Objective: Early diagnosis is central to the management of chronic obstructive pulmonary disease (COPD). In time-constrained clinical situations, a pre-interview questionnaire can be a useful method for alerting both clinicians and patients with COPD, particularly for elderly patients. To screen subjects who might have COPD, we have developed an efficient pre-interview questionnaire. Methods: In study I, we developed an 11-item questionnaire (11-Q) to alert primary care providers to the possibility of COPD, and the validity of this questionnaire was investigated. In study II, a randomized and prospective cross-sectional study was performed on a total of 245 subjects with or without respiratory symptoms. Results: Good test-retest reliability and validity were shown in study I; the internal consistency of 11-Q was highly preserved (Cronbach α value of 0.867), with a high reproducibility of responses by inter- and intra examinees. Study II showed that the 11-Q in COPD patients with more than moderate severity was significantly higher than that in bronchial asthma or non-cardiopulmonary subjects (both, p<0.0001). Among the COPD patients, the total score significantly distinguished the severity of COPD as mild or more than moderate. Conclusion: The pre-interview questionnaire, 11-Q, was found to be a useful tool to alert primary care providers to subjects with COPD and could also be used to distinguish COPD with a more than moderate severity from bronchial asthma. The 11-Q can be used as a simple and inexpensive method of predicting COPD, thus being a useful tool to alert primary care providers to patients with suspected COPD, particularly among the elderly.
Objective: Although meningism manifesting acute headache has been observed to be associated with common viral and bacterial infections, its definition and pathogenesis have not been clarified. Clinical findings and cerebrospinal fluid (CSF) cytokines in adult patients with meningism were investigated and compared with those in viral meningitis. Patients and Methods: Among the adult inpatients in our hospital from 1997 to 2004, 5 with meningism and 17 with viral meningitis were identified according to the criteria described in this study, and their clinical data were analyzed. In the CSF samples of the 5 patients with meningism and the 17 with viral meningitis, the concentrations of interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α), interleukin-2 (IL-2), IL-4, IL-6, and IL-10 were determined using a cytometric bead array. Results: The five patients with meningism all showed fever and meningeal signs such as severe headache and nuchal stiffness without CSF pleocytosis (<5 cells/mm3). Four patients were associated with herpetic Kaposi's eczema, herpes simplex, or herpes zoster, and all five patients had favorable outcomes. The levels of all CSF cytokines in patients with meningism were below normal values, whereas IFN-γ and IL-6 in patients with viral meningitis were moderately elevated. Conclusion: The normal cytokine levels in meningism may possibly reflect the lack of direct viral infection and may be helpful in differentiating both meningism and viral meningitis at an early stage.
We report a patient whose cryoglobulinemic vasculitis recurred due to reactivation of lamivudine-resistant HBV. Our patient with hepatitis B-related cryoglobulinemic vasculitis was administered lamivudine. Her vasculitis regressed, ALT normalized, HBV-DNA became negative. Under lamivudine therapy, her cryoglobulinemic cutaneous vasculitis recurred. ALT increased significantly; it was found that tyrosine-methionine-aspartate-aspartate (YMDD) motif in the DNA polymerase gene had been replaced by YIDD. Adefovir was added to lamivudine. During follow-up, her purpura disappeared, ALT normalized, HBV-DNA became negative. Our patient is the first whose cryoglobulinemic vasculitis recurred under lamivudine, who had a HBV virologic breakthrough with YMDD mutation, and was successfully treated with adefovir.
A 23-year-old woman was admitted to our hospital with jaundice and hepatic coma. She had taken a weight-loss supplement for one month before admission. Her clinical and laboratory findings were consistent with fulminant hepatic failure and fulfilled the criteria of autoimmune hepatitis. Despite corticosteroid pulse therapy and plasma exchange, her symptoms and laboratory findings deteriorated. Her condition improved after she received a living donor-liver transplant from her sister. Autoimmune hepatitis usually follows a chronic course, but it should be considered a type of fulminant hepatic failure and treated promptly.
We describe a case of 57-year-old man who presented with acute myocardial infarction (AMI) and heart failure with rapid progression of cardiomegaly. Cardiac multislice computed tomography and echocardiography showed the ventricular pseudoaneurysm, probably due to cardiac free wall rupture caused by AMI. Cardiac CT is another useful tool for the non-invasive diagnosis of cardiac rupture.
Here, we report a case of acute liver dysfunction complicated with uncontrollable glycemia due to insulin antibody. The patient was admitted to our hospital due to diabetic ketoacidosis. He was administered insulin immediately, however, his fasting plasma glucose level remained unstable despite the insulin treatment. Blood biochemistry revealed severe liver dysfunction, although no markers including hepatitis virus or autoantibodies associated with autoimmune liver diseases were detected. The 125I-insulin binding rate was high (54%). The characteristics of insulin antibody in this patient were similar to the antibodies of IAS patients, therefore we administered oral glucocorticoid against insulin antibody. The reduction in the 125I-insulin binding rate and the binding capacity of the high affinity site of insulin antibodies were balanced after oral glucocorticoid therapy. In addition, preprandial subcutaneous regular insulin was switched to lispro insulin. Postprandial plasma glucose levels were relatively improved by lispro insulin. The etiology of acute liver dysfunction was unknown, however, we believe that the combination of oral glucocorticoid and lispro insulin was suitable and useful for preventing recurrent liver dysfunction in this patient.
A 49-year-old woman with hypertension, obesity and impaired glucose tolerance (IGT) was admitted for evaluation of pituitary incidentaloma. Although she presented no Cushingoid feature, endocrine examination of hypothalamo-pituitary-adrenal (HPA) axis showed elevated basal plasma ACTH and cortisol levels, their lack of circadian rhythm, non-suppressibility to low-dose (1 mg) dexamethasone, and responsiveness to CRH, suggesting autonomous ACTH secretion from a pituitary tumor. She underwent transsphenoidal surgery, and was diagnosed as chromophobe adenoma with positive ACTH immunoreactivity. Postoperatively, her abnormal HPA axis was resolved, along with improvement of hypertension, obesity and IGT. Thus, her metabolic comorbidities are likely due to subclinical Cushings disease.
Although there are some case reports of combined aldosterone and cortisol producing adrenal tumor, overt diabetes mellitus has been rarely described. A 55-year-old hypertensive woman had hypokalemia and overt hyperglycemia without Cushingoid clinical features. The body mass index was 18.2 kg/m2, fasting blood glucose was 302 mg/dl and hemoglobin A1c was 11.6%. Endogenous insulin secretion was well preserved, whereas insulin sensitivity measured by short insulin tolerance test was markedly impaired. A solitary left aldosterone- and cortisol-producing adrenal tumor was diagnosed. We described a rare case of overt diabetes mellitus in a patient with combined primary aldosteronism and Cushing's syndrome.
A 71-year-old man was admitted with malaise, mild fever, anorexia, body weight loss, lower back pain, thirst, and polydipsia. He showed bilateral swelling of the submandibular glands. Examinations showed panhypopituitarism and a high serum IgG4 concentration. Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed uptake in the pituitary gland, bilateral submandibular gland, bilateral hilar and mediastinal lymph nodes, and a mass consistent with retroperitoneal fibrosis, but not in the pancreas. Biopsy specimens from the submandibular gland and retroperitoneal mass indicated sialadenitis and retroperitoneal fibrosis respectively, and showed severe fibrosis and inflammation with marked lymphoplasmacytic infiltration and IgG4-positive plasma cell infiltration. Hormone replacement therapy with hydrocortisone resulted in marked clinical improvement. Systemic involvement found in this patient possibly corresponded to the new concept of IgG4-associated multifocal systemic fibrosis.
A 46-year-old man presented with frontal headache, a visual field defect and general fatigue. Magnetic resonance imaging (MRI) of the brain showed symmetrical enlargement of the pituitary gland and stalk due to the presence of a mass lesion extending toward the optic chiasm. Gadolinium injection further revealed homogeneous strong enhancement with involvement of the adjacent dura (dural tail). Basal plasma levels of ACTH, free thyroxine and gonadotropins were decreased, and 24-h urinary 17-OHCS excretion was reduced. An elevated anti-thyroglobulin antibody titer indicated the presence of autoimmune thyroiditis. Under the suspicion of autoimmune hypophysitis, 60 mg/day prednisolone sodium succinate was intravenously administered for two weeks followed by a decreasing dose of oral prednisolone. Clinical symptoms and pituitary dysfunction recovered during steroid treatment and MRI showed marked shrinkage of the pituitary mass. Early initiation of an intravenous dose of glucocorticoid followed by oral steroid administration therefore seems to be an efficient treatment for autoimmune hypophysitis even in patients with visual dysfunction.