We investigated the production of reactive oxygen intermediates (ROI) by monocytes and neutrophils cultured from traumatized patients on the second and the seventh day after emergency surgery by the chemiluminescence method with or without phorbol myristate acetate (PMA) stimulation. The patients enrolled in this study were assigned into two groups according to the severity of their injuries: 11 moderately traumatized patients (Injury Severity Score: ISS<25: group M), and 12 severely traumatized patients (ISS≥25: group S). One patient in group M and 11 patients in group S developed secondary organ failure and 4 of those in group S died. On the second day, the level of ROI produced by monocytes from groups M and S was significantly higher than that in healthy volunteers (group C: n=12), but there was no significant difference between groups M and S. In contrast, the level of ROI produced by neutrophils without PMA stimulation in group S was significantly higher than the levels in groups M and C. On the seventh day, there was no significant difference in the level of ROI produced by monocytes and neutrophils with or without PMA stimulation between groups M and S. In group S, the level of ROI produced by monocytes and neutrophils in the 4 patients who died was significantly lower than the level in the 8 patients who survived. These results suggest that the mechanism of ROI production is different between monocytes and neutrophils, and that ROI production by neutrophils is more closely related to organ failure in traumatized patients than ROI produced by monocytes. Furthermore, the suppression of ROI production by neutrophils and monocytes observed in severely traumatized patients markedly influences on clinical outcome.

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Objective: This study retrospectively examined the characteristics of computed tomography (CT) findings in patients with tracheal injuries. Materials and Methods: The clinical records, including bronchofiberscopic and CT findings, of patients with 1) cervical subcutaneous emphysema; 2) deep cervical emphysema or mediastinal emphysema, as revealed by a plane chest x-ray examination; or 3) deep cervical emphysema, as revealed by a plane lateral neck x-ray examination were examined. All patients had been examined at our institution within the last 4 years. The CT images obtained in these cases were evaluated with regard to 1) the presence of emphysema adjacent to the trachea, 2) irregularities and discontinuities of the tracheal wall, 3) abnormal low density areas (LDA) adjacent to the trachea, and 4) the relative locations of the above findings. Results: Sixteen patients were enrolled in the study. Tracheal injuries were diagnosed by bronchoscopy in 5 cases and not detected in the remaining 11 cases. CT images obtained in all 5 cases with tracheal injuries revealed an irregular and discontinuous tracheal wall, abnormal LDAs adjacent to the irregular and discontinuous regions, and massive emphysema adjacent to the abnormal LDAs. In the 11 cases without tracheal injury, the CT examinations revealed massive emphysema adjacent to the trachea, in 8 patients (73%), an irregular and discontinuous tracheal wall in 5 patients (45%), and abnormal LDAs in 2 patients (18%). These abnormal LDAs, however, were not adjacent to the irregularity and discontinuous regions of the tracheal wall. Conclusions: Irregularities and discontinuities in the tracheal wall, abnormal LDAs adjacent to these irregular and discontinuous regions, and massive emphysema adjacent to the abnormal LDAs are useful CT findings indicating the presence of a tracheal injury.

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A 50-year-old man who had been diagnosed as having von Recklinghausen disease was admitted to our emergency room after experiencing a severe pain in his abdomen and back and collapsing. Abdominal CT and US examinations revealed a retroperitoneal hematoma with intraperitoneal hemorrhaging, and an emergency operation was performed. During the operation, active bleeding was observed around the pancreas and the retroperitoneum. The origin of the bleeding could not be found, so gauze packing was used. After this first operation, a celiac angiography and an abdominal CT examination showed leakage from blood vessels, indicating bleeding. Four additional operations for hemostasis were performed over the next three consecutive days. Though the patient's vital signs were stable after the 4th operation, except for liver dysfunction and jaundice, he collapsed suddenly 8 days after admission, and an emergency angiography and operation were immediately performed. The uncontrolled retroperitoneal bleeding was completely different from the previous episode, and gauze packing was performed once again. In spite of receiving more than 30, 000ml of blood transfusions, the patients died of blood loss. A hematoma in the pancreas communicating with the portal vein was found at the time of autopsy, but no signs of arteriosclerosis or aneurysm in the main arteries of the abdomen and retroperitoneum were observed. Microscopically, the fragmentation of the elastic laminae was observed in the superior mesenteric artery. Retroperitoneal hemorrhaging in association with von Recklinghausen disease may require an emergency angiography, TAE and laparotomy, even if the patient's condition appears to be stable.

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We report a case of severe aneurysmal subarachnoid hemorrhage (SAH) associated with pulmonary edema (PE) that was treated using endovascular surgery. A 65-year-old female was brought to our hospital with a history of disturbed consciousness. She was diagnosed as suffering from SAH in association with PE. An angiography examination revealed a ruptured anterior communicating artery aneurysm; an intraaneurysmal embolization using Guglielmi detachable coils was performed about 6 hours after the onset of the event. The partient's PE worsened during the first 12 hours after the procedure, necessitating artificial ventilation with a positive end-expiratory pressure. The patient's condition resolved in about 5 days. Endovascular surgery may be useful for the teatment of aneurysmal SAH episodes associated with cardiopulmonary complications. Careful cardiopulmonary monitoring and patient management are necessary in such cases.

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A 40-year-old Japanese man was brought to our hospital presenting with a deterioration of consciousness and respiratory failure after being bitten by an imported snake. On admission, he was in a deep coma with generalized paralysis. Because of his difficulty in breathing, he was intubated orally and controlled mechanical ventilation was started. To identify the snake, we obtained a photocopy of the snake and transferred it to the Japan Snake Institute via E-mail. The snake was identified as Bungarus candidus, and the antivenom was transferred to our hospital by a police car. The antivenom was given 16 hours after the bite, and neostigmine was administered for 10 days. The patient recovered from the respiratory paralysis six days after admission. His muscle weakness gradually improved, and he was discharged from hospital on the 44th hospital day. He continues to complain of fatigue almost one year after the incident.

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A 52-year-old woman with abdominal symptoms associated with severe ascites and splenomegaly developed dyspnea and consciousness disorder and was transferred from another hospital. On admission, her platelet count was very low, her clotting function had failed, and she had developed disseminated intravascular coagulation (DIC). We treated DIC symptomatically while searching for the etiology. When the patient's renal failure, dyspnea, and bleeding diathesis rapidly worsened, she developed multiple organ failure. Circulatory maintenance by continuous hemodiafiltration succeeded only temporary and she died on hospital day 5. Autopsy showed that hemophagocytic histiocytes had infiltrated organs and blood vessels throughout the body, and the final diagnosis was hemophagocytic syndrome secondary to Epstein-Barr virus associated with peripheral T-cell lymphoma (lymphoma-associated HPS: LAHS), based on immunostaining results. Severe cases of LAHS pursue a fulminant course, often leading to death. HPS must be kept in mind in the differential diagnosis of treatmentresistant cases giving rise to fever of unknown origin, pancytopenia, and splenomegaly. Determining the cause of HPS and conducting adequate chemotherapy immediately after diagnosis are vital to saving the patient's life.

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A 55-year-old woman was admitted to our hospital for somnolence and fever (38°C). A chest computed tomography (CT) scan performed at the time of admission showed pneumonia. A blood test showed pancytopenia. The patient received artificial respiration in the ICU. Steroid and antibiotic medication were administrated. However, the patient's blood findings deteriorated. The serum ferritin level was markedly elevated to 14, 379ng/ml. A bone marrow smear showed 4.6% hemophagocytosis. A bacterial culture of the sputum was positive for Pseudomonas aeruginosa. Under a diagnosis of bacteria-associated hemophagocytic syndrome (HPS), plasma exchange (PE) was performed. After PE, the hematological data improved markedly. The patient was extubated on the 5th hospital day and discharged on the 27th hospital day. To diagnosis HPS, hyperferritinemia and evidence of hemophagocytosis from a bone marrow biopsy should be confirmed. However, the etiology of HPS can vary, and a standard treatment has not been established. PE has been reported to be useful for removing cytokines. However, the mechanism behind the efficacy of PE remains to be clarified. In patients with HPS, treatment using PE, steroids and immunosuppressive agents should be started as early as possible, preferably before the development of hypercytokinemia-related multiple organ failure.

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