Ultrastructural study of the synapses of central chromatolytic anterior horn cells in motor neuron disease

This report deals with an ultrastructural investigation of the synapses on the somata of central chromatolytic anterior horn neurons of seven patients with amyotrophic lateral sclerosis (ALS) and four patients with lower motor neuron disease (LMND) who had no upper motor neuron or corticospinal tract involvement. Specimens from 24 age-matched individuals who died of non-neurological diseases served as controls. We examined a total of 171 anterior horn neurons with central chromatolysis (51 from ALS, 42 from LMND and 78 from controls), and 174 normal-appearing anterior horn neurons as controls. The cross-sectional area, the number of synapses, and the length of active zone were significantly reduced in the chromatolytic neurons of both patients and controls as compared with normal-appearing neurons of the controls (p < 0.0001). However, regarding chromatolytic neurons, no significant differences were seen in the number of synapses, length of each individual synapse, and length of its active zone between patients and controls and also in the frequency of presynaptic alterations on the somata. There was no overall difference between ALS and LMND patients in any of these parameters. Our findings suggest that the flow of electrophysiological information from afferent fibers to the somata may be greatly impaired in central chromatolytic neurons of both control individuals and patients with motor neuron disease (MND), and that the observed synaptic alterations may reflect pathological events resulting from anterior horn neuron degeneration. It may represent a compensatory mechanism of the synapses for diminished synaptic function that synapses were relatively well preserved on the somata of central chromatolytic neurons of the MND patients as compared with those of the chromatolytic neurons of the controls despite of markedly reduced cross-sectional area in the former. It also suggests that the pathomechanism involved in central chromatolysis differs between normal individuals and patients with MND.

[Follicular bronchiolitis associated with rheumatoid arthritis]

A 52-year-old man with an 8-year history of rheumatoid arthritis was admitted to the hospital because of coughing and purulent sputum. A chest X-ray film obtained on admission showed small nodular shadows without overinflation in both lower lung fields, and a high-resolution CT scan showed many micronodular shadows in the centrilobular regions. Follicular bronchiolitis was diagnosed from the results of an open-lung biopsy, and prednisolone therapy was started at a dosage of 40 mg/day. Sinusitis developed 4 years later. Five years after the start of steroid therapy, dilation of bronchi and thickening of bronchial walls appeared on a CT scan, which also showed areas of low attenuation that were presumed to be bronchiolitis obliterans. These findings suggest that the pattern of airway disease can vary during the course of rheumatoid arthritis.

Impairment of fast axonal transport in the proximal axons of anterior horn neurons in amyotrophic lateral sclerosis

We studied the possible impairment of fast axonal transport in patients with amyotrophic lateral sclerosis (ALS) to gain some insight into the pathogenesis of the disease. We carried out an ultrastructural investigation of the proximal axons (axon hillock and initial segment) of the anterior horn neurons on samples from 11 ALS patients; specimens from 12 age-matched individuals who died of nonneurological diseases served as controls. Eighty-seven proximal axons that emanated directly from normal-appearing neurons were examined in each group of subjects. Increased smooth endoplasmic reticulum (SER) and the formation of bundles of fibrillary SER with a single unit membrane were not uncommonly observed in the initial segment of the patients with ALS. In some instances, there was loss of the parallel SER arrangement along the longitudinal axis. When viewed in transverse sections, the bundles had a tubular appearance. These morphologic changes of SER were exclusively demonstrated in patients with ALS. A marked increase or accumulation of mitochondria and lysosomes was more common in the proximal axons, particularly in the axon hillock, of ALS patients than of control subjects. The accumulation of these membrane-bounded cytoplasmic organelles suggests that fast axonal transport is impaired in the proximal axons of individuals with ALS. In addition, there were Lewy body-like hyaline inclusions, lipofuscin granules, and multiple membranous structures in the proximal axons. The presence of these unusual structures may also be a reflection of axonal transport dysfunction. By contrast, in the central chromatolytic neurons, there was not only a decrease in the number of neurofilaments in the axon hillock and initial segment, but also of mitochondria, lysosomes, and SER. In some instances, none of these cytoplasmic organelles was seen. These findings support the notion that the outflow of cytoplasmic constituents from the anterior horn cell body into the proximal axon may be impaired in central chromatolytic neurons.

[Peripheral nerve myelin antigen-specific T cells in human]

In recent years, anti-myelin glycolipid antibodies have been reported to be specific for acute inflammatory demyelinating polyneuritis (AIDP) so the involvement of autoimmune mechanism by such autoantibodies was strongly suggested as a cause of AIDP. However, the cellular immunity of AIDP has been seldom reported yet. To examine the T cell response to peripheral nerve antigens in human, we tried to establish T cell lines reactive to peripheral myelin antigens. P0 56-71, P0 180-199 and P2 59-78 peptides from human peripheral blood of controls and patients with inflammatory demyelinating polyneuritis. Frequencies of T cells reactive with P0 56-71, P0 180-199 and P2 59-78 peptides in five controls were (0.59 +/- 0.81) x 10(-7), (1.53 +/- 0.53) x 10(-7) and (0.11 +/- 0.24) x 10(-7), respectively. Frequency of P0 180-199-reactive T cells in one AIDP patient of acute stage was 3.5 x 10(-7) and approximately 2 times high value of controls. There is no significant association between their frequency and specific MHC class II genotypes in subjects until now. Thus, peripheral myelin antigen-specific T cell lines in particular recognizing P0 180-199 were established from the majority of controls and polyneuritis patients. These results suggest that the residues of P0 180-199 might be one of T cell epitopes also in human subjects.

Activation of prefrontal and posterior superior temporal areas in visual calculation

Regional cerebral blood flow was measured with H2(15)O-positron emission tomography during the performance of visually presented calculation tasks to clarify cortical areas involved in arithmetic operations. The findings on a calculation task were compared with those on a covert reading task and with those of a fixation control task. Region of interest-based analysis showed that the left prefrontal area was activated in visual calculation relative to covert reading and the posterior superior temporal gyrus including part of Wernicke's area was activated in calculation relative to fixation control. The role of the prefrontal area in computation (arithmetic operations) and that of the posterior superior temporal gyrus in both comprehension of the stimuli and computation were suggested.

The 160k alpha 1(IV) chain, a short form of a type IV collagen polypeptide, of bovine lens capsule retains the NC1 domain

We recently reported that the bovine lens capsule contained a shorter alpha 1(IV) chain (160k) as a major polypeptide in addition to the 180k alpha 1(IV) chain [J. Biochem. (1995) 117, 1298-1304]. Two experiments were performed to examine whether or not the 160k polypeptide retained the carboxyl-terminal NC1 domain. On immunoblotting analysis with a monoclonal antibody (H11) raised against the NC1 domain of the human alpha 1(IV) chain [positions 1643-1650; near the carboxyl-terminal end of the human alpha 1(IV) chain], the 180k and 160k polypeptides showed identical immunoreactivity, suggesting that the two chains had the same human alpha 1(IV) collagen NC1 domain sequence. Another monoclonal antibody (H21) specific for the NC1 domain of human alpha 2(IV) did not react with these polypeptides, but with the bands corresponding to 175k and 155k. The 160k polypeptide was selectively solubilized from bovine lens capsules, leaving the other major polypeptides, 180k and 175k, insoluble. The 160k polypeptide was separated by preparative electrophoresis. Bacterial collagenase digestion of the separated 160k polypeptide produced collagenase-resistant segments of about 29k and 30k in size based on globular standards. These sizes corresponded well with those of the NC1 domains of type IV collagen alpha chains (25-30k). The results indicated that the 160k polypeptide retained the carboxyl-terminal NC1 domain of the alpha 1(IV) chain. In turn, the 20k polypeptide of the amino-terminal region or the 7S domain of 180k alpha 1(IV) would have been excised to yield 160k alpha 1(IV), assuming that the 160k alpha 1(IV) chain is a processed form of the 180k alpha 1(IV) one and not an alternatively spliced chain of the alpha 1(IV) gene.

[Regulation of thymocyte apoptosis and positive selection]

Developing T cells undergo thymic selection at the CD4+CD8+ stage. Only less than 5% of CD4+CD8+ thymocytes are positively selected to survive and differentiate into mature single positive CD4 or CD8 T cells. Positive selection requires signaling through the T cell receptors (TCR) with assistance of CD4 or CD8 coreceptor and LFA-1, but its molecular mechanism is poorly understood. By using glucocorticoids, anti-apoptotic activity was detected in CD4+CD8+ thymocytes upon proper cross-linking of TCR/CD3 complex with CD4, CD8, or LFA-1, and was mimicked by a combination of a calcium ionophore and a protein kinase C activator. Isolated CD4+CD8+ thymocytes underwent differentiation and commitment to the CD4 T cell lineage by moderate and transient stimulation with this combination of the drugs.

[Swyer-James syndrome with unilateral pulmonary edema]

A 64-year-old man with ischemic heart disease was admitted to our hospital because of dyspnea. A chest X-ray film showed a butterfly shadow in the right lung. A chest X-ray film obtained before the patient had respiratory symptoms showed hyperlucency of the left lung. CT scans obtained at maximal inspiration and expiration revealed air trapping. Pulmonary arteriography showed that the left pulmonary artery and its branches were very small. Cardiac catheterization showed poor cardiac function. Swyer-James syndrome should be included in the differential diagnosis of patients with unilateral pulmonary edema.

Rheological analysis of peripheral blood neutrophils in a patient with cutaneous and arthropathic psoriasis accompanying hypopyon-iridocyclitis

A 32 year old Japanese male has had several synchronized attacks of psoriatic arthritis and hypopyon-iridocyclitis. During exacerbations, he has a leucocytosis with neutrophilia and elevated C-reactive protein. Assessment for adhesiveness, aggregation and deformation of peripheral neutrophils revealed strikingly high rheological activity whereas during periods of remission the activity was only slightly elevated above normal.

[A case of relapsing Guillain-Barré syndrome following Miller Fisher syndrome]

Miller Fisher syndrome (FS) is thought to be a variant of Gullain-Barré syndrome (GBS), both of which rarely relapse. We report a rare case of GBS that followed FS. A 38-year-old woman had ophthalmoplegia, ataxia and areflexia following an upper respiratory tract infection with a diagnosis of FS. Serum anti-GQ1b IgG antibody was found to be increased, but decreased through immunoadsorption as the neurological symptoms of the patient improved. She became completely asymptomatic three months after the onset of FS. Following a common cold two months later, however, she developed weakness of all four limbs and dysesthesia of hands and feet with albuminocytologic dissociation of cerebrospinal fluid, which was consistent with the diagnosis of GBS. Moreover, serum anti-GQ1b IgG antibody had increased again. Anti-GQ1b IgG antibody frequently becomes positive not only in FS but also GBS with ophthalmoplegia. However, the antibody was positive in this particular patient with GBS, even in the absence of ophthalmoplegia. This case suggests that anti-GQ1b IgG antibody might be a common pathogenesis of both FS and GBS.

[Amyloidosis secondary to bronchiectasis]

A 77-year-old woman was hospitalized repeatly due to frequent hemoptysis and production of bloodly sputum for several years. Bronchography in 1989 revealed bronchiectasis. She had complained of abdominal pain and diarrhea since 1991, and her urine was first positive for protein in 1992. She was admitted to our hospital in October 1992 because of edema, anemia, and hypoproteinemia. Despite treatment, renal dysfunction and the gastrointestinal disorder progressed and she died in January 1993. An autopsy revealed diffuse depositions of amyloid in many organs, especially in the kidney and the gastrointestinal tract. This amyloid protein was identified as AA protein, which was suggestive of secondary amyloidosis. Bronchiectasis appears to have been the disease underlying this patient's amyloidosis.

[Increased CA19-9 level in serum and bronchoalveolar lavage fluid from a patient with pulmonary tuberculosis]

A 66-year-old woman was admitted to the hospital because of general malaise and loss of appetite. Laboratory examination revealed an abnormally high level of CA19-9 in serum and a chest roentgenogram revealed soft reticular shadows in the right mid-lung field. An extensive examination revealed no malignant disease. Bronchoalveolar lavage fluid obtained from the right B5 contained an abnormally high level of CA19-9. Immunochemical staining for CA19-9 was positive in the epithelial cells of respiratory bronchioles. The level of CA19-9 decreased during anti-tuberculosis therapy. This case suggests that the CA19-9 level can reflect the activity of pulmonary tuberculosis.

Synaptic loss in anterior horn neurons in lower motor neuron disease

This report concerns an ultrastructural investigation of the synapses of anterior horn neurons in the lumbar spinal cord of four patients with lower motor neuron disease (LMND) who had no upper motor neuron and corticospinal tract involvement. Anterior horn neurons of five normal individuals served as controls. The cell body area and the number of synapses of the normal-appearing neurons of the LMND patients were significantly reduced (P < 0.0001). These findings suggest that synaptic changes of anterior horn neurons could be ascribed to the degeneration of lower motor neurons rather than to the influence of upper motor neuron system degeneration. On the other hand, the lengths of individual synapses (P < 0.0001) and of their active zones (P < 0.05) were significantly increased in the patients. These increases would indicate that synapses on anterior horn neurons of individuals with LMND appear to have the capacity to react to progressive degeneration and loss of other synapses by means of a compensatory response or plasticity that enhances their efficiency.

Assessment of clinical significance of positive blood cultures of relatively low-virulence isolates

In Omori Hospital, Toho University School of Medicine, relatively low-virulence blood isolates, including coagulase-negative staphylococci (CNS), enterococci and nonfermentative gram-negative rods other than Pseudomonas aeruginosa comprised c. 60% of total blood isolates. A retrospective study was conducted to assess their clinical significance by reviewing a total of 91 hospital charts. The physicians' assessments of these positive blood cultures as recorded in the charts were classified into four categories--sepsis, possible sepsis, contamination and no comment. The episodes classified as sepsis accounted for 5.0-19.6%. These episodes were also evaluated by a graded clinical significance score based on multiple factors, including number of positive cultures and clinical signs. The scores for the 91 episodes covered a wide range from 1 to 9, indicating that both contaminants and causative organisms may have been involved. The episodes judged as sepsis or possible sepsis tended to have higher scores. The scores for the episodes associated with enterococci were also higher than those involving CNS or non-fermentative gram-negative rods. The scores for episodes associated with intravenous hyperalimentation catheters were higher than those not associated with the catheters.

[Diffuse alveolar septal amyloidosis associated with multiple myeloma (IgA lambda type)]

A 75-year-old man with multiple myeloma presented with fever and respiratory symptoms. A chest roentgenogram showed interstitial shadows and transbronchial lung biopsy revealed diffuse infiltration of amyloid in the alveolar walls. Analysis of bronchoalveolar lavage fluid showed the presence of an IgA-lambda paraprotein, and the IgA/albumin ratio was similar to that in serum. However, plasma cells could not be detected in the cells obtained by lavage. We know of no previous case in Japan in which bronchoalveolar lavage fluid was examined in a case of diffuse alveolar septal amyloidosis.

In vitro differentiation and commitment of CD4+ CD8+ thymocytes to the CD4 lineage, without TCR engagement

Thymocyte positive selection is based on protection of immature CD4/CD8 double-positive (DP) thymocytes from apoptosis and their differentiation into CD4 or CD8 single-positive (SP) cells. Intracellular signals essential for positive selection appear to be induced through the TCR and some of the accessory molecules including LFA-1, CD4 and CD8 upon interaction with thymic stromal cells. The signals, however, still remain to be identified. Since physiological levels of glucocorticoids potentially induce or enhance thymocyte apoptosis even in vivo, the signals are likely to inhibit the apoptotic effect of glucocorticoids. We have previously shown that proper cross-linking of TCR-CD3 with LFA-1, CD4 or CD8 inhibited glucocorticoid-induced thymocyte apoptosis in vitro, and that a proper combination of the calcium ionophore, ionomycin and the protein kinase C (PKC) activator, phorbol 12-myristate 13-acetate (PMA), mimicked the inhibitory effect. Here we determined whether this combination of ionomycin and PMA induces differentiation of isolated DP thymocytes from normal and TCR transgenic mice. We found that pretreatment of DP thymocytes with ionomycin and PMA followed by 1 day culture of the cells without the reagents resulted in the differentiation of the cells into CD4 SP and CD4+ CD8lo T cells that have mostly committed to the CD4 lineage. The changes in expression of other differentiation markers were also in good accordance with those associated with positive selection, except the final maturation. The results indicate that moderate and transient increases in intracellular Ca2+ level and PKC activity induce differentiation and commitment of DP thymocytes to the CD4 lineage, and suggested that the biochemical pathway leading to positive selection is based on a similar mechanism.

[Diagnosis of intracardiac thrombi by various imaging techniques and activation of platelets and coagulation-fibrinolysis in patients with cardioembolic stroke]

Recent epidemiological studies have suggested that 15 to 30% of all ischemic stroke is comprised of cardioembolic stroke. The presence of intracardiac thrombi might prove to be the most reliable tool when making a diagnosis of cardioembolic stroke, although not always easy to determine even with recent advanced technique. In this study, sensitivities to detect intracardiac thrombi of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), cardiac-enhanced CT (CCT) and scintigraphy with indium-111-tropolone-labelled platelets (PSG) were compared, in order to provide a relevant guideline for the diagnosis of intracardiac thrombi in 83 patients suspected of cardioembolic stroke. Also studied was the correlation of intracardiac thrombi with activation of platelets and coagulation-fibrinolysis through performing various hemostatic tests in order to investigate their utility for the evaluation of in situ thrombosis or prothrombotic state in the heart chamber. Detection rates of intracardiac thrombi were 35% in TEE, 26% in CCT, 19% in PSG, and 11% in TTE. There was a significant difference in the sensitivity between TEE and TTE (p < 0.05). Left atrial thrombi were frequently detected in TEE (4 out of 5 patients) and CCT (7 out of 10), while they were found less in PSG (2 out of 4) an TTE (4 out of 10). Thrombi in the left appendage were visualized in 3 out of 3 by TEE, while only in 1 out of 3 by PSG, 1 out of 4 by TTE and 1 out of 4 by CCT. Left ventricular thrombi; CCT (3 out of 3), TTE (2 out of 3), PSG (1 out of 1); TEE was not performed since this technique could not be expected to provide high-quality images of left ventricular thrombi. Thus, left atrial thrombi were considered to be more sensitively detected by TEE and CCT, left appendage thrombi by TEE, and left ventricular thrombi by TTE and CCT. There was no patient in whom an intracardiac thrombus was visualized by PSG alone. On the basis of the results above, we propose the following guideline for the detection of intracardiac thrombi in patients presented with cardioembolic stroke. First, TTE and CCT appear to be relevant for screening tests because of simple and non-invasive techniques. These two tools might be sensitive enough to find left ventricular thrombi. Second, TEE should be recommended when a thrombus is suspected in the left atrium or appendage. Finally, PSG may be used to determine the activity of the thrombus, according to its necessity. Among the patients having intracardiac thrombi, frequently observed was the increase of beta-thromboglobulin, platelet factor 4, platelet lysis, thrombin-antithrombin III complex, D-dimer in 67%, 75%, 71%, 80% and 80%, respectively, as well as the shortening of platelet survival in 100%, while anrithrombin III was reduced in only 38%. In addition, when hemostatic abnormalities were compared between positive and negative groups of intracardiac thrombi, the shortening of platelet survival (p < 0.0001), the increase of platelet lysis, and the increase of D-dimer (p < 0.04) were more frequent in the positive group than in the negative group. These results indicate that the findings of activation of platelets and coagulation-fibrinolysis, except for the reduction of antithrombin III, especially the findings of platelet consumption and lysis as well as fibrinolysis activation are useful as sensitive parameters of in situ thrombosis or prothrombotic state, which may lead to the formation of intracardiac thrombi.

Progressive dysphagia due to adult Chiari I malformation mimicking amyotrophic lateral sclerosis

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Ultrastructural study of synapses in the anterior horn neurons of patients with amyotrophic lateral sclerosis

This report concerns an ultrastructural examination of the synapses present on the surface of somata of anterior horn neurons of the lumbar spinal cord of seven patients with amyotrophic lateral sclerosis (ALS). Specimens from six age-matched, neurologically normal control individuals were included for comparison. Examination of presynaptic terminals revealed a wide range of changes not only in degenerated neurons (central chromatolytic neurons), but, to a lesser extent, in normal-appearing neurons. The alterations included dense conglomerates of aggregated dark mitochondria and presynaptic vesicles, bundles of neurofilaments, as well as marked increase of presynaptic vesicles. Our observations suggest that in patients with ALS a substantial synaptic alteration does take place in the early stages of anterior horn neuron degeneration and degeneration of axosomatic synapses of anterior horn neurons in ALS may be of consequence on lower motor neuron degeneration.

Dendritic synapses of anterior horn neurons in amyotrophic lateral sclerosis: an ultrastructural study

This ultrastructural study deals with the synapses of primary dendrites of the anterior horn neurons in the lower lumbar spinal cords of seven patients with amyotrophic lateral sclerosis (ALS) who had mild neuronal depletion. Specimens from seven age-matched, neurologically normal individuals served as controls. In each instance, the autopsy was performed within 6 h after death. Our results indicate a statistically significant increase in degenerative changes in the dendrite presynapses of normal-appearing neurons of the ALS patients. The alterations included aggregation of electron-dense synaptic vesicles and dark mitochondria with dense cristae, and bundles of neurofilaments. However, we found no significant difference between controls and patients with respect to cross-sectional area and length of the dendrites, number of synapses per dendrite, and lengths of individual synapses and their active zones in the normal-appearing neurons, even though the patients' neurons had a smaller cross-sectional area. In chromatolytic neurons, the number of synapses and the length of the active zone of the primary dendrites were significantly diminished. These findings suggest that despite degenerative changes of the presynapses, the synapses in the primary dendrites of the anterior horn neurons are preserved at the early stage of ALS. The preservation of these synapses may be due to their relative resistance to degenerative processes, or may represent a compensatory mechanism of the synapses for diminished synaptic function in distal dendrites.

Cloning and characterization of a probenazole-inducible gene for an intracellular pathogenesis-related protein in rice

Probenazole (3-allyloxy-1,2-benzisothiazole-1,1-dioxide) induces disease resistance in rice against rice blast fungus. To investigate the molecular mechanism of probenazole-induced resistance, we isolated and characterized a cDNA clone of a probenazole-inducible gene in rice, which encoded a protein designated PBZ1. Sequence analysis revealed that significant homology at the amino acid level exists between the predicted PBZ1 protein and intracellular pathogenesis-related (IPR) proteins. Accumulation of PBZ1 mRNA was not induced by wounding, but markedly induced by inoculation with rice blast fungus. In addition, it was induced sooner by inoculation with an incompatible race than that with a compatible race. On the other hand, when the accumulation of the PBZ1 mRNA was examined after treatment with probenazole-related compounds, it was not fully correlated with anti-rice blast activity. However, it was induced after treatment with N-cyano-methyl-2-chloro-isonicotinamide (NCI), which belongs to another group of compounds known to induce disease resistance. Thus, although the accumulation of the PBZ1 mRNA was not fully correlated with anti-rice blast activity, our findings suggest that the PBZ1 gene has an important function during the disease resistance response in rice.

Psoriatic arthritis and hypopyon-iridocyclitis. Possible mechanism of the association of psoriasis and anterior uveitis

BACKGROUND

We present a 32-year-old Japanese man with psoriatic arthritis who developed recurrent episodes of hypopyon-iridocyclitis associated with exacerbations of the arthropathy.

OBJECTIVE

To evaluate the mechanism of the association between psoriasis and uveitis, we analyzed the rheological characteristics of the patient's peripheral blood neutrophils during attacks and during remissions.

METHODS

The rheological activity of neutrophils was determined by the micropore filtration method. It was expressed as micropore filtration time when a neutrophil-erythrocyte suspension passes through a micropore filter (pore size 5 microns).

RESULTS

The micropore filtration time in this patient was longer than that of healthy control subjects (p < 0.01) and of psoriatic patients without uveitis (p < 0.05); it was also longer during the appearance of the eye disorder with the exacerbation of psoriatic arthritis than during remissions.

CONCLUSIONS

Activated neutrophils in the peripheral blood of our patient were probably responsible for the attacks of hypopyon-iridocyclitis as well as the exacerbation of psoriatic skin lesions and/or arthritis.

A clinical profile of corticobasal degeneration presenting as primary progressive aphasia

We report a patient with primary progressive aphasia who first presented with amnesic aphasia that developed over the course of 3 years into nonfluent aphasia with buccofacial apraxia, followed in the next year by cognitive impairment and parkinsonism. Pathological findings were typical for corticobasal degeneration except for the distribution of cortical atrophy. This case suggests that corticobasal degeneration should be included in the differential diagnosis of primary progressive aphasia, especially in association with parkinsonism.

[Middle lobe syndrome--incidence and relationship to atypical mycobacterial pulmonary disease]

We evaluated the incidence of middle lobe syndrome in the Haibara area, and its relationship to atypical mycobacterial infection. Of the 30,588 persons who underwent annual mini-chest roentgenography in 1992 or 1993 or both, 51 (0.17%) had middle lobe syndrome, diagnosed from posteroanterior and lateral chest X-ray films. The incidence was significantly higher in persons over 50 years old than in persons under 50 years old (0.26% vs 0.02%: p < 0.001), and was higher in femals than in males (0.20% vs 0.11%: p = 0.527). Of 16 patients examined by bronchoscopy and computed tomography, 7 showed evidence of cylindrical bronchiectasis, and four had mycobacterium avium complex pulmonary disease presenting as middle lobe syndrome. All four were women who were 51 years of age or older and none had predisposing pulmonary disorders. Computed tomography showed multiple nodular shadows with or without bronchiectasis located in the middle lobe or the lingula. Cavitary lesions were not seen. These results indicate that middle lobe syndrome is not rare, and that infection with mycobacterium avium complex should be considered when multiple nodular shadows are seen in the middle lobe or the lingula.