Relapsing polychondritis diagnosed by Tc-99m MDP bone scintigraphy

PURPOSE

Relapsing polychondritis is a generalized recurring disease of cartilage that involves joints, trachea, bronchi, laryngeal cartilages, costal cartilages, and cartilages of the ear and nose. It is associated with autoimmune diseases, including Hashimoto disease in some cases.

METHODS

The authors evaluated a 29-year-old man with relapsing polychondritis who had symptoms and signs of a common cold for 2 months and anterior chest pain near the sternum for 1 month.

RESULTS

After the diagnosis, the authors found that the patient had a history of thyroid therapy for hyperthyroidism 15 years before. Tc-99m MDP bone scintigraphy performed to evaluate anterior chest pain showed diffusely increased accumulation of radioactivity in all costocartilages and sternoclavicular joints. Based on that information, relapsing polychondritis was diagnosed. Ga-67 citrate scintigraphy was preformed to determine the optimum biopsy site of the cartilage. The diagnosis was histologically supported by the results of the open biopsy.

CONCLUSIONS

In this case, Tc-99m MDP bone scintigraphy was useful for diagnosing relapsing polychondritis, and Ga-67 citrate scintigraphy was helpful in determining the biopsy site.

Histochemical and immunohistochemical analysis of the mechanism of calcification of Meckel's cartilage during mandible development in rodents

It is widely accepted that Meckel's cartilage in mammals is uncalcified hyaline cartilage that is resorbed and is not involved in bone formation of the mandible. We examined the spatial and temporal characteristics of matrix calcification in Meckel's cartilage, using histochemical and immunocytochemical methods, electron microscopy and an electron probe microanalyser. The intramandibular portion of Meckel's cartilage could be divided schematically into anterior and posterior portions with respect to the site of initiation of ossification beneath the mental foramen. Calcification of the matrix occurred in areas in which alkaline phosphatase activity could be detected by light and electron microscopy and by immunohistochemical staining. The expression of type X collagen was restricted to the hypertrophic cells of intramandibular Meckel's cartilage, and staining with alizarin red and von Kossa stain revealed that calcification progressed in both posterior and anterior directions from the primary centre of ossification. After the active cellular resorption of calcified cartilage matrix, new osseous islands were formed by trabecular bone that intruded from the perichondrial bone collar. Evidence of such formation of bone was supported by results of double immunofluorescence staining specific for type I and type II collagens, in addition to results of immunostaining for osteopontin. Calcification of the posterior portion resembled that in the anterior portion of intramandibular Meckel's cartilage, and our findings indicate that the posterior portion also contributes to the bone formation of the mandible by an endochondral-type mechanism of calcification.

Early local recurrence of rectal cancer showing extremely rapid growth after curative surgery: report of a case

We report herein the case of a 59-year-old woman who developed a local recurrence of rectal cancer which showed extremely rapid growth. The patient had undergone a curative low anterior resection with total mesoexcision, and was discharged on postoperative day 25 after an uneventful recovery. However, 2 months after the operation, she developed bleeding from the rectum during defecation, the quantity of which gradually increased. A colonoscopy performed during the fifth postoperative month revealed a circular tumor at the suture line. The tumor was unresectable because it had firmly invaded not only the sacrum, but also the right ureter. Despite the administration of 5-fluorouracil and leucovorin, the patient died of cancer 18 months after her initial surgery. Considering that local recurrence of rectal cancer does not usually occur within 1 year after surgery, this case is unusual because the local recurrence developed very early and showed extremely rapid growth, occupying the entire lumen of the rectum by the time it was detected by colonoscopy during the fifth postoperative month.

Acquired undescended testis

We report an unusual case of a 22-year-old man who presented with the left testis spontaneously ascended to a non-scrotal position. The testis had been documented to be intrascrotal without any sign of up-migration when the man was 12 years old. On surgery, the cryptorchid testis was found to be located within the superficial inguinal pouch. The testis was atrophic with the spermatic cord too short. On dissection, a remnant string of the closed processus vaginalis was observed within the cord, and the distal end of the gubernaculum was abnormally attached to the fascia near inguinoscrotal junction. Histopathologic findings of the testis were that of the Sertoli-cell-only syndrome which may represent the end-stage of germinal cell hypoplasia, a pathologic sequela common in postpubertal undescended testis. We recommend 3 diagnostic criteria for the acquired undescended testis and emphasize that testicular descent should be confirmed in infancy and re-confirmed periodically through puberty by the health care physician. Our observations seem to support the theory that acquired undescended testis may be caused by a postnatal failure of the spermatic cord to elongate in proportion to somatic growth.

False negatives at neonatal screening for congenital adrenal hyperplasia in two siblings with 21-hydroxylase deficiency

We report on two siblings with classic simple virilizing 21-hydroxylase deficiency whose neonatal screening for serum 17alpha-hydroxyprogesterone (17-OHP) gave normal results. The proband, a girl with clitoromegaly whose screening 17-OHP value had been 9.2 ng/ml, was diagnosed at the age of 6 months, and her elder brother with the initial screening level of 15.7 ng/ml was diagnosed at the age of 6 years due to precocious puberty. Although the occurrence of false-negative cases is extremely rare, it can happen in a simple virilizing form of 21-hydroxylase deficiency. This experience informs that normal results for neonatal screening cannot be an excuse for not evaluating siblings of the proband with congenital adrenal hyperplasia.

Papillary urothelial carcinoma of the urinary bladder demonstrating prominent signet-ring cells in a smear. A case report

BACKGROUND

The appearance of numerous signetring cells (SRCs) without any other type of adenocarcinoma cells originating in papillary transitional cell carcinoma (TCC) in a urine smear is rare.

CASE

The cytology from mucus-urine that was initially obtained by washing from a 69-year-old female revealed three different types of cells: (1) numerous single SRC carcinoma-type cells, (2) low grade TCC-type cells arranged in sheets, and (3) intermediate (transitional)-type cells with both aspects of TCC and adenocarcinoma (SRC carcinoma) and mucus in the background. The latter two cell populations were retrospectively confirmed after histologic diagnosis of a primary papillary TCC with glandular differentiation.

CONCLUSION

One should keep in mind that even a low grade papillary TCC with glandular differentiation of the bladder can exhibit excessive SRC-type cells in urine.

[A case of sellar T cell type malignant lymphoma]

A case of primary T cell type malignant lymphoma of the sellar region was reported. This 53-year-old male was admitted to our neurosurgical service because of slowly progressive occipitalgia and diplopia over the previous 5 months. On admission neurological examination revealed a slight limitation of the lateral movement of the left eye. Endocrinological examination showed no abnormalities. Despite a mild neurological deficit, a CT scan revealed an extensive bony destruction around the sellar region including the dorsum sellae, the bilateral petrous apices, and the upper two thirds of the clivus. Magnetic resonance imaging (MRI) disclosed that the tumor was slightly hypointense on T1-weighted image, isointense on T2-weighted image, and faintly and homogeneously enhanced after administration of Gd-DTPA. Since the tumor was enhanced faintly on MRI, it was diagnosed as an invasive pituitary adenoma, but it was thought that chordoma and germinoma should be considered. The patient underwent a transsphenoidal surgery. A firm, grayish and avascular tumor was partially removed. The histopathological examination using monoclonal surface marker of the specimen revealed the tumor was stained with UCHL-1 and CD3 antibodies directed against T cells, and diagnosed as T cell type malignant lymphoma of the sellar region (diffuse, large cell type; LSG). Postoperatively he received radiation therapy. His symptoms much improved and no regrowth of the residual tumor has been found in follow-up studies to the present. Primary malignant lymphomas very rarely occur in the skull base. As far as we are aware, this is the only second case of primary T-cell lymphoma in the sellar region reported so far in the medical literature. Although preoperative diagnosis is extremely difficult because of a paucity of data, malignant lymphomas should be kept in mind in the differential diagnosis of sellar tumors, especially if neuroimaging studies show an extensive bony destruction in the skull base.

Spontaneous reduction of a recurrent craniopharyngioma in an 8-year-old female patient: case report

OBJECTIVE AND IMPORTANCE

The spontaneous rupture of a craniopharyngioma is an extremely rare condition confined to adults. This is the first report of a patient younger than 10 years who experienced spontaneous reduction (possibly rupture) of a craniopharyngioma.

CLINICAL PRESENTATION

An 8-year-old female patient with a recurrence of a craniopharyngioma experienced fever, headache, and visual disturbance that lasted a few days. Concurrent with the improvement of these symptoms, marked reduction in the size of the tumor was revealed using magnetic resonance imaging, suggesting the occurrence of a rupture.

INTERVENTION

Subsequent magnetic resonance imaging of the hypothalamic-pituitary region was performed while the patient received growth hormone therapy.

CONCLUSION

There was no increase in the size of the tumor 1 year after the reduction occurred. Prompt evaluation of the hypothalamic-pituitary region using magnetic resonance imaging is warranted to rule out the possibility of spontaneous reduction (including rupture) of the tumor in a situation in which the patient with a craniopharyngioma shows meningeal signs or a rapid change of neurological symptoms (such as headache, fever, or visual disturbance).

Instability of the 12-nucleotide repeat in c-myb gene of bovine T-lymphoma cells

Insertion of a 12-nucleotide repeat in c-myb gene exon 9 was observed in about 15% of sporadic bovine T-lymphomas. The 12-nucleotide repeat in the T-lymphoma cells showed deletion and insertion of the repeat units during cultivation of the cells. To know whether deficiency in DNA loop repair is involved in the instability of the repeat, abilities to bind and correct the loop structure in nuclear extracts were examined. The nuclear extracts of all examined cells had ability to bind and correct the loop structure. These data suggest that instability of the 12-nucleotide repeat in bovine T-lymphoma cells might be independent of deficiency of DNA loop repair function.

Deletion of c-myb exon 9 induced by insertion of repeats

A simple repeat was found to be inserted into exon 9 of the c-myb gene in three out of 20 bovine T lymphomas. The repeat was composed of multiple copies of a 12-nucleotide motif and had no significant homology to the sequences reported so far. Tumor cells containing the repeat expressed two kinds of c-myb mRNA: (1) are that included the repetitive sequence in exon 9, and (2) are that lacked the whole sequence of exon 9. Transfection of an expression vector containing exon and intron sequences and reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of the mRNA demonstrated that the insertion of the repeat enhanced exon skipping of the transfected minigene. These observations imply that the insertion of the repeat may enhance exon skipping of the c-myb pre-mRNA. Although the transcription-activating activity by the c-Myb with the repeat was low, that by the c-Myb without exon 9 was three- to eightfold higher than the wild-type c-Myb. These data suggest that insertion of the 12-nucleotide repeat in codon 359 may result in c-Myb proteins having high- and low-transcription-activating activity.

Homozygous Q258X mutation in the steroidogenic acute regulatory gene in a Japanese patient with congenital lipoid adrenal hyperplasia

Congenital lipoid adrenal hyperplasia (CLAH) is an autosomal recessive disorder characterized by impaired synthesis of all adrenal and gonadal steroid hormones. It has recently been reported that mutations in the steroidogenic acute regulatory protein (StAR) gene cause CLAH. We analyzed the nucleotide sequences of exon 7 of the StAR gene in a Japanese CLAH patient with a karyotype of 47,XYY, and her parents. The patient was homozygous for a nonsense mutation Q258X, which changed codon 258 (CAG) encoding Gln to the stop codon TAG, and the her parents were heterozygous for the Q258X mutation. Since the Q258X mutation destroys a MvaI site normally present in the StAR gene sequence, we confirmed the Q258X mutation by means of the restriction endonuclease MvaI digestion of the PCR products. Endocrinological examinations of the parents revealed normal responses of adrenal steroid hormones to exogenous adrenocorticotropin administration, confirming the failure to detect the heterozygous carriers of CLAH by hormonal evaluation.

Indication of chemoembolization therapy without gelatin sponge for hepatocellular carcinoma

This study evaluated the effect of chemoembolization (C-LIP) consisting of ethiodized oil (Lipiodol Ultra Fluid; André Guerbet, Aulnay-sous-Bois, France) and epirubicin, without gelatin sponge on hepatocellular carcinoma (HCC), administered by hepatic arterial infusion. We analyzed the cases from two points of view: the local recurrence rate for hypervascular solitary small HCC (tumor size: < or =3 cm in diameter) and the cumulative survival rate for advanced HCC (stage VI according to the criteria of Liver Cancer Group of Japan) following C-LIP therapy. The C-LIP also was compared with transcather arterial embolization (TAE; C-LIP followed by gelatin sponge) and percutaneous ethanol injection therapy (PEIT). In the small HCC cases, the recurrence rate at 1 year after C-LIP was 77% (10 of 13 patients), while the local recurrence rate was 46% (six of 13 patients) at 6 months and 61% (eight of 13 patients) at 1 year. The local recurrence rate at 1 year was 29% (four of 14 patients) after TAE and 20% (three of 15 patients) after PEIT. These results showed that the effect of local anticancer therapy by C-LIP was not as potent as that of TAE or PEIT. In advanced HCC cases, the cumulative survival rate for 13 patients treated by C-LIP was 72% at 6 months, 36% at 1 year, and 14% at 2 years. However, the survival rates for 13 patients at 6 months, 1 year, and 2 years after TAE were 46%, 23%, and 8%, respectively. There was no difference between the C-LIP patients and TAE patients with regard to the pretreatment liver function. Three patients died within 2 months after the initial TAE. These deaths were mainly due to damage to the noncancerous liver parenchyma. Therapy with C-LIP alone was not appropriate for hypervascular solitary small HCCs, and additional treatment was necessary. We think C-LIP therapy should be selected instead of TAE for advanced HCCs to avoid severe parenchymal damage.

A specific elevation of RANTES in bronchoalveolar lavage fluids of patients with chronic eosinophilic pneumonia

Chronic eosinophilic pneumonia (CEP) is a rare, idiopathic lung disorder characterized pathologically by massive eosinophil infiltration into lung. In the bronchoalveolar lavage fluid (BALF) of patients with CEP, eosinophil numbers were markedly increased but returned to normal-levels upon the resolution of clinical symptoms, which suggests the crucial role of eosinophils in the pathogenesis of CEP. To clarify the mechanism of eosinophil accumulation in CEP, we determined the BALF levels of RANTES and macrophage inflammatory protein-1 alpha, two chemokines that predominantly exhibit in vitro eosinophil chemotactic activities. RANTES (106.7 +/- 27.2 pg/mg albumin; n = 16) concentrations in BALF from patients with CEP were significantly elevated in comparison with those of normal control subjects (1.4 pg/mg albumin; n = 13), whereas BALF macrophage inflammatory protein-1 alpha levels were not. In addition, eosinophils, lymphocytes, and macrophages in BALF were positively stained with a specific anti-RANTES antibody, which suggests that RANTES was produced locally in the lungs of CEP patients. Moreover, BALF-RANTES levels correlated significantly with the proportion of eosinophils in BALF. Furthermore, nearly half of the eosinophil chemotactic activities in BALF were abrogated by the anti-RANTES antibody in vitro. Collectively, these data suggest that locally produced RANTES is involved in eosinophil accumulation in the pulmonary alveolus and interstitium of patients with CEP.

[Increased CA19-9 level in serum and bronchoalveolar lavage fluid from a patient with pulmonary tuberculosis]

A 66-year-old woman was admitted to the hospital because of general malaise and loss of appetite. Laboratory examination revealed an abnormally high level of CA19-9 in serum and a chest roentgenogram revealed soft reticular shadows in the right mid-lung field. An extensive examination revealed no malignant disease. Bronchoalveolar lavage fluid obtained from the right B5 contained an abnormally high level of CA19-9. Immunochemical staining for CA19-9 was positive in the epithelial cells of respiratory bronchioles. The level of CA19-9 decreased during anti-tuberculosis therapy. This case suggests that the CA19-9 level can reflect the activity of pulmonary tuberculosis.

[Diffuse alveolar septal amyloidosis associated with multiple myeloma (IgA lambda type)]

A 75-year-old man with multiple myeloma presented with fever and respiratory symptoms. A chest roentgenogram showed interstitial shadows and transbronchial lung biopsy revealed diffuse infiltration of amyloid in the alveolar walls. Analysis of bronchoalveolar lavage fluid showed the presence of an IgA-lambda paraprotein, and the IgA/albumin ratio was similar to that in serum. However, plasma cells could not be detected in the cells obtained by lavage. We know of no previous case in Japan in which bronchoalveolar lavage fluid was examined in a case of diffuse alveolar septal amyloidosis.

Primary squamous cell carcinoma of the liver: a case report

BACKGROUND

Bile cytology from percutaneous transhepatic cholangio-drainage (PTCD) is a useful procedure in case of obstructive jaundice.

CASE

Repeated cytology via PTCD from a cystically dilated duct in a 56-year-old female with a long clinical history permitted a diagnosis of squamous cell carcinoma (SCC). The smears showed excessive benign-appearing squamous cells with or without a nucleus and a few keratinized- and nonkeratinized-type SCC cells. No adenocarcinoma-derived cells were identified. No focus of SCC was detected clinically. The resected hepatic specimen disclosed a keratinized-type SCC simultaneous with benign metaplastic squamous epithelium.

CONCLUSION

This case of cytology of primary SCC of the liver seems to be the first reported. Even when showing a great number of benign-appearing squamous cells, the possibility of malignancy should not be ruled out. Repeating the cytology from PTCD is effective for a diagnosis.

Induction of CD40 in promyelocytic HL60 cells cultured with retinoic acid and/or various cytokines

The antigenic protein CD40 on the surface of B lymphocytes plays an important role in their proliferation, immunoglobulin class switching, and rescue from apoptosis in the germinal center through interaction with T lymphocytes expressing CD40 ligand. The protein is also found on the cell surface of other antigen-presenting cells such as monocytes, dendritic cells, and thymic epithelium cells, but its presence in other myeloid cells has not been reported. We show here that CD40 protein is induced in promyelocytic HL60 cells, when cultured with retinoic acid, a vitamin that converts them to granulocyte-like cells. The cultured cells also expressed CD15, a marker for granulocytes, and cytochrome b(558), an essential component of the superoxide-generating system in phagocytes, on their surface. No detectable amount of mRNA for CD40 was found in naive HL60 cells, whereas a large amount of the message was induced in the cells cultured with the vitamin. Although CD40 expression was enhanced when the cells were further cultured with GM-CSF or IFN-gamma, expression of CD14, a marker for monocytes, was also enhanced. HL60 cells, therefore, express CD40 protein during differentiation not only toward monocytes but also toward granulocytes, at least transiently.

Role of cathepsin B as prorenin processing enzyme in human kidney

Renin is synthesized from an inactive precursor, prorenin, through cleavage at a pair of basic amino acids catalyzed by prorenin processing enzyme (PPE). A lysosomal protease, cathepsin B, has been suggested to be a strong candidate for PPE. However, there still remains a possibility that other protease(s) can also catalyze prorenin processing. We studied the subcellular distribution of PPE in human renal cortex using pure recombinant prorenin as a PPE assay substrate. PPE and renin activities, and cathepsin B activity and protein were colocalized in the lysosomal fraction. The PPE activity was completely inhibited by a cathepsin B specific inhibitor, CA074. Taken together with the immunohistochemical data showing that cathepsin B and PPE are colocalized in dense secretory granules of juxtaglomerular cells of kidney, we conclude that cathepsin B is the authentic PPE in human kidney.

Alpha fetoprotein-producing acinar cell carcinoma of the pancreas showing multiple lines of differentiation

An alpha fetoprotein (AFP)-producing tumour occurring in the head of the pancreas of a 30-year-old woman is reported. Histological examination revealed a markedly solid proliferation of tumour cells with prominent nucleoli and occasional luminal structures, some of which contained mucinous material stained with mucicarmine and alcian blue. No squamoid corpuscles were recognized. Immunohistochemistry showed intense positivity for lipase trypsin, and AFP basically, and single cells were also positive for carcino-embryonic antigen, CA19-9, synaptophysin and neuron-specific enolase. Pancreatic hormone-positive cells were absent. Electron microscopical examination revealed numerous granules of variable sizes in the tumour cells, which were considered to be zymogen. The tumour is an acinar cell carcinoma with multi-directional differentiation including the ability to produce AFP. Among AFP-positive pancreatic tumours, acinar cell carcinoma and pancreatoblastoma seem to be the most frequent.