Clinical subgroup of autoimmune hepatitis type 1 sustaining remission without additional drugs

BACKGROUND/AIMS

Many patients with autoimmune hepatitis type 1 need additional non-steroidal immunosuppressants to maintain remissions, but the indication should be limited to avoid the unnecessary side effects. The aim of this study is to clarify the clinical subgroups of autoimmune hepatitis type 1 sustaining remission without additional drugs.

METHODOLOGY

We studied 20 patients with autoimmune hepatitis type 1, in whom complete remissions were achieved in the natural course or by prednisolone alone. Remissions were maintained with none or less than 10 mg/day of prednisolone.

RESULTS

In the course (average: 6 years), 8 patients (40%) remained in remission for more than three years. In the remitted group, initial values of serum gamma-globulin (p<0.05) and serum immunoglobulin G (p<0.01) were lower than those in the relapsed group. The group with less than 30 mg/ml of gamma-globulin and 3000 mg/dl of immunoglobulin G showed a significantly lower relapse rate than the other one (p<0.01).

CONCLUSIONS

There is a clinical subgroup of autoimmune hepatitis type 1 that sustains remission with low-dose prednisolone alone. Additional immunosuppressive drugs may not be needed to maintain remissions in such patients.

[Clinical analysis of patients with nosocomial pneumonia during mechanical ventilation (so-called ventilator-associated pneumonia)]

To clarify the clinical features of nosocomial pneumonia during mechanical ventilation (ventilator-associated pneumonia) and to select the appropriate antibiotic therapy for patients, we performed a clinical analysis of 19 patients (26 episodes) with this condition. The following results were obtained. 1, The average age of the patients was 68 years old (male 16, female 3). 2, VAP occurred three times in 2 cases, twice in 3 cases, and once in 14 cases. 3, The duration of mechanical ventilation was from 7 days to 11 years and 5 months (the average was 2.1 years). 4, The microorganism isolated from the aspiration sputum of the VAP patients was Pseudomonas aeruginosa frequently, but it was difficult to determine whether this microorganism was the causative microorganism. Ten strains of Staphylococcus aureus (MRSA seven strains and MSSA three strains) were newly isolated at the same time as VAP and especially in the cases in which these were thought to be causative microrganisms, all the patients died within a short time. 5, Antibiotics were clinically effective for 53.8% of all the VAP patients and carbapenem antibiotics (for example, IPM/CS) were also used for the effective group. 6, Regarding the risk factors for VAP, factors such as the duration of mechanical ventilation, the existence of chronic obstructive pulmonary disease, a hyponutritional state, prior antibiotics, aspiration of gastric contents, histamine-type-2 receptor antagonist, and multiple organ failure showed significant differences and were suspected to be associated with the appearance of VAP.

Fibrolamellar carcinoma of the liver with a mixture of ordinary hepatocellular carcinoma: a case report

Fibrolamellar carcinoma (FLC) of the liver is a rare variant of hepatocellular carcinoma (HCC), and only 13 cases have been reported in Japan up to 1997. We described a histologically unusual case of FLC. A 52-yr-old man was admitted to our hospital for work-up of hepatic mass. Laboratory examinations revealed no abnormalities except elevated serum alpha-fetoprotein (AFP) (2098 ng/ml). A diagnosis of HCC was made by imaging findings, and left lobectomy of the liver was performed. Histologically, the tumor was composed of areas of FLC mixed with ordinary HCC and those of pure ordinary HCC. Staining for AFP was positive in the HCC component and negative in the FLC component. Some cases of such mixed tumors have been reported in Europe and the United States, but not in Japan. We regarded our case as the first of the mixed tumor in Japan.

[Adverse reactions of antituberculous agents]

We experienced adverse reactions to antituberculous agents in 17 patients (53%) out of 32 patients treated for tuberculosis and nontuberculous pulmonary mycobacteriosis. Side effects were seen in 15 patients (47%), and abnormal laboratory findings were observed in 9 patients (28%). Most side effects mostly appeared within two weeks after the administration, and were of short duration. However, there were also side effects such as neurological symptoms, arthralgia, and general fatigue which appeared after one month and lasted for a long duration. These results suggest that careful observation for adverse reactions in antituberculous treatment is required. Finally, 11 patients with adverse reactions were successfully treated by changing antituberculous agents or readministration after temporary stop of the administration. Four patients improved even with continued use of agents causing side-effects. However, in the case of two patients who had to change antituberculous agents, adverse reactions to all antituberculous agents appeared and the treatment for tuberculosis and nontuberculous pulmonary mycobacteriosis had to be stopped.

[Clinical analysis of patients with severe pneumonia requiring mechanical ventilation]

To clarify the clinical features and select the appropriate antibiotic therapy for patients with severe pneumonia requiring mechanical ventilation, we performed a clinical analysis of 65 patients with this condition. The following results were obtained. The majority of the patients were elderly males, whose performance status was poor (PS 2.2) and who had an underying disease. Abnormal physical signs included tachypnea, tachycardia and consciousness disturbance. Abnormal laboratory findings included hypoalbuminemia, and liver and renal dysfunction. The causative microorganisms were isolated from half of these patients. A number of antibiotics were administered and steroid pulse therapy was also performed for half of these patients. Nevertheless the prognosis was poor because the percentage of deaths was high (50.8%).

[A case of Listeria monocytogenes sepsis in an elderly who survived]

A 81-year-old man who complained of fever and disturbance of consciousness was admitted to our hospital. Listeria monocytogenes type 1/2aA was cultured from only the blood. He was treated with gamma-globrine and sensitive antibiotics (PAPM/BP, EM) immediately after admission, and recovered in spite of multiple organ failure due to septic shock. He was not an immunocompromised host and did not have complication of meningitis, but had rhabdomyolysis and liver dysfunction.

[Effect of 5'-DFUR used concurrently in radiotherapy and immunotherapy uterine cervical cancer--pilot study. Study of 5'-DFUR for Uterine Cervical Cancer]

We conducted a preliminary controlled study in order to evaluate 5'-DFUR dose dependency in efficacy and safety in combination therapy of radiotherapy, 5'-DFUR and SPG for patients with uterine cervical cancer, which was regarded as suitable for cases of radiotherapy. The patients were randomly allocated into group A (5'-DFUR 600 mg/body/day) and group B (5'-DFUR 800 mg/body/day), who underwent radiotherapy with simultaneous administration of 5'-DFUR and SPG (20 mg twice/week or 40 mg/ week). Those enrolled were 33 patients in stage II, III or IV a with histologically diagnosed primary squamous cell carcinoma of uterine cervix. CR was shown in 19, PR in 7, NC in 1, and PD in 2 out of 29 efficacy-evaluable cases, so the overall response rate was 89.7% (26/29, 95% CI 72.7%-97.8%). Regarding safety, some side effects were observed in 26 out of 33 safety-evaluable cases (81.3%, 95%, CI 63.6%-92.8%), but no serious cases. No significant difference in efficacy and safety was observed between the two treatment groups. These results suggested that the combination therapy of radiotherapy, 5'-DFUR and SPG might be one of the therapies whose effectiveness must be confirmed for advanced squamous cell carcinoma of uterine cervix. To confirm dose dependency of 5'-DFUR, it seems further consideration with more patients is needed.

Prognostic factors in uterine carcinosarcoma: a clinicopathologic study of 25 patients

BACKGROUND

Carcinosarcoma (malignant mixed mullerian tumor) of the female genital tract is a highly malignant neoplasm. The tumor stage and histologic grade of the carcinomatous component are among the important prognostic indicators cited in the literature for this tumor.

METHODS

Twenty-five patients with uterine carcinosarcoma at 4 hospitals in the Kyoto and Nara areas of Japan were studied retrospectively. The clinicopathologic and immunohistochemical data including p53, bcl-2, Ki-67, and proliferating cell nuclear antigen (PCNA) staining were analyzed using univariate and multivariate analysis with the Cox proportional hazards model to investigate potential prognostic indicators for this neoplasm.

RESULTS

The 5-year survival rate was 36.4% for all stages, 62.3% for Stage I, and 0% for Stages II-IV. From the univariate analysis, stage (P = 0.0001), endometrioid adenocarcinoma as a carcinomatous component (P = 0.0006), age (P = 0.0355), and a heterologous sarcomatous component (P = 0.0421) were found to be prognostically significant for patient survival. Stage was the only independent significant factor in the multivariate analysis (t = 2.212). None of the other factors (history of pregnancy and gestation, gross appearance of the tumors, grade of the carcinomatous component, mitotic count of the sarcomatous component, Ki-67 and PCNA reactivity, or p53 or bcl-2 positive staining) was found to be a significant prognostic indicator.

CONCLUSIONS

Stage appears to be the only definite independent prognostic indicator of survival in patients with uterine carcinosarcoma. It is uncertain whether age, endometrioid adenocarcinoma as a carcinomatous component, or absence of a heterologous component in the sarcomatous area are prognostic factors. Immunohistochemical expression of p53, bcl-2, Ki-67, or PCNA is not a prognostic indicator. The immunohistochemical results of the current study may support the hypothesis of a common stem cell origin of this tumor.

Multiple pancreatic masses associated with autoimmunity

A 59-year-old woman was detected to have a high titer of serum gamma-globulin, positive antinuclear antibody and multiple pancreatic masses. In the course of 1 yr, Sjögren's syndrome developed, and her pancreatic masses spread diffusely and compressed the main pancreatic duct. A pancreatic biopsy by an exploration of the abdomen showed that many CD4 positive T-lymphocytes had infiltrated to the ducts and acinar cells expressing HLA-DR antigens. This suggested a diagnosis of autoimmune-related pancreatitis. She was treated with oral prednisolone, and a marked improvement of the above abnormal findings followed. In this report, a case of autoimmune-related multiple pancreatic masses associated with Sjögren's syndrome is presented, and a possible mechanism is discussed.

[A case of acute eosinophilic pneumonia due to Sho-saiko-to]

A 16-year-boy who had taken a common over-the-counter cold remedy containing Sho-saiko-to, presented with fever, severe cough, sputum and dyspena. Two days later, he was admitted because a negative density, pulmonary edema-like shadow was noted on chest X-ray. A diagnosis of drug-induced pneumonia was strongly suspected, because an arterial blood gas analysis showed severe hypoxemia and leukocytosis with eosinophilia, and the chest X-ray showed a diffuse negative density pulmonary edema like shadow bilaterally. The findings on microscopic examination of transbronchial lung biopsy specimens were compatible with eosinophilic pneumonia. The eosinophil percentage in the bronchoalveolar lavage fluid was high. The result of a lymphocyte-stimulation test was positive for Sho-saiko-to, and Sho-saiko-to-induced pneumonia was strongly suspected. The patient ceased taking the cold remedy, and prednisolone was given. The clinical symptoms, severe hypoxemia, and chest X-ray findings markedly improved. To the best of our knowledge, there have been no previous reports of acute eosinophilic pneumonia induced by Sho-saiko-to.

Advanced endometrial cancer detected at 7 months after childbirth

It is very rare to find endometrial cancers arising within a short period following childbirth, presumably because pregnancy has a protective effect against endometrial cancer mediated by elevated secretion of progesterone. We present the case of a 30-year-old Japanese woman with stage IIIC endometrial cancer that was found 7 months after childbirth. The patient was treated with surgery followed by 6 cycles of intravenous combination chemotherapy and oral administration of medroxyprogesterone acetate. Histopathological examination of surgical specimen revealed poorly differentiated adenosquamous carcinoma of the endometrium with deep myometrial invasion, cervical stromal involvement, and pelvic and paraaortic lymph node metastases. The disease progressed rapidly and the patient died of the disease.

[Acute eosinophilic pneumonia induced by cigarette smoke]

An 18-year-old man was admitted to our hospital because of a dry cough and high fever of acute onset. A chest radiograph revealed diffuse bilateral infiltrates, mainly in peripheral lung zones. Laboratory data showed hypoxemia and leukocytosis, and no eosinophilia. The diagnosis was acute eosinophilic pneumonia, and was based on examination of a transbronchial lung biopsy specimen and on the clinical course. The patient was treated with a corticosteroid and responded quickly. We suspected that the disease was related to smoking because the patient had started smoking two days before the onset of the symptoms. Therefore, a challenge test was done in which the patient smoked cigarettes. By 15 hours after the challenge, he had become severely hypoxemic and by 21 hours after the challenge his pulmonary function had decreased. In this patient, smoking cigarettes appeared to have induced acute eosinophilic pneumonia.

[Home oxygen therapy in the elderly]

Between 1984 and September 1995, we prescribed home oxygen therapy for 155 patients (96 men and 59 women), mean age 68.6 years) with chronic respiratory failure. Here we describe the underlying diseases, laboratory findings (arterial blood gas analysis and pulmonary-function tests), and outcomes. We also report differences between those who were of least 70 years old (n = 82) and those less than 70 years old (n = 73). The underlying diseases were chronic obstructive pulmonary disease in 55 patients, lung cancer in 33, old pulmonary tuberculosis in 29, and pulmonary fibrosis in 27. Chronic obstructive pulmonary disease, especially pulmonary emphysema, was the most frequently encountered underlying disease in the older patients, whereas pulmonary fibrosis and lung cancer were most common in the younger patients. The duration of observation ranged from less than 1 month to 10 years. At the time of this study 82 patients had died, 31 were still being treated as outpatients at our hospital, 32 had transferred to other hospitals, and the status of 10 patients was unknown. The older and younger patients did not differ with regard to arterial blood gases, pulmonary function at the time home oxygen therapy began, or outcome: We believe that home oxygen therapy was very beneficial in these patients with chronic respiratory failure, because their quality of life improved after the start of this therapy.

[Dermatomyositis complicated by sarcoidosis]

We encountered a patient with dermatomyositis complicated by sarcoidosis. A 57-year-old woman was admitted to our hospital because of fever dry cough, and myalgias. There were reticular shadows on her chest X-ray film. Although the typical skin rash and myositis suggested the diagnosis of dermatomyositis biopsy specimens from a salivary gland, muscle, and lung revealed noncaseating granulomas as well. Uveitis was also noted. These findings suggested the coexistence of sarcoidosis with dermatomyositis. Examination of the lung-biopsy specimens showed interstitial pneumonia compatible with dermatomyositis, except for the granuloma. The typical rash of dermatomyositis and pathological findings of the lung specimen were inconsistent with sarcoidosis. Therefore we concluded that this patient had both dermatomyositis and sarcoidosis. This case sheds new light on the importance of pathological examinations.

Salazosulfapyridine-induced angioimmunoblastic lymphadenopathy

A 20-year-old man with ulcerative colitis was admitted because of fever, eruption and lymphadenopathy. He had started taking salazosulfapyridine one month previously. Lymph node biopsy revealed angioimmunoblastic lymphadenopathy. Autoantibody titers were all negative, and viral antibody titers were not increased retrospectively. Rearrangement of T-cell receptor beta and chromosomal aberration were not seen on the lymph node. This case is considered not to be a peripheral T-cell lymphoma but rather salazosulfapyridine-induced angioimmunoblastic lymphadenopathy (AIL), which is the second case in English language literature.

[Four cases of pulmonary tuberculosis resembling pulmonary abscess with a so-called niveau-like shadow in a medical school hospital: discussion concerning the formation mechanism of niveau-like shadows]

Four cases of pulmonary tuberculosis resembling pulmonary abscess radiographically were reviewed from their clinical features, chest X-ray and chest CT, and the mechanism of formation of so-called niveau-like shadows was discussed. Only one case showed a newly formed tuberculous cavity with air fluid level on chest X-ray, however, even in this case, the possibility of the infection with tubercle bacilli of an emphysematous bulla of the lung could not be completely excluded as several bulla were found on chest CT. The remaining three cases showed a slightly different mechanism of the formation of niveau-like shadows. Namely, mycobacterium tuberculosis spread into an existed bulla and a tubercle bacilli infected bulla was formed. Regarding the clinical features, no remarkable findings were detected and we could find no differences with common tuberculosis. Based on these experiences, the presence of pulmonary tuberculosis resembling the shadow of pulmonary abscess should be emphasized.

[Chronic necrotizing pulmonary aspergillosis complicated by pneumothorax]

A 66-year-old man was admitted to the hospital due to a rapidly progressing interstitial shadow in both lower fields on a chest roentgenogram taken on November 30 1993. The diagnosis was idiopathic interstitial pneumonia. A corticosteroid and a neutrophil elastase inhibitor were administered and the interstitial shadow resolved. A new infiltration shadow appeared in the right upper lung field one and a half months after the start of steroid therapy. This shadow gradually grew and Aspergillus fumigatus was detected in sputum cultures. In spite of treatment with FCZ+5-FC and 5-FC+AMPH, the abnormal shadow increased in size and mixed with the cavity, and the patient died of respiratory failure, with a pneumothorax caused by ruptures of the cavity formed by CNPA. The clinical and radiological course were considered to the indicative of chronic necrotizing pulmonary aspergillosis, which was described by Binder et al. in 1982.

[Pneumonia and mortality in patients requiring prolonged mechanical ventilation]

We examined patients who required prolonged (>60 days) mechanical ventilation. A total of 31 patients were studied, 23 with pulmonary disease, 4 with neurologic disease and 4 with other conditions. Many of these patients were elderly. The survival rates one year and two years after the start of mechanical ventilation were 40% and 33%, respectively. Respiratory tract infection was the most common and most serious complication, and ventilator-associated pneumonia was the main cause of death. It is difficult but quite important to prevent these complications, especially ventilator-associated pneumonia.

Inconsistent association of Epstein-Barr virus with CD56 (NCAM)-positive angiocentric lymphoma occuring in sites other than the upper and lower respiratory tract

We previously described nine cases of angiocentric lymphoma of a possible natural killer (NK)-cell lineage with a surface CD3-CD56+ phenotype occurring in sites other than the upper and lower respiratory tract. This study was performed to investigate the association of Epstein-Barr virus (EBV) with these lymphomas, using the polymerase chain reaction (PCR) for the presence of EBV-DNA, in situ hybridization (ISH) for EBV-encoded small RNAs (EBERs) and immunohistology for EBV-determined nuclear antigen-2 (EBNA-2) and latent membrane protein-1 (LMP-1) in paraffin sections. PCR and ISH produced almost identical results, and EBERs were identified in the nuclei of the lymphoma cells of three cases, two of which exhibited LMP-1 in the cytoplasm of tumour cells without EBNA-2 expression. Molecular genetic analysis revealed EBV to be incorporated into these three EBER-positive cases either clonally or biclonally. It was revealed by re-evaluation of their morphology with the established EBV status on each case that, in contrast to the rather variable and irregular cellular composition of the EBV-positive tumours, the EBV-negative tumours stood out because of their remarkably uniform 'blastoid' appearance, and could be grouped as blastic NK-cell lymphoma. The relationship of the EBV-positive cases with nasal NK-cell tumours has yet to be clarified.

[An adult case of pneumonia due to Mycoplasma pneumoniae and Chlamydia psittaci]

A 18-year-old male was admitted to another hospital complaining of his chest X-ray. After transfer to our hospital, increased serum antibody titers to simultaneous M. pneumoniae and C. psittaci were noted. These antibody titers decreased after about four months. Positive results for M. pneumoniae was obtained by Polymerase chain reaction in the right pleural effusion. Based on these findings, this case was diagnosed as M. pneumoniae and C. psittaci pneumonia. A transbronchial lung biopsy and a bronchial biopsy revealed rare histological findings, including histiocytic intra-alveolar pneumonia with palisaded granuloma and small foci of necrosis in the left upper lobe and eosinophilic bronchitis in the right middle bronchus. His chest X-ray and chest CT showed a nodular shadow, obstructive pneumonia and pleural effusion which are rare in M. pneumoniae and C., psittaci pneumonia.

[Expression of bc1-2 protein in collagen vascular diseases with pulmonary interstitial involvement]

Expression of bc1-2 protein was studied immunohistochemically in 25 patients with collagen vascular diseases and in 10 patients with idiopathic interstitial pneumonia. The collagen vascular diseases included rheumatoid arthritis (n = 9), progressive systemic sclerosis (n = 9), polymyositis/dermatomyositis (n = 4), Sjögren's syndrome (n = 2), and systemic lupus erythematosus (n = 1). All 35 patients underwent open lung biopsy; cellular infiltration, fibrosis, and lymphoid aggregation were scored according to Cherniack's classification. T lymphocytes (CD43: DFT-1) and B lymphocytes (CD20:L-26) were also evaluated. Expression of bc1-2 protein was dominant in T lymphocytes infiltrating the alveolar interstitium and in B lymphocytes in the mantle zone of lymphoid follicles. In collagen vascular diseases, the degree of expression of bc1-2 protein in those T lymphocytes was closely related to the alveolar lymphocyte infiltration score. However, these findings were not marked in the patients with idiopathic interstitial pneumonia, and were not related to the underlying disease in the patients with collagen vascular diseases. The expression of bc1-2 protein in T lymphocytes was not related to fibrosis or to lymphoid aggregation. Expression of bc1-2 protein in B lymphocytes did not correlate with pathological scores or with underlying disease. Bc1-2 protein has been recognized as an oncogene that suppresses apoptosis. Marked expression of bc1-2 protein in T lymphocytes from patients with collagen vascular diseases indicates that oversuppression of apoptosis may be related to the pathogenesis of pulmonary interstitial involvement in these conditions. Further clinicopathological studies focusing on apoptosis in collagen vascular diseases and in idiopathic interstitial pneumonia are needed.