Objective The aim of this study is to identify risk factors for asymptomatic cerebral infarction (ACI) in the general Japanese population.
Materials and Methods A total of 634 subjects (272 men aged 55.4±8.8 years and 362 women aged 55.2±8.5 years) who visited the Health Management Center at Aoyama Hospital (Tokyo, Japan) from January 2004 through January 2005 for an annual brain dry dock examination were analyzed. We evaluated 21 risk factors for ACI by multivariate logistic regression analysis.
Results Abnormal or potentially abnormal conditions were detected in 258 subjects (40.7% of all subjects who had an annual check-up program for brain disease). The most frequent abnormal finding was ACI, which was observed in 208 subjects. The significant risk factors for ACI, as determined by multivariate logistic analysis, were age (P <0.01), hypertension (P <0.01), and hypertensive vascular changes in the fundus (P <0.05).
Conclusion The hypertensive vascular abnormalities in the fundus might be a risk factor for ACI independent of age and hypertension.

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Background Although restenosis after successful coronary stenting is associated with changes in adhesion molecules and chemokines, it is unclear whether the differential effects of these molecules between a bare metal stent (BMS) and sirolimus-eluting stent (SES) may help to prevent coronary restenosis. The aim of this clinical study was to compare the expression levels of those molecules after elective placement of either a BMS or SES.
Methods and Results The subjects included 32 consecutive patients with stable angina who had undergone successful coronary stenting and who randomly received either a BMS (n=16) or SES (n=16). Quantitative angiographic analysis 6 months after stenting showed that the minimal lumen diameter was significantly greater in the SES as compared to the BMS group, while the percent diameter stenosis and in-stent lumen loss were significantly lower. Plasma monocyte chemotactic protein-1 (MCP-1) increased significantly after 14 days and 6 months and monocyte CCR2 expression increased 24 hr and 48 hr after stenting in the BMS but not the SES group. Changes in plasma MCP-1 (ΔMCP-1) within 6 months after stenting correlated significantly with in-stent lumen loss. The ΔMCP-1 (between 6 months and baseline) was significantly related only to the lumen loss (r=0.443, p=0.023), which suggests that the reduction of MCP-1 is the best contributor to decreased lumen loss.
Conclusions These data suggest that reduction in MCP-1 production by SES may be one mechanism to prevent restenosis after coronary stenting.

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Background Pneumocystis jiroveci pneumonia (PCP) is a potentially fatal complication in interstitial pneumonia patients receiving glucocorticoid therapy. Prophylaxis of PCP during glucocorticoid therapy is an important issue in the treatment of interstitial pneumonia.
Objective We evaluated the prophylactic effect of sulfamethoxasole-trimethoprim (TMP-SMX) in interstitial pneumonia patients receiving glucocorticoids.
Methods We retrospectively analyzed 74 interstitial pneumonia patients who received glucocorticoid therapy.
Results Seven of the 74 patients developed PCP. At the time of diagnosis of PCP, the mean duration of glucocorticoid therapy was 71 days and the mean daily dose of prednisolone was 37 mg. Among the 7 patients, the circulating CD4+ lymphocyte count was 370 /μl on average and it was over 200 /μl in 3 cases. The PCP patients showed a significant reduction of the lymphocyte count at 4 weeks after initiation of steroid therapy. None of the patients who received prophylactic TMP-SMX therapy developed PCP even if the CD4+ lymphocyte count was less than 200 /μl.
Conclusion Interstitial pneumonia patients receiving glucocorticoid therapy can benefit from TMP-SMX prophylaxis against PCP. Development of PCP cannot be ruled out in patients with a CD4+ lymphocyte count of greater than 200 /μl.

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Purpose The possibility that hyperammonemia may be associated with generalized convulsion (GC) was retrospectively investigated.
Methods Subjects comprised 17 patients with GC who were transported to our department and underwent analysis of serum biochemistry, including ammonia, since October 2004.
Results Causes of convulsion included intracranial lesions (n=8), endocrine diseases (n=2), epilepsy (n=2) and others (n=5). Ammonia levels in all cases exceeded the upper limit of normal range. Ammonia levels in 8 subjects were re-checked on hospital day 2, and all were lower than levels on hospital day 1 without any treatment for hyperammonemia.
Conclusion GC itself appears to be associated with hyperammonemia. Although hyperammonemia is also known to induce convulsion, biochemical analysis immediately after GC is not useful for diagnosing hyperammonemia-induced convulsion.

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Objectives Our aim was to analyze the incidence of new onset chest symptoms for the period of a month and to evaluate the possible association of these chest symptoms with demographic, socioeconomic or clinical characteristics.
Design Prospective observational cohort study using a self-reported health diary among subjects without baseline chest diseases.
Setting A nationally representative sample of households in Japan.
Participants Of a total 3,568 subjects from the study recruitment sample, 3,477 participants completed the diary; of these, 127 participants with active chest diseases at baseline were excluded and the remaining 3,350 participants were analyzed.
Measurements and Results The mean number of episodes of chest symptoms was 1.19 with 95% confidence interval (CI) of 1.0-2.0 and the incidence was 21% (95% CI, 10-30%). Cough was the most frequent chest symptom with the mean number of episodes of 1.14 and the prevalence of 20%. Chest pain, dyspnea, palpitation, and wheezing were identified in less than 1%. Associated factors for cough were younger age, unemployment, and poor physical quality of life. Associated factors for chest pain included older age, living in smaller cities, unemployment, higher educational attainment, and poor physical and mental quality of life.
Conclusions Chest symptoms are common in the Japanese general population. Cough is the most frequent symptom, followed by chest pain. Younger age, unemployment, and poor physical quality of life are significantly associated with cough.

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A santorinicele is defined as a focal cystic dilatation of the terminal portion of the dorsal pancreatic duct at the minor papilla; most cases have been reported in patients with pancreas divisum. It has been suggested that a santorinicele results from a combination of a minor papilla obstruction which prevents the flow of pancreatic juice and a weakness of the duodenal wall where the dorsal pancreatic duct terminates. However, these conditions can occur in patients with invasive ductal cancer in the pancreatic head. We encountered a rare case of a santorinicele with unresectable adenocarcinoma of the pancreatic head in an 81-year-old woman.

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We encountered a case of drug-resistant hypertension and hypokalemia. Laboratory data suggested primary aldosteronism (PA). Computed tomography imaging appeared normal for a long duration with a left-sided nodule appearing far later; adrenal scintigraphy was first normal, and the second test showed right-sided uptake. However, a repeat selective adrenal venous sampling (SAVS) indicated a left-sided lateralization of the hypersecretion of aldosterone. Left adrenectomy was performed, and his clinical symptoms improved. The histopathological findings demonstrated the aldosterone-producing microadenoma with secondary micronodules. In conclusion, SAVS should be performed to determine the laterality of PA with obscure CT imaging.

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We report an adult end-stage renal disease patient with only cerebellum involvement of reversible posterior leukoencephalopathy syndrome (RPLS). A 37-year-old woman, diagnosed as chronic glomerulonephritis, was admitted to our hospital with progressive visual disturbance and severe headache. MRI revealed hyperintense signal intensity changes restricted in the cortex and subcortical white matter of the cerebellum. With appropriate control of blood pressure and intracranial pressure, her symptoms were improved and complete resolution of previous hyperinternse lesion was shown on MRI after the 19th day of admission. This is first case of isolated cerebellar involvement of RPLS without other cerebral involvement in an adult.

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We report a patient with pneumoperitoneum that recurred concomitantly with asthmatic exacerbation. The patient was a 71-year-old man with a medical history of bronchial asthma. Chest X-rays obtained during asthmatic exacerbation showed intra-abdominal air beneath his diaphragm. Subsequently, a computed tomography scan of his chest confirmed mediastinal emphysema and intra-abdominal air beneath his diaphragm. The intra-abdominal air disappeared after his asthmatic exacerbation was relieved by treatment. The patient showed recurrent pneumoperitoneum concomitant with asthmatic exacerbation. The cause of his pneumoperitoneum was conjectured to be the movement of air from the mediastinum to the peritoneal cavity through the sternocostal triangle.

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We report a case of leukemoid reaction (LR) complicating renal abscess caused by Morganella morganii infection in an 80-year-old man. On administration, laboratory tests revealed white blood cell count of 76160 /μL and C reactive protein 3.09 mg/dL. Although chronic myeloid leukemia was suspected, bcr/abl fusion transcript was not observed. Contrast enhanced computer tomography imaging of the abdomen showed abscess in the right kidney. M. morganii was detected repeatedly in material of liquid from the abscess and arterial blood culture. To our knowledge, this is the first case of M. morganii infection complicating LR.

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Malignant pleural mesothelioma and peripheral adenocarcinoma, of the lung, also known as pseudomesotheliomatous adenocarcinoma, have similar clinical and radiological characteristics and even similar microscopic findings, and this makes it difficult to differentiate them. Malignant pleural mesothelioma rarely invades the bronchial lamina or bronchioloalveolar spaces, and tumor cells are not usually found in the sputum. Therefore, the appearance of tumor cells in sputum more likely supports the diagnosis of peripheral lung cancer. We report a rare case in which malignant pleural mesothelioma cells were found in the sputum. For the differential diagnosis of a mass involving both the pleura and lung, physicians should consider that malignant mesothelial cells can be found in the sputum, although this is very rare.

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Pulmonary complications occur in up to 60% of patients after hematopoietic stem cell transplantation (HSCT), causing significant morbidity and mortality. Among them, non-infectious bronchiolitis is considered a late complication in the form of bronchiolitis obliterans. We report a patient who developed non-infectious bronchiolitis within four weeks after undergoing HSCT for biphenotypic leukemia. Chest CT revealed centrilobular nodules that were reminiscent of diffuse panbronchiolitis, and lymphocytic bronchiolitis was confirmed by biopsy. Infection and bronchiolitis obliterans were ruled out, and the bronchiolitis resolved when leukemia relapsed. This case suggests that bronchiolitis may be another early, non-infectious pulmonary complication of HSCT.

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The clinical features of familial Creutzfeldt-Jakob disease with a codon 200 point mutation [fCJD (E200K)] are similar to those of sporadic CJD (sCJD). MRI diffusion-weighted imaging (MRI-DWI) has been reported to be useful for the early diagnosis of CJD. We describe a Japanese fCJD (E200K) case in which thalamic symptoms were the initial manifestations. On admission, electroencephalography (ECG) showed no periodic synchronous discharge (PSD), and MRI showed no abnormalities. However, single photon emission computed tomography (SPECT) using ^99mTc-ethyl cysteinate dimer (^99mTc-ECD) revealed hypoperfusion in the right thalamus. We conclude that the thalamic form of CJD tends to show no high-intensity area (HIA) by MRI-DWI, and that SPECT may be more useful for visualizing the affected area responsible for the thalamic symptoms at an early stage.

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Splenic abscess is not an uncommon complication of patients with sickle-cell disease. Here we describe an 18 year-old boy with sickle cell disease and left upper quadrant abdominal pain. Computerized axial tomography revealed left sided free flowing pleural effusion and splenomegaly with liquefaction and possible gas formation. The splenic fluid grew an unusual organism known as Bacteroides distasonis. The patient received antimicrobial therapy and underwent a splenectomy with full recovery. The spleen was cystically infarcted and measured 22×16×5 cm. The capsule was thickened and covered by fibrinous exudate. Histopathologic examination of the spleen showed complete necrosis with reparative fibrosis. This case presents an unusual cause of splenic abscess due to Bacteroides distasonis with a subacute to chronic course. The presence of fever and left sided pleuritic chest pain in patients with sickle cell disease should raise the suspicion of splenic abscess.

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