Protective immunity to Streptococcus mutans induced by nasal vaccination with surface protein antigen and mutant cholera toxin adjuvant

In this study, mice were immunized nasally with surface protein antigen of Streptococcus mutans serotype c (PAc) and a nontoxic A subunit mutant of cholera toxin (mCT) E112K, as a mucosal adjuvant. Immunization with PAc and mCT elicited significant PAc-specific secretory IgA in saliva and in nasal secretions. Antibody-forming cell (AFC) analysis confirmed the antibody (Ab) titers by revealing significant numbers of PAc-specific IgA AFCs in the submandibular gland and nasal passages. Furthermore, CD4(+) T cells from cervical lymph nodes exhibited significant proliferative responses when restimulated with PAc in vitro. Importantly, mice that were nasally immunized with PAc plus mCT E112K exhibited significantly reduced oral colonization by S. mutans. These results show that nasal administration of PAc and mCT E112K is potentially an effective mucosal vaccine against dental caries and reduces the colonization of S. mutans in the oral cavity.

Genetically manipulated bacterial toxin as a new generation mucosal adjuvant

Cholera toxin (CT) and heat-labile toxin (LT) of Escherichia coli act as adjuvants for the enhancement of mucosal and serum antibody (Ab) responses to mucosally co-administered protein antigen (Ag). Both LT and CT induce B7-2 expression on antigen-presenting cells (APCs) for subsequent co-stimulatory signalling to CD4+ T cells. CT directly affects CD4+ T cells activated via the TCR-CD3 complex with selective inhibition of Th1 responses whereas LT maintains Th1 cytokine responses with inhibition of interleukin (IL)-4 production. Interestingly, while CT failed to induce mucosal adjuvant activity in the absence of IL-4, LT did so. Nontoxic mutant (m)CTs (S61F and E112K) retain adjuvant properties by inducing CD4+ Th2 cells, which provided effective help for the Ag-specific mucosal immunoglobulin (Ig)A, as well as serum IgG1, IgE and IgA Ab responses. The mCT E112K has been shown to exhibit two distinct mechanisms for its adjuvanticity. Firstly, mCT enhanced the B7-2 expression of APCs. Secondly, this nontoxic CT derivative directly affected CD4+ T cells and selectively inhibited Th1 cytokine responses. Thus, several lines of evidence indicate that enzyme activity can be separated from adjuvant properties of CT and this offers promise for the development of safe delivery of vaccines for mucosal IgA responses.

Gene transfer of calcitonin gene-related peptide prevents vasoconstriction after subarachnoid hemorrhage

We sought to determine whether adenovirus-mediated gene transfer in vivo of calcitonin gene-related peptide (CGRP), a potent vasodilator, ameliorates cerebral vasoconstriction after experimental subarachnoid hemorrhage (SAH). Arterial blood was injected into the cisterna magna of rabbits to mimic SAH 5 days after injection of AdRSVCGRP (8x10(8) pfu), AdRSVbetagal (control virus), or vehicle. After injection of AdRSVCGRP, there was a 400-fold increase in CGRP in cerebrospinal fluid. Contraction of the basilar artery to serotonin in vitro was greater in rabbits after SAH than after injection of artificial cerebrospinal fluid (P<0.001). Contraction to serotonin was less in rabbits with SAH after AdRSVCGRP than after AdRSVbetagal or vehicle (P:<0.02). Basal diameter of the basilar artery before SAH (measured with digital subtraction angiogram) was 13% greater in rabbits treated with AdRSVCGRP than in rabbits treated with vehicle or AdRSVbetagal (P:<0.005). In rabbits treated with vehicle or AdRSVbetagal, arterial diameter after SAH was 25+/-3% smaller than before SAH (P<0.0005). In rabbits treated with AdRSVCGRP, arterial diameter was similar before and after SAH and was reduced by 19+/-3% (P<0.01) after intracisternal injection of CGRP-(8-37) (0.5 nmol/kg), a CGRP(1) receptor antagonist. To determine whether gene transfer of CGRP after SAH may prevent cerebral vasoconstriction, we constructed a virus with a cytomegalovirus (CMV) promoter, which results in rapid expression of the transgene product. Treatment of rabbits with AdCMVCGRP after experimental SAH prevented constriction of the basilar artery 2 days after SAH. Thus, gene transfer of CGRP prevents cerebral vasoconstriction in vivo after experimental SAH.

The spatial arrangement of L and M cones in the peripheral human retina

The spatial arrangement of L and M cones in the human peripheral retina was estimated from red-green color naming of small test flashes (0.86 min of arc, 555 nm, constant intensity) presented at different locations (grid with 1.5 min of arc steps) centered at 17 degrees temporal eccentricity. Simulated red-green color naming ratings were generated by a model based on an ideal observer for all possible patterns of placement and relative numerosities of L and M cones, constrained by the anatomical data on the statistics of cone spacing at this retinal location. The best matching simulated performance as compared to the human observer's data determined the cone array most likely to produce that observer's color naming results. The mosaics for two color normal observers showed L and M cones randomly arrayed over this retinal region. Consequences of random cone placements for spectral sampling and color opponency are discussed.

Alternate mucosal immune system: organized Peyer's patches are not required for IgA responses in the gastrointestinal tract

The progeny of mice treated with lymphotoxin (LT)-beta receptor (LTbetaR) and Ig (LTbetaR-Ig) lack Peyer's patches but not mesenteric lymph nodes (MLN). In this study, we used this approach to determine the importance of Peyer's patches for induction of mucosal IgA Ab responses in the murine gastrointestinal tract. Immunohistochemical analysis revealed that LTbetaR-Ig-treated, Peyer's patch null (PP null) mice possessed significant numbers of IgA-positive (IgA+) plasma cells in the intestinal lamina propria. Further, oral immunization of PP null mice with OVA plus cholera toxin as mucosal adjuvant resulted in Ag-specific mucosal IgA and serum IgG Ab responses. OVA-specific CD4+ T cells of the Th2 type were induced in MLN and spleen of PP null mice. In contrast, when TNF and LT-alpha double knockout (TNF/LT-alpha-/-) mice, which lack both Peyer's patches and MLN, were orally immunized with OVA plus cholera toxin, neither mucosal IgA nor serum IgG anti-OVA Abs were induced. On the other hand, LTbetaR-Ig- and TNF receptor 55-Ig-treated normal adult mice elicited OVA- and cholera toxin B subunit-specific mucosal IgA responses, indicating that both LT-alphabeta and TNF/LT-alpha pathways do not contribute for class switching for IgA Ab responses. These results show that the MLN plays a more important role than had been appreciated until now for the induction of both mucosal and systemic Ab responses after oral immunization. Further, organized Peyer's patches are not a strict requirement for induction of mucosal IgA Ab responses in the gastrointestinal tract.

L and M cone relative numerosity and red-green opponency from fovea to midperiphery in the human retina

The relative numerosity of the long-wavelength-sensitive (L) and middle-wavelength-sensitive (M) cones and the red-green color appearance, as assessed by means of unique yellow, are stable from fovea to midperiphery (+/- 28 deg nasotemporal). As foveal tests decrease in size, unique yellow progressively shifts toward longer wavelengths, favoring a model of red-green opponency carried by cells whose centers receive input from either L or M cones and whose surrounds receive mixed contributions from both. Individual differences in unique yellow over a 20-nm range and the relative numerosity of L and M cones can be linked by means of this model, suggesting that the relative number of L and M cones is a factor that regulates individual variations in red-green color appearance.

Current and future imaging of acute cerebral ischemia: assessment of tissue viability by perfusion imaging

With the advances and availability of new imaging modalities, the role of imaging of acute stroke has been broadened from making diagnosis to providing valuable information for patient management. We need to have rapid diagnostic modalities that distinguish reversible ischemic tissue from irreversibly damaged tissue for successful thrombolytic therapy. Although diffusion imaging has been reported to have both high sensitivity and specificity for acute ischemia in clinical studies, previous reports do not conclude whether the diffusion abnormality is indicative of reversibly or irreversibly injured tissue. Perfusion imaging such as perfusion magnetic resonance imaging and single-photon emission computed tomography may have the potential for providing useful information that determines tissue viability and/or reversibility. Cerebral blood flow thresholds evaluated by pretreatment single-photon emission computed tomography provide important information that is potentially useful in the management of acute stroke patients with intra-arterial thrombolysis. Perfusion imaging, when combined with diffusion imaging, may thus be potentially useful in improving patient selection for thrombolytic therapy.

Diagnosis of microvasculopathy in CNS vasculitis: value of perfusion and diffusion imaging

Functional imaging may come to play an important role in the evaluation of CNS vasculitis by demonstrating pathology on the microcirculatory level. A positive finding of microvascular ischemia may assist in the diagnosis of CNS vasculitis. More importantly, the demonstration of normal microcirculation may reliably exclude CNS vasculitis.

Direct effects on antigen-presenting cells and T lymphocytes explain the adjuvanticity of a nontoxic cholera toxin mutant

The present study has elucidated two distinct mechanisms that may explain how a mutant of cholera toxin (mCT), E112K, retains adjuvant effects though it lacks ADP-ribosyltransferase activity and associated toxicity. In the first mechanism, we show that mCT E112K, like native cholera toxin (nCT), enhances B7-2 expression, but, to some extent, also enhances B7-1 on Peyer's patch B cells and macrophages. Cocultivation of CD4+ T cells with E112K- or nCT-treated B cells and macrophages in the presence of anti-CD3 stimulation resulted in the induction of T cell-proliferative responses. Further, the responses were blocked by mAbs to B7-1 and/or B7-2; however, the effect of anti-B7-1 was minimal. In the second mechanism, addition of mCT E112K or nCT to anti-CD3 mAb-stimulated Peyer's patch CD4+ T cells inhibited proliferative responses, while recombinant CT-B subunit (rCT-B) did not. Analysis of cytokine responses showed that both mCT E112K and nCT preferentially inhibited IFN-gamma production. Interestingly, however, nCT, but not mCT E112K, induced apoptosis in CD4+ T cells activated via the TCR-CD3 complex. These results indicate that CT uses at least two pathways for inhibition of Th1 responses and that, while nCT induces cAMP accumulation that in turn leads to apoptosis in Th1-type cells, mCT E112K, which lacks ADP-ribosyltransferase activity, inhibits IFN-gamma synthesis by a separate mechanism. Thus, mCT E112K, like nCT, induces adjuvant responses via up-regulation of mainly B7-2 on APCs and through preferential inhibition of Th1-type CD4+ T cell responses in the absence of ADP-ribosyltransferase activity.

[Surgery for mitral regurgitation in children]

In pediatric patients, mitral valve (MV) repair is preferable than MV replacement because of no need for anticoagulation and its feasibility in small children. However, long-term outcome of MV repair is still unclear. In the present study, fifty-two pediatric patients who underwent MV repair (n = 46) and MV replacement (n = 6) against mitral regurgitation (MR) between January 1970 and December 1996 were evaluated. 46 patients had associated diseases. Mitral annuloplasty was applied in 20 patients (by Kay method (n = 14) and Paneth-Burr method (n = 6) before and after 1991, respectively). Freedom from reoperation rate in patients with partial endocardial cushion defect (ECD) was significantly lower than that in other patients after MV repair, which was significantly higher than that in patients with MV replacement. Diameter of mitral annulus grew within normal range after MV repair. In conclusion, MV repair may provide better outcomes with respect to reoperation and growth of MV in pediatric patients except with partial ECD.

MR imaging of muscular sarcoidosis after steroid therapy

The nodular type of muscular sarcoidosis has been known to show characteristic MR findings: however, MR imaging features after steroid therapy have not been reported. A 48-year-old man with nodular type of muscular sarcoidosis is reported. Prior to steroid therapy, axial MR images showed peripheral increased signal intensity and central star-shaped decreased signal intensity. Coronal images showed an inner stripe of decreased signal intensity and outer stripes of increased signal intensity. After steroid therapy, axial images showed only the central star-shaped area of decreased signal intensity. Coronal images showed only the inner stripe of decreased signal intensity. It is important to know that the central area will continue to exist after steroid therapy.

Amyloid arthropathy of the hip joint: MR demonstration of presumed amyloid lesions in 152 patients with long-term hemodialysis

The aim of this study was to determine the spectrum of MR findings of presumed amyloid arthropathy of the hip joints in patients on long-term hemodialysis. We prospectively performed T1- and T2-weighted spin-echo imaging on 152 consecutive patients on hemodialysis. The duration of hemodialysis ranged from 5 months to 24 years, 2 months (mean: 8 years, 8 months). The frequency, location, and signal intensity of bone lesions were assessed. In 12 cases with contrast-enhanced MR examination, enhancement pattern of bone lesions, synovial lesions, and intra-articular lesions were characterized. Bone lesions presumed to be amyloid deposits were identified in 60 patients (39%). Magnetic resonance imaging revealed that amyloid lesions were more extensive than anticipated by plain radiographs. All bone lesions showed decreased signal intensity on T1-weighted images. On T2-weighted images, bone lesions showed increased signal intensity in 32 patients (54%), decreased signal intensity in 11 patients (18%), and both increased and decreased signal intensity in 17 patients (28%). Following intravenous injection of gadolinium-based contrast, all bone lesions showed moderate enhancement. Synovial thickening could not be identified on T1- and T2-weighted images. However, contrast-enhanced images showed thickened synovial membrane, which could be differentiated from joint fluid. Intra-articular nodules showed decreased or intermediate signal intensity on T1-weighted images and decreased signal intensity on T2-weighted images; the intra-articular nodules were contiguous with subchondral bone lesions. Magnetic resonance imaging is useful for evaluating the distribution and extent of amyloidosis of the hip joints in patients undergoing long-term hemodialysis.

Cryopreservation of in vitro-derived bovine blastocysts microinjected with foreign DNA at the pronuclear stage

Days 6 and 7 bovine blastocysts derived from in vitro-fertilized and DNA-injected zygotes (day of IVF = Day 0) were cryopreserved either by conventional two-step freezing or by vitrification. Foreign DNA used for microinjection was the green fluorescent protein gene under the control of the immediate early promoter of human cytomegalovirus. All blastocysts were produced by an in vitro system and were harvested on Days 6 and 7. The proportion of DNA-injected zygotes developing into blastocysts on Days 6 and 7 (total 8%) was lower than that of nontreated zygotes (total 19%; P < 0.01). After cryopreservation in 1.5 M ethylene glycol, the survival rates of DNA-injected blastocysts assessed by re-expansion at 24 h of culture (Day 6: 59%, Day 7: 71%) were comparable with those of nontreated blastocysts (Day 6: 76%, Day 7: 71%). The post-thaw hatching rate within 72 h of culture of DNA-injected Day 7 blastocysts (38%) was not different from that of nontreated Day 7 blastocysts (40%), but the hatching rate of DNA-injected Day 6 blastocysts (23%) was lower than that of nontreated Day 6 blastocysts (47%; P < 0.05). After vitrification in 7.2 M ethylene glycol, 0.0026 M Ficoll-70 and 0.3 M sucrose, the survival and hatching rates of DNA-injected Day 7 blastocysts (61 and 28%, respectively) were similar to those of nontreated Day 6 (71 and 33%, respectively) and Day 7 (75 and 36%, respectively) blastocysts. However, the post-warming survival rate of DNA-injected Day 6 blastocysts was only 30%, and none of the blastocysts hatched (P < 0.01). The mean cell number of DNA-injected Day 6 blastocysts (100.3 +/- 36.4 cells) was lower than that of nontreated Day 6 blastocysts (130.5 +/- 37.1 cells; P < 0.01), while those of DNA-injected and nontreated Day 7 blastocysts were not different (111.2 +/- 42.8 and 119.6 +/- 31.4 cells, respectively). These results indicate that Day 7 IVMFC bovine blastocysts derived from DNA-injected zygotes can be successfully cryopreserved by conventional two-step freezing or vitrification.

[Reoperation after the Fontan operation in single ventricle and tricuspid atresia]

The outcome of the Fontan-type operation for complex heart disease has been significantly improved, and low morbidity and mortality rates are reported. However, some problems still occur in late follow-up, including ventricular failure, hepatic congestion, supraventricular arrhythmia, cerebrovascular events, exercise intolerance, and residual or new cardiac lesions. Reinterventions after the Fontan-type operation for complex cardiac defects in 43 patients are reviewed. In addition to catheter interventions, the main reasons for reoperation were subaortic stenosis, pulmonary artery and vein obstructions, and interatrial shunt. Early intervention, particularly for subaortic obstruction, is recommended, and the Damus-Kay--Stansel anastomosis appears to be the procedure of choice. Reoperation was required in 6 of the 43 patients, with one operative death. The total event-free survival rate after 10 years of follow-up was 53%. The need for reoperation appears to be reduced after performing the total cavopulmonary shunt procedure compared to that after atriopulmonary connection. However, late arrhythmia remains a significant problem in this group of patients, and further assessment of the results of reintervention for arrhythmia is required.

Cervical cord ependymoma with numerous microrosettes

"Microrosette ependymoma," which is ependymoma with numerous microrosettes throughout the tumor, has rarely been reported. We describe an autopsy case of cervical cord ependymoma with two unusual features: the presence of numerous microrosettes and the formation of trabecular architecture. The tumor originated in the C2 segment of a man aged 23 years and gradually expanded over the following 15 years and 10 months until the entire cervical cord was involved. Beside the low grade of malignancy, the tumor cells exhibited a strong tendency to form microrosettes and trabecular architecture, which formed many perivascular pseudorosettes. The microrosettes mostly consisted of only two or a few more cells, in the absence of large rosettes. Thus the constituent cells were those forming perivascular pseudorosettes. Electron microscopy and immunohistochemistry characterized the ependymal properties of the microrosettes, whose lumina frequently contained fibril bundles similar to those of the Reissner's fiber fibrils, in addition to cilia and microvilli. The pathogenesis of the occurrence of numerous microrosettes is unknown; however, a defect in the mechanism of regulation of rosette formation and enlargement is the most likely explanation.

Unusual high signal intensity on MR images in a patient with multiple tendinous xanthomas

The MR features of a 57-year-old man with multiple tendinous xanthomas are reported. The lesions of the peroneus longus tendons and the Achilles tendons showed diffuse reticulated pattern, which is the typical MR finding of tendinous xanthomas. However, the lesions of the patellar tendons showed no diffuse pattern and contained focal regions of high signal intensity on T 1-weighted images suggesting the deposition of triglycerides. The regions showed high signal intensity on T 2-weighted images and moderate enhancement on contrast-enhanced T 1-weighted images suggesting the presence of associated inflammation.

Passive immunization against dental plaque formation in humans: effect of a mouth rinse containing egg yolk antibodies (IgY) specific to Streptococcus mutans

Passive immunization involving the delivery of antibodies specific to pathogens of infectious diseases to the host has been an attractive approach to establish protective immunity against a variety of microbial pathogens, including Streptococcus mutans, which is the principal etiologic agent of dental caries in humans. The overall purpose of the present study was to determine the effectiveness of a mouth rinse containing antibodies to S. mutans in preventing the establishment of this bacterium in dental plaque of humans. The antibodies were derived from egg yolks obtained from hens immunized with whole cells of S. mutans grown in sucrose-containing medium. The immunoglobulin derived from the yolks (IgY) of immunized hens was characterized in vitro and in vivo in human volunteers. Cross-reactivity tests showed that immune IgY reacted with every serotype, except serotype b, which had lost its GTase activity, when the bacteria were cultured in sucrose-containing medium. Immune IgY inhibited S. mutans adherence to saliva-coated hydroxyapatite discs by 59.2%, while control IgY caused an inhibition of only 8.2%. In the short-term (4-hour) test using a mouth rinse containing 10% sucrose, immune IgY decreased the ratio of the percentage of S. mutans per total streptococci in saliva. In the long-term (7-day) test using a mouth rinse without sucrose, the ratio in saliva was not significantly reduced in the volunteers using the immune IgY due to the large standard deviation. However, comparing the ratios of the percentage of S. mutans per total streptococci in plaque of individual subjects, there was a tendency for a reduction of the ratios in the volunteers receiving the mouth rinse containing immune IgY. These results support the effectiveness of IgY with specificity to S. mutans grown in the presence of sucrose as an efficient method to control the colonization of mutans streptococci in the oral cavity of humans.

Reference lines for oblique axial MR imaging of the brain

Reference lines that correspond to the three reference lines used at computed tomography were determined on 50 normal midsagittal magnetic resonance brain images. Lines were drawn from the mammillary body to the posterior tentorial attachment to the sinus (orbitomeatal), from the center of the pituitary gland to the posterior tentorial attachment to the sinus (Reid baseline), from the mammillary body to the posterior edge of the fourth ventricle (supraorbitomeatal).

Management of disseminated intra-abdominal lymphangiomatosis with protein-losing enteropathy and intestinal bleeding

We encountered an unusually severe case of intra-abdominal lymphangiomatosis associated with protein-losing enteropathy and intestinal bleeding. A low-fat diet effectively raised the patient's serum levels of hemoglobin and the total serum protein, perhaps by inducing a reduction in intestinal lymph flow and pressure.

[MMIP chemotherapy for the treatment of the relapsed and refractory non-Hodgkin's lymphoma]

For salvage chemotherapy, 30 cases of relapsed or refractory non-Hodgkin's lymphoma (NHL) were treated with MMIP regimen (mitoxantrone 15 mg/m2, methotrexate 400 mg/m2, and ifosfamide 2 g/m2 intravenously in day 1, respectively, and prednisolone 20 mg/m2 orally from day 1 to 5). The overall complete response rate (CR rate) was 20% and the median survival duration was 153 days. In patients with favorable performance status (PS), the CR rate and survival duration were 30% and 407 days, respectively. These results were almost equivalent to previously proposed salvage regimens. The overall disease free survival rate of CR cases at 4 years was 62%, which was excellent as compared with the other salvage regimens. Five of 8 (62.5%) patients previously treated with etoposide-non-containing regimens achieved CR, and the CR rate was significantly superior to that of patients previously treated with etoposide-containing ones. These results indicate that MMIP is a useful salvage regimen for relapsed or refractory NHL, while it seems to be difficult to salvage patients previously treated with etoposide-containing regimens.

Calcific tendinitis of the gluteus maximus tendon with cortical bone erosion: CT findings

A case of calcific tendinitis of the gluteus maximus tendon with cortical erosion is presented. Roentgenography demonstrated calcification on the posterior surface of the proximal femur. Computed tomography showed flame-like appearance of calcific tendinitis and bone erosion. Magnetic resonance imaging showed minimal inflammatory reaction around the lesion.

Sarcoidosis involving skeletal muscle: imaging findings and relative value of imaging procedures

OBJECTIVE

Muscular involvement of sarcoidosis is rare and occurs in two forms: nodular and myopathic. In the nodular variety, patients have single or multiple nodules in the skeletal muscles. Patients with the myopathic type have myalgia, muscle weakness, and atrophy. The purpose of this study was to determine the imaging features of these two types of muscular sarcoidosis and to compare the merits of different imaging procedures in establishing the diagnosis.

MATERIALS AND METHODS

I retrospectivity reviewed the imaging findings of 28 patients with proved muscular sarcoidosis: 20 patients with the nodular type and eight with the myopathic type. Of the 20 patients with the nodular type, 20 had MR imaging, 17 had 67Ga scintigraphy, 10 had CT, six had sonography, and two had angiography. All eight patients with the myopathic type had MR imaging, and six of them had 67Ga scintigraphy.

RESULTS

In the nodular type of muscular sarcoidosis, the lesions were long and extended along muscle fibers. Axial MR images showed a star-shaped central structure of decreased signal intensity. Coronal and sagittal MR images showed three stripes, including an inner stripe of decreased signal intensity and outer stripes of increased signal intensity. After IV injection of gadopentetate dimeglumine, contrast-enhanced MR images showed enhancement in the peripheral area of the lesions of the nodular type. On sonograms, the central structure was hyperechoic and the peripheral area was hypoechoic relative to surrounding tissue. 67Ga scintigraphy showed increased uptake of radionuclide in the nodules. CT and angiography were of less diagnostic value. In the myopathic type, MR images showed no abnormalities. Myopathic involvement was visualized only with 67Ga scintigraphy, which showed diffusely increased uptake of radionuclide.

CONCLUSION

The unusual MR findings seen in the patients studied were suggestive of the nodular type of muscular sarcoidosis. 67Ga scintigraphy was useful for evaluating the whole body in patients with the nodular type and was the only imaging method that could show the myopathic type of involvement.

[Cerebrospinal fluid fistula following an operation of mediastinal schwannoma: a case report]

A 33-year-old man was operated for the mediastinal schwannoma. During the operation, the 9 th intercostal nerve was avulsed and revealed liquorrhea. Lyodura and fibrin glue was applied for sealing the site of dural defect. But post-operative course was not successful. So, we used the external cerebrospinal fluid drainage system. After this procedure, thoracic fluid from the chest tube was reduced and we could remove the chest tube in the 20th post operative day. This case indicates that in case of thoracotomy, it is difficult to expect easy closure of cerebrospinal fluid fistula under conservative therapy. Therefore it was considered that specific repair during the operation and spinal drainage in the post-operative early phase should be performed.