After orthotopic liver transplantation, splenic artery syndrome (SAS), a phenomenon by which the main blood flow of the impaired hepatic artery is shifted to the splenic artery or gastroduodenal artery despite the absence of a structural lesion involving the anastomosis, has occasionally been observed. We report a 20-year-old women who developed SAS with pancytopenia and refractory ascites after living donor liver transplantation despite intraoperative ligation of the splenic artery as a prophylactic treatment for SAS. In this case SAS was diagnosed by digital subtraction angiography (DSA). A celiac trunk angiogram showed relative hypoperfusion of the hepatic artery together with augmentation of the blood flow toward the spleen with the unique collateral circulation through the left gastric artery, stomach and short gastric artery, and distal splenic artery. Embolization of one of the two left gastric arteries was performed. After embolization the hepatic artery perfusion showed significant improvement, but reduced again the next day. We ultimately conducted splenectomy. This case showed portal hyperperfusion and portal hypertension, consistent with previous reports that have described an association of SAS with portal hyperperfusion. After splenectomy, there was significant improvement in the hepatic artery perfusion, ascites disappeared promptly, and pancytopenia was significantly improved.

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We report a case of advanced HCC with multiple intrahepatic metastases who obtained long-term survival by reductive hepatic resection as part of a multidisciplinary treatment. The patient was a 75-year-old man who had HCC, 13.5 cm in diameter in the right lobe of the liver with multiple intrahepatic metastases around the main tumor and 7 intrahepatic metastases in the left lobe of the liver. The large main tumor and intrahepatic metastases around the main tumor were initially resected by right lobectomy as reduction surgery. Transcatheter arterial chemoembolization (TACE) with epirubicin for intrahepatic metastases in the remnant liver was started 1 month after initial hepatectomy and repeated every 3 months. Twelve months after initial hepatectomy, lung metastases appeared, so we started systemic chemotherapy with 5-fluorouracil (5-FU) and cisplatin (CDDP). In addition, we changed epirubicin to CDDP for TACE. Despite this combination therapy, 20 months after the initial hepatectomy, the lung metastases showed an increase in size. We decided to discontinue systemic chemotherapy and administer sorafenib. The patient was alive without progression of intrahepatic metastasis and lung metastasis more than 26 months after the initial hepatectomy.

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A 60-year-old female patient was admitted to our hospital in April, 2010 because of low-grade fever and malaise for several months. Physical examination on admission revealed no abnormalities except for a body temperature of 37.2°C. Blood examinations showed moderate anemia and a high erythrocyte sedimentation rate. There were no other specific abnormal findings. A systemic CT scan study disclosed diffuse thickening of the artery wall through the ascending, descending and abdominal aorta to the bilateral iliac arteries. In order to evaluate the quality of the vessel lesions, a FDG-PET/CT study was performed and revealed abnormal accumulation of 18F-FDG in the thickened wall, suggesting an inflammatory process in the lesion. Taking all these findings into consideration, we made the diagnosis of Takayasu's arteritis, and treated the patient with prednisolone. The treatment was effective and her symptoms improved. A later CT scan revealed that the artery wall became somewhat thinner. Takayasu's arteritis is a disease whose diagnosis is difficult to make because there are neither specific signs nor diagnostic laboratory findings in its early stage. We found that FDG-PET/CT was helpful in the diagnosis and evaluation of lesions in a patient with Takayasu's arteritis.

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A 28-year-old man with a history of mental retardation was admitted to our hospital because of dyspnea, cough and high fever. His SpO₂ level at room-environmental conditions was in the eighties, and his chest radiograph showed diffuse infiltrates in both lungs. He was diagnosed as suffering from influenza A by a rapid influenza virus antigen test. The echocardiogram showed no evidence of left cardiac failure; therefore, his symptoms were consistent with acute respiratory distress syndrome (ARDS). Oseltamivir was started, and antibiotics were also given because of the possibility of secondary bacterial infection. Due to respiratory failure and low blood pressure, which suggested septic shock, intensive treatments including mechanical ventilation were performed. Corticosteroid therapy was started for ARDS and sepsis, and these therapies improved his respiratory condition. Polymerase chain reaction of his pharyngeal swab revealed that he had influenza A (H1N1). This is the first case of ARDS following infection by influenza A (H1N1) virus in Japan.

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