Recombinant Plasmodium falciparum dihydrofolate reductase-based in vitro screen for antifolate antimalarials

We describe the system for screening the effective antifolate antimalarials that uses the recombinant Plasmodium falciparum DHFR domain of the bifunctional DHFR-TS expressed in Escherichia coli, and were designed with amino acid alterations found in the DHFR genes of the antifolate resistant strains. The validity of the screen was verified by the subsequent examination of several substituted pyrrolo[2,3-d]pyrimidines for their antimalarial activity. Among the 120 chemical derivatives, 5 compounds were identified by their preferential inhibition of the drug sensitive pfDHFR to that of the mammalian isoenzyme. As compared to the sensitive enzyme, the decrease in response of the cycolguanil-resistant and pyrimethamine-resistant enzymes to the selected compounds were relatively moderate. This gave folds decrease in sensitivity of 0.8-7.5 and 3.6-29, respectively, while those for cycloguanil and pyrimethamine were 400 and 308. The compounds inhibited the growth of drug-sensitive cultured P. falciparum with 50% effective concentrations of the ranged 0.17-30 nM. As contrasted with the sensitive strain, the fold decrease in sensitivity of the resistant parasites were 0.9-2 and 15-50 in the case of the test compounds, while those for cycloguanil and pyrimethamine were 690 and 20,500. Moreover, the most selective pyrrolo-pyrimidine (P-1) showed in vivo activity against P. berghei in mice.

[Usefulness of continuous arterial infusion chemotherapy for post operative multiple recurrence and residual hepatocellular carcinoma]

Twenty five patients with postoperative multiple recurrence and residual hepatocellular carcinoma received continuous arterial infusion of CDDP and 5-FU via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days as one course, and 4 courses were basally administered. The efficacy rate was 60%, and there were 7 (28%) CR (complete response) cases. The survival rate was 76.0% for 1 year and 36.5% for 3 years, which is a favorable result considering their advanced stage. Thus, this treatment seemed to be effective for multiple hepatocellular carcinoma.

Chilblain lupus erythematosus of Hutchinson responding to surgical treatment: a report of two patients with anti-Ro/SS-A antibodies

We report two patients with chilblain lupus erythematosus of Hutchinson (CL) who responded to surgical treatment. One of them was a 72-year-old woman (case 1), and the other a 62-year-old man (case 2). We attempted to treat these patients by excising the lesions and subsequently performing full-thickness free skin grafting, using skin from the abdominal region. No recurrence was seen in the operated area 7 years (case 1) and 3 years (case 2) after surgery. However, lesions persisted in the areas not operated upon, and in the areas where lesions had not been adequately excised. These results suggest that surgical removal of local factors reduces the rash in these cases. In addition, both patients were serologically positive for the anti-Ro/SS-A antibody suggesting that local expression of the Ro/SS-A antigen may be involved in the pathogenesis of the skin lesions. To our knowledge, full thickness free skin grafting has not been used previously to treat CL-associated skin lesions, and is promising as a treatment for patients who do not respond to conventional means.

Do ictal, clinical, and electroencephalographic features predict outcome in West syndrome?

Ictal electroencephalographic/video recordings of 42 patients with West syndrome (WS) were reviewed to define the relation between ictal, clinical, and EEG features and etiology or prognosis. The duration and type of spasms, the number of spasms per cluster, and the interval between spasms did not correlate with the etiology or the short-term prognosis. However, eye deviation, asymmetric spasms, and partial seizures concomitant with spasms were observed only in symptomatic WS patients with poor outcome. In particular, all 8 patients with concurrent partial seizures had severe psychomotor retardation. The ictal EEG characteristics did not correlate with etiology and prognosis. There was no significant difference between the patients with persistence or reappearance of hypsarrhythmia and the patients without interspasm hypsarrhythmia.

[The study of continuous arterial infusion chemotherapy with CDDP and 5-FU in patients with hepatocellular carcinoma]

Between Feb. 1992 and April in 1995, 22 patients with hepatocellular carcinoma (10, recurrence; 12, unresectable) received continuous arterial infusion of CDDP and 5-FU via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days as one course, and 4 courses were basally administered. Patients were divided into 2 groups (6 hours group and 24 hours group) according to the duration of the administration of 5-FU. There were no differences in efficacy rate between the 2 groups (6 hours group, 64%; 24 hours group, 62.5%), but CR (complete response) cases appeared in only the 6 hours group. There were no severe side effects in the 2 groups, but systemic side effects appeared in 6 hours group more often than in 24 hours group. Only in the 24 hours group, 2 patients had the narrowing and obstruction of hepatic artery which was suggested to be caused by intimal injury due to continuous administration of 5-FU. Continuous arterial infusion chemotherapy with CDDP and 5-FU seemed to be effective. Further study on adequate time and volume of administration including pharmacokinetics is needed to enhance the clinical effectiveness of continuous arterial infusion of CDDP and 5-FU.

Assessment of cellular proliferation of sebaceous neoplasms by AgNOR counts and immunohistochemical demonstrations of PCNA and Ki-67

We assessed cellular proliferation of sebaceous neoplasms by AgNOR counts and the immunohistochemical demonstration of proliferating cell nuclear antigen (PCNA) and Ki-67, using formalin-fixed and paraffin-embedded tissue specimens. We used three categories of sebaceous neoplasms: four cases of sebaceoma, three cases of basal cell carcinoma with sebaceous differentiation (BCSD), and seven cases of sebaceous carcinoma (SC). Significant differences were noted between SC and non-SC tumors (sebaceoma and BCSD) in AgNOR counts and semi-quantitative grading of PCNA and Ki-67 labelling indices (P < 0.01). When a cut-off value of 6 was chosen, the AgNOR value discriminated SC from non-SC tumors with high specificity and sensitivity. When a cut-off value of 25% was chosen, PCNA and Ki-67 labelling indices also discriminated between these tumors. Significant differences were not observed between sebaceoma and BCSD with PCNA and Ki-67 labelling indices. AgNOR counts of BCSD were a little higher than those of sebaceoma, but the number of cases was too small to perform statistical assessment. We consider AgNOR counts and semi-quantitative grading of PCNA and Ki-67 labelling indices to be useful in differentiating SC from BCSD and sebaceoma.

Synthesis and antitumor activity of pyrrolo[2,3-d]pyrimidine antifolates with a bridge chain containing a nitrogen atom

Novel pyrrolo[2,3-d]pyrimidine antifolates (1a, b and 2a, b) with a nitrogen atom in the bridge chain between the 2,4-diaminopyrrolo[2,3-d]pyrimidine and phenylene rings were designed and efficiently synthesized. These compounds exhibited more potent inhibitory activities than methotrexate (MTX) against the proliferation of human epidermoid carcinoma KB cells and human non-small cell lung carcinoma A549 cells despite their modest dihydrofolate reductase (DHFR)-inhibitory potency.

[Studies on auditory brainstem responses showing absence or significantly poor formation of waves II-V in children]

We performed a retrospective study on 7 children in whom the auditory brainstem responses (ABR) showed absence or significantly poor formation of waves II-V. Two patients had degenerative diseases that affected the brains diffusely. In the remaining 5 patients, the symptoms consisted of action tremor (3 patients) or pyramidal signs (2 patients). There were neither clinical signs nor neuroimaging findings suggesting brainstem involvements. The evolutional changes of the ABRs had a good correlation with the clinical course. Absence or significantly poor formation of waves II-V of ABR occurs in various diseases and may not necessarily reflect severe organic brain lesions.

[The study of continuous arterial infusion chemotherapy with 5-FU and CDDP in patients with hepatocellular carcinoma]

Between Feb. 1992 and March in 1994, 14 patients with hepatocellular carcinoma (7: recurrence, 7: unresectable) received continuous arterial infusion of 5-FU and CDDP via implanted reservoir. For the next five days, 10 mg/body of CDDP and 250 mg/body of 5-FU using arterial infusion were administered. It was discontinued for two days, as one course, and 4 courses were basally administered. The duration of the administration was 24 or 6 hours/day. Side effects consisted of nausea or loss of appetite for 7 (50%), suppression of bone marrow for 3 (21%), and they disappeared after the agents were discontinued. However, there were 3 patients with gastro-duodenal ulcer, so careful follow-up was necessary. The efficacy rate was 64% and two-year survival rate was 57% and thus this treatment seemed to be effective. Further study on the duration and dose of the administration is necessary to improve the therapeutic effect and QOL.

An immunohistochemical study of sebaceous carcinoma with anti-keratin monoclonal antibodies: comparison with other skin cancers

Formalin-fixed and paraffin-embedded tissue specimens of six cases of extraocular sebaceous carcinoma were studied immunohistochemically with eight anti-keratin monoclonal antibodies, 34 beta B4, 35 beta H11, Ks13.1, Ks19.1, PKK1, LP34, KL1 and AE1. The staining patterns of sebaceous carcinoma were compared with those of normal sebaceous glands and other skin cancers which should be distinguished from sebaceous carcinoma histopathologically. The other skin cancers compared were eccrine porocarcinoma, malignant clear cell hidradenoma, extramammary Paget's disease with underlying adenocarcinoma, malignant trichilemmoma, and squamous cell carcinoma. Most cases of sebaceous carcinoma were stained with 35 beta H11, Ks19.1, LP34, KL1 and AE1, while normal sebaceous glands were positive only with 35 beta H11, LP34, KL1 and AE1. By immunostaining, sebaceous carcinoma was distinguishable from extramammary Paget's disease with underlying adenocarcinoma, squamous cell carcinoma, malignant trichilemmoma, and eccrine porocarcinoma, but was not clearly distinguishable from malignant clear cell hidradenoma. These findings demonstrate that sebaceous carcinoma shows positive reactions with antibodies to simple epithelial keratin, probably as a result of neoplastic transformation, and that immunohistochemical examination using anti-keratin monoclonal antibodies is useful in distinguishing sebaceous carcinoma from several other skin cancers.

Focal spasms in clusters, focal delayed myelination, and hypsarrhythmia: unusual variant of West syndrome

We report a patient who began to have clusters of seizures characterized by brief elevation of the right arm at 6 months of age. An interictal electroencephalogram (EEG) at 7 months revealed hypsarrhythmia without definite asymmetry. Simultaneous EEG and video recording disclosed that these focal spasms were associated with fast wave bursts superimposed on slow waves most markedly in the left centro-midtemporal region. The patient became seizure-free after synthetic ACTH therapy. The patient is developmentally normal at 3 years 5 months, but magnetic resonance imaging studies revealed findings suggestive of delayed myelination in the left frontal region. This patient is considered to have had an unusual variant of West syndrome associated with focal delayed myelination.

Evolutional changes of cortical hypometabolism in West's syndrome

The pathophysiological basis of the epileptic encephalopathy West's syndrome remains unknown. We have done serial positron emission tomography (PET) with fluorine-18-labelled 2-deoxy-3-fluoro-D-glucose (FDG) in twelve patients with newly diagnosed West's syndrome. Throughout follow-up, PET revealed diffuse or focal cortical hypometabolism in eleven patients, whereas magnetic resonance imaging (MRI) showed morphological abnormalities in only five. At disease onset, PET showed cortical hypometabolism in eight patients (diffuse in three, focal in five). The second PET showed normal metabolism in six of these patients but focal abnormalities in three of the four with normal results on first PET. In all seven patients with normal findings on the second PET, tonic spasms ceased after initial treatment and no epileptic seizure occurred thereafter. In the five patients with cortical hypometabolism on the second PET, tonic spasms persisted or recurred, or partial seizures appeared. However, in two patients PET abnormalities disappeared in accordance with the later resolution of epileptic seizures. All patients with normal MRI and second PET results had normal psychomotor development. Diffuse or focal cortical hypometabolism that cannot be detected by MRI or computed tomography is common in patients with West's syndrome. However, this anomaly is not permanent and changes with clinical symptoms. These functional abnormalities in the cerebral cortex may be associated with the development of West's syndrome.

Senile dry skin type Sjögren's syndrome

BACKGROUND

Elderly patients may show asteatotic dermatitis complicating Sjögren's syndrome (sjs) that we have named "senile dry skin type sjs." To define the condition further, we have examined a group of patients with sjs and have recorded clinical and laboratory findings in these patients.

PATIENTS AND MATERIALS

Of the 36 patients, 11 were men and 25 were women, with a mean age of 72 years. In addition to the subjective sensation of dryness of the eyes and oral cavity and objective signs of dryness revealed by the Schirmer test, the rose bengal test, minor labial gland biopsy, and sialography were carried out, as well as other hematologic and immunologic tests.

RESULTS

The following abnormal laboratory tests were found: elevated erythrocyte sedimentation rate (85%), mild hepatic dysfunction (50%), and anemia (45%), leukopenia (42%), and thrombocytopenia (16%). Immunologic abnormalities were also observed, such as: positive antinuclear antibody (55%), an increase in gamma globulin (28%), and a positive rheumatoid factor (20%). In 11 of the 36 patients (30%), the subjective sensation of dryness was absent and only objective signs of dryness were present.

CONCLUSIONS

The present study suggests that dry-skin-dermatitis associated with sjs is rather common in the elderly.

Photosensitive epilepsy in children

We performed a retrospective analysis of 17 children with photosensitive seizures (PSS) who had been followed for more than 3 years (mean: 9 years). PSS were verified in all patients by simultaneous video-EEG monitoring. The seizures were precipitated by flickering stroboscopes (14 patients) or were induced by patients themselves (3) with head-nodding in front of illumination, blinking at television or close viewing of striped patterns. PSS consisted of myoclonic seizures (eight patients), generalized tonic-clonic convulsions (5), partial seizures (3) or atypical absence (1). According to the International Classification of Epileptic Syndrome, three patients were classified as having severe myoclonic epilepsy in infancy and five as having juvenile myoclonic epilepsy. The remaining nine could not be categorized as any specific epileptic syndrome. Children with age of the onset of epilepsy at 7 years or younger tended to suffer intellectual deficit in addition to intractable seizures.

Transient focal cortical hypometabolism in idiopathic West syndrome

Positron emission tomography (PET) using 18F-labeled 2-deoxy-D-glucose was performed serially in 5 infants with idiopathic West syndrome. While tonic spasms persisted, 2 infants had hypometabolism in the bilateral temporo-parieto-occipital regions, which disappeared after cessation of spasms. In 2 other infants, PET revealed focal hypometabolism in the temporal region a few months after the disappearance of tonic spasms, but subsequent PET studies were normal. PET can detect transient metabolic abnormalities of the cerebral cortex which may be associated with the pathophysiology of West syndrome.

A case of malignant haemangioendothelioma treated with recombinant interleukin-2

A case of malignant haemangioendothelioma of the scalp in an 82-year-old female treated with intralesional, intra-arterial and intravenous recombinant interleukin-2 (rIL-2) is reported. The scalp lesions disappeared after injection of 35,350,000 Japan reference units of rIL-2 and excision of the residual tumour. Immunohistochemical characterization of the cells infiltrating the lesion after rIL-2 administration revealed 30-40% CD4+ and CD8+ T lymphocytes, 20-30% macrophages and 5-10% natural killer cells. These findings are similar to those in other human cancers. Almost all of the cells in the intersticies of the lesion after rIL-2 injection expressed leucocyte function-associated antigen-1, and some of the tumour cells and the infiltrating cells around them expressed intercellular adhesion molecule-1. HLA-DR-positive cells markedly increased in number after rIL-2 administration. This report suggests that rIL-2 administration is the most effective therapy for malignant haemangioendothelioma.

Wernicke's encephalopathy in a child with acute lymphoblastic leukemia

PURPOSE

We describe the case of a 9-year-old boy who developed Wernicke's encephalopathy while receiving chemotherapy for acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

After suffering anorexia for 4 weeks following chemotherapy, he exhibited nystagmus and ataxia. Symptoms rapidly worsened following an increased glucose load, and included a depressed consciousness, irregular respiration, and ophthalmoplegia. The serum thiamine level was 9 ng/ml (normal: 20-50). Cranial computed tomography (CT) revealed a low density area bilaterally at the neostriatum. Thiamine 100 mg/day was administered intravenously.

RESULTS

The patient's neurological signs improved dramatically. However, he subsequently developed pancytopenia and died of pneumonia.

CONCLUSION

The possibility of Wernicke's encephalopathy should be considered in children who are receiving chemotherapy for malignant disease when a persistent loss of appetite is followed by such neurological symptoms as nystagmus and ataxia.

Benign partial epilepsy with secondarily generalized seizures in infancy

Seven infants with benign idiopathic partial epilepsy presented with apparently generalized tonic-clonic seizures (GTCs) which proved to be partial seizures evolving to secondarily generalized seizures. All were easily controlled with phenobarbital (PB) or carbamazepine (CBZ), and remained seizure-free > 3 years even after discontinuation of medication, and had a normal developmental outcome. The initial seizure manifestation consisting of motion arrest, staring or blank eyes, or crying associated with focal paroxysmal discharges was followed by GTCs in accordance with generalization of paroxysmal discharges. Four infants had a family history of benign type of childhood convulsions. The term "benign partial epilepsy in infancy" is proposed to combine this syndrome with the previously described benign infantile epilepsy with complex partial seizures.