Loss of 123I-MIBG uptake by the heart in Parkinson's disease: assessment of cardiac sympathetic denervation and diagnostic value

Myocardial imaging with 123I-metaiodobenzylguanidine (MIBG) was performed on 35 patients with Parkinson's disease and 24 control subjects to evaluate cardiac sympathetic function in patients with Parkinson's disease, verify this phenomenon and examine whether myocardial MIBG uptake and clearance are correlated with the clinical severity of Parkinson's disease.

METHODS

We studied 35 patients with Parkinson's disease and 24 control subjects with other central nervous system diseases. The latter group consisted of 12 subjects with other neurodegenerative disorders (4 with spinocerebellar degeneration, 2 with amyotrophic lateral sclerosis, 3 with progressive supranuclear palsy and 3 with corticobasal degeneration and 12 patients with cerebral infarction (CI), 6 with vascular parkinsonism and 6 without it. Early and delayed images of the anterior view were obtained 15 min and 4 h after injection of 123I-MIBG, respectively. MIBG uptake was quantified by calculating a heart-to-mediastinum count (H/M) ratio.

RESULTS

The H/M ratio was markedly reduced in the patients with Parkinson's disease (II to V on the Hoehn and Yahr scale) compared with the control subjects. None of the subjects with neurodegenerative diseases showed a marked decrease in myocardial MIBG uptake nor did any subject with CI.

CONCLUSION

Our findings indicate that, in Parkinson's disease, a reduction in myocardial MIBG uptake is a very common, specific phenomenon that can be used to detect cardiac autonomic dysfunction to diagnose Parkinson's disease, particularly in patients without typical signs and symptoms.

[Spontaneous peripelvic urine extravasation associated with ileocecal cancer: a case report]

A case of spontaneous peripelvic extravasation with ileocecal cancer is reported. A 60-year-old man with right flank pain was referred to our department. Dripinfusion pyelography showed right peripelvic extravasation. Neither computed tomography (CT) nor retrograde pyelography revealed any ureteral stones or tumors. Urinary cytology was negative. One month later, right retrograde pyelography demonstrated the filling defect in the right ureter, but no stones, ureteral tumors or other tumors related to the ureter were detected by CT. An exploratory laparotomy was done. We found an ileocecal tumor invading to the right ureter and disseminated to the peritoneum. Histological diagnosis was mucinous carcinoma.

Specificity of omega-conotoxin MVIIC-binding and -blocking calcium channel antibodies in Lambert-Eaton myasthenic syndrome

An immunoprecipitation assay was used to measure omega-conotoxin MVIIC (P/Q-type) binding and blocking calcium channel antibodies in 67 patients with Lambert-Eaton myasthenic syndrome (LEMS) and in a large control population. We first showed the presence of omega-conotoxin MVIIC-blocking antibody in LEMS patients. Binding antibodies were detected in 55 of 67 (82.1%) LEMS patients and in 2 of 296 (0.7%) controls. In contrast, blocking antibodies were positive in 14 of 67 (20.9%) LEMS patients and 8 of 171 (4.7%) controls. No LEMS patient had negative binding antibodies and positive blocking antibodies. The immunoprecipitation assay detected no antibodies against the whole P/Q-type calcium channel in either the paraneoplastic cerebellar degeneration or the amyotrophic lateral sclerosis sera. Neither the omega-conotoxin MVIIC-binding nor the -blocking calcium channel antibodies were correlated with clinical severity across the individuals, but longitudinal studies of some LEMS patients showed an inverse relation between binding antibody titre and disease severity. We concluded that the 125I-omega-conotoxin MVIIC assay for anti-P/Q-type voltage-gated calcium channel antibodies is highly specific for LEMS and that this sensitive binding antibody assay could be more valuable than the blocking antibody assay in the diagnosis of LEMS.

CAG repeat length and disease duration in Machado-Joseph disease: a new clinical classification

To evaluate the clinical characteristics of Machado-Joseph disease (MJD) with reference to CAG repeat length and disease duration, we analyzed neurologic findings in 108 patients from 84 families. The majority of MJD patients presented with an ataxic gait as the initial symptom. Dysarthria and nystagmus were observed from an early stage. Bulging eyes, muscle atrophy and bradykinesia developed later. Patients with a shorter CAG repeat length or later onset had more frequent involvement of proprioceptive sensory deficit. Incidence of abnormal reflexes, tones, and proprioceptive sensation was not associated with disease duration, but with CAG repeat length. Based on these results, we propose a new clinical classification: type A (juvenile type), with hyperreflexia and dystonia, but without a proprioceptive sensory deficit; type C (adult type), with hyporeflexia and a proprioceptive sensory deficit, but without dystonia; and type B (intermediate type), the remaining patients with a mixed presentation.

Distribution of intramembranous particle size in the muscle plasma membrane of the mdx mouse

We investigated whether the reduced intramembranous particles (IMP) in the muscle plasma membrane in mdx mice reflects a preferential depletion of a particular size of the IMP. The experiments were performed using the freeze-fracture method to analyze the frequency distribution of the size of IMP, the density of orthogonal array and caveolae in the extensor digitorum longus (EDL) and soleus (SOL) muscles obtained from mdx and control mice. We detected a reduced density of IMP and orthogonal array, and the increased density of caveolae in EDL muscle but not in SOL in the mdx mouse compared with those of the same muscles in control animals. The reduction of IMP was, however, not limited to any specific size of IMP. Our results suggest that the dystrophin associated glycoprotein present in the membrane does not reflect a specific size of IMP. Therefore, our findings indicate that the mechanism of reduced IMP in dystrophinopathy may be different from that of diminished dystrophin binding glycoprotein associated with dystrophin deficiency in Duchenne muscular dystrophy.

Extrapontine myelinolysis presenting with parkinsonism as a sequel of rapid correction of hyponatraemia

Images

[Total defect of metaiodobenzylguanidine (MIBG) imaging on heart in Parkinson's disease: assessment of cardiac sympathetic denervation]

This study was conducted to evaluate sympathetic cardiac innervation using MIBG imaging in PD. Uptake of MIBG was measured in 35 PD patients. Although normal MIBG uptake was observed in PD patients with HY stage l, PD with stage 3-5 revealed a total defect of visual MIBG imaging on heart area. Quantitative measurements of MIBG uptake assessed by the radioactivity ratio of cardiac to mediastinal tissue(H/ M) in early imaging was associated with the clinical severity of PD(control; 2.0 +/- 0.3, stage l; 2.0 +/- 0.1, stage 2; 1.6 +/- 0.4, stage 3-5; 1.3 +/- 0.1). In conclusion, homogeneous impairment of sympathetic cardiac innervation was observed in PD patients and this abnormality was associated with the clinical severity of PD, indicating that MIBG imaging of heart is useful not only for the evaluation of cardiac sympathetic impairment of PD but also for the diagnosis of PD.

Renal cell carcinoma: preoperative assessment for enucleative surgery with angiography, CT, and MRI

PURPOSE

Our purpose was to assess various imaging methods in detecting a pseudocapsule of renal cell carcinoma (RCC), which is critical for successful tumor enucleation.

METHOD

In 42 patients with histopathologically proven RCC, images obtained at angiography (n = 42), CT (n = 30), and MRI (n = 19) were investigated retrospectively. All patients underwent treatment (enucleation: n = 15; nephrectomy: n = 27). The imaging criteria for the presence of a pseudocapsule were as follows: a surrounding radiolucent rim on angiography, a low or high density rim on CT, and a low intensity rim on MRI. All images were retrospectively reviewed by three radiologists without knowledge of the clinical and histological findings.

RESULTS

Thirty-three of 42 RCCs showed a pseudocapsule on the surgical specimen. A pseudocapsule was detected in 67% of tumors (22/33) on angiography, 26% (6/23) on CT, 27% (4/15) on T1-weighted MRI, 93% (14/15) on T2-weighted MRI, 67% (8/12) on dynamic enhanced T1-weighted MRI, and 15% (2/13) on delayed enhanced T1-weighted MRI.

CONCLUSION

T2-weighted MR images are superior for visualizing a pseudocapsule of RCC and for providing reliable selection criteria for tumor enucleation.

[Clinical experience of total prostatectomy using DDV-L (deep dorsal venous ligator]

BACKGROUND

We evaluated blood loss in operation and postoperative urinary incontinence to total prostatectomy using the DDV-L.

METHODS

We performed total retropubic prostatectomy for 38 patients from May 1979 to May 1995. In 14 patients from October 1994 to May 1995 the DDV-L was used. The DDV-L is used in transurethral approach, disposable device to ligate the deep dorsal vein complex by delivering the needle to lateral of deep dorsal vein complex.

RESULTS

We composed the 14 patients which was used the DDV-L with the 14 patients which was from April 1990 to July 1994 was not used that. The mean operating time of 14 patients which was used the DDV-L was 178.5 min, 14 patients which was not used that was 188.0 min. The mean blood loss of 14 patients which was used th DDV-L was 735.7 ml, 14 patients which was not used that was 1250.2 ml. We transfused blood into 2 of 14 patients which was used the DDV-L (14.0%), 10 of 14 patients which was not used that (71.4%). The one of 14 patients which was used the DDV-L (7.5%) and 5 of 14 patients which was not used that (35.7%) had postoperative urinary incontinence needing pad.

CONCLUSION

Accordingly the operating results of 14 patients which was used the DDV-L was undoubtedly better that of 14 patients which was as regards blood loss in operation, postoperative urinary incontinence. We can perform easily the management of deep dorsal vein complex by DDV-L, so we can cut of urethra without excess hemostasis and electronic coagulation, and leave enough long membranous urethra. We consider the DDV-L is helpful to total prostatectomy.

Renal cell carcinoma: preoperative assessment for enucleative surgery with angiography, CT, and MRI

PURPOSE

Our purpose was to assess various imaging methods in detecting a pseudocapsule of renal cell carcinoma (RCC), which is critical for successful tumor enucleation.

METHOD

In 42 patients with histopathologically proven RCC, images obtained at angiography (n = 42), CT (n = 30), and MRI (n = 19) were investigated retrospectively. All patients underwent treatment (enucleation: n = 15; nephrectomy: n = 27). The imaging criteria for the presence of a pseudocapsule were as follows: a surrounding radiolucent rim on angiography, a low or high density rim on CT, and a low intensity rim on MRI. All images were retrospectively reviewed by three radiologists without knowledge of the clinical and histological findings.

RESULTS

Thirty-three of 42 RCCs showed a pseudocapsule on the surgical specimen. A pseudocapsule was detected in 67% of tumors (22/33) on angiography, 26% (6/23) on CT, 27% (4/15) on T1-weighted MRI, 93% (14/15) on T2-weighted MRI, 67% (8/12) on dynamic enhanced T1-weighted MRI, and 15% (2/13) on delayed enhanced T1-weighted MRI.

CONCLUSION

T2-weighted MR images are superior for visualizing a pseudocapsule of RCC and for providing reliable selection criteria for tumor enucleation.

Autoantibodies and immunoglobulins in atomic bomb survivors with human T-lymphotropic virus type I

The association of human T-lymphotropic virus type I (HTLV-I) with autoimmune disorders was investigated on the basis of prevalence of antinuclear antibody (ANA), rheumatoid factor and anti-thyroglobulin antibody as well as immunoglobulin (Ig) serum level (IgG, IgA, and IgM). The subjects, all atomic bomb survivors, were 59 HTLV-I-seropositive people without HTLV-I-associated myelopathy or adult T-cell leukemia and 149 HTLV-I-seronegative persons. The mean serum level of IgM was higher in HTLV-I-seropositive subjects than in HTLV-I-seronegative subjects, and a significant association with HTLV-I and sex was indicated in the IgM serum level. No association with HTLV-I was indicated in the prevalence of the autoantibodies except for ANA. These results suggest some clear humoral immunity differences between HTLV-I-infected and noninfected subjects, but whether HTLV-I infection can lead to autoimmune disorders remains uncertain.

Immunohistochemical study of utrophin and dystrophin at the motor end-plate in myasthenia gravis

We studied the densities of utrophin and dystrophin at the motor end-plates of patients with myasthenia gravis (MG) using immunohistochemical analysis. The densities were compared with those found in patients with amyotrophic lateral sclerosis, Lambert-Eaton myasthenic syndrome and normal controls. Utrophin was reduced at the motor end-plates of MG patients, in association with a reduction of alpha-bungarotoxin binding sites. In contrast, the density of dystrophin at the motor end-plate of MG patients was not significantly different from that found in the controls. We conclude that, at the motor end-plate, utrophin may be more closely associated than dystrophin with the acetylcholine receptor, and that it plays a different role.

'Split tolerance' induction by intrathymic injection of acetylcholine receptor in a rat model of autoimmune myasthenia gravis; implications for the design of specific immunotherapies

Experimental autoimmune myasthenia gravis (EAMG) in the Lewis rat, induced by a single injection of acetylcholine receptor (AChR) protein, is a model used to study human myasthenia gravis (MG). The production of anti-AChR antibodies in the animal model and human MG is T cell-dependent, and AChR-specific T cells have been considered as a potential target for specific immunotherapy. Intrathymic injection of antigens induces antigen-specific tolerance in several T cell-mediated autoimmune models. We examined the effect of intrathymic injection of AChR on T cell responses and the production of antibodies to AChR in EAMG rats. Primed lymph node cells from rats receiving intrathymic injection of AChR exhibited reduced proliferation to AChR with marked suppression of interferon-gamma (IFN-gamma) secretion in the antigen-stimulated culture, compared with those of rats injected with PBS. However, neither anti-Narke AChR nor anti-rat AChR antibody production was suppressed or enhanced in intrathymically AChR-injected animals compared with that of animals injected intrathymically with PBS or perithymically with AChR. This 'split tolerance' may be attributable to the suppression of type-1 T helper cells (Th1). Our results suggest that the suppression of Th1 function alone may not be sufficient for the prevention of antibody-mediated autoimmune diseases.

Experimental neonatal autoimmune myasthenia gravis: an immunohistochemical, ultrastructural and electrophysiological study of the motor end-plate

Neonatal rats born of and nursed by mothers immunized with Narke japonica acetylcholine receptor protein had elevated serum anti-acetylcholine receptor antibodies that reached the mother's level on day 10 after delivery and decreased rapidly after weaning. IgG was present at the motor end-plates up to day 170, and the motor end-plate fine structure remained abnormal up to day 80. Miniature end-plate potential amplitudes in the diaphragm were at the control levels within 10 days of birth, but were lower than those of the controls up to day 80 after birth. We could not obtain the direct evidence that transient synthesis of antibodies occurs in experimental autoimmune myasthenia gravis pups. This model can serve as an experimental model of transient neonatal myasthenia gravis in humans, exception for the route of antibody transfer and the time of the onset of illness.

[Diagnosis and therapy of incidental renal cell carcinoma]

Renal cell carcinoma (RCC) especially incidentally found RCC has been markedly increased in the world due to development of ultrasound or computerized tomography (CT) instruments. Controversy existed on the nephron sparing treatment for incidental RCC. We have operated the incidental RCC using a technique of tumor enucleation shelling out with 5 mm normal surrounding parenchyma. It is important to demonstrate its pseudocapsule for indication of the procedure. For the purpose MRI (T2) is the most reliable method in comparison with angiography, CT and ultrasound. In 42 cases of incidental RCC, 22 cases were nephrectomized and 19 cases were enucleated. One was not operated on. In our cases there was no local recurrence, metastasis or impaired renal function for over one year. However, some problems still remain such as local recurrence (0% approximately 10%), multicentricity (7%) and residual renal function in the literature. Therefore, we propose the following 4 points for indications of tumor enucleation, (1) asymptomatic completely and incidentally, (2) < or = 4 cm in diameter, (3) stage 1 (T1, T2) with pseudocapsule, (4) peripheral location.

[Multilocular cystic renal cell carcinoma treated with tumor enucleation: a case report]

We report a 65-year-old man with a multilocular cystic renal cell carcinoma which was found incidentally. Computed tomography (CT) demonstrated a 3.0 cm x 3.0 cm multilocular cystic mass at the upper pole of the left kidney. Dynamic MRI demonstrated that the septic wall of the multilocular cystic mass was enhanced. Renal angiography showed a hypovascular tumor. We diagnosed that the tumor was multilocular cystic renal cell carcinoma with a tumor capsule and performed tumor enucleation. The histopathological examination showed that the cystic and septic wall consisted of renal cell carcinoma, clear cell subtype, grade 1. From the review of the literature, the prognosis of multilocular cystic renal cell carcinoma was good, so we selected nephron sparing surgery for this case.

Molecular features of the CAG repeats and clinical manifestation of Machado-Joseph disease

Machado--Joseph disease (MJD) is an autosomal dominant spinocerebellar degeneration mapped to chromosome 14q32.1. The CAG expansions of the MJD1 gene was identified as the cause of the disease. We have analyzed 90 MJD individuals from 62 independent MJD families and found that the MJD1 repeat length is inversely correlated with the age of onset (r = -0.87). The MJD chromosomes contained 61-84 repeat units, whereas normal chromosomes displayed 14-34 repeats. In the normal chromosomes, 14 repeat units were the most common and the shortest. In association with the clinical anticipation of the disease, a parent--child analysis showed the unidirectional expansion of CAG repeats and no case of diminution in the affected family. The differences in CAG repeat length between parent and child and between siblings are greater in paternal transmission than in maternal transmission. Detailed analysis revealed that a large degree of expansion was associated with a shorter length of MJD1 gene in paternal transmission. On the other hand, the increments of increase were similar for shorter and longer expansion in maternal transmission. Among the three clinical subtypes, type I of MJD, with dystonia, showed a larger degree of expansion in CAG repeats of the gene and younger ages of onset than the other types.

Exaggerated messenger RNA expression of inflammatory cytokines in human T-cell lymphotropic virus type I-associated myelopathy

OBJECTIVE

To investigate the expression of inflammatory cytokine messenger RNA (mRNA) in peripheral blood mononuclear cells of patients with human T-cell lymphotropic virus type I (HTLV-I)-associated myelopathy (HAM).

PATIENTS

Seventeen patients with HAM, 18 HTLV-I-seropositive carriers, and 10 seronegative individuals were studied.

MAIN OUTCOME MEASURE

We compared the expression of tumor necrosis factor alpha (TNF-alpha), granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon alpha (IFN-alpha), IFN-beta, and IFN-gamma, and interleukin 1 alpha (IL-1 alpha) and IL-1 beta by reverse transcriptase-polymerase chain reaction.

RESULTS

In patients with HAM, the reverse transcriptase-polymerase chain reaction products of TNF-alpha, GM-CSF, IFN-gamma, and IL-1 alpha were detected in significantly higher incidences than in HTLV-I-seropositive carriers and seronegative controls. Furthermore, simultaneous mRNA expression of three or more of these four cytokines was detected in all patients with HAM compared with only 21.4% of HTLV-I-seropositive carriers. By contrast, there was no significant difference in mRNA expression of IFN-alpha, IFN-beta, and IL-1 beta among patients with HAM, HTLV-I-seropositive carriers, and HTLV-I-seronegative controls.

CONCLUSIONS

An exaggerated mRNA expression of several inflammatory cytokines, including TNF-alpha, GM-CSF, IFN-gamma, and IL-1 alpha, was demonstrated in peripheral blood mononuclear cells of patients with HAM. Moreover, transcripts of these cytokines were simultaneously up-regulated in patients with HAM, suggesting that an inflammatory state in the central nervous system may be related to the pathogenesis of HAM.

[Laser-TURP with a lateral firing fiber for contact irradiation]

We have operated 25 BPH patients with transurethral Nd-YAG laser ablation for prostate from June of 1993 till December of 1993. We used UltraLine fiber for contact laser irradiation of the prostate. This is a lateral firing quartz fiber with high density laser energy output, and so made it possible for us to vaporize prostatic tissue rapidly and deeply. We used 60 Watts of power for all cases. For the prostates larger than 50 cm3, limited resection after laser ablation allowed early relief of patients' symptoms. Two months after the treatment, average flow rate improved from 3.7 ml/sec to 7.8 ml/sec. Volume of residual urine decreased from 48.4 ml to 17.0 ml. Twenty-four percent decrease of prostatic volume was also recognized with transrectal sonography. Only 4 patients complained of transient urinary retention, although another 3 or 5 days catheter placement relieved their symptoms. Bleeding was negligible and the other postoperative complications were not recognized at all. Laser-TURP is a new treatment that is effective, less morbid and economical, compared with the ordinary TUR-P. So it will soon become an alternative method to electrocautery TUR-P.

A long surviving case of amyotrophic lateral sclerosis with atrophy of the frontal lobe: a comparison with the Mitsuyama type

A female patient with amyotrophic lateral sclerosis (ALS) showing psychiatric symptoms during her last 2 years of life is reported. Although pseudobulbar signs were seen at the onset of ALS and no respirator was used, the period from onset to death was rather long (9 years). The spinal lesions showed features common to ordinary ALS, while the marked atrophy with destructive changes throughout the frontal lobe seemed to be considerably more severe than that seen with either ordinary ALS or the Mitsuyama type of ALS. Since the clinical manifestations and histological characteristics are apparently different from those of the Mitsuyama type, our case may be a new nosological variant of ALS with psychiatric manifestations.

[Asymptomatic pheochromocytoma: a report of three cases]

We present three cases of asymptomatic pheochromocytoma treated at Sumitomo Hospital. They had no hypertensive episode. The tumors of Case 1 and Case 3 were incidentally detected by abdominal ultrasonography at the Health Screening Center of Sumitomo Hospital. The tumor of Case 2 was incidentally detected by abdominal ultrasonography in the health examination of his company. Case 1. A 49-year-old male was hospitalized in Apr. 1992 because of further examination of a right adrenal mass. He underwent right adrenalectomy and its histological examination revealed pheochromocytoma. Case 2. A 45-year-old male was referred to our department for further examination of a left adrenal mass in Aug. 1993. On admission, endocrinological examination was almost normal. He underwent surgical removal of the tumor and its histological examination revealed pheochromocytoma. During the operation, blood pressure and pulse rate were almost unchanged. Case 3. A 51-year-old female was hospitalized in Oct. 1993 because of further examination of a left retroperitoneal mass. She underwent surgical removal of the tumor and its histological examination showed paraganglioma.