Objective Little attention has been paid to possible cardiovascular involvement in patients with chronic fatigue syndrome (CFS), although many of their symptoms and signs suggest cardiovascular dysfunction. Possible cardiovascular symptoms and cardiac function were investigated in CFS patients.
Methods Cardiovascular symptoms were intensively investigated and cardiac function was evaluated echocardiographically.
Patients Fifty-three patients (23 men and 30 women, mean age: 31±7 years) with CFS under 50 years were studied.
Results Slender build (body mass index <20 kg/m²) was common (47%). Possible cardiovascular symptoms including shortness of breath (32%), dyspnea on effort (28%), rapid heartbeat (38%), chest pain (43%), fainting (43%), orthostatic dizziness (45%) and coldness of feet (42%), were all frequent complaints. Hypotension (28%) was occasionally noted. Electrocardiograms frequently revealed right axis deviation (21%) and severe sinus arrhythmia (34%) suggesting accentuated parasympathetic nervous activity. Small heart shadow (cardiothoracic ratio ≤42%) was noted on the chest roentgenogram in 32 patients (60%). Echocardiographic examination demonstrated low cardiac indexes (<2 L/min/m²) with low stroke volume indexes (<30 mL/m²) due to a small left ventricular chamber in 19 (36%, p<0.05 vs. 8% in 36 controls). None had reduced left ventricular ejection fraction.
Conclusion Cardiovascular symptoms are common in CFS patients. Cardiac dysfunction with low cardiac output due to small left ventricular chamber may contribute to the development of chronic fatigue as a constitutional factor in a considerable number of CFS patients.

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Objective Several studies have reported a significant association of metabolic syndrome with urinary albumin excretion, high-sensitivity C-reactive protein, or chronic kidney disease; however, no study has investigated the association of metabolic syndrome with these 3 factors together in the same individual. Therefore, we conducted the present study to obtain more information on this association.
Methods We enrolled 712 Japanese subjects without diabetes, macroalbuminuria, or medications, who entered our hospitalized health check-up program (180 women and 532 men; mean age, 53.2 years; mean body mass index, 24.1 kg/m²). Metabolic syndrome was diagnosed by 4 major definitions. Low glomerular filtration rate was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m².
Results Both urinary albumin excretion and high-sensitivity C-reactive protein were significantly higher in those with metabolic syndrome than without, and metabolic syndrome was an independent determinant of both. In contrast, estimated glomerular filtration rate and the prevalence of low glomerular filtration rate did not differ significantly between those with and without metabolic syndrome. Among the 5 components of metabolic syndrome and other clinical variables, systolic blood pressure was an independent determinant of urinary albumin excretion; the 5 components and low-density lipoprotein cholesterol were all independent determinants of high-sensitivity C-reactive protein; systolic blood pressure was an independent determinant of low glomerular filtration rate.
Conclusion Metabolic syndrome is associated with vascular dysfunction and low-grade inflammation and the latter association is strong, whereas the association of metabolic syndrome with low glomerular filtration rate may be less apparent among those without diabetes, macroalbuminuria, and medications.

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Objective Obstructive sleep apnea syndrome (OSAS) often accompanies obesity and diabetes mellitus. This study was performed to investigate the prevalence of glucose intolerance and to determine independent predictors for insulin resistance in patients with OSAS.
Methods A cross-sectional study of 679 OSAS patients with an apnea-hypopnea index (AHI)≥5/h and 73 controls subjects (AHI<5/h) was done in a tertiary university-based medical center. They were assessed by nocturnal polysomnography and underwent an oral glucose tolerance test.
Results The prevalence of diabetes mellitus in OSAS patients was higher than that of the control group (25.9% vs. 8.2%, p<0.001) and 424 patients (62.4%) received a new diagnosis of impaired glucose tolerance or diabetes mellitus. The very severe OSAS group (AHI ≥45/h) had significantly higher homeostasis model assessment of insulin resistance (HOMA-IR) and HOMA beta-cell function than the other OSAS groups (AHI<45/h) and the control group. In a logistic regression model adjusting for potential confounders: age, AHI, minimum SpO₂ and body mass index (BMI), only BMI was associated with insulin resistance (HOMA-IR>3) (odds ratio: 1.272, 95% confidence interval 1.206-1.343, p<0.0001).
Conclusion Glucose intolerance was more common in patients with OSAS. Insulin resistance was associated not with AHI but rather with BMI.

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Objective Accumulating evidence suggests that statins might positively affect bone metabolism. In the present study, we compared the effect of rosuvastatin with that of ezetimibe on bone turnover markers in patients with type 2 diabetes mellitus as well as hypercholesterolemia.
Design and Methods A total of 36 Japanese patients were enrolled in this open-label study and randomized to either rosuvastatin (2.5 mg/day) or ezetimibe (10 mg/day) groups at Shimane University Hospital. Bone turnover markers, such as bone-specific alkaline phosphatase, serum osteocalcin, urinary N-terminal telopeptide of type 1 collagen, and urinary deoxypyridinoline, were collected and compared between at baseline and at 3 months of treatment in each group.
Results Background data was not significantly different between the two groups. Total cholesterol and LDL cholesterol levels were significantly decreased at 3 months in both groups. Serum osteocalcin levels in the rosuvastatin group were significantly increased with mean changes of 0.48 (95% confidence interval; 0.05 to 0.91, p=0.03), while no other bone marker in the ezetimibe group was changed. Changes in total cholesterol or LDL cholesterol levels were not significantly correlated with the changes in bone turnover markers.
Conclusion Rosuvastatin may have a beneficial effect on bone metabolism in patients with type 2 diabetes and hypercholesterolemia by stimulating osteoblast function and bone formation, which seems to be independent of its cholesterol-lowering effect.

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Objective Previous studies have documented a high frequency of thrombotic events in lupus nephritis patients with antiphospholipid (aPL) antibodies in the serum, but there is little information on the impact of serum aPL antibodies on the clinical outcome of lupus nephritis. The aims of this study were to evaluate the seroprevalence of aPL antibodies in patients with lupus nephritis and assess their prognostic value in relation to long-term renal outcomes.
Patients and Methods A retrospective analysis was undertaken in 49 patients with lupus nephritis who underwent renal biopsy. The serum aPL antibodies were monitored regularly in the patients who were followed up for a mean of 76.4±47.2 months, and possible factors associated with the long-term renal outcomes in these patients were analyzed.
Results The overall seroprevalence of aPL antibodies was 41%. During the follow-up, 40% of aPL antibody-positive patients experienced thrombotic events. The frequency of class V lupus nephritis was lower in the aPL antibody-positive patients (6 out of the 20 aPL antibody-positive vs. 14 out of the 29 patients aPL antibody-negative patients; p=0.03). A multivariate analysis identified age (p=0.0001), eGFR at presentation (p=0.0015) and presence of hypertension (p=0.0025) as independent risk factors for the development of chronic kidney disease (CKD) with eGFR less than 60 ml/min/1.73 m².
Conclusion Detection of aPL antibodies in the serum of patients with lupus nephritis is useful to identify patients at risk of thrombotic events. Hypertension is associated with the probability of CKD with eGFR less than 60 ml/min/1.73 m².

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Xanthogranulomatous inflammation (XGI) is histopathologically characterized by a marked proliferative fibrosis, parenchymal destruction, and infiltration of foamy histiocytes intermixed with other inflammatory cells. Herein, we report a case of a 73-year-old man without symptoms who was initially diagnosed with a pancreatic cystic tumor but later with XGI in the peripancreatic region. Although XGI has been reported to occur in various organs or tissues, such as the gallbladder, kidney, bone, stomach, colon, appendix, lymph nodes, and soft tissues, XGI involving the pancreas or its surrounding tissues is extremely rare. When a pancreatic cystic lesion does not have typical clinicoradiological features of common pancreatic cystic neoplasms, this pathologic condition should be considered in the differential diagnosis.

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A man with abscess of the round ligament of the liver associated with acute obstructive suppurative cholangitis and portal thrombosis is reported. A 63-year-old man was admitted with epigastralgia and high fever. Blood tests showed elevation of hepato-biliary enzymes and coagulopathy consistent with acute obstructive suppurative cholangitis and disseminated intravascular coagulation. Computed tomography revealed a small abscess of the round ligament of the liver and left portal thrombosis. After endoscopic biliary stenting, antibiotics and thrombolytic therapy, the high fever, disseminated intravascular coagulation and portal thrombosis rapidly improved, and the round ligament abscess was also later resolved.

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We present a 43-year-old Japanese man with major pancreatic duct disruption caused by blunt pancreatic head damage. Computed tomography (CT) revealed pancreatic head injury, and endoscopic retrograde pancreatography showed pancreatic duct disruption at the injury site along with contrast media leakage. We placed a pancreatic stent for 3 months, after which closure of the pancreatic duct fistula was confirmed. CT on the 9th hospital day showed acute pancreatic fluid collections, but these had disappeared at the 3 month follow-up CT. The patient has remained asymptomatic at follow-up for 3 years.

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We describe a case of aneurysmal coronary-pulmonary artery fistula and a communicating anomalous vessel arising from the right coronary sinus that was clearly demonstrated by 64-multidetector row computed tomography (MDCT). MDCT angiography was more useful than cardiac catheterization for planning the surgical strategy.

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A 57-year-old man was admitted to our hospital complaining of poor appetite. He had been diagnosed with diabetes mellitus and was anti-GAD antibody (GAD-Ab) negative 1 year previously, at the age of 56 years old. Abdominal CT revealed pancreas tail swelling; elastase-I level was elevated and he was diagnosed with pancreatitis. The level of GAD-Ab was increased and HLA haplotype was DRB1*0901-DQB1*0303, which is seen frequently in type 1 diabetic Japanese patients. However, his endogenous insulin secretion ability was not deteriorated. After elastase-I level and pancreas swelling improved, GAD-Ab returned to a normal range. One year after the onset of pancreas swelling, he was still not in an insulin-dependent state. In this case, transient GAD-Ab positivity with susceptible haplotype for type 1 diabetes mellitus might have been induced by a GAD antigen discharged from the destroyed islet due to pancreatitis.

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We present the case of a 23-year-old man with steroid-resistant nephrotic syndrome due to minimal change disease who was treated with rituximab. The patient was resistant to conventional therapy. We therefore treated him with a single dose of rituximab (375 mg/m²). One month after the administration of rituximab, complete remission was achieved. However, six months later, the patient was administered a second dose of rituximab as the peripheral B cell counts began to recover. Thereafter, at present, that is, one year after the first rituximab administration, complete remission has been maintained. We conclude that rituximab may be an effective treatment agent for resistant nephrotic syndrome and the peripheral B cell count may be a useful marker in such patients for preventing disease relapse.

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We report a 90-year-old woman who had complained of bloody sputum and for whom a chest CT showed a nodular lesion on the right lower lobe. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed and adenocarcinoma was revealed in both a subcarinal lymph node (#7) and in the primary lung tumor. Epidermal growth factor receptor (EGFR) gene mutation status was evaluated, and an exon 21 point mutation (L858R) was identified by direct sequencing. Two weeks after administration of gefitinib, the tumor size decreased and bloody sputum disappeared. The patient has remained in good condition for 6 months.

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MRI findings of sarcoidosis are usually intraparenchymal granuloma with leptomeningeal lesions. This appearance is dependent upon leptomeningeal lesions subsequently infiltrating to parenchyma. We describe a 52-year-old man with slowly progressive paresthesias and weakness in his legs. MRI showed diffuse leptomeningeal lesions throughout the brainstem and spinal cord without intraparenchymal lesions. A diagnosis of sarcoidosis was confirmed by cervical lymph node biopsy which detected noncaseating granuloma. Only leptomeningeal lesions throughout the brainstem and spinal cord could be observed in sarcoidosis.

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The case of a 48-year-old Japanese man with idiopathic bronchostenosis in the right lower lobe is reported. The patient had fourteen episodes of pneumonia in two years and therefore surgical resection of the right lower lobe was performed for both diagnosis and treatment. Histopathology demonstrated no evidence of malignancy, tuberculosis, sarcoidosis or amyloid deposition. Despite an exhaustive evaluation, a specific etiology was never determined. The patient was given the diagnosis of acquired idiopathic localized bronchostenosis with frequent recurrence of pneumonia.

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We report a peculiar case in an 80-year-old man with multiple bone metastases due to the recurrence of thymic carcinoid tumor after surgical resection and radiation therapy ten years earlier. He was admitted to our hospital with a complaint of lumbago. Fluoro-2-deoxy-D-glucose (FDG) PET was useful for recognition of multiple bone metastases due to the recurrence of thymic carcinoid tumor, while ²⁰¹Tl-whole body scintigraphy and by ⁹⁹mTc-methylene diphosphonate (⁹⁹mTc-MDP) bone scintigraphy did not reveal the metastases. Finally, we performed a CT-guided bone biopsy from lumbar vertebra and could obtain the diagnosis of metastases of carcinoid tumor histologically. As evident in this case, it is important to consider the recurrence of carcinoid tumor even if a long time has passed after the surgical resection and radiation therapy; also FDG-PET may be a useful diagnostic imaging modality to detect metastases from thymic carcinoid tumor to other organs.

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