Disseminated Mycobacterium avium-intracellulare infection in a patient with myelodysplastic syndrome (refractory anemia)

A 31-year-old woman presented with fever and arthralgia. Despite treatment with antimicrobials and corticosteroids, her symptoms persisted. A diagnosis of myelodysplastic syndrome (MDS)-refractory anemia (RA) was made by pancytopenia, dysplasia, and trisomy 8. Cultures of bone marrow, blood, and gastric juice showed Mycobacterium avium-intracellulare (MAI). She was treated with antimycobacterial drugs and recombinant human G-CSF/M-CSF and showed an initial response, but spike fever recurred and pancytopenia progressed. Hepatosplenomegaly and marked retroperitoneal lymphadenopathy were revealed, indicating further dissemination of MAI. Treatment with recombinant human GM-CSF and very-low-dose cytosine arabinoside, was started but was not effective. This case showed significant reduction in peripheral blood T-lymphocytes, especially the CD4+ population, and low immunoglobulin levels. Immunodeficiency state associated with long-term steroid therapy and MDS seemed to contribute to the development of the disseminated infection with MAI.

A deletion mutation in the 3' end of the alpha 5(IV) collagen gene in juvenile-onset Alport syndrome

Alport syndrome is a hereditary progressive glomerular basement membrane disorder in which juvenile-or adult-onset renal failure is often accompanied by sensorineural deafness and ocular abnormalities. Recently, mutations have been found in the type IV collagen alpha 5 chain gene in patients with X-linked Alport syndrome. This study searched for gene mutations in seven unrelated Japanese patients by the use of conventional Southern blot analysis with cDNA probes for the carboxyl-terminal noncollagenous domain that is encoded by exons 46 to 51. A deletion mutation was found in a patient who developed juvenile-onset (age 15) ESRD with typical ultrastructural glomerular basement membrane destruction and sensorineural hearing loss but no characteristic ocular abnormalities. His mother showed hematuria and proteinuria with normal renal function, suggesting that she may be the heterozygous carrier. Exon-specific polymerase chain reaction amplified the coding sequence of exon 48 but not exons 49 to 51. Analysis with pulsed-field gel electrophoresis revealed that the deletion is approximately 10 kb in length and does not involve the CpG island, which is located in the 3' distal site of the gene. Identification of this novel deletion causing juvenile-type Alport syndrome would contribute to elucidating the mechanisms of renal failure progression in the syndrome.

[Two cases of lung infection due to Mycobacterium chelonae subsp. abscessus]

Two cases of lung infection due to Mycobacterium chelonae subsp. abscessus are reported. Case 1, a 50-year-old female, was a secondary infection-type, and case 2, a 53-year-old female, was a primary infection-type. The 16 cases reported, between the ages of 29 and 76 years, there were 6 males and 10 females. The roentgenographic examinations, revealed that the ratio of the primary and secondary infection-type was 3:1. Effective agents for this organism has not been yet confirmed. In the present study, we treated two patients with AMK and IPM/CS, and obtained negative conversion of the sputum culture as well as improvement of roentgenographic features.

A morphological study of acute respiratory tract lesions in a lipopolysaccharide instilled rat model

Acute inflammatory reactions in different respiratory regions were studied in a lipopolysaccharide (LPS) instilled rat model. Rats were sacrificed at 1, 2, 4, 8, 12, 24 and 48 h after administration of Escherichia coli LPS to the lumen of the trachea, and changes in the trachea, bronchioles and alveoli were observed by light and electron microscopy. In the trachea, neutrophils were markedly increased in subepithelial connective tissue and between tracheal epithelial cells, from 2 h on, showing a peak at 8 h. The number of tracheal mast cells increased at 4 and 8 h. Different structural features of secretory granules between mast cells in the tracheal epithelium and subepithelium were noticed, and the possible involvement of mast cells in airway acute inflammation is discussed. In the bronchioles, Clara cells showed characteristic morphological alterations. At 8 to 12 h, Clara cells revealed well-developed smooth and rough endoplasmic reticula and many free ribosomes, possibly for enhanced synthesis of secretory substances. Many Clara cells possessed a large apocrine-like protrusion filled with an amorphous substance, likely indicating an apocrine secretion of the cells. At 24 h, Clara cells were observed to take on a pseudostratified arrangement, suggesting enhanced proliferation of progenitor cells and their differentiation into Clara cells. In the alveoli, neutrophils infiltrated alveolar walls and pulmonary venules at 4 h and disappeared at 12 h. Prior to morphological changes in bronchioles and alveolar walls at 2 h, the macrophages with well-developed filopodia and free-ribosomes appeared in alveolar sacs and ducts. They may contribute to histological changes especially at the initial stage of acute inflammation in alveoli.

Small hepatocellular carcinoma with intravascular tumor growth into the right atrium

A 66-year-old man with ascites and marked edema in the lower extremities was suspected of having secondary Budd-Chiari syndrome due to primary liver cancer, based on imaging diagnosis, i.e., ultrasonography, computed tomography, and inferior venacavogram. At autopsy, an encapsulated small liver cancer was found to have extended into the inferior vena cava and right atrium. There have been few reports of small hepatocellular carcinoma with intravascular tumor growth into the right atrium.

Effect of a platelet-activating factor antagonist, WEB 2086, on inhibition of active oxygen generation in human polymorphonuclear leukocytes

We investigated the effect of WEB 2086, 3-[4-(2-chlorophenyl)-9-methyl-6H-thieno[3,2-f][1,2,4]triazolo- [4,3-a][1,4]-diazepin-2-yl]-1-(4-morpholinyl)-1-propanone, an antagonist of platelet-activating factor, on the generation of active oxygen by human polymorphonuclear leukocytes. This agent inhibited the production of oxidative metabolites by these cells following stimulation by opsonized zymosan and formyl-methionyl-leucyl-phenylalanine in a time-dependent fashion. To determine whether it would directly inhibit the production of oxygen metabolites by these cells, they were preincubated with WEB 2086 and washed prior to stimulation. WEB 2086 was found to directly inhibit the generation of active oxygen metabolites by these cells. WEB 2086 may be a scavenger of active oxygen metabolites since it rapidly inhibited the production of active oxygen metabolites by these cells. It also directly affected the scavenging of active oxygen metabolites that were generated by the opsonized zymosan-stimulated human polymorphonuclear leukocytes. This action of WEB 2086 was also noted to be exerted against hydroxyl radicals and superoxide anions produced biochemically by an electron spin resonance spectrometer. It thus follows that WEB 2086 may inhibit the generation of active oxygen metabolites by human polymorphonuclear leukocytes and directly influence the scavenging of these metabolites.

[Prognosis of interstitial pneumonitis (IP) in polymyositis (PM)/dermatomyositis (DM)]

IP, the major complication of PM/DM, is closely related to the life of these patients. In this study the course and prognosis of IP associated with PM/DM were investigated. Thirty IP patients with PM/DM were divided into 4 groups according to the course of IP. Clinical manifestations, laboratory data, chest radiographs and treatment were examined retrospectively. Eleven cases improved (Group I), 11 cases were exacerbated (Group E), 3 cases were unchanged (Group U), 2 cases died due to rapid progression of IP (Group D) and 3 cases dropped out. Both Group D patients were middle aged female DM patients without CPK elevation. All cases were treated with corticosteroids. The clinical manifestations, laboratory data, chest radiographs and initial dose of corticosteroid were not markedly different between Group I and E. The total dose of corticosteroids during the first 3 months tended to be higher in Group I than in Group E. Unlike idiopathic interstitial pneumonitis, the decrease in lung volume on chest radiographs improved after the treatment in 5 cases. We conclude that IP associated with PM/DM should be treated initially with high doses of corticosteroids.

Acquired type II protein C deficiency in a long-term hemodialysis patient

We present a 57-year-old man with end-stage renal failure due to chronic glomerulonephritis, who had been on hemodialysis for 13.5 years and had suffered from recurrent painful swelling of the left leg for 4.7 years. A diagnosis of deep venous thrombosis was made by the phlebography. Coagulation studies showed decreased protein C activity despite a normal protein C antigen level. None of his relatives had decreased protein C activity, and the levels of the other coagulation factors synthesized by the liver were all normal. Accordingly, the patient was diagnosed as having acquired type II protein C deficiency.

Haemophilus parainfluenzae antigen and antibody in renal biopsy samples and serum of patients with IgA nephropathy

IgA nephropathy may be associated with colonisation with Haemophilus parainfluenzae. In patients with glomerular diseases, we examined renal-biopsy specimens for presence of bacterial antigen by immunofluorescence microscopy with rabbit antiserum against H parainfluenzae, and by enzyme-linked immunosorbent assay looked for IgA antibody against H parainfluenzae in patient sera. The rabbit antiserum recognised by immunoblotting four components of H parainfluenzae outer membranes (OMHP) of molecular weights 19.5, 30, 33, and 40.5 kDa. All 44 patients with IgA nephropathy and 2 of 39 patients with other glomerular diseases showed mesangial deposition of OMHP antigens (p < 0.001). Patients with IgA nephropathy had significantly more IgA antibody against H parainfluenzae than did patients with other glomerular diseases. IgA antibody in the sera of patients with IgA nephropathy recognised by immunoblotting the same four components of OMHP as recognised by rabbit antiserum. Glomerular deposition of OMHP antigens and the presence of IgA antibody against OMHP in patients with IgA nephropathy suggest that H parainfluenzae has a role in the aetiology of this disease.

Alternative splicing in the alpha 5(IV) collagen gene in human kidney and skin tissues

Type IV collagen is a complex molecule composed of three alpha chains that can be of types alpha 1(IV) to alpha 5(IV). Each alpha chain contains an amino-terminal collagenous domain and a carboxyl-terminal noncollagenous (NC) domain consisting of 229 amino acids, which is involved in intermolecular cross-linking to construct the basement membrane network. Specific localization of alpha 5(IV) collagen in glomerular basement membranes (GBM) in the kidney indicates its crucial role for that construction. In human kidney cortex and skin RNA, we found an alternative splicing transcript which skips exon 50 of the alpha 5(IV) collagen gene using reverse transcription-polymerase chain reaction and direct sequencing of the PCR products. This alternative splicing introduces a stop codon at the first codon of exon 51, resulting in an mRNA encoding a protein lacking the 84 NC domain carboxylterminal amino acid residues encoded by exons 50 and 51. Recently, gene mutations affecting the alpha 5(IV) collagen NC domain have been reported in patients with X-linked Alport syndrome who display GBM destruction and progressive renal failure, which are usually milder in female patients. Therefore, the alternative splicing, if its truncated products are dominantly expressed in glomeruli, may cause GBM impairment and renal failure progression.

Nephrotoxic serum nephritis in nude rats: the role of cell-mediated immunity

The role of T cell-mediated immunity in the early phase of nephrotoxic serum nephritis (NTN) was examined by transfer of pan T, CD8-positive, and CD4-positive cells. The disease was induced by transferring rabbit gamma-globulin (RGG)-sensitized T cells to nude (rnu/rnu) rats pretreated with a subnephritogenic dose (a dose insufficient to cause proteinuria) of nephrotoxic serum. Mild but abnormal proteinuria was detected, and macrophages showed significant accumulation in glomeruli. Transfer of not only RGG-sensitized CD4-positive cells but also CD8-positive cells separated by the T cell markers OX8 and OX38 using the panning method caused an increased accumulation of macrophages in isolated glomeruli. No host antibody against rabbit immunoglobulins was demonstrated either in glomeruli by immunofluorescence or sera by ELISA in the early disease phase. These findings support a pathological role of T cells in initiation of glomerular injury in NTN.

The effect of leukotriene C4 on the permeability of brain capillary endothelial cell monolayer

The role of leukotrienes as mediator of brain edema is still controversial. Recently, the ability of gamma-GTP to act as enzymatic barrier and to inactivate leukotrienes in normal brain capillaries was pointed out. A hypothesis tested in our experiments was that Leukotriene C4 (LTC4) increases permeability of a cerebral capillary endothelial monolayer which lacks gamma-GTP activity. Brain capillary endothelial cells were obtained of 10 rats from cerebral cortex by an enzymatic isolation procedure. The cells have an intact function, however, lack gamma-GTP activity. The endothelial cells were cultured on an optically clear collagen membrane mounted on a plastic frame. Effects of bradykinin (1 x 10(-5) M) and LTC4 (1 x 10(-7) M, 1 x 10(-6) M, 5 x 10(-6) M, 1 x 10(-5) M) were tested on permeability of the endothelial cell monolayer by measuring leakage of 14C-sucrose. The effect of LTC4 and bradykinin on intracellular calcium was studied by laser scanning confocal microscopy. LTC4 did not increase permeability of the brain capillary endothelial cell monolayer which lacked gamma-GTP activity. LTC4 did neither increase the concentration of intracellular calcium. Differences of LTC4 receptor function in normal brain capillaries and tumor capillaries remain to be studied.

Nodular glomerulosclerosis of unknown origin associated with the nephrotic syndrome

A 35-year-old male patient clinically characterized by massive proteinuria and hypertension without evidence of systemic diseases is reported. Histological investigation of renal biopsy specimens revealed extensive nodular formations in the mesangial areas in every glomerulus. Light-microscopic examination did not allow discrimination between the glomerular changes found in these specimens and the nodular glomerulosclerosis described in patients with diabetes mellitus. Electron-microscopic examination confirmed the presence of massive, nodular, mesangial expansions consisting of finely fibrillar substances without electron-dense deposits and circumferential mesangial interposition. Immunofluorescent examination showed deposition of IgG, C3, fibrinogen and kappa and lambda light chains in mesangial areas, peripheral capillary loops and a part of the nodules. Furthermore, collagen types IV, V, VI and laminin were detected in the nodules. Amyloid was not observed in these nodules. This diagnosis has not been made, and the mechanism of this nodular glomerulosclerosis remains unknown.

Autosomal dominant polycystic kidney disease complicated by primary aldosteronism. Case report and review of the literature

We report the case of a 42-year-old woman with autosomal dominant polycystic kidney disease complicated by primary aldosteronism. She had a history of hypertension for 12 years and was found to have hypokalemia and polycystic renal and hepatic disease. Endocrinological tests revealed hyporeninemia and hyperaldosteronemia. Adrenal scintigraphy and venography demonstrated a left adrenal adenoma. Blood sampled from the adrenal veins confirmed hyperaldosteronemia originating from the left adrenal gland. Left adrenalectomy was performed. After surgery, plasma renin activity, plasma aldosterone titer, and serum potassium level normalized. The mechanism for the development of primary aldosteronism with autosomal dominant polycystic kidney disease may be related to the activation of the renin-angiotensin system. Four years after left adrenalectomy, hepatic but not renal cysts showed a remarkable increase; the improvement in hypokalemia may have delayed the progression of kidney cysts.

Blood levels of leukotrienes (LTC4, D4, E4, B4) in asthmatic patients during attack and remission

To assess the contribution of the leukotrienes, LTC4, D4, E4 and B4 during bronchial asthma attacks, simultaneous determination was made of their levels in venous blood. 25 patients with bronchial asthma (15 atopic types, 10 non-atopic types) participated in this study and 4 normal controls were used. Samples were obtained using heparinized syringe from the patients before treatment. A radioimmunoassay was conducted to measure LTs after purification with a Sep-pak column and separation by HPLC. In normal subjects, the levels were less than the minimal detectable amounts. LTC4, D4, E4 and B4 during asthmatic attacks were 100 +/- 179, 88 +/- 116, 479 +/- 291, and 55 +/- 73 (Mean +/- SD) pg/ml respectively (n = 27). Peptide LTs in remission were below minimal detectable levels. LTD4 in patients with moderate attacks was significantly (p < 0.05) higher than in those with mild attacks. Peptide LTs in moderate attack exceeded those in mild attacks, although not to a statistically significant degree. No significant differences in LT during attacks could be detected in atopic or non-atopic type patients. LTs would thus appear importantly involved in asthmatic attacks in atopic and non-atopic type patients, although other chemical mediators may give rise to airway inflammation.

Treatment of advanced primary lung cancer associated with malignant pleural effusion by the combination of immunotherapy and chemotherapy

Twelve patients with advanced primary lung cancers associated with malignant pleural effusion were treated with intrathoracic instillation of recombinant interleukin-2 with or without in-vitro-sensitized cells. Two cases achieved complete response, and 7 partial response. The adverse effects seen in the protocol were marginal, and the protocol was well-tolerated and feasible. Furthermore, 4 cases were treated with the combination of systemic chemotherapy and adoptive immunotherapy. Of these, 3 cases responded well to the therapy and have shown a complete response for more than 20 months, indicating that adoptive immunotherapy together with chemotherapy might be a beneficial treatment for advanced lung cancer patients.

Effects of acetylsalicylic acid on pulmonary vascular tone and membrane permeability in blood-perfused dog lung

We studied the effects of acetylsalicylic acid (ASA) on pressor response, microvascular filtration coefficient (Kf), extravascular lung water, and plasma concentrations of cyclooxygenase- and 5-lipoxygenase-derived products in 21 blood-perfused dog lungs with constant flow. The lungs were perfused for 1 h with an intrapulmonary injection of saline as vehicle (n = 5), a low dose of ASA [136 +/- 25 (SD) micrograms/ml perfusate; n = 5], a high dose of ASA (1,006 +/- 278 micrograms/ml perfusate; n = 6), or alloxan (1,000 mg; n = 5). Alloxan significantly increased Kf and extravascular lung water, whereas neither the low nor high dose of ASA increased Kf or extravascular lung water. The ASA-induced increase in vascular resistance did not correlate with the extent of the decrease in perfusate 6-keto-prostaglandin F1 alpha or the ratio of perfusate 6-ketoprostaglandin F1 alpha to thromboxane B2. Moreover, ASA did not enhance the generation of perfusate leukotrienes B4, D4, or E4. We conclude that pulmonary microvascular permeability is unaltered by ASA and that neither the decrease in plasma prostacyclin nor the increase in plasma sulfidopeptide leukotrienes may account for ASA-induced pulmonary vasoconstriction.

Application of confocal laser scanning microscopy to the observation of bone biopsy specimens

Iliac bone biopsy specimens from five patients with endstage renal disease were observed by confocal laser scanning microscopy. Images of affected bone specimens were accurately focused, whereas images viewed with conventional light microscopy from thick ground sections were obscure. Especially at high magnifications, fine structures of bone cells, otherwise blurred, were clearly observed with confocal scanning microscopy. From thin-cut sections, images satisfactory for pathological diagnosis were viewed with light microscopy even at high magnification. However, the sections tended to shrink vertically compared with the cross-sectional images of the blocks observed directly by confocal laser scanning microscopy. A three-dimensional image of bone tissue was also constructed from serial optical sections. Confocal laser scanning microscopy is a useful technique for observing bone tissues, and may become essential for the evaluation of bone biopsy specimens.

[Serum level of Pseudomonas aeruginosa-specific IgA in patients with chronic lower respiratory tract infection and its clinical significance]

Elevation of the serum IgA level has been observed in many cases of chronic lower respiratory tract infection. To determine the specificity of elevated serum IgA for the pathogen colonizing the respiratory tract of patients, we measured Pseudomonas aeruginosa-specific IgA titers in patients with chronic lower respiratory tract infections by ELISA. Sonicated P. aeruginosa strain BB5746 was used as the coating antigen. Optical density was significantly elevated in sera from patients in whom P. aeruginosa was consistently isolated from sputum cultures, when they were respondent to the antigen, indicating that bacteria-specific IgA is not localized in the respiratory tract surface, but is circulating in the blood stream of these patients. The other two groups, chronic bronchitis patients from whom bacteria other than P. aeruginosa were occasionally isolated from sputum culture, and IgA nephropathy patients, had no detectable specific IgA in their sera as is the case in normal adults. Our results indicate that bacteria-specific serum IgA levels appeared to correlate with duration from the time of bacterial colonization with P. aeruginosa and the degree of bronchial and alveolar destruction seen on chest X-rays. In addition, detection of increased serum P. aeruginosa-specific IgA seems to contribute to the recognition of persistent bacterial colonization of the respiratory tract.

[Effects of epidural analgesia combined with general anesthesia on hemodynamics during neck surgery]

The aim of the present study was to investigate the effect of epidural analgesia combined with general anesthesia on hemodynamics. Thirty patients undergoing surgery for the treatment of cancer of the neck were studied. The patients were divided into two groups of those who received epidural analgesia combined with general anesthesia group (Group 1) and those with general anesthesia alone (Group 2). Blood pressure was not different between the groups. But heart rate and rate pressure products in Group 1 were significantly lower than those of Group 2. CVP in Group 1 increased significantly to 10.1 +/- 2.9 mmHg during surgery from 6.8 +/- 1.8 mmHg at the beginning of the surgery. There was no difference in intraoperative blood loss and the amount of fluid infused between the two groups. These results suggest that epidural anesthesia combined with general anesthesia is effective to stabilize hemodynamics during cervical surgery, but we have to be careful about using local anesthetics during long cervical procedures, because it increases CVP which might result from the depression of cardiac function.

[A case of chronic persistent cough caused by gastroesophageal reflux]

A 69-year-old female was admitted for the evaluation of chronic persistent cough of about six week duration which was particularly worse at night and did not respond to antibiotics or cough medicines. She did not smoke and had no history of allergies or abnormal inhalations. Eosinophil counts, serum IgE, CRP, titers of cold hemagglutinin (CHA), and antibody to mycoplasma were all within normal ranges. Chest X-ray films and respiratory function tests showed no abnormalities. Because of her complaint of mild heartburn, gastroesophageal reflux (GER) was thought to be a possible cause of her chronic cough. Upper gastrointestinal X-ray films revealed barium reflux up to the cervical esophagus, and gastrointestinal fiberoscopy showed reflux esophagitis. Bronchial biopsy specimens taken by fiberoptic bronchoscopy showed chronic inflammatory changes of bronchial mucosa with focal squamous metaplasia, mucosal basement membrane thickening, and lymphocytic infiltration in the submucosa. She made favorable progress following treatment with a histamine H2 blocker and cisapride for six weeks. She met Irwin's criteria and we concluded that her cough was caused by GER. We speculate that repeated tracheobronchial microaspirations of refluxed gastric acid may cause chronic inflammatory changes of the bronchial mucosa resulting in persistent cough.