Objective The efficacy of lamivudine for fulminant hepatitis B has been reported in Europe and West Asia. However, in these reports, the main infection genotype is D. Furthermore, if lamivudine improves survival, prognostic factors for fulminant hepatitis B may differ from those reported previously. The aim of this study was to clarify the prognostic factors and the efficacy of lamivudine for fulminant hepatitis B in Japan, where the main infection genotype is B. Methods This study was a retrospective cohort study. We selected 37 consecutive patients with fulminant hepatitis due to acute hepatitis B virus infection. As 4 of them had received liver transplantation, the data of 33 patients with a median age of 45 (range, 20-74) years were analyzed. Results Lamivudine was administered to 10 patients. There were no differences in clinical features at the time of the diagnosis of fulminant hepatitis B between patients treated with and without lamivudine. Survival rates of patients treated with and without lamivudine were 70% and 26%, respectively. Age (≥45 years), systemic inflammatory response syndrome, and non-administration of lamivudine were associated with fatal outcomes. The survival rates of patients treated with and without lamivudine, who were in a state of systemic inflammatory response syndrome, were 50% and 9%, and in patients aged ≥45 years, 50% and 8%, respectively. Conclusion This study suggests the efficacy of lamivudine for fulminant hepatitis B in the area where the main infection genotype is B. We consider that lamivudine is worth administering to patients with fulminant hepatitis B.
Objective The aim of this study was to determine the suitable treatment period in patients who achieve virological response during combination therapy of peginterferon and ribavirin for chronic hepatitis C virus infection. Methods Inclusion criteria were HCV-genotype 1b, serum HCV RNA level of ≥100 KIU/ml before treatment, and negativity of serum HCV RNA during treatment. The 366 patients were enrolled in this retrospective cohort study. Patients were classified into four groups according to difference of response: rapid-virological response (RVR) at week 4 after the initiation of treatment (n=37), early-virological response (EVR) at week 5-12 (n=161), late-virological response (LVR) at week 13-24 (n=131), and superlate-virological response (SLVR) at week 25-48 (n=37). A non-relapse in patients with undetectable HCV RNA during therapy was defined as clearance of HCV RNA 6 month after the cessation of therapy. Results Of the 366 patients, 241 had non-relapse and the non-relapse rate in each group was 89% (33/37) in RVR, 79% (127/161) in EVR, 54% (71/131) in LVR, and 27% (10/37) in SLVR. In RVR, 26 of 27 patients with continuance of negative HCV RNA of ≥30 weeks during treatment had non-relapse. In EVR, patients with period of negative HCV RNA of ≥40 weeks had non-relapse rate of 90% (71/79). In LVR and SLVR, all nine patients with continuance of negative HCV RNA of ≥60 weeks had non-relapse. Conclusion A suitable treatment period of combination therapy for chronic hepatitis C should be determined based on the time of attainment of negative HCV RNA.
Objective Whether to treat subclinical hypothyroidism (SH) remains controversial. Serum chitotriosidase activity, a marker of activated macrophages, predicts new cardiovascular events. Chitotriosidase activity (ChT) is a new cardiovascular risk marker and is independent of C-reactive protein. The purpose of this study was to determine ChT levels in SH and to examine the effect of levothyroxine replacement on ChT. Subjects and Methods A cohort of 60 patients with subclinical hypothyroidism and 62 healthy controls were enrolled in this study. Serum total and LDL cholesterol, total homocysteine (t-Hyc), highly sensitive C-reactive protein (hsCRP) levels and serum ChT in patients with subclinical hypothyroidism at baseline and after achieving euthyroid state by levothyroxine were assessed. Results Pretreatment levels of TSH (10.06±5.09 vs. 2.08±0.95 mIU/L, p<0.05), and free T4 (0.94±0.21 vs. 1.35±0.26 ng/dl, p<0.05) were significantly higher than controls while total cholesterol, LDL cholesterol, t-Hyc, ChT and hsCRP levels were not different. ChT levels significantly increased after replacement therapy (137.2±14.18 vs. 156.88±13.10 nmol/mL/h, p<0.05). T-Hyc and hsCRP levels were not significantly different after treatment with levothyroxine therapy even in this subgroup of patients. None of the other biochemical risk factors improved after euthyroidism in patients with SH with average dose of 85±30 μg/day when compared to pretreatment levels. Conclusion We conclude that clinical management of subclinical hypothyroidism does not decrease the serum hsCRP or t-Hyc levels but does increase the serum ChT levels. The clinical significance of this increament should be studied in further studies.
Objective Reduced glomerular filtration rate (GFR) is a risk factor of cardiovascular diseases. Accurate assessment of GFR together with early and appropriate treatment of chronic kidney disease (CKD) is important. Although the Japanese Society of Nephrology has recently announced two equations (equation 0.741 and equation 194) to estimate GFR for Japanese, the clinically significant estimated GFR (eGFR) in Japanese has not been identified. We examined the clinical significance of eGFR with regard hyperkalemia. Methods A total of 9,196 patients who were examined and treated at the Toranomon Hospital between January and October 2005 were studied. Patients with a serum potassium level of 5 mEq/L or above or who were taking potassium adsorbent were classified as hyperkalemic. The effect of eGFR on the incidence of hyperkalemia was examined. The factors causing elevated serum potassium were analyzed after excluding the patients on potassium absorbent. Results Multivariate analysis identified reduced eGFR, diabetes, male gender, aging, and use of renin-angiotensin system inhibitors as the factors associated with an elevated serum potassium level. In an eGFR-stratified analysis, each subgroup with eGFR below 50 mL/min/1.73 m2when equation 0.741 was used, and eGFR below 60 mL/min/1.73 m2 when equation 194 was used had a significantly higher incidence of hyperkalemia compared with almost all of the subgroups with higher eGFR. Conclusion From the viewpoint of the increase in incidence of hyperkalemia, using an eGFR below 50 mL/min/1.73 m2 as the cutoff has clinical significance when equation 0.741 is used and a cutoff at 60 mL/min/1.73 m2 is appropriate when equation 194 is used.
Background Many women's health centers (WHC) in Japan use female obstetrician-gynecologists, not trained in primary care medicine, as providers. It is not known whether the clinical needs of patients at WHC are met by these providers. Objective To identify the clinical needs of patients attending a WHC in Japan by examining their presenting problems and diagnoses. Methods We performed a case-series study of 53 patients at a WHC in a public medical center in Chiba Prefecture, Japan. Charts were reviewed for the presenting problems and diagnoses. Results The most common presenting complaints were related to the female genital system or the breast (42%) and psychological problems (13%). At discharge, the most common diagnoses were psychological (42%). The next most common diagnoses were related to the female genital system or the breast (36%). The remainder (22%) were related to a variety of organ systems. Conclusion Patients at the WHC presented with not only gynecological but also general medical and psychological problems and had discharge diagnoses involving a variety of organ systems. Physicians at WHCs should be trained in primary care medicine to meet the clinical needs of patients.
Objectives To identify patient reports about their difficulties with medical jargon, to classify the most problematic types, and to examine the socio-demographic factors associated with them. Methods A cross-sectional nationwide survey (October 6 and November 4, 2004) was conducted. Out of 4,500 Japanese people (aged 15 years and older) who had seen physicians, 3,090 agreed to participate (response rate: 69%). Participants were asked the following: "Do you find physicians that use medical jargon difficult to understand?" and "What type of words did your physician use that required further explanation or clarification?" Results Of 3,090 respondents, 1,117 participants (36.1%; 95% confidence interval, 34.5-37.8%) reported difficulties understanding medical jargon. Those between the ages of 30 and 49 years, self-employed workers, homemakers, and unemployed individuals experienced the most difficulties. Difficult jargon included: 1) technical Japanese words, such as Kakutan Saibo-shin (sputum cytology) (57% of participants); 2) English medical terminology, such as clinical path (57%); and 3) English medical abbreviations, such as EBM (47%). Conclusions In addition to avoiding technical words when communicating with their patients, Japanese physicians should consider the unique medical situation in which foreign terminology and abbreviations are used in Japan. Translation of foreign terminology into Japanese can be helpful for patients. Physicians should take the initiative to educate patients and familiarize them with foreign terminology and abbreviations.
An 18-year-old healthy woman was admitted to our department for further evaluation of a pancreatic mass (45 mm in diameter) by transabdominal ultrasound at a general health check. Solid-pseudopapillary tumor (SPT) was suspected from the findings of diagnostic images. Therefore, surgery was recommended. The patient and her family, however, refused surgery. Ultrasound-guided transcutaneous biopsy revealed proliferation of tumor cells with small nuclei showing a pseudopapillary arrangement. PAS positive granules and alpha-1-antitrypsin positive cells were proven, which led to the diagnosis of SPT. As the grade of atypism of the tumor cells was low, the patient underwent follow-up examination once a year at our outpatient department thereafter. The tumor gradually decreased its maximum diameter in 10 years from 45 mm to 15 mm. Thus far, there have been very few reports on the natural course of SPT, and this is the first report describing marked spontaneous shrinkage of a tumor in a long follow-up period.
Most cases of cytomegalovirus (CMV) colitis that develop in patients with inflammatory bowel disease (IBD) are caused by a reactivation of a latent virus; acute CMV infections are rare. Treatment with immunosuppressive agents further increases the infection risk. Here, we present a 32-year-old man with acute CMV-mononucleosis and colitis, superimposed on corticosteroid-naïve ulcerative colitis (UC). The diagnosis was confirmed by a viral-like prodrome, positive CMV antigenemia (C7-HRP), a positive CMV IgM titer, the presence of atypical lymphocytes, mild transaminase elevation, and immunohistological detection of CMV positive cells in his colonic mucosa. Gancyclovir was intravenously administered, and all symptoms were improved.
We report a case of obvious pseudoaldosteronism which occurred after the additional administration of cilostazol against arteriosclerosis obliterans (ASO) for bilateral legs in a 65 year-old man patient who had safely received glycyrrhizin for the previous ten years. Serum potassium level of the patient had been kept above 4 mEq/L until initiating cilostazol in November, 2006, then gradually decreased to 2.5 mEq/L for the following seven months. Both plasma renin activity and aldosterone were suppressed under co-administration of the angiotensin converting enzyme inhibitor, imidapril and the angiotensin II receptor blocker, olmesartan, both of which had been prescribed for longer than a year. Urinary potassium excretion was accelerated even in the critical level of hypokalemia. Because other drugs and supplements had not been changed at least for a year, pseudoaldosteronism caused by the combination of glycyrrhizin and another triggering factor, possibly cilostazol was highly suspected. By discontinuation of glycyrrhizin, potassium supplement, and the additional administration of the aldosterone blocker, spironolactone, the serum potassium level returned to the normal level two weeks later, even though cilostazol had been continued to avoid progression in his ASO. This is the first report of a case exhibiting pseudoaldosteronism induced by the interaction of glycyrrhizin with cilostazol, not by glycyrrhizin alone.
The advent of highly active anti-retroviral therapy (HAART) has reduced both the morbidity and incidence of acquired immunodeficiency syndrome (AIDS)-related central nervous system (CNS) diseases. However, some patients seem to suffer paradoxical clinical deterioration after starting HAART, known as immune reconstitution inflammatory syndrome (IRIS). We report a rare case of probable Mycobacterium avium complex (MAC) infection of the brain in a patient with AIDS who had been treated effectively for probable pulmonary and cerebral MAC infection, with both lesions recurring after significant decreases in plasma human immunodeficiency virus type-1 viral load following initiation of HAART. This case appears to represent the first precise clinicopathological description of severe ventriculo-encephalitis in CNS MAC-related IRIS.
A 56-year-old man with anti-acetylcholine receptor antibody-mediated myasthenia gravis had bilateral facial muscular atrophy and had noticed blepharoptosis 15 years earlier. From 45 to 51 years of age, 5-10 mg prednisolone and 180 mg pyridostigmine daily relieved his symptoms. Subsequently, these treatments no longer improved the facial weakness, though blepharoptosis was absent. At 56 years of age, the edrophonium test and repetitive supramaximal stimulation testing of the orbicularis oris were negative. Frontalis muscle needle electromyography showed low amplitude polyphasic units and an incomplete interference pattern. Facial muscle atrophy, caused by disuse atrophy from neuromuscular junction depletion, contributed to this patient's facial weakness.
A 5-year-old Japanese boy passed tapeworm strobila while he was living in Switzerland. During a short visit to Japan, he was successfully treated with a single dose of praziquantel. DNA sequences of ITS1, cox1 and nd3 genes from the tapeworm were compatible with those of Diphyllobothrium nihonkaiense rather than Diphyllobothrium latum, which is prevalent in Europe. The patient consumed imported salmon in Switzerland. This case highlights the globalization of D. nihonkaiense, which was once restricted to the Far East, and reflects the worldwide demand for seafood.
Campylobacter coli (C. coli) is a rare pathogen of bacteremia, but in immunocompromised hosts, C. coli occasionally causes bacteremia which can be refractory to antibiotic treatment. We report a case of C. coli bacteremia in a patient with X-linked agammaglobulinemia. Bacteremia relapsed repeatedly in spite of treatment with combined intravenous antibiotics. C. coli was observed in the biopsy specimens from the intestinal mucosa, suggesting intestinal carriage and reservoir of recurring infection. The addition of oral kamamycin with intravenous antibiotics was successful in eradicating C. coli from the blood and intestine.
Congenital bronchobiliary fistula (CBBF) is quite a rare malformation and the diagnosis is usually made within a few hours or years from birth because of lower respiratory diseases beginning from early infancy. Surgical repair is neccessary. Of the 29 cases reported, 4 occurred in adults aged 22-32 years. We detected CBBF incidentally in a 65-year-old woman. During bronchoscopy and thoracic computed tomographic study of the pulmonary nodules, we found an accessory bronchus descending from the carina and composed of a dark green secretion that contained 10% bilirubin. Drip infusion cholangiography revealed air in the left bile duct. Cholescintigraphy showed dilatation of the left bile duct and radiotracer pooling at the top edge of the left hepatic lobe. These findings indicated a narrow fistula between the airway and biliary duct. We attributed the patient's long survival without major complications to the narrowness of the communication. To our best knowledge, this is the fifth and oldest reported adult diagnosed with CBBF.