Immunoelectron-microscopic demonstration of NACP/alpha-synuclein-epitopes on the filamentous component of Lewy bodies in Parkinson's disease and in dementia with Lewy bodies

We examined brains from Parkinson's disease and from dementia with Lewy bodies (LBs) by using antibodies to NACP/alpha-synuclein. Immunohistochemically, all of the antibodies against the amino-terminal region, NAC domain, and carboxyl-terminal region of NACP labeled not only LBs, pale bodies (PBs), and dystrophic neurites, but also fine thread-like structures in the neuronal perikarya (perikaryal threads) in the hypothalamus and brainstem nuclei. On electron microscopy, immunoreactive products were found to label the 9 to 12 nm-thick filamentous component (LB-filaments) of LBs, PBs, and perikaryal threads. The NACP-immunoreactive perikaryal threads, consisting of small bundles of LB-filaments and randomly oriented LB-filaments, presumably represent an initial stage of LB- or PB-formation. The present study indicates that the entire molecule of NACP is involved in the neuronal filament-aggregating processes of LB disorders.

[Extracorporeal shock wave lithotripsy in patients with coagulopathies: report of three cases]

We describe our experience with extracorporeal shock wave lithotripsy (ESWL) in three patients with coagulation disorders (one case of hemophilia A, and two cases of thromboasthenia). We successfully performed ESWL using factor VIII or transfusion of platelets without any severe hemorrhagic complications, such as perirenal and subcapsural hematomas. We consider that adequate supplement of coagulation factor or platelets may lower the risk of hemorrhagic complications in coagulopathic patients who undergo ESWL.

CT and MRI findings in a case of pelvic schwannoma

We compared the diagnostic utility of computed tomography (CT) and magnetic resonance imaging (MRI) in a patient with a pelvic schwannoma. This 46-year-old woman was admitted for evaluation of a retroperitoneal pelvic mass and myoma uteri. The retroperitoneal pelvic mass had been detected by a CT scan at a routine health examination. A CT scan revealed a well-circumscribed cystic tumor (4 x 3 cm) at the right internal obturator muscle portion. The CT number of the inner part of the tumor was 21. Only the cyst wall was enhanced by injection of a contrast medium. MRI showed a 4 x 3 x 3-cm retroperitoneal cystic tumor that demonstrated low-intensity signals on T1-weighted images and high-intensity signals on T2-weighted images. Small areas of low intensity inside the tumor were observed on T2-weighted images. Histological examination revealed a typical schwannoma of mixed Antoni type A and type B. These findings indicate that both MRI and CT are useful for diagnosis of retroperitoneal schwannomas.

Immunohistochemical and ultrastructural characterization of ubiquitinated eosinophilic fibrillary neuronal inclusions in sporadic amyotrophic lateral sclerosis

We found eosinophilic fibrillary neuronal inclusions (EFNI) that were argyrophilic and immunoreactive for anti-ubiquitin in the cerebral cortex of a patient with sporadic amyotrophic lateral sclerosis (ALS) and mild personality changes. Both hematoxylin and eosin and Bodian's preparations revealed the EFNI to be rod-, flame-shaped, or spherical structures existing within the swollen neuronal perinuclear region in the third, fifth, and sixth layers of the fronto-parieto-temporal cortices including the primary motor cortex. On electron microscopy, filamentous profiles aggregated and formed a single bundle or globule in the neuronal perikaryon without any limiting membrane. Most EFNI had a characteristic multiple layer arrangement. The inner core consisted of randomly oriented granule-free tubules with a fuzzy outer contour, measuring 15-20 nm in diameter. The surrounding layer was made up of granule-associated filaments, electrondense free granules, and small vesicular profiles. Large autolysosome-like membrane-bound vesicular profiles were found scattered at the periphery. Neurofilaments were usually mingled with in the surrounding cytoplasm. Many EFNI were also found in dendrites, but only a few in axons. Both granule-free tubules and granule-associated filaments expressed ubiquitin protein epitopes. Aberrant phosphorylation of neurofilament protein and induction of alphaB-crystallin were shown to exist in EFNI-bearing swollen neurons. Despite having a variety of histological appearances, our observations revealed that EFNI all have common immunocytochemical and ultrastructural characteristics, and thus we assume that EFNI represent a series of cytological alterations in the motor and extra-motor cortices of ALS patients.

Interferon therapy in LKM-1 positive patients with chronic hepatitis C: follow-up by a quantitative radioligand assay for CYP2D6 antibody detection

BACKGROUND/AIMS

Liver/kidney microsomal type 1 (LKM-1) antibodies described by indirect immunofluorescence using frozen sections of kidney, stomach and rat liver define a group of patients with type 2 autoimmune hepatitis. Sera react with a non-glycosylated 50-kD protein of the endoplasmic reticulum, which was recently identified as cytochrome P4502D6 (CYP2D6). LKM-1 antibodies may also be associated with hepatitis C virus infection (HCV+/LKM-1+). For this subset of patients, the choice of steroids or interferon alpha therapy may be difficult because of the association of hepatitis C virus infection and autoimmune manifestations. Recently we developed a quantitative immunoprecipitation radioligand assay using 35S-methionine-labeled CYP2D6 protein produced by in vitro transcription and translation reaction. This method detects antibodies against linear and conformational epitopes in both AIH-2 and HCV+/LKM-1+ patients. The aim of this study was to analyze the time-course of HCV+/LKM-1+ patients, applying our radioligand assay over a long follow-up.

METHODS

We studied five patients who were positive for CYP2D6 antibodies from among 235 chronic hepatitis C virus hepatitis patients (2.1%) treated with interferon alpha for a minimal follow-up of 2 years. We analyzed LKM-1 antibody titer sequentially by radioligand assay, HCV RNA titer and alanine aminotransferase activity in these patients.

RESULTS

We found no aggravation of liver disease in this group of patients. Three of these patients showed a sustained biochemical and virological response after interferon. Two others responded partially to interferon therapy. Alanine aminotransferase levels and HCV-RNA decreased during interferon therapy in responder patients. CYP2D6 antibodies did not change in three responder patients during follow-up. One responder patient decreased CYP2D6 antibody level by radioligand assay, but indirect immunofluorescence titers showed a similar pattern. One partial responder patient decreased CYP2D6 antibody level but was negative by indirect immunofluorescence.

CONCLUSIONS

Our results show that patients with hepatitis C virus who are positive for CYP2D6 antibodies may be treated with interferon, and respond in the same way as CYP2D6 antibody negative patients. Radioligand assay could be helpful for monitoring HCV+/LKM-1+ patients receiving interferon therapy.

Antibodies to Ro/La, Cenp-B, and snRNPs antigens in autoimmune hepatitis of North America versus Asia: patterns of immunofluorescence, ELISA reactivities, and HLA association

To assess whether demography is one of the important factors determining antibody response to nuclear antigens [ANA: SSA-Ro (52K and 60K), SSB-La, snRNPs (A, 70K, B'/B), and Cenp-B], we investigated 95 and 47 sera of autoimmune hepatitis (AIH) from North America and Asia, respectively, by immunofluorescent (IF) and recombinant ELISA. Correlations among nuclear IF patterns, ELISA, and disease indices were analyzed. The frequency and titer of individual antibodies differed significantly between the groups. Patients with speckled patterns were younger in both regions and had higher aspartate aminotransferase levels only in North America. HLA-A1, B8, DQ2, and DR4 or DR3 or both in North America, and A2, B61, DQ7, and DR4 in Asia were predominant. In Asia, B61 correlated with anti-70K, and DQ7 correlated with antibodies to 52K, Cenp-B, and B'/B. In North America, A1, B8, DR3 haplotype, and DQ2 correlated with antibodies to A and 70K. Anti-B'/B and DR4 in North America, and A2 in Asia, were associated with concurrent immunologic disorder. Individual ANA clusters correlated with individual HLA in the demography, and different HLA alleles might determine disease expression as well as different ANA being produced in AIH.

[A case of renal cell carcinoma with metastasis in clivus presenting as diplopia]

We report a rare case of renal cell carcinoma presenting as diplopia which was caused by a metastasis to the clivus. A 58-year-old man was admitted to our hospital with the chief complaint of diplopia. Head magnetic resonance imaging showed a mass in the clivus accompanied by bone destruction. Metastatic tumor to the skull base was suspected. Further examinations for the primary lesion revealed left renal cell carcinoma. He was relieved of diplopia by radiotherapy to the clivus and subsequently underwent left radical nephrectomy.

[Laparoscopic fenestration of lymphocele after renal transplantation: report of two cases]

Lymphocele after renal transplantation is a complication that often requires surgical treatment. We performed laparoscopic drainage for the postoperative lymphocele in two renal transplantation patients. The patients were suffering from perineal discomfort and urinary frequency due to the lymphocele after the renal transplantation. Percutaneous catheter drainages and injections of tissue sclerosing agents such as povidone-iodine solution and tetracycline were not effective. Then fenestration of the lymphocele by laparoscopic technique was done. This procedure made the lymphatic fluid free from the lymphocele in the retroperitoneal space to the peritoneal cavity following creation of a peritoneal window. There were no apparent complications. The patients were free from symptoms and had no relapse 10 months after the operation. We report the procedure and the results of the laparoscopic fenestration.

[Estimated prevalence rate of HTLV-I uveitis in Chikugo]

To estimate the prevalence rate of human T-cell lymphotropic virus type 1 (HTLV-I) uveitis, an epidemiological survey was carried out in the Chikugo District of Fukuoka Prefecture between 1 September and 31 October 1995. The survey was done by sending questionnaires on uveitis patients to all ophthalmological institutes in the district and measuring the serum antibody to HTLV-I. The recovery rate of the survey was 39 of 48 institutes (81.3%). A total of 357 patients with uveitis were reported in the survey, of whom 317 (88.8%) were tested for their seropositivity to HTLV-I. Among them, 18 patients were counted as having HTLV-I uveitis (HU) on 1 October 1995. Based on these data together with the age- and sex-specific population of HTLV-I carriers in the Chikugo District, it was estimated that the crude prevalence rates of HU per 100,000 HTLV-I carrier population were 58.6 in males, 152.0 in females, and 112.2 in both sexes. The prevalence rate of HU was slightly higher than that of HTLV-I associated myelopathy.

Characterization of anti-histone antibodies in patients with type 1 autoimmune hepatitis

We have recently found that antibodies to total histones are common in a group of American patients with type 1 autoimmune hepatitis (AIH). In an attempt to determine the profile and clinical association of anti-histone antibody (AHA), 45 Japanese AIH patients were studied for serum isotypic reactivity with individual histones (H1, H2A, H2B, H3, H4) by enzyme-linked immunosorbent assay and western blotting. The results revealed that 40% of sera had reactivities with at least one of individual histones and that the antibodies were detected in all three classes of immunoglobulins (IgG, IgM, IgA). Immunoglobulin G type anti-H3 showed the dominant reactivity and it characterized 72% of sera with AHA. The titre of anti-H3 decreased significantly (P < 0.0075) after steroid therapy and the index of decrease for anti-H3 was correlated in individuals with that for serum aminotransferase. In general, patients with AHA showed higher serum level of alanine aminotransferase (P < 0.05), immunoglobulin G (P < 0.025), and higher frequency of A2-DR4 haplotype (53 vs 17%) than their seronegative counterparts. However, the titre of AHA was low in this disease condition and histone class-specific antibodies did not distinguish patients with distinctive clinical features, although patients with anti-H3 tended to be younger than those without AHA.

SNAP-25 deficit and hippocampal connectivity in schizophrenia

Regional abnormalities of brain connectivity may be an important substrate for the expression of schizophrenia, a severe form of mental illness. Brain imaging and postmortem morphometric studies indicate hippocampal structure is abnormal in schizophrenia. To study molecular components of hippocampal connectivity the presynaptic proteins SNAP-25 and synaptophysin were assayed in postmortem samples. Immunocytochemical studies indicated reduced SNAP-25 immunoreactivity in schizophrenia compared to controls, particularly in the terminal fields of entorhinal cortex projections. Although there were no overall changes in synaptophysin immunoreactivity, in the granule cell layer of the dentate gyrus synaptophysin immunoreactivity was increased in schizophrenia. These results indicate that disconnection of a subset of hippocampal circuitry from the entorhinal cortex, as well as intrinsic changes in hippocampal connectivity, may contribute to the mechanism of illness in schizophrenia.

[An autopsy case of rhino-orbito-cerebral mucormycosis associated with multiple cranial nerve palsy and subsequent subarachnoid hemorrhage]

We report an autopsy case of 53-year-old male with poor controlled diabetes mellitus and hepatocellular carcinoma who developed rhino-orbito-cerebral mucormycosis. Initial complaints were epistaxis and headache followed by a sudden blindness, the 2nd through 7th cranial nerve palsy and diabetes inspidus. Laboratory data revealed that he had liver cirrhosis due to hepatitis C virus infection and diabetes mellitus. Head CT and MRI showed no significant findings. Eleven days after the onset, he died of subarachnoid hemorrhage. The postmortem examination revealed severe infiltration of numerous mucors in the sphenoid sinus, cavernous sinus and bilateral internal carotid arteries. Severe granulomatous vasculitis was seen in the cavernous portion of the bilateral internal carotid arteries. Thus, we considered that this case had been caused by the infiltration of mucors to the cavernous sinus, resulting in the obstruction of ophthalmic arteries. Rupture of the right internal carotid artery was seen at the branching portion of the ophthalmic artery, demonstrating the cause of his death. We would like to emphasize that rhino-orbito-cerebral mucormycosis should be ruled out if we examine a nondiagnostic case of diabetes mellitus or immunosuppressed disease associated with rapid multiple cranial nerve palsy following the orbital symptoms.

Evidence for structural differences between the two highly homologous actin-regulatory proteins, destrin and cofilin

The amino acid sequences of destrin and cofilin are very similar (84% homology) throughout the entire range of proteins, but they have different functions. In this study, we constructed a new cofilin expression plasmid, which had high expression frequency, and the structures of destrin and cofilin were analyzed by limited proteolysis and circular dichroism (CD). When destrin was digested by trypsin, two fragments of 17.0 kDa and 9.2 kDa were obtained, whereas only one 8.4 kDa fragment was obtained from cofilin. In spite of the overall sequence homology, an N-terminal amino acid sequence analyses of the fragments revealed the cleavage sites on destrin and cofilin to be different. These results suggest that destrin and cofilin differ in their overall tertiary folds. Cofilin showed activity similar to destrin at high pH values, although no pH-dependent structural change in cofilin was confirmed by using limited proteolysis and CD.

Angiographic study of mutant tissue-type plasminogen activator versus urokinase for acute myocardial infarction

The effects and problems of intravenous thrombolytic therapy with a bolus injection of mutant tissue plasminogen activator (t-PA) were investigated in 34 patients with first acute myocardial infarction (AMI). In contrast, 114 patients were selected from 1,003 patients with AMI for treatment using intravenous infusion urokinase (UK). Angiography of these 148 patients revealed a complete occlusion of infarct-related artery with no clear contraindications to the study treatment. With the exception of thrombolysis in myocardial infarction (TIMI-3) recanalization 60 min after a bolus injection of mutant t-PA, the patients were given intracoronary UK in addition to mutant t-PA. The study comparisons were assessed using the following criteria: (1) 60-min assessment of recanalization rates, mutant t-PA vs UK; (2) time interval from initiation of thrombolysis to recanalization, mutant t-PA vs UK; (3) angiographic reocclusion rates within 1 month, mutant t-PA alone vs UK vs mutant t-PA plus UK; and (4) intracerebral hemorrhage rates, mutant t-PA alone vs UK vs mutant t-PA plus UK. There were no significant differences in the recanalization rates between mutant t-PA and UK, but there was a significant reduction in the time to recanalization with mutant t-PA (31.8 +/- 12.7 min) compared with UK (56.5 +/- 6.3 min). There was a significant difference in the reocclusion rates among the 3 treatment groups (20% mutant t-PA alone vs 4% UK vs 0% mutant t-PA plus UK). On the other hand, no significant differences in intracerebral hemorrhage rates among the 3 treatments were observed. In conclusion, thrombolytic therapy with a bolus injection of mutant t-PA achieved more rapid recanalization, but treatment with mutant t-PA led to a high rate of reocclusion.

Ultrastructure of astrocytes associated with selective neuronal death of cerebral cortex after repeated ischemia

Astrocytic swelling after ischemic insult has been considered a sign of parturbed cell viability. Investigations using cultured astrocytes and C6 glioma cells have revealed that viable astrocytes swell, spatially buffering various metabolites which are increased by the metabolic turmoil following ischemic insults. In the present study, we have studied the temporal profile of ultrastructural changes of astrocytes in the cerebral cortex associated with progressive selective neuronal, death where infarction is not induced. We occluded the left carotid artery of the Mongolian gerbil twice for 10 minutes at a 5 hr interval. In this model, following reperfusion, selective neuronal death progresses in the coronal section cut at the infundibular level. The whole brains of the sham operated control and postischemic animals were fixed by transcardiac perfusion of glutaraldehyde fixatives, at 15 min, 5 and 12 hr after the 2nd 10 min ischemia. Ultrathin sections including the 3rd and 5th cortical layers were prepared from the cut surface at the level of infundibulum. Mild swelling of astrocytic processes and perivascular end-feet was observed in the 15 min group. Glycogen granules were not prominent. In the 5 hr group, we found a few necrotic neurons disseminated in the cortex. All astrocytic cell processes were swollen with increased number of glycogen granules, especially marked in the perivascular end-feet. In the 12 hr group, necrotic neurons increased in number, astrocytic swelling was more extensive, and glycogen granules were evident in astrocytes. No cellular destruction was observed. We conclude: 1. Swelling progresses in astrocytes which however still remain viable and this process is associated with selective progression of neuronal death. 2. Glycogen granules increase in the swollen yet viable astrocytic cell processes.

Argyrophilic tau-positive twisted and non-twisted tubules in astrocytic processes in brains of Alzheimer-type dementia: an electron microscopical study

This report concerns pathological astrocytic tubular structures (astrocytic tubules, As-Tbs) that coexist with glial filaments in astrocytic processes in brains with presenile-onset Alzheimer-type dementia. The formation of As-Tbs appears to be related to the duration of disease and the intensity of Alzheimer histopathology. In three cases in which the disease was of extremely long duration, As-Tbs were found in the frontal and temporal neocortices, the temporal pole and the hippocampus using electron microscopy, whereas they were not found in two cases with a long, but not extremely long, illness duration. As-Tbs were almost exclusively found in the highly devastated neuropil, and we could not find them in regions of moderate neuronal degeneration despite intensive inspection. As reported previously, some As-Tbs was seen adjacent to extracellular neurofibrillary tangles (NFTs) and in perivascular astrocytes. Our novel finding is that they can exist independently from these, in the highly devastated neuropil. Two types of As-Tbs were observed, twisted tubules with periodic constrictions at 50- to 80-nm intervals and non-twisted tubules where no constrictions were seen but which had a 15-nm fuzzy outer contour. They were positively stained by anti-human tau antibody, an antibody that does not recognize extracellular NFTs. Thus, it is most likely that As-Tbs are not the sequestration of extracellular NFTs, and that they are of astrocytic origin. Moreover, As-TBs showed argyrophilia. As-TBs appear indistinguishable from dystrophic neurites under the light microscope. The present data suggest that they may be more widely distributed in the damaged cerebral neuropil than previously thought.

[Percutaneous sclerotherapy for chyluria with leg edema: a case report]

A 45-year-old woman with left leg edema was admitted to our hospital because of chyluria from the previous year. Her left leg edema appeared after Caesarean section for her first delivery and hysterectomy at the age of 31. Because microfilaria was not detected, she was diagnosed with postoperative lymphangiomatosis. The instillation of 0.1-0.5% silver nitrate into the renal pelvis was not effective. We however, after percutaneous sclerotherapy to the left inguinal lymph nodes with doxycycline, the chyluria disappeared and her left leg edema improved. Then, the surplus skin of her left lower leg was resected. We considered percutaneous sclerotherapy to be a good procedure for chyluria due to postoperative lymphangiomatosis.

[A case of metastatic ureteral tumor from rectal cancer]

A 67-year-old man was referred for further examination of left hydronephrosis. He had undergone anterior resection for rectal cancer 2 years previously and also right lobectomy for a solitary hepatic metastasis one year postoperatively. Antegrade pyelography demonstrated a filling defect in middle portion of the left ureter. Cytology of the aspirated urine was class V. Left nephrourete-rectomy was performed. Histologically metastatic adenocarcinoma with intact ureteral mucosa was demonstrated.

[A case of papillary cystadenocarcinoma of the prostate]

An 86-year-old was admitted to our hospital with the complaint of urinary retension. Ultrasonography and CT scan revealed a large cystic intrapelvic mass which was palpated on the bilateral inguinal portion. When the needle aspiration was performed, we aspirated serous fluid which a concentration of prostate-specific antigen (PSA) was remarkably elevated to 6200 ng/ml. Following hormonal therapy with diethylstilbestrol diphosphate, maximum androgen blockade with Flutaminde and LH-RH analog was performed. But no reduction in the size of the cyst was observed, he died from dyspnea caused by carcinomatosa 91 days later. Autopsy revealed a papillary cystadenocarcinoma of the prostate. Furthermore, we revealed that the cyst is primary and neoplastic changes supervened in this case. Seven cases of papillary cystadenocarcinoma of the prostate in the Japanese literature are reviewed briefly.

Conservative treatment using a methotrexate-lipiodol emulsion containing non-ionic contrast medium for a cervical ectopic pregnancy

We present a case in which a viable cervical pregnancy was successfully treated with preservation of the uterus. A 26 year old female presented with a 6 week cervical pregnancy with acute moderate bleeding. On the day of admission the patient underwent embolization of the descending uterine artery to decrease the bleeding. The following day, 4 mEq potassium chloride and methotrexate (MTX)(1 mg/kg) dissolved in saline was injected into the amniotic cavity using transvaginal sonographic guidance. The fetal heart beat ceased; however, the urinary beta-human chorionic gonadotrophin (HCG) concentration increased and the gestational sac size also increased. After a second injection of an emulsion of MTX (1 mg/kg) dissolved in a non-ionic contrast medium, iopamidol and lipiodol, the betaHCG concentration in the urine began to decrease. After a third injection with the same emulsion, the cervical mass became necrotic. The betaHCG concentrations in the urine and serum were undetectable and the external cervix returned to normal 44 days after admission. No vaginal bleeding or significant side effects of MTX were observed throughout the treatment. An in-vitro dissolution test revealed that the dissolution rate of MTX was slower from MTX-lipiodol-iopamidol with sonication than without sonication. The present study indicates that use of an MTX emulsion enables slow release of MTX and may be applicable for conservative treatment of ectopic pregnancies, including cervical pregnancy.

[A case of bilateral renal infarction]

A 67-year-old woman was admitted with aching pain in her left flank and nausea. Bilateral renal infarctions were noticed by CT scan and arteriography. Selective intra-arterial thrombolytic therapy was performed. Urokinase (UK) was administered through a balloon catheter embedded into the occlusive segment of the left renal artery selectively. UK (20,000 units/hour) was continuously infused after short-term high dose UK (360,000) infusion. In spite of recanalization of the occluded artery, CT scan and renoscintigraphy image did not suggest recovery of renal function. Conservative intra-arterial thrombolytic therapy is considered to be the most effective treatment for renal infarction.

Detection of Borna disease virus genome in normal human brain tissue

Borna disease virus (BDV), a neurotropic virus naturally infecting horses and sheep, has been suggested to be associated with human psychiatric disorders. Thus far no extensive studies have been done, providing the evidence of BDV genome in normal human brain tissue. We therefore examined four brain regions of 30 normal autopsy brains for BDV p24 genome. By highly sensitive nested reverse transcriptase (RT)-mediated PCR analysis, we found positive PCR products in two brains: one in frontal and temporal cortices and hippocampus and another in frontal cortex and olfactory bulb. Our results suggest that BDV can infect human brain tissue latently, without causing an apparent neuropsychiatric disorder.

Adenomyomatous polyp of the uterus in a patient receiving tamoxifen

We report a case of adenomyomatous polyp that developed during treatment with tamoxifen for breast cancer. A 63-year-old Japanese woman was admitted complaining of atypical genital bleeding. Nine months earlier, she had undergone a modified radical mastectomy for cancer of her right breast, estrogen receptor-positive stage I (T1N0M0). The administration of tamoxifen, 20 mg/day, was started immediately postoperatively. Pelvic examination after tamoxifen administration for 9 months revealed that the uterus was enlarged to the size of a fist. Transvaginal ultrasonography and magnetic resonance imaging revealed a large solid mass with multiple cystic areas in the uterine cavity. The pathological diagnosis of the tumor after total hysterectomy was typical adenomyomatous polyp. It was believed to have developed during tamoxifen administration.