyangiitis after influenza vaccination. Corticosteroids and cyclophosphamide were effective. Careful attention should be paid to severe adverse effects such as systemic vasculitides after influenza vaccination.