Object Electrolyte abnormalities are frequently observed in patients with hyponatremia. The aim of this study was to determine the incidence of various electrolyte abnormalities encountered in hyponatremic patients admitted to an internal medicine clinic, as well as to investigate the possible pathogenetic mechanisms responsible for these abnormalities.
Patients and Methods We prospectively studied 204 adult patients who either on admission to our clinic or during their hospitalization were found to have hyponatremia.
Results Ninety-two patients (45.5%) had at least one additional electrolyte abnormality. Hypophosphatemia was the most frequent electrolyte disorder observed (35 patients, 17%). Hypokalemia was seen in 32 patients (15.8%), hypomagnesemia in 31 patients (15.2%) and hyperkalemia in 12 patients (5.9%). Moreover, 5 patients (2.5%) had hyperphosphatemia, 4 patients (1.9%) exhibited hypermagnesemia, 3 patients (1.4%) had hypercalcemia, and 6 patients (2.9%) had true hypocalcemia. There were no statistically significant differences regarding the incidence of these electrolyte abnormalities (as a whole) between the main subgroups of hyponatremic patients (diuretic-induced, syndrome of inappropriate antidiuretic hormone, hypovolemia-induced and edematous state-related). However, hypokalemia and hypomagnesemia were more frequently observed in patients with diuretic-induced hyponatremia, while hyperkalemia was more frequently seen in edematous state-related hyponatremia.
Conclusions Additional electrolyte abnormalities are frequently encountered in patients with hyponatremia of any origin admitted to an internal medicine clinic.

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Purpose The aim of the study was to evaluate serum uric acid (UA) levels before and after non-invasive positive pressure ventilation (NPPV) to assess the utility of serum UA as an indicator of acute exacerbation of chronic respiratory failure (CRF) in patients treated with NPPV.
Methods We analyzed change in the serum UA level in 29 patients with CRF due to restrictive thoracic disease and treated with NPPV.
Results After NPPV therapy, PaO₂ was significantly increased and PaCO₂ was significantly decreased in all patients. Sixty-two percent of patients (18 of 29) showed a decreased serum UA/creatinine (Cr) ratio after NPPV therapy, but, overall, there was no significant change in serum UA/Cr (P=0.0688). The change in serum UA/Cr was not correlated with the changes in PaO₂ and PaCO₂ after NPPV. When we compared patients in whom serum UA/Cr decreased (n=18) with patients in whom serum UA/Cr did not decrease (n=11), there were significantly fewer patients who suffered CRF exacerbation in the group with a decrease (P=0.0021). Furthermore, the cumulative proportion (Kaplan-Meier) of patients who did not suffer exacerbation of CRF was significantly higher in the group in which serum UA/Cr decreased (P=0.0003).
Conclusions Our data suggest that serum UA may be a useful clinical indicator of CRF exacerbation in patients treated by NPPV.

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Objective To determine whether the development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) associated with systemic inflammatory response syndrome (SIRS) can be predicted by the plasma neutrophil elastase level.
Patients and Methods Patients were sequentially enrolled after obtaining informed consent. Twenty-three adult patients with SIRS were classified into the following groups; SIRS alone (5 patients), Group A of ALI/ARDS with SIRS (9 patients) that did not require mechanical ventilation, and Group B of ALI/ARDS with SIRS (9 patients) that required mechanical ventilation. Blood samples were obtained after the diagnosis of SIRS, and the sequential sampling was performed.
Results The plasma neutrophil elastase level was significantly elevated in all patient groups as compared with healthy controls (43.7±5.4 ng/ml). The elastase levels in SIRS alone, Group A of ALI/ARDS, and Group B of ALI/ARDS were 126.9±11.0 ng/ml, 316.2±68.9 ng/ml, and 458.4±132.8 ng/ml, respectively. The elastase level in ALI/ARDS with SIRS was significantly greater than that in SIRS alone. The maximal level in 13 of 18 patients with ALI/ARDS with SIRS was more than 220 ng/ml. The level in all patients with SIRS alone was consistently less than 220 ng/ml over the study period. The serum levels of inflammatory cytokines were elevated in these patients, but no statistical significance was detected among the groups.
Conclusion The critical level of plasma neutrophil elastase is 220 ng/ml, and the SIRS patients with more than 220 ng/ml neutrophil elastase are highly likely to develop ALI/ARDS.

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Follicular lymphoma of the small intestine remains relatively rare, especially in its early stage. Recently, double-balloon endoscopy has enabled observation of the entire small intestine. We describe a case of follicular lymphoma with multiple lesions in the small intestine detected by double-balloon endoscopy. The patient showed multiple whitish granules in descending portion of the duodenum on screening esophagogastroduodenoscopy, which were subsequently diagnosed as follicular lymphoma by immunohistochemistry. Endoscopic examination of the entire small intestine revealed multiple follicular lymphoma tumors in inferior portion of the duodenum and in the proximal jejunum. Double-balloon endoscopy is useful for evaluating tumor distribution of follicular lymphoma.

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A 65-year-old man with positive anti-hepatitis C antibody and chronic renal failure was diagnosed as having a ruptured hepatocellular carcinoma (HCC) based on computed tomography (CT). The patient underwent transcatheter arterial embolization (TAE) for the HCC. After one more session of TAE, the patient underwent surgery. But HCC seeding peritoneally was pointed out. Vitamin K2 and vitamin E were administered as a conservative treatment. Six months after starting vitamins K2 and E, the primary tumor did not increase in size and intraperitoneal dissemination disappeared on CT with a significant decrease of alpha-fetoprotein. Even though this is only one case, combination therapy of vitamin K2 and E may induce growth suppression of HCC.

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A19-year-old man complaining of severe diarrhea and hematochezia was admitted to our hospital. Endoscopic findings and laboratory data revealed that he had ulcerative colitis (UC). Despite combination therapy with high-dose corticosteroids and intensive granulocytapheresis, his condition did not improve. Therefore, we initiated tacrolimus therapy. Intravenous administration of tacrolimus with a trough level of 10 to 15 ng/ml relieved his abdominal symptoms within 1 week. The patient experienced no UC relapse 1 year after treatment with oral tacrolimus. Tacrolimus is a promising therapy for patients with UC refractory to the combination of high-dose corticosteroids and leukocytapheresis.

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A 52-year-old man who was admitted for cardiogenic shock after acute myocardial infarction developed severe left ventricular dysfunction despite reperfusion therapy with coronary stents. After the 40th hospital day, he started to have cough and pulmonary infiltrates. Antimicrobial therapies and subsequent prednisolone for bronchiolitis obliterans organizing pneumonia were ineffective. Bronchoscopic examination revealed diffuse pulmonary bleeding and exudation of hemosiderin-containing macrophages in bronchial lavage fluid. Pulmonary capillary bleeding has been reported in the terminal stage of patients with mitral stenosis in the pre-cardiac surgery era. This complication reemerges in patients with severe heart failure receiving intensive anti-coagulation therapy after implanting a sirolimus-eluting coronary stent.

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Background Chronic disseminated intravascular coagulation (DIC) is a rare but critical complication of aortic aneurysm, and can represent a difficult long-term management problem. Although surgical correction is the treatment of choice, alternative therapy is required for inoperable patients.
Results We report herein a case of acute exacerbation of chronic DIC with inoperable dissecting aortic aneurysm, which was recurrent and resistant to regular treatment. Intermittent subcutaneous self-injection of heparin calcium 15,000 units per day achieved stabilization of coagulation and fibrinolytic parameters and relief of the bleeding tendency.
Conclusion Subcutaneous heparin injection can be an alternative treatment for long-term management of chronic DIC associated with inoperable aortic dissection, beneficial for providing good symptomatic control on an outpatient basis.

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This study presents the case of rapidly progressing pulmonary aspergillosis in a 47-year-old woman who had healed cavitations of pulmonary tuberculosis in the right upper lobe. She had been treated for pulmonary tuberculosis seven years prior to admission. The initial manifestations of the disease on admission included cough, dyspnea, hemoptysis, pulmonary infiltrate, and renal failure. As anti-myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA) were positive, she was diagnosed with ANCA-associated vasculitis and treated with corticosteroids. This treatment resulted in remission of the vasculitis. However, she developed new pulmonary symptoms and an enlarged cavitary lesion associated with the rapid formation of a fungal, ball-shaped shadow that was serially observed by radiological analysis. Pulmonary resection was finally performed because of acute progressive respiratory failure due to massive recurrent hemoptysis. A subsequent pathological analysis revealed a mass of hyphae with acute-angle branching, features consistent with Aspergillus, within the cavitary lesion, and she was diagnosed with pulmonary aspergillosis. The rapid development of pulmonary aspergillosis associated with the formation of an Aspergillus mycetoma should be attri-buted to the loss of normal immune mechanisms due to immunosuppressive treatment.

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Angioimmunoblastic T-cell lymphoma (AILT) is a rare variant of nodal and aggressive lymphoma. It is sometimes difficult to distinguish AILT from reactive lymphoid hyperplasia from the histopathological aspect. We report a case of AILT which developed with bilateral pleural effusion. The effusion consisted predominately of small lymphoid cells. Analyses of the effusion showed trisomy 3, and rearranged bands of TCR β gene. Flow cytometry showed a very small amount of CD10-positive cells. Although we could not further identify the tumor cells in this case, analysis of pleural effusion cells will increase our understanding of the pathogenesis and the pathophysiology of AILT.

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Neck extensor muscle weakness and the dropped head sign are associated with various neuromuscular disorders. However, these symptoms are comparatively rare in myasthenia gravis (MG). We report a MG case that presented with dropped head sign as the main symptom. A 55-year-old man developed subacute weakness of the neck extensor muscle and presented with dropped head. We established a diagnosis of MG based on the results of an edrophonium test and a voluntary single fiber electromyogram (vSFEMG), and a high serum antiacetylcholine receptor antibody level. This patient was treated with pyridostigmine and his neurological symptoms improved. There are reported cases of dropped head sign as the first symptom of MG, however, in those cases, other muscles showed weakness during the first few months after onset. In the present case, throughout the clinical course no other symptoms outside of dropped head sign were seen.

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Recent reports have discussed the many causes of dropped head syndrome and bent spine syndrome. We described a case of myasthenia gravis with concomitant severe degeneration of spinal muscle, mitochondrial DNA⁴⁹⁷⁷ deletion and sensorineural deafness. These associations were thought to be independent, however this is an important case to consider the etiology of bent spine syndrome.

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We report two patients with spinocerebellar ataxia (SCA) with cranial and spinal motor neuron involvement. They initially presented with cerebellar ataxia, followed by bulbar palsy and limb motor neuron sign. One of the patients had a brother with allied disorder. SCA type 1 (SCA1), SCA3 and SCA6 have been reported to involve the motor neuron system, but they were excluded by DNA analyses in the present two patients. These two patients may form a distinct disease entity among SCAs.

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We report a 46-year-old male patient with late-onset vacuolar myopathy and dilated cardiomyopathy. Acid maltase activity of the muscle was normal, but the biopsied muscle specimen stained for lysosome-associated membrane protein-2 (LAMP-2), which has recently been reported to be deficient in muscles of patients with Danon disease. The clinical features of the patient are distinct from X-linked myopathy with excessive autophagy, infantile autophagic vacuolar myopathy and autophagic vacuolar myopathy with late-onset and multiorgan involvement (Kaneda).

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We report a 41-year-old man with meningoencephalitis associated with herpes simplex virus type 1 (HSV-1). The patient developed fever, headache and dysuria followed by generalized convulsion and neck stiffness, and the CSF showed pleocytosis. The titers of enzyme-linked immunosorbent assay against HSV measured 6 days after onset showed a significant rise; IgG antibody 4.89 (<0.2) and IgM antibody 1.45 (<0.8) in CSF, IgG antibody 46.1 (<2.0) and IgM antibody 1.76 (<0.8) in the serum. The antibody index for IgG was 0.50, and that for IgM was 4.2. CFS neutralization test showed HSV-1 antibody of ×16 and HSV-2 antibody of <×4. MRI showed atypical features: disseminated cortical lesions without massive hemispheric involvement. All of the cortical lesions were small and appeared to be located in the gray matter. The patient recovered with acyclovir. This report demonstrates that disseminated encephalitis can be a feature of acute HSV-1 infection.

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A 10-year-old girl was noted to have microscopic hematuria and proteinuria in 1986. As her urinary abnormalities were persistent, she underwent a renal biopsy on 4 occasions until 2003. Although the appearances of the renal biopsies were strongly suspicious of systemic lupus erythematosus, she never exhibited specific autoantibodies or distinctive symptoms. She received corticosteroid therapy and the urinary findings responded. The 4th component of complement remained low during the period of the observation. Both genotyping and allotyping analysis revealed complete C4B deficiency. Some case reports have mentioned renal disease associated with C4B deficiency and we consider the nephropathy in this case to be related to the C4B deficiency.

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We report three cases of multicentric Castleman's disease (MCD) successfully treated with anti-interleukin-6 receptor antibody (tocilizumab). Tocilizumab was administered intravenously at a dose of 8 mg/kg every 2 weeks. In each case, tocilizumab alleviated symptoms, including generalized fatigue, pyrexia, and alleviated biochemical abnormalities, including anemia, hypoalbuminemia, hypergammaglobulinemia, and increased C-reactive protein (CRP). Side effects included hypercholesterolemia, acute pyelonephritis, mild inflammation of the parotid glands, and upper respiratory system inflammation. Other severe side effects were not observed. These results indicate that tocilizumab is effective for the treatment of MCD. This is the first report on tocilizumab efficacy for Castleman's disease after approval for use for Castleman's disease.

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A 35-year-old man developed invasive pulmonary aspergillosis (IPA) with severe neutropenia after umbilical cord stem cell transplantation for chronic myelogeneous leukemia. Filamentous fungus isolated from his sputum was identified as Aspergillus terreus. Despite systemic amphotericin B (AMPH) administration, IPA progressed. However, intravenous administration of micafungin (MCFG) and oral itraconazole improved clinical data and symptoms, although he later died of massive hemoptysis. Examination of the in vitro susceptibility of this A. terreus isolate to MCFG revealed a good minimum inhibitory concentration and good time-kill assay results compared to AMPH. Thus, MCFG might be useful for IPA caused by A. terreus.

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A 39 year-old male was admitted to our hospital because of relapsing episodes of pneumonia. His chest roentgenogram showed a consolidated shadow and cavity formation in the left lower lobe. During a left lower lobectomy an enteric cyst in the posterior mediastinum involving lung was found. This cyst in the lung contained normal gastric parietal cells and pancreatic tissue, and was surrounded by adenocarcinoma characteristic of gastric cancer. This is a rare case in which an adenocarcinoma arise from an enteric cyst in the mediastinum.

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A 78-year-old woman was treated with 40 mg of prednisolone for microscopic polyangitis, and favorable effects were observed. However, her blood pressure increased and she developed severe thrombocytopenia. Thrombotic microangiopathy (TMA) due to malignant hypertension was suspected and she was treated with an angiotensin-converting enzyme inhibitor; her platelet count then rose. She showed a close temporal relationship between initiation of corticosteroid therapy and the onset of TMA. Corticosteroid therapy should be used with caution in patients with underlying vascular endothelial damage.

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