Indications for palliative reduction surgery for hepatocellular carcinoma with multiple intrahepatic metastases

We evaluated the efficacy of and the indications for palliative reduction surgery as a procedure to improve the prognosis of hepatocellular carcinoma (HCC) patients with multiple intrahepatic metastases. From January 1986 to October 1997, 25 HCC patients with multiple intrahepatic metastases who underwent necessary palliative reduction surgery due to advanced disease, were participated in the study. The 1-, 3-, 5-year survival rates of 25 patients with reduction surgery were 54.7%, 29.9%, 22.4%, respectively. Moreover, the 1-, 3-, 5-year survival rates of patients with some postoperative supplemental treatment were 68.8%, 41.2% and 30.9%, respectively. All 6 patients who had been alive for more than 3 years had had primary tumors with diametric sizes of approximately 5 cm and had undergone, at most, one segmentectomy. These patients received postoperative supplemental treatments. The indication for palliative reduction surgery for HCC patients with multiple intrahepatic metastases was patients with a relatively small primary tumor (around 5 cm) which could be removed by one segmentectomy or less.

Ubiquitin-immunohistochemical investigation of atypical Pick's disease without Pick bodies

Six cases of atypical Pick's disease (PD) without Pick bodies (PB) were examined immunohistochemically. These cases showed severe neuronal loss with gliosis predominantly in the temporal cortices. Ubiquitin immunohistochemistry revealed ubiquitin-positive intraneuronal inclusions in the dentate gyrus and ubiquitin-positive neurites in the cerebral cortex. In the dentate gyrus, the dendrites in the stratum moleculare as well as the intraneuronal inclusions in the granular cells were positively stained. Both structures were composed of ubiquitin-positive ribosome-like granular components and a few filamentous components immunoelectron-microscopically. In the cerebral cortex, ubiquitin-positive neurites were distributed in layers II-IIIab and layers V-VI, and were considered to be the distal dendrites from the small neurons. The dendrites and perikarya of these neurons contained ubiquitin-positive components similar to those in the dentate gyrus. Some ubiquitin-positive neurites were also found in the hippocampal subiculum, amygdala and striatum. The results of this study suggest that the granular cells in the dentate gyrus and the small neurons in the cerebral cortex share common ubiquitin-related and ribosome-associated abnormalities in both the perikarya and dendrites, that the degeneration of the perforant pathway caused by the parahippocampal lesion participates in the ubiquitin related abnormalities in the granular cells, and that PD cases with and without PB have common affected neurons, as shown immunohistochemically.

[A case of paradoxical brain embolism in a 17-year-old boy]

A 17-year-old healthy high school boy suddenly suffered from consciousness disturbance immediately after a karate match. His neurological findings on admission were consciousness disturbance, motor aphasia, right hemiparesis, and right Babinski reflex. Cerebral angiography showed occlusion of the precentral branch of the left middle cerebral artery, and X-ray CT scan on the second day revealed low density area in its territory. No abnormality was found on transthoracic echocardiography or Holter ECG. Contrast transesophageal echocardiography with Valsalva maneuver was performed twice (the 2nd and the 14th day), and patent foramen ovale (PFO) was found only on the second trial. It was supposed that paradoxical embolism had occurred. Transesophageal echocardiography is necessary for the embolic patients of unknown origin, especially young adults. To find PFO, it is important to repeat contrast transesophageal echocardiography carefully. if it is negative on the first trial.

Generalized erythematous skin eruptions due to trimethoprim itself and co-trimoxazole

A 20-year-old Japanese woman (Case 1) and a 70-year-old Japanese man (Case 2) consulted us with slight fever and disseminated erythematous papules. Examinations revealed that the first case was a skin eruption due to trimethoprim itself and the second was due to both trimethoprim and sulphamethoxazole. To our knowledge, our Case 1 is the first reported case with an erythematous papular type skin eruption caused by trimethoprim itself, and our Case 2 is the first case of a skin eruption in reaction to both trimethoprim and sulphamethoxazole.

A large number of tandem repeats in the polymorphic epithelial mucin gene is associated with severe acne

Polymorphic epithelial mucin (PEM) or MUC1 is a glycoprotein secreted from various epithelial gland tissues. In skin, PEM is detected in sweat glands and sebaceous glands by the DF3 monoclonal antibody. The gene of PEM includes an allele exhibiting length polymorphism due to a variable number of tandem repeats (VNTR); this is expressed co-dominantly, which may influence the microenvironment of the skin. The allelic size variation of the PEM gene was investigated in Japanese acne patients, atopic dermatitis patients, and healthy controls. The frequency of longer length alleles was significantly higher in severe acne patients.

[Anesthesia in two patients with essential thrombocythemia]

Case 1. The patient was a 69-year-old man with essential thrombocythemia (ET), who underwent urgent laparotomy. On admission he was dehydrated and the platelet count was more than 160 x 10(4).microliter-1, with hematocrit of 50%. Anesthesia was induced with ketamine i.v. and maintained with nitrous oxide and sevoflurane in oxygen. Postoperative care included the administration of gabexate mesilate (GM) which is an antiplatelet agent. Case 2. An 84-year-old woman with ET was diagnosed as gastric cancer and elective gastrectomy was scheduled. The platelet count was more than 100 x 10(4).microliter-1. The patient was anesthetized with nitrous oxide and oxygen supplemented with fentanyl and mepivacaine via epidural catheter. Intravenous infusion of GM was performed at a rate of 1 mg.kg-1.hr-1 during surgery. PF-4 and beta-TG were measured. These are platelet releasing factors. The level of PF-4 decreased to normal level during this procedure. In conclusions, it will be important to use GM during anesthesia in order to avoid the complications such as myocardial or pulmonary infarction caused by thrombocythemia.

Purification and gas chromatographic-mass spectrometric characterization of non-methylene interrupted fatty acid incorporated in rat liver

A C20 non-methylene interrupted trienoic acid detected in the liver of rat fed with a pine (Pinus koraiensis) seed oil diet was purified by two-step argentation thin-layer chromatography (AgTLC) and characterized by gas chromatography-mass spectrometry (GC-MS). First, a C20 methyl trienoate fraction was obtained from fatty acid methyl esters prepared from rat liver by 5% AgTLC developed with petroleum ether-diethyl ether-acetic acid (70:20:2, v/v) as a solvent system. The fraction was then subjected to AgTLC developed with benzene-acetone-diethyl ether-acetic acid (65:15:15:5, v/v) which could separate non-methylene interrupted fatty acids (NMIFA) from usual MIFAs. The purified C20 NMIFA was partially hydrogenated, and the resulting three kinds of the C20 monoenoate were analyzed by GC-MS after conversion to their dimethyl disulfide (DMDS) adducts. The results revealed that the original C20 non-methylene interrupted trienoic acid detected in the liver of rats fed with a pine seed oil diet was delta-5,11,14/20:3, a minor component of pine seed oil.

Cross-reactivity to olive tree pollen and orchard grass pollen in patients with pollinosis

We studied 92 patients with allergic rhinitis in Syodoshima, Japan, during the pollen season between April and June to evaluate the cross-reactivity to different antigens, including pollen from the olive tree (Olea europaea) and orchard grass (Dactylis glomerata). Olive tree pollen was present in the atmosphere for 23 days, from May 19 to June 12, 1994. Specific IgE antibodies for olive tree pollen antigen were present in 21 (26.9%) of the 78 patients with allergic rhinitis. Nine (24.3%) of the 37 patients with allergic rhinitis exhibited positive skin reactivity to an extract of olive tree pollen. Fifteen (88.2%) of the 17 patients who had IgE reactivity in their sera to olive tree pollen antigen demonstrated allergic reactions to an extract of olive tree pollen. Specific IgE antibodies for orchard grass pollen antigen were present in 43 (48.3%) of the 89 patients with allergic rhinitis and 20 (95.2%) of the 21 patients who had IgE reactivity in their sera to olive tree pollen antigen. The inhibition test using the CAP System revealed that the reactivity of the IgE antibody specific for olive tree pollen antigen was inhibited dose-dependently by an extract of orchard grass pollen. These findings show that there is a reaction in some patients with grass (Gramineae) pollinosis that might be induced by olive tree pollen.

Reduction of telencephalin immunoreactivity in the brain of patients with Alzheimer's disease

Telencephalin (TLN) is a cell adhesion molecule expressed in the telencephalon of the mammalian central nervous system. We have investigated immunohistochemically the expression of TLN in human brain tissue from control subjects and patients with Alzheimer's disease (AD). In control brain, neuropil of the gray matter was stained diffusely with the anti-TLN antibody. TLN immunoreactivity was markedly decreased in the brain of AD patients, particularly in the hippocampal formation.

[Clinical and immunological findings of hepatitis B virus associated spastic paraparesis--a comparison with HAM]

We investigated clinical features and immunological parameters in 40 patients with slowly progressive spastic paraparesis including 13 cases (4 men and 9 women, aged 43 to 71, mean 61 years) with positive antibody to hepatitis B virus (HBV), 13 (6 men and 7 women, aged 39 to 75, mean 63 years) with positive antibody to HBV and HTLV-I, and 14 (3 men and 11 women, aged 33 to 71, mean 55 years) with positive antibody to HTLV-I (HAM). None showed obviously organic changes of the spine on magnetic resonance image. Patients with positive antibody to HBV (hepatitis B virus associated myelopathy, HBM) were significantly lower in disability grade and had a fewer incidence of micturition than in the HAM. Furthermore, natural killer (NK) activities were in normal range and peripheral blood lymphocytes did not show autologous proliferation response (APR). Patients with positive antibody to both HBV and HTLV-I showed APR similar to HAM, but in most patients NK activities were within normal range. These results suggest that the mechanism of myelopathy in HBM may be different from that in HAM, and HBV infection may play a role as a cofactor in HAM.

[Clinical characteristics and muscle histopathology in polymyositis positive anti-hepatitis with C virus antibody]

In 14 patients with polymyositis (PM), 5 patients (2 males and 3 females) were positive for anti-hepatitis C virus (HCV) antibody measured by a second generation assay. We analysed the clinical characteristics and histopathological findings of the biopsied muscles from those 5 patients. They aged from 42 to 65 years averaging 53.6 years. Two asymptomatic patients visited our hospital due to elevated muscle enzyme levels, who had slight weakness in their orbicularis oculi and neck muscles on physical examination. The other 3 patients had moderate weakness of the proximal muscles. Anti-nuclear antibody was positive in 2 of the 5 patients and anti-Jo 1 antibody was negative in all patients. The serum enzymes elevated were creatine kinase (215-2, 207 (IU/l)) and glutamate oxaloacetate transaminase (40-119 (KU)). HCV-RNA was positive in the sera of 4 patients examined. All muscle biopsy specimens revealed variation in fiber size with inflammatory cellular infiltration and observed degenerating and regenerating fibers. The scant infiltration type was observed in 2 asymptomatic patients in whom the infiltrated cells were CD4 positive. The endomysial infiltration type was observed in 3 symptomatic patients; CD8 positive cells were found focally to diffusely in 2 patients examined. The expression of class 1 molecules from the major histocompatibility complex was detected mainly in infiltrated fibers to variable degrees. All of the patients showed a good response to the initial steroid therapy. The present study suggests that autoimmune reaction related to HCV infection causes myositis, therefore anti-HCV antibody should be checked in cases of PM.

[Prolonged neuromuscular blockade with vecuronium in patient with triple pregnancy treated with magnesium sulfate]

A 33 year-old parturient with triplet pregnancy underwent emergency cesarean section at 35 week of gestation under general anesthesia. The patient had received magnesium sulfate to prevent uterine contraction immediately before the cesarean section. Although serum magnesium value was not beyond therapeutic levels (3.3 mEq.l-1), the neuromuscular blocking effects with vecronium were strengthened. It was not likely that volatile anesthetic enhanced neuromuscular blockade produced by vecuronium because the onset time of vecuronium had already been faster than that in pregnant patients untreated with magnesium before she was exposed to isoflurane. In addition, it is possible that magnesium could interfere with postpartum uterine contractions because of its tocolytic properties. Magnesium sulfate therapy has several implications to anesthetic agents. We, anesthesiologists, should know about the biophysiological effects of magnesium and control the interaction between anesthetic agents and this electrolyte.

Aneurysm of a patent ductus arteriosus in an adult

An adult patient with a spontaneous aneurysm of a patent ductus arteriosus was successfully treated. The lumen of the aneurysm communicated with the distal aortic arch and the pulmonary artery. Closure of the pulmonary arterial orifice of the ductus arteriosus and replacement of the inferior wall of the distal aortic arch and proximal descending aorta with prosthetic graft were performed under partial cardiopulmonary bypass using a centrifugal pump. The postoperative recovery was uneventful.

Survey of herpes simplex virus infections of the central nervous system, including acute disseminated encephalomyelitis, in the Kyushu and Okinawa regions of Japan

We analysed data from 27 patients with herpes simplex virus (HSV) infections of the central nervous system (CNS) found in a 1990-1992 survey in Kyushu and Okinawa, Japan. Patients ranged in age from one year to 70 years, with peaks seen in the 20s and 50s. Temporal lobe-limbic encephalitis was the most common HSV infection (13 patients), followed by meningitis (5), diffuse encephalitis (4), disseminated encephalomyelitis (ADEM) (3) and brain stem encephalitis (2). Another three patients with non-herpetic, non-paraneoplastic acute limbic encephalitis were presented. Our study indicates that HSV infection can course ADEM, although temporal lobe-limbic encephalitis or meningitis are more common. The early diagnosis of HSV-related ADEM is important because of the efficacy of the timely administration of corticosteroids.

[A case of Prader-Willi syndrome with bilateral middle cerebral artery occlusion and moyamoya phenomenon]

We report a case of Prader-Willi syndrome (PWS) complicated with juvenile stroke. The patient is a 19-year-old man with right hemiplegia, who has had a history of non-insulin-dependent diabetes mellitus (NIDDM) for ten years. The diagnosis of PWS was confirmed genetically by the method of fluorescence in situ hybridization which showed the deletion of chromosome 15. His brain MRI revealed abnormal signal intensities in the left basal ganglia and around the right trigone of the lateral ventricle. Angiographic examination showed occlusions of bilateral proximal middle cerebral arteries with basal moyamoya vessels. The left vertebral artery was also occluded at its origin. Only a few cases of PWS complicated with stroke have been reported before and, to date, there has been no case with arterial occlusion similar to our case. Though the cause of these arterial occlusions is unknown, it may be related to arteriosclerosis following NIDDM.

Prediction of interferon-alpha-induced thyroid dysfunction in patients with chronic hepatitis C

To predict interferon-alpha (IFN-alpha)-induced thyroid dysfunction, anti-thyroglobulin (anti-TgAb) and anti-thyroid peroxidase antibodies (anti-TPOAb) were determined by radio-immunoassay (RIA) before IFN-alpha treatment in 30 patients with chronic hepatitis C in whom the conventional haemagglutination test had failed to detect anti-thyroid auto-antibodies. Seven patients developed thyroid dysfunction during IFN-alpha treatment (transient thyrotoxicosis in four patients, transient hypothyroidism in two, and Graves' disease in one). Anti-TgAb and/or anti-TPOAb were detectable before IFN-alpha treatment in six of these seven patients, while these antibodies were detected before treatment in only four of 23 patients who did not develop any thyroid dysfunction. The prevalence of these antibodies was significantly higher (P = 0.002) in the former group of patients than in the latter. In four patients with detectable anti-TgAb before treatment but no subsequent thyroid dysfunction, the antibody disappeared during IFN-alpha treatment. Haemagglutination tests for anti-thyroid microsomal antibodies have previously been reported to be a useful predictive marker of IFN-alpha-induced thyroid dysfunction. In conclusion, sensitive detection of anti-thyroid auto-antibodies using RIA may also be useful for the prediction of IFN-alpha-induced thyroid dysfunction in patients with a negative haemagglutination test.

Albumin synthesis by rat hepatocytes cultured on collagen gels is sustained specifically by heparin

We investigated the influence of various kinds of glycosaminoglycans (GAGs) in collagen gels on the maintenance of albumin synthesis in primary culture of rat hepatocytes. Among the GAGs examined (heparin, heparan sulfate, keratan sulfate, chondroitin sulfate A, dermatan sulfate, and hyaluronic acid), only heparin-containing collagen gel cultures could significantly sustain albumin synthesis. However, other GAGs, such as heparan sulfate and keratan sulfate, had almost no effect on the maintenance of albumin synthesis. Heparin in collagen gels exhibited a dose-dependent effect on albumin synthesis: heparin at 400 micrograms/ml-collagen solution maintained albumin synthesis for over 3 weeks. On the other hand, when an equivalent amount of heparin was added directly to the collagen gel culture medium, it prolonged albumin synthesis for only 10 days. The results demonstrate that specific regulation of albumin synthesis by heparin was significantly promoted by coincubating it with collagen, suggesting that some specific interaction between heparin and collagen might be of importance for the maintenance of hepatocyte functions.

[Significance of hepatitis B virus antibody in motor neuron disease]

We present here an assumption that hepatitis B virus (HBV) is involved in the pathogenesis of motor neuron disease (MND) in part, because of very high incidence of HBV antibody in patients with MND. In this study HBV antibodies were determined in 34 patients with MND (15 with ALS, 7 with SPMA, 8 with PBP and 4 with PBP+SPMA), and it was revealed that hepatitis B surface antigen (enzyme immunoassay: EIA) was negative in all the patients, whereas hepatitis B surface antibody (HBs-Ab) (EIA) was positive in 25 patients (73.5%) (9 with ALS, 6 with SPMA, 7 with PBP and 3 with PBP+SPMA). In contrast, HBs-Ab was positive only in 2 out of 28 patients with brain infarction (7.1%), and in 1 out of 16 patients with spinocerebellar degeneration (6.3%), both of which were used as control. Of 22 patients with indefinite complaints, none was positive for HBs-Ab. Thus, the number of HBs-Ab positive individuals was significantly (P < 0.001) greater in patients with MND than that in the patients having other disorders of central nervous system. From the above result, we conclude that MND may be partially ascribed to HBV.

[A case report: abdominal aorta-femoral artery bypass grafting in patient with essential thrombocythemia]

A 58-year-old man was admitted to our hospital suffering from intermittent claudication and angiogram revealed complete obstruction of the left common iliac artery. The essential thrombocythemia was diagnosed from platelet count over 1,000,000/mm3 as well as bone marrow finding. After the platelet count was reduced into normal range by administration of ranimustine (MCNC), abdominal aorta-femoral artery bypass grafting using 8mm-diameter Gelseal graft was successfully performed without any complications such as thrombus formation or bleeding. Coldness and cyanotic discoloration of the lower extremities were diminished with the decrease in platelet count. He was discharged in satisfactory condition and has been on postoperative control with warfarin, ticlopidine chloride and aspirin therapy.

[The use of prostaglandin E1 for emergency cesarean section in a patient with HELLP syndrome]

A 23-year-old female, gravida 0 para 0, underwent emergency cesarean section under general anesthesia, because of the complication of HELLP syndrome. Prostaglandin E1 (PGE1) was used to prevent hypertension and uterine atony just after the infant's delivery. The disorder was improved with the postpartum care. HELLP is the syndrome of hemolysis, elevated enzyme, and low platelets presented by a unique group of pre-eclamptic/eclamptic patients with or without the usual clinical findings of pregnancy-induced hypertension. PGE1 may be useful for microangiopathic hemolytic anemia, which might be related with the hemolysis, because of its inhibitory effect on both platelet aggregation and thrombus formation, and its ability to improve red cell deformability.

[Pulmonary edema after cesarean section in a parturient with long term use of ritodrine]

A 31-year-old multigravida with a gestation of 31 weeks was admitted in premature labor with placenta previa. The premature labor had been inhibited for two and half months with a tocolytic agent (ritodrine). However, at 32-week gestation an infection was found, the labor broke through the therapy and cesarean section was carried out under spinal anesthesia. Acute pulmonary edema developed post-operatively. An endotracheal intubation was performed followed by respiratory management for four days. Ritodrine is the beta-minetic used most extensively in the therapy of premature labor. However, with overdosage, maternal cardiac and pulmonary complications may occur. In this case, it is possible to have been caused by the long term use of ritodrine. Additionally, the excessive fluid administration, hypoprotenemia, decreased colloid osmotic pressure and infection also might have been the contributing factors for the disorder.

[Binswanger's type encephalopathy without alopecia and lumbago in young hypotensive patients]

Binswanger's type encephalopathy is characterized by progressive dementia and diffuse subcortical ischemic lesions associated with arteriosclerosis. Hypertension is believed to be a major pathogenic factor in causing this encephalopathy but there are some cases of the encephalopathy not suffering from hypertension. In 1985, Yamamura et al. and Fukutake et al. reported familial cases of normotensive juvenile Binswanger's type encephalopathy with alopecia and lumbago, and considered it to be possibly a new clinical syndrome. We reported three cases of relatively young-onset (under the age of 40) Binswanger's type encephalopathy with persistent hypotension. All three patients suffered from neither alopecia nor lumbago. Patient (male aged 40) had repeated episodes of ischemic stroke and had progressive dementia. Patients 2 (male aged 41) and 3 (male aged 34) were not in a state of dementia, but had a history of transient ischemic attacks, and at present are completely symptom-free. Though there were no risk factors for cerebrovascular disease in these cases, the repeated episodes of ischemic stroke and the existence of small multiple lacunes in the basal ganglia on CT and MRI suggest that the white matter damage was principally due to a vascular disorder. In these cases, persistent hypotension was characteristic and might be a factor for the induction and exacerbation of this encephalopathy. These three cases are different from the classic form of Binswanger's type encephalopathy based on hypertension. Normotensive cases have been described before, but our cases do not seem to fall into this category because the blood pressure constantly remained hypotensive.(ABSTRACT TRUNCATED AT 250 WORDS)

[Non-herpetic acute limbic encephalitis]

We reported four cases of acute encephalitis, in which MRI abnormalities localized in the limbic system. In the four cases, fever and consciousness disturbance were commonly found and convulsive seizures appeared in three. Within 10 days, their consciousness level became clear, but severe amnestic syndrome remained as sequela. Cerebrospinal fluid (CSF) at the acute stage revealed mild lymphocytic pleocytosis and elevated protein. MRI revealed abnormal signal intensities in both hippocampi and amygdaloid bodies, although CT scans were normal. Herpes simplex encephalitis selectively affects one or both temporal lobes and the limbic system, But our cases spared the temporal lobes. Additionally, serum and CSF antibody titers by CF and ELISA for herpes simplex virus (HSV) were within normal range from the acute to convalescent stages. Neither HSV type 1 and 2 DNA genomes by sensitive PCR-hybridization method were detected in CSF taken from the acute stage of all four cases. On the other hand, paraneoplastic limbic encephalitis is known as a subacute encephalitis predominantly involving the limbic system. MRI shows high signal intensities on T2-weighted in both medial temporal lobes. In our cases, this type of limbic encephalitis was excluded because of the acute onset and lack of malignancy. Accordingly, our four cases are regarded as non-herpetic acute limbic encephalitis. Several Japanese similar cases have been reported. Further etiological studies should be performed.

Magnetic resonance imaging findings in Japanese encephalitis. White matter lesions

Ten patients with Japanese encephalitis diagnosed by serological criteria underwent magnetic resonance imaging (MRI) in axial and coronal sections. In 6, a second MRI study was done. The MRI findings were compared with the clinical outcome. Four patients died within several months of onset, 2 had sequelae such as hemiparesis and dementia, and the remaining 4 had no sequelae. In 9 of 10 patients, either diffuse or patchy white matter lesions were observed bilaterally, together with abnormalities in areas such as the thalamus, basal ganglia, and brainstem. For 3 patients who died or remained demented, the second MRI revealed extensive, diffuse white matter abnormalities. This study indicates that Japanese encephalitis can produce white matter involvement, although gray matter structures such as the thalamus, basal ganglia, and brainstem are more severely affected. The severity of these MRI lesions correlated with the clinical outcome.

Differentiation of herpes simplex virus 1 and 2 in cerebrospinal fluid of patients with HSV encephalitis and meningitis by stringent hybridization of PCR-amplified DNAs

Differentiation of herpes simplex virus (HSV) types 1 and 2 in cerebrospinal fluid of 17 patients with serologically diagnosed HSV encephalitis and meningitis or acute limbic encephalitis was determined by stringent hybridization of polymerase chain reaction--amplified DNAs. Ten of 17 patients were positive; six with HSV 1 isolates and four with HSV 2 isolates. We detected HSV type 1 in two cases of meningitis, although meningitis is generally thought to be caused by type 2. Additionally, HSV type 2 was found in one case of acute adult encephalitis, which is generally due to HSV type 1. HSV DNAs could be detected for over 1 month after onset, although our patients included several prolonged and recurrent cases. HSV DNA genomes were not detected in three cases of acute limbic encephalitis. Our study indicates that this method can be used for type differentiation in HSV CNS infections.

[Hepatitis B virus antibody positive spastic paraparesis]

We present here thirteen patients (5 men and 8 women, aged 31 to 73, mean 55 years) with spastic paraparesis who showed clinical features similar to those of HTLV-1 associated myelopathy without HTLV-1 antibody, but with positive antibody to hepatitis B virus (HBV). All of these patients showed slowly progressive difficulty in walking. Five patients had previous histories of blood transfusion, of these one with history of B hepatitis. Neurologically, muscle weakness, spasticity and exaggerated deep tendon reflexes in the lower extremities were common to all the patients. Seven patients showed Babinski's reflex. Disturbance of micturition was noted in 3 patients. None showed organic changes of the spine on magnetic resonance image (MRI). None was serologically positive for syphilis and had cryoglobulin and hypergammaglobulinemia. Elevated levels of the liver enzymes were noted in two patients. All patients were positive for hepatitis B surface antibody (HBs-Ab) (EIA) but negative for hepatitis B surface antigen (HBs-Ag) (EIA). Five patients were seropositive for hepatitis C virus (HCV) (PHA). In 3 of them, reverse transcriptase polymerase chain reaction was performed but failed to detect HCV-RNA. All patients underwent spinal tap, and showed normal cell count and protein concentration in their cerebrospinal fluid (CSF). Atypical cells were not observed in all the patients. The CSFs from three patients were tested for HBs-Ag and HBs-Ab. HBs-Ag was negative in all three patients, but HBs-Ab was positive in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

DF3 (CA15-3) antibody as a marker of cutaneous adnexal tumors

DF3(CA15-3) monoclonal antibody detects the 20 amino acid sequence of epithelial mucin. In normal cutaneous tissue DF3 antibody exhibits strong and constant positive reactivity with sebaceous and secretory segments of eccrine and apocrine sweat glands. All epidermal tumors are DF3 negative but poorly differentiated squamous cell carcinoma. Various adnexal tumors such as eccrine hidrocystoma, tubular apocrine adenoma, syringocystadenoma papilliferum, eccrine poroma, eccrine spiradenoma, clear cell hidradenoma, mixed cell tumor, eccrine porocarcinoma, extramammary Paget's disease and adenoid cystic carcinoma are DF3 positive, which indicates epithelial mucin production by these tumors.

[Familial cases of spastic paraparesis, mental disturbance and thinning of the corpus callosum]

We reported a family in which two brothers and one sister out of five siblings were affected by a neurological disease showing the following clinical manifestations: 1) intellectual disturbance with relative preservation of memory and orientation probably developed on child food, 2) spastic paraparesis beginning at the age of about 20 years, 3) mild peripheral neuropathy and cerebellar sign. Their clinical courses were stereotyped, and so much the worse in elder patients. Two of them were investigated in detail. Laboratory findings including chromosomal analysis, amino acid analysis and thyroid function were normal. HTLV-1 antibody was negative. Several lymphocytes lysosomal enzymes including beta-hexosaminidase and arylsulfatase A and serum very long fatty acids were also within normal range. CT and MRI showed characteristic thinning of corpus callosum, dominant in anterior portion. However, changes in intensity of white matter in T2 weighted image were not so prominent. In the older patient, more mentally deteriorated, were demonstrated hypoperfusion in the fronto-parietal lobes by SPECT and slow wave bursts dominant in the same region by EEG. Therefore, we considered that the change of corpus callosum was hypoplasia, but not atrophy, and it may provoke dysfunction of relevant nervous system. Family cases of such clinical feature were rare. We could confirm only three families in literatures, all of them were Japanese.

Relapsing acute disseminated encephalomyelitis associated with chronic Epstein-Barr virus infection: MRI findings

A 25-year-old women had a fever, left cervical lymphadenopathy, neurological symptoms and signs, CSF pleocytosis and persistent high serum antibodies to the Epstein-Barr virus (EBV); she had a recurrence 1 year later. She was thought to have relapsing acute disseminated encephalomyelitis associated with chronic EBV infection. MRI revealed abnormalities, mainly in the right basal ganglia and left midbrain. At the time of the recurrence, further abnormalities appeared in the opposite basal ganglia and right cerebral white matter.

A study of haemolytic streptococci isolated from outpatients in dermatological clinics

A total of 44 patients suspected of streptococcal infections were studied in outpatient clinics in Tokyo during the one year from December 1988 to December 1989. Employing bacteriological culturing and serodiagnosis, the following results were obtained. 1) There were 9 cases of impetigo and 15 cases of erysipelas with typical clinical manifestations and age distributions. 2) It seemed that some of the skin infections were caused by group A streptococci whose M-types were different from those of upper respiratory infections typically occurring in Japan. 3) The type distribution of group A streptococci found were quite similar to those isolated in Thailand or Malaysia. 4) There were found group A streptococci exhibiting unique combinations of T- and M-types, such as T11 and M9, T11 and M62 or T13-49 and MOD8 (Provisional type). 5) As for serodiagnostic method, ADNB (anti-deoxyribonuclease B) titer reflected infection by group A streptococcus only, while ASK (anti-streptokinase) and ASO (anti-streptolysin O) reflected not only group A streptococcal infections but group G infections as well.

[Surgery of atrial septal defect in patients aged over 40 years: comparative study of direct suture and patch closure]

Thirty patients over 40 years of age with atrial septal defects were operated on between 1981 and 1989. They were divided into two groups according to operative technique, group A of patients with direct suture of defect (17 cases) and group B patch closure (13 cases), in order to investigate the incidence of postoperative complications. Patient age and size of defect in group B were both greater than in group A. One group A patient had pulmonary stenosis, two group B patients had mitral valvular disease and six group B patients had pulmonary hypertension. The incidence of postoperative heart failure was 29% in group A and 61% in group B and that of arrhythmia was 47% and 69% respectively, however there were no intraoperative and postoperative deaths. We concluded that, although a high incidence of postoperative complications was observed in group B, patch closure was recommended for older patients with atrial septal defect because direct suture was more likely to distort the atrial septum.

Hepatocellular carcinoma and bladder cancer as complications following five years of chemotherapy for acute myeloblastic leukemia

Acute myeloblastic leukemia (AML) was diagnosed in a 54-year-old male, a chronic hepatitis B surface antigen (HBsAg) carrier, in June, 1983. Prompt remission was achieved, and maintenance and intensification chemotherapy were given for five years. He was readmitted in March, 1988 because of a mass in the liver and was diagnosed as having hepatocellular carcinoma (HCC). Curative right segmentectomy was performed in May, 1988. In December, 1988, transitional cell carcinoma of the bladder was discovered, and resected transurethrally. These secondary neoplasms, HCC and bladder cancer, were thought to be associated with the long-term chemotherapy given for the AML.

Pigmented villonodular synovitis of patellar plica

This article reports a rare case of pigmented villonodular synovitis (PVS) arising from the plica synovialis mediopatellaris that impeded the knee joint when it was extended. This lesion was diagnosed and treated by arthroscopy.

[Surgical treatment of ventricular septal rupture following myocardial infarction in an aged patient with bronchial asthma]

Urgent surgery for ventricular septal rupture following myocardial infarction in a 75-year-old female with bronchial asthma was successfully performed. On Feb 28, 1988, she had chest pain, and was admitted 5 days later because of the appearance of heart murmur. Pansytolic murmur (Levine 4/VI) on 3 LSB and piping sound on both lung fields was heard, ECG showed acute anteroseptal infarction. Right heart Swan-Ganz catheterization revealed left to right shunt, and the diagnosis was ventricular septal rupture following acute anteroseptal infarction with bronchial asthma. The initial hemodynamic condition was not serious, but soon after the diagnosis was confirmed, IABP was inserted and operation was indicated because of the advanced age, high shunt ratio (70%) and complication of bronchial asthma. The operation was performed a day after septal rupture. The perforation in the ventricular septum of the apex was sutured with a xenopericardium patch by mattres sutures through a left ventricle approach, and the ventricular wall was closed with this patch together. The postoperative course was uneventful, and the patient was discharged on the 43rd day after the operation.

[Hepatocellular carcinoma treated with a curative segmentectomy five years after complete remission of acute myeloblastic leukemia]

Acute myeloblastic leukemia (AML) was diagnosed in a 54-year-old male who had been known to carry a chronic hepatitis B surface antigen (HBsAg) from June, 1983. Prompt remission was achieved with combination chemotherapy of BHAC-DMP. Follow-up maintenance and an intensification of this chemotherapy had been given for five years. He was readmitted to our hospital in March, 1988 because a mass was detected in the right lobe of the liver by ultrasonography. His serum alpha fetoprotein (AFP) level was found to be 180.1 ng/ml, and was diagnosed as having a hepatocellular carcinoma though there was no evidence of liver cirrhosis. A curative right hepatectomy was performed in May, 1988 after transcatheter arterial embolization and portal embolization. After resection of the tumor, the AFP level decreased to 10.7 ng/ml and no HbsAg was detected in the serum.

[A case of spinal artery aneurysm presenting transverse myelopathy associated with coarctation of the aorta]

We report a case of spinal artery aneurysm, secondary to the coarctation of aorta, who presented with initial signs of transverse myelopathy. A 45-year-old woman was admitted to the hospital because of quadriplegia. She had a history of subarachnoid hemorrhage traced to unknown origin. Physical examination revealed hypertension of upper limbs, but any artery of the lower limbs was not palpable. On neurological examination, she was alert, quadriplegic, and anesthetic below C4 level. Neck was stiff and meningeal signs were presented. The liquor was bloody. Myelography demonstrated complete block at C5-6. The right retrograde brachial angiography showed an aneurysm of cervical spinal artery. Digital subtraction angiography demonstrated a coarctation of the aorta. Coarctation of the aorta was considered to have caused spinal artery aneurysm, and is the first reported case in Japan.

Human leukocyte antigen in Sweet's syndrome and its relationship to Behçet's disease

A 41-year-old man with Sweet's syndrome (SS) had symptoms similar to Behçet's disease (BD). To study the relationship of the two diseases, human leukocyte antigen (HLA) typing was performed on 28 patients with SS and 49 patients with BD. Of the 28 patients with SS, seven had BD symptoms. The frequencies of both HLA-B51 and -DQw3 were significantly higher in patients with BD. However, the frequencies of the two HLA antigens in the 28 patients with SS and the 21 patients with SS without BD symptoms were not significantly different from the controls. The frequency of HLA-Bw54 was significantly increased in both groups of patients with SS. Taken together, these data indicate that SS is a genetically distinct disease entity from BD, although their symptoms are similar and the incidence of SS among patients with BD is high in Japan.