Objective The aim of this study was to assess the significance of multiple risk factors for early carotid atherosclerosis in the Japanese population.
Methods The relation between traditional vascular risk factors and serum high-sensitivity CRP (hs-CRP) or atherosclerotic lesions in the carotid arteries detected by B-mode ultrasonography was evaluated.
Patients The subjects were 1,880 persons (1,240 men and 640 women, mean age 55+/-10 years old) without ischemic stroke, infection or collagen diseases.
Results In the men, the odds ratio (OR) for atherosclerotic lesion was increased at 1.90 (95% CI: 1.05-3.43, P=0.032) in those with one risk factor, 2.42 (1.36-4.32, P=0.002) in those with two, and 2.95 (1.69-5.16, P<0.001) in those with three or more. In the women, the OR was similarly increased 1.93 (95% CI: 1.04-3.56, P=0.035) for one risk factor, 2.31 (1.23-4.33, P=0.009) for two, and 3.52 (1.80-6.87, P<0.001) for three or more. The mean hs-CRP concentration increased significantly with the increasing number of risk factors (men and women, P<0.001) and with the degree of carotid arterial stenosis (men, P=0.011; women, P=0.008).
Conclusion Multiple risk factors are more predictive than a single risk factor for early carotid atherosclerosis in the Japanese population.

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Objective Alpha2-Heremans Schmid glycoprotein/Fetuin-A (AHSG) is a circulating negative acute-phase protein, which inhibits bimineralization. It is often considered as a potential mediator between chronic inflammation and cardiovascular diseases. The metabolism of AHSG in patients with rheumatoid arthritis (RA) is unknown.
Methods Serum AHSG concentrations were measured in 102 patients with RA using a newly developed indirect enzyme-linked immunosorbent assay (ELISA).
Results The serum AHSG levels in the RA patients were significantly lower than that in healthy volunteers (249.8 ± 84.1 vs 425.0 ± 93.0 μg/ml, P<0.0001). Serum C-reactive protein concentration and erythrocyte sedimentation rate were inversely correlated, while albumin, hemoglobin and total cholesterol were positively correlated with AHSG. Current serum AHSG levels did not affect the presence of aortic calcification, whereas cumulative glucocorticoid dosage was significantly related to aortic calcification (P=0.005).
Conclusion Serum AHSG levels were significantly decreased in patients with RA. The levels reflected inflammatory and malnutritional conditions. Its role in the development of cardiovascular diseases or inflammatory bone resorption remain uncertain in RA patients.

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We report a case of 65-year-old man with alcoholic cirrhosis and diabetes mellitus, in whom a cervical mycotic aneurysm suddenly developed after sepsis with methicillin-resistant staphylococcus aureus. Severe infection associated with alcoholic cirrhosis may cause a typical mycotic aneurysm.

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A 59-year-old Japanese woman was diagnosed in 1998 with systemic sclerosis (SSc). The patient presented with a one-month history of postprandial vomiting prior to hospitalization. The patient underwent esophago-gastroduodenoscopy which revealed a diaphragm-like stricture in the second part of the duodenum in January 2004. Unexpectedly, the patient had not used NSAIDs for any long period of time. Retrospective endoscopic findings from 2000 showed the presence of duodenal circular erosions at the same site. This is the first report of a patient diagnosed with SSc who also presented with endoscopic evidence of a stricture of the duodenum, unrelated to NSAIDs.

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Colorectal polypoid lesions are classified as either neoplastic or non-neoplastic, and the differentiation between the two lesions is important for clinical practice, however, this is not easy in some rare cases. Cases of colonic prolapsing mucosal polyps are rare (1-3). They are often, but not always, associated with diverticular disease and present with abdominal pain, obstructive symptoms or bleeding. On colonoscopic examination, the lesions are characterized by multiple polyps or elevated patches with smooth and bright red colored surface. The histological features include: glandular crypt abnormalities, fibromuscular obliteration of the lamina propria, and thickened and splayed muscularis mucosa. We report herein a case of sigmoid colonic prolapsing mucosal polyps presenting with acute lower abdominal cramping pain and colonic obstruction who was diagnosed based on colonoscopy and endosonography findings and treated with conservative management.

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AL amyloidosis is a disease in which immunoglobulin L chain is deposited in multiple organs, and the prognosis of cardiac amyloidosis is extremely poor. Although several treatments based on that for multiple myeloma, have been performed, there is no clear evidence that cardiac function is improved. We report a case of AL cardiac amyloidosis with moderate cardiac dysfunction for which we performed autologous peripheral blood stem cell transplantation (auto-PBSCT) in combination with high-dose melphalan therapy. This treatment resulted in significant improvement in cardiac function and good prognosis for about 3.5 years after the diagnosis. Therefore, auto-PBSCT is a possible option as up-front therapy for AL cardiac amyloidosis.

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We report the case of a 38-year-old man with secondary adrenal insufficiency due to pituitary stalk transection that may have been caused by birth injury. He was admitted to our hospital with epigastalgia and severe hyponatremia (120 mEq/L). His past history showed fetal distress due to an abnormal delivery, and he received growth hormone replacement therapy for growth hormone-deficient short stature. Magnetic resonance imaging of the brain revealed an atrophic anterior lobe, a pseudo-posterior lobe of the pituitary gland, and a transection of the pituitary stalk. Endocrinological examination revealed secondary adrenal insufficiency due to a suprapituitary lesion, with concomitant impaired secretion of growth hormone, gonadotropins, and thyroid-stimulating hormone. Hyponatremia was improved immediately after administration of hydrocortisone. This is a case of adult development of pituitary stalk transection syndrome, involving the sequential impairment of the secretion of several pituitary hormones, and finally presenting severe hyponatremia caused by secondary adrenal insufficiency.

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¹²³I-Metaiodobenzylguanidine (¹²³I-MIBG)-accumulation in angiomyolipoma (AML) is demonstrated. A 24-year-old Japanese woman presented with tumors in the right retroperitoneal space. The tumors, which accumulated ¹²³I-MIBG, had been thought to be adrenal pheochromocytoma before surgery. They were removed, and were found to be AML. ¹²³I-MIBG was accumulated in AML. ¹²³I-MIBG-accumulation in AML led to a false-positive diagnosis of adrenal pheochromocytoma. Cathecholamine levels had been normal. No chromograffin cells were found in the histological examination of the tumors. MIBG accumulation does not necessarily indicate the presence of pheochromocytoma.

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Cholangiocarcinoma is a predominantly fatal cancer, which can be difficult to treat. We report a 73-year-old man who developed cholangiocarcinoma with cholangiohepatitis and diabetes. Administration of pioglitazone, peroxisome proliferator-activated receptor γ (PPARγ). agonist, improved not only diabetic control, but also the tumor-induced cholangiohepatitis, and improved the patient's quality of life. Although he finally died of obstructive jaundice, thiazolidinedione should be considered for treatment of tumor-induced hepatitis in the presence of diabetes, unless severe side effects occur.

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Diffuse hepatic calcification is a rare condition. Previous reports have described patients with end-stage renal disease who developed diffuse hepatic calcification after ischemic hepatitis caused by shock. We herein present a similar case. A 41-year-old man on chronic hemodialysis developed ischemic hepatitis due to shock induced by ventricular tachycardia, followed by progressive hepatic failure. Necropsy of the liver revealed diffuse hepatocellular calcification. Given the similarity by which our case and previously reported cases developed this rare condition, we postulate that chronic renal failure is involved in the pathogenesis of diffuse hepatic calcification.

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A 70-year old man was admitted to our hospital because of nonproductive cough, fever and increasing dyspnea associated with alveolar opacities on chest roentgenogram, which later migrated to previously unaffected areas. The diagnosis of Chlamydial pneumonitis was made on serological grounds. Organizing pneumonia was documented by transbronchial lung biopsies and the subsequent course was satisfactory under minocycline therapy. Chlamydial infection should be considered in the differential diagnosis of migratory pulmonary infiltrates.

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A 64-year-old woman with rheumatoid arthritis and treated with bucillamine presented with a productive cough. No obvious infiltration was detected in chest radiography, but CT revealed patchy ground glass opacities in bilateral lung fields. Her serum KL-6 level was elevated and transbronchial lung biopsy showed interstitial pneumonia. Drug lymphocyte stimulation test (DLST) for bucillamine was negative for blood lymphocytes, but positive for bronchoalveolar lavage (BAL) lymphocytes. The pneumonitis improved after the cessation of bucillamine. We therefore made a diagnosis of bucillamine-induced interstitial pneumonia. DLST with BAL lymphocytes is thus suggested to be useful for such diagnoses.

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A case of esophageal cancer who suffered from tracheal stenosis at the tracheostomy after stent implantation is presented. The patient received a covered metallic tracheal stent to seal the esophago-respiratory fistulation. After six months, the tracheal retainer for his tracheostomy was difficult to insert into his trachea due to the growth of the cancer. Argon plasma coagulation (APC) has been successfully employed in the dilatation of tracheal stenosis at the tracheostomy. We herein describe the use of APC as an effective treatment for further palliative therapy of tracheal dilatation in order to treat tracheal stenosis by esophageal cancer after stent implantation.

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We describe a 64-year-old man with locally advanced lung adenocarcinoma who had meningeal relapse soon after the completion of intensive chemo-radiotherapy. Diagnosis of the malignant meningitis was established by cytological examination of the cerebrospinal fluid, which showed malignant cells consistent with adenocarcinoma from the primary site. Although very rare, it is possible that successful chemo-radiotherapy for locally advanced lung cancer could not prevent malignant meningitis as observed in our patient. Physicians should consider performance of brain MRI or contrast CT of the brain and a lumbar puncture to exclude the diagnosis of malignant meningitis, an uncommon but devastating complication of malignancy.

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Behçet's disease is a chronic, relapsing, inflammatory disease of unknown origin. The association of myelodysplastic syndrome and Behçet's disease is rare, and recent reports have indicated that immunosuppressive agents alone are not sufficient to control Behçet's disease associated with MDS and many patients die of infection or hemorrhage. We report a case of MDS with intestinal Behçet's disease. We performed cord blood transplantation with a myeloablative regimen as the primary treatment. The patient achieved complete remission for both diseases, which continued for more than 16 months. Our experience suggests that CBT may provide a potent therapeutic option for the treatment of MDS-related Behçet's disease.

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Langerhans cell tumors are neoplastic proliferation of Langerhans cells and are classified into Langerhans cell histiocytosis (LCH) and Langerhans cell sarcoma (LCS). We report a case of LCH in an 89-year-old-woman with left axillary lymphadenopathy. A histologic examination demonstrated a proliferation of histiocytoid cells which were positive for CD1a, S-100 protein, and Lagerin (CD207). Initial diagnosis was LCS based on morphologic features, high MIB-1 index, and multi-system involvement detected by FDG-PET. However, the disease disappeared spontaneously without specific treatment in six months. The disease was considered to be spontaneously regressed LCH with multi-system involvement rather than LCS.

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