[Repeated pneumonia in the middle lobe caused by congenital bronchoesophageal fistula]

A 52-year-old woman was admitted to our hospital because of repeated episodes of pneumonia in the middle lobe. She had also experienced coughing during meals. The history and chest CT findings suggested the presence of a bronchoesophageal fistula. An upper GI series revealed a fistula between an esophageal diverticulum and the superior segment bronchus of the right lower lobe. Fiberoptic bronchoscopy done immediately after the upper GI series revealed barium sulfate leaking from the superior segment bronchus of the right lower lobe into the middle lobe bronchus. These findings indicated that the repeated pneumonia in the middle lobe was caused by a congenital bronchoesophageal fistula. Examination of the resected fistula showed that it was a Braimbridge type I bronchoesophageal fistula. Although of at least 49 cases of congenital bronchoesophageal fistulas with esophageal diverticula have been reported in the Japanese medical literature, we know of no previous case in which such a fistula was associated with middle-lobe pneumonia.

[Selenium deficiency associated with cardiac dysfunction in three patients with chronic respiratory failure]

We encountered three patients with chronic respiratory failure who had heart failure of cardiac arrhythmias and low levels of serum selenium. All three had tracheostomies and had received long-term parenteral nutrition that had not included selenium. All three also had refractory cardiac dysfunction, which was manifested in edema, heart failure, and various tachycardias. We suspected that selenium deficiency had caused their cardiac dysfunction. Serum selenium concentrations were found to be much lower than normal in all three, so 100 micrograms/day of selenium was administered in addition to their tube feedings. Cardiac function improved after replacement of selenium. These cases show the need for preventing selenium deficiency in patients with chronic respiratory failure during long-term administration of parenteral nutrition.

Protective effects of dibutyryl cyclic AMP on acute hepatic failure in rats

To study the effect of cyclic AMP on liver dysfunction, dibutyryl cyclic AMP (DBcAMP, 15 mg/kg) was given to rats with acute hepatic failure induced by D-galactosamine (D-Gal; 500 mg/kg) and lipopolysaccharide (i.e., endotoxin) (Et; 0.5 mg/kg). The survival rate was only 7% for rats given D-Gal and Et (control group), while it was 100% for rats given seven doses of DBcAMP, and 53% for rats given two doses. The ALT level was high at 3475 +/- 488 KU in group III, while it was 242 +/- 69 KU in group I, and 376 +/- 49 KU in group II. The hepaplastin test level was decreased at 24 hr in all groups except group I, in which it was high at 55 +/- 11%. The serum tumor necrosis factor (TNF) level was 155 +/- 42 IU/ml in group I, 463 +/- 30 IU/ml in group II, and 1334 +/- 328 IU/ml in group III. The results of the blood biochemistry and liver tissue blood flow studies were better in the DBcAMP-treated groups, and the serum TNF levels were also lower in the treated groups. Histological examination of the liver showed extensive necrosis in the control group, but mild necrosis and inflammatory cell infiltration in the DBcAMP-treated groups. Therefore, treatment with DBcAMP suppressed acute hepatic failure induced by D-Gal and Et, resulting in a significant increase in the survival rate.

[The usefulness of induced sputum in the diagnosis of pulmonary tuberculosis]

This study was designed to compare the results of culture for tubercle bacilli using induced sputum by an ultrasonic nebulizer and gastric aspirates from same patients who were suspected of having active tuberculosis with little or no sputum and had received no prior chemotherapy. 22 patients included in this series were either culture positive for tubercle bacilli or showed unequivocal radiographic improvement after three months of therapy with three anti-tuberculosis drugs. Induced sputum from 17 patients and gastric aspirates from seven patients were culture positive for M.tuberculosis. This difference is significant (p < 0.01). Paired induced sputum and gastric aspirates were both positive for tubercle bacilli in seven patients. The finding of acid-fast bacilli on microscopy or tubercle bacilli in culture in four of the seven patients were available much earlier with induced sputum than with gastric aspirates. Positive gastric aspirates and negative induced sputum for tubercle bacilli was not seen. These results suggest that induced sputum by an ultrasonic nebulizer is superior to gastric aspirates in terms of high sensitivity and early finding for tubercle bacilli and induced sputum and gastric aspirates do not supplement each other.

[High dose inhaled steroid therapy--usefulness and limitation]

Our data indicate that 1800 micrograms of per day is more effective than 1400 micrograms/day at the beginning of long-term management of severe asthma in adults whose symptoms are not controlled with the combination of 800 approximately 900 micrograms/day BDP and bronchodilators. Therapy with a higher dose (at least 1600 micrograms/day) of inhaled steroid is more useful and should be promptly began to treat severe asthma. Oral steroid therapy for long-term management should be introduced to mostly severe case after high dose inhaled BDP therapy reveals to be failure.

Electron microscopic study of chronic eosinophilic pneumonia

Two cases of chronic eosinophilic pneumonia were examined electron microscopically to study the role of eosinophil granulocytes. Eosinophils, together with macrophages and lymphocytes, were observed to have infiltrated prominently in the lung tissues of the two cases. Degeneration and necrosis of pneumocytes were observed, and denuded basement membranes and destroyed alveolar structures were occasionally found. In the alveolar septa, swelling of the endothelial cells of the blood capillaries, edema of the stroma and fibrin deposition were observed. Eosinophils, released eosinophil granules and macrophages phagocytosing eosinophil granules were found frequently near the degenerated and necrotic alveolar tissues. These findings suggest that the tissue injuries were induced by the cytotoxic effects of the eosinophil granules.

[Outbreaks of pulmonary tuberculosis in a family and in a hospital. Analysis of restriction-fragment-length polymorphisms]

Restriction-fragment-length polymorphism, analysis was used to study two outbreaks of pulmonary tuberculosis, one in a family and one in a hospital. The DNA probe was derived from the insertion sequence IS 6110. Two groups of isolates were analyzed, both of which were suspected to be common sources of each infection. Both groups showed identical fingerprints within each group. These results suggest that analysis of restriction-fragment-length polymorphism is useful in epidemiological studies of pulmonary tuberculosis.

Screening of antipsychotic drugs by wide-bore capillary gas chromatography with nitrogen phosphorus detection--detection levels in plasma

The detection levels of 12 antipsychotic drugs as ascertained from drug screening were examined in order to use the screening results effectively for treatment of patients or medico-legal examinations in cases of poisoning. Wide-bore capillary gas chromatography with nitrogen phosphorus detection was used for the analysis. The detection limits of drugs in plasma using 3 extraction procedures, single-solvent, 3-step solvent and solid-phase extractions were 50-100 ng/ml, 10-200 ng/ml and 5-50 ng/ml, respectively. The detection limits were compared with blood levels previously reported in the literature. Only 4 drugs were detected at the therapeutic level, thioridazine, floropipamide, sultopride and oxypertine using the single-solvent extraction procedure. Using the 3-step solvent extraction procedure, chlorpromazine, levomepromazine and zotepine in addition to the above 4 drugs were detected. Using the solid-phase extraction procedure, 8 of 12 drugs were able to be detected at the therapeutic level, with the exception of perphenazine, haloperidol, bromperidol and nemonapride. These data were proved to be useful for a rapid forensic diagnosis.

[Tracheal carcinoma causing severe tracheal stenosis]

A 47-year-old woman was admitted to our hospital because of shortness of breath. She had wheezed for a long time before admission. A flow-volume curve showed a pattern consistent with a fixed obstruction of the trachea. CT findings also revealed severe stenosis of the trachea caused by a tumor mass. Tracheal carcinoma was diagnosed after transbronchoscopic biopsy. The patient received chemotherapy and radiation therapy concurrently for about six weeks. Her symptoms resolved, and a second flow-volume curve had a normal pattern. Tracheal carcinoma should be included in the differential diagnosis of airway obstruction. In such cases, the flow-volume curve can be useful as a screening test.

[High-dose inhaled beclomethasone in long-term management of chronic severe asthma--usefulness and dose-dependence]

We studied the usefulness of 18 weeks of therapy with two high doses of inhaled beclomethasone dipropionate (BDP) in the management of severe asthma in adults. The patients had asthma symptoms that had not been controlled by combination therapy with BDP (800 micrograms/day) and bronchodilators. They were divided into two groups. Patients in group A (n = 16) were treated with 1800 micrograms/day of BDP and bronchodilators. Patients in group B (n = 10) were treated with 1400 micrograms/day of BDP and bronchodilators. BDP was inhaled via a large spacer (Volumatic). Eleven patients in group A and 6 patients in group B had been given an oral steroid regularly before the study. Asthma symptom scores, peak expiratory flow (PEF), pulmonary function, bronchial reactivity to methacholine, the total amount of oral steroid, and adrenocortical function were recorded. Results. 1) Clinical characteristics before the start of the study did not differ between groups. 2) Asthma symptom scores decreased to a greater extent in patients who received the higher dose of BDP than in those who received the lower dose. 3) Only the higher dose of BDP significantly increased evening and morning % PEF, as measured 6 weeks and 8 weeks after the start of the treatment. 4) Only the higher dose of BDP significantly increased the FEV1 and the PC20 for methacholine. FVC did not increase. 5) Only the higher dose of BDP significantly decreased the total amount of oral steroid needed to control asthma. 6) Results of the rapid ACTH test indicated that neither dose of BDP suppressed adrenocoritical function. Furthermore, the serum cortisol level measured early in the morning increased to within the normal range in the three patients in whom oral steroid therapy could be reduced or stopped after treatment. These data indicate that 1800 micrograms of BDP per day is more effective than 1400 micrograms/day at the beginning of long-term management of severe chronic asthma in adults whose symptoms are not controlled with the combination of 800 micrograms/day BDP and bronchodilators. Therapy with a higher dose (at least 1600 micrograms/day) of an inhaled steroid is more useful and should be promptly begun to treat severe asthma.

[Clinical characteristics of chronic sinusitis with different lower respiratory tract diseases]

We determined the clinical characteristics of chronic sinusitis in patients with different lower respiratory tract diseases. Sinusitis was divided into three groups. The first group was sinusitis with bronchial asthma. The second group was sinusitis with chronic bronchitis, bronchiectasis or diffuse panbronchiolitis. This type of sinusitis is generally called sinobronchial syndrome (SBS). The third group was sinusitis without lower respiratory tract disease. Because the pathogenesis of these lower respiratory tract diseases differs with the diseases, the pathogenesis of sinusitis accompanied by these lower respiratory tract diseases also may be different. Clinical and laboratory examinations used in this study were rhinoscopy, X-ray examination of the paranasal sinuses, cytological study of nasal secretion and the saccharin test for the muco-ciliary function of the nasal mucosa. By rhinoscopic examination, no difference was found in the size of the nasal polyp among three groups. The results of other examinations were as follows. X-ray examination: Involvement of the ethmoid sinuses was greater than that of the maxillary sinuses in the patients with sinusitis with bronchial asthma. In contrast, involvement of the maxillary sinuses in SBS patients was greater than that of the ethmoid sinuses. Cytology of nasal secretion: Dominant inflammatory cells in the patients with sinusitis with bronchial asthma were eosinophils, while neutrophil were more frequently found in the SBS patients. Saccharin test: Most of the patients with bronchial asthma showed normal responses. In the SBS patients, however, only a few patients showed a normal response and the others showed prolonged responses. Clinical characteristics of the patients with sinusitis without lower respiratory diseases were more similar to those of the SBS patients. In conclusion, there were distinct differences in these clinical characteristics between sinusitis with bronchial asthma and SBS. These results suggest that the pathogenesis or the inflammatory process of sinusitis is heterogeneous and whether the inflammation is allergic or not may be important.

[Rigid spine syndrome associated with marked hypoxemia and hypercapnia]

A 48-year-old man was referred to our hospital because of hypoxemia (PaO2 = 43 mmHg), hypercapnia (PaCO2 = 70 mmHg), complete atrio-ventricular block, and heart failure. He also had limitation of spine flexion, scoliosis, deformity of the rib cage, and constriction of the ankle joints, complicated by cor pulmonale. These findings were compatible with rigid spine syndrome. To avoid progressive pulmonary hypertension and hypoxemia, nasal BiPAP and home oxygen therapy (0.5 liters/minute) were begun. Rigid spine syndrome is clinically characterized by limitation of spine flexion, and the limitation of thoracic movement often causes severe constrictive respiratory dysfunction. This syndrome should be considered when evaluating patients who have both thoracic deformity, especially scoliosis, and respiratory failure.

Brain death diagnosed by forensic analysis of drug distribution in human tissues-II--Distribution of caffeine in brain dead patients

Caffeine concentrations in human tissues of 6 brain death cases as well as 5 non-brain death cases were examined in order to assess the possibility of diagnosing brain death based on an analysis of this compound. Concentrations of caffeine in human tissues were determined using gas chromatography/mass spectrometry. The tissue-to-blood concentration ratios were used to evaluate the distribution pattern in each case. In non-brain death cases, the ratios in all examined tissues were similar, and the values were close to 1 in all tissues except adipose, of which the value was near 0.3. In brain death cases, the ratios in all tissues except brain and adipose were similar to those in non-brain death cases. The ratios in the brain were higher than those of non-brain death cases, in 5 brain death cases, and lower in 1 brain death case to whom blood transfusion was done in a hospital. The ratios in the adipose were slightly higher in brain death cases than those in non-brain death cases. The discorded distribution of caffeine in brain death cases was presumably related to cessation of cerebral blood circulation at the time of brain death. Therefore, comparing caffeine concentrations in the brain with those in the other tissues can be useful for a forensic diagnosis of brain death.

A case of drowning linked to ingested sulfides--a report with animal experiments

An adult male was found dead beneath a pool of sewage in the pump room of a fish market. Autopsy revealed the cause of death to be suffocation after aspirating sewage into the respiratory tract. Since hydrogen sulfide gas was detected in the atmosphere at the scene of the accident, gas poisoning was suspected and toxicological analysis of sulfides in body tissues was performed. The concentrations of sulfides in the blood, lung and kidney were 0.95 mumol@ml, 0.22 and 0.38 mumol/g, respectively. These values were remarkably higher than those in previously reported cases involving exposure to hydrogen sulfide gas. Therefore, oral intake of sulfides was assumed and the distribution of sulfides in tissues following oral administration of sodium sulfide solution was examined by means of animal experiments using rats. The concentration of sulfides in the blood from rats following oral intake was much higher than that seen following gas exposure. Based on these results, we concluded that the victim had been exposed to hydrogen sulfide gas and had then collapse into a pool of sewage containing sulfides. The sulfides which were distributed throughout the body tissues had mainly issued from the alimentary tract prior to death by drowning.

Sensitive determination of bromazepam in human tissues using capillary gas chromatography-mass spectrometry

A reliable and sensitive gas chromatographic-mass spectrometric method was devised to determine the levels of bromazepam in human tissues. Bromazepam was extracted from body tissues using a three-step solvent extraction procedure. N-Desmethyldiazepam served as the internal standard. Selected ion monitoring with m/z 317 for bromazepam and m/z 270 for internal standard was used for quantitation. Calibration curves in all body tissues were linear over the concentration range from 50-500 ng/g. The lower detection limit in body tissues was 2-5 ng/g and the absolute recovery in body tissues was 27.8-68.0%. This method was used to determine the levels of bromazepam in tissues of an autopsied individual who had been prescribed psychotropic drugs and who was found dead in a car.

Determination of cyanide and thiocyanate in blood by gas chromatography and gas chromatography-mass spectrometry

We devised a sensitive and simple method for determining cyanide and its major metabolite, thiocyanate, in blood using an extractive alkylation technique. Pentafluorobenzyl bromide was used as the alkylating agent, and tetradecyldimethylbenzylammonium chloride was used as the phase-transfer catalyst. The derivatives obtained were analyzed qualitatively by gas chromatography-mass spectrometry and quantitatively by gas chromatography with an electron-capture detection. The detection limits of cyanide and thiocyanate were 0.01 and 0.003 mumol/ml, respectively, while the gross recovery of both compounds was 80%. The calibration curve was linear over the concentration range from 0.02 to 1.0 mumol/ml for cyanide and from 0.01 to 1.0 mumol/ml for thiocyanate. The accuracy and precision of the method were evaluated, and the coefficients of variation were found to be within 10%. Using the method, the blood levels of two victims who had died from cyanide poisoning were determined.

[Eosinophil cationic protein in serum from adults with asthma and with chronic obstructive pulmonary disease]

Levels of eosinophil cationic protein (ECP) in serum are abnormally high in bronchial asthma, and may reflect the degree of eosinophilic inflammation in the lung. The purposes of this study were to evaluate whether serum ECP levels are more closely related to the severity of asthma than are peripheral blood eosinophil counts, and whether these levels can be used to distinguich bronchial asthma from pulmonary emphysema and chronic bronchitis. Serum ECP levels were measured and blood eosinophil counts were obtained in 46 symptomatic adults with asthma (31 atopic and 15 non-atopic), 10 patients with pulmonary emphysema, 11 patients with chronic bronchitis, and 30 non-smoking healthy subjects. Both serum ECP levels and blood eosinophil counts were higher in patients with asthma than in those with pulmonary emphysema, chronic bronchitis and in healthy subjects. Neither serum ECP levels nor blood eosinophil counts differed between atopic and non-atopic patients with asthma. After therapy, serum ECP levels were found to have decreased to have decreased significantly (p < 0.025), but blood eosinophil counts were not. We conclude that both serum ECP levels and blood eosinophil counts are useful for distinguishing bronchial asthma from chronic obstructive pulmonary diseases. These data also indicate that in adults with asthma serum ECP levels may be more closely related to clinical severity than are blood eosinophil counts.

[Antituberculous drug-resistance among homeless peoples]

We studied on the prevalence of drug-resistance among 65 homeless cases who were admitted and treated for active tuberculosis at the Nakano National Chest Hospital during the period from 1990 to 1992 and at the International Medical Center of Japan during the period from 1993 to 1994. Resistance to one or more first line antituberculous drug were revealed in 14 cases out of 65 (21.5%) in initially treated cases 6 out of 43, and in retreated cases 8 out of 22. The prevalence of drug resistance in this study was significantly higher compared with 2 out of 39 cases (5.1%) in our previous report during the period from 1986 to 1988. In these drug-resistant cases, multidrug-resistant cases, namely, resistant to at least 2 drugs including both INH and RFP were founded in 6 cases (9.2%). Compared with drug-sensitive cases, the negative convertion rate of bacilli was lower and the number of defalters was significantly larger. It was suggested that higher prevalence of drug-resistance and defalting from the adequate treatment in homeless cases of tuberculosis possibly makes the prognosis of drug-resistant tuberculosis worse and treatment of such cases more difficult.

[Metastatic lung cancer from renal cell carcinoma effectively treated by bronchial artery embolization]

A 55-year-old man was admitted to the International Medical Center of Japan because of obstructive pneumonia in the right middle and lower lobes. His left kidney had been removed 3 years earlier because of renal cell carcinoma. Metastatic lung cancer from renal cell carcinoma was diagnosed. Bronchial artery embolization was done twice with sponges, because the tumor was thought to be resistant to interferon. Three days after the second embolization, the tumor was removed through the trachea, and atelectasis was relieved. Bronchial artery embolization may be useful for treatment of metastatic lung cancer from renal cell carcinoma.

[Pulmonary involvement in immunoblastic lymphadenopathy: case reports and review of literature published in Japan]

To investigate pulmonary involvement in immunoblastic lymphadenopathy (IBL), we report five cases of IBL and 21 other reports from the literature published in Japan. Three of the present patients had respiratory symptoms and showed hypoxemia on admission. Radiographic findings in the present cases showed bilateral mediastinal and hilar lymphadenopathy (LA: 4/5), pleural effusion (PE: 5/5), interstitial shadow (Int S: 1/5), alveolar shadow (A1S: 2/5), and atelectasis (1/5). In the present cases and those previously reported in Japan, the following radiographic findings were observed; LA (56%), PE (40%), Int S (52%), and A1S (24%). Atelectasis was reported only in the present cases. The nine patients with Int S consisted of four with interstitial pneumonia and five with bronchopneumonia. Four of five patients with bronchopneumonia had an opportunistic infection (three had pneumocystis carinii and one had cytomegalovirus). Among the five patients with A1S, two had interstitial pneumonia and the others had bronchopneumonia. Pulmonary involvement was frequently seen in patients with IBL, and may be an important determinant of the outcome of the disease.

Peripartum heart disease in cows

Thirteen Holstein dairy cows aged 5.1-10.6 years died or were killed as a result of severe illness during the peripartum period, associated with lateral recumbency, moaning, tachycardia and dyspnoea. They were all high milk producers (> 9000 kg/year) and had experienced at least three pregnancies. The average duration of the clinical course was 2.5 +/- 1.7 days. Electro-cardiography revealed marked tachycardia associated with atrial fibrillation or atrioventricular dissociation. Serum clinical chemistry showed severe hypocalcaemia (3.6 +/- 1.3 mg/dl) and at necropsy multifocal myocardial necrosis was invariably found. Myocardial necrosis was accompanied by neutrophilic and mononuclear cellular infiltrates with interstitial fibrosis. The cause of this lesion was not established.

Determination and properties of acetyl conjugate of N-desisopropylpropranolol, AcNDP

1-Acetamino-3-(1-naphthyloxy)-2-propanol (AcNDP) detected in human urine was formed as a metabolite of propranolol (PL) via 1-amino-3-(L-naphthyloxy)-2-propanol (N-desisopropylpropranolol, NDP). The excreted amount of AcNDP was determined by GC-MS using an isotope dilution method. More than 40% of total AcNDP in 24 h urine was detected 10 h after the oral administration of PL to two volunteers, and the total amounts during 24 h urine were at least 1.9-3.9% of the PL dose. As AcNDP is an intermediate metabolite of PL, its urinary amount cannot be determined exactly. Incidentally, AcNDP was chemically stable and was not formed from NDP when acetyl CoA was added to the inactivated hepatocyte system. Thus, the acetylation of NDP, an aliphatic primary amine, was confirmed to be catalyzed by N-acetyltransferase, and interestingly, the acetyl conjugation was inhibited not by sulfamethazine but by p-amino benzoic acid.