Objective: Because of an increasing number of case reports of copper deficiency associated with long-term tube feeding nutrition in Japan, we identified patients with copper deficiency associated with long-term tube feeding and described the prevalence, clinical data and cocoa treatment for these patients.
Materials and Methods: We conducted a retrospective study to identify patients who were referred from long-term care institutions and had copper deficiency associated with tube feeding. We reviewed all serum copper concentration data during a 6-year period. We also compared admission and post-treatment peripheral blood counts.
Results: Among 210 consecutive admissions with nutritional tube feeding from long-term care institutions (N=210), we identified 13 (6.2%) patients with copper deficiency (aged 46-91; 12 women). All patients had anemia, while most had neutropenia. The range of serum copper concentrations of these patients was 0.1-2.4 μg/L (normal; 6.8-12.8 μg/L). Their feeding formulas revealed a low copper content (5 to 12 μg per 100 kcal of each formula). Cocoa powder was used as the treatment. With cocoa supplements, the blood leukocyte count and hemoglobin significantly improved in all patients. Median leukocyte counts were 1,800 /mm³at admission and 6,300/mm³ at follow-up (p=0.001). Median hemoglobin were 7.0 g/dl at admission and 10.3 g/dl at follow-up (p=0.001). Two patients developed transient tachycardia as a possible adverse effect of cocoa.
Conclusion: We identified many cases with copper deficiency associated with tube feeding in Okinawa, Japan. Cocoa supplement appeared to be a safe and effective treatment. Increasing the copper content of Japanese tube feeding formulas should be considered for its prevention.

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Hepatoid adenocarcinoma (HAC) is a rare tumor that occurs mostly in the gastrointestinal tract. We encountered a 68-year-old man suffering from HAC with severe ascites. The serum and ascitic α-fetoprotein (AFP) levels were markedly high. Computed tomography (CT) revealed that multiple nodular lesions were disseminated only in the peritoneal cavity. Based on laparoscopic and histological findings, this tumor was diagnosed as diffuse HAC which was developed primarily in the peritoneum. Despite treatments with appropriate chemotherapy, he died six months after diagnosis. According to literature updates, this is the first documented case of diffuse HAC which developed in the peritoneum.

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A 62-year-old woman was admitted because of chest pain. Coronary angiography demonstrated stenosis of the left anterior descending coronary artery, where two bare metal stents had been implanted. Over 5 months in-stent restenosis occurred four times, and was treated at first with angioplasty but finally with two sirolimus-eluting stent insertions. Six months after the second insertion, angiography showed restenosis within one stent. The mechanism underlying this succession of rapid restenoses is unknown, but sirolimus-eluting stents appeared to show relative resistance.

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A pregnant 26-year-old woman developed hemosputum, dyspnea and pneumothorax. Lymphangioleiomyomatosis was suspected based on multiple cystic lesions on chest computed tomography. Additionally, moderate thrombocytopenia occurred during the last trimester. Hyperplasia of megakaryocytes in a bone marrow specimen and a high serum titer of platelet-associated IgG led to a diagnosis of idiopathic thrombocytopenic purpura. High-dose intravenous gammaglobulin promptly restored her platelet count, and the patient successfully gave birth to a healthy baby by cesarean section. After delivery, lymphangioleiomyomatosis was diagnosed by lung biopsy that was obtained during a video-assisted thoracoscopic abscission for recurrent pneumothorax. Underlying lymphangioleiomyomatosis and idiopathic thrombocytopenic purpura may be obviated by pregnancy.

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